Journal of Nursing Management, 2016, 24, 80–87
Work stress among newly graduated nurses in relation to workplace and clinical group supervision ALLVIN R N , KARIN BLOMBERG R N , P h D , A s s o c i a t e p r o f e s s o r 1, ANN-KRISTIN ISAKSSON R N , P h D 1, RENEE 1,2 € ENGSTROM , BIRGITTA BISHOLT R N , P h D 3, MONA EWERTSSON R N , M S c 4, AGNETA KULLEN RN, PhD 5 1 6 P h D , ULLA OHLSSON R N , P h D , ANNELIE SUNDLER JOHANSSON R N , P h D , A s s o c i a t e p r o f e s s o r and MARGARETA GUSTAFSSON R N , P h D , A s s o c i a t e p r o f e s s o r 1 2 € € Senior Lecturer, School of Health and Medical Sciences, Orebro University, Orebro, Research Supervisor, 3 € € Senior Lecturer, Department of Nursing, Karlstad Clinical Skills Centre, Orebro University Hospital, Orebro, 5 € € University, Orebro, Senior University, Karlstad, 4PhD Student, School of Health and Medical Sciences, Orebro 6 Lecturer, School of Health, University of Bor as, Bor as and Senior Lecturer, School of Life Sciences, University of Sk€ ovde, Sk€ ovde, Sweden 1
Correspondence Karin Blomberg School of Health and Medical Sciences € Orebro University € S-70182 Orebro Sweden E-mail: [email protected]
€ ENGSTROM BLOMBERG K., ISAKSSON A.-K., ALLVIN R., BISHOLT B., EWERTSSON M., KULLEN A., OHLSSON U., SUNDLER JOHANSSON A. & GUSTAFSSON M.
(2016) Journal of Nursing Management 24, 80–87 Work stress among newly graduated nurses in relation to workplace and clinical group supervision Aim The aim was to investigate occupational stress among newly graduated nurses in relation to the workplace and clinical group supervision. Background Being a newly graduated nurse is particularly stressful. What remains unclear is whether the workplace and clinical group supervision affect the stress. Method A cross-sectional comparative study was performed in 2012. Data were collected by means of a numerical scale measuring occupational stress, questions about workplace and clinical group supervision. One hundred and thirteen nurses who had recently graduated from three Swedish universities were included in the study. Results The stress was high among the newly graduated nurses but it differed significantly between workplaces, surgical departments generating the most stress. Nurses who had received clinical group supervision reported significantly less stress. The stress between workplaces remained significant also when participation in clinical group supervision was taken into account. Conclusions Newly graduated nurses experience great stress and need support, especially those in surgical departments. Nurses participating in clinical group supervision reported significantly less stress. Implications for nursing management It is important to develop strategies that help to adapt the work situation so as to give nurses the necessary support. Clinical group supervision should be considered as an option for reducing stress. Keywords: clinical group supervision, newly graduated nurses, occupational stress,
workplace Accepted for publication: 28 September 2014
80
DOI: 10.1111/jonm.12274 ª 2014 John Wiley & Sons Ltd
Work stress among newly graduated nurses
Introduction Stress is well documented in the nursing literature (Lambert & Lambert 2001, McGrath et al. 2003, McVicar 2003, Chang et al. 2005, Zeng 2009, Lim et al. 2010a,b) as are numerous consequences of high levels of stress, such as burnout, sick-leave and a high nurse turnover (Garrosa et al. 2008, Sveinsd ottir & Gunnarsd ottir 2008, Duvall & Andrews 2010, Epp 2012, Lu et al. 2012, Toh et al. 2012). Both the quality and safety of care are jeopardised by extreme stress. Being a newly registered nurse has been described as particularly stressful (Adlam et al. 2009, Higgins et al. 2010, Horsburgh & Ross 2013, Suresh et al. 2013). What has not been studied is whether the workplace has an influence on stress experienced by such a nurse. Furthermore, factors such as a lack of support during the first year after registration has been indicated as contributing to stress (Higgins et al. 2010, Horsburgh & Ross 2013). Clinical group supervision as a means of support has been available for years in several countries (Hyrk€ as et al. 1999, Butterworth et al. 2008, Buus & Gonge 2009). However, despite the fact that several studies have provided evidence regarding the benefits of supervision for reducing stress among nurses there is still only limited indication of its effect (Francke & deGraaff 2012), especially in newly graduated nurses.
Background The transition from a student nurse to a registered nurse has been described as a stressful process (Adlam et al. 2009, Higgins et al. 2010, Bisholt 2012a,b, Horsburgh & Ross 2013, Suresh et al. 2013) – even as ‘a shock’ in the earliest literature (Kramer 1974). A variety of reasons have been proposed: for example a shift from a university culture to varying clinical cultures and practises; the shift from a student to a registered nurse and an employee with formal responsibility; a change in expectations regarding the profession; and a gap between ‘the ideal world/theory and the reality of the work. Nursing has been designated a particularly stressful profession (Lambert & Lambert 2001, McGrath et al. 2003, McVicar 2003, Chang et al. 2005), nurses’ working environment being widely perceived as inherently stressful (Weinberg & Creed 2000). The experience of stress is a common phenomenon in life and can be positive or negative. Stress is defined by Lazarus and Folkman (1984) as a relationship between the person and the environment, with the focus on the cognitive appraisal of the situation. Thus it is important to evaluate the ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
relations between the individual and the environment. The transition process of the newly graduated nurses is still ill defined and there is a need for further investigation of its nature and the practise environment (Higgins et al. 2010). The lack of formal support for newly graduated nurses has also been indicated as a contributing factor with regard to stress during the first year after registration (Higgins et al. 2010, Horsburgh & Ross 2013). Several orientation as well as residency programmes have been introduced, implemented and evaluated in order to meet the need for support (Bisholt 2012a,b, Rush et al. 2013). In a recent integrative review of international literature, common elements in transition programmes for newly graduated nurses are identified and described including such as mentorship, formal education and peer support opportunities (Rush et al. 2013). The length, type of education and support vary among these programmes. However, the review reports that further research with longitudinal and experimental designs are needed to identify best practises of introductory/transition programmes for newly graduated nurses (Rush et al. 2013). Clinical group supervision as a model for supporting nurses in different care contexts has been implemented for many years in several countries (Hyrk€ as et al. 1999, Williamson & Dodds 1999, Butterworth et al. 2008, Buus & Gonge 2009, Francke & deGraaff 2012). The term ‘clinical supervision’ covers a range of theoretical definitions and practises (Lynch et al. 2008) but these almost always include support, development and shared reflection. Clinical group supervision is often organised in a group of nurses (6–8 supervisees) with a trained clinical supervisor for 60–90 minutes once a month to discuss, in confidence, questions concerning day-to-day care (White & Winstanley 2010, Andersson et al. 2013). Several studies have indicated the benefits and outcomes of clinical supervision. Two prior systematic literature reviews in the past 15 years have established the evidence that clinical group supervision provides support and stress relief for nurses (Williamson & Dodds 1999, Brunero & Stein-Parbury 2008), but also pointed to a lack of scientific rigour in the underlying studies. There is still only limited evidence of the effect of clinical group supervision (Francke & deGraaff 2012) and specifically among newly graduated nurses.
