Nursing is a profession that touches other’s lives. Nurses are responsible for bringing wellness to patients. Nevertheless, nursing is considered a stressful profession (Ibrahim et al., 2016). A nursing job is complex because they must apply competencies—knowledge, motor skills, and affection—simultaneously. Nursing students are prepared for those three competencies in the nursing education profession (Ibrahim et al., 2016).
Some barriers would interfere with a nurses’ work quality. Studies show that nurses’ workloads make them susceptible to stress (Regan et al., 2017). Because of their workload, time restriction, and lack of professional role understanding, nurses lack compassionate care and tend to do routines (Babaei & Taleghani, 2019). A study at a hospital in Thailand showed that nurses’ emotional fatigue affected service delivery for patients, such as falls, errors in drug administration, and increased infections (Nantsupawat et al., 2016). Thus, a nurse’s psychological condition can interfere with their work performance. However, Foster et al. (2015) highlighted that someone who has a strong capacity for soft skills would show the ability to control personal emotion, flexibility to face changes and adapt, optimism, innovation, and initiative.
Soft skills are a set of skills believed to be helpful in workplaces. As for nurses, soft skills contribute to meet the demands of the nursing profession. Clinque (2016) groups soft skills into several categories: personal skills, social skills, self-skills, and learning skills. Soft skills involve social or interpersonal skills and the ability to achieve and apply competencies in various situations (Clinque, 2016). In relation to nursing jobs, some studies confirmed that soft skills play important roles in nursing practice (Seutloadi, 2015; Ng, 2020). Raghubir (2018) stated that the quality of patient care, using critical thinking for decision making are essential soft-skill attributes. These are also needed in order to make satisfying collaboration with fellow nurses and other healthcare professionals. Thus, having soft skills make it easier for nurses to do their nursing job. This also applies to a novice nurse. Novice nurses need to use both of their hard- and soft-skills attributes in their adaptation phase to succeed in their nursing careers. Soft-skills capacities enable them to succeed in their job. However, such competencies are considered more problematic for freshly graduated nurses.
Generally, in Indonesia, novice nurses are those who have just graduated with a diploma or bachelor’s degree in nursing, should have one year of experience for the orientation at a hospital, guided by senior nurses who have authority when they are in charge during a shift at a ward/unit. Nurses who undergo clinical practice have independent management and provide holistic nursing care (Hariti & Rejeki, 2020; Hartiti et al., 2020). The human resources hospital management has requirements for qualified nurses who show professional attitudes to provide patients’ satisfaction. A better quality of nursing care indicates a higher level of nursing services (Hartiti et al., 2020).
Studies about soft skills in nursing education are considered scarce. However, one of the preliminary studies from 264 bachelor nursing students about soft skills in Indonesia found that the soft skills of nursing students in the 2nd, 4th, 6th, and 8th semesters have increased each semester. The study could be underlined as the maturity of professional attitude. In addition, it is also found that 32.3% of nursing students had high soft skills, 55.7% with moderate soft skills, and 12% with low soft skills. The best soft skills of the students were teamwork, morale, and professional ethics, while the lowest soft skills were the ability to lead and the capability for critical thinking (Hartiti & Ernawati, 2016).
Several studies have examined some essential soft skills to support carrying out duties and responsibilities in the workplace; one of the studies was conducted by Chiu et al. (2016). However, fewer studies have captured important soft skills for nursing jobs. To deliver the quality of nursing care, nurses need to have such essential characteristics: reliability, responsiveness, empathy, and assurance (Ng, 2020). In the context of Indonesia, the study conducted by Ariani and Aini (2018) found that nurses caring behavior is one of the factors that determine a patient’s satisfaction. However, those two studies did not specifically capture the soft skills needed by new graduate nurses to be successful in their early career life.
In addition, those studies only included the patients and or their families as the research participants. In fact, in doing nurses’ works, the freshly graduated nurses need to collaborate with other healthcare workers to achieve nursing goals. Therefore, it is necessary to know the perception of senior nurses about what essential soft skills are needed by new fresh graduate nurses or novice nurses. Therefore, this qualitative study aimed to explore the perceptions of senior nurses in a private hospital in the capital city of Indonesia regarding essential soft skills for novice nurses.
