Resilience in new nurses: a qualitative study

Abstract Objectives To explore the resilience experience of new nurses and how new nurses develop and apply resilience strategies to cope with the difficulties during the transition period. Methods A descriptive qualitative research method was on data acquired using data semi-structured interviews with 12 new nurses aged 20–26 years whose working time was more than 12 months but less than 24 months. Results Analysis of the data could determine participants adopting resilience strategies to withstand difficulties and challenges in transition period. This period consisted of three main phases: “self-protection,” “undertaking challenges,” and “planning future.” The first-line nurse managers’ feedback and flexible shift scheduling paid a vital part in promoting the resilience development of new nurses. Conclusions Recognizing the importance of understanding and developing the resilience of new nurses in the transition period could greatly reduce the turnover rate and alleviate the shortage of nurses in global nursing workforce.


Introduction
The training and recruitment of newly graduated nurses are one of the most important ways to alleviate the shortage of nurses for developed and developing countries. [1][2][3] Actually, the newly graduated nurses in the transition period from nursing student to nursing staff have been experiencing a high turnover rate in the globe. In Europe, Hasselhorn et al. 4 reported that 9.3% of new European nurses left the profession, ranging from 4.5% in Italy to 14.6% in Germany.
A study by Brewer et al. showed 15% of newly licensed registered nurses left their profession in the initial work year in the United States. 5 In Korea, Cho et al. reported 18.1% and 26.2% of new nurses left nursing profession within the first and second year of practice. 6 Obviously, the high turnover rate of new nurses deteriorates the shortage of nurses and causes a serious waste of nursing education resources and financial costs of hospitals. 7 Thus, this tends to impose a negative influence on the security of patients and the quality of patient care. face of adversity or huge pressure, and this process is a dynamic change. 17 Despite different definitions about resilience, it possesses some similar characteristics, such as overcoming adversity, adapting to change, and adjusting oneself/environment.
With the high-speed development in global health, resilience application in the field of nursing has drawn more and more attention in the past decades. Current studies confirm that there exists interaction relationship between nurses' psychological resilience and many factors such as job burnout, social support, etc. And many researchers have been dedicated to building the theory model of psychological resilience and developing effective intervention strategies. Rushton et al., through an investigation on 114 nurses about psychological resilience, burnout, and distress, reported that great resilience could keep nurses out of emotional exhaustion, and make them obtain achievement. And the greater resilience can help nurses relieve stress and achieve more expectations. 18 A similar study 19 made in China also found resilience is conducive to alleviate burnout and psychological distress for female nurses. McDermid et al. 20 made semi-structured, and conversational interviews on 14 new nurses, and found that the improvement of psychological resilience needs social support, especially from peers and colleagues. In short, psychological resilience plays an important part in enhancing nurses' ability to overcome adversity, thus likely to improve nursing skills and coping with stress for new nurses in the transition period.
The aim of this study is to explore clinical new nurse's understanding and experience on workplace resilience during the transition period, which provides the basis for better understanding the resilience and developing effective interventions. To achieve this aim, the study includes the following objectives:

