Challenges and Difficulties During the Nursing Internship Program Using 5 Domains: A Cross-Sectional Study

Background

Overview of the Nursing Internship Program in the Asir Region of Saudi Arabia

The internship nursing program (Bisha University- nursing department) is a 12-month rotatory program during which the intern nurses are assigned to different clinical units/ departments after the completion of 4 years of nursing studies. This program was designed and planned as a requirement to attain the Baccalaureate degree in nursing program and, eventually enable the graduated nurses to enter the healthcare system with competency and satisfaction. Hence each patch of nursing interns will be allocated to different clinical settings at Asir province or outside communicating with other setting at KSA. Accordingly, the intern nurses represent those nurses who have achieved achievement and success of all required courses within nursing department program and are ready to join the internship nurses’ program.

The internship period for nursing students; is the period of transition from nursing students to professional nurses who are capable of working at different health organizations. The intern nurses were equipped with the procedures/ skills logbook that was designed to provide a guideline for the nursing students during the internship program. The implementation of this logbook is followed and evaluated by the preceptors and agreed upon between the nursing department and the hospital administration of nursing training and education management. In addition, follow up by assigned internship nurses committee at the level of the university. Therefore, nursing internships period for nursing students represent the essential instrumental program for gaining experience across multiple nursing skills which in turn, enables nurses to be well-equipped and ready for the transition into professional roles. In the Asir region of Saudi Arabia, these programs offer students the opportunity to gain clinical experience and develop competencies. However, nursing students encounter several challenges and barriers during their internship.¹

Consequently, the current study focused on 5- Domains of challenges and difficulties faced by the internship program during implementation which include: the administrative procedures, the regulatory procedures, the nursing procedures, and the challenges faced by the intern nurses. Last domain is the communication barriers. Example of such domains is the administrative procedures’ challenges which was identified and evaluated such as the process for joining the training or the internship nursing program and the availability of the correspondence channel between the college (nursing department) and training administration. Whereas the regulatory procedure domain challenges concerned with internship nursing program objectives and whether it was coinciding with the hospital regulations, then consider its clearness and reliability to be implemented.

Comparatively, a qualitative study conducted at a hospital in Medina, Saudi Arabia, revealed that the internship nursing students faced obstacles and difficulties but, it was addressed in a general concept such as a lack of support, distrust, inappropriate behaviours, and the absence of a preceptorship program. These difficulties proposed to result in a negative impact on nursing practice in clinical settings.²

Moreover, another research emphasized the need to provide adequate training skills and positive experiences acquirement for internship nursing students in healthcare settings. Otherwise, many challenges were discovered to stand as barriers to the achievement of desirable internship program outcomes. This research intended to identify these challenges because it is crucial for the enhancement of the intern nurses’ training and ultimately ensures the effective development of clinical skills competency and easy joining nursing profession.³

Paramountcy, these challenges encountered by the intern nurses ought to be addressed thoroughly. Then, it can lead to anxiety, stress, and difficulty adapting to the fast-paced and demanding clinical environment.⁴ These challenges can adversely affect learning experiences and professional growth. It is essential to address these challenges by providing targeted training programs, assigning dedicated mentors or preceptors, integrating stress management techniques into the curriculum, and encouraging reflection and feedback.

Concerning this pioneer a study, intern nurses encounter several difficulties and problems, including, but not limited to, the organizational domain such as movement between departments and units, the communication domain with nursing practitioners, other health professions and, patient-to- intern nurses, then the administrative procedures (domain) such as follow-up, and cooperation between colleges and hospitals. These are examples of the targeted challenges that threaten the situation of the available supportive learning and training environment for intern nurses. Such issues as lack of administrative and regulatory support are likely to jeopardize future nursing internship programs in the Asir region (ie may eminently lead to quitting the nursing profession or poor performance in the nursing career). Therefore, it is important to explore the implications of domain of the 5-domain of challenges- designed by the researcher to easily address the research problem.

