VOLUME 38 | ISSUE 4 | JULY-AUGUST 2018

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Perceptions of confidence among Saudi nursing interns during internship program: a cross-sectional study

Ahmad E. Aboshaiqah,a Regie B. Tumala,a Joel G. Patalagsa,a Ahmed A. Al-Khaibary,b Haya Al Fozan,c John Paul Ben T. Silanga

From the aCollege of Nursing, King Saud University, Riyadh, Saudi Arabia; bDepartment of Nursing Affairs, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; cKing Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

How to cite this article:

Aboshaiqah AE, Tumala RB, Patalagsa JG, Al-Khaibary A, AL Fozan H, Silang JP. Perceptions of confidence among Saudi nursing interns during internship program: a cross-sectional study. Ann Saudi Med 2018; 38(4): 288-298.

Abstract

BACKGROUND: Saudi nursing students are trained in theoretical and clinical nursing competencies for four years before transition to newly graduated nurses through a one-year internship program. The transition period is crucial as nursing students have low confidence without adequate clinical experience. 

 

OBJECTIVES: Validate and culturally adapt the Arabic version of the Self-Efficacy for Clinical Evaluation Scale (SECS) and explore nursing interns perceived confidence (self-efficacy).

 

DESIGN: Cross-sectional.

 

SETTING: Four public tertiary training hospitals in Riyadh, Saudi Arabia.

 

METHODS: A survey was conducted among nursing interns. Validity, reliability, and the cultural relevance of the Arabic-translated instrument was determined. Tests for differences and correlations were undertaken.

 

MAIN OUTCOME MEASURES: Perceived self-efficacy and impor.tance of learning objectives.

 

SAMPLE SIZE: 300 Saudi nursing interns.

 

RESULTS: The Arabic version of SECS was successfully adapted cross-culturally and was valid. Reliability tests showed Cronbach’s a=.95 for confidence and Cronbach’s a=0.96 for the importance subscales. The overall mean (SD) for perceived confidence and importance of clinical evaluation were 3.7 (0.9) and  4.1 (0.8), respectively. Gender (P<.001), length of internship (P=.009), and training hospital (P<.001) were significantly correlated and had a medium effect size with perceived self-efficacy.

 

CONCLUSION: Gaining knowledge that the gender, length of intern.ship and area of training affect the perceptions of the Saudi nursing interns towards self-efficacy can help preceptors formulate better strategies in developing nursing intern competence and gaining self-efficacy as they move from the academic to clinical nursing practice. The knowledge gathered in this study should be beneficial to nursing administrators, faculty, and mentors/preceptors.

 

LIMITATIONS: Results may not be generalizable due to the limitations in the setting and there are other factors not included in the study that may have explained variances in perceived self-efficacy.

 

CONFLICT OF INTEREST: None.

 

One of the aims of the Saudization program is to increase the number of Saudis in the nursing profession. In response to this mandate, nursing education aims to increase enrollment among Saudis in nursing programs and, more importantly, prepare future Saudi nurse practitioners who will competently deliver safe and high-quality health care services.1 To support this goal, a one-year clinical nursing internship program was integrated into the Bachelor of Science in Nursing (BSN) curriculum to provide inten.sive clinical training and facilitate the transition of new nursing graduates into professional nursing roles.2 

 

The assessment of clinical competence requires meeting the defined national standards of the nursing profession.3 Assessments can be complemented by additional data. The self-efficacy beliefs of students are useful supplements to ratings by mentors or preceptors because they offer additional insights into how students view their own level of clinical proficiency.4 Self-efficacy is defined by Bandura5 as people’s beliefs about their capabilities to produce effects. Thus, confidence is interchangeable with self-efficacy as both terms suggest one’s’ belief in being able to accomplish tasks relevant to the development of nursing competencies. Competencies and self-efficacy in clinical performance contribute to the quality of care provided by nursing students.6 The assessment of self-efficacy is robust in determining competency level.7,8 The assessment of self-efficacy requires collaboration and validation between clinical partners and academia in order to contribute toward enhancing the clinical credibility of academics, the professional development of mentors or preceptors, and, more importantly, the clinical experiences of nursing students.9 

 

Studies on self-efficacy assessment among Saudi nursing interns seem limited. The twofold aims of the current study were to validate and culturally adapt an Arabic version of the Self-Efficacy for Clinical Evaluation Scale (SECS) and explore the perceived self-efficacy that Saudi BSN interns obtained while undertaking their clinical internship. 

