Vanuatu is a country located in the South Pacific and comprises more than 83 islands with a population of approximately 340,000[8]. The capital, Port Vila, is the largest of the two urban centres on the island of Efate, with 60,000 people. The other urban centre is Luganville, on the island of Espiritu Santo (Santo), which has a population of 20,000[8, 9]. The country is divided into six provinces: Malampa, Penama, Sanma, Shefa, Tafea, and Torba[8, 9]. Each province has a hospital, although there are two referral hospitals located in the municipal islands of Efate and Santo [8]. Vila Central Hospital (VCH) in Port Vila receives referrals from the southern islands, and Northern Provincial Hospital (NPH) in Santo receives referrals from the northern territory of Vanuatu.

The Ministry of Health in Vanuatu has been running internship programs for NGN since 1983. The internship program lasts two years. During the first few months of the internship program, NGNs are assigned to various hospital units and rotate through them. After they complete their allocated internship period in the hospital, they are then posted to rural health facilities around Vanuatu. During the hospital rotation of the internship program, NGNs are rostered to work in the ED for 2 weeks.

The internship bridges theoretical knowledge (knowing what), skills (knowing how), and competence (applying both effectively in practice). Knowledge represents conceptual understanding, skills denote practical application, and competence integrates both within real-world contexts. The internship aims to strengthen these dimensions, equipping NGNs to function confidently in high-pressure environments such as the ED [10].

Anecdotally, patients and relatives have reported that the ED may not be the best place for NGNs to work because they lack sufficient experience and skills, particularly in managing critically ill patients. NGNs have also complained that working in the ED causes them a lot of stress, especially when a patient's life is at risk or when they have to work alone as a result of the nursing shortage.

This study aims to investigate the barriers and enablers that impact the transition from nursing student to NGNs working in the ED in Vanuatu.

This study employed qualitative and quantitative approaches; therefore, the design lends itself to a Mixed-Method (MM) approach [11]. MM design addresses the limitations of using either method alone by combining numerical data with in-depth contextual insights to improve the validity and depth of findings [12] A mixed-methods approach combined qualitative and quantitative techniques to enrich the findings.

Participants included 47 newly graduated nurses (NGNs) who met the inclusion criteria (Table 1), having completed a nursing diploma within the past 12 months and currently working in Emergency Departments (EDs) in Vanuatu. Survey instruments adapted from [3] and [1] were initially piloted with five ED nurses in Vanuatu who did not meet the eligibility criteria. The final survey comprised three sections: demographic information, challenges experienced by NGNs, and enablers supporting their transition into the ED. Minor modifications were made to ensure the survey’s relevance to the Vanuatu context.

Purposive sampling was employed to recruit participants. The sample was selected based on the researcher’s knowledge of the participants in relation to the phenomenon under study [13]. Paper-based surveys and information sheets were placed in envelopes and distributed to the ED nurse in charge. Participants completed the survey, placed it back in the envelope, and returned it to a box at the Nursing College. The researcher collected the completed surveys two weeks later. Data collection occurred between July and August 2024.

Qualitative and quantitative data were analysed separately. Quantitative data were analysed using descriptive and inferential statistics. Thematic analysis was employed to analyse open-ended questions. This process involves reviewing the data to identify patterns in meaning, helping to find themes. Thematic analysis is a qualitative research method used to identify, analyse, and report patterns (themes) within data. By recognising both expected and unexpected patterns, thematic analysis allows researchers to explore complex phenomena [14].

Participation in this study was voluntary and anonymous. Ethical approval to conduct the study was provided by Fiji National University (CHHREC: 098.24), where the primary author was studying. Permission was also granted by the Vanuatu Health Research and Ethics Committee (VHREC) to conduct the study in Vanuatu. The nursing service managers also granted the researcher permission to conduct the research at each of Vanuatu's five hospitals.

Participants ranged in age between 24 and 37, with an average age of 27.9 years. Most participants (60%, n = 28) were female, and 40% (n = 19) were male. Most participants had been working as NGNs for 2-3 months or more (Table 2).

Three subthemes were identified: (1) organizational barriers (workload, lack of support, limited orientation), (2) personal barriers (stress, fear, lack of confidence), and (3) family/relational barriers (complaints and lack of cooperation from patients and relatives). Organizational barriers, particularly workload and lack of supervision, were the most significant.

The majority of NGNs (n= 33, 70%) reported occasionally feeling inadequately prepared. This suggests that there are instances when they may be unprepared, while a smaller proportion (n=6, 13%) reported frequently feeling inadequately prepared, which may point to more substantial gaps in their readiness or confidence. Meanwhile, 11% (n=5) of respondents stated they feel inadequately prepared only rarely, implying that while this is an issue, it is not a recurring concern for this particular group (Appendix 1).

