Internship Program Strengths and Weaknesses As Perceived by Nurses Intern By

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Mansoura Nursing Journal (MNJ) vol.1 No.1 ISSN:18235-2014 Internship Program Strengths and Weaknesses as Perceived by Nurses Intern By

1WalaaMursyHalema, 2 Fouada Mohamed Shaban, 3 Seham Ibrahiem Hamouda , 4 Karima Ahmed El-Sayed. 1,2,3,4, Nursing Administration Department, Faculty of Nursing-Tanta University E-mail of corresponding author: dr.karima ahmed @yahoo.com Abstract: Background: Clinical nursing internship program provides tremendous opportunities for nursing students to successfully transfer from educational classroom to clinical settings. Under one year supervision, nurses intern are guided towards mastery of nursing skills and improved patient service. Internships also provide the opportunity to explore various responsibilities in different nursing fields through rotations. Aim of the study: To assess the internship program strengths and weaknesses as perceived by nurses intern of Tanta University Faculty of Nursing. Setting: The study was conducted at Tanta Main University Hospital. Subjects: Sample was included all 289 nurses intern during their internship year training at medical, surgical, neonatal, anaesthia, pediatric, cardiology, obstetrics and gynecology units. Tool: Data was collected by using a questionnaire sheet. It was included three parts. I-Demographic data about the sample, II- emphasis of internship program according to domains of National Competency Standard and III- four subscales (Opportunities offered by clinical environment support, Level of Confidence in nursing practice , Perception to role of preceptor (supervisor) and Perception to Conflicts and rotation).Results and Conclusion: Results revealed that strengths of internship program at Tanta University Hospital as perceived by nurses intern showed that high emphasis put on rotation, level of confidence in nursing practice and domains of competency. While the weaknesses showed that little emphasis put on avoid conflict, role of supervisor and opportunities offered in clinical environment. Recommendations: Prime importance the availability of clinical preceptors, structured orientation program, coordination between faculty and hospital, evaluating system and feedback and strategies to avoid conflict and lateral violence. Key words: internship program, strengths, weaknesses Introduction: healthcare team (2,6). The internship Nursing internship is one year program for experience and socialization into the baccalaureate nursing graduates who will professional role of the nurse assist the be employed as staff nurses on clinical nurses intern to understand the demands units (1, 2). The goals of the internship and expectations they will experience as program are to facilitate transition of the new graduates. This in turn can decrease new graduates’ nurses to professional the amount of role conflict and anxiety registered nurses, prepare the beginning during the transition to the graduate nurse level staff nurses who are confident, role (7). Indeed internship program competent and provide safe patient care (3). enhances nurses interns’ competences and Internship combines academic learning facilitates them to advance more quickly with supervised practical experience and from novices to competent nurses by serves as a link from the classroom to the lessening time as advanced beginners (8,9). work place. It provides nurses intern with For nursing, competence is the knowledge, the opportunity to earn academic credit skills, abilities and behaviors that nurses and professional work experience through need to perform their work in a acquiring a true and realistic sense of job professional standard (10). It includes ten expectation, the workplace environment, competency standards which are involving skills and attitudes needed (4,5). the responsibilities related to four domains. During internship year, the baccalaureate These domains are professional and ethical graduates are paid the salary and benefits practice, critical thinking and analysis, of beginning staff nurses and are defined management of care and enabling (11). by job code as nursing interns. Nurses Nurses intern who complete a nursing intern collaborate with other members of internship program have more professional