Objectives The aim of the study was to investigate occupational stress among newly graduated nurses in relation to 81
K. Blomberg et al.
their workplace and clinical group supervision. The objectives were: To describe work stress among newly graduated nurses. To investigate whether their stress differs depending on the workplace. To investigate whether clinical group supervision makes a difference with regard to the reported stress.
Methods Design and settings A cross-sectional study with comparative design was conducted in the spring of 2012 involving nurses who had recently graduated from one of three universities in central Sweden. The nursing programmes at the universities in question are 3 years in duration and the courses include clinical practicums which account for approximately half of the time and credits. The nursing programmes have similar content and lead to a Bachelor’s degree.
Sampling A sample of nurses was recruited from lists of those who had graduated in spring 2011 from the three universities. The number of eligible subjects was 207. Five could not be located but the others received a letter with an information sheet and a questionnaire enclosed. Those who did not answer within a month were sent a reminder letter. Of the 202 contacted, two answered that they did not work as nurses (and thus they did not meet the study criteria). Of the remaining 200, 113 answered the questionnaire. The response rate was 57% (113/200), with no significant difference between the three universities.
Data collection The nurses answered the postal questionnaire at home and returned it back in an enclosed prepaid envelope. The questionnaire obtained information about age, gender, work experience in health care before attending the nursing programme, months of employment as a graduated nurse, change of workplace at least once after graduation, current workplace, shift work and work time per month. A numerical scale (NRS-10) with endpoints ‘no stress at all’ (=1) and ‘a high stress’ (=10) was used for to measure stress during 82
work. The scale has been used among nursing students and was tested for reliability in that study with satisfying results (Blomberg et al. 2014). The question concerning stress was ‘Do you experience stress while working at your current workplace?’ and the respondent was to circle one of the ten numbers provided. The questionnaire also obtained information about clinical group supervision. The question was ‘Are you offered clinical supervision (supervision in nursing) in group form at your current workplace?’ and the respondent was to answer with a simple Yes or No.
Data analysis Demographic data and data describing the work situation are reported by means of descriptive statistics that take into account the scales’ statistical level and the distribution of the collected data. Ratings of stress had a negatively skewed distribution and are described with median (md), first and third quartiles (q1 and q3) and range. Differences in ratings of stress are described in figures by means of box and whisker plots. Non-parametric tests were used for statistical analyses concerning differences in stress. The Kruskal-Wallis test was used for the analysis of differences in experience of stress between workplaces. Comparisons were then performed by means of the Mann-Whitney test to investigate differences between the groups. The Mann-Whitney test was also used for the analysis of stress between two independent groups (male/female, working part-time/ full-time). Spearman’s rank correlation analysis was used to test for relationship between stress and age and length of time working as a nurse. Differences in stress between nurses who had received clinical group supervision and those who had not were investigated by means of the Mann-Whitney test. Finally, the differences in stress between workplaces were repeated excluding those who had received clinical group supervision. The IBM SPSS Statistics 20 for Windows (Armonk, NY, USA) was used for statistical analyses. The significance value was set to p < 0.05.
Results Study participants and their work environment The majority of the 113 nurses participating in the study were females (90%). The age range was 21–51 years (md 26). About half of them (57%) had worked in the health-care sector before attending the ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
Work stress among newly graduated nurses
Table 1 Description of the study participants (n = 113) Descriptive statistics Gender Female Male Age, years
102 (90%) 11 (10%) md 26, q1 24, q3 31, range 23–51 Had worked in health care before attending the nursing programme Yes 64 (57%) No 49 (43%) Time for employment as graduated m 9, SD 1.4, nurse, months range 1–11 Shiftwork Day/evening 58 (51%) Day/evening/night 55 (49%) Working hours Full-time 79 (70%) Part-time 34 (30%) Workplace Hospital department for medical care 56 (50%) General medicine 13 Neurology 9 Cardiology 6 Infectious disease 5 Lung medicine 5 Psychiatry 5 Nephrology 4 Oncology/palliative care 3 Others (haematology, rehabilitation 6 and geriatrics) Hospital department for surgical care 36 (32%) General surgery 22 Orthopaedic surgery 8 Urological surgery 2 Other (ear, nose and throat, 4 gastrointestinal and gynaecological surgery) Workplace outside hospital 21 (18%) Elderly care in the community 13 Prehospital care 8 md, median; q1, first quartile; q3, third quartile; m, mean; SD, standard deviation. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
in departments for medical care, two in departments for surgical care and six outside the hospital.
Stress in relation to workplace and in relation to clinical group supervision The newly graduated nurses’ ratings of stress during work were moderately high (md 7, q1 6, q3 8,5, range 2–10). There was no statistically significant relationship between occupational stress and any of the following: age; gender; working in health care before attending the nursing programme; length of employment since graduation; change of workplace since graduation; working full-time or part-time; type of shift work. The nurses experienced high stress at all types of workplace, nevertheless there was a significant difference between different workplaces (p 0.004). The stress was highest among the nurses who worked in hospital departments for surgical care (md 8, q1 6.5, q3 9, range 4–10), followed by hospital departments for medical care (md 7, q1 6, q3 8, range 2–10) and workplaces outside hospital (md 6, q1 5, q3 7, range 2–9) (Figure 1). Pairwise statistical analyses using surgical care as a control showed that work in departments for surgical care generated more stress than work in any of the other workplaces. The difference in respondents’ stress between hospital departments for surgical care and other workplaces remained significant also when controlling for type of shift work or working full-time or part-time.
10 9 8 7
Stress
nursing programme. When the study took place, on average they had worked as nurses for 9 months since graduation. Forty-nine (43%) had changed workplace at least once after graduation. At the current workplace they normally worked in shifts, 51% worked day/evening shift (7:00 am–4:00 pm and 2:00 pm– 10:00 pm) and 49% worked day/evening/night shift (7:00 am–4:00 pm, 2:00 pm–10:00 pm and 9:00 pm– 7:00 am). Most (70%) worked full-time (Table 1). Most of the nurses worked in hospital departments (Table 1). For the purposes of statistical analysis the workplaces were grouped to: hospital departments for medical care (n = 56, 50%), hospital departments for surgical care (n = 36, 32%) and non-hospital workplaces (n = 21, 18%). Twenty-seven nurses (24%) reported that they received clinical group supervision at their workplace. Of them, 19 were working
6 5 4 3 2 1 Hospital department for surgical care (n = 36)
Hospital department for medical care (n = 56)
Workplace outside hospital (n = 21)
Workplace
Figure 1 Ratings of stress among nurses who worked in hospital departments for surgical care, hospital departments for medical care or worked outside hospital.