This is demonstrated through statements made by the participants (Appendix 2).

I have come across many emergency cases in which I had a lot of fear. (Participant 5).

I was working during a shift with my colleague. It was my first day of work in the ED. There were many critically ill patients to attend. Therefore, I had fear, running to and from helping my colleagues. We started to receive complaints from patients and relatives, which built our frustration and fear and made us lose our confidence in the workplace (Participant 27).

A significant portion of NGNs reported challenges during their time in the ED. Specifically, 34% (n=16) expressed a lack of knowledge when faced with real-life emergencies and life-threatening situations. Additionally, 32% (n=15) of participants reported feeling fearful when working in the ED, particularly when assigned to work alone. In response to these concerns, NGNs requested the opportunity to complete specific competency-based procedures during their internship. They believe that hands-on experience with these procedures would help build their confidence and enhance their ability to work effectively in the ED.

Sometimes when we came across a real emergency, we felt the lack of knowledge. (Participant 24).

Workload remains a significant challenge for NGNs practicing in ED, with 45% (n=21) reporting it as a major source of stress. Such situations can overwhelm NGNs and compromise both performance and patient care.

When I worked in a shift where there were many patients compared to the number of emergency cases presented, I sometimes felt panicked and stressed dealing with them due to the lack of knowledge, especially in the case of rare cases. (Participant 13).

Sometimes, when I had too much work to do, and you were only working with one colleague, I felt a lack of support from the colleague. (Participant 11).

Additionally, 32% (n=15) of respondents identified a lack of support as a significant barrier to effective performance. This challenge is particularly pronounced in situations where only one NGN is assigned to work alongside a senior nurse—or, in some instances, solely with an assistant nurse—while simultaneously managing multiple emergency cases. Furthermore, 45% (n=21) of NGNs reported that the intensity of the workload contributed to heightened stress levels, with 21% (n=10) specifically citing burnout as a result (Table 2).

The least satisfying areas of ED are when the staff are not cooperative and you lack their support. (Participant 2).

17% (n=8) of the NGNs responded that if they are not well oriented to the department and the processes and systems used, it will hinder their ability to efficiently and effectively manage emergency cases (Appendix 1).

During our first day working in the ED, we were not well oriented; therefore, when emergencies presented, we were confused and disoriented about the instruments’ location, which affected our ability to adapt. (Participant 18).

Participants felt frustrated when the equipment was not working during emergencies.

It is very frustrating when you are dealing with emergency and you lack the appropriate equipment or the equipment you need is faulty. (Participant 12).

Complaints and a lack of collaboration from patients and relatives create a stressful environment that might impair NGNs' capacity to manage and think critically, leading to a loss of confidence.

Sometimes the patients and relatives complain and criticize you, saying that you have no experience and knowledge. (Participant 14).

Patients and relatives were not cooperative. (Participant 2).

When patients were not cooperative and were under the influence of alcohol or drugs. This affects my ability to perform a procedure confidently. (Participant 23).

Enablers are factors or resources that help NGNs improve their abilities, knowledge, and practice in highly dependent situations. Two subthemes emerged: (1) organizational enablers (teamwork, fair scheduling, and mentorship) and (2) personal enablers (motivation, learning opportunities). Most NGNs reported that supportive teams and ongoing education improved their confidence and job satisfaction.

Participants described working with others and the fair allocation of tasks and rosters as enablers.

The most satisfying areas of working in the ED are the resuscitation room and the acute room. It helps me to manage the emergency cases with the assistance of our senior staff. (Participant 7).

The most satisfying aspect is when you come across new cases each day and you manage to attend and treat them with the assistance of other senior staff, which gives you the opportunity to learn so that you can manage future presented cases. (Participant 15).

The most satisfying area is when there is effective communication and cooperation between doctors, nurses, and patients in regards to the patients’ condition and plans. (Participant23).

Furthermore, the most satisfying area is when the nurses and doctors work as a team, and they are most helpful and teach us NGNs, which help us learn and build confidence in areas we are not confident at. (Participant 10).

Another satisfying area is when there is fair task allocation and roster, which prevent burnout and tiredness. (Participant 10).

66% (n=31) of NGNs confirmed that clinical rotation from nursing college has provided sufficient exposure to emergency cases, and 40% (n=19) of NGNs acknowledged that nursing college has adequately prepared them to work in ED.

Nursing studies had helped us a lot in identifying abnormal from normal and able to prioritize cases accordingly. Nursing studies were effective because we follow standard procedures step by step. And it also helps us gain knowledge from there and implement what is taught during clinical practicum which is a way of gaining confidence and experience. (Participant 23).

