Newly Graduated Swedish Nurses' Inadequacy in Developing Professional Competence

Employers' requests when advertising for nurses-A national mapping of recruitment advertising for nurses in Sweden

INTRODUCTION

There is a shortage of nurses and many are leaving the profession. Maintaining sufficient nursing staff is a major healthcare challenge for societies worldwide. Work conditions, job orientation, and career opportunities all factor into nurses' rates of attrition, exit, and turnover. Newly graduated nurses have requested structured introductory and/or mentoring programmes to ease their transition from education to work life and develop the skills and knowledge necessary in their particular work setting. Nurses also seek opportunities to continue learning and developing professionally.

AIMS

To map and describe the content of recruitment advertisements for nurses. Research questions were: 'What qualifications do healthcare employers request when recruiting nurses?' and 'What sorts of professional development do healthcare employers offer nurses?

MATERIALS AND METHODS

A comprehensive national mapping of recruitment advertisements for nurses in Sweden where all advertisements, N = 450, on 20 of the 21 regional hospital websites were collected. A qualitative and a quantitative content analysis was performed.

RESULTS

Personal characteristics dominated requested competence in recruitment advertisements. Employers offered general nursing opportunities with unspecific work content and focused more on recruiting newly registered, rather than experienced, nurses. In only a few advertisements, employers asked for a master's degree. No employer requested nurses with a PhD or research experience.

CONCLUSION

While the World Health Organization stresses the need for a sustainable recruitment and attainment of nurses to secure health care, employers' recruitment of mostly newly graduated nurses and offering little professional development and few career opportunities may be one explanation for the difficulties in securing safe nurse staffing.

Assessment of Differential Perceptions of Core Nursing Competencies between Nurse Managers and Nursing Graduates: A Cross-Sectional Study

BACKGROUND

The literature review on perceptions of nursing competencies shows a critical shortage of studies addressing this topic.

AIM

To examine and compare perceptions of important nursing competencies of nursing graduates, and nurse managers.

METHODS

A cross-sectional study was conducted among 148 students, who were recent graduates of the nursing school with RN degrees and had completed advanced training lasting 3 months at the Sheba Academic School of Nursing and the Academic School of Tel Aviv-Yafo, and 183 nurse managers with at least one year of seniority in the position in hospitals and community clinics in Israel. The recruitment and data collection of the nurse managers lasted 12 months, from July 2021 to July 2022, and for nursing graduates, two months, from June 2022 to July 2022. An online questionnaire was constructed and validated by five professional and experienced individuals in the research domains for adequate content validity. The questionnaire consisted of 47 items in total. Domains included: (1) professionalism in research; (2) skills for direct treatment; (3) support and communication; (4) professional knowledge; (5) personal abilities; and (6) critical thinking and innovation.

RESULTS

Overall, 331 valid questionnaires were collected (85% response rate). The difference in the nurse's research professionalism index was found to be statistically significant with a higher rating given by nurse managers, p = 0.003. However, the difference in the direct treatment index of nurses was found to be statistically not significant, p = 0.610, between newly graduated nurses and nurse managers. The independent sample t-test indicated a significant difference with a higher rating among nurse managers in the nurse's support and communication index, p = 0.020; professional knowledge index, p < 0.001; personal abilities index, p < 0.001; and critical thinking index, p = 0.006, between newly graduated nurses and nurse managers.

CONCLUSION

Nursing education programs aimed at training future nurses with core competences should include a curriculum designed to promote the acquisition of these six core competences leading to a congruence between the role expectations of nurse managers and those of newly graduated nurses.

When caring becomes an art - how clinical gaze are perceived to be developed

PURPOSE

This qualitative study describes nurses' experiences and perceptions of how they develop the clinical gaze.

METHODS

This qualitative study used an inductive approach and content analysis to assess the experiences of newly graduated nurses, nurse managers, and nursing teachers. Nineteen interviews were conducted. To achieve credibility, the study followed the guidelines of the Consolidated Criteria for Reporting Qualitative research (COREQ).

RESULTS

Two themes emerged: nurses' personal abilities and the learning culture. Learning culture was considered the foundation of the development of the clinical gaze. The clinical gaze was found to be developed in relationships with patients and when learning together with colleagues, in which the opportunities for reflection are central. To develop the clinical gaze, structures for learning activities, such as reflection, communication exercises, and simulation, are needed so that they become a natural part of daily work. This can also be achieved through supervision and skills training both at university and in a care context.

