Year : 2019 | Volume
: 8 | Issue : 1 | Page : 6--11
The challenges and difficulties of the nursing interns during their clinical internship in Qassim Region, Saudi Arabia
Asma Rayan Alharbi1, Khaled Fahad Alhosis2,
1 Department of Nursing, King Fahad Specialist Hospital, Dammam, Saudi Arabia
2 College of Nursing, Qassim University, Buraydah, Al-Qassim, Saudi Arabia
Dr. Khaled Fahad Alhosis
College of Nursing, Qassim University, Buraydah, Al-Qassim 52571
Context: The relationship between the staffs and the nursing students is an essential factor that affects the clinical learning experience of the nursing students. However, students conveyed negative experiences in the clinical setting that provided a negative impact on their learning process. Aims: This study explored the challenges and difficulties encountered by nursing students during their internship year. Settings and Design: This study used descriptive qualitative design. It was conducted in select hospitals in Qassim Region that provides clinical internship to nursing students. Subjects and Methods: Data were gathered using face-to-face semi-structured interview among select 17 nursing interns from three colleges of nursing in Qassim Region: Qassim University, AlGhad Private Colleges, and Buraydah Colleges between December 2016 and February 2017. Analysis Used: Data were analyzed using thematic content analysis established by Morse and Field (1996). Results: The nursing interns experienced inappropriate treatment from the clinical staffs through lack of communication, disregard, and exploitation from the staffs. Further, they perceived feeling lost because of the identified gap in the organizational structure in the training department of some hospitals, scarcity in regular follow-ups from the college, and lack of willingness to teach from the clinical preceptors. Furthermore, they feel shocked from reality due to the existence of some staffs who were found to have unsatisfactory knowledge and skills in the clinical area and the limitations set by the hospital policies and procedures in the scope of practice of nurses in their institution. Conclusions: There is a vast need to improve the internship program for nursing students in the Qassim Region. A joint effort between the hospital and college administrators should be encouraged to establish an internship program with well-defined policies and procedures.
|How to cite this article:|
Alharbi AR, Alhosis KF. The challenges and difficulties of the nursing interns during their clinical internship in Qassim Region, Saudi Arabia.Saudi J Health Sci 2019;8:6-11
|How to cite this URL:|
Alharbi AR, Alhosis KF. The challenges and difficulties of the nursing interns during their clinical internship in Qassim Region, Saudi Arabia. Saudi J Health Sci [serial online] 2019 [cited 2019 Oct 22 ];8:6-11
Available from: http://www.saudijhealthsci.org/text.asp?2019/8/1/6/256782
Nurses play an essential role in health-care delivery. They are known to be advocates for health promotion, educators of patients and the public about the prevention of illness, and provider of care to assist in the curative and rehabilitative aspects of the complex treatment for each individual, and it is remarkable that no other health-care provider has these extensive roles. However, health-care organizations around the globe face a stark shortage of registered nurses.
In Saudi Arabia, there is a persistent shortage of registered nurses with a remarkable number on its turnover rate. It is noteworthy that an enormous portion of the nursing workforce in Saudi health-care institutions is composed of expatriates, with Saudi nationals covering only 29.1% of the entire nursing workforce. This shortage is caused by educational, system, social, and individual factors. Specifically, a vital factor in nursing education is the clinical experience as it transforms the knowledge of the students into practice which serves as the foundation of nursing practice in the health-care delivery. However, it is evident in the nursing literature that a high in turnover rates, particularly among new graduate nurses, is caused by poor training, lack of support systems, and extreme stress in the working environment. It is remarkable that successful nursing internship programs which are composed of teaching and learning were recognized to help the new graduates to transition from novice to advanced beginner who could demonstrate performance within the set standards and cope in real situations.
