Benner's novice-to-expert theory and preceptorship impact on nursing competence

Saudi Nursing Interns' Perceptions of Clinical Competence Upon Completion of Preceptorship Experience

Saudi Nurse Edit

Saudi Nursing Interns' Perceptions of Clinical Competence Upon Completion of Preceptorship Experience

The purpose of this quantitative cross-sectional descriptive/correlational design research study is to test Benner's (1982) theory "From Novice to Expert" in relation to the impact of preceptorship on the competency of undergraduate nursing interns at King Fahad Medical City (KFMC). This study seeks to determine if preceptors provide the support recommended by Benner (1982) to the undergraduate nurse during their preceptorship program and if these have an impact on undergraduate competency levels. The study will use two reliable validated clinical competence questionnaires based on Benner's (1982) competencies (Shwu & Ching, 2014) and Knowles Adult Learning theory and nursing process (Kim, 2007). Benner's (1982) theoretical framework of novice-to-expert practitioner development will provide the framework for the study. The research question will address the impact of the preceptorship on undergraduate nurse interns' competency levels. A probability sampling technique will be used to recruit undergraduate nursing interns from King Fahad Medical City, Saudi Arabia who will be asked to complete the tool. Probability sampling technique will enable the researcher to make statistical inferences (i.e., generalizations) from the sample being studied to the population of interest and assess how confident the researcher is about such inferences. The researcher used the probability sampling technique to help minimize sampling bias (Creswell, 2011). These interns have completed a five-year full time nursing training educational program including a 12-month foundation year followed by a12-month structured nursing internship program. It is the 12-month internship program that is the focus of this study.

Problem Statement

King Fahad Medical City (KFMC) is a unique health care system where 95% of the nursing workforce is recruited from outside the country. Nurses of different backgrounds and nationalities are expected to precept graduate nurses. These nurses have their own cultural beliefs and values that are different from those in the Saudi culture (AlMalki & Fitzgerald, 2011). Despite completing four full years of nursing degree programs, 12 months of a structured internship program and opportunities for clinical placement supported by dedicated preceptors, it was noted that nurses who recently graduated from the 12-month long internship program lacked the basic nursing skills to enter into the nursing workforce (KFMC Internship program report, 2013). Educators, nursing leaders and medical teams reported graduate nurses not only struggle with performing basic nursing duties, but also lack the theoretical background to perform them. Many are questioning why these problems exist and why graduate nurses fail to perform basic nursing skills (KFMC Nursing Internship Program, 2013).

According to Mamchur and Myrick, (2003), the transition period from being a student nurse to becoming a staff nurse may lead to increased feelings of anxiety, depression and frustration. These feelings can lead to absenteeism resulting in lower work productivity, job dissatisfaction, burnout and ultimately them leaving the nursing profession, which only further contributes to the nursing shortage.

Nursing graduates have reported feeling disoriented and on the verge of rethinking their choice of nursing as a career. This additional stress may lead to early termination of their first position and the possibility of leaving nursing altogether. Nurse graduates experience a stressful role transition into healthcare organizations, with 30% leaving their first job within 1 year and 57% leaving by 2 years of employment (Aaron, 2011). The nursing education department at King Fahad Medical City recently conducted a basic nursing competency validation with written exams that showed poor performance by the participants. Unless the current situation is reversed, KFMC will risk having graduating nurses that are not capable of providing safe patient care.

Background

There have been significant changes in undergraduate nursing education over the last decade with emphasis on students' experiences and learning in the clinical environment (Bridie & Siobhan, 2010). These changes have come at a time when hospitals are struggling to hire qualified staff nurses while also managing increasing numbers and complexity of patient populations (Lillibridge, 2007). RN's as part of their professional duties are now expected to support nursing student clinical education and assessment in their role as clinical preceptors (Chow & Suen, 2001).

The role of preceptors was developed in the 1970s to facilitate the transition of new nurses to the reality of clinical nursing practice (Omansky, 2010). The role gained popularity and has become the most common method of preparing nursing students for the clinical environment (Bott & Lawlor, 2011). Nursing students and new nurse graduates very often face challenges in transitioning to the professional role due to insufficient experience, limited exposure to clinical skills and patient management; lack of critical thinking skills; and other environmental factors (Chen, Duh, Feng & Huang, 2011; Sandau & Halm, 2010).