CONCLUSIONS

Prerequisites for the development of the clinical gaze include physical presence with the patient combined with learning activities such as conscious reflection with others in a safe learning culture.

Comparison of the Iranian and Scandinavian bachelor of nursing curriculum (Sweden): A scoping review

BACKGROUND

The comparison of the educational curriculum improves the content and quality of the curriculum and needs to be revised and modified in line with the current needs of society. Development of nursing knowledge, the emergence of emerging diseases requires that the nursing curriculum be codified and provide the necessary skills to provide quality and safe care.

MATERIALS AND METHODS

The study aimed to Comparison of Iranian and Scandinavian Bachelor of Nursing Curriculum (Sweden). This descriptive-comparative study was conducted based on the Bereday model in four stages: Description, Interpretation, Juxtaposition, Comparison, and Analysis in 2022. We use relevant electronic databases such as PubMed, CINAHL, Web of Science, Iran Medex, SID, Magiran, Google Scholar, Iran Doc, and Science Direct databases.

RESULTS

The results showed that despite the similarities, the Swedish nursing curriculum had special features in most of the mentioned dimensions. Including decentralized admission, Fits the need, competency-based curriculum, attention to holistic care and intercultural care, use of new digital technologies in education, and clinical training and evaluation.

CONCLUSION

It seems that the Iranian nursing curriculum is far from the mentioned perspective. Using the experiences of the world's top universities, such as Sweden, can improve the quality of nursing undergraduate programs and improve the nursing profession by eliminating current shortcomings.

The Experiences of Newly Graduated Nurses during Their First Year of Practice

The present study aimed to explore the experiences of newly graduated nurses during their first year of practise. A qualitative descriptive design was employed in this study. In-depth, semi-structured interviews were conducted with newly graduated nurses to gather detailed descriptions and experiences during their transition to the workplace in the first year after graduation. Thematic analysis was utilised to identify patterns and themes in the collected data. Ethical considerations were strictly enforced throughout the study. There are two main themes: factors contributing to the integration of new nurses into the workplace and the difficulties faced by new nurses in a work environment. Within the first theme, three subthemes emerged: the positive role of trainers, the gradual handling of patients, and the benefit of pre-employment training and volunteering. The theme of difficulties faced included three subthemes: difficulty dealing with the health system and devices, fear of dealing with new patients, and difficulty applying policies and procedures in the workplace. The study provides insights into the challenges faced by newly graduated nurses and the factors that contribute to their integration into practise settings. Educational departments in hospitals' support and efficient access to policies are crucial for these nurses as they begin their early professional years.

Development and validation of experienced work-integrated learning instrument (E-WIL) using a sample of newly graduated registered nurses - A confirmatory factor analysis

INTRODUCTION

Research indicates that newly graduated registered nurses struggle to develop practical skills and clinical understanding and to adapt to their professional role. To ensure quality of care and support new nurses, it is vital that this learning is elucidated and evaluated. Aim The aim was to develop and evaluate the psychometric properties of an instrument assessing work-integrated learning for newly graduated registered nurses, the Experienced Work-Integrated Learning (E-WIL) instrument.

METHOD

The study utilized the methodology of a survey and a cross-sectional research design. The sample consisted of newly graduated registered nurses (n = 221) working at hospitals in western Sweden. The E-WIL instrument was validated using confirmatory factor analysis (CFA).

RESULTS

The majority of the study participants were female, the average age was 28 years, and participants had an average of five months' experience in the profession. The results confirmed the construct validity of the global latent variable E-WIL, "Transforming previous notions and new contextual knowledge into practical meaning," including six dimensions representing work-integrated learning. The factor loadings between the final 29 indicators and the six factors ranged from 0.30 to 0.89, and between the latent factor and the six factors from 0.64 to 0.79. The indices of fit indicated satisfactory goodness-of-fit and good reliability in five dimensions with values ranging from α = 0.70 to 0.81, except for one dimension showing a slightly lower reliability, α = 0.63, due to the low item number. Confirmatory factor analysis also confirmed two second-order latent variables, "Personal mastering of professional roles" with 18 indicators, and "Adapting to organisational requirements" with 11 indicators. Both showed satisfactory goodness-of-fit, and factor loading between indicators and the latent variables ranged from 0.44 to 0.90 and from 0.37 to 0.81, respectively.