83
K. Blomberg et al.
Ratings of stress were significantly lower among those who received clinical group supervision than among those who did not (p 0.002). The nurses who received supervision reported moderate stress (md 6, q1 4, q3 7, range 2–9), while nurses without clinical group supervision reported higher than moderate stress (md 8, q1 6, q3 9, range 2–10) (Figure 2). The statistical analysis comparing nurses with and without clinical group supervision working only in hospital departments for medical care (19 with vs. 37 without clinical group supervision) showed significant differences in ratings of stress (md 7 and md 8 respectively, p 0.007) also when the workplace specialty was held constant. Finally, we tested whether participation in clinical group supervision was related to the differences in stress between workplaces. The statistical analysis showed that nurses who worked in the surgical department experienced more stress than others also when those who had received clinical group supervision were excluded.
Discussion The newly graduated nurses experienced high stress no matter what their workplace was. This confirms the finding of several previous studies that the period of transition from a student to a registered nurse is one involving stress, uncertainty and fear (Higgins et al. 2010, Horsburgh & Ross 2013). The stress among newly graduated nurses has been shown to be related to a perception of excessive workload and to the demands associated with direct patient care, the
10 9 8
Stress
7 6 5 4 3 2 1 Yes (n = 27)
No (n = 86)
Clinical group supervision
Figure 2 Ratings of stress among nurses who had clinical group supervision at their workplace and those who did not.
84
care of patients gravely ill or dying (Wu et al. 2012, Suresh et al. 2013). Newly graduated nurses have also reported difficulty in being accepted by the staff, and their skills are often challenged by other nurses and doctors (Bisholt 2012b, Suresh et al. 2013). Such factors can appear at all workplaces, and this may explain why the newly graduated nurses in the present study experienced high levels of stress regardless of where they worked. The study revealed that the newly graduated nurses working in hospital departments for surgical care experienced the most stress and those working outside hospital experienced the least. This confirmed findings in previous studies involving experienced nurses showing that medical–surgical nurses experienced more stress than nurses working in home care (Salmond & Ropis 2005, Sveinsd ottir & Gunnarsd ottir 2008, McCarthy et al. 2010). Both nurses working in a hospital and those working outside hospital complained of excessive paperwork, lack of cooperation on the part of co-workers and time stress due to high workload. The two groups experienced a similar severity of stress but the nurses working in a hospital experienced such stress more frequently (Salmond & Ropis 2005). Earlier studies have also indicated that there are some distinctions between work on the medical and surgical units of an acute hospital affecting both the quality of care and the nurses job satisfaction, stress and burnout (e.g. McGillis Hall & Doran 2007). Surgical nurses assessed their work as more demanding and experienced less support from their superiors and rated the leadership as less empowering than the medical nurses (Koivu et al. 2011). Thus, the question is whether it is the very nature of the surgical department that causes increased stress (i.e. short length of stay, acuity of patients with limited opportunity for planning, technical equipment) or that the organisations are not adapted to the demanding and rapidly changing work situations. The question is also whether the results of this study apply only to newly graduated nurses (suggesting that the education does not prepare them very well for work in a surgical department). Further research is needed to be able to answer these questions. Meanwhile, managers need to be aware that all newly graduated nurses need support, most of all those working in surgical departents. A lack of support and stress among newly graduated nurses could contribute to a high turnover in the nursing profession (Hayes et al. 2012). Therefore these issues need to be addressed by health organisations worldwide as a priority. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
Work stress among newly graduated nurses
Nurses who had clinical group supervision reported less stress. This supports results in other studies (Brunero & Stein-Parbury 2008, Koivu et al. 2012). However, nurses who attended to clinical supervision might differ from those who did not attend. In a prospective study of registered nurses (RNs) and assistant nurses by Koivu et al. (2011) the RNs who were attracted to clinical supervision were seen as more work-orientated and assessed leadership as more empowering and fair. This aspect needs to be a focus of further studies in the newly graduated nurses. Despite the fact that clinical group supervision has existed in many countries (including Sweden) for years (Francke & deGraaff 2012), it does not seem to be widespread. Only a quarter of the newly graduated nurses who participated in the present study had received such supervision. There is a need for effectiveness studies in order to strengthen the evidence concerning clinical group supervision among nurses (Francke & deGraaff 2012) – and in particular among newly graduated nurses, as suggested by Cummins (2009).
Limitations The results should be considered in the light of the limitation of the study design. Cross-sectional studies do not allow conclusions to be drawn about the effects of group supervision. A control group and a larger sample would have strengthened the study. Studies with experimental design are needed to confirm our results. Also the possibility of sample bias should be considered as a non-probability sampling method (i.e. convenience sample) was used and there was a rather low response rate. These limitations will have impact on the study’s generalisation. Further, self-reported questionnaires might contribute to overor under-reporting stress. However, we do believe that the results of the study provide valuable information concerning newly graduated nurses and their stress, and also the significance of clinical group supervision. The results indicate the need for further research with a focus on the nursing environment at different workplaces and the role of clinical supervision in supporting those who report high stress.
Conclusions Newly graduated nurses experience high stress. It is important that nurse managers pay attention to the fact that these nurses are new and inexperienced and in a working environment that places considerable ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
demands on them. Nurse managers need to consider strategies that help to adapt the current environment to the nurses’ needs and approaches, such as clinical supervision, that provide newly graduated nurses with the necessary support. This applies particularly to nurses working in a surgical department. The study showed that clinical group supervision can be one way of reducing stress among newly graduated nurses, regardless of workplace.
Implications for nursing management A lack of support and stress among newly graduated nurses (Higgins et al. 2010, Horsburgh & Ross 2013) could contribute to a high turnover in the nursing workforce (Hayes et al. 2012), and consequently impact on the individual nurse’s well-being and ultimately on the quality of care. Hence, the nurse managers have the responsibility to create a supporting environment that promotes learning and also provides optimal and safety nursing care for patients. Managers need to be aware that all newly graduated nurses need support, and that those working in surgical departments need it most of all. It is difficult to change the character of the practises and patient care just to make the environment less stressful. Instead a change of work-flows, care models and leadership could be options where a healthy organisation would be a priority. Clinical group supervision should be considered as an opportunity for supporting newly graduated nurses (Cummins 2009), regardless of workplace. However, it must also be taken into consideration that it may be combinations of interventions (i.e. clinical supervision in group or individual, transitions programmes etc.) that facilitate best.
Source of funding No source of funding.
