Like any other profession, nursing has its benefits and challenges, where it has been known to be a challenging profession that is physically and emotionally demanding. Being a nurse is presently a vast and diverse role that requires relentless work lasting from seven to longer hours to provide daily care for patients’ physical, emotional, and spiritual needs. Working in a stressful environment, nurses need to have resilience as a protective factor for their physical, mental, and emotional well-being, such as fatigue, unhappiness, depression, and emotional exhaustion (Yilmaz, 2017). Resilience is defined as overcoming stress or the ability to rebound from adversity and overcome a difficult situation in life, such as trauma, threats, tragedies, interpersonal problems, serious health problems and coping with changes or disasters (Çam & Büyükbayram, 2017). The diversity of resilience approaches in response to the challenges that nurses endure are classified into physical resilience, which includes physical activity and outside interests (Robertson et al., 2016); social resilience, which provides for social support or relationships, gives great credence, and modifies current behaviours (Manomenidis et al., 2019); and psychological resilience, which includes holistic self-care, positive emotions, and self-control (Shin et al., 2018).
Every year, hospitals are prepared to recruit nurses to replace retiring senior nurses, resulting in an increased demand for nurses. It is however salient that those pursuing this nursing career are expected to be mentally and physically well-prepared for all the challenges that await. It can be challenging at times, particularly for new graduate nurses making the transition from graduate nursing student to professional nurse whereby they are highly expected to work skilfully. It is stated that the most vulnerable time as a graduate nurse is during the first 12 to 24 months in practice (Parker et al., 2014). Several studies also found that nurses find the transitioning period challenging, stressful, and emotionally exhausting. For example, Ankers et al. (2018) reported that the variety of demands placed on nurses throughout their transition stage may cause them to feel shocked, leading to negative emotions.
Since 2015, when the first Women and Children Centre was officially opened in Brunei Darussalam, there has been a significant increase in the recruitment of new graduate nurses to work in the paediatric settings. Paediatric settings have different services in terms of care and treatment than nurses in adult wards due to physiological and emotional differences between adults and children. Because they provide care to vulnerable paediatric patients with a high potential for emotional interaction and underlying complexities, the nurses may face different challenges than nurses who care for adult patients (Buckley et al., 2020). According to a recent study by (Waterworth & Grace, 2021), paediatric nurses show deficient levels of resilience and a high rate of burnout. Hence, to develop better insights into such resilience, we sought to explore and describe the resilience experience of nurses when they first started working in paediatric wards.
Methods
Study Design
The qualitative approach used in this study was based on Thorne (2016) interpretative description design. This approach laid the framework for data collecting and analysis, allowing researchers to look at everyday nursing practice in relation to social, personal, and organisational constructs.
Study Participants
The study participants were recruited using a purposive sampling strategy involving seven paediatric wards in the largest hospital of Brunei, RIPAS Hospital, namely Paediatric General Ward, Isolation Ward, Acute Paediatric Unit (APU), High Dependency Unit (HDU), Neonatal Intensive Care Unit (NICU), Paediatric Intensive Care Unit (PICU), and Special Care Baby Unit (SCBU). The researcher did not have any direct contact with the participants before the commencement of the study. Therefore, the gatekeepers played a role in limiting to limit possible bias. The inclusion criterion was that the participants had to be registered nurses with less than six years of working experience and had at least one month’s work experience in any paediatric ward. This is to increase the probability of having adequate working exposure. The participants were approached face-to-face through a single recruitment briefing, narrowing down to 19 nurses in total. They were then informed about the research study and the interview process. As a result, a total of eight paediatric nurses agreed to participate in the study. Nonetheless, more than half of the potential volunteers were unable to participate due to their hectic schedules, and some did not fit the study's inclusion criteria.
Data Collection
This study was conducted in Brunei Darussalam between October 2020 and December 2020. The research team conducted semi-structured individual face to face interviews. Participants were asked to describe their early experiences and reflections on their roles in paediatric wards and how they have developed their sense of resilience in the workplace. Depending on the interview, further follow-up questions were used for clarification when needed, such as “Can you tell me more about that?” and “Can you give an example?” The interview lasted between 25 - 85 minutes. After the eighth interview, the researcher observed repetitive and similar responses from the subjects, indicating that the data had achieved saturation.