Methods

This descriptive cross-sectional study was conduct.ed in four public training tertiary hospitals in Riyadh, Saudi Arabia, where nursing interns were undertaking their internship program between October 2016 and March 2017. Purposive sampling was used to obtain wide participation among Saudi nursing interns, as defined by the inclusion and exclusion criteria. Included in the study were students who were officially registered in the internship program during academic year 2016–2017 who were bonafide students from the four nursing colleges in Saudi Arabia. They had to be undertaking a clinical internship program in one of the four public tertiary training hospitals in Riyadh, Saudi Arabia. Participants had to be available at the time data were collected, and willingly and voluntarily participated. Excluded from the study were those who were enrolled in an undergraduate practicum program, who were non-Saudi, unwilling to participate at the time data were collected, and had participated in the pre-test. Respondents in the pretest were not included as respondents in the final data gathering. 

 

The demographic data comprised age, gender, length of internship, training hospital of internship, and nursing school where the nursing interns graduated. The SECS was selected in this study because of the similarity of its items with the clinical internship learning objectives for nursing interns in the internship program. Thirty items in the scale were adapted for equivalency with the clinical internship learning objectives in this study. The self-efficacy/perceived confidence scale was rated by the participants using Likert-type scales with five responses ranging from very little to quite a lot. The same items were used in the importance scale with responses ranging from very little to very important.

 

Permission to translate and use the SECS was granted by the copyright holder (Electronic mail from Clark, M. on 06 February 2015). Guidelines in translation, cross-cultural adaptation, and validation of the SECS into the Arabic language and culture using five stages were adopted.10 In stage 1, two bilingual ex.pert English-to-Arabic translators translated the English items into Arabic. The objective at this stage was to attain equivalency of the English items into Arabic for cross-cultural adaptation. Stage 2 involved a review and synthesis of the Arabic translations by two bilingual native Arabic experts who evaluated the semantic, idiomatic, and conceptual equivalence of the Arabic translations. Minor discrepancies were resolved and consensus was attained on the Arabic translation. Stage 3 involved back-translation of the Arabic version to English by ex.pert Arabic-to-English translators. Stage 4 involved the review of the Arabic translation and back-translated versions by two bilingual experts for consensus validation of the pre-final version. Face validation based on consensus agreement of the pre-final Arabic version was obtained. An additional procedure was adapted to ensure robustness of the Arabic version. The Arabic version of the questionnaire was subjected to further item-level content validity index (I-CVI) and scale-level content validity index (S-CVI). Five item experts examined and rated the individual items. In Stage 5, a pilot study was conducted with 30 Saudi nursing interns who evaluated the instrument’s clarity and ease in completion. This sample size was adequate based on the suggested sample size for conducting a pilot study.11,12 The pretest participants provided feedback that the questionnaire was moderately easy to very easy to complete. They further reported that the questionnaire was easy to read, understand, and complete within 10–12 minutes. The instrument was subjected to an inter-item correlation coefficient test using data from the results of the pilot study. The self-efficacy/confidence and impor.tance scales yielded higher Cronbach’s a values after items were deleted. Both confidence and importance scales yielded very good reliability scores for the Arabic version of the SECS. After undergoing rigorous translation, cultural adaptation, validation, and reliability tests, the Arabic version of the SECS was then ready for use in this study.

 

Approvals from the Institutional Review Boards of the training hospitals and permission from the administrators of the schools where the participants were en.rolled was obtained before the study was conducted. Trained research assistants recruited prospective participants who were on duty during their clinical internship training. The research assistants approached the participants individually or in groups as the situation arose. The objectives were explained and implied consent was provided by those who voluntarily participated in the survey. Anonymity was explained and assured by not requiring participant names in the questionnaire. Confidentiality of the responses was also explained, and the participants were assured that only the codes of the responses would be used in processing and analyzing the survey results. They were also informed that they had the right to withdraw from the study at any time without consequences. Questionnaires were distributed to those who willingly and voluntarily consented to participate in the study. The questionnaires were retrieved after they finished answering.

 

The Arabic version of the questionnaire was further subjected with an item-level content validity index (I-CVI) after face validity, wherein each item was rated for relevance. A scale-level content validity index (S-CVI) computed the proportion of items rated quite or very relevant by each of the raters.13 The instrument was also subjected for reliability testing using the inter-item correlation coefficient test using data from the results of the pilot study.

