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Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 75-80

Assessing the effectiveness of two internship clinical training programs: Impact on the perception of competency enhancement and student satisfaction

1 King Abdullah International Medical Research Center; Department of Nursing, King Saud Bin Abdul Aziz University - for Health Sciences, Jeddah, Saudi Arabia
2 King Abdullah International Medical Research Center; Department of Nursing, King Saud Bin Abdul Aziz University - for Health Sciences, Jeddah, Saudi Arabia; Department of Nursing, Cairo University, Gizah, Egypt

Date of Web Publication13-Sep-2019

Correspondence Address:
Dr. Hend Alnajjar
College of Nursing, King Saud Bin Abdul Aziz University, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_41_19

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Context: An important subject for nurse educators both nationally and internationally is reducing the gap between the limited teaching time and unlimited content, and one approach to reducing the theory–practice gap is internship programs which provide support and mentorship to nursing interns in order to increase competence and satisfaction. Aims: This study aimed to assess different internship clinical training programs provided by the College of Nursing, Jeddah, Saudi Arabia, and to test the effect of these two internship models on students' perceptions of competency enhancement and satisfaction. Settings and Design: This study followed an exploratory comparative design at the College of Nursing, Jeddah, Saudi Arabia. Subjects and Methods: A convenience sample of 64 nurses was included. Data collection included the validated Nurse Competence Scale and Interns Satisfaction questionnaire. Statistical Analysis Used: Descriptive statistics included mean, standard deviation, frequencies, and percentages, and inferential statistics such as independent t-test and Chi-square were carried out using the Statistical Package for the Social Sciences software. Results: No statistically significant differences (P = 0.38) were noted between the two groups of nurse interns. The average overall perceived self-rated competence was 84.82 ± 9.34 with 75.47 frequency of use of competencies. The most highly rated subscale of competency was a work role (mean competence level of 87.86 and frequency of use of 78.67%). Conclusions: This study highlighted no significant differences between the two internship models and the mean satisfaction score for nurse interns from the new training model group was higher compared to those from the traditional model group. However, it is important to note that internship programs have brought about significant changes within nursing worldwide and more specifically within Saudi Arabia.

Keywords: Clinical competence, internship program, nurse interns, satisfaction

How to cite this article:
Alnajjar H, Bayoumy HM, Rawas H, de Beer J. Assessing the effectiveness of two internship clinical training programs: Impact on the perception of competency enhancement and student satisfaction. Saudi J Health Sci 2019;8:75-80

How to cite this URL:
Alnajjar H, Bayoumy HM, Rawas H, de Beer J. Assessing the effectiveness of two internship clinical training programs: Impact on the perception of competency enhancement and student satisfaction. Saudi J Health Sci [serial online] 2019 [cited 2023 Jun 10];8:75-80. Available from: https://www.saudijhealthsci.org/text.asp?2019/8/2/75/264949

  Introduction Top

A significant component of nursing education is clinical training which is also considered the heart of the nursing curriculum.[1] Attempts to reduce the gap between theoretical and practical knowledge in educational and practical environments are necessary to improve the training of qualified nurses.[2] In addition, an important subject for nurse educators both nationally and internationally is reducing the gap between the limited teaching time and unlimited content, in order to train highly competent nurses that are ready to adapt to the dynamic health-care system.[3] According to Sharif and Masoumi,[4] there is a need to reflect on the clinical skills training in nursing education. Further to this, these authors in their study found that nursing students expressed concerns about the theory–practice gap, clinical supervision, professional roles, and clinical anxiety. Hence, attempts to narrow the gap between theory and practice in an effort to facilitate training for professionalism in an action-based work environment may be useful.[2]

A major challenge in the hospital context is to develop competent and confident new graduate nurses who remain in the hospital.[5] A literature review by Nehrir et al.[6] showed that nursing students' competencies are defined within a dynamic process, focusing on individual experiences and positive interactive social and beneficial changes in the quality of one's professional life resulting in motivation, sound decision-making, job engagement, professional authority, increased self-confidence, and metacognitive abilities. This is also inclusive of the factors such as the “nursing process,” “caring,” “professionalism,” “communities,” and “diversity.” Al-Mahmoud et al.[5] further stated that clinical competence includes tactfully including and carrying out one's nursing knowledge related to one's specific context and skills that are housed on one's values, ethics, and therapeutic relationships.[5]

There is a strong need for adequate nursing competencies in improving and evolving care.[6] High quality of care is a significant requirement for nursing which is dependent on the nursing competency.[2] The role of competency in nursing education has increased drastically and is considered a crucial issue in professional nursing practice and nursing education.[7] Therefore, nursing students should possess specialized competencies in order to accurately assess patients and to foresee and manage problems that may occur during nursing care.[6]