Importance of Assessing Challenges and Difficulties Faced During Internships

Internship programs for nursing students play a vital role in helping them bridge the gap between theoretical knowledge and practical application. These programs are crucial for students to gain clinical experience, develop competencies, and make a successful transition into the professional world of nursing. However, it is essential to identify and address the challenges and difficulties encountered during internships to ensure that students receive the necessary support and preparation to excel in their future roles as nurses.¹

Numerous studies have emphasized the barriers and challenges faced by nursing interns during their internships. These challenges encompass communication challenges that have effect on patient care, and available strategies for coordination between departments.⁴ Another issue is the coordination problems between departments, and movement difficulties within hospitals. Recognizing these obstacles is important to implement effective strategies that will facilitate the progression of nursing interns’ clinical competence.²

It has been emphasized that nurse preceptors should receive sufficient training and certification to mentor nursing interns effectively. Furthermore, it is advised that hospital and college officials work together to develop a well-defined internship program with clear policies and procedures. In this respect, studies have suggested the importance of exploring nurse interns’ satisfaction with the internship program and identifying barriers to program success.⁵ Additionally, the effect of university and hospital support on nursing intern satisfaction has been investigated showed in a previously conducted study that, revealed a strong correlation between hospital support for nursing interns and their perception of a positive working environment. This highlights the significance of examining the effectiveness of the available support system and resources, within discovering the expected challenges from both sides of the university- the nursing department and hospital- nursing administration and education department and its effect on intern nurses’ satisfaction.³ According to research conducted at a hospital in Medina, Saudi Arabia, nursing students faced obstacles or challenges such as a lack of support, distrust, inappropriate behaviour, and the absence of a preceptorship program during their internship.⁶

Additionally, insights from a qualitative study exploring the experiences of nursing faculty, managers, newly graduated nurses, and students participating in a nursing internship program in Iran shed light on movement difficulties within hospitals. The theme “Achilles’ heel of the clinical setting” included subthemes such as “Delegated clinical education”, “Imposing more clinical work on the student”. and “Lack of amenities”. The shared experiences highlighted that despite the benefits of the internship program, it would be compromised if the clinical setting was not adequately prepared.⁷ Students felt trapped in ward routines and were not equipped with vital information about ward and care systems. Besides, they faced a heavy workload due to delegated clinical education and lack of amenities, leading to fatigue and jeopardizing patient safety.^4,8

Studies conducted in Saudi Arabia found that fourth-year nursing students had high levels of perceived clinical competence. Yet, there has been limited research to evaluate clinical competency throughout the internship year. This, in turn, emphasizes the need to investigate the surrounding challenges encountered by nursing interns during their practical training.^9,10

Overview of the Healthcare System in the Asir Region of Saudi Arabia (KSA)

Generally, overviewing the health care system in the KSA, within a total of 184,565 nurses in this country, only about 38% are Saudi citizens, with the majority being foreign nurses, most of them from other Arab countries, African or Asian. This heavy reliance on foreign nurses poses risks, such as sudden withdrawal from the career which may lead to difficulty in communication with the intern nurses due to language barriers accents and fluency, etc., and lack of adequate preceptors to train the intern nurses.⁸ Likewise, the distribution of nurses per capita varies widely geographically, with rural locations predominantly staffed by foreign nurses due to poorer living and working conditions.⁹

The challenges facing the nursing profession in Saudi Arabia are not specific to the country and mirror broader global trends. The growth in population and increasing prevalence of non-communicable diseases have contributed to a significant shortage of nurses. A Royal Decree was issued to promote the Saudization policy aimed at gradually replacing expatriate nurses with national nurses. While progress has been made in increasing the number of local nurses, it still falls short compared to projected needs for nursing positions by 2030.¹¹

In addition to these challenges, there are specific cultural considerations impacting nursing internships, particularly concerning gender-based placements and limited male-female interactions in clinical settings. The absence of national policy or formal internship programs for nursing students results in male nursing students completing their training solely in male wards.¹²

