Bullying, shortage of staff and resources in workplace: Qualitative experience of newly qualified nurses

Background The results of the study conducted at Alfred Nzo Municipality revealed that newly qualified nurses were overwhelmed with the challenges surrounding the execution of their duties in healthcare facilities. The experienced staff largely ignored the newly appointed personnel, which led to emotional distress among the newly qualified nurses. Objectives This study aimed to explore and describe the effects of bullying and the shortage of staff and resources in the workplace on newly qualified nurses and to evaluate the support offered to these nurses in the workplace. Method A qualitative, explorative, descriptive and contextual design was used with semi-structured interviews to gather data that were analysed using Tesch’s thematic analysis. Results The themes that emerged revealed that the participants felt bullied in the workplace, the shortage of staff and resources made the participants feel ineffective in their work environment, and the clinical exposure to different units and procedures added value to the participants’ development in the workplace. Conclusion The study revealed that bullying has adverse implications for newly qualified staff. The shortage of staff and resources made the newly qualified nurses feel ineffective and useless but their rotation through the wards added value to their development and confidence in their expertise. Contribution A conceptual framework serves as a guide to newly qualified professional nurses in guiding, protection and coaching in the workplace.


Introduction
The Eastern Cape Provincial Department of Health provides financial support to all institutions that train nurses in the province to ensure that an adequate number of nursing personnel are produced to ensure quality patient care. The newly qualified nursing professionals produced by these institutions are handed over to the clinical services for employment as novice professional nurses but these people often encounter bullying and a shortage of staff and resources in the workplace. The Department of Health, like any other organisation, has to maintain a certain standard by which it can be measured in its effort to ensure quality nursing care. This means that while the department is trying, by all means possible, to develop and groom newly qualified nurses, it must simultaneously provide a high level of healthcare for society. While the department is attempting to balance these two objectives, newly qualified nurses may experience an opportunity to reinforce implementation plans or fill gaps that need a quality improvement plan. A conceptual framework was developed to guide the discussion of bullying and the shortage of staff and resources in the workplace.

The rationale of the study
This study was anticipated to assist in guiding newly qualified nursing professionals to gain support from the Department of Health. The nursing education institutions could learn from the senior staff members how to deal with bullying and the shortage of staff and resources and identify gaps in their curricula. The multidisciplinary team may gain insight into the newly qualified professional nurses' clinical experiences to strengthen their assistance in the work environment.
This study attempted to assist hospital management by highlighting the gaps in the support system and strengthening strategies to enhance the newly qualified professional nurses' well-being. The study was anticipated to serve as a reference for future research studies and provide evidence-based practice in nursing.

Conceptual framework
A conceptual framework represents the researcher's synthesis of the literature to explain a phenomenon (Regoniel 2015:1). It also maps out the actions required in the course of the study, the researcher's previous knowledge and observations, and other researchers' points of view. Fawcett and DeSanto-Madeya's (2013:6) theoretical model was used to provide a frame of reference for the bullying encountered by newly qualified professional nurses in hospital facilities. The theoretical model describes how human beings cope with their health needs and the environment surrounding them in healthcare facilities concerning the nursing care they receive. The model maintains that human beings, both healthy and suffering, are the main focus of care provision to enhance their well-being and proceeds to argue that human beings want to be treated in a safe and peaceful environment. The authors state that human beings need to be taught and educated about their health, for example, the warning signs of ill health and lifestyle consequences. Finally, the model argues that nursing practice is the main factor in caring for those in need.
The combination of art and science in the nursing discipline could assist in achieving the nursing goal of caring for both the healthy and the suffering (Fawcett & DeSanto-Madeya 2013:6). That is only achieved when following the regulations that guide nursing as a profession. These observations and arguments led the researchers to identify four concepts, namely human beings, environment, health and nursing as the foundation for their conceptual model for advanced clinical practice.