In the contrary, the number of hours allocated to the Emergency course is not enough to capture all the knowledge and skills required to work in the ED but the longer you work in the ED can build your skills and help you become a very effective ED nurse. (Participant 2).

Additionally, 74% (n=35) of NGNs reported that having ongoing learning opportunities enables them to continuously develop and enhance their professional skills. Furthermore, 68% (n=32) acknowledged the presence of a positive and supportive work environment, which they believe contributes significantly to their job satisfaction and overall growth as healthcare professionals.

According to respondents, the most satisfactory parts of the ED were the treatment room, triage room, trauma room, all components of the ED allowing NGNs to be exposed to new and interesting cases, which helped them enhance their skills, knowledge, and confidence, cooperation between senior nurses, doctors, and NGNs, resuscitation and acute room, and fair allocation of tasks and roster.

I love all areas in the ED because they give me the opportunity to experience different scenarios. (Participant 8).

The most satisfying aspects is when you come across new cases each day and you manage to attend and treat them with the assistance of other seniors’ staff which give you the opportunity to learn so that you can manage future presented cases. (Participant 15).

The dressing and trauma room is the most satisfying area because it helps build your skills when treating and stabilizing different types of injuries from a fight or a road traffic accident with the assistance of doctors and senior nurses. (Participant 36).

Barriers faced by NGNs in Vanuatu can be grouped into three main categories: organisational factors, which encompass resource and support challenges; personal factors, including issues such as confidence, skill development, and stress management; and family- or relative-related factors, such as the impact of family expectations or responsibilities on their professional growth. Facilitators that support their transition are divided into two groups: organisational factors, which include positive elements such as a supportive environment, and personal factors, which encompass qualities like motivation and experience that help them overcome the challenges of transitioning into the emergency department.

NGNs reported that a lack of support and collaboration with ED staff increased their anxiety, compromised the delivery of safe patient care, and hindered their learning and professional development. NGNs noted that they occasionally worked alongside senior nurses who were not sufficiently supportive. This lack of support was often attributed to the perception among some colleagues that NGNs should already possess sound knowledge from their academic training and, as such, were expected to perform confidently and independently, without the guidance or assistance of more experienced staff. Moreover, a lack of support and collaboration from ED staff further exacerbates these challenges. Such an unsupportive environment can heighten anxiety among NGNs, reduce their confidence, and compromise their ability to provide safe, high-quality care. The absence of teamwork and mentorship also limits opportunities for learning and professional growth, particularly for less experienced nurses. The findings were supported by a previous study that found that the factors contributing to satisfaction among new graduate nurses in their working environment were the working system, interpersonal relationships, orientation, and nursing work environment [3]. Furthermore, a previous study supported this study's findings and found that negative relationships with other professionals in the clinical setting consume energy and hinder development [2].

Additionally, NGNs have been burdened with a heavy workload relative to their experience, while also facing pressure from their colleagues about their slower task performance, with expectations that they perform at the level of more senior staff. These findings were supported by a similar study that found that NGNs struggled to manage their workload due to high acuity and a heavy workload [1, 5]. In addition, a previous study found that nurses felt continually challenged to provide safe, effective patient care in this high-acuity, high-demand, technical environment with insufficient resources, including time, staffing, technology, and administrative support. Successful interventions must most likely be targeted at the work environment [15].

Vanuatu is also facing a nursing workforce shortage, which impacts the performance of registered nurses. Working conditions for nurses significantly impact their job satisfaction, performance, and the quality of care they provide to patients. Key issues identified include high patient admissions, staff shortages, and long or irregular working hours. In Vanuatu’s Ministry of Health (MoH) facilities, these challenges persist and are exacerbated by staffing levels of only 2–3 nurses per shift, which are insufficient for effective care [16, 17].

The shortage of certified nurses in Vanuatu is largely due to several interrelated factors. These include low annual intake of nursing students in training institutions, limited government recruitment budgets, and irregular workforce planning cycles. Furthermore, the profession’s modest remuneration and limited career advancement opportunities contribute to poor retention, while the small national pool of qualified educators restricts the training pipeline. Collectively, these systemic challenges have created persistent workforce shortages that directly contribute to nurse overload, long shifts, and stress in emergency departments [18, 19].

In addition to systemic workforce shortages, low remuneration and limited professional recognition were highlighted as key factors affecting nurse retention and motivation. Many NGNs expressed that while financial compensation was modest, the lack of social prestige and limited career progression opportunities were more discouraging [20]. Nursing in Vanuatu, though respected within health institutions, often receives limited visibility and acknowledgment at broader societal and policy levels. Addressing these financial and social dimensions could help attract and retain more qualified nurses, reduce turnover, and enhance the overall status of the nursing profession [19, 21].