CONCLUSION

The validity of the E-WIL instrument was confirmed. All three latent variables could be measured in their entirety, and all dimensions could be used separately for the assessment of work-integrated learning. The E-WIL instrument could be useful for healthcare organisations when the goal is to assess aspects of newly graduated registered nurses' learning and professional development.

Socialization in professional reality integration for nursing student transition (SPRINT) to improve professional competence: A quasi-experimental study

Background

Professional socialization could support competency achievement and assist the transition phase. It is rare to find quantitative studies examining the effects of professional socialization for nursing students (NS).

Objectives

To investigate the effects of a socialization in professional reality integration for nursing student transition (SPRINT) to improve the professional competence of undergraduate NS in Indonesia.

Design

A quasi-experimental study non-equivalent control group pre-test post-test design was conducted using convenience sampling.

Participants

One hundred twenty NS (60 participants in the experimental group and 60 participants in the control group) from two nursing departments in private universities in Indonesia.

Methods

The SPRINT educational intervention consisted of professional socialization training using several learning methods and activities. Meanwhile, the control group received conventional socialization. The Nurse Professional Competence short-form (NPC-SF) scale was evaluated prior to the participants' internship program, lasting from 6 to 12 weeks after clinical education in both groups.

Results

SPRINT intervention significantly increased overall professional competence scores of the experimental groups higher than the control group. By comparing the mean scores in three times measurement, the six competency areas mean score increased significantly for the experimental group while, for the control only three areas of competence increased in twelve week post-test.

Conclusion

A "SPRINT" as an innovative educational program developed in collaboration with academia, clinical preceptors, could improve professional competence. It is recommended to implement SPRINT program to assist the smooth transition from academic into clinical education.

Nursing Workforce Retention in Rural Ghana: The Predictive Role of Satisfaction, Rural Fit, and Resilience

Introduction. High turnover of nurses in rural healthcare settings contributes to challenges in healthcare delivery. Various incentive packages have been introduced in rural healthcare settings to curb this phenomenon, but the canker still exists. The study aimed at assessing the predictive role of job satisfaction, rural fit, and resilience on nurses’ retention in rural Ghana. Materials and Methods. A multicentre cross-sectional design was adopted to collect data from 462 nurses. Analysis through descriptive statistics, one-way ANOVA, Pearson moment product correlation, and multiple regression was done. Results. There was low resilience and rural fit among nurses with higher turnover intention, which was predicted by average daily attendance (β = 0.108), rural fit (β = −0.144), resilience (β = −0.350), satisfaction with prospects (β = −0.187), and satisfaction with prospect and pay (β = −0.171) at the significance of 0.05. Conclusion. Policymakers can be assured that not just improving financial incentives to nurses, but the integration of nurses to rural settings, commensurate workload and improving pay and prospects for professional growth and resilience are needed for rural retention. Implications for nursing management, nurse managers, and policymakers have a role to develop sustainable strategies to integrate rural fit, resilience, and job satisfaction to help reduce turnover among nurses.

Construction of learning objectives and content for newly graduated nurses in tertiary teaching hospitals: A Delphi study

BACKGROUND

Transition education is a robust strategy to improve the core competency of newly graduated nurses and the quality of clinical nursing and ensure people's safety. Limited information about the learning objectives and educational content for newly graduated nurses in China was available.

OBJECTIVE

Construct the learning objectives and educational content for newly graduated nurses based on defined core competencies.

DESIGN

We used a literature review and the e-Delphi method to conduct this study.

SETTINGS

Ten tertiary teaching hospitals and six nursing schools in Zhejiang Province, China, were selected.

PARTICIPANTS

Experts (n = 21) were invited to the e-Delphi study.

METHODS

Based on seven competencies from the literature review and the research group discussions, we formed an initial set of objectives and specific educational content for newly graduated nurses. Subsequently, experts provided supportive and modification advice on the competencies, objectives, and specific content in the two Delphi rounds. The consensus percentage and the weight of each first-level, second-level, and third-level item were calculated.