Description of concepts
The concepts that were utilised as a structure to explain the newly qualified professional nurses' experiences in hospital facilities are described as follows ( Figure 1): Environment (external conditions or surroundings): As newly qualified professional nurses are human beings, they also need to live in an environment conducive to their well-being. This concept refers to the four hospital facilities that were chosen for this study and applied to the participants' relationships with teammates, patients and their relatives in the clinical units in which they were tasked to carry out their duties. This concept includes the resources available and the points of delegation for the participants to execute their duties.
The subconcepts described hereunder were used to measure the environment to which the newly qualified professional nurses were exposed to in the daily execution of their tasks.
Teammates: This concept refers to the professionals who interacted with newly qualified nurses daily to provide quality healthcare. These professionals might have been supervisors, colleagues, subordinates or members of multidisciplinary teams.
Resources: It refers to the stock or supply of budget, materials, staff and other assets that a hospital facility may need to function effectively (Cambridge Dictionary 2020).

Point of delegation:
The area in which one is assigned a specific task or purpose (Juneja 2015:1).
Patients (a person receiving medical care): This subconcept includes all the people who use hospital services as patients, healthy persons, families, relatives, communities and populations in general, not focusing solely on patients (World Health Organization 2019:1).
Newly qualified professional nurse: A beginner professional nurse practitioner and midwife who has the necessary knowledge, skills, attitudes and values to provide an efficient and professional healthcare service (Morolong & Chabeli 2021:1). In this study, the term newly qualified professional nurse was used when referring to a registered nurse with 2 years of experience, excluding the community service period.
Health status: An individual's relative level of wellness and illness, considering the presence of biological or physiological dysfunction, symptoms and functional impairment (American Thoracic Society 2007:6). It could also be described as the affected individual's subjective ratings of health perceptions and health status (American Thoracic Society 2007:6).
Nursing: A profession within the healthcare sector, focused on the care of individuals, families and communities to attain, maintain or recover optimal health and quality of life (International Council of Nurses 2019:1). Other key roles in nursing are advocacy, promotion of a safe environment, research, participation in shaping health policy and care for patients, health system management and education (International Council of Nurses 2019:1).
Health: A state of complete physical, mental and social well-being and not merely the absence of illness or infirmity (Weller 2009:182). In this study, this concept implied the occupational suffering and health status of newly qualified professional nurses. Their development and non-development, including evidenced-based practice in the working area, were observed under this concept, which also measured the participants' morale against their experiences in the workplace.
The subconcepts described hereunder were used to measure the newly qualified professional nurses' health needs.
Human beings: In this study, this concept refers to all professional nurses who had 2 years of experience as professional nurses, excluding the community service period, specifically the professional nurses who work in hospital facilities in the catchment area that was selected for the study (Webster 2020:1).
In this study, the nursing concept was used as newly qualified professional nurses' core business at the centre of all other concepts.
The core business is an idealised construct intended to express the organisation's main or most essential task (Collins English Dictionary 2019).

Study population
The research population for this study included all newly qualified professional nurses working in hospital facilities in the Alfred Nzo District Municipality.

Sampling
The study employed purposive sampling (De Vos et al. 2012:228) and 19 participants were interviewed before data saturation was achieved.

Data collection
The researcher contacted the hospital managers for data collection immediately after the Department of Health and the Walter Sisulu University Research Committee had approved the study. The researcher used interviews, observations and audio material as tools to obtain information from the participants.

Data analysis
Data analysis was performed according to Tesch's thematic analysis (1990, as cited in Creswell 2014:186) as described hereunder: • The data were organised and prepared for analysis, which involved transcribing the interviews, optically scanning the material, typing field notes, and sorting and arranging the data into different types depending on the source of the information. The interviews, containing descriptions of the participants' experiences, were transcribed one by one.

Research findings
The research findings revealed that the participants felt bullied in the workplace.