WalaaMursyHalema et.al. self-confidence and job satisfaction training could have weaknesses such as because they are in a supportive inadequate staffing patterns, conflict with environment which offers opportunities for other healthcare providers, lack of support professional growth and autonomy. This in dealing with death and dying, supportive environment helps the nurses unresponsiveness in leadership, poor intern to participate actively as members of communication among staff and poor the clinical team (12,13). administration, unrealistic expectation, By implementing internship program, poor support, bullying and lateral violence nurses intern will have the necessary (22,23). support to guide them through the clinical Significance of the study: and emotional challenges of their first year Nurses intern are exposed to many as professional nurses (14,15). It provides sources of dissatisfaction in clinical clinical supervision that is tailorated to environment. It includes inadequate match the nurses intern's skills. This staffing patterns, conflict with other concept of supervision involves various healthcare providers, lack of support in roles for the clinical supervisor as teacher, dealing with death and dying, model, coach, counselor, and peer (16). unresponsiveness in leadership, poor For nurses’ intern, they rotate to various communication among staff and poor units in the hospital through specialty areas administration. The disparity in the and accommodate different shifts. The educational experiences of the student rotations included general as well as nurses and the expectations of new intensive care units within the hospital (11). graduate nurses by healthcare As a result, It allowed them to learn both organizations contributes to the unit and hospital policies (17) . overwhelming lack of new nurses’ self- Usually, some formal class work is confidence. Thus, this study was associated with the experience but majority conducted to study strengths and of the time is spent in the direct patient weaknesses of internship program. care often under the supervision (18). Operational definitions: During a yearlong program, nurses intern 1-Nurses intern: are defined as new can have social and reality integration graduate nurses who have completed a (19).So they find themselves as practitioners baccalaureate nursing degree at the with new roles, responsibilities, and faculty of nursing, Tanta University, accountability for their practice while they and who are responsible for providing are still learning and developing their professional nursing care to assigned knowledge and skills (20). clients under the direct supervision. At the end of the training year, nurses Nurse interns who are enrolled during intern are expected to be able to function the year 2009-2010. as competent and ethical professional. 2-Clinical supervisor or preceptor: is an Who are equipped to provide various experienced staff nurse who assumes the clinical services from generalist role of clinical teacher, role model, perspective? More specially, the nurses counselor and resource person for a intern's competencies which acquired over baccalaureate nurse intern in the clinical the course of the training year will setting. prepared the nurses intern to provide 3- Internship year: used synonymously effective clinical services to children, with capstone experience or course, and adolescent, adults, elderly and their clinical practicum; concentrated families with the intent to help them, experience in the healthcare maintain or enhance their quality of life environment designed to decrease through therapy, assessment and reality shock by giving students a consultation (21). Finally, internship glimpse of real practice and assisting

Internship Program Strengths and Weaknesses as etc…. transition into the role of the graduate recent related researches (24-27), to assess nurse. the above mentioned aim. 4- Domain: a cluster of competencies that Tool development: have similar intents, functions and 1) The tool was presented to jury of five meanings experts in the area of specialty to check 5- Competency: the ability to fulfill the the content validity. nursing role effectively and / or expertly The five experts were two professors from across the whole range of competencies Faculty of Nursing Cairo University at applicable to the nurse which result in Nursing Administration department. Three effective performance that is judged to professors from Faculty of Nursing be appropriate for level of the nurse Alexandria University, two professors being assessed (115). from Nursing Administration department Aim of study: and one professor from Critical Care This study aimed to assess the department. internship program strengths and 2) The experts were asked to evaluate tool weaknesses as perceived by nurses’ intern items in relation to its relevance and of Faculty of Nursing at Tanta University. appropriateness on 4 points rating scale Study question : as 1 = not relevant, 2= little relevant, What are the strengths and weaknesses of 3= relevant and 4= strong relevant. the internship program as perceived by 3) Opinions of experts on tool of the study nurses intern of Faculty of Nursing at were analyzed and determined the Tanta University? following the face validity 88.61% and Subjects & Methods : internal consistency reliability 0.8413. Study Design:- Based on the experts’ responses, the A descriptive design was utilized in the researcher takes the items agreed on present study. and works with it. Setting:- 4) A pilot study was carried out two times The study was conducted at Tanta Main on twenty nine nurse’s intern out of University Hospital. It is a teaching proposed sample and the questionnaires hospital with curative and educational were given to them again two weeks services. The setting is a combination of later to compute test- retest reliability. profit and nonprofit services. It has 902 •The first time aimed at evaluating the beds, the units understudy included content clarity of the tools; and identifies medical, surgical, neonatal, pediatric, any obstacles that may be encountered cardiology, obstetrics and gynecology during data collection as confusion about units. meaning of specific word or item. Subjects:- • After two weeks, the second time was All nurses intern (289) have trained at carried out for the same twenty nine Tanta Main University Hospital during nursing interns. The tool was applied their internship year 2009/2010. Nurses again for evaluating the test – retest intern train for three months in neonatal, reliability, its result was 0.880. cardiology and anaesthia units. While, they 5) Modifications were done based on the train for a one month in the other units. results of pilot study and opinions' Nurses intern follow weekly schedule panel of five experts. The pilot study which always between morning, evening, was collected from 9th January 2010 to night and days off. 23th January 2010. The administration Tools: time for filling questionnaires' sheets The data of the study was collected by was approximately 20 minutes. using a questionnaire sheet. It was Questionnaire was consisted of three parts. developed by the researcher guided by First part contains demographic data about