RESULTS

Consensus was achieved on seven core competencies, 44 learning objectives, and 60 components of educational content. The positive coefficient of the two Delphi rounds was 100 %, the authority coefficient was 0.83 and 0.87, the proportion of experts who made suggestions was 71.40 %, the coefficient of variation (CV) was <0.25 (P < 0.05) except for two items and the Kendall coefficient (W) was 0.15-0.48 (P < 0.01).

CONCLUSION

The developed objectives and content framework provide a reference for implementing systematic and standardized education for newly graduated nurses.

Self-Rated Emergency Core Nursing Competencies Among Emergency Nurses in Qassim, Saudi Arabia

Introduction Emergency situations require advanced and specialized knowledge and skills to handle urgent situations. However, there is a scarcity of literature on emergency nurses' competencies. We assessed the competencies of nurses working in the emergency departments of hospitals in the Qassim region. Methods A cross-sectional study was conducted among 213 nursing staff at the emergency departments of all government hospitals in the Qassim region. A standardized tool was adopted for data collection which encompassed sociodemographic and self-reported competencies in nine emergency nursing domains, reflecting the core competencies using a 5-point Likert scale. Data was collected through an online survey. SPSS version 26 (IBM Corp., Armonk, USA) was used for data analysis. Linear regression analysis was carried out to explore the factors associated with competencies.  Results A total of 213 nurses were included in the study with a mean age of 32.9±4.6 years. More than two-thirds of the nurses were female (69.5) and more than half were Saudi nationals. The mean experience of the participants was (6.3±3.7) years. The nurses at the emergency department had satisfactory knowledge about most of the core emergency nursing competencies with some areas such as genitourinary, gynecological assessment, and documentation being deficient. Increasing age, being non-Saudi, married and nurse supervisor were associated with higher competencies. Conclusions Nurses generally had satisfactory knowledge of most of the core competencies of nurses in the emergency department in the Qassim region. However, there were deficiencies in core competencies in some domains. There is a need to provide on-the-job training and coaching for emergency nurses to improve their competencies and the quality of emergency care in the hospitals.

Existence and perceived application of pain management protocols in German neonatal intensive care units

We explored the existence and application of standard operating procedures (SOPs) for pain management (PM) in German neonatal intensive care units (NICUs), and identified the factors associated with their application in practice. This study was part of the Safety4NICU project, a cross-sectional survey conducted from 2015 to 2016. All 224 German NICUs were invited to participate, providing written consent from the head neonatologist and head nurse. We distributed questionnaires to the head neonatologist, the head nurse, and the NICU staff (physicians and nurses). We asked the head neonatologist whether written SOPs for PM existed, and we asked the staff whether these SOPs were applied in their daily routine. We received evaluable responses from 468 physicians and 1251 nurses from 76 NICUs. Of these 76 NICUs, the head neonatologists from 54 NICUs (71.1%) reported that written SOPs for PM exist. However, only 48.5% of the physicians and 53.7% of the nurses declared that these existing SOPs were also applied. We found various predictors for the existing SOPs as being applied, depending on the profession. For physicians, clinical training was important (OR: 2.482, p ≤ 0.05), while for nurses their working experience was a decisive predictor (OR: 1.265, p ≤ 0.05). For both, a high level of perceived cooperative norms between physicians and nurses increased the probability that SOPs for PM were applied, whereas a high bed turnover rate decreased that probability. According to the responses from head neonatologists, written SOPs for PM were common in German NICUs. However, if management strategies on pain existed, this did not mean that these were directly applied in the daily routine. Clinical training of the staff, the promotion of adequate interprofessional cooperation, as well as allowing time to deal with these SOPs might be all essential measures to strengthen the application.

Home administration of needle injections for children with rheumatic diseases: A qualitative study on nurses' perception of their educational role

PURPOSE

To explore nurses' perceptions of their educational role, pedagogical competence, and practice in teaching children with rheumatic diseases and their parents to manage subcutaneous injections at home.

DESIGN AND METHODS

In this qualitative study, we used thematic analysis to analyze data from three focus groups with 14 nurses responsible for patient education at one pediatric ward and two outpatient clinics.

RESULTS

We identified three main themes capturing nurses' perceptions of their educational role: myriad expectations, awareness of own competence, and facilitation and prioritization of patient education. Nurses perceived patient education as an expected but challenging duty of their work. They described a lack of pedagogical competence, insecurity in managing parents' and children's fears and worries, and limited organizational structures guiding their educational role. Nurses who worked in outpatient clinics felt freer to individualize education compared to ward nurses.