Ethical approval Together with the questionnaire, the nurses received an information sheet concerning the study where it was emphasised that participation was voluntary and that collected data would be treated as confidential. The information sheet was also enclosed in the reminder letter sent to those who had not responded. Data were coded for anonymity before being entered in the electronic file for statistical analysis. The study was granted ethical approval by the Uppsala Regional Ethical Review Board (reg. no. 2011/071). 85
K. Blomberg et al.
References Adlam K., Dotchin M. & Haywards S. (2009) Nursing first year of practice, past, present and future: documenting the journey in New Zealand. Journal of Nursing Management 17, 570– 575. Andersson C., Danielsson A., Hov R. & Athlin E. (2013) Expectations and experiences of group supervision: Swedish and Norwegian preceptors’ perspectives. Journal of Nursing Management 21, 263–272. Bisholt B. (2012a) The learning process of recently graduated nurses in professional situations – experiences of an introduction program. Nurse Education Today 32, 289–293. Bisholt B. (2012b) The professional socialization of recently graduated nurses – experiences of an introduction program. Nurse Education Today 32, 278–282. Blomberg K., Bisholt B., Kullen Engstr€ om A., Ohlsson U., Sundler Johansson A. & Gustafsson M. (2014) Swedish nursing students’ experience of stress during clinical practice in relation to clinical setting characteristics and the organisation of the clinical education. Journal of Clinical Nursing 23, 2264– 2271. Brunero S. & Stein-Parbury J. (2008) The effectiveness of clinical supervision in nursing: an evidenced based literature review. Australian Journal of Advanced Nursing 25, 86–94. Butterworth T., Bell L., Jackson C. & Pajnkihar M. (2008) Wicked spell or magic bullet? A review of the clinical supervision literature 2001–2007. Nurse Education Today 28, 264– 272. Buus N. & Gonge H. (2009) Empirical studies of clinical supervision in psychiatric nursing: a systematic literature review and methodological critique. International Journal of Mental Health Nursing 18, 250–264. Chang E., Hancock K., Johnson A., Daly J. & Jackson D. (2005) Role stress in nurses: review of related factors and strategies for moving forward. Nursing and Health Sciences 7, 57–65. Cummins A. (2009) Clinical supervision: the way forward? A review of the literature. Nurse Education in Practice 9, 215– 220. Duvall J. & Andrews D. (2010) Using a structured review of the literature to identify key factors associated with the current nursing shortage. Journal of Professional Nursing 26, 309–317. Epp K. (2012) Burnout in critical care nurses: a literature review. Dynamics (Pembroke, Ont.) 23, 25–31. Francke A. & deGraaff F. (2012) The effects of group supervision of nurses: a systematic literature review. International Journal of Nursing Studies 49, 1165–1179. Garrosa E., Moreno-Jimenez B., Liang Y. & Gonz alez J. (2008) The relationship between socio-demographic variables, job stressors, burnout, and hardy personality in nurses: an exploratory study. International Journal of Nursing Studies 45, 418–427. Hayes L., O’Brien-Pallas L., Duffield C. et al. (2012) Nurse turnover: a literature review – an update. International Journal of Nursing Studies 49, 887–905. Higgins G., Spencer R. & Kane R. (2010) A systematic review of the experiences and perceptions of the newly qualified nurse in the United Kingdom. Nurse Education Today 30, 499–508.
86
Horsburgh D. & Ross J. (2013) Care and compassion: the experiences of newly qualified staff nurses. Journal of Clinical Nursing 22, 1124–1132. Hyrk€ as K., Koivula M. & Paunonen M. (1999) Clinical supervision in nursing in the 1990s – current state of concepts, theory and research. Journal of Nursing Management 7, 177–187. Koivu A., Saarinen P. & Hyrk€ as K. (2011) Stress relief or practice development: varied reasons for attending clinical supervision. Journal of Nursing Management 19, 644–654. Koivu A., Saarinen P. & Hyrk€ as K. (2012) Does clinical supervision promote medical-surgical nurses’ well-being at work? A quasi-experimental 4-year follow-up study. Journal of Nursing Management 20, 401–413. Kramer M. (1974) Reality Shock – Why Nurses Leave Nursing. CV Mosby Company, St Louis. Lambert V. & Lambert C. (2001) Literature review of role stress/strain on nurses: an international perspective. Nursing and Health Sciences 3, 161–172. Lazarus R. & Folkman S. (1984) Stress, Appraisal and Coping. Springer, New York. Lim J., Bogossian F. & Ahern K. (2010a) Stress and coping in Australian nurses: a systematic review. International Nursing Review 57, 22–31. Lim J., Bogossian F. & Ahern K. (2010b) Stress and coping in Singaporean nurses: a literature review. Nursing and Health Sciences 12, 251–258. Lu H., Barriball K., Zhang X. & While A. (2012) Job satisfaction among hospital nurses revisited: a systematic review. International Journal of Nursing Studies 49, 1017– 1038. Lynch L., Hanox K., Happell B. & Parker J. (2008) Clinical Supervision for Nurses. Wiley-Blackwell, Chichester. McCarthy V.J.C., Power S. & Greiner B.A. (2010) Perceived occupational stress in nurses working in Ireland. Occupational Medicine 60 (8), 604–610. McGillis Hall L. & Doran D. (2007) Nurses’ perceptions of hospital work environments. Journal of Nursing Management 15 (3), 264–273. McGrath A., Reid N. & Boore J. (2003) Occupational stress in nursing. International Journal of Nursing Studies 40, 555– 565. McVicar A. (2003) Workplace stress in nursing: a literature review. Journal of Advanced Nursing 44, 633–642. Rush K., Adamack M., Gordon J., Lilly M. & Janke R. (2013) Best practices of formal new graduate nurse transition programs: an integrative review. International Journal of Nursing Studies 50, 345–356. Salmond S. & Ropis P. (2005) Job stress and general wellbeing: a comparative study of medical-surgical and home care nurses. Medsurgical Nursing 14, 301–309. Suresh P., Matthews A. & Coyne I. (2013) Stress and stressors in the clinical environment: a comparative study of fourthyear student nurses and newly qualified general nurses in Ireland. Journal of Clinical Nursing 22, 770–779. Sveinsd ottir H. & Gunnarsd ottir H. (2008) Predictors of selfassessed physical and mental health of Icelandic nurses: results from a national survey. International Journal of Nursing Studies 45, 1479–1489. Toh S., Ang E. & Devi M. (2012) Systematic review on the relationship between the nursing shortage and job satisfacª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
Work stress among newly graduated nurses
tion, stress and burnout levels among nurses in oncology/haematology settings. International Journal of Evidence-Based Healthcare 10, 126–141. Weinberg A. & Creed F. (2000) Stress and psychiatric disorder in healthcare professionals and hospital staff. The Lancet 355, 533–537. White E. & Winstanley J. (2010) A randomised controlled trial of clinical supervision: selected findings from a novel Australian attempt to establish the evidence base for causal relationships with quality of care and patient outcomes, as an
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
informed contribution to mental health nursing practice development. Journal of Research in Nursing 15, 151–167. Williamson G. & Dodds S. (1999) The effectiveness of a group approach to clinical supervision in reducing stress: a review of the literature. Journal of Clinical Nursing 8, 338–344. Wu T., Fox D., Stokes C. & Adam C. (2012) Work-related stress and intention to quit in newly graduated nurses. Nurse Education Today 32, 669–674. Zeng Y. (2009) Review of work-related stress in mainland Chinese nurses. Nursing and Health Sciences 11, 90–97.