Methods
Study Design
This study used a qualitative research design with interpretive phenomenology as the methodology to get the perception of experienced nurses of how soft skills may impact the performance of novice nurses. Phenomenology is considered appropriate for understanding the significance of one’s experience (Polit & Beck, 2017). Furthermore, interpretive phenomenology describes the phenomenon and emphasizes researchers’ understanding of socio-historical context when interpreting and understanding a phenomenon (Polit & Beck, 2017). The study was conducted at one private hospital in Jakarta, the capital city of Indonesia, as a meeting place for various people from different cultures in Indonesia.
Participants
The recent study includes ten nurses who matched the inclusion criteria: nurses with ten years of working experience at the hospital, interacting intensely for at least three months with new graduate nurses, and serving as mentors for novice nurses during the orientation period in the hospital. The participants were from several different care units: Intensive Care Unit (ICU), emergency department, surgery room, medical care unit, pediatric room, and primary care unit. Data saturation could be achieved even when only five to eight participants are included (Norwood, 2010; Boswell & Cannon, 2014; Polit & Beck, 2017). The participants were recruited using a purposive sampling technique.
Data Collection
The data were collected in one private hospital in Jakarta, the capital city of Indonesia, from June to July 2018. Semi-structured interviews were used, and several interview questions were prepared prior to data collection (Table 1). The interview was held in a secure place in the participants’ work unit for about 30-60 minutes, audio recorded, and conducted in Indonesia language by the first author.
| Question |
|---|
| 1. What routine tasks do new graduate nurses do in health care service in the hospital? |
| 2. What specific tasks are usually given in their early days of working as novice nurses? |
| 3. What factors enable the new graduate nurses to adapt quickly to their job and working environment? |
| 4. What experiences regarding the new graduate nurses’ soft skills do you have? |
| 5. What soft skills should the new graduate nurses have? |
| 6. What are your expectations for educational institutions in educating prospective nurses? |
Data Analysis
Data were analyzed using Gadamer’s hermeneutic approach (Gadamer, 1989). This approach has three characteristics: prejudice (prior knowledge), hermeneutical circle, and tradition (culture or context). In interpreting the meaning of the studied object, the researchers should bring together the prior knowledge and the background into the hermeneutical circle (Gadamer, 1989). Prejudice (prior knowledge) helped researchers to understand the topic being studied and the process of data interpretation. The initial perception obtained from the experiences as lecturers in one of the nursing schools in Jakarta would enrich the study results. Prior knowledge makes it possible for the researchers to understand research’s participants’ perspectives. Some of the prior knowledge owned were: nature of the nurses’ job, researchers’ previous experience in guiding nursing students, and Indonesian cultural understanding. Knowing and experiencing all of those things makes the researchers have a sense of a research context. The background is essential to help researchers understand the reason for one’s behavior. The hermeneutical circle process makes it possible for the researchers to track back again to the previous steps. With prior knowledge and background, as well as the hermeneutical circle process, it is believed it might bring the researchers to make the correct interpretation of the studied topic.
In this study, firstly, the researchers attempted to gain a sense of the data. After that, the researchers analyzed the data in more detail. Finally, in generating the precise meaning, the transcripts were read repeatedly until fusion was gained and a new understanding was developed. The analysis process is described in the cycle below (Figure 1 and Table 2).