The most crucial factor that affects the clinical learning experience of nursing students is the relationship between the staffs and the nursing interns as this facilitates the learning process in the clinical areas., Nursing students anticipate a supportive clinical environment that is innovative and highly individualized where they feel that they are an essential part of the health-care team. The clinical assignments allow nursing students to acquire essential qualities of caring, critical thinking skills, application of knowledge, competence, and clinical skills. Thus, it is important that each member of the health-care team should contribute to providing a positive clinical experience which facilitates the advancement of the clinical competence of the nursing students. However, the nursing students reported negative experiences in the clinical setting that provided a negative impact on students' attitude and confidence which in turn impeded their learning. Specifically, the nursing students have recognized that one of the barriers to learning in the clinical setting is their poor interpersonal relationships with clinical staff and preceptors. Furthermore, the experience of severe incivility has led the nursing students to abandon the program in several instances. Nursing schools should be cautious in safeguarding the students' experiences to effectively meet the clinical objectives and proficiently bridge the gap between theory and practice.
The nursing students in Saudi Arabia should successfully finish their internship for 1 year to register and get professional classification. It is noteworthy that an average of only 9.1% from those nursing graduates successfully passed the board examination given by the Saudi council, and the identified factors were poor preparation, theoretical education, and clinical learning. Thus, this study explored the challenges and difficulties faced by nursing students during their internship year. The knowledge about the barriers that could hinder their learning in the clinical environment is essential to assist the nurse educators as well as the staffs in the clinical setting to develop appropriate strategies to facilitate the progress of the clinical competence of the nursing interns.
Subjects and Methods
This study aimed to explore the challenges and difficulties faced by nursing students during their internship year. Thus, the present study used descriptive qualitative design to explore the new perspectives on this area. Internship year was defined as the 1-year intensive clinical practicum in the hospital by the nursing students after graduation to be eligible to register and take the board examination given by the Saudi Commission for Health Specialties.
Permission to conduct the study and ethical clearance was secured from various colleges of nursing in the Qassim Region, namely Qassim University, AlGhad Private Colleges, and Buraydah Colleges. The authors obtained the list of nursing interns for the academic year 2016–2017 from each college, and then, they were chosen using simple random sampling. Those who were under internship training in Qassim hospitals for at least 6 months were included in the study. However, those interns from the bridging program who have had previous job experience before the internship year were excluded from the study. Signed informed consent was secured from each student before they participated in this study.
Data were acquired using face-to-face semi-structured interview which consisted of a general and nonspecific question “what are the challenges and difficulties you have encountered during your internship year?” Furthermore, the participants were asked to elucidate any points they mentioned with specific examples which they could then expanded upon. The interviews were conducted between December and February 2017 based on the availability and convenience of each participant in a quiet area within their workplace. In this study, the data saturation was satisfied after interviewing the 15th participant, and the researchers verified it by interviewing two more participants. Thus, this study included a total of 17 nursing interns. Each interview lasted between 20 and 30 min which was recorded with permission from all the participants. Then, all the recorded interviews were carefully transcribed. The interviews were conducted in Arabic, and then, the researchers translated the written transcripts into English and have it validated by a language expert both in Arabic and English. Confidentiality was maintained by ensuring that the recorded interviews and transcripts were stored in a secure location which can only be accessed by the researchers involved. Furthermore, the pseudonym was assigned to each participant to maintain their anonymity.
Data were analyzed using thematic content analysis which involves four stages, namely comprehending, synthesizing, theorizing, and re-contextualization. Comprehending is the first stage wherein the researchers are getting familiar with the data which took place during the frequent playback of recorded interviews while being transcribed by the researchers. The next stage is synthesizing which involves the initial scrutinizing of data into some form of a pattern wherein the norms and variations can begin to emerge. The third stage is theorizing which includes sorting of data into themes. In this study, the funneling or collapsing method was used to identify relationships present between identified categories. The final stage is re-contextualization which comprises the development of emergent theory based on the findings derived from the analysis of data by the researchers.
Of the 68 eligible nursing interns in the Qassim Region, 17 were chosen to partake from three nursing colleges whose ages were between 23 and 26. These participants were 8 (47.06%) males and 9 (52.94%) females; 5 (29.41%) of the students came from Buraydah College, while 8 (47.06%) and 4 (23.53%) were from Qassim University and AlGhad College, respectively. These interns have trained in one of these hospitals: King Fahad Specialist Hospital, Buraydah Central Hospital, Maternity and Children Hospital, Ayoun Aljawa Hospital, Al Rass General Hospital, and King Saud Hospital.