Data Analysis
We used an inductive analytic approach in this study, based on Thorne (2016) method, to find patterns in the participants’ experiences and better understand the phenomenon unique to their social and personal context within the clinical practice setting. Data analysis was used throughout the data collection process to look for emergent themes and patterns based on the participants’ responses, which referred to their experiences and perspectives when they first started working in paediatric wards (Thorne, 2016). Within and across transcripts, participant narratives were compared and contrasted to see if any emerging patterns or relationships matched the data acquired from previous interviews and transcripts. Patterns in the data were compared and contrasted to see if they reflected our interpretation of the nurses’ experiences or if they contradicted our interpretation (Thorne, 2016). The research team compared the findings to audio data interviews and written transcriptions to ensure that the data was authentic. The transcripts were not returned to participants for any comments and corrections. English words or phrases were used when translating from Malay to English since the source words have an English translation. There were no complicated words or phrases to translate or interpret.
Trustworthiness
This study utilised the Consolidated Criteria for Reporting Qualitative research (COREQ) to guide the reporting (Tong et al., 2007). Using purposive sampling ensured that the participants’ accounts offered adequate descriptions of the phenomenon under study. The interviews were guided by semi-structured open-ended questions that allowed them to express as much as they wanted regarding their experiences freely. The discussions strived to promote dialogue and asked for clarification of the narratives to achieve credibility.
Furthermore, the analysis process was conducted in a reflective dialogue between the researchers. The research team conducted the interviews for dependability, transcribed the recordings verbatim, and quotes from the nurses were presented in the findings for conformability. The research team performed coding, analysing, and categorising of the data. The team then further checked and confirmed the data to reach a consensus on allocating and matching findings to sub-themes and themes. The results might be transferred to improve other nurses’ understanding of the quality of care, getting to know each detail and information, and a positive mindset with sufficient representation by the participants’ quotes.
Ethical Considerations
A Joint Committee of Institute of Health Sciences Research Ethics Committee and Medical and Health Research Ethics Committee approved the research (Reference: UBD/PAPR SBIHSREC/2020/41). The four ethical principles of respect, autonomy, beneficence, non-maleficence, and justice, were considered. The heads of the hospital and paediatric wards gave their approval for the study. All participants were given verbal and written information about the study’s aim, including its design, and that their participation was voluntary. They have the option to withdraw at any point before the data analysis. All participants provided written informed consent, and data confidentiality was maintained at all times.
Results
The participants were aged between 23 and 31 years old, consisting of one male and seven female participants. Two work in the Paediatric General ward, four work in the acute wards and two in intensive care settings. They had worked as paediatric nurses for a period ranging between one and six years. Only half of the participants had previous clinical experience in the paediatric department as student nurses. None had undergone paediatric nursing training. Three overarching themes were identified from the analysis: (1) The transition period, (2) Gaining the trust of others (3) Having a positive mindset.
The transition period
This theme describes how the participants feel about their role during the transition at their workplace. They were very well aware that they lacked experience in caring for paediatric patients. Half of the participants expressed anxiety about working as paediatric nurses because they had no practical experience in paediatric wards throughout their student years. As one participant put it,
Initially, I had no experience in paediatric nursing because I chose community and operating theatre as my elective course. I was scared when handling kids as I did not know how to (Participant 7)
Despite this, the participants with clinical experience in paediatric wards had concerns about their abilities during their student year. Some participants reported that their clinical experience in certain paediatric wards was restricted to a few days and that their practical involvement was minimal. The majority of them were only permitted to observe clinical procedures. The participants reported feeling anxious about treating paediatric patients since they lacked expertise and had no paediatric nursing training. To them, the health of paediatric patients is more delicate than that of adults, and hence they must be more attentive and efficient when caring for paediatric patients.
The majority of the participants believed that enhancing their knowledge is one strategy to address the difficulty. This is performed by enlisting the support of co-workers who are willing to mentor them in order to improve their performance at work. Several participants believed that having a colleague from the same cohort has aided them in sharing their experiences and learning from one another’s mistakes. Furthermore, most of them highlighted the importance of consulting an expert such as a senior nurse or a doctor when in doubt.
