Structure of difficulties novice nurses encounter in providing care for older patients with dementia in acute care settings

By 2050, more than 150 million people will live with dementia globally. In Japan, prevalence is projected to exceed 25% by 2045.^{[1, 2]} Individuals with dementia are hospitalized more frequently than those without the condition, a trend that has been consistently associated with older age,^[3] often leading to adverse outcomes, including prolonged stays, higher mortality rates, and institutionalization.^[4,5,6]

Acute care hospitals pose significant challenges for people with dementia. These environments often fail to meet their physical, psychosocial, and autonomy-related needs due to communication difficulties and disruptive settings.^[7,8,9] In response, behavioral and psychological symptoms of dementia (BPSD) frequently emerge, affecting approximately 75% of older patients with dementia.^{[8, 10, 11]} Nevertheless, the primary focus in acute care remains on somatic issues, often marginalizing dementia care.^{[12, 13]}

The person-centered care (PCC) model, which emphasizes respect for the individual and their autonomy, has shown benefits for both patients and caregivers, including reductions in BPSD and caregiver burden.^{[14, 15]} Despite growing international support for implementing PCC in acute settings, its practical application is frequently hindered by systemic barriers such as hospital culture, environmental constraints, and staff knowledge gaps.^{[16, 17]}

Nurses hold a central position in dementia care, with their role becoming particularly vital within acute care settings. However, in practice, they frequently encounter complex care demands, ethical dilemmas, and considerable emotional and time burdens, all of which contribute to a heightened risk of burnout.^[18,19,20] These challenges highlight the need for targeted support grounded in dementia nursing competencies, such as those outlined by Yamaguchi et al.^[21]

In 2016, the Japanese government introduced a financial incentive scheme to improve dementia care by promoting specialized teams, enhancing staff education, and reducing physical restraint use.^[22] Yet restraint reduction has been modest, frontline challenges remain unresolved,^[23] and little is known about the preparedness of novice nurses—raising concerns about whether system-level reforms sufficiently address the realities of early-career practice.

Prior research has largely centered on mid-career nurses and other healthcare professionals, identifying challenges such as high physical and emotional demands, limited confidence, and ethical conflicts.^{[13, 18]} Consequently, most existing educational interventions target mid-level staff and have been shown to enhance confidence, knowledge, and self-efficacy.^[24,25,26] In contrast, novice nurses face a steep learning curve as they develop clinical competence and adapt to professional environments—a process often accompanied by “transition shock”, which involves emotional, physical, social, and intellectual challenges.^[27,28,29] This shock negatively affects job satisfaction, stress levels, and care quality.^[30] Although dementia education programs for pre-registration nurses improve knowledge, attitudes, and confidence, their long-term impact remains unclear.^[31] Moreover, nursing students also report experiencing distress during dementia care placements,^{[32, 33]} suggesting that acute dementia care may exacerbate transition shock.

Although an Australian study acknowledged that dementia care is particularly difficult for novice nurses, it lacked detail.^[34] A Canadian study identified specific emotional and cognitive difficulties—such as anxiety, frustration, and heightened vigilance—but did not examine how these challenges are interrelated. Notably, participants in that study had an average of 5.4 months of experience.^[35]

To address this gap, the present study provides the first comprehensive account of how difficulties in dementia care are interconnected and evolve across novice nurses’ first year of practice. These findings offer foundational evidence for designing early-career training that bridges classroom preparation with the realities of acute dementia care and supports workforce policies to strengthen dementia care readiness. Therefore, the objective of this study was to clarify the structure of difficulties experienced by novice nurses during their first year of dementia care in acute care settings, using the KJ method, to inform supportive interventions.