Measurement
The research design follows a descriptive qualitative research method. It focuses on the detailed descriptions of new nurses' understanding and experience For years, considerable attention has been paid to the transition period in the nursing field. Krame 8 referred to the transition period as reality shock for the first time, where new nurses found themselves inadequately preparing for their new role, thus causing the conflict between idealized role and actualized role, and contributing to leaving the profession. Based on the theory of reality shock, Duchscher reported that new nurses are more likely to witness the huge changes in four aspects of responsibility, character, knowledge, and human relationship during the early period of working, easy to make them feel some negative emotion such as anxiety, instability self-doubt, insecurity, and confidence lack. 9,10 Another study by Whitehead found the main stress source came from dealing with their new role and duty as newly qualified nurses. 11 In addition, there exist many other important factors influencing the success in the transformation process from nursing students to nursing staff, such as workplace environment, available support, workplace cultures, and expectations from themselves and others. 12 In short, the transition period is an ambiguous and uncontrollable one, and likely becomes the most difficult stage for some new nurses in nursing career. And it is likely to produce a significant influence on their future career development as new nurses.
To make the transition period smoother for new nurses, many researchers have been trying to change the negative environment, or provide additional resources support. Lee suggested a supportive working environment for new nurses. It may be produced through available educational projects and some standardized manuals. 13 Although some measures have been taken in transition period, a large amount of stress for new nurses cannot be avoided and changed. Additionally, some studies found the majority of new nurses still achieved personal or professional development even though they underwent similar pressure and challenges during the transition period, when resilience plays a vital role in making the transition period smooth.
Resilience is a discipline of psychology that appeared in 1970s. 14 Originally, psychological resilience was considered to be recovery capability after children experienced major traumatic stress. In recent years, the concept of resilience and the importance of developing new nurses' resilience have gained increasing attention globally. There is no unified definition about resilience. In terms of different focus in study, the definition of resilience can be divided into three categories. The first emphasizes on the individual's ability to quickly recover from the adversity. 15 The second focuses on the results of adapting adversity for individuals. Namely, the individuals can still smoothly adapt to condition when experiencing the major adversity. 16 And the third regards resilience as a good adaptation process in about the process of resilience development during the transition period. This method aims to define the varieties from the perspective of participants and to develop and expand the existing studies. 21 Compared with other methods, qualitative research method better suited to analyze data for semi-structured face-to-face interview technique with limited resources and time.

Setting and samples
The study was conducted from March to August 2017 and carried out at a tertiary general hospital in Nanjing. The hospital has 2,499 beds and its services include medical treatment, scientific research, and education. In addition, the hospital recruits new nurses every year. However, the hospital has not developed any systematic and targeted intervention courses for promoting resilience development for new nurses during the transition period.
A purposive sampling method is used for the research. To effectively focus on resilience experience of new nurses in transition period, the following criteria are considered: (1) Registered nurses in clinical work; (2) Working time more than 12 months but less than 24 months; and (3) The nurses did not receiving any course or training about resiliency Participants were recruited via e-mails. Nurses having interest could contact the team leader, request to sign informal consent forms, and completed personal information. The nurses would be informed of the schedule and venue for the interview for data collection. In all, 12 new nurses (11 women and 1 men) participated at an age range of 20-26 years old and a mean age of 23.3 years (SD = 2.0, range = 20-26). Length of time working as nurses averages 17.9 months (SD = 3.6, range = 13-24). The detailed information is provided in Table 1.

Data collection
Semi-structured, face-to-face in-depth interviews were conducted to collect data. Guide questions were developed after discussions of researchers. The guide questions consist of four open-ended questions ( Table 2). The interviewers would adjust the interview questions depending on relevant topics raised by participants.
The time and place of the interview were determined at the convenience of the participant. Nine interviews were held in hospital meeting rooms and three in university classrooms near the hospital. Interviewers had to be impartial to prevent bias negative effect on the answers of the interviewed nurses. Questions for clarification were asked to validate answers from participants. The interview process was digitally recorded and typically lasted 50 min. The recordings were then transcribed. The researchers looked out for the following, expressed ideas, changes of facial expressions, body language, etc.

Data analysis
Manual content analysis was used to analyze the data. 22 The researchers played a key role in finding meaningful parts of the data, then codified, classified, and organized them. The data analysis proceeded immediately after the interview was completed. The data were transcribed and then coded independently by the researchers. Data   analysis was composed of four stages. In the first stage, the transcripts were read repeatedly and were coded word for word to determine some words or sentences related to resilience experience. In the second stage, the coding was summarized into the same category and examples of participants were reviewed and assigned to the related category. In the third stage, the themes were determined by making continuous comparison between characteristics and dimensions of each category. In the last stage, after discussion, the coding was gathered and separated into categories and themes.

Trustworthiness
The trustworthiness standard of this study was based on four evaluation criteria of credibility, transferability, dependability, and confirmability created by Lincoln and Guba. 23 To ensure the credibility and dependability of the study, the researchers were closely supervised by their research adviser, who had extensive experience in clinical and nursing education. The researchers also had many years of combined clinical experience and were familiar with the work conditions in clinical environments. They were also involved in qualitative research and data analysis. To control researcher's bias and ensure consistency of results, the researchers simultaneously did the transcription and encoding of data. The participants were given feedback of the results to allow them to verify the authenticity of data. To ensure its confirmability, the participants went over the content of the translation and validated the findings of the study. Ensuring transferability, a detailed description of the findings, methods of data collection, transcription and analysis, and demographic characteristics of samples were shown to readers.