Subtheme 1.1: The participants sometimes felt bullied by their seniors
The research participants sometimes felt bullied by their colleagues because they were new to the employment environment. They also felt exploited because of their age because a senior staff member would sometimes remain idle while the newcomers performed all the routine procedures in the unit. Although they were loath to question their colleagues about why they were not assisted with the routine work, they felt that if the ward matrons made rounds unexpectedly to check if all the nurses were tending to patient care, it could reduce bullying in the clinical units. Lindfors and Junttila (2014:3) opine that the experience of incivility and bullying is often associated with the higher job and career turnover intentions, especially among nurses in their first year of practice. The quotes presented hereunder depict how the participants felt about being bullied by their seniors: 'And another thing that have happened is that when you are new, I sometimes felt bullied because if you are new professional nurse, then the elderly professional nurse will just seat by the nursing station the whole day, in order for you to [do] this, to [do] that. To do that you will do rounds, you will do injections then you do the books and everything. You do admin duties but she is there also but she doesn't assist you and we just don't know why. And it is difficult to even ask sister why am I doing everything alone here? Mmh! Am I the only sister? It's difficult to ask that because they will say yhoo you are cheeky and all that everything.' (P6, 22 year old female) Some of the participants perceived being undermined in front of junior categories of nurses because they were newly qualified professional nurses. This treatment resulted in the juniors refusing some of the work that was delegated to them because they thought there were sufficient suitable staff members on duty to execute those tasks. Ruiters (2020:54) concedes that the bullying behaviour exhibited by the managers belittled the novice nurses. This belittling behaviour included managers speaking rudely to staff members and gossiping about some staff members with the most junior personnel: 'And I was like why she would delegate me a chamber if she can't do it herself as a sister too after all? Like why she is not delegating the lower categories, why is she delegating to me?' (P18, 38 year old female) The foregoing quotes revealed the bullying behaviour the participants perceived from their senior colleagues. The ensuing discussion focuses on the high expectations of the participants' colleagues.

Subtheme 1.2: The participants felt that their colleagues expected them to know everything despite the minimal experience they had as novice professionals in the service
The participants experienced that they were expected to be experts in the wards because of their 4-year training as nurses. They reported that their colleagues would create an environment where they felt they could not ask questions about how to perform their duties. Several of the participants became frustrated to the extent that they thought they were not worthy to be nurses. Liang, Lin and Wu (2018:74) agree that newly graduated professional nurses are in transition between an environment in which supervision is the norm and somebody would take responsibility for their actions and an environment in which they are expected to make important decisions about nursing matters. They also posit that a reduction in the supervision of the newly graduated nurses increased self-confidence and the courage to accept new tasks in the clinical area. 'For other procedures we are not actually supervised, because they will want to delegate you to do something you don't even know like where do you start. Like how are you supposed to go on with it in order for it to be productive?' (P18, 38 year old female) 'Yes! Because now you are expected to know everything but it's not easy when you go to this ward in this month and you go to the next one, yes, and people expect you to know although they have stayed there for like ten years, when we just came in just for …' (P14, 27 year old male) The latter quotes explain how the participants felt when their colleagues expected them to know everything with the minimal experience they had as novice professionals in the service. This theme with its subthemes focused on a description of the negative attitudes the participants experienced at the hands of colleagues and multidisciplinary team members. The next theme focused on the shortage of staff and resources at work that triggered the participants' feeling ineffective in the work environment.