 

Descriptive statistics were used to present the characteristics of the participants. Items in perceived confidence and importance were ranked, and the median and mean were computed and interpreted. The top three items are presented in this paper. The Mann-Whitney U test was used to find significant differences in perceived competence and importance when the nursing interns were grouped according to gender, school graduated, and age group. The Spearman rank correlation coefficient was used to determine the bivariate relationship between perceived competence and importance with the background characteristics. The coefficient of determination was used to find the percentage of variability explained by the characteristics that were significantly associated with the perceived competence and importance. Significant findings were inferred if P<.05. Data were processed using IBM SPSS Statistics for Windows v.21 (IBM, Armonk, NY).14

Results

Instrumentation

Of 320 nursing interns recruited, 301 surveys were retrieved, for a response rate of 94%. Post hoc power analysis using G*Power 3.1.9.2 showed that the sample size for the two-tailed test for difference between two groups (gender: male=88; female=213) yielded a medium effect size of 0.5, a=.05, and statistical power =.97. The sample size for the two-tailed test for significant correlations between confidence and background characteristics and between importance and background characteristics (N = 301) yielded a medium effect size of 0.5, a=.05, and statistical power=.99. These results provided evidence that the sample size in this study was appropriate for producing a medium effect size and the power of the statistical tests was sufficient for significant differences and correlations.

 

Validity and reliability of the instrument

The validation tests yielded an average of 1.0 for the I-CVI and an overall S-CVI of .98, suggesting that the items in the instrument were important and relevant. When taken as a whole, the Arabic version of the SECS is acceptable and has very good content validity. The reliability test yielded a Cronbach’s a=.95 with a corrected item-total correlation ranging between .416 and .804. If an item was deleted, the Cronbach’s a for the confidence scale ranged between .955 and .959. On the other hand, the importance scale has a Cronbach’s a=.96 with a corrected item-total correlation ranging between .444 and .838. If an item was deleted, the Cronbach’s a for the importance scale ranged between .961 and .964. Both confidence and importance scales yielded very good reliability scores for the Arabic ver.sion of the SECS. After undergoing rigorous translation, cultural adaptation, validation, and reliability tests, the Arabic version of the SECS was then ready for use in this study.

 

Perceived competence of clinical internship learning objectives

Most of the participants were 23-year-old females (48.2%) who were undertaking a four-month internship (48.2%) in training hospital 3 (43.2%) and had finished their BSN in public schools (92.7%) (Table 1). Most of the participants perceived that they were confident in realizing the effect of one person’s chronic illness on the other family members, understanding the coping styles of people with chronic illness, and understanding the impact of people with chronic illness on health care (Table 2). Most of them perceived that they were fairly confident in explaining the effect that the Health Care Financing Administration has on health care, knowing the direct and indirect costs of chronic illness, and identifying how much of the total medical costs for people with chronic illness is paid for by government-funded insurance (Medicare and Medicaid). Taken collectively, the participants perceived that they achieved confidence in their clinical internship.

 

Perceived importance of clinical internship learning objectives

Most of the participants perceived that the three most important clinical learning objectives are describing the rationale for nurses learning functional assessment, effectively documenting client care, and listing the skills a nurse case manager needs (Table 3). In comparison, most of them perceived that the three least important clinical learning objectives are describing how man.aged care works, implementing the components of a home visit, and explaining the effect that the Health Care Financing Administration has on health care. Taken collectively, the participants perceived the clinical learning objectives as important .

 

Differences in overall confidence and importance by background characteristics

Perceived confidence in achieving the clinical learning objectives was significantly different by gender (Table 4). Females were more likely to be confident compared to males. The importance of the clinical learning objectives was perceived as significantly different by gender. Females were more likely than males to perceive that the clinical learning objectives were more important. No significant differences in perceived self-efficacy (confidence) and importance were observed when the nursing interns were grouped according to school graduated and age group. Gender (P<.001), length of internship (P=.009), and training hospital (P<.001) were significantly correlated (Table 5).

Discussion

The first part of the study involved the translation, cultural adaptation, validation, and reliability testing of the Arabic version of the SECS. The robust procedures undertaken clearly provided a semantically and idiomatically appropriate Arabic version for SECS which could be used by Arabic users (Table 6). This study further examined the confidence (perceived self-efficacy) in attaining and perceived importance of selected clinical learning objectives among Saudi nursing interns. 