WalaaMursyHalema et.al. the sample . This part was included age , Statistical analysis : marital status, Previous nursing Results were tabulated and statistical qualification and graduation level. Part two analysis was performed with Statistical contains questions on emphasis of Package for Social Science (SPSS version internship program according to domains 11). For quantitative data, the range, mean, of National Competency Standard was and standard deviation were calculated. included 20 items classified into four For qualitative data the number and domains namely (1) domain of percent was calculated. Correlation professional and ethical development 3 between variables was evaluated using items , (2) domain of critical thinking and Pearson’s Correlation. Coefficient. P analysis 5 items , (3) domain of values of <0.05 were considered management of care 5 items and (4) statistically significant, while P value of domain of enabling 7 items . Part three <0.001 indicates a high significant result. was included four subscales namely (1) (115) opportunities offered by clinical Ethical consideration: environment support was included 6 1) An official permission to conduct the items , (2) level of confidence in nursing study for data collection obtained from practice was included 15 items , (3) responsible authorities. perception to role of preceptor was 2) The purpose of the study was explained included 4 items and (4) perception to and clarified to both hospital director conflicts and rotation was included 18 and nurse manager of each unit items . understudy. The nurses intern s’ responses were 3) Nurses intern were told that anonymity represented into four likert scale ranging would be maintained. They were from no emphasis to high emphasis. 1= no informed of the purpose of the study emphasis, 2 = little emphasis, 3= moderate and assured that their answers would be emphasis and 4= high emphasis. The kept confidential and would not be used Scores would be calculated from lowest to evaluate them. scores to highest scores, ranging between Results: these classifications into three classes; Table 1 represents that above half 52.6% little was <60%, moderate was from 60% of nurses intern had aged ≤ 21 years with to 80%, and high was >80%. mean age (21.47± 16.975). Less than two Methods: thirds of nurses intern 60.2% were single . 1) Meetings with head nurse in each unit Sixty three of nurses intern had grade very in the different settings were conducted good and only 12.6% had grade excellent. by the researcher on an individual basis Sixty six of nurses intern were graduated to inform them about the aim of the from general secondary school, while 34% study. graduated from health technical institute. 2) The researcher met with nursing interns Figure 1 revealed that majority of nurses in small groups based on their intern 80.6% perceived high emphasis availability and willingness to share level of internship program put for total during their different work shifts at the domains of competencies. While only units and wards where they train. 5.2% of them perceived little emphasis 3) The nurses intern recorded their answers level. in the presence of the researcher.

Internship Program Strengths and Weaknesses as etc…. Table (1): Demographic Characteristics of Nurses Intern The intern nurses (n=289) variables n % Age ≤ 21 years 152 0.526 >21 years 137 0.474 Range 21- 22.8 Mean ± SD 21.47 ± 16.975 Marital status Single 174 0.602 Marriage 115 0.398 Graduate Level - Excellent 36 0.126 Very Good 179 0.630 Good 74 0.244 Previous graduation school General Secondary school 166 0.660 Health Technical Institute 123 0.340

5.20%

14.20%

80.60%

High emphasis Moderate emphasis Little emphasis

Figure(1): Levels of Internship Program Emphasis on Total Domains of Competency as Perceived by Nurses Intern. 4 3.5 3 2.5 2 1.5 1 0.5 0

Figure (2) Nursing Interns Mean Perception Score for the levels of Internship Program Emphasis on Its Items.

WalaaMursyHalema et.al.

Figure 3 demonstrates that high percent of environment, while low percent 15% of nurses intern 60.5% perceived that them perceived high emphasis level on this internship program put little emphasis on domain opportunities offered in clinical

15.0%

24.5% 60.5%

High empasis Moderate emphasis Little emphasis

Figure (3): Levels of Internship Program Emphasis on Total Opportunities Offered by Clinical Environment as Perceived by Nurses Intern

Figure 4 shows that majority of nurses percent of them 2.6% perceived that intern 87.2% perceived that internship internship program put moderate and little program put high emphasis on level of emphasis level on this domain confidence in nursing practice. While low . ٢.٦% ١٠.٢%

٨٧.٢%

High emphasis Moderate emphasis Little emphasis

Figure (4) Levels of Internship Program Emphasis on Confidence in Nursing Practice as Perceived by Nurses Intern

Figure 5 revealed that less than two thirds minority of them (15%) perceived that of nurses intern (63.1%) perceived that internship put high emphasis level on this internship program put little emphasis level domain for role of clinical supervisor. While the

١٥%

٢٢.٩% ٦٣.١%

High emphasis moderate emphasis Little emphasis

Figure (5) Levels of Internship Program Emphasis on Role of Clinical Supervisor as Perceived by Nurses Intern

Internship Program Strengths and Weaknesses as etc….

