A Comprehensive Practice Package to Support Clinical Competence and Transition of Newly Qualified Registered Nurses

1. Introduction

Newly qualified registered nurses (NQRNs) often enter the healthcare workforce facing multiple challenges, including high patient acuity, complex technology, and critical decision-making demands. These challenges may result in anxiety, burnout, and decreased performance [1,2]. A Comprehensive Competency Improvement Package (CCIP) is therefore essential to support their development and ensure safe, high-quality patient care.

The post-academic acknowledgement of complete professional responsibility is one of the critical stages of the much-needed challenge to NQRNs. During this period, there is usually a period of transition shock wherein the student feels anxious, unstable, and a lack of fit between training and the harsh requirements of clinical practice [3]. These global challenges have been further compounded in the South African context by system-level challenges, such as exceedingly high patient loads, a shortage of resources, and reported deficits of practical skills, role definition, and clinical confidence among new graduates [4,5]. The inability to support this vulnerable stage properly jeopardizes patient safety and lowers the quality of care, leading to excessive turnover and burnout rates, which are causing the healthcare workforce to be in a weak state. Although international evidence is available on the application of structured transition programs [6,7], a standardised, evidence-based, and contextually relevant framework regarding the South African context is largely lacking. The package of comprehensive, theory-guided practices is described at length in this document and is proposed to help fill this gap. It offers an orderly framework that will lead to the development of clinical competence, professional adaptation, and maintaining NQRNs in the South African healthcare system.

To address these challenges, structured interventions are necessary to build competence, confidence, and professional identity among NQRNs. This study aims to explore and design a comprehensive practice package, guided by Roy’s Adaptation Model (RAM) 1976 [8], to support NQRNs in adapting effectively to their professional roles. Roy’s Adaptation Model views the individual as a biopsychosocial being who continuously interacts with and adapts to environmental stimuli. Adaptation occurs in four adaptive modes:

• Physiological-physical mode – meeting basic needs and developing skills to function effectively.
• Self-concept mode – building confidence, self-esteem, and professional identity.
• Role function mode – clarifying professional responsibilities and expectations.
• Interdependence mode – fostering supportive relationships and teamwork.

Applying RAM to NQRNs, the transition period can be understood as a time when multiple stressors (workload, responsibility, clinical complexity) act as stimuli. The practice package was therefore designed to strengthen adaptation in all four modes by providing structured orientation, mentorship, competency assessments, and reflective practice opportunities.

1.1. Aim

To explore the transition challenges of newly qualified registered nurses and inform a structured clinical competency package to support their professional development.

2. Methodology

2.1. Research Design

This study adopted a mixed-methods explanatory sequential design [10], beginning with a quantitative phase followed by a qualitative phase. The choice of this approach was deliberate: the quantitative phase provided a broad statistical picture of the experiences, competence levels, and transition needs of newly qualified registered nurses (NQRNs) across the district. Building on these results, the qualitative phase explored in depth the personal narratives of NQRNs, thereby contextualizing and enriching the initial findings. The explanatory sequential design ensured that the numbers highlighted the what—such as areas of competence deficits and stress points—while the focus groups revealed the why and how behind these challenges. Integrating both forms of evidence supported the development of the Comprehensive Clinical Integration Package (CCIP) in a way that was empirically grounded yet sensitive to the realities of clinical practice.

2.2. Quantitative Phase

2.2.1. Sample Size, Sampling, and Recruitment

The study targeted the entire population of 1,380 newly qualified registered nurses (NQRNs) in the Chris Hani District. A statistically representative sample of 301 respondents was calculated using the Raosoft sample size calculator, and 272 NQRNs ultimately completed the survey, resulting in a high response rate of 90%. A simple random sampling technique was employed to ensure fairness and representativeness, giving each eligible nurse an equal opportunity for selection. Inclusion criteria comprised registered nurses with less than five years of professional experience working within the district, while senior nurses, managers, and those employed outside Chris Hani District were excluded to maintain focus on nurses in the early, often most challenging, stages of professional practice.

