New Graduate Nurses' Experiences by Generation in South Korea: A Qualitative Meta-Synthesis

ABSTRACT Background As the nursing organization environment evolves into one in which several generations work together, there are concerns about generational differences leading to conflicts. Purpose A synthesis of qualitative studies was used to gain insight into the experiences and perceptions of new nurses working in South Korean hospitals and identify generational differences between nurses of Generations X and Y. Methods Eight databases were searched systematically for qualitative studies published up to June 2020. The Critical Appraisal Skills Programme Checklist for Qualitative Research was used to evaluate the quality of the retrieved studies, and the data were synthesized thematically using the Thomas and Harden method. Results Of the 2,482 studies retrieved, 19 were included in this meta-synthesis. The experience of new nurses were presented in the three analytical themes of work experience, interpersonal relationships, and adaptation, from which eight descriptive themes were derived: (a) dissatisfied with own work performance, (b) negative feedback on work outcomes, (c) irregular daily life, (d) colleagues who help adapt to work life or make work life harder, (e) feelings of sympathy toward peers, (f) disrespectful patients or caregivers, (g) effective reactions, and (h) ineffective reactions. Although the new nurses from Generations X and Y reported similar experiences during their first year of nursing, differences were found in their values and tendencies regarding work and interpersonal relationships. Compared with new Generation X nurses, new Generation Y nurses placed more value on the meaning of individual work contributions, intimacy with colleagues, and appropriate feedback. Conclusions/Implications for Practice The findings of this study support nursing administrators implementing strategies that both acknowledge and reduce the impact of generational category on nursing teams. Furthermore, emphasizing communication and acknowledging ongoing change as generations progress may strengthen bonds that lead nurses to value each other and their work.

Since around 2000, research into the generational differences among nurses has been conducted in several countries because in part of the need to resolve chronic nurse shortages.In addition, the trend toward later-age retirement in the United States is making healthcare workplaces more multigenerational.Efforts have been made to identify the management implications of this change (Christensen et al., 2018;Waltz et al., 2020), as generational differences in terms of an individual's characteristics, occupational views, and attitudes may increase the risk of conflict among colleagues and affect productivity and patient safety (Stevanin et al., 2018).
In Korea, most Generation Y nurses, accounting for over 80% of the nursing workforce, were educated and are currently managed by Generation X nurses.Therefore, nursing managers must acknowledge different generational experiences and employ appropriate strategies to foster desirable peer relationships within the organization.

Search Results
The study screening and selection process followed the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines for systematic review reporting (Page et al., 2021).Two thousand four hundred eighty-two articles were retrieved from nine databases.After reviewing 1,932 titles and abstracts, 550 duplicate articles were removed, and after considering the study selection criteria, another 1,903 articles were excluded.After reviewing the full text of the remaining 29 articles, a further 10 were excluded as not meeting the eligibility criteria, leaving 19 studies available for inclusion and analysis in the meta-synthesis (Figure 1).

Quality Appraisal
The quality of the included studies was appraised using the Critical Appraisal Skills Programme Checklist for Qualitative Research (Critical Appraisal Skills Programme, 2018).This checklist, consisting of 10 yes/no response items, is designed to evaluate the validity of research results, the statement of results, and the value of the research.The appraisal was conducted independently by, respectively, one author and one research assistant.In cases of disagreement, consensus was reached through mutual discussion.For all of the 19 articles, the answers to all 10 items were "yes," confirming all of the selected articles as suitable for this study.

Data Synthesis
The study data were extracted and sorted by author, publication year, aim, participant characteristics, methodology, data collection method, analysis method, and main themes using Excel software (Table 2).The thematic synthesis method proposed by Thomas and Harden (2008) was used.First, two of the authors of this study independently performed code generation to discern the meaning and content of each sentence while reading the results of each article.The articles were read multiple times.Codes were compared and categorized based on common content.In the process, differing opinions between the two authors were synthesized through repeated review.Subsequently, descriptive themes representing the classified content were determined.Finally, analytical themes presenting integrated interpretations were extracted by synthesizing the themes presented in individual research results and focusing on their relevance.
To ensure trustworthiness, the authors shared data analysis with each other during regularly held meetings.The authors were all nurses with clinical experience, graduate-level training in qualitative methodology, and prior experience conducting systematic reviews.In addition, one of the authors had previous experience conducting qualitative studies.

Inclusion Exclusion
• Qualitative studies

Ethical Consideration
This study was approved by the institutional review board of the Catholic University of Korea (No. MC19ZESI0097).