Cheraghi et al.[8] emphasized that students find difficulty while undergoing theirs clinical training in order to be able to merge theory and practice and become clinically competent. Thus, finding ways to mentor and support these nurses during the internship programs should be the ultimate goal of programs of transitions to increase the competence of new nurses and help with retention and satisfaction of nurses.[5] Promoting clinical learning should, therefore, be dependent on improving ones' own culture and organization and changing learning conditions to develop learner-oriented environments in clinical settings.[9] Consequently, the importance of academic nursing education and clinical environment for nursing competency is highlighted.[2] Hence, clinical experiences should be planned to support students to develop skills clinically, integrate theory with practice, utilize problem-solving skills, and become socialized into the nursing profession.[10]

Similarly, Al-Mahmoud et al.[5] contended that the internship phase is an exciting time for students, but it also poses major challenges for students on various levels. These challenges include the need to acquire and demonstrate communication and clinical skills. In addition, nursing students are not satisfied with the clinical aspect of their education. They experience anxiety due to feeling incompetent and lack of professional nursing skills and knowledge to meet the care needs of the diverse patient profile in the clinical setting.[4] Nursing students' experiences of their clinical practice should offer greater insight for nursing faculty to develop a strategy in nursing education that is effective for clinical teaching. These issues highlight the need to satisfactorily expose nurse graduates to a supportive environment with various high-quality clinical placement settings that are required for competency training and development as well as guiding future career decision. In this regard, a clear and proper expectation of what and how much competencies considered a must for their professional development as well as continuous competency assessment are considered the critical elements of novice nurse training. In this regard, Al-Neami et al.[11] emphasized that it is necessary that training of nurses not only be made intensive but the assessment of their competencies be undertaken so that when they start to practice as registered professionals, they will be confident and live up to the expectations and demands of the profession.

In addition, it is necessary to assess the strengths and weaknesses of the learning–teaching process in the clinical field as part of continuous quality improvements in clinical education.[1] Assessment of competencies of nursing students during their internship is essential in order to obtain feedback as to the extent the nursing school and training hospital have equipped them to assess their readiness to practice their profession.[11]

Furthermore, the process of graduates of nursing competency development assessment through the utilization of an efficient clinical training model is complex and should comprise both quantitative and qualitative data. Hence, this study aimed to assess different internship clinical training programs provided by the College of Nursing, Jeddah, Saudi Arabia. In addition, the study aimed to test the effect of these two internship models on students' perceptions of competency enhancement and satisfaction. The objectives of the study are:

  • Comparing the impact of the two different clinical training program models on interns' perception of their competence
  • Comparing the effect of the two different clinical training program models on interns' satisfaction with the internship training.

  Subjects and Methods Top


An exploratory comparative research design was utilized in the current study. The College of Nursing, Jeddah, was the setting for the study. The college interns constituted the study participants during the internship program which lasted for 12 months. During the study, the internship program adopted two different training models: the first model was already in use (traditional model) and the second was a newly developed model (new model). Both the teaching models followed a 12-month internship program.

The traditional model (Group 1) was a 1-year internship training model which was divided into two phases. Phase I covered 32 weeks, and all requirements were unified for all nurse interns. Phase II covered a period of 16 weeks and started after successful completion of Phase I. The program is designed to prepare nurse interns effectively for their targeted future positions as nurses. Within this model, by the end of Phase 1, a nurse intern is expected to achieve certain generic and rotation-specific competencies. At the end of Phase II, nurse interns have to complete unit-specific competencies which were not standardized by the college.

The new model (Group 2) was developed by a task force of ten nursing academic staff from various disciplines within the college. The competencies used in the traditional model were reviewed, and a list of core competencies with a checklist was developed for Phase I and Phase II for the new model. All the revised competencies and their checklist were reviewed by the task force. Thereafter, the clinical training department, clinical preceptors, and nurse interns were orientated to the new competencies, with the respective checklists before being implemented in this group.

The two groups of interns were included in the study. Group 1 started their internship in September 2015 (traditional model), and Group 2 started their internship in March 2016 (new model). The 12 months of the internship was divided into two phases: Phase 1 consisted of 8 months of rotation in the medical, surgical, pediatrics, and maternity disciplines, whereas Phase 2 included rotation in the specialty areas such as critical care and the operating room. The only difference between the two internship program training models was that each group of students had different core competencies to complete. The study included a convenience sample of 64 interns (33 interns from the traditional model and 31 from the new group were recruited).