87
Work stress among newly graduated nurses in relation to workplace and clinical group supervision ALLVIN R N , KARIN BLOMBERG R N , P h D , A s s o c i a t e p r o f e s s o r 1, ANN-KRISTIN ISAKSSON R N , P h D 1, RENEE 1,2 € ENGSTROM , BIRGITTA BISHOLT R N , P h D 3, MONA EWERTSSON R N , M S c 4, AGNETA KULLEN RN, PhD 5 1 6 P h D , ULLA OHLSSON R N , P h D , ANNELIE SUNDLER JOHANSSON R N , P h D , A s s o c i a t e p r o f e s s o r and MARGARETA GUSTAFSSON R N , P h D , A s s o c i a t e p r o f e s s o r 1 2 € € Senior Lecturer, School of Health and Medical Sciences, Orebro University, Orebro, Research Supervisor, 3 € € Senior Lecturer, Department of Nursing, Karlstad Clinical Skills Centre, Orebro University Hospital, Orebro, 5 € € University, Orebro, Senior University, Karlstad, 4PhD Student, School of Health and Medical Sciences, Orebro 6 Lecturer, School of Health, University of Bor as, Bor as and Senior Lecturer, School of Life Sciences, University of Sk€ ovde, Sk€ ovde, Sweden 1
Correspondence Karin Blomberg School of Health and Medical Sciences € Orebro University € S-70182 Orebro Sweden E-mail: [email protected]
€ ENGSTROM BLOMBERG K., ISAKSSON A.-K., ALLVIN R., BISHOLT B., EWERTSSON M., KULLEN A., OHLSSON U., SUNDLER JOHANSSON A. & GUSTAFSSON M.
(2016) Journal of Nursing Management 24, 80–87 Work stress among newly graduated nurses in relation to workplace and clinical group supervision Aim The aim was to investigate occupational stress among newly graduated nurses in relation to the workplace and clinical group supervision. Background Being a newly graduated nurse is particularly stressful. What remains unclear is whether the workplace and clinical group supervision affect the stress. Method A cross-sectional comparative study was performed in 2012. Data were collected by means of a numerical scale measuring occupational stress, questions about workplace and clinical group supervision. One hundred and thirteen nurses who had recently graduated from three Swedish universities were included in the study. Results The stress was high among the newly graduated nurses but it differed significantly between workplaces, surgical departments generating the most stress. Nurses who had received clinical group supervision reported significantly less stress. The stress between workplaces remained significant also when participation in clinical group supervision was taken into account. Conclusions Newly graduated nurses experience great stress and need support, especially those in surgical departments. Nurses participating in clinical group supervision reported significantly less stress. Implications for nursing management It is important to develop strategies that help to adapt the work situation so as to give nurses the necessary support. Clinical group supervision should be considered as an option for reducing stress. Keywords: clinical group supervision, newly graduated nurses, occupational stress,
workplace Accepted for publication: 28 September 2014
80
DOI: 10.1111/jonm.12274 ª 2014 John Wiley & Sons Ltd
Work stress among newly graduated nurses
Introduction Stress is well documented in the nursing literature (Lambert & Lambert 2001, McGrath et al. 2003, McVicar 2003, Chang et al. 2005, Zeng 2009, Lim et al. 2010a,b) as are numerous consequences of high levels of stress, such as burnout, sick-leave and a high nurse turnover (Garrosa et al. 2008, Sveinsd ottir & Gunnarsd ottir 2008, Duvall & Andrews 2010, Epp 2012, Lu et al. 2012, Toh et al. 2012). Both the quality and safety of care are jeopardised by extreme stress. Being a newly registered nurse has been described as particularly stressful (Adlam et al. 2009, Higgins et al. 2010, Horsburgh & Ross 2013, Suresh et al. 2013). What has not been studied is whether the workplace has an influence on stress experienced by such a nurse. Furthermore, factors such as a lack of support during the first year after registration has been indicated as contributing to stress (Higgins et al. 2010, Horsburgh & Ross 2013). Clinical group supervision as a means of support has been available for years in several countries (Hyrk€ as et al. 1999, Butterworth et al. 2008, Buus & Gonge 2009). However, despite the fact that several studies have provided evidence regarding the benefits of supervision for reducing stress among nurses there is still only limited indication of its effect (Francke & deGraaff 2012), especially in newly graduated nurses.
Background The transition from a student nurse to a registered nurse has been described as a stressful process (Adlam et al. 2009, Higgins et al. 2010, Bisholt 2012a,b, Horsburgh & Ross 2013, Suresh et al. 2013) – even as ‘a shock’ in the earliest literature (Kramer 1974). A variety of reasons have been proposed: for example a shift from a university culture to varying clinical cultures and practises; the shift from a student to a registered nurse and an employee with formal responsibility; a change in expectations regarding the profession; and a gap between ‘the ideal world/theory and the reality of the work. Nursing has been designated a particularly stressful profession (Lambert & Lambert 2001, McGrath et al. 2003, McVicar 2003, Chang et al. 2005), nurses’ working environment being widely perceived as inherently stressful (Weinberg & Creed 2000). The experience of stress is a common phenomenon in life and can be positive or negative. Stress is defined by Lazarus and Folkman (1984) as a relationship between the person and the environment, with the focus on the cognitive appraisal of the situation. Thus it is important to evaluate the ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
relations between the individual and the environment. The transition process of the newly graduated nurses is still ill defined and there is a need for further investigation of its nature and the practise environment (Higgins et al. 2010). The lack of formal support for newly graduated nurses has also been indicated as a contributing factor with regard to stress during the first year after registration (Higgins et al. 2010, Horsburgh & Ross 2013). Several orientation as well as residency programmes have been introduced, implemented and evaluated in order to meet the need for support (Bisholt 2012a,b, Rush et al. 2013). In a recent integrative review of international literature, common elements in transition programmes for newly graduated nurses are identified and described including such as mentorship, formal education and peer support opportunities (Rush et al. 2013). The length, type of education and support vary among these programmes. However, the review reports that further research with longitudinal and experimental designs are needed to identify best practises of introductory/transition programmes for newly graduated nurses (Rush et al. 2013). Clinical group supervision as a model for supporting nurses in different care contexts has been implemented for many years in several countries (Hyrk€ as et al. 1999, Williamson & Dodds 1999, Butterworth et al. 2008, Buus & Gonge 2009, Francke & deGraaff 2012). The term ‘clinical supervision’ covers a range of theoretical definitions and practises (Lynch et al. 2008) but these almost always include support, development and shared reflection. Clinical group supervision is often organised in a group of nurses (6–8 supervisees) with a trained clinical supervisor for 60–90 minutes once a month to discuss, in confidence, questions concerning day-to-day care (White & Winstanley 2010, Andersson et al. 2013). Several studies have indicated the benefits and outcomes of clinical supervision. Two prior systematic literature reviews in the past 15 years have established the evidence that clinical group supervision provides support and stress relief for nurses (Williamson & Dodds 1999, Brunero & Stein-Parbury 2008), but also pointed to a lack of scientific rigour in the underlying studies. There is still only limited evidence of the effect of clinical group supervision (Francke & deGraaff 2012) and specifically among newly graduated nurses.