2.2.2. Data Collection Process

Following ethical approval and gatekeeper permission, the researcher accessed the district’s nursing managers’ WhatsApp group to obtain contact details for the sampled NQRNs. A digital survey link was then distributed to participants via WhatsApp and email, with managers assisting in disseminating the link across different healthcare facilities to ensure representation from various settings. The survey included demographic questions and structured Likert-scale items, and its opening section outlined the study’s purpose, assured participants of anonymity and confidentiality, and incorporated an informed consent statement. Participants were informed that their involvement was voluntary and that they could withdraw at any time. To enhance response rates, gentle reminders were sent throughout the data collection period.

2.2.3. Data Analysis

Quantitative data were initially captured in Microsoft Excel and subsequently analysed using SPSS version 29.0. The analysis commenced with descriptive statistics, including frequencies, means, and standard deviations, to provide a comprehensive overview of respondent characteristics and key survey responses. Building on these results, inferential statistical tests were conducted to examine significant relationships between variables, with particular focus on factors related to clinical competence, workplace support, and the adaptation challenges experienced by newly qualified registered nurses (NQRNs).

2.3. Qualitative Phase

2.3.1. Participants and Sampling Strategy

For the qualitative phase, a purposive sampling approach was employed to select participants capable of providing rich, in-depth insights into the transition from training to independent practice. Inclusion criteria required participants to be registered nurses with one to five years of post-qualification clinical experience, currently working within the Chris Hani District. Senior nurses, managers, and nurses employed outside the district were excluded to maintain focus on early-career experiences. A total of 25 newly qualified registered nurses (NQRNs) volunteered to participate in the qualitative phase.

2.3.2. Data Collection

Three semi-structured focus group interviews were conducted, each lasting 40–60 minutes and involving six to eight participants. Sessions took place in public hospital meeting rooms to ensure participant comfort and confidentiality. The primary researcher facilitated each group using an interview guide with open-ended questions, supplemented by follow-up probes to encourage deeper reflection. With participants’ consent, all discussions were audio-recorded, and field notes were taken to capture non-verbal cues and contextual details.

2.3.3. Data Analysis

Data were analysed using Braun and Clarke’s (2006) six-phase thematic analysis framework [11]. This inductive approach allowed themes to emerge naturally from the focus group discussions. The research team collaborated throughout the process, enhancing rigour through peer discussions and cross-checking of interpretations.

2.4. Ethical Considerations

Ethical approval was granted by the University of KwaZulu-Natal Humanities and Social Sciences Research Ethics Committee (HSSREC/00007754/2024) and the Eastern Cape Health Research Committee (EC_202410_033). Approval date was 16 October 2024. Written informed consent was obtained from every participant after they received a clear explanation of the study’s purpose, procedures, and their rights.

3. Results

3.1. Results for the Quantitative Study

3.1.1. Descriptive Results

These constructs were verified by the measurement model, which was rigorously evaluated for reliability and validity. Cronbach’s alpha and Composite Reliability (CR) were implemented to guarantee reliability testing. All constructs exhibited satisfactory reliability, as Cronbach’s alpha values for each construct exceeded the predetermined threshold of 0.70, suggesting a suitable level of internal consistency.

3.1.2. Demographic Profile of Respondents

This demographic spread provides a representative cross-section of early-career nurses in the district, ensuring that both educational pathways and varying levels of practice exposure are reflected in the findings as shown in Table 1.

Table 1: Variable		Frequencies	Percentage
AGE	20-24	46	16.99%
	25-29	140	51.35%
	30-34	53	19.31%
	35-39	21	7.72%
	40+	13	4.63%
GENDER	Male	116	42.64%
	Female	155	56.98%
	Prefer not to say	1	0.39%
WORK EXPERIENCE	One Years	99	36.43%
	Two Years	52	18.99%
	Three Years	121	44.57

3.1.3. Descriptive Statistics

Descriptive statistics were used to summarise and present the research data systematically, providing a clear overview of respondents’ characteristics and survey responses. Measures such as frequencies, means, and standard deviations were calculated, and findings are presented to highlight key patterns and trends. This analysis offered important insights into the professional profile of newly qualified registered nurses (NQRNs) in the Chris Hani District.