CONCLUSIONS

Nurses perceive their educational role as significant in enabling children and parents to manage subcutaneous injections at home; however, they require pedagogical competence integrated with daily practice to provide high-quality care. Short-term admissions require a different organization of patient education than before.

PRACTICAL IMPLICATIONS

Nurses need increased training in communication and management of children's pain and fear during needle injections. Competence development should include opportunities for reflection and guidance in clinical practice. Pediatric specialist nurses at outpatient clinics seem to have better competence to provide individual patient education for these families. The potential advantage of web-based solutions for nurses' patient education is a promising avenue for future research.

Effectiveness of the use of concept maps and simulated cases as a teaching-learning strategy in enhancing the learning confidence of baccalaureate nursing students: A qualitative approach

BACKGROUND

Didactic lectures and exam-oriented learning can lead to students becoming passive learners who rely on rote memory. This learning style negatively impacts their ability to cultivate the core nursing values and critical thinking.

OBJECTIVES

This study aimed to investigate the impact of a concept mapping teaching-learning strategy on undergraduate nursing students' ability to integrate theoretical biosciences knowledge into care practice and on their skills in critical thinking and teamwork.

METHODS

A qualitative research design was adopted. A course entitled Evaluation and Analysis of Adult Nursing Cases was developed based on a concept mapping strategy involving 24 simulated cases relevant to medical and surgical nursing. The participants were students from the two-year undergraduate nursing programme at a university in Taiwan. Data were collected from September 2020 to February 2021. Qualitative data were collected from semi-structured face-to-face interviews with 20 students and from 100 reflective reports on students' learning journeys. The data were analysed using qualitative content analysis.

RESULTS

Two major themes were identified: (1) changes in learning style and thinking and (2) rewards from learning. The participants reported that their learning style had changed from reliance on rote learning to image memory, and their thinking process from linear (cause-effect) to multifaceted thinking at different levels. The teaching and learning strategies contributed to feelings of ability advancement and psychological safety, which led to learning achievement and confidence.

CONCLUSION

The use of a concept mapping strategy and simulated cases enhanced students' learning by enabling them to integrate theoretical knowledge and improve their thinking abilities. The teaching and learning strategies helped participants in learning about psychological safety and increased their learning confidence.

Battling extraordinary situations and conflicting emotions-A qualitative study of being a newly graduated Registered Nurse in the emergency department during the COVID-19 pandemic

Aim

To describe newly graduated registered nurses’ (NGRNs’) experiences of encountering stress in emergency departments (EDs) during the COVID‐19 pandemic.

Design

A qualitative descriptive study.

Methods

Data from 14 in‐depth interviews with NGRNs working in an ED for 3‐36 months after graduation was analysed by the means of qualitative content analysis as described by Graneheim and Lundman. Interviews were conducted from March to November 2020 covering the first two waves of the pandemic.

Results

Data revealed three categories and nine subcategories comprised in the theme Battling extraordinary situations and conflicting emotions. Empowered by acknowledging themselves as important caregivers during the pandemic NGRNs struggle against limitations and exert themselves beyond their known limit. External stressors due to work overload in combination with understaffing force NGRNs into the role of the experienced nurse prematurely and internal stressors derives from part taking in less qualitative care.

Nursing Faculties' Perceptions of Integrating Theory and Practice to Develop Professional Competence

BACKGROUND

Nursing faculties' perceptions influence nursing education. This article describes how nursing faculty perceive nursing students' development of professional competence by integrating theory and practice, and by examining how this context influences this integration.

METHOD

With a phenomenographic approach, interviews were conducted with nine participants and analyzed into qualitatively different categories of description.

RESULTS

The integration of theoretical and practical knowledge is perceived as a challenge or as naturally intertwined in the entire education, focusing mainly on individual prerequisites for learning. Perceptions of a common mission create coherence for students. Evident learning structures are needed, and there is a perceived discrepancy between nurses' competence and expectations in health care.

CONCLUSION

If the theory and practice gap could be perceived as a driving force for continuous learning, it could become an incentive for closer collaboration by creating structures for competence development that include individuals, teams, and organizations. [J Nurs Educ. 2022;61(5):236-241.].

