The readiness of Saudi nursing interns for the professional role

Abstract

BACKGROUND:

The nursing education program offers opportunities to prepare nursing students with the knowledge and skills required for their professional roles. The level of their readiness and confidence will affect their ability to provide effective and sufficient nursing care. The purpose of this study is to assess nursing interns readiness for professional roles.

MATERIALS AND METHOD:

To accomplish the study’s objectives, a cross-sectional, descriptive design was employed. All nursing interns who graduated from the KAU School of Nursing in the academic year 2018–2019 were recruited from different hospitals in Jeddah, Saudi Arabia, from March 2019 until May 2019. Participants completed the Casey–Fink Readiness for Practice Survey. Descriptive statistics were conducted to answer the research questions.

RESULTS:

The results of this study demonstrated that the students felt ready and confident to assume their professional nursing roles. The students had some difficulties with managing multiple patients and certain skills, such as how to deal with dying patients and prioritize patient care needs.

CONCLUSION:

The findings of this study showed the students felt entirely ready for the professional nursing role. The nursing college at King Abdul-Aziz University is making a great effort to prepare its students for their professional roles. We still need to develop skills and clinical competencies in preparation for effective professional roles. In addition, continuous assessment is considered important for patient safety, to increase nurses’ work retention, and to enhance professional nurse confidence and the quality of care they must provide.

Introduction

The Bachelor of Science in Nursing program at King Abdul-Aziz University (KAU) is designed to prepare nursing students to be efficient nurses in clinical nursing care to fulfill the needs of nursing shortages and provide quality care because it is one of the most important parts of a health care team. The nursing program consists of 4 academic years followed by one internship year. The first year is a preparatory year, followed by 3 years of study within the college to build the basic knowledge and skills in nursing through theoretical lectures, clinical practice, and nursing skills labs. The most important courses that are studied cover basic concepts of professional nursing, foundations of professional nursing, nursing care of adults, child health nursing, maternity nursing, critical care nursing, psychiatric/mental health nursing, and nursing leadership/management. The last year of the nursing program is dedicated to applying high-quality nursing care. It is called the nursing internship year.[1] This internship year is an intensive, compulsory training period for nursing students. During this period, students are exposed to different clinical settings. The goal of this year is to link theoretical information and practice from the past 4 years. The internship year is a prerequisite for obtaining a license to become a registered nurse in Saudi Arabia, and it lasts for 12 months. The internship is a period of transition from the classroom to real-life practice. The clinical placement of the nursing intern during internship will include the following units: medical-surgical, pediatrics, maternity, emergency, intensive care, neonatal or pediatric intensive care, surgery, dialysis, and endoscopy. Nursing interns are required to choose one elective area for a 7–8-week period to be attached to the letter of request for training in a specific hospital. A nurse intern is required to receive a total score of at least 60% to pass the evaluation in each area. The hospital will assign a nurse preceptor for each nursing intern. The preceptor serves as a mentor, facilitates student autonomy, and helps students transition into the field of clinical nursing practice smoothly.

The relationship between hospital staff and nursing interns is the most important factor that influences nursing students’ clinical learning experiences. However, the nursing interns described unpleasant clinical experiences that negatively affected their attitudes and confidence, which ultimately hampered their ability to learn.[2] These experiences included unwelcoming clinical settings, language barriers, staff shortages, improper delegation of tasks, or theory-practice gaps.[3]

Benner’s (1984) model of clinical competence described five stages of a nurse’s progress from novice to expert.[4] Each stage features the abilities that a nurse demonstrates in clinical practice. Nursing students often fall into the novice stage with limited nursing experience. Nurses in their first year of practice after graduating are advanced beginners. Nursing professionals with at least 1 year of experience are considered competent. After 3–5 years of practice, a nurse reaches the fourth level, proficient. Not all nurses advance to the fifth stage, expert, which requires a minimum of 5 years of clinical practice. Benner’s model is helpful for understanding the progression of a nurse’s career and can help nurses identify their strengths and areas for improvement.[5] In addition, Benner’s model can help hospital and nursing educators design appropriate guidance, support, and continuing education opportunities. Nursing administrators can use the data to create policies for monitoring development and giving feedback to new nurses.

The nursing education program prepares nursing students to assume the essential roles of a professional nurse. It is expected that nursing interns are qualified with sufficient nursing education to prepare them for professional nursing practice.[6] Therefore, the level of their readiness and confidence will affect their ability to provide effective and sufficient nursing care. The readiness of nursing students toward clinical practice has been the focus of many research studies. The clinical skills aspect is an important part of nurse development because it provides opportunities to prepare nursing students to become ready and willing to provide care in the workforce as registered nurses. A certain level of uncertainty is expected at the beginning of the training, but the sense of inefficiency will affect the practice and put the patient at risk.[7] Additionally, self-confidence is considered an important attribute, and nursing interns who have high self-confidence can succeed professionally in terms of clinical practice and decision-making because they can improve their skills better than interns with less confidence.[8] Nursing internship students have clinical experiences from their nursing education program and are expected to be adequately prepared to work in hospital environments and deliver high-quality care for their patients.[1] The purpose of this study is to assess the psychological readiness of the nursing intern for a professional position.