| Phrases | Formulated meaning | Code | Cluster |
|---|---|---|---|
| ● “Do not be easily offended, yes this attitude has to be eliminated, mmm...because if everybody is reacting like that, it won’t solve any problems.” (P1) | The irritable character has the potential to impede the work. | Self-control | Personal Skills |
| ● “Fresh graduate nurses may inform any experienced nurses that they actually cannot do a procedure properly. If they doubt their abilities in conducting a procedure, they may ask for a companion because the orientation process has not finished yet.” (P2) | Any incompetence needs to be told openly to experienced nurses or mentors. | Initiative | |
| ● “… for example, we can sit in front of patients and their families. We care about him, so we educate him to prevent complications …” (P3) | Caring behavior for patients and families is done by giving a lot of time and educating them. | Caring | |
| ● “So, if the motivation is only to have a job and get the salary, they won’t enjoy their work. So, it’s easy to get frustrated, easily bored, and so on […] we live our profession as if we have married our profession. We walk with it entire life” (P3) | Novice nurse’s working motivation would help them to endure the challenging situation in the working place. | Self-motivated | |
| ● “In my opinion, nurses’ attitude is the most necessary thing for patients. Do not need to prescribe a lot of medicine; the most important is nurses’ attitude. Smiling, greeting, … I always say “Please keep smiling” to everyone. “(P2) | One study participant thinks that patients need nurses with good habits such as smiling and greeting. | Hospitality | Social Skills |
| ● “For example, yesterday, it was supposed to be my day off, but because there were many patients at that time, and more nurses were needed, I was called to come to work … I was called at 4 in the morning.” (P4) | The expectation for novice nurses to be flexible to change their day off at any time if needed by their colleague in the working unit. | Flexibility | |
| ● “As the mobility is high here … I want them to be fast too. If they work slowly, it would add burden to other team members. So, it cannot take a long time to adapt” (P2) | The need to adjust to the rhythm of work in the working unit. | Adaptability | |
| ● “… I would say that they have to think critically.” (P5) | Analytical thinking is an important attribute. | Analytical skill | Self-regulation of the learning process |
| ● “The first three months were preparing them to make a real presentation in front of the committee who evaluated them.” (P1) | Conducting a scheduled nursing care presentation as an evaluation method for novice nurses. | Presentation skill |
Trustworthiness/ Rigor
The interviews of all participants were recorded using an electronic audio recorder to seek the study’s credibility. This process enabled the researchers to pick up all of the information. Then, the transcripts of the interview were sent to all participants to be validated. The transcripts of the interview were translated by the researchers to eliminate the risk of imprecise meaning. Dependability was obtained by reaching an agreement between two researchers on the data analysis process, while conformability was sought by providing clear research steps. Finally, transferability was obtained by selecting participants from many fields.
Ethical Consideration
Ethics permission was obtained on 15 January 2018, with protocol number 18-01-0051, from the Ethics Committee of the Health Research Ethics Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo Hospital in Jakarta, Indonesia. Prior to data collection, researchers sought approval from all study participants through informed consent. In conducting this research, the researchers still uphold ethical values such as participant confidentiality and autonomy. Each participant was given the flexibility to withdraw from the study if they felt uncomfortable without any consequences. The benefit of this research for research respondents is that through this research, they could provide an overview of the hospital’s facts and provide suggestions for curriculum improvements to educational institutions, which will affect the quality of nursing care in the hospital’s future.
Results
The study participants ranged in age from 33 to 56 years old nurses from ten different rooms and seven different care units. Their units were: medical care unit, surgical care unit, pediatric intensive care unit, pediatric care unit, intensive care unit, outpatient unit, and emergency care unit. Of ten participants, nine of them were female, and only one was male.
This study revealed nine attributes from three major categories of soft skills needed by novice nurses from the perspective of ten experienced nurses (Figure 2). Based on the experienced nurses’ perspectives, having those soft skills would enable the novice nurses’ successful transition. As a profession with altruistic characteristics, nurses’ soft skills play an essential part in their daily duty. Soft skills contribute to the quality of patient care and the success of collaborating with colleagues, which in turn will bring positive impacts on the institution where they work. Participants’ quotes of each category can be seen in Table 2.
Personal Skills
Personal skills are aspects related to feeling comfortable and loving what we do. This helps nurses to be part of a good teamwork members because we understand other needs and desires. It also includes honesty of our emotions towards us, co-worker, or people around us. Study participants mentioned some personal skills needed from novice nurses: self-control, initiative, caring, self-motivation (Table 2).