Despite these challenges, there are opportunities for growth and improvement within the healthcare system through collaboration between the Ministry of Health and partners across different sectors. Ongoing reforms aim to facilitate this collaboration and transform the nursing profession into a modern, self-sustainable workforce.¹³

These literature findings emphasize the significance of addressing communication challenges, coordination issues, restrictions on duties for male nurses, and enhancing reflective practice and clinical competence within nursing internship programs in general in Saudi Arabia.¹⁰ Therefore, while Saudi Arabia faces significant challenges within its healthcare system and nursing internship programs, there are opportunities for improvement through strategic reforms and collaborations across various sectors.¹⁴

Comparison with Other Regions or Countries

Contrasting the challenges encountered in nursing intern programs in the Asir region of Saudi Arabia with those in other areas or countries, it is evident that these difficulties are not exclusive to this specific region. Similar issues have been documented in healthcare systems worldwide. A common obstacle is that there were limited skills to be implemented during the internship period, which was a common constraint on their involvement in clinical areas. This limitation was a concern in Saudi Arabia and was simultaneously found in numerous other countries where hospital policies and procedures should be implemented with senior nurse supervisors who were expert and registered nurses; that is; independent nursing skills were restricted.

Moreover, the lack of opportunities for nursing interns to participate in hospital decisions is a challenge that extends beyond the Asir region. Nurses globally have expressed feeling marginalized in decision-making processes, with a perceived absence of nurse leaders at the top management level. This dearth of representation can hinder the dissemination of information about clinical issues that require resolution.

Similarly, Communication challenges and coordination issues between departments were prevalent problems faced by nursing interns worldwide. Movement difficulties within healthcare facilities have been identified as a barrier to effective patient care in many hospitals. These issues have been reported in Saudi Arabia as well as in various other regions and countries.

In conclusion, despite these challenges being widespread, it is crucial to recognize that strategies and recommendations for improvement may vary based on specific regional or country contexts. This current research focused on challenges that encountered by intern nurses. While there are similarities in the difficulties faced during nursing internships compared with other studies, it’s imperative to tailor solutions according to the unique circumstances of each region or country.⁵

Research Objectives

The primary aim of this study is to evaluate the obstacles confronted by nursing interns during their internships in the Asir region of Saudi Arabia. This includes investigating the elements that support and hamper nursing interns’ clinical practice. The study sought to identify the impact of these challenges on patient care and propose strategies for improvement.

The Specific Research Objectives Include

1. Determine the administrative procedures that facilitate the clinical practice of nursing interns in the Asir region.
2. Identify and then analyze the challenges that impact on nursing interns’ clinical practice in the Asir region.
3. Evaluating the effects of communication challenges on patient care during nursing internships.
4. Recommending solutions for overcoming mobility issues within hospitals, thereby enhancing the overall internship experience for nursing students.

Methods

The methodology utilized for this research was involved gathering data from various hospitals in the Asir region through the questionnaire. The data was meticulously analyzed to gain insights into the challenges faced by nursing interns and their impact on patient care.

Design

Across-sectional descriptive design was followed to study the challenges and difficulties faced by nursing graduates during the internship.

Study Area

This study was carried out in Asir region of the Kingdom of Saudi Arabia, and included four hospitals (King Abdullah Hospital in Bisha, Khamis Mushayt General Hospital, Mental Health and Long-Term Care Hospital, and Tathlith General Hospital), these are considered government public hospitals in Asir region, in which internship students are distributed. The research will take place in the Asir region of Saudi Arabia, where there is a significant presence of nursing colleges and hospitals, providing a diverse and suitable population for the study. The region’s robust healthcare system includes multiple government hospitals where nursing interns can acquire valuable experience. Furthermore, the diversity of the population allows for a more comprehensive representation of the experiences and challenges faced by nursing interns during their internship period.

Sample

Convenience sampling was employed as the sampling technique for this research. This approach enabled the selection of nursing interns who were readily accessible and willing to take part in the study within the Asir region of Saudi Arabia.