Materials and Methods

Study design and setting

A descriptive, cross-sectional design was used to answer the research question. Participants in this study were recruited from the KAU School of Nursing. They were distributed throughout many hospitals in Jeddah, Saudi Arabia. These hospitals were KAU Hospital, King Fahad General Hospital, King Fahad Armed Forces Hospital, King Abdullah Medical Complex Hospital, King Faisal Specialist Hospital, KAU Hospital (Al-Mahjar), and East Jeddah General Hospital. There are nursing students who work in different units in each of the above-mentioned settings.

Study participants and sampling

Convenience sampling was the method employed by the researcher to find volunteer participants. The cohort size for this academic year was 88 female nursing interns. The target population was nursing interns who graduated from the KAU School of Nursing in the academic year 2018–2019 and were in their internship for at least 3 months. Excluding the students who have been in the internship for less than 3 months and are unable to speak or read English.

Data collection tool and technique

The Casey–Fink Readiness for Practice Survey (CFRPS, 2011) was used in this study.[9] The questionnaire consists of three sections. The first section consists of demographic characteristics such as participants’ gender, age, ethnicity, other non-nursing degree, previous healthcare work experience, average hours worked, healthcare-related position, why you selected nursing as a career, type of Bachelor of Science in Nursing (BSN) program enrolled, type of scholarship program, and clinical area. The second section consists of participants who are asked to identify their level of confidence in managing a patient care assignment on an adult medical/surgical unit (three items); the third section focuses on the students’ comfort with both clinical and relational skills performance, and students are presented with a list of 20 items asking for a self-report about their level of comfort/confidence in performing key nursing activities, communication with physicians, delegating tasks, ability in problem-solving, knowing what to do for a dying patient, and relationship with the clinical instructor using a Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). For every one of the subscales, the Cronbach’s alpha ranged from 0.5 to 0.8.[9]

After obtaining ethical approval from the Faculty of Nursing at KAU, we contacted the vice dean of clinical affairs for intern students’ contact information. Then, the online survey was sent to the nursing intern students via emails and their phone numbers. After that, we followed up with them because we had a fewer responses than we anticipated. We tried to reach them by going to the hospital and asking the vice dean of clinical affairs to send a reminder email. Unfortunately, we only got 42 responses. A brief introduction was given before the survey link, and once they answered the survey, that meant they agreed to participate in this survey. The Casey–Fink Readiness for Practice Survey should not take more than 15 minutes to complete. By utilizing an online survey, their answers were anonymous, with no identifying information obtained.

Data analyses were performed using an Excel spreadsheet and then exported to the latest version of SPSS 22 (Statistical Package for Social Sciences). Descriptive statistics were conducted for demographics and survey items, and the data of the sample of 42 females had a frequency distribution that included measures of central tendency (mean), variability (standard deviation), and shape of distribution (skewness and kurtosis).[10] In order to analyze the Casey–Fink Readiness for Practice Survey results, descriptive statistics were used.

Ethical consideration

Ethical approval was obtained from the Research Ethical Committee of the Faculty of Nursing at King Abdul Aziz University (Reference No. 1B.23). Participants were informed that their participation was voluntary and that they could withdraw at any time. There is no benefit to their participation in this study, and there will be no reimbursement provided. There will be no financial cost to them as a result of taking part in this study.

Results

Main sample

In the present study, 44 students were enrolled. Table 1 shows that participants’ ages ranged from 22 to 25 years, with a mean age of 22.79. All students were female, enrolled in traditional curricula at KAU (100%) with an average grade point of 4.14, and were not employed at the time. The majority of students were non-White (61.9%). More than a quarter chose nursing as a career to care for others (38.1%). The mean average hours worked in a week was 37.55. All of the students reported being unemployed and in supported scholarship programs. The intern students are trained in a wide variety of clinical areas. Senior practicum experience was high in the emergency department (16.4%), OR/perioperative setting (14.7%), OB (L and D, postpartum; 13.8%), adult ICU (13.8%), pediatric M/S (11.2%), NICU (10.3%), and pediatric ICU (96.9%). More than three-quarters (85.7%) had their clinical practicum in an urban setting. to help people cope with illnesses (14.3%) and to educate themselves on diseases and health problems (14.3%), and 14.3% were not sure why they chose the nursing field.

Table 1.