Self-control
There will be a time when workplace strain cannot be avoided. The strain arises as a result of interaction made in teamwork or with patients. In an emergency, sometimes it is unavoidable if other team members are outspoken with each other. In this situation, nurses need to control their feelings and not be easily offended so that their performance at work will not be affected.
Initiative
It is understandable if, in orientation time, the novice nurses have not mastered all nursing procedures properly. However, suppose novice nurses feel they are unable to carry out nursing procedures for patients. In that case, they need to take the initiative to inform the experienced nurses so that they are accompanied. It is hoped that this will reduce the risk of mistakes.
Caring
Every nurse should be familiar with the values of conduct in the nursing profession. The nursing profession has a moral idea of caring. This value must be attached to every single part of their action. A nurse needs to be aware of whether their actions are displaying caring values.
Self-motivated
Nursing is known as a “dirty job,” one that is considered close to “smelly” and “dirty” things. Many nurses’ daily activities are unpleasant. A nurse needs to be aware of her interest in the nursing job. Feelings of bored and easily frustrated might prove that they do not enjoy their job. Thus, a novice nurse needs to realize whether the nursing profession is the choice or not. Developing self-belonging requires quite a long time. A study participant has a high priority on her career as a nurse. She believes that the profession is part of her life. In addition, from the interviews, personal skills are most expected from the novice nurse working in the place where this study was conducted. Besides being useful during the orientation period, personal skills are also crucial for their future career.
Social Skills
Social skills are vital soft skills possessed by all nurses as they need to interact with many people, with patients and their families, and with their teamwork. This study revealed three elements of social skills necessary for novice nurses: hospitality, flexibility, and adaptability.
Hospitality
One of the social skills needed when provides nursing care is hospitality. Hospitality makes it possible for a nurse to make patients feel comfortable and welcome during hospitalization time. This attitude is believed would bring greater contribution to patients’ healing.
Flexibility
Due to a lack of nursing staff in the inpatient unit, a nurse often gets a sudden call to work even though they were previously scheduled to be off work. In a particular situation, the nurses must be willing to change their working schedules.
Adaptability
Novice nurses hope to be adaptive with their team members and follow the rhythm in the workplace. Therefore, the ability to adapt is essential. Due to the quality and effectiveness of nursing care for patients, the new nurses need to adapt quickly to the working culture in the workplace, including adjusting their working speed. Nursing is a profession close to humans as a social being. To be a nurse, it is a must to have strong social skills as they need to interact and collaborate with people with different characteristics. It is undeniable that this profession requires members with excellent social skills.
Self-Regulation of the Learning Process
Self-regulation of the learning process was also a concern of study participants. From the study participants, in the orientation time, novice nurses were also needed to have analytical skills and presentation skills.
Analytical skill
This study revealed the analytical skills needed from a novice. As nurses need to oversee patients’ health conditions for 24 hours, they need to assess patients’ health changes and analyze what intervention modifications should be made.
Presentation skill
In the private hospital where the study was conducted, all novice nurses would also be evaluated through the nursing case presentation. In this study, they set a target for novice nurses to make a presentation. In addition, they must present the implementation of one nursing care they manage in the first three months. Thus, they need to regulate themselves so that the task of presentation and their daily duty at work could be handled well.
Discussion
This study was the first study in Indonesia to examine the essential soft skills for novice nurses, especially in their transition time from education into practice in the workplace. Through the findings of nine essential soft skills, this study has given an overview of what sort of soft skills will be needed in the transition phase that may significantly contribute to improving the quality of nursing care. In addition, the findings in this study can be used to set standard soft skills on nursing staff recruitment in hospitals.
To begin with, the job of a nurse is close to the safety issue. In carrying out their work, a nurse strives to provide high-quality nursing care for the patient’s health status. To achieve optimal patient health, a nurse needs to work in a team. Cooperate and collaborate with other nurses and other health care professionals in a hospital, and complement each other according to their competencies. Thus, a nurse needs to have soft skills which will help her to work as a team. Several soft skills that are important to enable nurses to work in a group are self-awareness (Turan, 2018) and a set of social skills.