Data Collection

The development of the questionnaire for this study was meticulously planned to obtain a comprehensive understanding of the participants’ experiences. It encompassed inquiries regarding the challenges and difficulties encountered during the internship program, aspects disliked about the program, and recommendations for enhancing clinical practice. The questions were formulated to comprehend the perspectives and experiences of nursing interns, aiming to gain valuable insights into the challenges they confront throughout their internship.

Moreover, the questionnaire sought to capture intricate details concerning the participants’ perceptions of clinical practice and their specific encounters with challenges. The questions were intentionally designed to be closed-ended, which validate by expertise.

The data was collected using a questionnaire that consists of 5 domains (administrative procedures, organizational procedures, nursing procedures, challenges faced by the preceptors, and communication barriers) designed by the researcher and reviewed by the study team. The questionnaire was validated by experts in internship and various nursing disciplines and then approved by the local committee of research ethics.

Ethical Considerations

The study received approval from the Institutional Ethics Committee UB-RELOC H-06-BH-087/ (0605.23). Participants were provided with the opportunity to sign an informed consent form after the research’s aims and methods were clearly explained to them. Participation was completely voluntary, and students had the right to withdraw at any point without facing any negative consequences.

Data Analysis

Data analysis included statistical procedures frequency, weighted mean, and standard deviation, and a comparison was made between demographic data and different domains of study.

Results

The results of the study in general showed that most of the participants strongly agreed with the administrative procedures average (Mean 4.45), for the rest of the other four domains the participants agreed the average range (Mean 4.0–4.1).

Demographic Data

The participants included were 93 (83%) preceptors, and 19 trainers (17%) who were willing to take part in the study, using Google form surveillance. However, most of the participants were female 73% (82/112). Amazingly, concerning experience that exceeds one year only responded by 12.5% (14/112) were absolutely trainers. (Table 1)

Table 1 Demographic Data

Administrative Procedures

This domain includes system management for the internship process and procedures which facilitate joining the nurses for training. Results showed that most of the intern nurses were satisfied with the administrative procedures (Table 2) (Mean 4.51). Moreover, student nurses were received at their training department with support (Mean 4.54). Whereas compliance with regulations during training was strongly agreed by 61.6% (69/112) and agreed by 30.4% (30/112) in sequence, and their (Mean 4.53). However, regarding the likelihood of postponing or apologizing for training, 29.5% (33/112) agreed as easily compared with 50.9% (57/112) who strongly agreed (Mean 4.27). Considering the feasibility of communication to follow training between training management in the clinical setting and the college 31.3% agreed versus 60.7% strongly agreed (Mean 4.48). (Table 2)

Table 2 Domain 1: Administrative Procedures

Regulatory Procedures

This Domain includes 7 elements of regulatory actions, and the results of this domain were that the participants agreed that the regulatory procedures were good, and most were satisfied with them (Mean 4.19). However, a small number of participants believe that some sections and units are exceeded during the concession period (Mean 3.17). (Table 3)

Table 3 Domain 2: Regulatory Procedures

Nursing Procedures

Most of the participants in the study agree that nursing procedures are adequate and satisfactory (Mean 4.09), except for assigning participants to non-nursing tasks The mean was low, meaning that all the tasks assigned to the preceptors during the internship are nursing tasks, a few of them believe that there are non-nursing tasks (Mean 3.46). (Table 4)

Table 4 Domain 3: Nursing Procedures

Challenges Faced by Trainees

The participants showed a strong agreement (mean 4.33) with the challenges faced during the internship, with the most common challenges being lack of support and difficulties in resolving conflicts. (Table 5)

Table 5 Domain 4: Challenges Faced by the Trainee

Communication Barriers

The participants also showed a strong agreement (mean 4.24) with the communication barriers faced during the internship, with the most significant barriers being coordination issues between departments. (Table 6)

Table 6 Domain 5: Communication Barriers N = 112

Overall Interpretation

The weighted mean interpretation for the domains is as follows:

Scores from 1 to 1.8 indicate “Strongly Disagree”.