Study Description
The 19 included articles were published between 2001 and 2020 and included 182 individuals, all of whom had participated in interviews.In 17 of the studies, the participants had fewer than 12 months of work experience, with the remaining two including participants with over 12 months of work experience (Lee et al., 2017;K. O. Park & Kim, 2013).
As the articles included in this study did not contain sufficient data, for example, participant age or year of birth, to infer their generational affiliation, the participants were categorized into Generation X or Generation Y for this study based on their general characteristics (average age) and year of data collection.As data for the 19 articles were completed between 1998 and 2019, baby boomer participants were excluded.The participants in the four studies conducted between 1998 and 2003 were classified as Generation X, and those in the 15 studies conducted between 2007 and 2019 were classified as Generation Y.

Qualitative Synthesis
The experiences of new nurses were divided into three analytical themes, from which eight descriptive themes were extracted.

Work experience
1. Dissatisfied with own work performance After graduating from university, new nurses, regardless of generational affiliation, expressed feeling "overwhelmed," "frustrated," and "terrified" about the nursing tasks they performed for the first time as healthcare workers rather than as students.However, there were general differences among their responses.Generation X nurses found an external locus for their difficulties.For example, they believed that their training, which limited them to following and observing senior nurses around the wards, was inadequate and would not ensure their adaptation to independent nursing practice.
I had only been observing, and then I had to do it myself all of a sudden, which drove me crazy….If I had proper training on that, I would not have felt so lost.I could not stop thinking about it.(S. H. Yun, 2002) Generation Y nurses felt a greater burden of responsibility and were more likely to self-blame for being unable to solve problems independently and for making mistakes.When       The Journal of Nursing Research Heejin CHUNG and Mihyun PARK senior nurses intervened, they felt ashamed and worthless.Furthermore, millennials perceived their abilities and knowledge as insufficient and anxiously questioned their own judgment, decisions, and work.
I thought that I had to take responsibility and do my best to prevent problems from happening to my patients.…I really hate this situation where senior nurses have to take care of my patients because I am not good enough.It hurts my pride….(J.H. Park & Chun, 2008) I was [often] burdened by the roles and responsibilities given to me….I increasingly lost confidence when making many trivial mistakes….(Im et al., 2015) Am I doing right by the patient?Am I doing something wrong?I kept thinking about it….(Suh & Lee, 2013)  Note.Q1 = Was there a clear statement of the aims of the research?;Q2 = Is a qualitative methodology appropriate?; Q3 = Was the research design appropriate to address the aims of the research?;Q4 = Was the recruitment strategy appropriate to the aims of the research?;Q5 = Were the data collected in a way that addressed the research issue?; Q6 = Has the relationship between researcher and participants been adequately considered?; Q7 = Have ethical issues been taken into consideration?; Q8 = Was the data analysis sufficiently rigorous?;Q9 = Is there a clear statement of findings?;Q10 = How valuable is the research?
2. Negative feedback on work outcomes New nurses frequently reported difficulties related to receiving negative feedback from senior nurses.Furthermore, there were differences in their interpretations of and responses to this feedback.Generation X nurses complained about being scolded and hoped to avoid it.
I used to pray on my way to work: "I really hope that I can make it through the day without being scolded."(Son et al., 2001) What am I doing here being scolded like this?I was angry.(S.H. Yun, 2002) However, Generation Y nurses felt more strongly that it was unreasonable for them to be ignored or criticized for being new nurses and saw this as inhumane, especially when they were scolded in front of patients, caregivers, or nursing students.They felt disrespected and tormented by such treatment.
[No matter how good new nurses are,] I think they suffer some sort of stigma for a while.…I am the new whipping boy.(Y.M. Kim & Kim, 2016) There are people who make me feel personally attacked rather than being scolded for my own mistakes.I felt embarrassed and frustrated, and wanted to quit working.(H.J. Yun et al., 2018) 3. Irregular daily life New nurses frequently experienced "difficult adaptation," "lack of personal life, such as meeting with friends and hobbies," "sleep disturbance," and "fatigue" because of irregular shift work.Millennials in particular compared their situations with those of their peers engaged in other occupations and lamented that their lives, centered around the hospital, were neither happy nor normal.
My life does not feel normal.How do others live?Am I the only one living such a difficult and dull life?...I keep going back and forth between the hospital and home, so I have little joy in life.Even though I earn money, what can I do with the money living like this?...I do nothing….I am working to enjoy life, but I do not feel happy at all.My entire life is in the hospital.... (Suh & Lee, 2013)

Interpersonal relationships
The interpersonal work relationships of the participants were distinguished into work-related relationships with colleagues (senior and junior nurses, doctors, and healthcare workers in other departments), peers (cohort-mates in the organization), and patients and caregivers (recipients of nursing services).
1. Colleagues who help adapt to work life or make work life harder New nurses were forced to form new relationships with their colleagues in an unfamiliar environment.They reported feelings of "unfamiliarity," "distance," and "being disregarded" in their new surroundings.
Notably, unlike how they felt regarding their other colleagues, new nurses felt that nurse preceptors protected them like a mother and perceived them as reliable.