However, this study did not find self-awareness as one of the essential soft skills for novice nurses. Even though some literature highlighted that this soft-skill is crucial for nurses as an altruist profession (Son, 2018; Turan, 2018), self-awareness will lead nurses to understand their feelings, thoughts, beliefs, and values. Nurses with good self-awareness will provide more care to patients and will affect the quality of service to patients (Rasheed, 2015). It also influences their professional relationship and communication (Turan, 2018). Furthermore, self-awareness is crucial to be owned by novice nurses as it enables them to face difficult situations successfully (Younas et al., 2020). Even though the level of self-awareness is greatly influenced by age and working experiences (Rasheed, 2015), it is difficult for novice nurses to have a high self-awareness level, which is still possible to build during the education period. The education period is one of the opportunities that can be used to build self-awareness. Therefore, it is useful to include self-awareness into nursing curricula (Rasheed, 2015). This study is also supported by Kim and Yi (2015) suggested that self-awareness should be developed during students’ life. If it is not built during the education period, it will be more difficult for novice nurses to display good performance.
This study discovered that caring attribute is important. Caring is considered the identity of the nursing profession. Caring is the soul of the nursing profession. This value must be internalized in every nurse and reflected in their actions every day. One study participant was concerned about novice nurse caring action towards patients and families. In this regard, one application that requires caring values is Person-Centered Care (PCC). PCC by nurses strongly determines the quality of service for patients (Sagong & Lee, 2016). However, one study of 310 nurses in Turkey found that study participants were less concerned about a professional value called altruism (Erkus & Dinc, 2018). This study is consistent with this study finding which found an expectation for novice nurses to have caring value in every action they do. Dehghani (2020) highlighted that healthcare services could be improved by developing professional ethics during education. However, it is believed that one’s background and individual factors also play an essential role in professional ethics development among students (Dehghani, 2020).
Another highlighted finding from this study was social skills. For nurses, social skills are needed as they are closely related to “humans” who are social beings. Competent nurses are not only determined by their academic achievement but also their response to other people’s needs. Good social skills enable new graduate nurses to give a correct response when advice is provided to them. On the other hand, weak social skills result in any conflicts among the members of a team, for example, communication skills. Failing to apply communication results is a problem of interaction (Souza et al., 2016), which would make it difficult for a nursing job that relies heavily on the teamwork process. Interpersonal conflict at work will weaken teamwork (Kim et al., 2017), whereas the quality of patient care depends on solid collaboration. In carrying out his profession, a nurse needs to have social skills. Social skills are crucial for nurses as a teamwork profession. It is vital as, most of the time, nurses must work in a team (Abraham & Scaria, 2017). It is not enough for nurses to know only their responsibility, but nurses need to have a team-oriented mindset (Kaiser & Westers, 2018). As a team, they must be aware of the needs of others. Aside from that, Afsar et al. (2019) highlighted that willingness to help colleagues arises from a nurse’s sense of calling. Adaptability is also determined by career motivation (Fang et al., 2018). Minster (2020) highlighted that flexibility and adaptability are essential social skills for a nursing job, as it enables nurses to tolerate stress in their workplaces. In a study conducted by Mizuno et al. (2017), it is known that male nurses communicate more and are able to collaborate with colleagues compared to their counterparts. This study also underlines that when someone has good communication skills, they tend to have the ability to express their feelings well. Then, it will lead to physical and mental health problems. It is also suggested to enhance the knowledge and awareness of verbal communication among nurses to improve the patient-nurse relationship.
Regarding commitment & motivation, Fang et al. (2018) found that the careers of undergraduate nurses are affected by career motivation. In addition, the work motivation level is affected by age, years of experience, autonomy, education, and administrative positions (Baljoon et al., 2018). In addition, organizational factors also contribute to nurses’ work motivation. Sasaki et al. (2019) found that work commitment is considered weak during 1-2 years of work experience. Nurses’ work motivations are also affected by salary and career development; a conducive working relationship; and supervision (Baljoon et al., 2018). Above all the factors mentioned before, it is highlighted that compassionate love impacts professional commitment (Mersin et al., 2020). Thus, vocation is the most determinant factor for working commitment.