2.1Design

2.2Settings

2.3Participants

2.4Data collection

2.5Analytical methods

2.6Credibility and authenticity

2.7Ethical considerations

3.1Settings and participants

3.2Overall analysis

The overall analysis employed a total of 71 labels finalized from the individual analyses. These labels underwent a four-step grouping process, resulting in seven final labels and, subsequently, an affinity diagram illustrating their relationships and respective symbols (see Figure 1). Underpinned by ethical dilemmas involving the tension between ensuring patient safety and respecting patient dignity, novice nurses engaged in practice while navigating multiple difficulties. These included apprehension stemming from inexperience despite an awareness of their responsibilities, frustration arising from ineffective engagement despite repeated efforts, and emotional turbulence triggered by resistance from older patients with dementia. These difficulties—stemming respectively from being neophytes, the complexity of dementia, and the acute care environment—were interrelated, creating a complex and multilayered situation. As novice nurses continued their practice under such conditions and confronted the limits of their coping capacity, two emotions emerged as a common thread throughout their experiences: guilt over burdening others and inadequacy due to difficulty adapting and reliance on senior nurses’ support. Ultimately, what emerged were the consequences of coping: ongoing challenges beneath a superficial sense of accomplishment, and a perceived need for earlier, more practical dementia care education.

Figure 1.

Structure of difficulties novice nurses encounter in caring for older patients with dementia in acute care settings throughout the year

Each symbol is presented in bold and described in detail using its corresponding final label in angle brackets ([]), representative raw data excerpts in quotation marks (“”), and participant identifiers in parentheses.

3.2.1Stemming from the discrepancy between nursing education and clinical practice: Ethical dilemmas between ensuring patient safety and respecting dignity

[Although novice nurses had been taught the importance of ethical considerations during their nursing education, they were compelled to use physical restraints on older patients with dementia who exhibited dangerous behaviors within a safety-oriented organizational culture; imagining the situation from the perspectives of the patients and their families evoked feelings of pity and moral conflict, raised concerns about violating patient dignity, and ultimately led to ethical dilemmas.] The symbol expresses that it is difficult for novice nurses to reconcile safety with respect for patient dignity.

One novice nurse, describing inner conflict over how families might view restraints, shared: “I often wondered what the patient’s family would think if they saw the restraints. I would feel bad if I or my family were restrained in the future. I had opportunities to discuss the significance of restraints with my preceptor, but they said, “We have to prioritize life and safety.” (A)

Another, reflecting on the challenge of balancing safety and dignity in practice, said: “I once cared for a patient with a fracture who had dementia, could not follow the bed rest instructions, and tried to stand up on their own, resulting in a fall. I understood that their inability to follow instructions was due to dementia, but we had to use restraints. I felt ethically distressed.” (B)

A third novice nurse, describing the discrepancy between ideal and reality, shared: “According to textbooks, restraint is done for the sake of the patient, but in practice, sometimes it is done for executing duties.” (C)

3.2.2Stemming from being neophytes: Apprehension due to inexperience while being aware of responsibilities

[After entering clinical practice, novice nurses accepted the reality of providing care to older patients with dementia—who often require advanced treatment and present unavoidable risks such as wandering and falls—but were nonetheless shocked by the difficulty of responding to such situations and felt uncertain about how to cope as beginners in the field.]

This symbol encapsulates the shock, unpreparedness, and anxiety that novice nurses experience in acute dementia care.

One novice nurse, who had previously only interacted with two people with dementia before employment, described: “Right after I started working, I realized just how many different types of patients there are, and that caring for them is even more challenging than I had imagined.” (G)

Another nurse shared: “When I was working part-time, the older people with dementia I met were almost ready for discharge and not in very bad condition. But now, patients are being treated for severe physical conditions as well as dementia. It’s already a matter of life and death for them. I am more nervous in the ward than before.” (I)

One participant also expressed concerns about care quality when handling multiple patients alone: “During placement, I handled one patient with support; but at work, I sometimes had to care for three on my own. I worried I might negatively affect their care.” (J)

3.2.3Stemming from the acute care environment: Emotional turbulence due to resistance from older patients with dementia

[In the acute care setting, novice nurses, believing that negative emotions such as fear, frustration, sadness, and discouragement were inappropriate for nursing professionals, suppressed these feelings when essential nursing interventions—intended to ensure treatment and rest—were met with refusal or aggressive behavior by older patients with dementia, and began to question whether their own responses had been wrong.] This symbol demonstrates that, in acute care settings, novice nurses recognized that medical tasks should be performed even when irritation arises, leading to an emotional and professional conflict.