Three main themes emerged from the thematic content analysis, and these were treating inappropriately, feeling lost, and shocking from reality. Each of the identified themes is discussed below.
All participants expressed their concern regarding lack of communication from the nursing staffs which is shown either by negligence or nonresponsiveness.
Sometimes when I asked them about the meaning of some abbreviations or anything else, they said: we are busy! Some days they ignored me and walked away when I was talking, they did not answer me, I am wondering am I invisible? (Ali)
The participants also feel that they were being exploited by various staffs through delegation of tasks which are not within the scope of their duties. Furthermore, the interns feel that the staffs understand that the nursing interns' primary role is mainly for their own benefits but not for students' learning.
When other nurses saw me with my preceptor, they thought I am here for all, to help all. (Fatimah)
The head nurse looked for who from nurses have more ancillary procedures, then she assigned me with this nurse to help her in transferring patients! They dealt with me as a porter and assistant. Also, I missed our discussion because of helping them in sending blood samples and bringing medications from the pharmacy. When I tried to refuse they said: “You are here to work! If you refuse that, we will not evaluate you with a good grade!” (Fahad)
Some of the participants experienced being underestimated by the staffs either because they came from private colleges or they are poor in speaking English. Moreover, they also encountered being disrespected by patients, doctors, and other health-care personnel.
They asked me from which college I came from. When I told them, they said that all of the students from our college are poor in English and poor in practice, and then they ignored me. They already judged me even though they haven't seen yet my performance even just for 1 day. (Abdullah)
The nurses are being underrated by doctors. I did not see nurses are being given the chance to share in the treatment plan or team discussion. (Amani)
Some of the participants had experienced being refused by their patients because of discrimination, either because they are Saudi or they are just interns.
The patients unfortunately until now refuse Saudi nurses or interns even when I gave the effort to talk and I build a relationship with them. (Abdullah)
Another issue being faced by the nurse interns is the lack in sense of belonging. The participants expressed that some of the expatriate nurses kept ignoring them, and at times, they were speaking in their mother tongue in their presence which impedes their sense of belonging.
The dealing with non-Saudi nurses, especially if they have the same nationality for example, if they are all Filipino or Indians, they were speaking in their language even during the endorsements. I told them please speak in English, but they just ignored me. Unfortunately, they have a wrong image for Saudi nurses. (Nouf)
The nursing interns have identified gaps in the organizational structure, particularly in the training department. Specifically, the interns reported that there was no existing organizational structure for training, lack of communication between the administrators and interns, and ambiguous roles for the head nurses and preceptors in handling the nursing interns.
We did not see the objectives of training and the organizational structure. When we faced a problem, they said: “Okay, we will do something to prevent this problem to happen for the next trainees.” I'm wondering why for the next trainees and not us, especially that the administrators were trainees like us a few years ago and they faced the same problems. (Auhood)
The communication between the trainees and administrators was very poor and chaotic. There is no standard way in the pronouncement of new policies. Sometimes the announcements were disseminated in the form of a formal memorandum, word of mouth, or thru WhatsApp messages in our cellphone. (Reem)
The preceptors do not know about their roles. Also, the head nurses do not know their responsibilities toward us. There were instances that the head nurse did not assign me to any nurse. (Omar)
Most of the participants reported that there is a lack of regular follow-ups from their respective colleges either through call or visit.
I spent a year [internship] with no one ever asked from my college about me. No regular or irregular visiting. I thought it was because I am assigned from a distant hospital, but other interns have experienced the same problem. I faced a lot of problems related to college paperwork, but no one answered me. So, I took an emergency leave from the hospital to solve my problem at the college because I have no other ways to solve it. (Amani)
Majority of the participants were disappointed to the nursing staffs because oftentimes the staffs were not teaching them due to lack of time, willingness, and sense of responsibility.
In the first hospital during my internship year, no one has taught us. We asked several times in order to get information. The staffs either did not have the time or did not want to teach us about some important skills, even the administration of medications. I even overheard that the head nurse was telling the preceptor not to let me do any procedure. (Shoroog)
They (nursing staffs) feel irresponsible for us. The preceptor knew I was assigned to her and my name is in the assignment board with her name. When I asked her, she did not answer me. When I asked her to do some procedure, she always told me to do it next time. Thus, I somehow lost my desire to do so. (Ruba)
Shocking from reality
The nursing interns were much concerned about the inadequacy in the nursing skills of some staff nurses assigned to them.