Data collection

Data collection started at the end of Phase II for both groups using two questionnaires namely: the Nurse Competence Scale (NCS) which was developed by Meretoja et al.[12] to measure interns' self-assessment of their competence. The NCS was derived from Benner's From Novice to Expert competency framework. The original 73-item scale was given to expert scientists to assess and ensure the relevance of the scale to the nature of the participants, the program objectives, and the Saudi culture. Only 66 items were retained in the adopted version. These items were distributed into seven subscales: helping role (7 items), teaching–coaching (16 items), diagnostic functions (7 items), managing situations (8 items), therapeutic interventions (10 items), ensuring quality (6 items), and work role (19 items). Each item on the questionnaire was scored twice, and the nurse interns were requested to indicate their perceived competence from 0 to 100 in ratios of ten; with 0 for a very low level of competence and 100 for a very high level of competence. The nurse interns were further requested to rate the frequency of use for each individual subscale of competence using a 4-point scale (0, not applicable in my work; 1, used very seldom; 2, used occasionally; and 3, used very often).

Meretoja et al.[12] reported on the reliability and validity of the NCS. The Cronbach's alpha for the NCS ranged from 0.79 to 0.91. The evidence of construct validity was examined using the principal component analysis. As reported by Meretoja et al.,[12] the items of the NCS fitted into the expected factors, and the total variance accounted for was 52.7%. Reliability analysis using the current study data revealed a Cronbach's alpha of 0.984.

The second questionnaire was the Interns' Satisfaction which is a 20-item Likert scale developed by the researchers based on an extensive review of relevant literature.[5],[13],[14] This tool measures nurse interns' satisfaction with the internship program. Each item was assessed on a scale of 1–5 (1 being strongly agree and 5 being strongly disagree). Reliability of the questionnaire was assessed on a pilot of ten nurse interns who were excluded from the final data, and a Cronbach's alpha of 0.978 was shown. Content and face validity of the Interns' Satisfaction Questionnaire was assessed through a panel of five academic nursing experts in the different fields of nursing to ensure clarity, relevance, and the content coverage of the construct being measured.

  Results Top

Seventy-five nurse interns participated in the study. Of which only 64 nurse interns with complete data were included in the final data analysis. The nurse interns' mean age was 25.02 ± 2.41 years, with a range between 22 and 30 years. The nurse interns' grade point average (GPA) was 3.58 ± 0.50 out of 5. The GPA ranged between 2.50 and 4.70. The study included 33 nurse interns from the traditional training program versus 31 nurse interns from the newly mandated model. Concerning their marital status, the majority of nurse interns were single (n = 47, 73.4%). [Table 1] further summarizes the distribution of demographic details of nurse interns between the study groups.
Table 1: Sociodemographic characteristics of nurse interns in both training models

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Concerning nurse interns' level of assessed competency and frequency of use, as summarized in [Table 2], the work role subscale of competence was rated the highest among the different subscales of clinical competence (87.86 ± 9.77). The rest of the competence subscales were similarly and highly rated as summarized in [Table 2]. In comparison, the frequency of using the studied competencies varied across the different subscales. The subscale of work role was identified as the most frequently used subscale of competence, followed by the subscale of diagnostic functions, whereas the subscale of ensuring quality was the lowest rated subscale of competence as compared to others (78.67, 77.39, and 71.85, respectively). The average overall perceived self-rated competence was 84.82 ± 9.34 with 75.47 frequency of use.
Table 2: Mean distribution for levels of self-assessed competencies and their frequency of use among nurse interns (N=64)

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As summarized in [Table 3], the mean overall competence among nurse interns from both internship training models was not statistically significant (P = 0.38). Nurse interns from the traditional model, however, showed higher self-assessment of their competence compared to those from the new model. Both groups similarly had higher self-perception of their work role, followed by diagnostic functions in the traditional model group, whereas teaching–coaching was the second rated subscale of competence in the new model. In addition, ratings related to the level of competence from both groups did not yield any statistically significant difference. Nurse interns from the new training model had rated their use of nursing competencies highly as compared to their counterparts from the traditional group. In addition, the subscale of the working role was the most commonly used competence subscale among nurse interns from the traditional model while diagnostic functions were used more frequently by nurse interns from the new model. The least used competence subscale was ensuring quality in the traditional group compared to the subscale of teaching–coaching in the new model.
Table 3: Mean self-assessed competence and its frequency of use among nurse interns from both the traditional and new models (n=64)

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For descriptive purposes, the Visual Analog Scale (VAS) 1–100 was divided into four parts to represent the level of nurse interns' competence as low (VAS 0–25), quite good (VAS 25–50), good (VAS 50–75), and very good (VAS 75–100). As summarized in [Table 4], the majority of nurse interns from both model groups rated their level of competency as either good or very good. Very few nurse interns rated their competency as quite good, and none of the nurse interns rated themselves as poor in any of the subscales of competence.
Table 4: Frequency distribution for level of self-assessed competence among nurse interns from both the traditional and new models (N=64)

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Finally, the mean satisfaction score for nurse interns was 42.92% ± 18.58%. Nurse interns' satisfaction ranged from 20% to as high as 97.89%. The mean satisfaction score for nurse interns from the new training model group was higher compared to those from the traditional model group. Nurse interns from the traditional model group had satisfaction scores ranging between 20% and 93.68% as compared to the range between 20% and 97.89% for the interns from the new model group.

