INTRODUCTION:

Induction programmes (IPs) are arguably the cornerstone for nurses’ professional development in the healthcare sector during their transition period, as professional practice limits nurses’ ability to hone themselves further academically due to commitments to build professional confidence.¹ The theoretical knowledge and practical skills imparted in student nursing quickly become outdated or irrelevant in current healthcare settings.^2,3,4 Thus, these challenges broaden in speciality care areas as high-stress clinical units like the operating room (OR) reduce practical skills involvement opportunities.^5,6

Therefore, trying to compress the knowledge and skills of perioperative nursing into newly-joined nurses (NJNs) OR IPs within a few weeks is not feasible.⁷ In addition, the challenges of attracting nurses to take up perioperative nursing as a profession, and the increasing volume of surgeries, have also put the quality of care delivered to patients in the OR unit at risk.⁸ Thus, nursing IPs such as transitional support programmes (TSPs) are ideal platforms for transferring learning between experienced and novice nurses.^1,9,10,11

However, the current global nursing shortages raise concerns in Singapore, significantly when the republic depends heavily on foreign nurses to fill its nursing shortfalls.¹² This is due to the lack of Singaporeans interested in taking up the nursing profession because of how Singapore society views nursing as a profession.¹³Singapore’s highest nursing immigrants, the Philippines that were temporarily stopped from working overseas during the SARS-CoV-2 pandemic to help its domestic nursing workforce, have further added to the burdens faced by the Singapore health system.^14,15 Thus, hospitals might not be ready or have enough time to recover their lost workforce when business is to back usual once the fight against SARS-CoV-2 has been resolved.^16,17

Various studies have shared the importance of IPs in the professional development of nurses.^{9,11,18,19,20} These included feeling more confident with their nursing skills after 12-month,^7,18 and correlated to having a positive experience with adaptation, work satisfaction, and support system.^7,9,20 Despite the efforts of the nursing division to impart efficient and effective nursing IPs for all nurses during their transition period, the growing body of evidence reflected that many challenges exist in running such programmes. One study shared that one these challenges included staffing issues to conduct such programmes if available.²¹ Furthermore, even with a well-designed IP, the lack of support that newly-graduated nurses (NGNs) and NJNs received during their transition remained a challenge that impacts nurses professionally.^22,23 With time and human resource constraints, senior nurses found it challenging to continue guiding new nurses over a long period if the learning threshold was not progressive.²³ Furthermore, even with the availability of experienced nurses in the OR to guide novice nurses, some were not prepared to do so as they would prefer to maintain their social position within the OR team, which they feared novice nurses might challenge in the future.²²

The significance of this study was paramount. From the evidence in the extant literature of similar conditions faced by Singapore international counterparts, this paper explored the impacts OR nursing IPs had on NJN in Singapore OR units. Hence, in line with the Singapore government’s recognition of the need to sustain and retain more local nurses, this study would better understand how reducing clinical stress and having more guided learning in specialised nursing fields would better prepare new nurses for their new full-time roles. Furthermore, the findings of this study provided essential inputs to supplement Singapore’s healthcare system with strategies to improve the professional development of NJNs in the OR units.

RESEARCH OBJECTIVES:

The purpose of this mixed method study was to explore the impacts current OR nursing IPs in Singapore had on its NJNs as a result of the challenges they faced during the IP period to better prepare nurses in providing competent OR nursing care. The objectives of this study were, in the Singapore context of OR unit NJNS, to:

1. Explore the impacts current OR nursing IPs in Singapore OR units had on its OR nurses.

2. Explore the effectiveness of current perioperative IPs for NJNs in Singapore OR units.

3. Understand the different group experiences of OR nurses who were given structured IPs versus the ones who did not.

4. Explore the potential benefits of having structured perioperative nursing IPs for enrolled and registered nurses.

Research Questions and Hypotheses

To help explore the phenomenon, specific research questions and hypotheses were established. These included:

RQ1. To what extent did having an OR unit specific specialised nursing IP enhance OR unit nurses’ knowledge and skills in performing new job roles?