Scores from 1.8 to 2.6 indicate “Disagree”.

Scores from 2.6 to 3.4 indicate “Neutral”.

Scores from 3.4 to 4.2 indicate “Agree”.

Scores from 4.2 to 5 indicate “Strongly Agree”.

Comparison of Responses

By Category

No significant differences were found between trainees and trainers across most domains. (Table 7)

Table 7 Domain According to Category

By Age

Younger participants (20–30 years) generally rated the domains slightly higher than older participants (30–40 years), though differences were not statistically significant. (Table 8)

Table 8 Domain According to Age

By Gender

Males reported higher satisfaction in nursing procedures, challenges faced, and communication barriers compared to females, with significant differences in nursing procedures. (Table 9)

Table 9 Domain According to Gender

By Experience

Participants with less than a year of experience rated the domains similarly to those with more experience, with no significant differences observed. (Table 10)

Table 10 Domain According to Experience

Discussion

Domain (1) Administrative Procedures

Considering the feasibility of follow up training between training management in the clinical setting and the college 31.3% agreed versus 60.7% strongly agreed (Mean 4.48). The study highlighted the importance of administrative issues concerning conducting interns in their journeys toward professional competency. ³ This in turn showed a respectful relationship between the college and the hospital management of intern students. Additional support was exposed by a descriptive comparative study, which was applied between Benha University Hospital and the private hospital, showing great appreciation for the internship program at the level of leadership management and administrators. ¹⁵

Domain (2) Regulatory Procedures

This Domain includes 7 elements of regulatory actions, and the results of this domain were that the participants agreed that the regulatory procedures were good, and most of the trainers were satisfied with the regulatory procedures (Mean 4.19). However, a small number of participants believe that some sections and units were skipped during the internship course (concession period) (Mean 3.17). Sharare Ahmadi (2020) designed a Conceptual model of the challenges confronting the internship program, one of which is the lack of support. In this respect, some students have difficulties in resolving conflicts, handling complaints, lacking insurance for encountering errors, and blaming students for making mistakes. ¹¹

Domain (3) Nursing Procedures: Coordination Issues Between Departments

In the realm of nursing intern training experiences, the Asir region of Saudi Arabia poses unique coordination challenges between departments. These issues are reflected in the following domains: administrative procedures (domain 1), regulatory procedures (domain 2), and nursing procedures (Domain 3). The administrative procedures (Domain 1) cover eight elements which show an overall satisfactory level of strong agreement (mean 4.45). Most importantly, postponing and apologizing for training was a little bit easy (mean 4.27).¹⁶ Moreover, the procedures for joining the training were clear and quickly reflected (Mean 4.51). Besides, the result showed participant compliance with regulations during training (Mean 4.53). Relatively, the insufficient allocation of resources and equipment in clinical settings has adversely affected the quality of training for nursing interns. ¹⁷ The shortage of necessary equipment and sterile packs has led to instances where students are forced to reuse items, jeopardizing their ability to practice proper patient care. Additionally, the assignment of many students to a single ward has hindered the development of crucial nursing skills and knowledge. Students have voiced concerns about their limited exposure to practical training due to overcrowding and inadequate resources. Whereas the eight elements of regulatory actions (Domain 2) were met with most interns with a strong agreement (mean 4.19). However, some research evidence denoted that the lack of cooperation among healthcare professionals across different departments has emerged as a significant obstacle for nursing students during their internships. ¹⁸

Except for assigning participants to non-nursing occupations, most respondents believe that nursing procedures are acceptable and satisfying for internship nursing students (mean = 4.09). The mean was low (mean 3.46), indicating that intern nurses were assigned by the preceptors to non-nursing responsibilities throughout their internship rotations. Additionally, intern nurses were satisfied (mean 4.12) related to the permission allowed by trainers and qualified staff to use the patient’s file and understand the treatment instructions Moderately, reports from students indicate struggles in accessing essential information from physicians and nurses, with some professionals exhibiting mistrust and reluctance to involve interns in patient care responsibilities.¹⁹ This lack of trust impedes the learning process for internship nursing and consequently impairment in confidence and readiness for future careers may be imminent.²⁰

