Over 1.3 million people work in the NHS, treating more than a million patients a day (Health Education England (2015). Health Education England (2015) emphases the importance of ensuring staff are equipped to deliver high quality care by understanding the fundamental principles that enable them to be flexible and resilient.
It was well established that many new nurses lack confidence to begin with and require positive feedback about their performance (Vessey et al, 2009), alongside the “reality shock” described by Kramer (1974). Duchscher (2009) builds on the theory of “transition Shock”’ by outlining how the newly qualified nurse engaged in a professional practice role for the first time, confronted with a broad range of physical, intellectual, emotional, developmental and sociocultural changes that are mitigating factors within the experience of transition.
The participants gave examples of some early career nurses who were struggling to fit into the profession because of their “odd” character traits, who could be further disadvantaged by the transition period of moving into the nursing profession.
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This research reveals how some newly qualified nurse’s lack the ability to quickly integrate safely into the workplace and require a degree of support. Participants referred to running bespoke programmes to support newly qualified nurses:
“I’ve been running a trial programme for a small group of new qualifiers…they have a session together about … the emotional difficulties of … being a mental health student” - Participant 18
There appears to be a growing expectation for the nurse to meet the expectations of enhancing the patient experience, improving the health of the nation, with reduced resources. Odenheimer and Sinsky (2014) argues this has moved to “a quadruple aim”, to include optimising health system performance. The participants experienced some nurses who required an additional level of support to function safely which was beyond sustainability. Participant 5 gave an example of a newly qualified nurse, who over an eight week period of supernumerary status could not function safely. As a consequence, this impacted on the nursing team who became increasingly anxious for the welfare of the patients. They voiced concerns about the degree of responsibility involved in supporting a significantly underperforming nurse, whilst working with their own extensive workload in a busy acute surgical setting:
“They (nursing team) are very good, and they’re pretty good at saying, I’ll give it time (explain) why we do things? But we weren’t even allowing her to do much, she was on
another planet, and they (nursing team) got very frightened I think because of safety” - Participant 5.
Yet it is well reported that newly qualified nurses experience limited support on qualification (Brakovich and Bonham, 2012; Flinkman and Salantera, 2015), compounding the challenges for the nurse. In particular, newly qualified nurses tend to have greater risk for errors than the experienced nurses (Berkow and Virkstis, 2008). In addition, it has been reported between 49% and 53% of newly qualified nurses are involved in nursing errors (Smith and Crawford, 2003; Kenward and Zhong, 2006). Nurses who are not adequately prepared will be more prone to making significant mistakes as they begin to practice (Gibson, 2011).
Whereby, Brunton (2005) states that nurses must “stake out their emotional boundaries with patients, doctors, families, and each other, even in the face of incessant demands, crises, and mistakes”. Hochschild (1983) describes people who handle emotional displays “ranging from superficial to deep acting levels”. According to Larson and Yao (2005), healthcare professionals engage in emotional labour through deep acting by feeling sincere empathy before, during, and after interactions with patients. This work has been referred to as “emotional labour of nursing” by Pam Smith (1992). Thus, there has been a continuing attempt
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to address the role of emotions in healthcare (Mark, 2005). Larson and Yao (2005) continues to describe the empathy should characterise health care professionals' interactions with their patients because, despite advancement in medical technology, the interpersonal relationship between physicians and patients remains essential to quality healthcare. Thereby, if a nurse is involved in an error, they too, can be injured. The pain inflicted on a nurse after making an error has been described as the “second victim” (Marmon, 2015; Micco, 1997; Wu, 2000). However, the participants described the complexity of assessing and managing the risk of patient safety. This research has revealed internal mitigating factors do not outweigh the need to protect the public. Participant 4 gave an example of how an act of dishonesty can have a detrimental effect on the relationship between the nurse and the employer. This is discussed in the chapter – a chain of expectations:
“But you know, for me it’s a complete breakdown of trust between me and the employee and so also between me as an Accountable Officer and (registered) professional … beholder of
professional standards within the organisation. It’s about whether I can trust them to practice in the future” - Participant 4.
Participant 9 gave a similar recollection:
“You’ve lost all trust then … regardless of the mitigation, if they’re living on the street or they’ve got ten kids to feed, it doesn’t make a difference. You know we’ve got mechanisms
to support people …. But yeah it is completely unacceptable. It’s a breach of trust” - Participant 9.
A stressful environment can result from inadequate staffing and daily “hassles”, such as “hunting and gathering activities”, which restrict nurses from meaningful patient care (Beaudoin and Edgar, 2003); for example the time taken to find medications and supplies. These stressors can affect patient safety and adversely influence the nurses' perceptions of their work place environment (Paris and Terhaar, 2017).
“How can you make good clinical decisions under tonnes of pressure in those circumstances?” - Participant 14.