One novice nurse, describing painful experiences of rejection, shared: “Even though I explained various things for their well-being, I was met with resistance through physical actions or words. At such times, I wondered why they reacted that way toward me, and it was painful.” (A)

Another reflected on an episode of being struck by a patient while managing routine tasks: “I was just busy doing my tasks when he hit me. A part of me wanted to hit back, but I thought maybe he was trying to tell me something in the only way he could, and that it was my failure to understand him. I tried to suppress those tangled feelings and hold myself back.” (J)

3.2.4Stemming from the complexity and individuality of dementia: Frustration from ineffective engagement despite repeated efforts

[Despite repeated engagement, novice nurses struggled to interpret the individualized characteristics of restless behaviors and the underlying emotions, especially when compounded by communication difficulties, which contributed to a persistent sense of frustration.] Participants felt frustrated at misinterpreting symptoms.

One novice nurse, describing the challenges of differentiating BPSD from delirium during night shifts with limited staff support, shared: “When I work the night shift, some patients exhibit delirium-like symptoms. It is difficult to distinguish.” (G)

Another novice nurse, reflecting on the difficulty of guiding patients to express their needs, said: “Some patients didn’t express their needs, so I had to ask in detail. Maybe he didn’t remember me or didn’t want to open his heart. I felt at a loss.” (H)

Another participant, describing the time it takes to understand the individuality of each patient, shared: “I try to understand the patterns of people with dementia, but it really takes time. I have to read their behavior to understand them, and that part is difficult. When a new patient comes in, I often feel it’s quite challenging.” (J)

3.2.5Stemming from the limits of coping: Guilt over burdening others

[Lacking sufficient knowledge and skills in dementia care and overwhelmed by multiple routine tasks, novice nurses found themselves mentally unprepared to properly face older patients with dementia, which led to delays and disorientation that burdened these patients, other patients, and senior nurses, ultimately resulting in feelings of self-blame.] For novice nurses, dementia care adds a significant workload, requiring time, skills, and emotional energy as it impacts both patients with dementia and those around them.

One novice nurse expressed their distress over not being able to attend sufficiently to patients: “I felt truly sorry that I couldn’t spend enough time with patients with dementia. There were times when, because I prioritized my tasks, a patient who probably wanted to go to the toilet ended up soiling themselves, and that really weighed on me.” (B)

Another reflected on the burden placed on senior staff: “I felt guilty for troubling my senior nurses when I couldn’t manage everything myself.” (E)

Yet another novice nurse stated: “I felt I had to stay with dementia patients constantly, which sometimes delayed me in bringing medications to other patients. It was difficult, and I felt truly sorry.” (G)

3.2.6Stemming from the limits of coping: Inadequacy due to difficulty adapting and reliance on senior nurses’ support

[Despite attempting to apply their basic knowledge and experience, novice nurses found responding to older patients with dementia difficult and confusing, which led them to rely on senior nurses in challenging situations, and as they became more independent, they increasingly struggled with the limits of their abilities.] Participants felt inadequate due to reliance on senior nurses and limited practical knowledge.

One novice nurse described the difficulty of bridging the gap between classroom learning and real-world practice: “The situation I’m in now is different. I was taught the important basics at school, but I’m expected to build on that, and that’s been challenging.” (E)

Another, reflecting on increasing responsibility and anxiety as senior support decreased, said: “By October or November, the severity of the patients I was responsible for had gradually increased. My seniors began to step back, and I had to take responsibility for my work. I felt a lot of anxiety at that time.” (F)

A further participant reflected on comparing themselves with experienced colleagues: “I admired the competence of senior nurses, while also being reminded of my own limitations.” (H)

3.2.7Consequences of coping: Ongoing challenges beneath the sense of accomplishment and the need for early education

[While novice nurses developed a more constructive attitude toward caring for older patients with dementia and gained a certain degree of composure through a year of involvement, difficulties in dementia care persisted, highlighting the need for early-stage training.] Participants reflected on their first-year experiences, expressing both improvements and ongoing challenges.