  Discussion Top

Even though the findings from this study did not yield any significant differences between the two groups of interns, a significant finding of this study highlighted that both groups of interns' perceived level of competence was rated good or very good. This could mean that interns were motivated, were positive, and were confident in terms of perceived competence at the end of the internship program. According to Khan et al.,[13] internship programs are a period of transition where nursing interns are engaged in clinical practice which consequently increases their competency. Further to this, Al-Neami et al.[11] stated that, during the early phase of the internship program, due to the fact that interns are in a new environment, they do not show satisfactory competence. Malouf and West[15] highlighted that interns are more likely to show competence at the end of the internship program.

In addition, Aboshaiqah and Qasim[14] reported a high positive correlation between clinical competence scores and performance in general, professional behavior, and core nursing skills. Gender norms within Saudi cultural context in addition to rapid population growth had resulted in a hugely significant impact on the nursing profession within Saudi Arabia,[16] with a strong reliance on expatriate nurses with different cultural backgrounds.[17]

Therefore, in 1992, the Royal Decree was issued by the Royal Monarchy in Saudi Arabia, regarding the policy of Saudization.[18] This has resulted in a fast increase in the number of Saudi nurses entering the health-care workforce from 22.3% to 50%.[19] Thereafter, national efforts were intensively directed toward the provision of high-quality nursing education programs offered by competitive Saudi institutions which are equipped with highly qualified academicians. However, despite these increases, Saudi Arabia still faces a staffing crisis and comprises only 34% of the nursing workforce.[20] Hence, the policy of Saudization is a priority, and nursing interns that perceive themselves to be highly competent are more likely to adhere to Saudization than nursing interns who perceive the contrary of this.

Another important finding of this study was that most interns from both groups perceived themselves to be most competent in the subscale of work role. In addition, most interns used the competencies related to a working role more frequently than any other subscales of competence. The subscale of work role was related to the issues of participating in multidisciplinary teams focused on developing patient care, participating positively in developing work environments, and including new knowledge to optimize patient care. This not only contributes to the nurse interns perceiving high levels of competence, but also contributes to interns believing that they can be successful in the clinical area. These findings could be attributed to the fact that college interns are being mentored throughout their training with highly qualified preceptors who prepare interns to competently provide holistic nursing care for their patients. Preceptors act as professional role models and are therefore responsible for displaying positive attitude toward the nursing profession and the patients while providing acceptable levels of conduct. They also facilitate smooth transition of nurse interns into the field of clinical nursing practice by informing and assisting them to understand social, psychological, religious and cultural aspects related to nursing. This is related to the Bandura's theory of self-efficacy which posits that for individuals to reach a desired outcome, they must not only value the outcome, but also they must believe that they can successfully perform the behaviors needed to achieve this outcome.[21] This can be indirectly related to the findings in this study in which nurse interns have perceived their level of competence to be good and very good, a belief that can be related to self-efficacy. Individuals may not be able to perform successfully as they may doubt their own competence or lack their self-confidence or self-efficacy to use their skills.[22] Based on the Bandura's theory, students who have been successful in their clinical experiences will show more self-efficacy and confidence in their subsequent experiences.[23] On the contrary, a lack of confidence will result in increased anxiety, altering the students' abilities to obtain new knowledge, and to use opportunities to apply the knowledge and skills they already possess.[24]

Finally, this study highlighted that most of the nurse interns were satisfied with the internship program. It is also shown that nurse interns in the new model were more satisfied than those in the traditional model. This could be related to the fact that nurse interns from the new model were engaged in more specific competencies for practice than their counterparts. However, regardless of this, all interns indicated satisfaction with the internship program. According to Al-Mahmoud et al.,[5] internship programs provide students “a taste of the working world, and let them become familiar with a potential job sector.” In addition, clinical internship programs are predicted to increase the expectations of self-efficacy of students and increase their perception of readiness to practice.[22] Conversely, if an intern does not experience readiness to practice, the intern will be faced with a “reality shock” which can lead to a lack of confidence, increasing anxiety.[25]

  Conclusions Top

This study highlighted no significant differences between the two internship models. However, it is important to note that internship programs can bring significant changes within nursing worldwide and more specifically within Saudi Arabia. Through internship programs, a nurse intern is more likely to develop high levels of competence, confidence, and self-efficacy, bridging the constant problem of the theory–practice gap.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]

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