Figure 6 shows that high percent of nurses them 12% perceived that internship intern 72% perceived that internship program put high emphasis level on this program put little emphasis level on the domain conflict management, while low percent of

١٢%

١٦% ٧٢%

High emphasis Moderate emphasis Little

Figure (6) Levels of Internship Program Emphasis on Manage the Conflict as Perceived by Nurses Intern

Figure 7 demonstrates that majority of 6.1% and 3.2% perceived that internship nurses intern 90.7% perceived that program put little emphasis and moderate internship program put high emphasis level emphasis level on it respectively on rotation, while the minority of them

6.1%3.2%

90.7%

H ig h em pha s is Modera te e m pha s is L ittle em pha s is

Figure (7) Levels of Internship Program Emphasis on Rotation as Perceived by Nurses Intern

Table 2 revealed that significant In other words, the internship program correlation between all internship program attend to provide opportunities in clinical items (P <0.001). This means when environment, clinical supervision, rotation opportunities offered in clinical and avoiding conflict that allows the environment, role of clinical supervisor, development of competency and rotation and avoiding the conflict increase confidence in nursing practice to nurses the level of confidence in nursing practice intern and domains of competency will increase.

WalaaMursyHalema et.al. Table (2): Correlations between internship program items with each others. Domains of Opportunities Level of Role of Avoid Rotation Items competency in clinical confidence supervisor conflict environment

Domains of .371** .440** .433** .595** .372** competency Opportunitie

in clinical environment .371** .536** .364** .455** .417**

Level of

confidence .440** .536** .348** .627** .377**

Role of

supervisor .433** .364** .348** .664** .475** Avoid

conflict .595** .455** .627** .664** .322**

Rotation .372** .417** .377** .475** .322** N.B * = Correlation is significant at the 0.05 level ** = Correlation is highly significant at the 0.01 level

Discussion: internship emphasis on all domains of The internship year is an important part of competency was high. undergraduate education, training and Within Egypt, Rashdan (2007)(32) stated preparation of new graduates for clinical that the Egyptian Nursing Syndicate practice (3). Internship program plays an encouraged to adopt an agency mission important role in improving the work that offers protection and promotion of the performance of the new nurses and welfare for the citizens of Egypt by establishes their attitudes toward the ensuring that each person practicing as a organizations they work. Therefore, the nurse in the country of Egypt is competent implementation of the internship program to practice safely. provides them with career development The present study results revealed that advice and psychosocial support (8). nurses intern feel possessing high The present study revealed that majority of professional and ethical competency. This nurses intern perceived high emphasis means that those nurses intern have the level of internship program put on total opportunities during the internship year to domains of competencies. This may be recognize accountability and responsibility related to that internship program assists for their action and practice within the nurses intern to develop their fundamental limits of their abilities and qualifications. clinical skills. Indeed they perform a lot of This is supported by Evans (2005)(24) who work in a short time and they practice side on lined with the results of the present by side with the professional healthcare study and she found that high emphasis of team. In this respect, Duchscher (2008) (28), internship program was for professional Evans (2009)(29), Good et al (2009)(30), and domain of competency. Ashlock et al (2010)(31) supported the The present study results revealed that results of the present study and they found nurses intern reported that internship the nurses intern reported that the program emphasis on possessing high