Moreover, the absence of a supportive learning environment within hospitals has further hindered the overall training experience for nursing interns. Ineffective communication and collaboration between departments have contributed to coordination issues and communication barriers. This not only impacts the quality of patient care but also influences the professional development and confidence of intern nurses.²¹

The findings emphasize the necessity of addressing these coordination challenges between departments to enhance the overall training experience for nursing interns in the Asir region. Strategies such as fostering collaboration among health professionals, ensuring adequate resource allocation, and establishing a supportive learning environment are essential for overcoming these challenges. It is imperative to prioritize effective communication, teamwork, and coordination within hospitals to provide nursing interns with a comprehensive and valuable training experience.²²

Domain (4) Training Challenges

The challenges faced by nursing internship programs in the Asir region will necessitate collaboration between educational institutions, clinical settings, and stakeholders involved in nursing education. By acknowledging these challenges and implementing strategies to tackle them, future nursing internship programs can be enhanced to provide a more effective learning experience for nursing students. ²³

Domain (5) Communication Barriers During Training

Most of the preceptors ‘responses were (Mean 4.12) to their agreement reflecting the handling of communication barriers, which enhances effective communication and was dealt with easily. Inconsistently, the previous study involved 16 students (2 males and 14 females) and six instructors; using interview qualitative data yielded 126 codes and seven subcategories under three categories, the second category was related to poor communication due to excessive workload, poor instructor-student relationship, and lack of communication skills. ²⁴ Despite the focus of this study on the same issue, the sample size and the nature of the study design were different, yet the results cannot be generalized. ¹⁵ Another study performed as a descriptive qualitative design in KSA: Qassim region revealed very poor communication between the preceptors and the administrators. This was identified through theme analysis of 17 intern nurses selected from three colleges in Qassim. ⁵

Domains According to Gender

Challenges were uncovered in a qualitative study focusing on hospital placements for clinical training, which delved into the experiences of Saudi male nurses pursuing a career in nursing. ²⁵ The study revealed that all participants encountered difficulties in securing hospital placements, with female nursing students being given priority in overcrowded hospital units. This disparity in placements creates barriers for male nursing students, limiting their chances for hands-on patient interaction and learning. ²⁶ Furthermore, the lack of faculty members to serve as clinical instructors exacerbates these challenges, resulting in reduced opportunities for Saudi male nurses to receive hospital training compared to their female counterparts. However, the current study showed substantial disparities when comparing demographic data and different domains based on gender (Table 3) there was a significant difference between gender and nursing procedures (P. value 0.001) as well as a significant difference between gender aligned with the preceptors’ challenges (P. value 0.006). Moreover, significant differences were found between gender and communication obstacles (P value 0.019). ²⁷

Conclusion

In conclusion, fostering an effective nursing internship program in the Asir region of Saudi Arabia entails overcoming various obstacles.²⁸ These hurdles encompass difficulties in communication, coordination issues between departments, and challenges with movement within hospitals. Addressing these barriers is crucial to ensure the success and efficiency of nursing internships. The literature reviewed underscores the significance of recognizing and tackling these challenges to offer a high-quality internship experience for nursing students.²⁹ Development an effective nursing internship programs in the Asir region of Saudi Arabia entails overcoming various obstacles that disrupt the smooth operation of activities within hospitals.³⁰

Recommendations

The most prominent findings are the allocation of nurses to non-nursing tasks, and gender-based discrimination among internship students when it comes to training opportunities. For future nursing internship programs in the Asir region, efforts should strive towards creating an educational environment that fosters the effective development of clinical skills among nursing students. Hence, better evaluation processes, and adequate support for nursing interns will help enhance coordination between departments during employment of nursing internship programs.¹⁹