Objectives The aim of the study was to investigate occupational stress among newly graduated nurses in relation to 81
K. Blomberg et al.
their workplace and clinical group supervision. The objectives were: To describe work stress among newly graduated nurses. To investigate whether their stress differs depending on the workplace. To investigate whether clinical group supervision makes a difference with regard to the reported stress.
Methods Design and settings A cross-sectional study with comparative design was conducted in the spring of 2012 involving nurses who had recently graduated from one of three universities in central Sweden. The nursing programmes at the universities in question are 3 years in duration and the courses include clinical practicums which account for approximately half of the time and credits. The nursing programmes have similar content and lead to a Bachelor’s degree.
Sampling A sample of nurses was recruited from lists of those who had graduated in spring 2011 from the three universities. The number of eligible subjects was 207. Five could not be located but the others received a letter with an information sheet and a questionnaire enclosed. Those who did not answer within a month were sent a reminder letter. Of the 202 contacted, two answered that they did not work as nurses (and thus they did not meet the study criteria). Of the remaining 200, 113 answered the questionnaire. The response rate was 57% (113/200), with no significant difference between the three universities.
Data collection The nurses answered the postal questionnaire at home and returned it back in an enclosed prepaid envelope. The questionnaire obtained information about age, gender, work experience in health care before attending the nursing programme, months of employment as a graduated nurse, change of workplace at least once after graduation, current workplace, shift work and work time per month. A numerical scale (NRS-10) with endpoints ‘no stress at all’ (=1) and ‘a high stress’ (=10) was used for to measure stress during 82
work. The scale has been used among nursing students and was tested for reliability in that study with satisfying results (Blomberg et al. 2014). The question concerning stress was ‘Do you experience stress while working at your current workplace?’ and the respondent was to circle one of the ten numbers provided. The questionnaire also obtained information about clinical group supervision. The question was ‘Are you offered clinical supervision (supervision in nursing) in group form at your current workplace?’ and the respondent was to answer with a simple Yes or No.
Data analysis Demographic data and data describing the work situation are reported by means of descriptive statistics that take into account the scales’ statistical level and the distribution of the collected data. Ratings of stress had a negatively skewed distribution and are described with median (md), first and third quartiles (q1 and q3) and range. Differences in ratings of stress are described in figures by means of box and whisker plots. Non-parametric tests were used for statistical analyses concerning differences in stress. The Kruskal-Wallis test was used for the analysis of differences in experience of stress between workplaces. Comparisons were then performed by means of the Mann-Whitney test to investigate differences between the groups. The Mann-Whitney test was also used for the analysis of stress between two independent groups (male/female, working part-time/ full-time). Spearman’s rank correlation analysis was used to test for relationship between stress and age and length of time working as a nurse. Differences in stress between nurses who had received clinical group supervision and those who had not were investigated by means of the Mann-Whitney test. Finally, the differences in stress between workplaces were repeated excluding those who had received clinical group supervision. The IBM SPSS Statistics 20 for Windows (Armonk, NY, USA) was used for statistical analyses. The significance value was set to p < 0.05.
Results Study participants and their work environment The majority of the 113 nurses participating in the study were females (90%). The age range was 21–51 years (md 26). About half of them (57%) had worked in the health-care sector before attending the ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
Work stress among newly graduated nurses
Table 1 Description of the study participants (n = 113) Descriptive statistics Gender Female Male Age, years
102 (90%) 11 (10%) md 26, q1 24, q3 31, range 23–51 Had worked in health care before attending the nursing programme Yes 64 (57%) No 49 (43%) Time for employment as graduated m 9, SD 1.4, nurse, months range 1–11 Shiftwork Day/evening 58 (51%) Day/evening/night 55 (49%) Working hours Full-time 79 (70%) Part-time 34 (30%) Workplace Hospital department for medical care 56 (50%) General medicine 13 Neurology 9 Cardiology 6 Infectious disease 5 Lung medicine 5 Psychiatry 5 Nephrology 4 Oncology/palliative care 3 Others (haematology, rehabilitation 6 and geriatrics) Hospital department for surgical care 36 (32%) General surgery 22 Orthopaedic surgery 8 Urological surgery 2 Other (ear, nose and throat, 4 gastrointestinal and gynaecological surgery) Workplace outside hospital 21 (18%) Elderly care in the community 13 Prehospital care 8 md, median; q1, first quartile; q3, third quartile; m, mean; SD, standard deviation. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
in departments for medical care, two in departments for surgical care and six outside the hospital.
Stress in relation to workplace and in relation to clinical group supervision The newly graduated nurses’ ratings of stress during work were moderately high (md 7, q1 6, q3 8,5, range 2–10). There was no statistically significant relationship between occupational stress and any of the following: age; gender; working in health care before attending the nursing programme; length of employment since graduation; change of workplace since graduation; working full-time or part-time; type of shift work. The nurses experienced high stress at all types of workplace, nevertheless there was a significant difference between different workplaces (p 0.004). The stress was highest among the nurses who worked in hospital departments for surgical care (md 8, q1 6.5, q3 9, range 4–10), followed by hospital departments for medical care (md 7, q1 6, q3 8, range 2–10) and workplaces outside hospital (md 6, q1 5, q3 7, range 2–9) (Figure 1). Pairwise statistical analyses using surgical care as a control showed that work in departments for surgical care generated more stress than work in any of the other workplaces. The difference in respondents’ stress between hospital departments for surgical care and other workplaces remained significant also when controlling for type of shift work or working full-time or part-time.
10 9 8 7
Stress
nursing programme. When the study took place, on average they had worked as nurses for 9 months since graduation. Forty-nine (43%) had changed workplace at least once after graduation. At the current workplace they normally worked in shifts, 51% worked day/evening shift (7:00 am–4:00 pm and 2:00 pm– 10:00 pm) and 49% worked day/evening/night shift (7:00 am–4:00 pm, 2:00 pm–10:00 pm and 9:00 pm– 7:00 am). Most (70%) worked full-time (Table 1). Most of the nurses worked in hospital departments (Table 1). For the purposes of statistical analysis the workplaces were grouped to: hospital departments for medical care (n = 56, 50%), hospital departments for surgical care (n = 36, 32%) and non-hospital workplaces (n = 21, 18%). Twenty-seven nurses (24%) reported that they received clinical group supervision at their workplace. Of them, 19 were working
6 5 4 3 2 1 Hospital department for surgical care (n = 36)
Hospital department for medical care (n = 56)
Workplace outside hospital (n = 21)
Workplace
Figure 1 Ratings of stress among nurses who worked in hospital departments for surgical care, hospital departments for medical care or worked outside hospital.