Regarding organizational commitment, Labrague et al. (2018) found that organizational commitment is affected by a nurses’ age, gender, education, rank, and work experience. Organizational commitment is vital to every nurse because it helps them better care for patients (Naghneh et al., 2017; Ha & Nuntaboot, 2020). On the other hand, the clarity of calling as a nurse makes a nurse have a stronger career and organizational commitment and tend to be willing to help colleagues and strive for the good of the organization (Afsar et al., 2019).
The efforts to develop soft skills for nursing students, as in the curriculum, are considered necessary (Ng, 2020). This is confirmed by a study conducted by Bratajaya and Ernawati (2020a), who found that new nurses did not have adequate soft skills at work. It is believed that soft skills must be internalized in their education. Improving the student’s social skills, for example, would improve their mental health (Moeller & Seehuus, 2019). Ghasemi et al. (2018) recommended workshops that can improve the nursing students to be mentally spiritually ready to carry out their job responsibility. It would help prepare individual nurses to be more prepared for any challenges in their workplace. Ideally, soft-skills education starts early. Kim and Yi (2015) suggested that self-awareness should be developed during a student’s life. If it is given only during higher education, the results will not be optimal. Challenges should be identified from the beginning of education. The education process is done for a moment in the classroom and integrated into the entire curriculum. On the other hand, Raeissi et al. (2021) suggested that the hospital is responsible for improving nurses’ emotional intelligence, such as self-awareness, through organized training. Moreover, it is found that experienced nurses and mentors can be potential role models for new nursing staff (Bratajaya & Ernawati, 2020b).
Other soft skills expected from experienced nurses were analytical and Self-regulation of the learning process. Experienced nurses in this study think that novice nurses must already have critical thinking skills. Lee et al. (2020) stated that critical thinking skills are not influenced by age or experience but by education. So, it is suggested that during education time, students are trained to have good critical thinking. In achieving this goal, one of the ways that can be applied in the learning process is case-based learning (Sapeni & Said, 2020). To enable students to make health care decisions while doing nursing jobs in the future, they need to be trained for critical thinking (López et al., 2020). Other than that, Ibrahim et al. (2016) highlighted that self-regulation is essential for nurses to be able to provide good quality care. Even though analytical and self-regulation were less mentioned in this study, these two skills are still paramount owned by novice nurses.
This study proved that the quality of nursing services could not be separated from nurses’ soft-skill attributes. Their soft skills need to attach to their personality. However, this study has some limitations. First, due to time and financial constraints, the researchers narrowed down the scope of study aim. Second, we only aimed to capture the perception of nurses working in a private hospital in Jakarta. With only ten participants, the data may not describe the perception of Indonesian nurses in general. Third, the findings might not capture the soft skills needed for nurses working in public hospitals in Jakarta or other regions of Indonesia. The need for soft skills might be different from public hospitals, which the public hospitals in Indonesia usually have more patients from lower-middle economic status and education levels. With the more complicated situation, it would be more soft-skills attributes needed. Regardless of the study limitations, this study is believed to give a significant contribution to the improvement of the quality of nursing care nationally and internationally. This study can be used as evidence to recommend integrating soft skills into the nursing education curriculum.
Conclusion
Soft skills are crucial for nurses’ professional practice, especially in the hospital setting. This study highlighted nine essential soft skills for novice nurses to successfully go through the transition from education to practice in the workplace as well as for their career ladder. As a profession that upholds altruism value, the members of the nursing profession must have strong, caring attributes. Moreover, this profession is also identical to teamwork, and it requires strong social skills as the implication. To improve the quality of nursing care, educational institutions need to incorporate soft-skills attributes into the curriculum and integrate them into the learning process throughout daily guidance or workshops and seminars. It is hoped they will be internalized and embedded in their professional life. In addition, studies about soft skills in nursing education need to be refined, especially for soft skills that have not been discussed much yet. Therefore, this study should be continued, and it is suggested for future studies to include more participants from patients and families, nursing students, and other health care professions.