H1₀. Having an OR unit specific specialised nursing IP would not result in the enhancement of OR NJNs in Singapore's knowledge and skills in performing their new job roles.

H1_a. Having an OR unit specific specialised nursing IP would result in the enhancement of OR NJNs in Singapore's knowledge and skills in performing their new job roles.

RQ2. To what extent did the challenges NJNs in Singapore OR face with the OR unit specific specialised nursing IP affect their ability to perform their roles?

H2₀. OR unit-specific specialised nursing IPs did not affect Singapore OR NJNs' challenges with their ability to perform their roles.

H2_a. OR unit specific specialised nursing IPs affected the challenges Singapore OR NJNs faced with their ability to perform their roles.

MATERIALS AND METHODS

Methods

The research approach of this study used the explanatory sequential mixed method study, which involved two phases in exploring the phenomenon. In phase one, a cohort study design using a descriptive self-administered quantitative survey was used to obtain data. In phase two, the phenomenology study design was adopted to examine all participants' views and exemplify the lived experiences based on those opinions based on the finding of phase one.

The From Novice to Expert theory,²⁴ and Conceptual Model of Nursing Motivation,²⁵ were applied as theoretical frameworks to guide the study. The five stages of skills and knowledge acquisition in the From Novice to Expert theory included, i) novice, ii) advanced beginner, iii) competent, iv) proficient, and v) expert.²⁴While the Conceptual Model of Nursing Motivation suggested that certain perceived efforts must be a product for nurses to respond to their behavioural actions, which included organisational rewards and incentives. The theorist further conceptualised that individual internalised these through three different variables related functions to self-evaluate individual traits to reduce motivational barriers. These included i) value, ii) identity, and iii) utility.²⁵ Independent variables identified in this study included demographic variables (job role, the outcome of stressors, whether NJNs received IPs, and years in the OR unit), whereby the dependent variables were causes of the stressors.

Population

The study was conducted online via Google Forms and Zoom. The population of the study were all OR nurses who met the inclusion criteria. These included nurses who newly joined the OR unit in the public hospitals in Singapore, working in OR unit areas, such as the reception and admission area, anaesthetic, operating room and recovery room. The nurses' roles included Admission, Anaesthetic Nurse, Post-Anaesthesia Care (PACU) and Scrub and Scout nurses, aged between 19 to 45 years old who are registered under the Singapore Nursing Board (SNB) as Registered Nurses (RN) or Enrolled Nurses (EN) and who are English literate. The final sample size was 91 for the quantitative study and eight for the qualitative study. Convenience and snowball sampling were used for the quantitative study, while the qualitative study used purposive sampling to obtain participant data.

Instruments

The study used two self-developed instruments questionnaires. The quantitative survey used the ‘Impacts on Operating Room Nurses with Transitional Support Programmes’(IORNTSP) survey and open-ended interview questionnaires as there were no existing validated surveys that explore impacts faced by OR nurses with their induction or orientation programme that are available to explore the construct of the study. The development of this study's instrument tools followed “The MEASURE Approach” developed by Kalkbrenner (Figure 1).²⁶ This approach was developed to help graduate students who had trouble accessing databases or textbooks for these resources as they were already financially burdened or had limited access to these resources from school and internet databases due to the requirement for product purchase or organisation affiliation to gain access.²⁶ The final pool of questions was set upon fine-tuning the questions in the instrument tools based on the expert reviewers' feedback. In total, there are 43 items in the quantitative survey and 24 items in the qualitative survey questionnaire guide. The items included demographic and time data and four operational variable data; behaviour presentation, causes, effects, and types. Cronbach's alpha was used to establish the tool's reliability. The reliability coefficient ranged between 0.74-0.81 during the pre-testing of the quantitative instrument and 0.76 – 0.88 for the actual study.