Feelings of sympathy toward peers
New Generation X and Generation Y nurses perceived peers as people with similar experiences.They formed relationships while "talking to each other a lot" about the mistakes they made during working, their experiences of being scolded by senior nurses, and hardships at work, relieving stress and providing mutual consolation and reliance.
The Generation X nurses compared their situations with those of their peers and felt relieved that they shared the same hardships.
Hey, it was even worse for me last time, you know.I was scolded even harder.(Son et al., 2001) My friends talk about how they have been scolded as well.It really makes things seem better.(G.L. Kim et al., 2013) The Generation Y nurses expressed feeling grateful to their peers because their peers understood them best, provided great support, and helped them endure hardships at work.I may not have made it through up to this point if not for my peers.(H. S. Park et al., 2011) When things got hard for me, I turned to my peers the most.They understand me the best.(Lee et al., 2017) 3. Disrespectful patients or caregivers New nurses frequently perceived distrust, disregard, and uncooperative attitudes from patients and caregivers while providing nursing care.These nurses were embarrassed and frustrated by situations they could not understand.

Adaptation 1. Effective reactions
A few months after joining their organizations, new nurses reported feeling they had improved their work performance and relationships with colleagues.
Generation X nurses gained skills, knowledge, and confidence through repeated experiences and learned to deal with problems with a more positive attitude.
I have done CPR three times.On my third attempt, I thought, "Oh, I get it."… I have gained know-how.(Son et al., 2001) The Journal of Nursing Research Heejin CHUNG and Mihyun PARK At first, I could say nothing when I was being scolded by the senior nurses for something that I did not intend to do.I was afraid I would appear disrespectful [to my senior].Now, I have some ideas about the work.When it is not my fault, I tell them.(Hwang et al., 2002) Generation Y nurses became increasingly familiar with their work and could fulfill their assigned duties.These nurses felt proud and gained confidence in their job performance when their colleagues and patient caregivers trusted them, when they were recognized as full-fledged nurses, and when they received positive feedback about their work.
I am very proud that I can help with this.I'm really happy when I've done my part.…As I make more friends in the ward, I receive more compliments.It feels great.(J.H. Park & Chun, 2008) I understand things more clearly now than before, and I make fewer mistakes.…There have been moments when I felt good and proud, when my senior nurses compliment me for being much better than before.(H.R. Kim & Kwon, 2014) The new nurses reported experiencing "comfort," "friendliness," and a "sense of belonging" in their relationships with colleagues.The Generation X nurses felt recognized as "ward members" as they helped and received help from senior nurses, whereas the Generation Y nurses reported feeling they became "family members" through daily communication and believed that private meetings with colleagues helped form close bonds.Now that I get help from my colleagues and give them help, I feel comfortable….I feel like I am being treated as a member of the ward.(S.H. Yun, 2002) We have some private conversations and invite each other to our homes….I feel happy.(J.H. Park & Chun, 2008) We go get a drink after work and talk about things.I feel like a family member.(H.R. Kim & Kwon, 2014) 2. Ineffective reactions New nurses who considered leaving their jobs were often concerned regarding the "uncertainty about their future" at the hospital.
At first, my future seemed very unclear to me.It is still not clear to me.(S.H. Yun, 2002) The biggest motivator (90%) that made me think about leaving the job was that I couldn't picture my future here.(Y.M. Kim & Kim, 2016) Watching experienced nurses, Generation X nurses found it difficult to envision an improvement in their current situation and pondered leaving their hospital, whereas Generation Y nurses expressed a desire to leave their position after failing to discover a sense of meaning in their work.
… I think it's better to leave the hospital if I have to keep doing trivial things, even if I'm in a high position.(S. H. Yun, 2002) I did not want to do it (my job) without knowing why I had to or needed to do it.(Im et al., 2015)