Perception toward resilience conception
Before the interview, participants had little understanding of resiliency and ignored it. However, they also said when faced with difficulties and challenges at work, they were able to developed coping skills to overcome them. It resulted in better performance at work. Therefore, they believed they possessed the so-called characteristics of resilience. Participants gave different perceptions and definitions of resilience. One participant regarded resilience as a spiritual characteristic to withstand adversity.
"When I met difficulties and pressure at work, I maintained a positive attitude toward them. It helped me to gather up the courage to pull through." (Participant 12) For other participants, resilience was seen as an individual ability to deal with difficulties and pressure. One participant believed that the so-called resilience was a skill to get over difficulties and pressure. She Whether resilience is seen as spiritual power to pull through, individual skill, or ability to achieve success, all participants express the same idea that the so-called resilience can help the individuals to get through adversities and develop professional skills and abilities.

Developing resilience
In analyzing the data about resiliency, it shows that the countermeasures to overcome setback and pressure are quite different as time and personal experience change. This means that resilience development is a process of self-adjustment. The development of resilience includes three stages: "self-protection," "undertaking challenges," and "planning future." The three stages reflect different levels understanding and judgment about the ability of new nurses on adversity and clearly showed differences in responding to difficult situation. As a result, the resilience development of new nurses is a dynamic process.

Self-protection
The behavior of self-protection often occurred in early period of work, when internal stress between role expectation and realities of work began. External factors such as lack of skill and ability together with a heavy workload, contributed to their uncertainty, depression, and anxiety. During the early period of the transition stage, participants developed cooperative strategies with experienced nurses and combined it with a positive mindset which helps in coping with the pressure and challenges.
The study showed that cooperation with experienced nurses is the most useful strategy in the stage of self-protection. It reduced uncertainty and increased confidence in their clinical work:

Undertaking challenges
Undertaking challenges is the second stage of resilience development in the transition period, when they realized that they cannot change the external working environment, thus decided to change themselves. The main strategies used by participants include learning more, building self-confidence, and releasing the negative emotions.
Participants agreed learning more is one of the most important strategies to develop the ability to deal with pressure and challenges. These included developing and learning skills and abilities such as, such as using new instruments, communication skill, preventing workplace conflict, dealing with crisis patients, etc.
"As a nurse, I think clinical work is not monotonous and repetitive but diverse and challenging. Rich and extensive knowledge is needed for nurses to provide high quality care for patients." (Participant 9) Building self-confidence is an important psychological strategy when new nurses face adversity. Participants said building self-confidence contributes to performing tasks smoothly. Several participants believed that expressing negative emotions can be an effective way to alleviate work place pressure and keeping a healthy life. This included finding a friend or family member to talk about unpleasant things, singing or listening to songs, reading, sleeping, etc.

Planning future
Participants believed that the development of resilience is a long dynamic process. After experiencing two stages, they plan for future by creating new goals to develop and maintain resilient attitude.
When it comes to career planning, most participants agreed they would like to promote the importance of self-growth and self-value in nursing. Career planning means, learning and expanding your knowledge, going abroad for further study, developing to be nurse managers in the near future, etc.

Feedback
In the process of describing resilience experience, many participants pointed out that feedback from first-line managers helped them improve their work performance. It is a significant part in the development of resilience. Department leaders should regularly evaluate performance of nurses to make them feel they are supported and cared for by the nurse managers and concurrently point out how their work can improve. Other participants said they are willing to accept the constructive and negative feedback from first-line nurse managers about their performance.

Flexible shift scheduling
Participants believed flexible shift scheduling is vital to resilience development of new nurses. It included reasonable time arrangement, the balance between human resource and the number of patients, the connection between new nurses and experienced nurses. Participant 12 said, "A reasonable time arrangement can grant me more time to think and learn. It made nursing work become colorful and meaningful." Participant 8 added, "In my department, our nurse manager adopted a flexible shift schedule. I can easily get support from other nurses and quickly adapt to the working environment."