Participants Characteristics (n=44)

Characteristics of participants	Statistics mean+SD
Age,	22.79+0.750
Clinical hours	66.96+156.458
Average number of hours worked/week	37.55+36.75
Grade average point	4.14+0.374
Number of primary preceptors	210.31+713.38
Month/year started in the BSN program:	2.358+1.586
How many hours did you spend with your unit charge nurse?	22.795+51.175

Students in the senior practicum applied the skills they gained in the learning lab (24.0%). Students showed they were uncomfortable performing the following skills/procedures independently: blood drawing/venipuncture, bladder catheter insertion/irrigation, central line care (dressing change, blood draws, discontinuing), responding to an emergency/CODE/changing patient’s condition, and giving verbal reports.

Part II: Confidence level in caring for two, three, and four patients

Students showed more confidence managing patient care assignments when they had a smaller number of patients. Results are listed in Table 2.

Table 2.

Confidence level in caring for two, three, and four patients

	Not confident 1	2	3	4	Very confident 5
Caring for two patients		(1) 2.4%	(5) 11.9%	(8) 19.0%	(28) 66.7%
Caring for three patients	(1) 2.4%	(6) 14.3%	(10) 23.8%	(16) 38.1%	(9) 21.4%
Caring for four patients	(6) 14.3%	(15) 35.7%	(12) 28.6%	(9) 21.4%

Part III: Level of comfort/confidence in performing key nursing activities

Students were comfortable communicating with physicians (M = 3.29, SD = 0.71) and interdisciplinary teams (M = 3.17, SD = 0.76). They were confident in identifying actual or potential safety risks (M = 3.07, SD = 0.68), solving problems (M = 3.02, SD =0.64), and using current evidence to make decisions (M = 3.12, SD = 0.63). However, the students felt uncomfortable dealing with dying patients (M = 2.71, SD = 0.89).

Regarding learning techniques, the students felt prepared for clinical experience by practicing in simulation labs (M = 3.1, SD = 0.73); however, writing reflective logs was not helpful for them (M = 2.86, SD = 0.75).

Regarding professional identity, the students were comfortable communicating with patients and asking for help (M = 3.67, SD = 0.48) and (M = 3.33, SD = 0.69), respectively. They were also satisfied with nursing as a career (M = 3.14, SD =0.78) and ready for their professional nursing role (M = 3.14, SD = 0.81). They did not feel their clinical instructor provided feedback about readiness to assume a RN role (M = 2. 69, SD = 0.81).

Finally, students were comfortable delegating tasks to the nursing assistant (M = 3.14, SD = 0.71) and practicing skills more than once (M = 3.33, SD = 0.61). However, the majority of students reported difficulty prioritizing patient care needs, recognizing a significant change in the patients’ conditions, documenting electronic medical records, and feeling overwhelmed by ethical issues associated with patient care responsibilities ([M = 2.83, SD = 0.82], [M = 3.14, SD = 0.68], [M = 3.02, SD = 0.84], and [M = 3.17, SD = 0.76], respectively.)

Discussion

The findings of this study demonstrated the confidence, comfort, and perception of readiness for practice among senior BSN students who have recently been practicing as nurse interns in hospitals. Additionally, perceptions of readiness for practice help broaden our understanding of the senior nursing students’ perceptions of readiness and confidence for the professional nursing role. This study showed students were prepared for some skills but not for others. Güner[7] (2015) showed students were not prepared enough.[7] Of the 20 skills students felt most uncomfortable performing on their own, the results showed the priority skills students could not perform independently included blood draw/venipuncture, bladder catheter insertion/irrigation, and central line care (dressing change, responding to an emergency/CODE/changing patient condition). Casey et al.[9] (2011) revealed that students experience difficulty responding to an emergency/code/changing patient situation.[9] Also, students reported having multiple opportunities to practice skills on mannequins in labs or simulations during their education program as opposed to dealing with real patients in a clinical setting. That may be because they did not get enough opportunities to practice the skills in their past clinical practice. Also, it may be because inadequate nurses guide, supervise, and mentor nurse’s interns where they work, so most nurses at KAU’s hospital did not have time to teach them because of their workload, or it may be due to the language and cultural barriers between students and nurses. Therefore, the most significant factor affecting how nursing students learn clinical skills in hospitals is their interactions with hospital staff.