You always have to ask, even if sometimes the question may seem dumb. You have to ask if you are unsure. You just have to ask. Do not act as if you know, or you will end up getting scolded (Participants 1 & 5)
During the transition period, several participants suggested about taking as much opportunity as possible to be more familiar with the practice. However, few reported that some co-workers seem reluctant to assist, particularly when too many questions are asked. The expectation was placed on new nurses to learn on their own, which was a common practice at the time. Participants emphasised the need to develop self-care by reflecting on themselves and engaging in activities that keep them focused and develop their knowledge. This can be accomplished by having a place or someone to express oneself to, praying, engaging in recreational activities, or working out to relieve stress after a long day at work. The participants described that self-care could provide them with a sense of relief and regain the strength they need to continue working.
Sometimes I catch up with my friend, vent and seek entertainment. Sometimes, I need to rest and do sports to improve my performance, which I find helpful (Participants 7 & 8)
Gaining the trust of others
Most participants found it difficult to get to know their patients, families, co-workers, and doctors as they transitioned into their jobs. The patient-family-nurse relationship, nurse-nurse relationship, and nurse-doctor relationship are all subthemes of this theme. Several participants held that it was difficult to perform a procedure on paediatric patients in a patient-nurse interaction. They stated that they would require one or more staff to undertake certain procedures because a child would not remain, for example during intravenous cannulation. In some cases, the participants observed that most paediatric patients would not cooperate since they are terrified or may even cry, making any assessment impossible for most nurses. In developing a rapport with the patient, the participants emphasised the need to interact with the child and convince them when performing any procedure. One participant shared:
I will ask them, “How are you today?” or persuade them by giving them a sticker if they cooperate during the procedure (Participant 2)
Meanwhile, since family members frequently accompany a child, the participants described how it might be challenging for inexperienced nurses to deal with the patient’s family, particularly when the parents press them with questions. On the other hand, some participants do not view parents as a threat. They accept and value the fact that parents are apprehensive and have several concerns. When the participants recognise the parents' anxiety, they must be prepared to reassure or discuss with them.
In a nurse-nurse relationship, the participants mentioned about getting along with senior nurses or co-workers at their workplace. The majority of them stated that they struggle to establish rapport with their co-workers in order to understand their personalities. Several participants reported encountering uncomfortable situations on the ward, including inappropriate comments, ragging, bullying, and backbiting. These incidents cause distress and may even result in a breakdown for some participants.
If they do not trust me, I respect their decisions, but their way of speaking does affect my mentality. If they are disrespectful, it tends to discourage me. I do not want any nurses to go through this (Participant 6)
The majority of participants felt that being helpful and demonstrating one's competence to perform the skill ensures and earns their trust. One participant expressed:
For me, all the little things we do to help them can make them feel appreciated (Participant 3)
Some participants described that it takes a while to get to know one another; therefore, they have to know when to talk and approach each co-worker. Moreover, several participants would try to start a conversation to build rapport with their co-workers.
Besides getting along with patients, their family and co-workers, most participants find it challenging to get along with doctors. Several have stated that they struggle to establish rapport with their doctors, and that they must be cognisant of a particular doctor's rigidity. Furthermore, some doctors would prefer looking for a senior nurse even when the particular nurse is not in charge. These instances create an impression among some participants that some doctors do not trust newly employed nurses.
Some doctors do not want new nurses when they make their rounds. Senior nurses, on the other hand, are preferred. Senior nurses, I believe, have a good understanding of how doctors conduct rounds and what they want without having to be reminded repeatedly (Participant 5)
However, most participants held that they would try to know the doctor’s routine by meticulously observing their ward rounds. Some participants would prepare the information and respond to the doctor’s inquiries to persuade and gain the doctor’s trust and demonstrate independence.
Having a positive mindset
This theme describes the participants understanding of resilience working in paediatric wards and its value towards themselves and others. The majority of them defined resilience as having a positive mind in their everyday work despite all the challenges they face as a nurse. They have taken into account a psychological approach of resilience when overcoming the challenges at their workplace. Their psychological perspective involves focusing on the positive aspect of the event. The participants revealed that they tend to accept what they have experienced since the beginning of their work in the ward and focus on providing care for patients.