Internship Program Strengths and Weaknesses as etc…. critical thinking and analysis competency. In regard to, Russel and Perris (2007)(36) This may be related to the internship supported the results of the present study program provided opportunities for nurses and they found that majority of interns intern to transfer fundamental nursing have rated high emphasis of preceptors skills from one situation to knowledge and during internship program on enabling demonstrate proficiency in skills. In domain, critical thinking domain and to concern with, Mallum (2010) (33) achieved at least minimum level for supported the present study results and she admission and discharge competencies. found that nurses intern rated themselves Also, Arthur (2008)(37) supported the high in critical thinking and analysis results of the present study and she found domain competencies at the end of the that nurses intern rated themselves a good program.In contrast to, Queen (2009)(34) or strongly developed ability to provide did not support the present study. His study nursing care with ability in evaluated 452 new graduate nurses who communication with patient and a strong worked at fourteen hospitals. The results ability to listen to patients without identified deficiencies in the critical diminishing their feelings. thinking and interpersonal skills of the new The present study results revealed that nurses during internship program. nurses intern perceived high emphasis The present study results revealed that level of internship program was put on nurses intern perceived high emphasis of confidence in nursing practice. This may internship program put on management of be related to the clinical supervision which care competency. It may related to that the nurses intern received at the internship nursing interns practice holistic nursing program. This clinical supervision care to patients and undertake all activities enhanced their sense of confidence and in relation to patient care and other competence. As well as, it improved their assigned duties. In this respect, Roberts performance to job responsibilities’ and and Farrel (2008) (35) supported the results patients care.Koerner and Walters of the present study and they stated that a (2010)(38) supported the results of the period of supervised practice during present study and they recognized that internship program gave the necessary internship program as an effective strategy support to nurses intern to improve their to build confidence in nursing practice by management of care competencies, provide clinical supervision. consolidate clinical and decision making The present study revealed that skills, help them to orientate to the culture majority of nursing interns perceived that of the nursing profession and become an internship program put high emphasis level effective member of the nursing on rotation. It may be related to the workforce. organized and structured rotation with The present study results revealed that enough time to permit them gain skills and nurses intern perceived high emphasis of abilities because it covers several clinical internship program was put on enabling experience which develop their domain. It may be related to that the nurses competencies and confidence. In regard intern communicate with flow numbers of to, Evans et al (2010)(39) supported the healthcare team, patients and their relatives results of the present study and they found during different shifts and different that high emphasis of internship program rotations. This apparent in the active for providing organized rotations. participation of the nurses intern as part of The present study revealed that nursing the multidisciplinary team, experience a interns reported little emphasis of variety of different areas of nursing internship program was put on specialization, understand and adapt to the opportunities offered in clinical culture of the hospital. environment. Those nursing interns

WalaaMursyHalema et.al. mentioned their causes as they rarely 80.6% of internship program was put on access to the clinical supervisors and rarely rotation, level of confidence in nursing receive feedback from them and the practice and domains of competency program coordinator. Beside they have no according to the perception of nursing time to attend the sessions for orientation interns respectively. While as weaknesses or educational components. Elliott points at the internship program, little (2002)(40) supported the results of the emphasis 72.0%, 63.1% and 60.5% of present study and he found that nursing internship program was found for the interns felt unsupported clinical conflict management, role of supervisor environment during internship year. and opportunities offered in clinical The present study results revealed that environment among of nursing interns nursing interns perceived little emphasis respectively. level of internship program put on role of Recommendations: clinical supervisor. In fact nursing interns Based on the results of this study it reported that clinical supervisors were not was recommended that building structured good role model in giving clinical preceptor-ship program, prime importance procedures, collaboration with nurse staff the availability of clinical preceptors, or healthcare team. Also their professional provision of job description for those role was unsatisfied to nursing interns as preceptors, structured orientation program, they did not use standards, policies and did open communication and coordination not give reports. Really they did not adhere between faculty and hospital, evaluating to the value of the profession. In respect to system and feedback and strategies to avoid Modic and Schloesser (2006)(41) supported conflict and lateral violence. In addition, the present study results and they found further researches were needed to analyze that nurses intern perceived poor the causes of weaknesses points of the preceptors role during their internship internship program and found the strategies program. to solve it. The present study revealed that nurses References: intern scored that internship program put 1. Ellis J.R. Nursing Today's world little emphasis level on avoiding conflict. trends, issues &management. 9th ed. The fact is that those nursing interns found Philadelphia: Lippincott Williams Inc, a lot of nonverbal innuendo and verbal 2008: 200-201. affront. As well as, they found withholding 2. Pine R. and Tart K. Return on information, sabotage, scapegoat and a lot Investment: Benefits and challenges of internal conflict. Beside, they failed to of a baccalaureate nursing residency get respect for privacy so their confidence program. Nursing Economics Journal. broken. Moreover, Delaney (2005)(42) and 2009, 25 (1):14. Olson et al (2008)(43) supported the present 3. Beecroft P.C., Kunzman E. and study results and they showed that Krozek C. RN Internship outcomes of graduates were aware of conflicting a one year pilot program. Journal of emotions regarding their transition. Nursing Administration. 2008, 31(12) Furthermore, the shortage of nurses which :575-576. the organization suffered and the 4. Tanner C. and Chesla C. Expertise in dependence on nursing interns as a golden nursing practice caring, clinical solution to solve this shortage with little judgment and ethics. 2 nded, USA support presented to nursing interns. :Springer company, 2009:322. Conclusion: 5. Linn L. and Howard A. Hand book As strengths points in the internship for researcher in cooperative education program offered at Tanta University and internship practical, 2004:137-138. Hospital, high emphasis 90.7%, 87.2% and

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