Newly qualified nurses found that moving wards contributed to stress. During the time of the study, the recruitment embargo, affected many newly qualified nurses’ working arrangements. Some had short or informal contracts, worked for nursing agencies or were working on different wards, often referred to as ‘relief work’. The demand for agency work has left dependence on relief work and lack of certainty regarding placement employment in one hospital not to mention one ward. This has impacted negatively on the newly qualified nurse’s learning experience in the crucial first six months as a great deal of energy is spent on getting to know and becoming established in each ward. This not only affected the newly qualified nurses sense of stress, but also has greater implications for nurses in their intention to stay or in their choice of specialty. Job security was considered an attraction to nursing (Coombs et al, 2003) and was considered significantly related to job satisfaction (DATHS, 2000),
contractual or part time basis with little assurance of permanency in the near future. Job insecurity and dependence on agency work, was perceived to negatively affect newly qualified nurse’s ability to settle into the new role.
5.15 Conclusion
Irish nursing has witnessed remarkable change over the past decade. Nurse education has undergone immense transformation influenced by the Commission on Nursing (Government of Ireland, 1998) and the Nurse Education Forum (Government of Ireland, 2000). These changes are not without their difficulties. Stress and stressors in the clinical environment in this study almost replicate the seminal work of Kramer over thirty years ago, with added stressors cited, particularly by student nurses who are amidst these changes.
Consistent with previous studies, stress remains a cause for concern in the clinical environment. Newly qualified nurses experience stress in the transition period and see this as a reality shock, however transient. This study has revealed that the student nurses are also under immense pressure in their final year. This study has compared levels of stress in each group. Perceived stress is not higher in newly qualified nurses compared to fourth-year student nurses for the following factors; death and dying, inadequate preparation, lack of staff support, uncertainty concerning treatment and conflict with other nurses. However, perceived stress in relation to workload and conflict with physicians is higher in newly qualified nurses compared to fourth-year student nurses. Stress frequency was considered high by both groups and comparatively high in relation to other studies. The overall mean score for newly
range of 0-102. Overall, while stress levels were high in both groups, there was no significant difference between groups using the Nursing Stress Scale. This study, not only supported the notion that the transition from student to newly qualified nurse is stressful, but also looked upon the transition as a ‘double edged sword’ as depicted by Amos (2000). The transition was met with anxiety, though newly qualified nurses appeared to combine the negative experiences with some positive ones. This supports the recent findings by O’Shea and Kelly, (2007) referring to the experiences of newly qualified nurses in Ireland as ‘highs and lows’.
In 1981, the Nursing Stress Scale was developed and is still relevant to study stress and stressors in nursing in modern society. Factors within this scale that were supported in the qualitative findings included workload, inadequate preparation, lack of staff support, uncertainty concerning treatment and conflict with other nurses in particular. Workload was considered to contribute to stress for both the student and newly qualified nurse. This attributed workload influenced in no small part to short staffing, time pressure, performance of non nursing duties all of which lead to unmet patients needs and unmet students learning needs. This was supported by the qualitative findings and also by previous literature.
Students also cited extraneous variables such as financial strain and academic pressure, particularly while working a 39-hour week. What was most interesting was their view that while these stressors were outside the clinical environment, the impact affected stress perceived within this environment. This was possibly the reason why the perceived stress was not higher in the newly qualified nurse as considered at the outset of the study. Student nurses often depicted stress and stressors exclusive to
their group in relation to the learning environment. This included dissatisfaction with preceptorship, learning exposure, and a feeling of a lack opportunity for hands-on learning. This was also associated with the perceived assignment of too much or too little responsibility. In particular, students highlighted the prominent stressor associated with not feeling part of the team or feeling excluded. ‘Conflict with other nurses’ or relationships with other nurses emerged as a significant stressor for student nurses, which has not been extensively supported in previous literature. Student nurses did not feel adequately supported and had difficulties with relationships with other nurses, from all levels and disciplines. This conflict appeared to be associated with time pressure and also with poor communication at all levels from within the clinical environment and throughout the organisation and the Health Service Executive. Relationship difficulties affect their clinical experience and limit their learning exposure. This was attributed to the nurses’ negative attitude towards the student and reasons given were workload, short staffing and pressure on the wards to care for patient in limited time.
A number of additional themes not included in this scale were developed qualitatively, some of which were not supported in previous literature. These included ‘moving wards’ which is a relatively new phenomenon in Ireland and is associated with dependence on agency nursing and job insecurity. Two further themes were highlighted and were associated with the clinical environment as a place of learning. These included stress associated with ‘unmet learning needs’ and stress associated with ‘combining academic demands with clinical nursing responsibilities’. The Nursing Stress Scale does not have particular provision for stress and stressors
associated with the clinical environment as a place of learning, which may be the reason why this was not supported quantitatively.
This study has focused on difficulties witnessed by newly qualified nurses and student nurses associated with a new education system. Cognisance of all of the difficulties on behalf of the stakeholders in nurse education may help to identify and pre-empt and manage difficulties encountered by student nurses and newly qualified nurses. Nurses must be aware of the possible consequences of the difference in power between themselves and the student nurse. It must be borne to mind, that the study only focused on the negative aspects of clinical placement, namely stress and stressors notwithstanding the many positive issues associated with nursing in the clinical arena which were only captured in the open-ended responses. It is hoped that the findings will contribute to the ongoing development and research into current education of Irish nurses in effort to produce and retain the graduate nurse that is competent, confident and hopeful about the future of Irish nursing.
Results can provide an insight for stakeholders in nursing clinical practice, nurse education and hospital administration in developing nurse education, practice and organisational workforce planning in effort to prevent, reduce or manage stress. This can lead to greater focus on stress awareness, management and prevention in the clinical environment. This will possibly lead to greater nurse satisfaction in the workplace and can influence staff retention and therefore better care in the provision of ‘A working environment where people feel valued, recognised and safe’ (Department of Health and Children, 2001 Quality and Fairness -A health system for you, p.123). Identification of the problem of stress and stressors can strive to improve
the clinical setting for these valuable members of our health service at a time when attrition in nursing is so prevalent (Muncey, 1998; Evans, 2001; Deary et al, 2003). While the findings of this study may not directly benefit the participants, they may indirectly benefit through the establishment of structures to support the transition of the newly qualified nurse.