The strength comes from my mindset. I have to think positive to be a better nurse. If I think negatively, it will affect my performance (Participants 5 & 6)
Instead of dwelling on negativity, the participants motivated themselves to stay strong and push themselves for self-improvement. It was learned from the interviews that the value of resilience is for the character growth of nurses to broaden knowledge for their satisfaction. Aside from physical and social resilience, being psychologically resilient has helped them endure stress at the workplace. One participant pointed out the presence of resilience in oneself.
If you do not have resilience, I do not think you can deal with the daily stresses that change day by day because stress experienced in one day is different from the next day and the day after, so if you cannot cope with the daily changes, I think the stress would add up (Participant 1)
The participants were mindful of the challenges they go through physically and socially and how this could also have psychological effects as these challenges interlink. The participants’ ability to stay positive in their everyday work enables them to manage their mental health, emotions, and relationships.
Discussion
This study entails the participants’ experiences and common challenges when working in paediatric wards and how they have empowered them by demonstrating the three resilience approaches: physical, social, and psychological resilience. They do not specifically use the term ‘resilience’. However, they show the same elements that develop their resilience. Firstly, the study indicates that the participants described their transition period when working in the paediatric setting. The transition period involves an effort towards increasing knowledge and self-care. The majority of them verbalised a lack of experience in paediatric care for nurses who do not have previous experience and those who have previous experience during their student years.
Furthermore, none of the participants in this current study has undergone pediatric nursing training, making them question their capability to perform their tasks. Previous studies reported that newly registered nurses felt immense pressure and stress for being lost due to inadequate knowledge and lack of experience for work (Woo & Newman, 2020). Consistent with Latimer et al. (2017), higher secondary trauma and burnout were experienced by the nurses with less experience. In Freeling and Parker (2015) study, experienced nurses viewed new graduate nurses lacking clinical experience and appropriate content during academic programmes. Even though previous studies are not pediatric-focused, a lack of experience is still the main challenge that new nurses face at their workplace. In response to a lack of experience, the participants seek guidance by asking for help from senior co-workers, other nurses, and doctors to increase their knowledge. Martin and Wilson (2011) established that graduate nurses have the highest incidence of errors and mistakes during their first few months. Therefore, the availability of experienced nurses’ support can be safer for the graduate nurse and improve patient care (Pineau Stam et al., 2015).
Providing adequate supportive educational measures for the nurses is based on the adequate contribution of the senior organisational level (Pineau Stam et al., 2015). Nevertheless, some co-workers were reluctant to help the participants. Similar studies were carried out where other nurses were considered unavailable or unconcerned in assisting the new nurses (Parker et al., 2014). In another study where all qualified registered nurses seek help when encountering difficulties, it becomes difficult to work around co-workers with challenging personalities (Teoh & Lim, 2019). Eventually, causing the nurses to experience stress can lead to potentially negative patient outcomes (Gardiner & Sheen, 2016) and hinder them from becoming competent nurses (Martin & Wilson, 2011). Even so, one study explored that the new qualified registered nurses would do a further reading at home to improve their clinical knowledge and skills (Baumberger-Henry, 2012), which the participants in this current study less frequently did.
Self-care can be defined as a care process by any action or behaviour that helps their well-being. This approach is considered physical resilience, which refers to the ability of the body to adapt to challenges and recover from them (Hurley, 2020). Like Berger et al. (2015), pediatric nurses used prayer, counselling, exercise, humour, and distraction coping strategies. Alternatively, self-care was an effective strategy and developed physical resilience to overcome stress at work. Practising self-care by looking after one’s emotional and physical health is a professional’s responsibility to provide quality care (Shimoinaba et al., 2015).
Secondly, gaining the trust of others in the workplace, including patients, family members, co-workers, and doctors, were the challenges that participants encountered in building social resilience. Social resilience indicates individuals or communities’ ability to tolerate, absorb, and adjust to environmental and social threats of various kinds (Keck & Sakdapolrak, 2013). When caring for paediatric patients, most participants find it challenging to perform assessments and procedures as most paediatric patients they had encountered were uncooperative, similar to a study of nurses working with children with chronic conditions, where they acknowledged their patients as non-compliant (Buckley et al., 2020). Different studies found higher levels of burnout in pediatric nurses who cared for specific patient populations, such as children with cerebral palsy (Vicentic et al., 2016). However, only several participants highlight their concern about caring for paediatric patients with uncommon diagnoses for the current study. Most participants highlighted challenges in giving care for paediatric patients in general. Other than uncooperative paediatric patients, the participants were concerned about reassuring family members, especially parents who ask too many questions. A similar study revealed the work is demanding as the nature of care requires them to work closely with the parents, especially when they encounter challenging parents such as angry, distrustful, confrontational, and demanding special attention (Dix et al., 2012).