Theme 2: The shortage of staff and resources made the participants feel ineffective in their work environment
The shortage of staff in the clinical facilities overwhelmed the participants to such an extent that they would have to multitask to complete all the routine duties allocated by their superiors in the units. They revealed that they were sometimes left alone to run the ward, perform all the necessary tasks and attend facility meetings in the absence of the professionals who were in their category. They perceived this as a significant challenge, as they were still correlating the theory that they had learnt with the practice in the ward. The participants highlighted that the shortage of staff was not only limited to nursing but also affected other general departments of the hospital facilities and they had to pause their tasks and assist where there were shortages. Haddad, http://www.curationis.org.za Open Access Annamaraju and Toney-Butler (2021:8) support the statement and opine that even in the United States, the nursing profession continues to face shortages of staff because of a lack of potential educators, high turnover and inequitable workforce distribution. Lindfors and Junttila (2014:2) admit that while the healthcare sector is struggling with a nursing shortage, nurses are leaving the profession, especially newly graduated nurses. The quotes presented hereunder attest to the shortage of staff: 'First of all, we are few in this hospital as a professional nurse yet the duties are over us but we manage. Sometimes you become alone in a facility whereby you have to do rounds, doctor's rounds. You have to give oral medication plus injection and still after that do assessment and also you are expected as a professional nurse to attend daily meetings of the institution. So it's really a workload that is, that is not good to us.' (P2, 25 year old female) 'But then the first challenge I've faced is that there is a shortage of staff in this institution. The participants also reported that the inadequate resources in the hospital facilities to execute daily duties were unresolved challenges that forced them to take equipment from other units. The participants expressed their concern about the provision of insufficient care to their patients, which worried them in their holistic healthcare approach. They reported that they sometimes felt helpless when they were unable to satisfy a patient's health needs. Rivaz et al. (2017:30) posit that inadequate equipment is one of the most vital stumbling blocks in the healthcare setting and leads to disruption, missed or delayed delivery of care and emotional tension. The quotes presented hereunder attest to the shortage of resources: 'No! We actually use the blood pressure machines but you have to go and fetch it from another ward or borrow it from another ward so that you can come and use it to another ward. Coming to a point where you don't have glucometer totally in the ward. So the ward has no glucometer. So actually you give minimal treatment to the patient, not the full range of the treatment that you are supposed to give or end up using like certain, depending on doctors to approve taking bloods so that it can be taken to the lab for investigation. So that's the other thing that is draining about it.' (P8, 26 year old male) 'We are emotionally drained, we are physically exhausted. We really need counselling, I mean psychological counselling. We have seen things happening in our wards. The shortage of staff and resources in the hospital facilities to which the participants were sent highlighted a significant gap in their support when executing their daily duties. As a result of the shortages described in Theme 2, the following subthemes explained significant moments when the participants felt that they were on their own: • The participants felt abandoned when they were put in charge of the coronavirus disease 2019 (COVID-19) units alone. • The participants were afraid and frustrated to be left alone in the units but this created an opportunity to gain clinical experience.

Subtheme 2.1: The participants felt abandoned when they were put in charge of the coronavirus disease 2019 units alone
The COVID-19 pandemic was another factor that led to psychological trauma and anxiety for the participants while they were executing their duties in the hospital facilities. They reported that they were left alone to nurse critically ill patients in the COVID-19 units. They reported that several patients died on their watch and for some of the participants, this was their first experience of a patient dying. The participants felt that they were sent to work in COVID-19 isolation units because they were young and new to the profession. They expressed that they felt like they had no say, as their older colleagues refused to work in the isolation units. The latest research proves that older people are at high risk of COVID-19 mortality because of the comorbidities associated with old age (Ho & Petermann-Rocha 2020:1). They expressed the need for professional counselling following the peaked waves that engulfed the Alfred Nzo District Municipality when they were working as novice professionals. The quotes presented hereunder are evidence of the forgoing discussion: 'Ah! You are … ok there was a case where I was left alone, it was isolation ward during this COVID-19 and it was very hectic because I was alone and the other nurse I was supposed to be with had a personal problem. She had to take a leave. The foregoing quotes focused on the participants' experiences when they felt abandoned in the COVID-19 units and had to take charge. The ensuing theme explains that the participants were afraid and frustrated to be left alone in the units but that it created an opportunity to gain clinical experience.