3.1.4. Job Satisfaction

The findings indicate that newly qualified registered nurses (NQRNs) exhibit a generally low to moderate level of job satisfaction, with a mean score of 2.25. The relatively low standard deviation (0.62) suggests that responses were fairly consistent across participants. Regarding perceived value in their roles, NQRNs reported a moderate level (mean = 2.17), with some variation (SD = 0.65), indicating that while some feel valued, others feel less so. When asked about recommending their job, NQRNs showed a moderate inclination (mean = 2.19), with the highest variability in responses (SD = 0.73), suggesting differing levels of willingness to endorse their work. Overall, the results portray a workforce with moderate satisfaction, perceived value, and endorsement, but with some inconsistencies among individuals.

Table 2: Job satisfaction
	N	Mean	Std. Deviation
Satisfied are you with your current job	256	2,2461	,61833
How often do you feel valued in your role as a NQRN	258	2,1667	,64775
Likely are you to recommend your workplace to another NQRN	258	2,1899	,73197
Valid N (listwise)	254

3.1.5. Training & Support

The results suggest that NQRNs perceive the adequacy of training during their transition phase as only fairly sufficient, with a mean score of 2.28. While some participants found the training effective, there is moderate variation in opinions (SD = 0.78), indicating differing experiences of instruction quality. Peer feedback was reported as relatively limited (mean = 2.20; SD = 0.75), reflecting variation in opportunities for collaborative learning. The mentorship program was viewed moderately positively (mean = 2.26), though perceptions of its effectiveness were mixed, as indicated by the moderate spread of responses (SD = 0.79). Continuing education emerged as a clear priority for NQRNs (mean = 2.86; SD = 0.41), with little variability, showing strong consensus on its importance for professional growth. Finally, self-directed learning received a moderate endorsement (mean = 2.41; SD = 0.67), highlighting differences among NQRNs in engagement with independent learning activities. Overall, the findings underscore that while structured training and mentorship provide some support, there is a strong and consistent recognition of the value of ongoing education and self-directed learn

Figure 1. Training & Support.

Figure 1. Training & Support.

3.1.6. Workload & Stress

Although respondents generally work fewer hours per week (mean = 1.62), they report feeling moderately to frequently overwhelmed (mean = 2.42) and experiencing moderate to high work-related stress (mean = 2.37). The relatively low variation in responses for stress and feeling overwhelmed suggests that these pressures are widely shared among NQRNs. Overall, the findings indicate that workload intensity and stress are significant, consistent concerns, even when actual hours worked are comparatively low.

Figure 2. Workload & Stress.

Figure 2. Workload & Stress.

3.1.7. Communication & Relationship

The findings indicate that NQRNs experience moderate levels of communication and support within the workplace. Peer communication and support are generally positive (means ≈ 3.48–3.58), though variability suggests that some feel closer or more supported than others. Communication with management is also moderate (mean = 3.35), with some perceiving it as effective while others find it lacking. Participation in team meetings is reasonably consistent (mean = 2.45), but engagement levels vary among respondents, reflecting differing experiences of inclusion in workplace interactions.

Figure 3. Communication & Relationship.

Figure 3. Communication & Relationship.

3.1.8. Patient Care

The findings suggest that NQRNs generally demonstrate moderate confidence in patient care, technical skills, and clinical decision-making (means ≈ 3.12–3.85), though experiences vary among individuals. While some respondents feel well-prepared and confident in supervising units, applying clinical reasoning, and integrating knowledge and skills, others report feeling less capable, as reflected in the moderate standard deviations (≈0.72–0.97). Overall, NQRNs show developing competence and self-assurance in patient care, with variability highlighting areas where further support or training may be needed.

Table 3: Patient care
	N	Mean	Std. Deviation
How confident do you feel in your ability to provide high-quality patient care	256	3,3750	,72491
Encounter situations where you feel unprepared to handle a patient’s needs	256	3,1172	,75273
Rate the overall quality of patient care provided by your team	257	2,8093	,78972
Feel proficient in the technical aspects of patient care	258	3,7016	,97042
Manage the nursing care unit	257	3,7821	,88344
Make independent decisions when providing nursing care	257	3,7665	,91428
Integrate knowledge and skills in clinical practice	256	3,8555	,88927
Apply clinical reasoning skills and reflective judgment in the execution of clinical practice	257	3,7510	,87514
Valid N (listwise)	250

3.1.9. Code of Ethics

The results indicate that NQRNs demonstrate strong adherence to ethical principles, including informed consent, patient confidentiality, respect for patient rights and dignity, and promotion of patient well-being (means ≈ 4.19–4.47). Low to moderate standard deviations (≈0.76–0.83) suggest general consistency in these practices, though some variation exists in advocacy for patient needs. Overall, the findings reflect a high level of professional integrity and a strong commitment to patient-centred, ethical care.