83
K. Blomberg et al.
Ratings of stress were significantly lower among those who received clinical group supervision than among those who did not (p 0.002). The nurses who received supervision reported moderate stress (md 6, q1 4, q3 7, range 2–9), while nurses without clinical group supervision reported higher than moderate stress (md 8, q1 6, q3 9, range 2–10) (Figure 2). The statistical analysis comparing nurses with and without clinical group supervision working only in hospital departments for medical care (19 with vs. 37 without clinical group supervision) showed significant differences in ratings of stress (md 7 and md 8 respectively, p 0.007) also when the workplace specialty was held constant. Finally, we tested whether participation in clinical group supervision was related to the differences in stress between workplaces. The statistical analysis showed that nurses who worked in the surgical department experienced more stress than others also when those who had received clinical group supervision were excluded.
Discussion The newly graduated nurses experienced high stress no matter what their workplace was. This confirms the finding of several previous studies that the period of transition from a student to a registered nurse is one involving stress, uncertainty and fear (Higgins et al. 2010, Horsburgh & Ross 2013). The stress among newly graduated nurses has been shown to be related to a perception of excessive workload and to the demands associated with direct patient care, the
10 9 8
Stress
7 6 5 4 3 2 1 Yes (n = 27)
No (n = 86)
Clinical group supervision
Figure 2 Ratings of stress among nurses who had clinical group supervision at their workplace and those who did not.
84
care of patients gravely ill or dying (Wu et al. 2012, Suresh et al. 2013). Newly graduated nurses have also reported difficulty in being accepted by the staff, and their skills are often challenged by other nurses and doctors (Bisholt 2012b, Suresh et al. 2013). Such factors can appear at all workplaces, and this may explain why the newly graduated nurses in the present study experienced high levels of stress regardless of where they worked. The study revealed that the newly graduated nurses working in hospital departments for surgical care experienced the most stress and those working outside hospital experienced the least. This confirmed findings in previous studies involving experienced nurses showing that medical–surgical nurses experienced more stress than nurses working in home care (Salmond & Ropis 2005, Sveinsd ottir & Gunnarsd ottir 2008, McCarthy et al. 2010). Both nurses working in a hospital and those working outside hospital complained of excessive paperwork, lack of cooperation on the part of co-workers and time stress due to high workload. The two groups experienced a similar severity of stress but the nurses working in a hospital experienced such stress more frequently (Salmond & Ropis 2005). Earlier studies have also indicated that there are some distinctions between work on the medical and surgical units of an acute hospital affecting both the quality of care and the nurses job satisfaction, stress and burnout (e.g. McGillis Hall & Doran 2007). Surgical nurses assessed their work as more demanding and experienced less support from their superiors and rated the leadership as less empowering than the medical nurses (Koivu et al. 2011). Thus, the question is whether it is the very nature of the surgical department that causes increased stress (i.e. short length of stay, acuity of patients with limited opportunity for planning, technical equipment) or that the organisations are not adapted to the demanding and rapidly changing work situations. The question is also whether the results of this study apply only to newly graduated nurses (suggesting that the education does not prepare them very well for work in a surgical department). Further research is needed to be able to answer these questions. Meanwhile, managers need to be aware that all newly graduated nurses need support, most of all those working in surgical departents. A lack of support and stress among newly graduated nurses could contribute to a high turnover in the nursing profession (Hayes et al. 2012). Therefore these issues need to be addressed by health organisations worldwide as a priority. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
Work stress among newly graduated nurses
Nurses who had clinical group supervision reported less stress. This supports results in other studies (Brunero & Stein-Parbury 2008, Koivu et al. 2012). However, nurses who attended to clinical supervision might differ from those who did not attend. In a prospective study of registered nurses (RNs) and assistant nurses by Koivu et al. (2011) the RNs who were attracted to clinical supervision were seen as more work-orientated and assessed leadership as more empowering and fair. This aspect needs to be a focus of further studies in the newly graduated nurses. Despite the fact that clinical group supervision has existed in many countries (including Sweden) for years (Francke & deGraaff 2012), it does not seem to be widespread. Only a quarter of the newly graduated nurses who participated in the present study had received such supervision. There is a need for effectiveness studies in order to strengthen the evidence concerning clinical group supervision among nurses (Francke & deGraaff 2012) – and in particular among newly graduated nurses, as suggested by Cummins (2009).
Limitations The results should be considered in the light of the limitation of the study design. Cross-sectional studies do not allow conclusions to be drawn about the effects of group supervision. A control group and a larger sample would have strengthened the study. Studies with experimental design are needed to confirm our results. Also the possibility of sample bias should be considered as a non-probability sampling method (i.e. convenience sample) was used and there was a rather low response rate. These limitations will have impact on the study’s generalisation. Further, self-reported questionnaires might contribute to overor under-reporting stress. However, we do believe that the results of the study provide valuable information concerning newly graduated nurses and their stress, and also the significance of clinical group supervision. The results indicate the need for further research with a focus on the nursing environment at different workplaces and the role of clinical supervision in supporting those who report high stress.
Conclusions Newly graduated nurses experience high stress. It is important that nurse managers pay attention to the fact that these nurses are new and inexperienced and in a working environment that places considerable ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
demands on them. Nurse managers need to consider strategies that help to adapt the current environment to the nurses’ needs and approaches, such as clinical supervision, that provide newly graduated nurses with the necessary support. This applies particularly to nurses working in a surgical department. The study showed that clinical group supervision can be one way of reducing stress among newly graduated nurses, regardless of workplace.
Implications for nursing management A lack of support and stress among newly graduated nurses (Higgins et al. 2010, Horsburgh & Ross 2013) could contribute to a high turnover in the nursing workforce (Hayes et al. 2012), and consequently impact on the individual nurse’s well-being and ultimately on the quality of care. Hence, the nurse managers have the responsibility to create a supporting environment that promotes learning and also provides optimal and safety nursing care for patients. Managers need to be aware that all newly graduated nurses need support, and that those working in surgical departments need it most of all. It is difficult to change the character of the practises and patient care just to make the environment less stressful. Instead a change of work-flows, care models and leadership could be options where a healthy organisation would be a priority. Clinical group supervision should be considered as an opportunity for supporting newly graduated nurses (Cummins 2009), regardless of workplace. However, it must also be taken into consideration that it may be combinations of interventions (i.e. clinical supervision in group or individual, transitions programmes etc.) that facilitate best.
Source of funding No source of funding.