Subtheme 2.2: The participants were afraid and frustrated to be left alone in the units but it created an opportunity to gain clinical experience
The participants revealed their mixed feelings about working alone in the clinical units. They were afraid to be left alone to perform their duties but at the same time, they realised that it was an opportunity to use their knowledge to manage the patients. They felt a sense of motivation to perform their duties, as some of the people they nursed recognised them as healthcare providers even when they were off duty. The quote presented hereunder attests to this: 'Eehm, at first it was an excitement because it was like whatever thing we were taught at school, it's time to put it into practice but in nursing we deal with human lives. So it's scary because you know whatever that happens, you are going to be accountable for that and you even pray because I remember the patient was going to Mtata. I was praying the whole day that she reach Mtata still alive and I was checking-up until the patient came back. The foregoing quote highlighted the threats and opportunities experienced by the participants when they were left alone in the clinical units without adequate support. The second theme with its subthemes explained the effects of staff and resource shortages in the workplace. The ensuing theme discusses the impact of the participants' clinical exposure to different units and procedures. It also explains how the exposure added value to the participants' knowledge and development.

Theme 3: Clinical exposure to different units and procedures added value to the participants' development
The participants reported numerous challenges while executing their duties in the hospital facilities in which they were placed that were discussed extensively under Theme 1. The participants reported that the challenges they encountered while performing their duties were often beneficial, as they had added value to their knowledge in the clinical field.
The participants reported that if the challenges mentioned under this theme were adjusted in their work environment, particularly in subtheme 3.1, they would be motivated to perform their duties. They acknowledged the training they received as novice professionals at the hospital facilities and reported a sense of morale when they had to discuss hospital cases with professionals.
A study conducted by Atakro et al. (2019:7) found that neophyte nurses were allowed to come into contact with complex diseases and medical devices as a result of placement in various clinical units in a variety of hospitals. They emphasised that the early exposure of novice professionals to a variety of clinical cases assists those nurses to develop a positive attitude towards patient care, as long as the necessary clinical support system is in place. The quotes presented hereunder illustrate the areas where the participants reported elements of development while performing their duties in the hospital facilities in the Alfred Nzo District Municipality: 'I'll start with the good ones that I've been placed in the wards that I was never been placed before. So I got the experience there I never had before. I saw different conditions that I never experienced even in my training, so it was good.' (P5, 27 year old male) 'Yeah the good experience that I had here, is that eh, we're usually exposed in many things due to shortage of doctors of which makes us more competent in other things like as you can argue someone theoretically and clinically.' (P16, 24 year old female) 'And can hear you and you can be respected with your argument because you know your story. Yeah what I like and a good monitoring. For example, in one ward, in casualty, there is a lot of work there. There's a ortho [orthopaedic], trauma nurses, they are very trained, they are NIMART [nurse-initiation and management of antiretroviral treatment] trained nurses. Ok. They usually teach you eh because …' (P16, 24 year old female) The aforementioned benefits resulted in a motivating work environment and boosted the participants' morale while correlating their knowledge with the duties they were executing in the hospital facilities. The following subthemes were explained by the participants: • Inadequate exposure to clinical learning during training, especially in speciality units, became a challenge when the participants were registered. • The participants who did not understand some of the units because of a lack of exposure during training became positive about the units during their employment period. • The participants felt that the difference in the behaviour of senior colleagues in some of the units helped them to understand that not all the professionals were the same; several senior colleagues assisted them with their duties, which motivated them.

Subtheme 3.1: Inadequate exposure to clinical learning during training, especially in speciality units, became a challenge when the participants were registered
The participants reported that several problems they experienced during the execution of their duties resulted from their inadequate training. They indicated that if some of the problems, such as clinical placement, were resolved during training, the experiences discussed under this subtheme would have been more positive. The participants claimed that the training institutions focused on theory more than practice, which resulted in a gap in their capacity when they qualified as registered nurses. Jamshidi et al. (2016:240)  'It was occurring in clinical and also in theory, yeah in class. Because even in class it's about marks, it's about you should get distinction. It's not a bad thing that we should get good marks but I feel like we should focus more on practical than on theory. Because there are students who are very good in practical but who are still in the course because they don't performing well in theory. So I don't know how to make it or practical be more prominent than theory because at school it was about marks.' (P7, 27 year old female) 'Mmmhh the other challenge I faced it was eeehmm, ok the other thing is that as we rotate as professional, as comm serv [community service] professional nurses we don't get a chance to go to other wards. Sometimes the change list would come and tell you're repeating the very same ward. For instance I have never been exposed to paeds [paediatric unit]. Unfortunately even when I was a student I was never exposed to paeds so I'm very scared because change list this year is changing like suddenly, every month you go to other ward, so like I'm not feeling ok because I'm gonna be like a professional nurse who knows nothing.' (P9, 26 year old male) The foregoing subtheme explains how inadequate exposure to clinical learning, especially in speciality units during the training, became a challenge when the participants were registered. The ensuing description refers to the mindset shift from the students' negativity period to the positivity period following exposure to practical work after being employed.