Table 4: Code of Ethics Descriptive Statistics
	N	Mean	Std. Deviation
Explain procedures and treatments to ensure the patient obtains informed consent	257	4,2335	,84315
Maintain the confidentiality of your patient information	256	4,4492	,80034
Ensure that patient rights and dignity are respected	255	4,4706	,77746
Advocate for patient needs and preferences in your care	254	4,1850	,83003
Promoting patient well-being and providing beneficial care	254	4,1969	,82968
Adhere to ethical standards and demonstrate integrity	255	4,3373	,75555
Valid N (listwise)	246

3.1.10. Leadership Skills

The findings suggest that NQRNs demonstrate moderate proficiency in conflict resolution (mean = 3.65) and task delegation (mean ≈ 3.70), though considerable variability exists, particularly when delegating to more experienced colleagues (mean = 2.92). This indicates that while many NQRNs feel capable of managing conflicts and delegating tasks, confidence and competence levels vary across individuals. In contrast, NQRNs show strong consensus regarding honesty and integrity in handling maladministration (mean = 3.91), reflecting a solid ethical foundation in professional practice.

Table 5: Leadership Skills
	N	Mean	Std. Deviation
How skilled are you at resolving conflicts	257	3,6459	,95765
Delegating tasks to other team members	256	3,6992	1,03628
Delegating subordinates who have more experience than you in the unit	256	2,9180	,94822
Demonstrate the level of honesty and integrity where there has been maladministration on your part	257	3,9105	,84535
Valid N (listwise)	255

Overall, NQRNs report a moderate level of work-life balance (mean = 3.50), though responses vary considerably (SD = 1.04), indicating divergent experiences among individuals. Balancing professional and personal demands is moderately challenging (mean = 2.16), with some NQRNs finding it easier than others (SD = 0.68). These findings suggest that while many NQRNs manage work-life balance reasonably well, individual differences highlight the need for targeted support.

3.1.11. Work-Life Balance

Overall, NQRNs report a moderate level of work-life balance (mean = 3.50), though responses vary considerably (SD = 1.04), indicating divergent experiences among individuals. Balancing professional and personal demands is moderately challenging (mean = 2.16), with some NQRNs finding it easier than others (SD = 0.68). These findings suggest that while many NQRNs manage work-life balance reasonably well, individual differences highlight the need for targeted support.

Figure 4. Work-life balance.

Figure 4. Work-life balance.

3.1.12. Career Intention

The findings indicate that NQRNs show a moderate inclination to remain in their current roles (mean = 2.81), with some variability in responses (SD = 0.89). There is a strong interest in pursuing further specialisation (mean = 3.54; SD = 0.73) and a high perception that career advancement is possible within their current roles (mean = 3.74; SD = 0.53), reflecting consensus on opportunities for professional growth. Overall, while retention in the current role is moderate, NQRNs are motivated by prospects for specialization and advancement.

Figure 5. Career Intention.

Figure 5. Career Intention.

3.2. Results for Qualitative

The NQRN participants represented diverse educational backgrounds and clinical experiences, with thirteen holding a diploma in nursing and twelve holding a Bachelor’s degree. Participants’ ages ranged from 24 to 40 years, and their clinical experience as NQRNs varied between 1 and 5 years (see Table 1 for detailed demographics).

Table 8. Demographic profile of participants.
Variable	Frequency
Gender
Male	10
Female	15
Age
24 30	7
30 34	9
35 40	5
40+	4
Qualifications
Bachelor’s Degree	12
Comprehensive Diploma	13
Years of experience
1- 2 years	10
3- 4 years	8
5 years	7

The thematic analysis of the focus group interviews revealed six major themes that encapsulate the profound and interconnected barriers faced by NQRNs in the Chris Hani District.