Discussion
This was the descriptive qualitative study focusing especially on nurse's resilience during the transition period in China. The findings of study provided some initial insights into resilience from the perspective of new nurses. Participants expressed their understanding of resilience, the process of resilience development, and affirmed first-line nurse managers play an important role in promoting resilience development.
Although there exist some subtle individual differences exist on participants' understanding of the concept of resilience, they all believe resilience obviously allows them to effectively cope with difficulties and challenges in the transition period.
Many researchers concluded that resilience is constantly changing. 24 In the dynamic process, resilience development of participants included three subprocesses: "self-protection," "undertaking challenges," and "planning future." The results also showed the process of resilience development depends on the interaction between working ability and environment. Furthermore, working ability and perception of resilience would change as time goes on and personal experience adds. Meanwhile, resilience strategies to adversity can also change. Ungar defined the resilience as a set of behaviors over time which reflect the interactions between individuals and their environments. 25 This point is consistent with the finding of the study. The dynamic development of resiliency of new nurses was discussed in detail. In the process of developing resilience, it is found that strategies to overcome adversity include specific behaviors such as positive thinking, building confidence, releasing negative emotion. Therefore, resilience development of new nurses can change their negative behavior to improve their physical and mental health, which enhances new nurses' work satisfaction and decrease burnout.
Researchers believed the transition process is a nonlinear one. 26,27 Thus, resilience development is not perfectly straight, as is shown in the stages of professional planning and development, the participants referred to vague professional goals, but lacked specific measures to achieve these goals, which may hinder the resilience development of new nurses.
Feedback is a necessary part in the learning process of new nurses. It gives them an idea on their work performance. Researchers reported that feedback can facilitate and enhance self-confidence of new nurses, but the study showed the feedback that new nurses received is insufficient, which is consistent with the findings of the study. 28 Participants are eager to get feedback from the leaders, either positive or negative feedback, which can make them aware of their real ability and cause them to be more confident in the face of difficulties and challenges. Therefore, feedback plays a vital role in resilience development for new nurses.
The study found that flexible shift scheduling and fair nursing staff allocation enable new nurses to have more time to enrich professional knowledge and experience, and are more likely to get support from experienced nurses. On the contrary, improper scheduling and nursing staff allocation increase workload of new nurses and affect their physical and mental health, which is an important factor in high work dissatisfaction and turnover rate among new nurses. It significantly affected the quality of care of patients. 29 Therefore, staff allocation problems and shift scheduling require clear insight and management ability for nursing managers.
Apart from feedback and flexible shift scheduling, all participants stressed the key role of first-line nurse managers in promoting resilience development. This is mainly because new nurses showed a higher sense of trust and respect toward first-line nurse manager.

Conclusions
The qualitative descriptive study expounds on the meaning of resilience and the process of resilience development from the perspective of new nurses in the transition period. The findings of the study provide valuable insights for future research on new nurses' resilience. Obviously, individual resilience plays a vital role to promote successful transition of new nurses. The study reveals that resilience development experiences three stages: self-protection, undertaking challenges, and planning future, where first-line nurse managers play an important role in facilitating the resilience development of new nurses. The results may help nursing managers get a deeper understanding on developing resilience of new nurses in transition period. It is also helpful in developing effective strategies in improving the existing nurse training programs to transform new nurses into better qualified nursing staff.

Limitations
Some limitations of the study: First, application and transferability of findings to a larger population of new nurses may be limited, due to a limited sample size. Second, geography is another constraint, considering the samples are only collected in Nanjing General Hospital, which, therefore, leads to the result was only conclusive to Nanjing other than other hospitals. So, more samples are needed to further the study. Besides, the study also poses another limitation, for it was only based on the views and experience from new nurses. Hospital managers and educators should be included in the sample to provide a complete description on resilience of new nurses. Even with these limitations, this study still provides rich and detailed data in exploring the process of resilience development of new nurses, which is definitely meaningful for clinical practice and other future study.

Ethical approval
This study was approved by the ethics committee of Clinical Research of Zhongda Hospital, Affiliated to Southeast University (IRB approval number: 2016ZDSYLL088-P01).