A healthy work place is identified by “an engaged nursing staff who exercise control over nursing-related issues, ground their practice in the evidence, and collaborate with colleagues from diverse disciplines” (Kramer and Schmalenberg, 2008). These positive environments are linked with favourable patient outcomes and an empowered workforce (Gallup, 2005).
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Studies have reported the reasons for errors and found multiple system factors including human factors (Brady et al, 2009; Keers et al, 2013; Parry et al, 2015). Ulanimo et al (2007) highlights a key barrier to reporting an error was the fear of peers’ reaction and fear of nurse managers’ reaction. Similar findings (Mrayyan, et al, 2007; 2011; Mayo and Duncan, 2004) found nurses were afraid of the reactions from the nurse manager. The practical implications impact on the healthcare organisation’s inability to collect data that is reliable to gather an accurate picture of problems in practice. If left unchecked, this may result in future otherwise avoidable harmful errors occurring (Secker-Walker and Taylor-Adams, 2002: 423; Amoore and Ingram, 2002). This leaves the organisation vulnerable to “latent factors” (Reasons, 1990). The culture and the reaction of managers and staff create an organisational barrier that inhibit the reporting of errors (Vrbnjak et al, 2016). Vrbnjak et al’s (2016) systematic review highlights a sense of fear, accountability, and characteristics of nurses as the personal and professional barriers that influence the reporting of errors. Therefore, a nurse needs an inner strength of personal and professional courage to disclose their deficiencies. This can be assisted by a real sense of confidence and motivation, commitment and engagement to disclose an error to their manager.
The culture of the workplace in relation to forms of bullying can have extreme negative impacts on the nursing workforce and patient care; this could be referred to as “horizontal violence” (McKenna et al 2003). Bullying in the nursing workplace has been identified as a factor that affects patient outcomes and increases occupational stress and staff turnover (Etienne, 2014; Cox, 2003). More recently, Lever et al (2019) systematic review concluded bullying occurs frequently amongst health care staff and is deleterious to health and occupational functionality. This has also been defined as inter-group rivalry, lack of unity and pride, and aggression turned inward (Cox, 2003; McKenna et al, 2003; Bartholomew et al, 2006). This could be a result of lack of leadership, role models, and performance management.
Moreover, bullying can be a major reason for leaving the profession (Etienne, 2014; Stark and DeMarco, 2011). One study found that almost half of new graduates had experienced a form of bullying, humiliation and rudeness across settings, and many had felt distress as a result of inappropriate supervision (Berry et al, 2012). These experiences were related to absenteeism and thoughts about leaving nursing, ultimately hindering performance and the ability to focus on developing their skills, knowledge and competence.
The transition from student to registrant is potentially challenging for nurses from all types of educational programmes, and has historically been shown to be a stressful experience (O’Shea and Kelly, 2007). The terms used to describe the transition from student to registered
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nurse include “reality shock” (Kramer, 1974). The stresses affecting transition include individual accountability, the risks and consequences of making errors, and management issues such as prioritising care needs (Gerrish, 2000). It has long been said that "nurses eat their young" (Bartholomew et al, 2006), and if left unhindered these negative acts can further escalate the nursing shortage. Novice nurses are the face of the future; experiencing workplace bullying when entering the nursing workforce sets a negative precedent (Etienne, 2014). Overton and Lowry (2013) explains that talented individuals leave a career that has such a strong need for them, partially because of their lack of skills in dealing with conflict. Overton and Lowry (2013) argues that it is the fault of the nurse leaders who are not visible or do not provide the opportunity to learn these skills and foster an environment where conflict is not acceptable.
The evidence suggests that a nurse’s behaviour and misconduct can have serious consequences for their colleagues and patients in their care. There may be consequences for the nurse leader demonstrating a lack of management and leadership skills. The organisation needs a support strategy and effective performance management, with a clear view to support staff who use their duty of candour to report staff.
7.7 Conclusion
To conclude the situational stressors and mental health category, there is now a greater understanding of the meaning of the experience as a whole. The situational stressors and mental health have clarified the pre-understandings identified at the out-set of this study in relation to the human factors and professional regulation in the introduction chapter.
This chapter has challenged the pre-understandings in a different way, through theoretical sampling and constant comparison of the data, when exploring the factors that contribute to an employer referring a newly qualified nurse to the NMC. This research confirms that there are some cases when the “second victim is the nurse”. It is evident that there is a need for a culture of sharing experiences and reasonable adjustments that can be made to accommodate personal circumstances and/or their working environment. It is apparent that there is greater importance for employers to provide supportive strategies to manage the individual needs of their staff members whlist demonstrating they are a “fair employer”.’ However, in some cases, a nurse whose conduct and performance has been questioned, may have little or no evidence of mitigating circumstances to compensate for the nurses actions. The research confirms that protection of the public outweighs the nurse’s individual needs, no matter now traumatic for the nurse.
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