Table 9. Themes and Subthemes of the research findings.
Themes	Subthemes
An Institutional Void of Clinical Support and Mentorship	1.1 Inadequate orientation and supervision
2. Systemic Failures in Management and Leadership	2.1 Ineffective in-service training and skills development.
3. Crippling Resource Constraints and Infrastructure Decay	3.1 Shortage of equipment and staff
4. Pervasive Emotional and Psychological Distress	4.1.1 Fear and anxiety 4.1.2 Inadequate leadership and emotional support
5. A Trajectory Towards Professional Burnout	5.1 High workload stress
6. Profound Job Dissatisfaction and Disillusionment	6.1 Poor job satisfaction

3.2.1. Theme 1: An Institutional Void of Clinical Support and Mentorship

Participants consistently reported a significant lack of structured clinical support and meaningful mentorship. Rather than experiencing a guided transition, they described an abrupt and isolating immersion into demanding roles, often referring to it as being “thrown in the deep end.” This absence of guidance was especially pronounced during the first months of practice, leaving NQRNs feeling professionally vulnerable and underprepared.

Subtheme: Inadequate Orientation and Supervision

Participants reported minimal or no structured orientation when starting their roles, leaving them uncertain about expectations and workflows. Supervision by senior staff was often inconsistent or absent, forcing new nurses to navigate complex clinical situations alone. This lack of guidance contributed to anxiety, reduced confidence, and frequent reliance on self-directed learning.

“There was no orientation. On my first day, they just showed me the ward and said, ‘This is your ward, these are your patients.’ I was terrified. I had no idea who to ask if I had a problem, because everyone else was just as busy and stressed.”

(P1)

“Mentorship is a nice word we read about in textbooks. Here, it doesn’t exist. The senior nurses are either burnt out or they see you as a threat. You learn by making mistakes, and you pray those mistakes don’t harm a patient. It’s a very hard way to learn.”

(P3)

3.2.2. Theme 2: Systemic Failures in Management and Leadership

Participants described a significant disconnect between themselves and the hospital management. This was characterized by a lack of visibility, poor communication, and a perceived indifference to the daily struggles of frontline staff. Management was often seen as a bureaucratic entity that imposed policies without understanding the clinical realities, further exacerbating feelings of frustration and disempowerment.

Subtheme: Inadequate Training and Skill Development

Training opportunities were described as inconsistent and poorly implemented, limiting professional growth.

“We had a training session on a new electronic system. They sent one manager, who then was supposed to train all of us. The training never happened properly. It’s always like that. Opportunities for skills development are there, but they don’t reach the people who actually need them on the ground.”

(P7)

“When there’s a critical incident, like a patient fall or a medication error, management’s first reaction is to find someone to blame. There is no culture of supportive, non-punitive incident reporting. It makes you afraid to speak up, so problems just get hidden until they become disasters.”

(P5)

3.2.3. Theme 3: Crippling Resource Constraints and Infrastructure Decay

This theme was one of the most dominant and emotionally charged in the discussions. Participants detailed a daily battle against a severe and chronic shortage of basic and essential resources, ranging from medical equipment and supplies to functional infrastructure and adequate staffing. This constant scarcity not only compromised their ability to provide safe and effective care but also eroded their professional morale.

Subtheme: Shortage of Equipment and Staff

Participants reported that shortages of essential equipment and chronic understaffing significantly hindered safe and effective patient care. Nurses often had to improvise or manage entire wards alone, performing multiple critical tasks simultaneously. These conditions contributed to increased professional stress and lowered morale, highlighting systemic challenges in the clinical environment.

“We have one working vital signs machine for a ward of 40-plus patients. You spend half your shift just waiting for the machine. How can you monitor a critically ill patient properly like that? It’s impossible. We are set up to fail.”

(P6)

“The staffing is a nightmare. It’s normal to be the only registered nurse for the entire ward at night, with one nursing assistant. You have to do everything admissions, drug rounds, emergencies, paperwork. The patient-to-nurse ratio is not just unsafe; it’s inhumane for both the patient and the nurse.”

(P2)

3.2.4. Theme 4: Pervasive Emotional and Psychological Distress

The cumulative effect of the preceding barriers manifested as profound emotional and psychological distress. Participants spoke of experiencing constant fear, anxiety, and a sense of hyper-vigilance. The fear of making a fatal error in such a high-stakes, low-support environment was a heavy burden, impacting their mental health both at work and in their personal lives.