Ethical approval Together with the questionnaire, the nurses received an information sheet concerning the study where it was emphasised that participation was voluntary and that collected data would be treated as confidential. The information sheet was also enclosed in the reminder letter sent to those who had not responded. Data were coded for anonymity before being entered in the electronic file for statistical analysis. The study was granted ethical approval by the Uppsala Regional Ethical Review Board (reg. no. 2011/071). 85
K. Blomberg et al.
References Adlam K., Dotchin M. & Haywards S. (2009) Nursing first year of practice, past, present and future: documenting the journey in New Zealand. Journal of Nursing Management 17, 570– 575. Andersson C., Danielsson A., Hov R. & Athlin E. (2013) Expectations and experiences of group supervision: Swedish and Norwegian preceptors’ perspectives. Journal of Nursing Management 21, 263–272. Bisholt B. (2012a) The learning process of recently graduated nurses in professional situations – experiences of an introduction program. Nurse Education Today 32, 289–293. Bisholt B. (2012b) The professional socialization of recently graduated nurses – experiences of an introduction program. Nurse Education Today 32, 278–282. Blomberg K., Bisholt B., Kullen Engstr€ om A., Ohlsson U., Sundler Johansson A. & Gustafsson M. (2014) Swedish nursing students’ experience of stress during clinical practice in relation to clinical setting characteristics and the organisation of the clinical education. Journal of Clinical Nursing 23, 2264– 2271. Brunero S. & Stein-Parbury J. (2008) The effectiveness of clinical supervision in nursing: an evidenced based literature review. Australian Journal of Advanced Nursing 25, 86–94. Butterworth T., Bell L., Jackson C. & Pajnkihar M. (2008) Wicked spell or magic bullet? A review of the clinical supervision literature 2001–2007. Nurse Education Today 28, 264– 272. Buus N. & Gonge H. (2009) Empirical studies of clinical supervision in psychiatric nursing: a systematic literature review and methodological critique. International Journal of Mental Health Nursing 18, 250–264. Chang E., Hancock K., Johnson A., Daly J. & Jackson D. (2005) Role stress in nurses: review of related factors and strategies for moving forward. Nursing and Health Sciences 7, 57–65. Cummins A. (2009) Clinical supervision: the way forward? A review of the literature. Nurse Education in Practice 9, 215– 220. Duvall J. & Andrews D. (2010) Using a structured review of the literature to identify key factors associated with the current nursing shortage. Journal of Professional Nursing 26, 309–317. Epp K. (2012) Burnout in critical care nurses: a literature review. Dynamics (Pembroke, Ont.) 23, 25–31. Francke A. & deGraaff F. (2012) The effects of group supervision of nurses: a systematic literature review. International Journal of Nursing Studies 49, 1165–1179. Garrosa E., Moreno-Jimenez B., Liang Y. & Gonz alez J. (2008) The relationship between socio-demographic variables, job stressors, burnout, and hardy personality in nurses: an exploratory study. International Journal of Nursing Studies 45, 418–427. Hayes L., O’Brien-Pallas L., Duffield C. et al. (2012) Nurse turnover: a literature review – an update. International Journal of Nursing Studies 49, 887–905. Higgins G., Spencer R. & Kane R. (2010) A systematic review of the experiences and perceptions of the newly qualified nurse in the United Kingdom. Nurse Education Today 30, 499–508.
86
Horsburgh D. & Ross J. (2013) Care and compassion: the experiences of newly qualified staff nurses. Journal of Clinical Nursing 22, 1124–1132. Hyrk€ as K., Koivula M. & Paunonen M. (1999) Clinical supervision in nursing in the 1990s – current state of concepts, theory and research. Journal of Nursing Management 7, 177–187. Koivu A., Saarinen P. & Hyrk€ as K. (2011) Stress relief or practice development: varied reasons for attending clinical supervision. Journal of Nursing Management 19, 644–654. Koivu A., Saarinen P. & Hyrk€ as K. (2012) Does clinical supervision promote medical-surgical nurses’ well-being at work? A quasi-experimental 4-year follow-up study. Journal of Nursing Management 20, 401–413. Kramer M. (1974) Reality Shock – Why Nurses Leave Nursing. CV Mosby Company, St Louis. Lambert V. & Lambert C. (2001) Literature review of role stress/strain on nurses: an international perspective. Nursing and Health Sciences 3, 161–172. Lazarus R. & Folkman S. (1984) Stress, Appraisal and Coping. Springer, New York. Lim J., Bogossian F. & Ahern K. (2010a) Stress and coping in Australian nurses: a systematic review. International Nursing Review 57, 22–31. Lim J., Bogossian F. & Ahern K. (2010b) Stress and coping in Singaporean nurses: a literature review. Nursing and Health Sciences 12, 251–258. Lu H., Barriball K., Zhang X. & While A. (2012) Job satisfaction among hospital nurses revisited: a systematic review. International Journal of Nursing Studies 49, 1017– 1038. Lynch L., Hanox K., Happell B. & Parker J. (2008) Clinical Supervision for Nurses. Wiley-Blackwell, Chichester. McCarthy V.J.C., Power S. & Greiner B.A. (2010) Perceived occupational stress in nurses working in Ireland. Occupational Medicine 60 (8), 604–610. McGillis Hall L. & Doran D. (2007) Nurses’ perceptions of hospital work environments. Journal of Nursing Management 15 (3), 264–273. McGrath A., Reid N. & Boore J. (2003) Occupational stress in nursing. International Journal of Nursing Studies 40, 555– 565. McVicar A. (2003) Workplace stress in nursing: a literature review. Journal of Advanced Nursing 44, 633–642. Rush K., Adamack M., Gordon J., Lilly M. & Janke R. (2013) Best practices of formal new graduate nurse transition programs: an integrative review. International Journal of Nursing Studies 50, 345–356. Salmond S. & Ropis P. (2005) Job stress and general wellbeing: a comparative study of medical-surgical and home care nurses. Medsurgical Nursing 14, 301–309. Suresh P., Matthews A. & Coyne I. (2013) Stress and stressors in the clinical environment: a comparative study of fourthyear student nurses and newly qualified general nurses in Ireland. Journal of Clinical Nursing 22, 770–779. Sveinsd ottir H. & Gunnarsd ottir H. (2008) Predictors of selfassessed physical and mental health of Icelandic nurses: results from a national survey. International Journal of Nursing Studies 45, 1479–1489. Toh S., Ang E. & Devi M. (2012) Systematic review on the relationship between the nursing shortage and job satisfacª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
Work stress among newly graduated nurses
tion, stress and burnout levels among nurses in oncology/haematology settings. International Journal of Evidence-Based Healthcare 10, 126–141. Weinberg A. & Creed F. (2000) Stress and psychiatric disorder in healthcare professionals and hospital staff. The Lancet 355, 533–537. White E. & Winstanley J. (2010) A randomised controlled trial of clinical supervision: selected findings from a novel Australian attempt to establish the evidence base for causal relationships with quality of care and patient outcomes, as an
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 80–87
informed contribution to mental health nursing practice development. Journal of Research in Nursing 15, 151–167. Williamson G. & Dodds S. (1999) The effectiveness of a group approach to clinical supervision in reducing stress: a review of the literature. Journal of Clinical Nursing 8, 338–344. Wu T., Fox D., Stokes C. & Adam C. (2012) Work-related stress and intention to quit in newly graduated nurses. Nurse Education Today 32, 669–674. Zeng Y. (2009) Review of work-related stress in mainland Chinese nurses. Nursing and Health Sciences 11, 90–97.
87