 

The results showed that most of the interns perceived they were confident in realizing the effect of one person’s chronic illness on the other family members, understanding the coping styles of people with chronic illness, and understanding the impact of people with chronic illness on health care. Taken collectively, the interns perceived that they achieved confidence in accomplishing the clinical learning objectives. The results showed similarity to those of a previous Finnish study where the highest level of competence was reported in helping patients to cope and in providing ethical and individualized care.15 As shown in the results, the inclusion of appropriate and relevant clinical learning objectives in clinical-setting -based-programs to nursing students, such as internships or cadetships, contributed in enhancing the perceived competence among new nursing graduates.16,17 Most of the participants perceived that describing the rationale for nurses learning functional assessment, effectively documenting client care, and listing the skills a nurse case manager needs are considered as essential clinical learning competencies. These competencies are regarded as the most required responsibilities of nurse managers in clinical settings.18 Collectively, the participants perceived the aforementioned skills as crucial clinical competencies during internship training. This finding indicates that nursing students considered the listed learning objectives as important in developing their clinical competencies. 

 

Conversely, the results showed that majority of the participants perceived they were fairly confident in explaining the effect that the Health Care Financing Administration (HCFA) has on health care and concurrently regarded it as one of the last important clinical learning objectives. Contrary to a previous study, most of the students believed that the above mentioned skill was important though they felt little confidence in performing it.4 In our study, nurse preceptors failed to persuade the interns on the importance of HCFA in health care. Thus, the interns felt they lacked skill in utilizing such information during their internship training in assisting their patients. Furthermore, they perceived that they were fairly confident in knowing the direct and indirect costs of chronic illness and identifying how much of the total medical costs for people with chronic illness are paid for by government-funded insurance (Medicine and Medicaid). Most of the interns perceived that describing how managed care works and implementing the components of a home visit as the least important clinical learning objectives.

 

The current study found that confidence and importance in achieving the clinical learning objectives are perceived differently by gender of the interns. Females were more confident and considered clinical learning objectives more important compared to their male counterparts. Confidence or perceived self-efficacy and perceived importance of learning objectives were developed along the course of their internship. This gender difference may be attributed to the gender factor in the relationship between mentors and interns, particularly when males were guided by female mentors. Most of the mentors were female and more likely to be expatriates. The socio-cultural factors that involve avoidance of opposite-gender interaction, which may be perceived by the mentors, more likely played a role in this difference, as explained in the findings of a study on the cultural challenges in implementing formative assessment in Saudi Arabia.19 The interaction gap may have affected the way male nursing interns approached their training objectives. In addition, our findings were contrary to a previous study wherein no significant differences were found in comparative competence on the basis of gender.20 Clearly, mentors need to exercise open-mindedness in interacting and providing guidance to opposite-gendered nursing interns, especially in light of the current generation of Saudi students opening up in their interactions with the opposite gender because of globalization.19 The nature of the nursing profession likewise necessitates nursing interns to develop confidence in providing care with opposite-gendered clients. Thus, mentors who are oppositely gendered need to be role models in providing non-discriminating interactions with oppositely gendered interns to help them develop confidence in providing care to oppositely gendered patients.

 

In our study, no significant correlation was noted between the interns’ age and their perceived confidence and importance of the learning objectives. This out.come means that age was not a factor in obtaining self-efficacy. Thus, regardless of age, the interns were approximately similar in appraising their perceived level of confidence and importance of the learning objectives. Contrary to our findings, previous studies showed that age has a positive impact on competence, especially when combined with additional training and experiences.21,22 Another study found that as age increased, self-directed learning readiness also increased.23 This finding means that as the interns gain maturity and additional training, the more confident they become.

 

The results of this study may not be generalizable due to the limitations in settings and that two factors were excluded in the study which may have contributed to the variances in perceived self-efficacy.  Nevertheless, the results are important because they provide insights into the level of confidence and the importance of clinical learning objectives set forth in an internship pro.gram. Future studies are encouraged to broaden the scope, participation, and inclusion of qualitative data and the use of mixed methods in generating information relevant to improving the competencies of nursing interns.

 

In conclusion, the findings of our study confirm that the Arabic version of the culturally adapted SECS is a valid and reliable instrument for assessing perceived self-efficacy among Saudi nursing interns during their internship. Hence, the Arabic version of the SECS can be used by Arabic researchers and prospective participants for future research. In light of the gender differences, mentors/preceptors need to exercise an open mind in their interactions, be it with same-gendered or opposite-gendered nursing interns. This characteristic would contribute to the development of their competencies and self-efficacy. Nursing interns can participate in shaping their competencies by enabling them to pro.vide self-ratings of their performance and feedback on what they consider as important in their training and development. The knowledge gathered in this study is beneficial to nursing administrators, faculty, and mentors/preceptors in realizing the need to collaborate in the formulation of strategies that will contribute to the development of nursing interns’ competencies, as well as providing support during their transition from newly graduated nurses to professional nurses.

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