Subtheme: Fear and Anxiety

Participants reported pervasive fear and anxiety stemming from the high-stakes nature of their work and the lack of adequate support. The constant pressure to manage critically ill patients alone, often with limited equipment and staffing, created a state of hyper-vigilance that affected their mental well-being both at work and at home.

“I have anxiety every single day before I come to work. My stomach is in knots because I’m so scared of what I might face a patient crashing and I’m alone, or a piece of equipment failing during an emergency. It’s a constant state of fear.”

(P1)

“It affects your personal life. You go home exhausted, not just physically but emotionally. You are irritable with your family. You can’t sleep because you are replaying everything that happened on your shift, thinking about what you could have done differently if only you had more time or more help.”

(P2)

Subtheme 3.4.2: Inadequate Leadership and Emotional Support

The lack of accessible leadership and structured emotional support exacerbated participants’ distress. Without debriefing sessions, counselling, or guidance from senior staff, NQRNs often felt isolated in coping with the emotional toll of trauma, patient deaths, and high-pressure clinical responsibilities.

“The emotional toll is immense. I’ve seen so much trauma and there’s no one to talk to about it. There’s no debriefing, no counselling. You are just expected to be strong and carry on. I have cried in my car after a shift more times than I can count.”

(P6)

“They is a huge gap that the managers need to do, to guide and support us, we are dying with stress and workload while they is no support are we getting.”

(P13)

3.2.5. Theme 5: A Trajectory Towards Professional Burnout

Participants described symptoms and experiences synonymous with professional burnout—emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. They felt that the relentless workload, coupled with the lack of support and resources, was pushing them beyond their limits, leading to absenteeism and a desire to leave the profession or, at the very least, the rural public sector.

Subtheme: High Workload Stress

Participants highlighted that relentless workloads and staffing shortages were major contributors to professional burnout. Managing entire wards alone, performing multiple clinical and administrative tasks, and coping with inadequate resources created chronic stress, emotional exhaustion, and a sense of depersonalization. These conditions not only threatened patient care but also led many NQRNs to consider leaving the profession or the rural public healthcare sector.

“I am burnt out. Completely. Some days I feel like a robot, just going through the motions. I don’t feel the same empathy I used to. It’s a defence mechanism, I think. If you feel too much, you won’t survive.”

(P6)

“I am actively looking for a way out. Maybe go overseas, or work for a private hospital, or just leave nursing altogether. I love being a nurse, but I can’t sacrifice my own health and sanity for a system that doesn’t care about me.”

(P7)

3.2.6. Theme 6: Profound Job Dissatisfaction and Disillusionment

The final theme captures the deep sense of disillusionment that permeated the participants’ narratives. There was a stark and painful contrast between the standard of nursing care they were taught to provide and the compromised care they were forced to deliver. This gap between their professional ideals and the harsh reality of their practice led to widespread job dissatisfaction and a loss of pride in their work.

Subtheme: Poor Job Satisfaction

Participants expressed profound dissatisfaction with their work, stemming from the gap between the high standard of nursing care they were trained to provide and the compromised care they were able to deliver in practice. Task-oriented, crisis-driven work environments, combined with systemic constraints, left them feeling ineffective, undervalued, and disillusioned. This mismatch between professional ideals and workplace realities significantly eroded their pride, motivation, and overall job satisfaction.

“I am not proud of the nursing care I give most days. I know it’s not my fault, but it’s my name on the patient’s chart. We were trained to be advocates for our patients, to give holistic, high-quality care. What we do here is just task-based crisis management.”

(P1)

“Is this what I studied so hard for? To work in these conditions? I feel cheated. I feel like the system has failed me, and in turn, it is failing the patients who depend on us. It’s a deep, deep dissatisfaction.”

(P5)

Overall, the study demonstrates that newly qualified registered nurses (NQRNs) exhibit moderate levels of job satisfaction, confidence in patient care, work-life balance, and professional competence, while strongly upholding ethical standards and patient-centred care. Quantitative findings showed variability in training, mentorship experiences, conflict resolution, task delegation, and career intentions, reflecting differing levels of preparedness, engagement, and ambition among participants. Qualitative insights contextualize these trends, revealing systemic challenges such as a lack of structured clinical support, inadequate mentorship, resource shortages, and staffing constraints, which contribute to professional stress and feelings of vulnerability. Despite these challenges, NQRNs consistently value continuing education, professional development, and ethical practice, suggesting a strong commitment to growth and patient care. Collectively, these findings highlight the need for targeted institutional support, enhanced mentorship programs, and resource allocation to strengthen the transition of NQRNs into independent, competent practitioners.