Discussion
In this study, the shared and divergent experiences of new nurses from different generations in South Korea were explored.New nurses from Generations X and Y were found to share common experiences related to work, interpersonal relationships, and adaptation.The characteristics of the Generation Y nurses in this meta-synthesis were similar to those in previous studies in terms of their valuing appropriate feedback, work-life balance, and flexibility more than the Generation X nurses (Keith et al., 2021;Waltz et al., 2020).The significant findings of this study are discussed in the following paragraphs.
The new Generation Y nurses were more likely to express a strong sense of responsibility for their work, anxiety, and self-reproach for poor performance.Previous studies have found that, although Generation Y individuals respond well to praise, have high self-expectations, and tend to utilize teamwork, they lack the confidence to work alone and become disheartened when they do not receive immediate feedback (Christensen et al., 2018;Feeg et al., 2022;Monaco & Martin, 2007).This study found that new Generation Y nurses experienced serious difficulties when they did not receive appropriate feedback from senior nurses.They felt inexperienced and incompetent in the face of the high expectations they set for themselves.Similarly, a Canadian study found new nurses experienced stress when they were unprepared for work and suggested that these nurses should receive appropriate feedback from senior nurses along with long-term coaching and should always have someone able to answer their questions (Lavoie-Tremblay et al., 2010).
Meanwhile, in response to negative feedback regarding work outcomes, new Generation Y nurses expressed that being scolded in front of patients and caregivers was unethical.Millennials emphasize collaboration rather than hierarchical relationships (Keith et al., 2021) and expect sincerity and ethical behavior from their superiors (Twenge & Campbell, 2008).Thus, other research confirms and reinforces the reported sensitivity of the new Generation Y nurses in this meta-synthesis to not being respected.To motivate new millennial nurses and increase their morale within an organization, horizontal relationships based on respect are needed, along with a safe and respectful working environment supported by ethical leadership.Furthermore, nursing organizations should create a mutual support system among colleagues to help new Generation Y nurses develop the confidence and competence necessary to grow as professionals.
The new nurses in this meta-synthesis who worked three shifts reported difficulties adjusting to their lifestyle and struggled to handle the related physical and mental health problems and the absence of a personal life.Although both new Generation X and Y nurses reported strongly valuing a balance between work and life, there were differences in what they considered "balanced."Individuals from Generation X tend to value recognition at home and work (Mahmoud et al., 2020), whereas those from Generation Y desire to develop themselves through work and live a leisureful and enjoyable life (Kilber et al., 2014).In this study, the new Generation Y nurses found their goal of living a joyful life hampered by three-shift hospital work and did not consider this work schedule to be normal or acceptable.In New Zealand, work-life balance for millennial nurses means having enough personal time and separating work from life (Jamieson et al., 2013).Thus, nurse managers should flexibly adjust working patterns in their units to help millennials balance their personal and work life and maximize their work efficiency.
A new discovery in this study was the finding that the new Generation Y nurses value intimacy with peers and colleagues and the meaning of individual work contributions more than the new Generation X nurses.Many of the new nurses in this study shared stories with their peers and experienced a strong sense of mutual sympathy.The Generation X nurses compared their situation with their peers and found peace of mind, reassured that their peers shared the same view.This sense of constant comparison may reflect the competitive tendencies of this generation, which had experienced intense competition in the college admissions process, especially in Korea.However, the Generation Y participants in this meta-synthesis were found to have stronger peer bonds than the Generation X participants.This result is consistent with Waltz et al. (2020) and Yap and Badri (2020), who reported that friendship with peers among millennials is important for feeling satisfied at work and contributes to job retention.In this study, the new Generation Y nurses were found to enjoy personal conversations with colleagues, indicating that private gatherings between senior and junior staff members provide opportunities to form close relationships.Generation Y nurses thrive in an informal, friendly, and intimate work environment (Magni & Manzoni, 2020) and build relationships with managers with whom they can talk to easily and who take the time to get to know them as individuals (Anselmo-Witzel et al., 2017).Therefore, nurse managers should work to help new nurses form friendly relationships and promote their adaptation inside the organization.This may best be done through small gatherings rather than large-scale meetings.In addition, to help mitigate the nursing labor shortage, new Generation Y nurses should be encouraged to form deep relationships with peers, senior nurses, and colleagues within their healthcare organization.An effective organizational operation plan may help resolve the grievances felt by new nurses and form support systems for them.Planned relationship-building activities are one example of a strategy that may yield positive results in this respect.