Construction of a Training Content System for New Nurses in Cancer Hospital Based on Competency

Objective

To construct a training content system for new nurses in cancer hospitals based on postcompetency and to provide guidance for clinical new nurse training.

Methods

Based on literature review, semistructured interviews, and questionnaire surveys, a new draft of the nurse training content system was initially established, and 17 experts were selected to make two rounds of inquiry on the system by the Delphi method, so as to construct a new nurse training content system.

Results

The effective rate of recovery of the two rounds of expert correspondence was 100%, the cooperation among experts was high, and the authoritative coefficient of experts was 0.89. The content system of new nurse training constructed included 2 first-class indexes, 5 second-class indexes, and 45 third-class indexes.

Conclusion

The new nurse training content system is closely combined with clinical work, pays attention to improving nurses' competence, reflects the characteristics of nursing work in cancer hospitals, has a certain scientific and practical significance, and can provide guidance for the training of new nurses in cancer hospitals.

Nursing students' experiences of applying problem-based learning to train the core competence teamwork and collaboration: An interview study

AIM

To explore nursing students' experiences of applying problem-based learning to train the core competence teamwork and collaboration.

DESIGN

The study used a qualitative descriptive design.

METHOD

The data were collected using individual interviews with a purposive sample of 11 students and analysed using inductive qualitative content analysis.

RESULTS

The students' experiences of applying problem-based learning to train the core competence teamwork and collaboration were described in two generic categories: prerequisites to train teamwork and collaboration and abilities practised in the base group. The generic category "prerequisites to train teamwork and collaboration" includes three subcategories: previous experience and education, composition of the base group, and common goals and values in the base group. The generic category "abilities practised in the base group" includes four subcategories: taking personal responsibility, practising role distribution and leadership, developing communication skills and creating togetherness in the base group.

A study of factors that predict novice nurses' perceived ability to provide care in acute situations

AIMS

To explore factors that predict novice nurses' trust in their ability to provide care in acute situations and identify factors that are related to their perceived ability to make clinical judgements in acute situations.

DESIGN

Exploratory cross-sectional study.

METHODS

Novice nurses employed within somatic care in Swedish hospitals completed an online survey. Univariate analysis facilitated exploration of the data and identification of predictor variables with the greatest association with: (1) trust in their own ability (one item) and (2) ability to make clinical judgements (four items). Multivariate binary logistic regression modelling was used to model the likelihood of outcomes based on each predictor variable.

RESULTS

The two most important predictors related to trust in ability to provide care were duration of work experience and participation in acute situations during nursing education. For clinical judgement, duration of work experience was significant in all four models and experience of acute situations post-graduation was significant in two models.

Perceptions of managers regarding prerequisites for the development of professional competence of newly graduated nurses: A qualitative study

AIM AND OBJECTIVES

To describe perceptions of managers regarding prerequisites for professional competence development of newly graduated nurses following a 1-year residency programme.

BACKGROUND

In general, managers are unsatisfied with the professional competence of newly graduated nurses. Therefore, they have been involved in residency programmes to support the nurses' transition from being nursing students to professional nurses. However, perceptions of managers regarding the professional competence development of nurses have been sparingly studied.

DESIGN/METHODS

Qualitative, descriptive study with a data-driven inductive approach with content analysis to obtain an understanding of the perceptions of nine managers through interviews. EQUATOR checklist COREQ is used (see File S1).

RESULTS

Three themes emerged: (a) the nurses' relationships with their teams and patients, (b) expectations regarding the development of practical skills and leadership skills and (c) prerequisites for continuing learning by supportive structures and a mutual responsibility between the manager and the nurse. Reflection was perceived by the managers as a cornerstone in the learning and development of professional competence. Learning theory was important, but learning practical clinical skills was essential for the nurses to develop competence and be able to perform their work, including being a leader of the team. Some structures discouraged continued learning in the development of professional competence, indicating a gap between the healthcare settings and the basic nursing programme.

CONCLUSIONS

There is a gap between the university and the healthcare settings in maintaining a structure for continued learning, which requires cooperation. This gap and tension can be a driving force for the learning process of competence development. Relationships with team members and patients are considered fundamental for developing professional competence.

RELEVANCE TO CLINICAL PRACTICE

To overcome the gap between the university and the healthcare settings, the managers can facilitate nurses' continued learning by creating structures for reflection.