4. Discussion

This study revealed that newly qualified registered nurses (NQRNs) exhibit moderate levels of job satisfaction, confidence in patient care, and work-life balance, while demonstrating strong commitment to ethical standards and patient-centred care. Quantitative findings indicated moderate means for job satisfaction, training adequacy, mentorship, and conflict resolution, with variability highlighting differences in individual experiences. Qualitative narratives further explained these results, describing an abrupt and isolating transition into practice, limited mentorship, and insufficient clinical support, reflecting an “institutional void” consistent with previous research on early-career nurse stress and professional vulnerability [3,7]. These findings collectively suggest a critical need for targeted interventions to better support NQRNs during their transition to practice. Specifically, enhancing formal mentorship programs, providing robust clinical support, and fostering environments that explicitly address work-life balance and conflict resolution could significantly improve their early career experiences and mitigate the risks associated with the “institutional void [9].” Such support systems would not only bolster individual nurse well-being but also contribute to improved patient outcomes and retention within the nursing profession, echoing the calls for greater structural support highlighted by Duchscher [3] and Rush et al. [7].

NQRNs reported moderate confidence in patient care and clinical decision-making, yet qualitative data revealed variability in preparedness, particularly in independent judgments and clinical reasoning. These findings align with literature emphasizing that structured preceptorship and mentorship programs improve competence, confidence, and retention among NQRNs [10,11]. Training, peer feedback, and self-directed learning were also rated moderately, underscoring the importance of ongoing professional development for enhancing clinical skills and job satisfaction. This suggests that while NQRNs possess a foundational level of confidence, there is a clear opportunity to strengthen their clinical judgment and decision-making capabilities through enhanced and consistent structured support. Implementing comprehensive, well-resourced preceptorship and mentorship programs, as advocated by Kang et al. [11], could bridge the gap between initial education and the demands of independent practice. Furthermore, fostering environments that actively promote and facilitate continuous professional development, including robust peer feedback mechanisms and accessible self-directed learning opportunities, would not only elevate their clinical skills but also contribute to higher job satisfaction and improved patient care outcomes, aligning with insights from [10].

To ensure NQRNs are fully equipped for the complexities of modern healthcare, strategies should focus on integrating advanced clinical reasoning exercises into both undergraduate curricula and postgraduate transition-to-practice programs. This integration, coupled with the consistent application of preceptorship and mentorship frameworks, would not only address the identified variability in preparedness but also cultivate a proactive approach to continuous skill development. By prioritizing these elements, healthcare institutions can foster a more confident, competent, and ultimately more satisfied nursing workforce, leading to better patient care and reduced attrition rates, as highlighted by numerous studies on early career nursing support [11]. Oshodi et al. [12] state that workload and stress emerged as consistent concerns, despite generally lower working hours. Participants described being overwhelmed due to understaffing, equipment shortages, and high patient demands, contributing to stress and low morale. Literature confirms that such systemic challenges adversely affect early-career nurse well-being and performance [13]. Peer and management communication were moderate, with variability in engagement, reflecting differing experiences of inclusion and support within the workplace. These findings underscore the critical need for healthcare organizations to address the root causes of workload and stress among NQRNs, even in the context of seemingly lower working hours. Focusing solely on hours without addressing systemic issues like understaffing, equipment deficiencies, and high patient acuity will continue to contribute to overwhelming stress and negatively impact morale, consistent with research by Shields et al. [14] Improving both peer and management communication—specifically by fostering environments of open dialogue, clear expectations, and active listening—could significantly enhance feelings of inclusion and support, ultimately buffering the effects of workplace stressors and promoting a healthier, more sustainable work environment for NQRNs. Ethical practice and patient-centered care were consistently strong, as evidenced by high quantitative scores and qualitative reports of upholding confidentiality, patient rights, and advocacy.