One day, the preceptor taught me a method to prepare medication. Then, when I moved to another department, the other preceptor have told me that I've been doing it the wrong way (preparing medication). (Auhood)
I was disappointed because when I performed the procedures in an ideal way which I have learned from my college, the assigned nurse told me that I just wasted her time, and we should do it the way they've been doing it. (Norah)
Some of the participants were apprehensive about the hospital's policy regarding the scope of practice of nurses. They were expecting that almost all of the nursing skills and procedures they have learned from school will be applied to their practice.
In our college, we have been trained to do most of the nursing procedures. The hospital's policy has some restrictions for nurses in performing certain procedures such as NGT (nasogastric tube) and foley catheter insertion. (Fahad)
This descriptive qualitative study explored the challenges and difficulties encountered by the nursing interns in select colleges of nursing in Qassim Region, Saudi Arabia. It is noteworthy that three themes have emerged from the thematic content analysis which includes treating inappropriately, feeling lost, and shocking from reality.
A supportive environment provided by the clinical staffs and faculty has a significant impact on the learning of the nursing students in the clinical area. However, it is remarkable that the participants in this study reported that the staffs in the clinical setting were treating them inappropriately. Specifically, there is a lack of communication between the students and the clinical staffs. The students found that they were being ignored by the staff every time they tried to reach out, and at times, the staffs were speaking in their local language that makes the interns feel embarrassed. The students also conveyed exploitation from staffs through improper delegation of tasks that are not within the scope of their learning objectives. Furthermore, some students had experienced discrimination from the staffs since the majority has an impression that all of the Saudi students are poor in English. Furthermore, some of the patients refused the nursing interns from their belief that nursing students have limited knowledge and skills than the staffs. It is noteworthy that one of the most influential factors identified for students' learning is the relationship between the staffs and the nursing students. The educators and clinical staffs should understand that students would succeed in a respectful environment, as the anxiety levels of the nursing students would increase in an unsupportive clinical environment which could lead to a hindered learning. Furthermore, valuable characteristics of preceptors such as being dedicated and approachable are identified as vital for an enhanced learning experience, and supportive environments could lessen the anxiety of the students which may boost their confidence as well as their learning.,
Some hospital organizations have a limited orientation structure for new graduate nurses that prompts difficulty in their transition to practice. This was evident in the second theme and that is feeling lost as perceived by the nursing interns in this study. Specifically, they found a gap in the organizational structure in the training department in some hospitals. Thus, there was an ambiguity in the duties and responsibilities of the preceptors and head nurses to the nursing interns as well as a gap in the communication between the administrators and the interns. It is noteworthy that the literature suggests that administrative policies intended to improve the quality of the clinical environment have a great effect on staff retention, and support staff and management were identified as factors that motivate nurses to remain in the hospital., Therefore, the existence of a lucid organizational structure with established policies and procedures is vital to promoting a positive practice environment. Another issue conveyed by the interns was the scarcity in regular follow-ups from their respective colleges. Similarly, a study conducted in Saudi Arabia found that only about one-third of the interns surveyed agreed with the presence of care and concern from the staff in their college, as well as with the easy communication with the internship staff every time they need advice. Furthermore, the interns expressed that their preceptors were unwilling to teach due to time constraints and lack in sense of responsibility. The major roles of clinical preceptors are to teach, support, evaluate, and protect the new nurse resident. It is noteworthy that a lack in providing adequate learning opportunities for the nursing interns could adversely affect their learning leading to inadequate clinical preparation and a low level of self-confidence in administering care independently.,
The internship program allows the nursing interns to apply their sound clinical judgment and critical thinking in patient care as well as the development of time management and delegation skills. It is remarkable that this is contradictory to the experience reported by the nursing interns that is identified as shocking from reality in this study. Specifically, they perceived that the staffs have unsatisfactory nursing knowledge and skills., It is vital that the administrators should responsibly assign the interns to qualified clinical preceptors with adequate clinical knowledge, skills, and experience who will play the role of being the coach and mentor to nursing interns as they transition from novice to expert in nursing care. Furthermore, the interns were apprehensive to the limited scope of practice of nurses as established in the hospital policies and procedures. They expected that most of the nursing skills could be practiced independently in the clinical areas. Similarly, a lack of opportunities to participate in hospital decisions was reported. The nurses perceived that there was an absence of nurse leaders in decision-making, and their top nurse executive was unequal to those of other hospital executives that hinders the acquiring of information by the top management about the problems that arise in the clinical area that needs to be resolved.