Also, interns’ previous clinical experiences were important in regard to their preparedness in clinical practice.[11] Participants appeared to feel more confident and comfortable with their communication skills. Students reported feeling comfortable communicating and coordinating care with interdisciplinary team members and delegating tasks to nursing assistants. This finding is also consistent with Güner’s (2014) report that many students have good communication skills.[7] Moreover, students felt more comfortable communicating with patients and their families and asking for help from others. This could be because, during their past clinical rotations, students were provided with numerous opportunities to interact with patients and their families, which could allow them to gain both experience and confidence. However, some students reported that they do not feel comfortable about what to do for dying patients. This is similar to Naylor and her colleagues[12] (2021), who showed that novice new graduate nurses experienced stress when performing skills such as dealing with the death of a patient.[12] This may be a result of not experiencing the death of a patient during their previous clinical experiences. Also, students felt less confident in documenting electronic records. There were different factors affecting their confidence in dealing with electronic records, which may be due to students not having ID access to enter the hospital’s electronic record system or nurses not being cooperative enough when helping students or teaching them.[11] Similarly, a few students reported having difficulty prioritizing patient care needs, recognizing a significant change in the patient’s condition, or documenting electronic medical records.[9] Students reported that they have difficulty prioritizing patient care needs and that they may need more working experiences because they are not given sufficient attention during nursing education. Lundberg (2008) showed that self-confidence for nurse interns is considered an important attribute (Lundberg, 2008). Nursing interns who have high self-confidence can succeed professionally in clinical practice and decision-making (Lundberg, 2008). Also, they may sense stress and confusion from changes in patients’ conditions when choosing what is most important for patients, and they may find out that selecting a particular intervention may preclude other desirable ones. They must be familiar with the hospital’s policies, rules, and procedures when prioritizing patient needs because they must rely on more experienced team members for advice and support. In addition, students noticed they did not receive feedback from their clinical instructors. Therefore, it is crucial to make sure preceptors receive training related to the growth of clinical reasoning to effectively support newly graduated nurses in their transition to practice.[13] In addition, good relationships between nursing internship students and their preceptors had a positive impact on their readiness for practice, and their increased self-esteem, and their willingness to practice efficiently.[14] The clinical instructor must encourage the nursing intern students’ efforts,[14] give helpful feedback, and share their expertise so that students enhance their performance in the future and increase their confidence and opportunities to develop their knowledge and experiences.

The results showed that students who felt overwhelmed by patient care responsibilities faced difficulties in recognizing patient conditions. Woo and Newman[15] (2020) reported that it is unrealistic for students to easily access the work environment because the transition from the study environment to the work environment requires training that extends to 6 months and more in order to acquire adequate information, apply what they learned at the university, and increase self-confidence.[15] Hussein et al.[16] (2017) found that the experience of new graduate nurses in the internship year of practice is often described as overwhelming and stressful because they seek to apply newly acquired skills from college and provide a high level of patient care.[16] Also, a nurse’s ability to recognize a patient’s condition may be a result of the limited time they were kept in a hospital during their clinical practice, so they could not see the changes that occurred in a patient’s condition.[17] As a result of this study, the students were confident about caring for two to three patients at a maximum, but their level of confidence significantly decreased when caring for four patients. This finding was similar to Wray (2017), who found that the level of confidence regarding caring for high numbers of patients decreased; this is most likely because they could not take care of more than three patients at one given time.[6] Overall, students felt entirely ready for the professional nursing role, which differs from Casey et al.’s[9] (2011) study that showed most intern students were not ready enough to start their clinical practice.[9]

Limitation and recommendation

Students who were the study’s participants were eager to participate, which facilitated the recruitment process and data collection. This study only sought to assess nursing interns readiness for professional roles at one particular institution in Saudi Arabia. In addition, all of the survey respondents were female students. Thus, additional research at other institutions with diverse populations is required to broaden the generalizability of the findings.

Conclusions

In conclusion, the nursing college at KAU is making a great effort to prepare their students for their professional roles during the internship period, where they prepared for senior practicum experience by practicing skills in learning labs. However, students showed they were uncomfortable and had no confidence in performing certain skills/procedures independently. This shows we still need to develop skills and clinical competencies in preparation for an effective professional role. Besides, continuous assessment is considered important for patient safety, \to increase nurses’ work retention, and to enhance professional nurse confidence and the quality of care they must provide.

For future research, we could consider a larger sample size that is not limited to one school or public system. Also, a mixed-method approach should be considered to understand students’ perceptions of their professional roles. Future research could be conducted using a longitudinal design at the beginning of the internship, at 6 months, and at the end of the internship to capture changes over time. Additionally, future research could include both students’ and preceptors’ perceptions to show a complete picture of student readiness. Finally, the findings from this study can be used by nursing educators and administrators to support the creation of orientation programs that are specifically tailored to the needs of advanced beginner students.

Author contributions

All authors helped shape the research, contributed to the analysis, reviewed, and provided critical feedback on the manuscript.

Institutional review board statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Research Ethical Committee of the Faculty of Nursing at King Abdul Aziz University (Reference No. 1B.23).

Informed consent statement

Informed consent was obtained from all subjects involved in the study.

Data availability statement

The data used and analyzed in this study will be promptly available to the publisher upon request.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.