This reinforces literature suggesting that professional values instilled during education remain resilient even under challenging clinical conditions [15]. Career intentions highlighted a moderate desire to remain in current roles, coupled with strong motivation for specialization and advancement, indicating that opportunities for professional growth are key to retention and satisfaction. The steadfast commitment of NQRNs to ethical practice and patient-centered care, even amidst stressful working conditions, provides a robust foundation upon which to build supportive professional environments [16]. As Grace et al. [15] suggest, these core professional values are deeply ingrained, offering a positive starting point for NQRNs. To capitalize on this strength and address career intentions, healthcare institutions should actively foster pathways for specialization and advancement, such as clear career ladders, access to continuing education, and mentorship for advanced roles. By recognizing and nurturing NQRNs’ strong motivation for professional growth, organizations can not only enhance job satisfaction and retention but also ensure the continued delivery of high-quality, ethically sound patient care.

In summary, while NQRNs show developing competence, strong ethical commitment, and a desire for professional growth, systemic challenges—including inadequate mentorship, staffing shortages, and resource limitations—pose significant barriers. Addressing these gaps through structured support, enhanced training, and targeted institutional interventions can improve confidence, job satisfaction, and retention, consistent with broader nursing workforce research.

4.1. Limitations of the Study

The relatively small number of participants limits the generalisability of the findings to all newly qualified registered nurses (NQRNs). The experiences captured reflect specific contexts and may not represent the broader nursing workforce in other regions or healthcare settings. Both the survey and interview data relied on self-reported perceptions, which may be influenced by recall bias, social desirability bias, or participants’ current workplace experiences. As a result, the findings may not fully capture objective measures of competence, workload, or job satisfaction. The study provides a snapshot of NQRNs’ experiences at a particular point in time. It does not capture changes in satisfaction, confidence, or career intentions over time, which may evolve as nurses gain more experience. The absence of additional data sources—such as direct observations, supervisor perspectives, or institutional documents—restricts the ability to triangulate findings. This may limit the depth and breadth of understanding of systemic challenges faced by NQRNs. The study was conducted in a specific healthcare context, where staffing shortages, equipment limitations, and resource constraints are prevalent. These contextual factors may not be identical in other healthcare systems, potentially limiting transferability.

4.2. Recommendations

Based on these findings, it is recommended that healthcare institutions strengthen structured mentorship and preceptorship programs, enhance continuous professional development opportunities, and address staffing and equipment shortages to support NQRNs more effectively. Efforts to foster supportive workplace relationships, promote work–life balance, and reinforce nurses’ strong ethical orientation are also essential for improving job satisfaction and retention. Finally, longitudinal research is needed to track NQRNs’ experiences over time and to inform sustainable strategies for professional development and workforce stability.

Table 10. below summarises the package. Comprehensive Support Package for NQRNs to Maximise Clinical Competence.
Domain	Key Components	Intended Outcomes
Mentorship & Preceptorship	Formal pairing with experienced mentors; structured role transitions; regular debriefing	Guided transition, reduced anxiet, enhanced confidence
Clinical Skills Development	Simulation training; refreshers on routine procedures; interprofessional teamwork training	Strengthened technical competence, improved patient safety
Professional Development	Accredited CPD workshops; online learning access; career pathway support	Ongoing competence growth, career satisfaction, retention
Workplace Integration	Orientation programmes; peer support groups; open communication with management	Smooth adjustment, reduced isolation, stronger teamwork
Wellness & Work-Life Balance	Stress management training; counselling services; adequate staffing and flexible rostering	Reduced burnout, improved morale and productivity
Ethical & Professional Practice	Ethics workshops; advocacy training; safe spaces for ethical dialogue	Reinforced professionalism, patient rights protection
Monitoring & Feedback	Competence checklists; mentor/peer evaluations; outcome tracking	Continuous improvement, accountability, evidence-based support

5. Conclusions

This study demonstrated that while NQRNs exhibit strong ethical commitment and moderate clinical competence, their transition to practice is undermined by limited mentorship, inadequate resources, and heavy workloads. The mixed-methods findings highlight the need for structured support systems, including clinical supervision, professional development, and wellness interventions, to strengthen confidence and competence. Addressing these systemic gaps through a comprehensive support package can improve NQRN retention, enhance patient care quality, and contribute to the sustainability of the nursing workforce in South Africa.