The study faces some important limitations. Although the study included a small number of participants, the researchers used simple random sampling from those who satisfied the set inclusion criteria from the three colleges of nursing in Qassim Region to ensure equal representation from each college. Furthermore, due to the small sample size, the generalizability of the findings should be treated with caution because some findings may not be applicable to the other regions in Saudi Arabia. Nevertheless, the authors establish the rigor of the findings in this study through member check by probing for feedbacks and agreement from the participants about the emerging thematic analysis by the investigators.
This study established the challenges and difficulties perceived by the nursing interns in Qassim Region in Saudi Arabia. First, it was found that they experienced inappropriate treatment from the clinical staffs through lack of communication, disregard, and exploitation from the staffs. Second, the interns perceived feeling lost because of the identified gap in the organizational structure in the training department of some hospitals, scarcity in regular follow-ups from the college, and lack of willingness to teach from the clinical preceptors. Finally, the interns feel shocked from reality due to the existence of some staffs who were found to have unsatisfactory knowledge and skills in the clinical area and the limitations set by the hospital policies and procedures in the scope of practice of nurses in their institution. These aforementioned results convey a vast need to improve the internship program for the nursing students in the Qassim Region.
Therefore, it is recommended that a joint effort between the hospital and college administrators with the help of the staffs and educators should be encouraged to ensure that there is an established internship program for the nursing students with well-defined policies and procedures. Furthermore, it is imperative that the nurse preceptors should receive training and certifications if appropriate to ensure that they are well prepared to teach, counsel, and mentor to provide a positive clinical and learning environment for the nursing interns. Further research is necessary on a larger sample size that involves interns from other regions in Saudi Arabia to establish the generalizability of the findings in this study. Furthermore, further studies are essential to explore the satisfaction of nurse interns, nurse preceptors, and college instructors with the internship program as well as to identify the existing barriers to the success of the program.
The authors would like to thank the nursing interns from Qassim University, AlGhad Private Colleges, and Buraydah Colleges who participated in this study. Furthermore, the authors would like to express their gratitude to the hospital and college administrators for giving permission to conduct this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Oulton JA. The global nursing shortage: An overview of issues and actions. Policy Polit Nurs Pract 2006;7:34S-9S.|
|2||Lamadah SM, Sayed HY. Challenges facing nursing profession in Saudi Arabia. J Biol Agric Healthc 2014;4:20-5.|
|3||Abu-Zinadah S. Nursing situation in Saudi Arabia. Riyadh: Saudi Nursing Board, Saudi Commission for Health Specialties; 2006.|
|4||Alamri AS, Rasheed MF, Alfawzan NM. Reluctance of Saudi youth towards the nursing profession and the high rate of unemployment in Saudi Arabia: Causes and effects. Riyadh: King Saud University; 2006.|
|5||Killam LA, Heerschap C. Challenges to student learning in the clinical setting: A qualitative descriptive study. Nurse Educ Today 2013;33:684-91.|
|6||O'Shea M, Kelly B. The lived experiences of newly qualified nurses on clinical placement during the first six months following registration in the republic of Ireland. J Clin Nurs 2007;16:1534-42.|
|7||Krugman M, Bretschneider J, Horn PB, Krsek CA, Moutafis RA, Smith MO, et al. The national post-baccalaureate graduate nurse residency program: A model for excellence in transition to practice. J Nurses Staff Dev 2006;22:196-205.|