Apart from that, having a supportive environment is necessary at the workplace. However, some participants in this study experienced difficulties getting along with their ward co-workers, where some encountered unpleasant events such as offensive conversations, ragging, bullying, and backbiting. Other studies faced similar problems with nurses they closely worked with, especially senior nurses, and described it as unprofessional behaviour (Freeling & Parker, 2015) or horizontal violence (Parker et al., 2014). Consistent with this finding, some participants end up in a breakdown. Walker et al. (2013) suggested that desensitisation and acceptance of this culture is one reason nurse unit managers may not be aware of this type of behaviour. These negative behaviours have been shown to cause the nurses resistant to ask their co-workers for help (Kelly & McAllister, 2013).
Aside from nurses, the participants also described the difficulties getting along with the doctors, where they remarked that the doctor would prefer senior nurses instead. Another study described doctors as being disrespectful to nurses (Teoh & Lim, 2019). This suggests that participants struggle to build interpersonal relationships with their co-workers and doctors. Nurses will experience lower burnout and post-traumatic stress disorder when a positive working environment (Caza & Milton, 2012) and good relationships (Dos Santos Alves et al., 2017) with their co-workers and the doctors.
Thirdly, the participants view resilience as having a positive mindset. Caza and Milton (2012) indicated that resilience incorporates behaviour, emotions, and psychological manifestation of active adaptation and professional growth in severe adversity. In developing a sense of resilience, the participants in this study used a psychological resilience approach when encountering any challenges by viewing the positive side of the challenges as they believe it benefits their performance quality. Psychological resilience is a developmental and psychosocial process through which individuals exposed to sustained adversity or potentially traumatic events experience positive psychological adaptation over time (Graber et al., 2015). Similar studies done by Cope et al. (2016) established that participants stayed focused on the positive by reflecting upon the event to learn a lesson from it. They described it as a valuable antidote to a fight-and-flight reaction to stress-dependent problems. In addition, the participants’ response to resilience is consistent with findings of studies on nurses from the different departments as positive thinking and positive expectations for the future (Gito et al., 2013). It is believed that psychological resilience is recognised as an overarching approach for the participants to deal with and adapt to the physical and social challenges in the ward.
This study finding suggests that nurses on paediatric wards experience multiple challenges, including doubting their ability to care for paediatric patients, difficulty seeking assistance, and developing interpersonal relationships with patients, family members, co-workers, and doctors. This study revealed that the participants used several resilience approaches as protective factors in their daily unpredictable, stressful working conditions. Thus, this study affects nurses and the nursing profession in Brunei Darussalam, especially those who educate, regulate, and manage nurses. The challenges of nurses entering the workforce must therefore be addressed. The organisations may also wish to consider further nursing training to prepare them better to work with paediatric patients.
Limitation
Firstly, there are more female participants compared with the male participant. However, this is also due to the total number of male nurses in the paediatric departments. Secondly, a few participants during the interview could not understand the term resilience, which may affect the information they provided. However, a simple definition was provided for a clearer view.
Conclusion
This study indicated fewer differences in challenges and resilience approach for paediatric nurses than other nurses in adult wards. The study identified three broad themes that represent the development of the resilience approaches of the participants in controlling over the work-related challenges. Based on the findings in this study, the participants encountered doubt of their skill in caring for paediatric patients, difficulty seeking help, and building interpersonal relationships with the patient, family members, co-workers, and doctors. Thus, nursing management must foster a more positive transition atmosphere in order to assist new nurses in developing resilience. Additionally, the effectiveness of nurse preceptors in assisting nurses should also be evaluated. These practices can assist nurses in developing resilience, managing work-related stress, and general well-being.