New Generation X and Y nurses who successfully overcame various difficulties and showed adaptive reactions several months after joining their organization felt a sense of security in their environment, adapted to their work, and gradually became more proficient.Unlike the Generation X nurses, the Generation Y nurses tended to gain confidence in their abilities after receiving recognition and trust from colleagues and patients rather than through repeated practice/experience.This finding may be explained by millennials being proud of work for which they receive organizational recognition and their generational preference for pursuing personal reward and self-perceived achievements (Keith et al., 2021;Kilber et al., 2014;Yoon & Ryu, 2021).Nursing organizations should create an atmosphere that supports and encourages their new Generation Y nurses to take pride in their work.Expressing an interest in, encouraging their professional growth, and understanding and trusting new nurses as professional nurses are examples of efforts that are likely to yield positive results.
In this meta-synthesis study, those new Generation X and Y nurses who reflected maladaptive reactions were more likely to be concerned and uncertain about their future at their hospital.The Generation Y nurses considered leaving their positions if they failed to find meaning and enjoyment in their work, including with regard to their shift work experiences.Millennial nurses wish to work in an environment that reflects their values and has professional significance (Magni & Manzoni, 2020).Therefore, it is important that nursing organizations remind new nurses that they are valuable assets, encourage them to learn and develop new knowledge and skills, and promote active colleague support relationships.These efforts may be expected to significantly assist new Generation Y nurses to discover meaning and enjoyment in their work.
This study was affected by several major limitations.First, because only studies conducted in South Korea were selected for inclusion in the study, the characteristics of new Generation X and Y nurses described are likely to be limited to the South Korean context.Thus, the results should be interpreted and understood in the context of the healthcare environment in South Korea only.Second, our reliance on the average age of participants and dates of study data collection may have resulted in the inaccurate classification of the generation affiliations of participants.In addition, because the periods used in prior studies to identify generational affiliation have varied, it is possible that some of the nurses in these studies were categorized incorrectly.Nurses born during the transition period between Generation X and Generation Yare the most likely to have been miscategorized.Third, this study may be biased because of the secondary data analysis approach used to derive the characteristics of Generations X and Y. Nevertheless, the results are meaningful, as they provide an in-depth explanation of differences between generations and the shared experiences of new nurses as well as suggest directions for future research on nursing workforce management.
The results of this study suggest several actions that nursing organizations may take to promote intergenerational harmony in their workforce.First, Generation X nurse managers should acknowledge the unique perspectives and needs of the different generations in their nursing organization.People often make the mistake of judging others based on their own experience.For example, it may be a mistake to assume that new nurses of different generations react and adapt to situations/ challenges in similar ways.Second, nursing managers should use informal, intimate, and small group activities to promote the retention of new nurses in their organizations.Informal groups are an easy-to-organize and important way of promoting comfortable and supportive relationships for new nurses to give them a sense of organizational belonging.Third, nursing managers should foster a respectful environment in their units.New nurses grew up in a more respectful environment than that experienced by past generations, and they have a strong sense of respectful relationships.Therefore, nursing managers should encourage senior nurses to criticize and compliment their juniors in a respectful manner.Fourth, to prevent new nurses from leaving because of lack of perceived meaning in their work, nursing managers and educators should help millennial nurses find a sense of meaning in their work.Job training and formal education should instill a sense of purpose in millennials and help them create exciting journeys that help them achieve their goals as nursing professionals.Sharing their goals and responding continuously to feedback related to their achievements are necessary.Finally, millennial nurses, who are on track to playing pivotal roles in nursing organizations as future nurse managers, should strive to develop an attitude that welcomes the instruction and advice of senior nurses.In addition, millennial nurses must acknowledge their important role in the future as a bridge between Generation X and Generation Z nursing professionals.
The final recommendation of this study relates to nurses of Generation Z (those born after 2001).Because nurses of this generation will soon begin joining hospital organizations, qualitative studies should be developed to explore their clinical experiences.Understanding the experiences and values of Generation Z nurses and comparing these with those of previous generations will help facilitate the achievement of short-and long-term goals, including (but not limited to) boosting staff morale, encouraging team-building, improving nursing education and orientation, and achieving high-quality patient care in a working environment that is positive for new nurses, experienced nurses, and all healthcare professionals.

Figure 1
Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flowchart for Study Screening and Selection Process

Table 2
Summary of Included Studies

Table 2
Summary of Included Studies, Continued • Core category: the process of being "routine"• The process of new nurses'

Table 2
Summary of Included Studies, Continued Heejin CHUNG and Mihyun PARK

Table 2
Summary of Included Studies, Continued

Table 2
Summary of Included Studies, Continued

Table 2
Summary of Included Studies, Continued