One participant expressed a continued sense of uncertainty despite increased exposure: “That vague sense of uncertainty hasn’t changed. Patterns and personalities differ so much that it’s hard to feel like things have gotten easier.” (I)

Another described a modest growth in confidence, while acknowledging that it stemmed from personal struggle: “Compared to when I didn’t know anything at all, I feel like I’ve grown a little and gained a bit more confidence in how I interact with people with dementia. It’s because I’ve had those experiences and struggled through them.” (K)

This study highlights that novice nurses’ first-year dementia care in acute settings is shaped by safety–dignity dilemmas. They faced three interconnected difficulties—apprehension from inexperience, frustration from ineffective engagement, and emotional turmoil from patient resistance. These challenges fostered feelings of guilt and inadequacy and underscored the need for earlier dementia education.

Our findings also suggest a fundamental incompatibility between the fast-paced demands of acute care and the ideals of person-centered care (PCC) for older patients with dementia, which novice nurses had learned during their primary nursing education. Previous studies indicate that experienced nurses also encounter ethical conflicts when using restraints that diverge from PCC principles.^{[39, 41]} However, novice nurses, who are especially prone to reality shock, appear even more inclined to experience such dilemmas. Moreover, novice nurses tend to absorb the dominant values of their organizational culture and peers, even when these differ from their initial beliefs.^[42] In this study, participants internalized safety-oriented norms from senior staff, which intensified ethical conflicts.

Although most participants had prior contact with older people with dementia, they felt unprepared and anxious about providing care in acute settings. This contrasts with the findings of a previous study, which reported that early exposure enhanced novice nurses’ confidence.^[35] The discrepancy may be attributed to the limited depth or context of prior experience or training. In this study, 10 out of 11 participants had entered the workforce immediately after graduation, and only one had professional caregiving experience. Younger students (under 25 years) are more susceptible to the negative influence of prior experiences than older students.^[43] Given that most participants were in their early twenties, their initial negative perceptions may reflect this tendency.

Patient falls have been identified as the most common incident involving novice nurses.^[44] Similarly, participants in this study expressed serious concerns about the safety of older patients with dementia, especially due to their unpredictable behaviors and the need to manage multiple patients simultaneously. This mirrors concerns previously expressed by mid-career nurses,^{[13, 18, 45]} but for novice nurses, such concerns are often intensified by anxiety about assuming clinical responsibilities. Despite this, participants demonstrated a strong sense of professional duty. Early orientation programs and adequate support are thus essential to enhance novice nurses’ understanding of dementia care and alleviate their apprehension.

This study also revealed the emotional distress novice nurses experience when encountering resistance from patients with dementia. Such resistance is common during acute admissions,^[46] yet acute care environments often prioritize safety, symptom management, and efficiency over relational care. This may intensify patient resistance and exacerbate emotional strain among staff.^{[12, 18, 46]} Novice nurses, in particular, undergo a dynamic transition characterized by fluctuating emotions^[29] and may experience disillusionment when clinical realities diverge from academic ideals.^[47] These factors render them particularly vulnerable to emotional turbulence. To mitigate this, staff should share information on patients’ histories and behavioral cues to support early recognition and proactive responses.

Participants also reported frustration with repeated failures to manage symptoms effectively. This aligns with earlier research identifying gaps in novice nurses’ clinical, communication, and decision-making skills.^[48] The high prevalence of BPSD,^[5] communication barriers,^[7] and patient variability^[8] further complicate dementia care. These results underscore the need to integrate management with person-centered approaches.

Novice nurses in dementia care frequently experience guilt about burdening others, which is closely intertwined with a persistent sense of inadequacy. These feelings can be attributed to three interrelated factors. First, the hospitalization of patients with dementia places heavy demands on nurses, who must manage multiple patients simultaneously while coping with unpredictable behaviors, leading to stress and delayed care for others.^{[10, 39]} Second, insufficient time and skills limit their ability to provide high-quality, person-centered care, while routines and fatigue leave little learning opportunity. Many consequently adopt a task-oriented approach, which hampers their capacity to address complex care needs.^{[17, 49]} Third, frequent reliance on senior staff reinforces feelings of dependence and guilt about imposing on others. Together, these factors amplify novice nurses’ feelings of guilt and inadequacy and highlight the need for protected time and structured, context-sensitive support to facilitate learning and engagement in dementia-specific training.