Make the purpose and rationale clear

Establish empirical framework

Articulate theoretical blueprint

Synthesize content and scale development

Use expert reviewers

Recruit participants

Evaluate validity and reliability

Figure 1: The MEASURE Approach by Kalkbrenner²⁷

DATA COLLECTION AND ANALYSIS:

Prior to the collection of data, ethical approval was granted by Unicaf University's ethical board. The purpose of the study was explained to participants via a participant information sheet and informed consent. Next, participants and organisational names were excluded during the data collection to ensure confidentiality and anonymity. Where applicable, email addresses received for the qualitative phase of the study were protected. Data analysis for the quantitative research was completed using SPSS Statistics version 28.0.1. It included descriptive analysis, measures of central tendency, regression analyses, Independent T-test and Spearman’s correlation. On the other hand, Braun and Clarke’s six-step thematic analysis was used for the qualitative data analysis to better guide the researcher during the thematic analysis procedure.²⁷ The six steps included familiarising oneself with the data, coding the data, searching for themes, reviewing the themes, defining and renaming the themes, and producing the report.^27,28

RESULTS:

The total number of completed quantitative surveys collected was 96, with only 91 valid based on the inclusion and exclusion criteria. The qualitative study reached data saturation after five interviews. Three more interested participants were nonetheless interviewed. However, data saturation was sustained. Data presented in Table 1 shows the general demographics of participants for both the quantitative and qualitative study.

a. Multiple mode exist. The smallest value is show

Research Question 1

To answer RQ1, each NJN evaluated eight statements from the IORNTSP survey related to either behaviour presentation or effects and types. These statements were evaluated using a 5-point Likert-scale for NJNs to respond. These included “Strongly agree = 1”, “Agree = 2”, “Neutral = 3”, “Disagree = 4”, “Strongly disagree = 5” or “Strongly satisfied = 1”, “Satisfied= 2”, “Neutral = 3”, “Dissatisfied = 4”, “Strongly dissatisfied = 5”. Additionally, “N.A.” was assigned the value “0” if participants viewed that the statement was not experienced by them.

The descriptive analysis reflected that 86% of respondents were satisfied with their OPs received. However, when it came to IPs, although there was a positive agreement that overall, the IPs received were helpful, nurses faced challenges due to the lack of technical skills exposure (60.4%), lack of content specific to the job role (59.3%), understanding and clarifying concepts during IP (50.5%), reaching competence level during probation (60.4%) and challenges with confidence due to lack of skills and knowledge received during their IPs (56%).

To answer RQ1, the independent T-Test showed no significance in knowledge and skills acquisition for those with or without IPs (p = .679). The Spearman correlation test to answer RQ1 reflects no significance and a weak positive relationship between not receiving necessary and sufficient technical skills with putting theory into practice (r_s = .14, p > .05).

The results from the qualitative data analysis for RQ1 derived from questions in the self-developed interview guide tool which emerged with two themes. These included quality of IP and skills and knowledge acquisition.

Research Question 2

To answer RQ2, each NJN evaluated 13 statements from the IORNTSP survey related to either behaviour presentation or effects and types. These statements were evaluated using a 5-point Likert scale for NJNs to respond.

RQ2 was analysed using multiple and single regression analyses. 13 statements from the self-developed tool were used to analyse this data. The results reflected the overall helpfulness of IP in preparing OR nurses in their ability to perform their job roles were dependent on five variables—for example, lack of technical skills exposure and the facilitators' guidance.

Additionally, the Spearman rank-order correlation test was used to answer RQ2. Variables were examined to understand their relationship, and it reflected that Q38 and Q39 had a moderate negative correlation and statistical significance with Q30, Q32, Q34, Q36 and Q37. Suggesting 5 out of 7 challenges OR nurses with IP faced impacted their ability to perform their job roles. The Spearman rank-order correlation test to answer RQ2 showed a weak correlation positive relationship and statistical significance of challenges faced understanding concepts and seeking clarification before and after IP (rs = .22, n = 90, p = .03).

For the qualitative study, questions from the self-developed interview guide tool were used to answer RQ2, with four themes emerging. These included adapting to a new clinical environment, quality of IP, resource persons during IP and challenges with skills and knowledge acquisition.