Subtheme 3.2: The participants who did not understand some of the units because of a lack of exposure during training became positive about the units during their employment
The participants' attitudes and behaviour changed positively when they were placed in the clinical units for extended periods, compared with their initial placement when they were not well-oriented in the units. This extended placement allowed them to gain a sense of responsibility in the execution of their duties. Some of the participants were even keen to specialise in some of the units that they disliked before their community service commenced. Geue (2018:300) holds that positivity in an organisation yields enhanced results and leads to positive behaviour among the employees and enhanced organisational performance. The quotes presented hereunder reveal the participants' attitudes when they were first placed in the clinical units and after they had adapted to these units' routines: 'Yes a huge, a huge difference, like it's a huge difference now, even my lecturers if they can come here, I'm sure they will think that they will get the bad record of me not coming to work but [laughing] I was not this good at school but they will meet the opposite results because here it's not about … nobody forces you to do anything, you see the need of doing it. The foregoing subtheme explained that the participants did not understand some of the units during their training but changed their attitudes positively during their employment period. The ensuing subtheme focuses on the participants' analysis of the work environment and the assistance they received from their colleagues, which motivated them.

Subtheme 3.3:
The participants felt that the difference in the behaviour of senior colleagues helped them understand that not all professionals are the same; several senior colleagues assisted them with their duties, which motivated them Although the participants sensed their senior colleagues' negative attitudes, they also observed that some staff members were always willing to assist them as novice professionals in nursing. The participants would seek assistance from these senior professional nurses, who had a supporting and welcoming attitude towards them until they grasped how things were performed in that particular clinical unit. Milliard (2020:389) reiterates that staff members perceive peer support as more than just a conversation but also a method of increasing their intellectual literacy. The quotes presented hereunder portray how the newly qualified professional nurses perceived the assistance they received from some staff members in the clinical units: 'So you find, ok this person and this person with attitude so you always go to this one and will say its fine, let me help you, because I know you are new here in the experience.' (P1, 27 year old male) 'It was great, it was great eeh I felt like I was not alone. They understand that I'm new yes, I am a new nurse yes that was good. Mmh! So as there were those experiences but I had assistance, yes and they had a level of understanding yes.' (P14, 27 year old male).
'We do allocation in the morning and people stick to it and people do things like if I'm busy with something else but I meant to do something they just follow up and do it.' (P19, 27 year old female).
The foregoing quotes illustrated the participants' analysis of their work relationships and the development that was facilitated by some of their colleagues. Theme 3 elaborated on the participants' experiences following their exposure to various units, particularly speciality units in which they felt that they had limited exposure before they qualified as practitioners. In this last theme, the participants explained their development through adequate exposure to clinical work.

Recommendations
• Hospital manager should place policy measures to guard against bullying of newly qualified nurses in the workplace. • Hospital management should employ more staff who would help in orientation of new staff. • Resources should be made available to assist health workers in the delivery of healthcare. • Mentors and coaches should be allocated to each newly employed nurse.

Conclusion
The research revealed that newly qualified professional nurses experienced disrespect from their colleagues when they delegated duties to both senior and subordinate staff members. This attitude led to the newly qualified professional nurses' feelings of anger and resentment. The disrespect they experienced was accompanied by insubordination. This behaviour increased the stress from overworking and tending to their responsibilities and duties.