Thirteen nurses were women. The average age of nurses was 37.31 ± 6.51. Fifteen had a bachelor's degree in nursing. Thirteen nurses worked in general wards (Table 1). Data analysis led to the extraction of three categories: professional challenges, managerial challenges, and unsuitable environment (Table 2).
The Categories and Sub-categories
Example of coding
Having a heavy workload due to shortage of nurse
Lack of specific time for morning doctor visits
Time-consuming inspection rounds accompanied by a supervisor
Unscheduled rounds of supervisors
Spend a lot of time helping and monitoring novice
Lack of professional skills in communicating with a patient
Unfamiliarity with the culture and behavior of patients
Shortage of medical staff
Improperly scheduled visits and rounds
Managers ignore the low salaries of nurses
Nurses' dissatisfaction with managers
Lack of motivation and energy due to fatigue and burnout of nurses
Ignoring the needs of nurses
Inappropriate management styles
Waste of time due to shortages of medical equipment
Crowded ward due to the presence of many medical students in the ward
Inadequate conditions of patients' rooms
Inadequate medical facility
Non-standard hospital environment
1. Professional Challenges
This category consists of five sub-categories: the shortage of medical staff, improperly scheduled visits and rounds, time-consuming supervision, inadequate competence, and cultural unfamiliarity.
1.1. Shortage of medical staff
The shortage of physicians, nurses, and nursing assistance was a significant barrier to the presence of nurses at the patients' bedside. Spending more time answering doctors' phone orders increased the workload of nurses. The shortage of nurses prevented the optimal ratio of nurses to beds. These conditions caused nurses to suffer from mental and physical fatigue not to spend enough time at the patient's bedside.
"The shortage of nurses and assistant nurses along with the high number of patients makes it impossible for us to always be present at the patients' bedside." (P.2)
1.2. Improperly scheduled visits and rounds
Participants cited improper scheduling of clinical visits and rounds as the reason for nurses' insufficient presence at the patient's bedside. Also, nursing officials did not act in a specific time frame to attend the wards; this caused nurses to lose useful time at the patient's bedside due to a doctor or supervisor's intrusive presence instead of addressing the patient's needs. Interruption in nursing programs leads to a waste of time and reduces the number and duration of nurses' stay at the patient's bedside.
"Physicians do not have a specific schedule for visiting patients. Sometimes during the day and sometimes at the end of each work shift, they enter the ward to visit. This interrupts patient care. "(P.6)
1.3. Time-consuming supervision
Participants stated that novice nurses supervising takes time and reduces nurses' presence at the patient's bedside. The nurses showed that part of their opportunities was wasted to monitor medical procedures.
"We have to spend a lot of time supervising trainees and novice nurses. This makes it impossible to much present in the patients' beds"(P. 10)
1.4. Inadequate competence
The nurses' citations showed that they lacked up-to-date communication skills, teamwork, and technical knowledge that made them fearful and anxious about medical procedures. This caused them to be less sunny at the patient's bedside. Such anxiety caused the nurses not to improve their clinical skills due to their absence from the patients' bedside.
"When the nurse's skills are low, the nurse is afraid that the patient will notice this weakness." (P.3)
1.5. Cultural unfamiliarity
Gender differences between nurses and patients and unfamiliarity with patients' culture make nurses less likely to present at the patient's bedside.
" It becomes really difficult to be in the patient's bedside when you are not familiar with the patient's culture and beliefs." (P.8)
2. Job attenuation
A set of factors weakened the professional work of nurses. In this way, nurses experienced dissatisfaction, fatigue, and burnout. Job attenuation consists of two sub-categories: ignoring the needs of nurses and inappropriate management styles.
2.1. Ignoring the needs of nurses
A set of factors weakened the professional work of nurses. In this way, nurses experienced dissatisfaction, fatigue, and burnout. The nurses stated that the managers' negligence towards the facilities (rest, nutrition, locker room, bed, etc.) reduces their job motivation to present at the patients' bedside.
"Nursing managers do not attempt to solve our problems such as salaries, high workload, and welfare facilities... Their upsets and discourages nurses." (P. 13)
"As an experienced nurse, because I see that no one in charge responds to my needs, I do not have the patience to spend more time in the patients' bedside." (P.6)
2.2. Inappropriate management styles
A management style was considered an important factor in nurses' presence at patients' bedside. Nursing managers decisions in an autocratic manner; rotation programs for nurses regardless of their interests, clinical skills, and always adopting functional labor division reduced nurses' motivation to present at the bedside.
"Nursing managers do not consult with us for decisions… It has happened many times that in the middle of the month I was transferred to another ward as a nurse assistant… Such actions are annoying "(P.9)
Nurses stated that being forced to perform non-clinical tasks such as completing forms and other written activities to accreditation program and attending in-service training sessions wastes time and prevents their presence at the patient's bedside.
"The workload is high… Doing accreditation processes has also doubled the problem. The number of patients has not decreased and has made it difficult for us to be at the patient's bedside." (P.14)
Nurses also spent a lot of time writing nursing reports, entering physician orders into cards, completing vital signs sheets, and entering some information such as drug reservation requests and tests into the computer. The lack of modern software and modern hospital information system made it difficult for nurses to send and receive nursing reports. For example, nurses stated that charting and plotting vital signs in all patient records for each shift wastes a lot of time. This was while they traditionally wrote nursing reports, admission, and discharge information every day. In this regard, a nurse said his experience:
"Frequent recording of information in a patient's medical record and documents, either manually or electronically, is time-consuming... It takes a lot of time for us." (P.6)
3. unsuitable environments
This category consists of three sub-categories: inadequate medical facility, ward congestion, and non-standard hospital environment
3.1. Inadequate medical facilities
Lack of proper and new medical equipment causes nurses to spend a lot of time reporting and following up on these problems.
"Failure of medical equipment always causes trouble... We must constantly worry that these devices will not work properly. For example, sphygmomanometer or even oxygen delivery devices, or the central suction ... This wastes a lot of our time so that sometimes we forget the patient." (P.3)
3.2. Ward congestion
Nurses stated that the presence of medical students and families Increased congestion in the wards. Also, answering students' questions and providing facilities for their practice takes many hours for nurses.
"The presence of medical students, families, and physiotherapist, etc., causes the ward to become crowded I cannot find enough time to be a presence at patient's bedside" (P.3)
3.3. Non-standard hospital environment
The non-standard design of wards in the hospital wastes nurses' time. Lack of proper facilities in patients' rooms, such as air conditioning and insufficient space for patients, creates challenging conditions for nurses to be much and effective in patients' bedsides. Experiencing these difficult conditions reduces nurses' willingness to be more present in patients' beds.
"Some rooms do not have enough light and because of the lack of air conditioning, the unpleasant odor and do not have good conditions ... Nurses under these conditions cannot be present in the patients' bedside much." (P.7)