Hypotheses

The hypotheses testing used 14 variables to measure correlations among the variables. Additionally, to reduce bias in analysis, participants who entered ‘N.A’ for any of the statements were excluded from Spearman’s test. However, the researcher ran several groups of analysis to ensure that all variables correlations were examined accurately based on the responses applied. The results reflected correlations among all except variable Q28 with Q38 and Q39.

Data in Table 1 shows that although Q38 had a relationship with Q26, Q29 and Q33, they were not significant, meaning these three variables were only significant with Q39 with their relationship.

Table 1. Relationship of variables with IP overall helpfulness in job role preparation (Q38) and Overall job role suitability after undergoing IP (Q39). N=84 for all variables except Q34 and Q37 N=83.

Variables	r_swith Q38	Inference	r_swith Q39	Inference
Q26. Job Description	0.16	Not Significant	0.24*	Significant
Q27. Lack in receiving the necessary and sufficient technical skills	-0.62**	Significant	-0.30**	Significant
Q28. Team acknowledgement	0.11	Not Significant	0.17	Not Significant
Q29. Inability to put theory into practice based	-0.18	Significant	-0.24*	Significant
Q30. Lack of adaptation time	-0.56**	Significant	-0.43**	Significant
Q31. Facilitator guidance	0.60**	Significant	0.36**	Significant
Q32. Insufficient topic coverage during IP	-0.54**	Significant	-0.32**	Significant
Q33. Seeking understanding and clarity of contents during IP	0.02	Not Significant	-0.24**	Significant
Q34. Seeking understanding and clarity of contents after IP	-0.36**	Significant	-0.37**	Significant
Q35. Provided sufficient time reach competence level before role confirmation	-0.41**	Significant	-0.28*	Significant
Q36. Challenges in reaching competence level due to lack of time given during probation	-0.52**	Significant	-0.30**	Significant
Q37. Challenges in self-confidence in job role due to lack of skills and knowledge received	-0.56**	Significant	-0.40**	Significant

Correlation is significant at the 0.05 level (2-tailed).*

Correlation is significant at the 0.01 level (2-tailed).**

DISCUSSION:

Findings in this mixed method study that NJNs identified to have impacted them in their role after receiving IPs were consistent with the extant literature. In addition, this study's predictor variables were interrelated in presenting these impacts. Ultimately, as nurses in this study’s qualitative interviews shared, developing resilience in their professional roles helped them acquire the knowledge and skills required and overcome the challenges faced due to the impacts of their IPs. These findings were consistent with the literature within OR nursing suggesting that enhancing resilience could reduce transition shock and stress among NGNs in the OR unit;²⁹ and individuals need to learn to develop resilience in difficult situations and environments.^{16,17,30,31,32}

In relation to theory and conceptual framework, this study surfaced relevance to the frameworks regarding fresh graduate nurses' experiences and presentation of challenges with workplace adaptation. With experienced OR nurses, these challenges were lesser observed. The interviews showed that OR nurses with more years of working experience were more resilient towards independently nurturing their skills. They also shared that having a systemic approach with their IPs would have been beneficial. These findings were supported by existing literature.^33,34,34 Also, it was noted that certain perceived efforts were the cause of NJNs' behavioural presentations, such as independent learning and self-resilience. It echoed Warren and Mills' framework and the extant literature, suggesting that certain perceived efforts must be a product for nurses to react to their behavioural actions.^25,35,36

Next, regarding the findings to answer the RQs and testing of the hypotheses, it emerged that for RQ1, challenges OR NJNs faced even when given an IP were multifaced. The quantitative survey revealed that these included a lack of technical skills exposure during IPs, insufficient content in the IPs to help function in their roles and ability to reach their competency level during probation due to the lack of resources.