Despite hospital managers' awareness of the problem, there are no adequate solutions due to a nationwide shortage that requires government-level planning and policy. Contributing factors include low enrolment and irregular training in nursing colleges, leading to an inadequate nursing workforce. Long shifts of 12–16 hours cause stress, physical exhaustion, and moral distress, impacting nurses’ well-being, motivation, and work-life balance.

Similar issues have been reported globally, where poor planning and policy lead to workforce shortages. As a result, many nurses experience job dissatisfaction and leave the profession due to stressful working conditions and poor work environments [22].

Finally, orientation also emerged as a critical issue in successfully transitioning NGNs into the ED. Orientation is an introduction to help NGNs adjust to the ED's new working environment and protocols. Without a comprehensive, structured orientation program, NGNs struggled to develop clinical judgment, confidence, and familiarity with the protocols needed to manage emergency cases efficiently and effectively. This lack of preparation can lead to delays in care, increased errors, and heightened stress levels, ultimately compromising patient safety and the overall quality of care. In contrast, a previous study revealed that orientation would help new graduate nurses understand the work environment. Practical orientation facilitates and develops an affirmative experience when supplemented with a supportive work environment [3].

NGNs frequently encounter both physical and emotional stress during their first year of nursing practice in the ED. This stress stemmed from various sources, including anxieties about their level of expertise, knowledge gaps, and challenges in communicating with physicians, patients, and senior nurses. This is supported in other studies, which find that NGNs often experience pressure related to managing high workloads, meeting role expectations, and navigating an unsupportive work environment, all of which significantly impact their well-being and ability to deliver optimal patient care [1, 5]. Stress during the internship year is often associated with fear and frustration, particularly when managing emergency cases without adequate supervision or when paired with another junior colleague. NGNs reported feelings of fear stemming from perceived knowledge and clinical competence gaps, leading to concerns about potentially harming patients. NGNs also experienced fear and frustration when confronted with life-threatening situations, primarily due to concerns about their limited clinical knowledge and skills. This lack of confidence often leads to anxiety about making critical errors or unintentionally causing harm to patients, further intensifying the emotional and psychological challenges associated with managing high-acuity cases in the ED [23]. To understand the emotional difficulties faced by NGNs, it is essential to distinguish between stress, burnout, and a loss of motivation. Stress refers to the immediate psychological and physiological response to work pressure or high responsibility. Burnout, however, develops over time and represents a chronic state of emotional exhaustion, depersonalization, and reduced sense of accomplishment resulting from prolonged stress exposure [24]. Loss of motivation often follows burnout and manifests as disengagement, low morale, and decreased professional commitment. Recognizing these distinctions is essential for designing interventions and workplace support systems that address each component appropriately [25-29]. Similar findings from the literature confirmed that NGNs often experience stress because they fear they will make medication errors or cause malpractice and harm the patient. Other forms of stress relate to anxieties about expertise, knowledge, and communication with physicians, patients, and senior nurses, as well as workload, role expectations, and unsupportive surroundings [23].

Complaints about NGNs and a lack of patient and family cooperation presented additional challenges for NGNs working in the ED. The findings of this study indicate that patients frequently expressed dissatisfaction with being treated by NGNs, often citing concerns about their perceived lack of experience and clinical knowledge. As a result, many patients and their relatives preferred to be attended to by more senior staff members. These complaints made NGNs feel undervalued and undermined in their professional role, leading to a loss of focus and reduced concentration during clinical tasks. This, in turn, negatively affected their self-confidence and increased feelings of inadequacy, further worsening the stress they experienced in an already demanding environment. A previous study also found that patients sometimes refused to be cared for by nursing interns because they believed the interns had limited knowledge and skills compared to other staff [7].

This study also revealed that newly recruited NGNs frequently encountered uncooperative and aggressive patients, often as a result of intoxication. Such encounters induced fear and increased anxiety among NGNs, particularly due to their limited experience in handling high-risk behavioural situations. This emotional response often impaired their ability to think clearly, respond appropriately, and act efficiently, potentially compromising both patient safety and the NGNs' sense of professional competence. This finding is consistent with a previous study, which found that nursing staff working within the ED are frequently exposed to workplace violence, including from patients who are intoxicated, aggressive, and suicidal, which significantly impacts the well-being of ED nurses, resulting in persistent stress and impeding their capacity to deliver high-quality patient care. These factors are emphasised as contributors to burnout [26].

To provide a visual overview of how the different factors interact, a conceptual model was developed (Fig. 1). The model illustrates how organizational, personal, and relational barriers influence the motivation and confidence of New Graduate Nurses (NGNs), ultimately shaping their transition outcomes within emergency departments. It also highlights that strong organizational enablers such as teamwork, supervision, and continuous learning can mitigate the negative effects of these barriers and enhance professional adaptation.