Younger nurses remain vulnerable to being overwhelmed by the complexity of dementia care, even after training.^[17] Similarly, in this study, all eight participants who had received dementia-related training continued to face significant challenges. This highlights the need for continuous, experience-sensitive education tailored to the developmental stages of novice nurses. Despite these difficulties, participants gradually improved in attitudes and responsiveness during their first year. They emphasized the need for structured dementia care training tailored to their evolving needs, highlighting the importance of flexible programs that combine foundational knowledge with opportunities for practice and reflection.

The structural framework identified in this study highlights that the difficulties experienced by novice nurses in acute dementia care are not isolated issues but are dynamically interconnected. Ethical dilemmas between patient safety and dignity underpin multiple challenges, while inexperience, the acute care environment, and the complexity of dementia interact to intensify emotional burden, guilt, and feelings of inadequacy. Importantly, the framework indicates that support needs differ across stages of the transition period and must address not only skill acquisition but also emotional and ethical challenges.

At the educational perspective, the framework suggests that support should be tailored to novice nurses’ stage of transition. In the early phase of employment, accessible resources such as e-learning should be offered to mitigate initial shock and emotional fluctuations. These programs can provide essential dementia care knowledge, including communication strategies, recognition of BPSD, and self-protection in situations of verbal or physical aggression. E-learning has been shown to improve nurses’ knowledge and confidence,^[50] while staff training in aggression management reduces workplace violence and its negative effects.^[51] Creating a safe work environment is therefore essential to support novice nurses’ transition and well-being. In addition to early support, ongoing educational interventions, such as structured reflection, are essential to mitigate transition shock and promote adaptive coping.

At the practical perspective, as novices gain experience and begin independent practice, timely preceptor follow-up becomes increasingly important. Preceptors familiar with available resources can support novices in interpreting complex situations and applying knowledge in practice, fostering the transition from novice to expert.^[52] In addition, the framework underscores the importance of shifting support from an individual focus to team-based approaches. Strengthening team-based support through regular case conferences, interdisciplinary collaboration, and participation in dementia care team activities allows ethical tensions to be shared and responsibility for risk management to be distributed. Such approaches may help novice nurses contextualize challenges within the care environment rather than internalizing them as personal failures. Organizational and team-based support has been shown to facilitate ethical decision-making in complex clinical situations.^[53]

At the policy perspective, the findings highlight the need for organizational structures that alleviate the cumulative burden on novice nurses caring for older patients with dementia in acute care settings. Policies should ensure access to specialized dementia care teams, protected time for learning, and continuity of preceptorship throughout the first year. Furthermore, restraint-reduction initiatives must be accompanied by practical and organizational support to enable novice nurses to navigate safety–dignity tensions without excessive moral distress.

Limitations and future research

This study visualized the complex difficulties novice nurses face in providing dementia care in acute settings, revealing their interrelated nature and ethical underpinnings. By clarifying this interaction structure, the study offers a foundation for developing multidimensional, stage-specific support strategies. Approaches such as e-learning, timely preceptor follow-up, team-based case discussions, and participation in dementia care team activities can help strengthen novices’ competencies, reduce emotional distress, and enhance the quality of dementia care. These findings highlight the need to integrate person-centered care principles into acute hospital practice and may inform nursing education and organizational policies aimed at supporting novice nurses and improving dementia care in aging societies worldwide.

Tingting Chen: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Validation, Visualization, Writing – original draft. Toshihiro Ono: Methodology, Formal analysis, Validation, Writing – review & editing. Harue Masaki: Conceptualization, Methodology, Formal analysis, Supervision, Writing – review & editing. All authors approved the final version of the manuscript and agreed with its content. No authors contributed equally to this work.

This work was supported by JST SPRING [grant number JPMJSP2109]. The sponsor had no role in the study design, data collection, data analysis, interpretation of the data, writing of the manuscript, or the decision to submit the article for publication. The funding was used for English language editing and publication fees.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Obtained.

The Publication Ethics Committee of the Association for Health Sciences and Education. The journal’s policies adhere to the Core Practices established by the Committee on Publication Ethics (COPE).

Not commissioned; externally double-blind peer reviewed.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

No additional data are available.