|8||Kelly C. Student's perceptions of effective clinical teaching revisited. Nurse Educ Today 2007;27:885-92.|
|9||Murphy F, Rosser M, Bevan R, Warner G, Jordan S. Nursing students' experiences and preferences regarding hospital and community placements. Nurse Educ Pract 2012;12:170-5.|
|10||Papathanasiou IV, Tsaras K, Sarafis P. Views and perceptions of nursing students on their clinical learning environment: Teaching and learning. Nurse Educ Today 2014;34:57-60.|
|11||Shaban IA, Khater WA, Akhu-Zaheya LM. Undergraduate nursing students' stress sources and coping behaviours during their initial period of clinical training: A Jordanian perspective. Nurse Educ Pract 2012;12:204-9.|
|12||Levett-Jones T, Lathlean J, Higgins I, McMillan M. Staff-student relationships and their impact on nursing students' belongingness and learning. J Adv Nurs 2009;65:316-24.|
|13||Löfmark A, Thorkildsen K, Råholm MB, Natvig GK. Nursing students' satisfaction with supervision from preceptors and teachers during clinical practice. Nurse Educ Pract 2012;12:164-9.|
|14||Saudi Commission for Health Specialties. Guideline of Professional Classification and Registration for Health Practitioners. 6th ed. Saudi Commission for Health Specialties; 2014. p. 15. Available from: https://www.scfhs.org.sa/en/registration/ClassAndRegister/Reregister/Documents/Professional%20Classification%20manual%20for%20Health%20Practitioners.pdf. [Last accessed on 2018 Nov 05].|
|15||Saudi Commission for Health Specialties. Journalist statement from the Saudi Commission for Health Specialties. Saudi Arabia: Saudi Commission for Health Specialties; 2016. p. 1.|
|16||Morse JM, Field PA. Principles of data analysis. In: Nursing Research. Boston, MA: Springer; 1996. p. 103-23.|
|17||Burnard P. A method of analysing interview transcripts in qualitative research. Nurse Educ Today 1991;11:461-6.|
|18||Bryan V, Weaver S, Anderson-Johnson P, Lindo J. The effect of interpersonal relationships between nursing students and lecturers on learning outcomes at a Jamaican nursing school. Caribb J Nurs 2013;1:41-8.|
|19||Mlek M. Nursing Students' Learning Experiences in Clinical Settings: Stress, Anxiety and Coping (Doctoral dissertation, Concordia University); 2011.|
|20||Alshmemri M. Job Satisfaction of Saudi Nurses Working in Saudi Arabian Public Hospitals; 2014.|
|21||Del Prato D, Bankert E, Grust P, Joseph J. Transforming nursing education: A review of stressors and strategies that support students' professional socialization. Adv Med Educ Pract 2011;2:109-16.|
|22||Papastavrou E, Lambrinou E, Tsangari H, Saarikoski M, Leino-Kilpi H. Student nurses experience of learning in the clinical environment. Nurse Educ Pract 2010;10:176-82.|
|23||Scott ES, Engelke MK, Swanson M. New graduate nurse transitioning: Necessary or nice? Appl Nurs Res 2008;21:75-83.|
|24||Naude M, McCabe R. Magnet hospital research pilot project conducted in hospitals in Western Australia. Contemp Nurse 2005;20:38-55.|
|25||Hayes LJ, O'Brien-Pallas L, Duffield C, Shamian J, Buchan J, Hughes F, et al. Nurse turnover: A literature review. Int J Nurs Stud 2006;43:237-63.|
|26||Al-Mahmoud SA, Dorgham SR, El-Megeed MI. Relationship between nurse interns' satisfaction regarding internship program and clinical competence. Med J Cairo Univ 2013;81:151-61.|
|27||Chuan OL, Barnett T. Student, tutor and staff nurse perceptions of the clinical learning environment. Nurse Educ Pract 2012;12:192-7.|
|28||Santucci J. Facilitating the transition into nursing practice: Concepts and strategies for mentoring new graduates. J Nurses Staff Dev 2004;20:274-84.|
|29||Turner P. Critical thinking in nursing education and practice as defined in the literature. Nurs Educ Perspect 2005;26:272-7.|
|30||Halfer D. A magnetic strategy for new graduate nurses. Nurs Econ 2007;25:6-11.|
|31||Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Sermeus W; RN4CAST Consortium. Nurses' reports of working conditions and hospital quality of care in 12 countries in Europe. Int J Nurs Stud 2013;50:143-53.|