The qualitative findings on the other hand reflected that these challenges were depended on the quality of IPs and their ability with skills and knowledge acquisition. The findings were similar shared in the literature stating the relationship between structure teaching program and its effectiveness in upgrading the nurses knowledge and skills.^{37, 38}

For RQ2, the findings reflected that the availability of resource persons during IPs was critical in the overall nurses' transition. The findings similarly echoed existing studies that shared the importance between resource persons and NJNs in a new to a nursing unit.^2,39 Secondly, the challenges nurses faced due to the IPs they underwent influenced their ability to perform in their assigned job roles. There was, however, no significance when it came to being identified as a team member and putting skills and knowledge with the lack of adaptation time.

Lastly, in the qualitative findings, it was noted that adapting to a new clinical environment was among the most prominent theme of the four themes that emerged when transitioning to their job role. The finding was similarly shared in the literature stating the relationship adapting to a new clinical environment from a student nurse to a professional nurse.⁴⁰

Lastly, based on the inferential analyses, the alternative hypotheses were to be accepted and the null hypotheses to be rejected. It illustrated that whether OR NJNs had or did not have IPs, it would enhance their knowledge and skills in performing their job role.

RECOMMENDATIONS:

This study supported the need to acknowledge the impacts perioperative NJNs in Singapore faced with their IPs. These impacts were the form of challenges identified that affected their ability to function efficiently in their job roles and their ability for knowledge and skills acquisition. Unknowingly to OR nursing management, educators and NJNs, the impacts discovered in this study had causal effects on all parties.

The recommendations arising from this study aimed at supporting Singapore OR nursing organisations to improve the structure of their IPs, encouraging NJNs self-initiative to partner with their OR nurse educators, preceptors and management in their knowledge and skills acquisition, and, lastly, lessen the burden of nurses in their transition to practice or a new clinical environment.

The recommendations for practical application include

· Reviewing the contents and delivery of OR nursing IPs in Singapore,

· Making available a new graduate programme for speciality care areas in Singapore, and

· Devising the roles of mentors and preceptors.

The recommendation of future research to future explore this study’s phenomenon would include adopting simple random sampling to allow all eligible participants to participate in allowing representativeness of the studied population, strengthening participants recruited for the qualitative study to have a broader demographic of OR units nurses, exploring more about OPs delivered to review its effectiveness and relevance in speciality care areas for their job preparedness, and lastly, undertake similar studies using a longitudinal approach to provide a better outlook of the phenomenon over some time.

CONCLUSION:

The central challenge that impacted OR nurses with their job role was reaching a competence level during probation due to the lack of resources. Nurses in this study also expressed that the problem with the lack of resources during their IPs later impacted their ability for purposeful knowledge and skill acquisition. The obstacles included in these issues were the lack of learning exposure, retention and reflection.

Participants in this study also expressed that acquiring the correct knowledge and skills was essential to help them function in their assigned job roles efficiently. This study found that IPs (theory-based) that were run for about 1-4 weeks long were helpful overall. It concerned the theoretical aspect of the job roles assigned. Ultimately, this study found that regardless of their IPs' effectiveness, OR NJNs' resilience and initiatives to seek clarification reduced the challenges that impacted them in their role performance after their IPs—additionally, all NJNs required time to adjust and adapt to their new environment and roles. Lastly, much nursing literature in Singapore and other work-related impacts focuses on resilience, while international counterparts focus on self-directed learning. This study shared the importance of immersing both elements to overcome the impacts of IPs on Singapore OR NJNs.

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Received on 28.06.2023 Modified on 09.09.2023

Int. J. Nur. Edu. and Research. 2023; 11(4):321-327.

DOI: 10.52711/2454-2660.2023.00072

Variable	Range	Mean	Median	Mode
Age	19-45years old	24.5	23	21^a
Gender	Male (1), Female (2) or Others (3)	1.65	2	2
Job rank	EN (1), RN (2)	1.65	2	2
Job title	Admission Nurse (1), Anaesthetic Nurse (2), Post-Anaesthesia Care (3) and Scrub and Scout nurses (4)	3.16	4	4
Qualifications	Nitec (1), Diploma (2), Bachelor Degree (3), Master or equivalent (4)	2.19	2	2