Supporting and precepting nursing students and new nurse graduates requires that preceptors act as a role model, mentor and teacher so that the preceptee can successfully integrate nursing theory into nursing practice (Aaron, 2011; Forneris & McAlpine, 2009; Omansky, 2010). Nursing preceptorship programs play an important role in retaining the new generation of nurses engaged to remain at the bedside. In addition, preceptors assist new nursing graduates to demonstrate leadership skills in problem solving, priority setting, decision-making, delegation of responsibility and accountability (Ferguson & Day, 2007). Preceptors facilitate educational activities that promote continued learning and professional growth.

Nursing in Saudi Arabia

The nursing history of Saudi Arabia dates back to the time of Prophet Mohammed, PBUH under the leadership of Rufaida Al Asalmiya when she set up outposts for Muslim armies during the holy wars (Miller-Rosser et al., 2006; Tumulty 2001). Rufaida and her colleagues provided first aid, drinking water and protected the wounded soldiers from getting infections from the desert wind and heat. Ms. Rufaida continued to provide nursing care in peacetime so she could train more women to become nurses and provide health education (Miller-Rosser et al., 2006). Ms. Rifaida is considered the first nurse and the founder of nursing in the Islamic era.

Nursing Education in Saudi Arabia

The Kingdom of Saudi Arabia is a young country with a new nursing profession, which is facing challenges in meeting the health care needs of a growing population. It was not until 1954 that the Kingdom of Saudi Arabia created the Ministry of Health, which was followed by the construction of public hospitals and health care centers. As a result, the development of nursing and nurse training began under the Ministry of Health (MoH) in collaboration with the World Health Organization (WHO).The first formal training for nurses was established at a health institute in Riyadh, known as a Health Institute Program, and was specifically for the training of male nurses only (Tumulty, 2001). The first fifteen male nursing students had only elementary school preparation and completed one year of the nursing training program (Tumulty, 2001). The limited education and training provided by this early program was inadequate in producing qualified nurses. As nursing education in the Kingdom developed, the Ministry mandated that nursing training programs be extended to three years and opened more training programs to increase the number of nurses in the country. The first full Bachelor of Science in Nursing (BSN) program was introduced in 1976 and was followed by the Master of Science in nursing program in 1987. There are currently over fifteen schools offering BSN Programs in the country.

Nursing Workforce

Like many Western and European countries, Saudi Arabia faces a chronic nursing shortage of nurses. The nursing workforce in Saudi Arabia relies heavily on foreign trained nurses who are recruited globally. They account for 70.9% of the total nursing workforce with Saudis comprising only 29.1% (Aboul-Enein 2002; Almali et. al., 2011; Luna 1998; Tumulty 2001). The majority of patients and families speak only Arabic, while most of the health care providers including nurses communicate in English. For many nurses practicing in Saudi Arabia English is not their first language and neither are they competent in Arabic (Simpson et al., 2006). Though the majority of these expatriate nurses are from India and the Philippines, the Kingdom also recruits from North America, the United Kingdom, Australia, South Africa, Malaysia and other Middle East countries (Aboul-Enein 2002; Luna, 1998).

Nursing compared to other professions is a less desirable career and not the career of choice for many in Saudi Arabia. There are many contributing factors to this such as a difficult and risky working environment, limited career opportunities, family commitments and the widespread perception of the role of a nurse as a submissive female hospital worker with a poor public image (Almutairi & McCarthy, 2012; Mansour & Saleh, 2014).The rapid development of the health care system in Saudi Arabia and the changes in the health care needs of the population as a result of the increasing affluent lifestyles demand an increase in the proportion of indigenous nurses who can deliver culturally appropriate high quality patient care and share the Arabic language of their patients (Aldossary & Barriball, 2008). The fact that only 30% of the nursing workforce are nationals meaning that the health care system relies heavily on expatriates who are expected to carry their daily duties and additionally to provide preceptorship to local nurses. If there were enough local nurses that could support the development of undergraduates and new graduates, then the impact of multinational nursing workforces providing preceptorship programs to local undergraduate nursing interns would be minimized.

Undergraduate Nursing Internship at KFMC

King Fahad Medical City (KFMC) is considered one of the largest health care facilities in the Gulf region and consists of four hospitals (Main, Maternity, Pediatric, and Rehabilitation hospitals) making up a total of 1,095 beds. In addition to the hospitals there are primary care clinics, Faculty of Medicine Medical Centers that includes Prince Salman Heart Center, Neuroscience Center, Prince Sultan Hematology and Oncology Center and the Specialized Diabetes and Endocrine Center. Contributing to the Kingdom's goal of Saudization of the workforce, King Fahad Medical City in collaboration with King Saud University (KSU) which is one of the leading universities in the Gulf region and is highly respected in Arab and Muslim countries developed a very comprehensive nursing internship program (KSU, 2013).

The undergraduate nursing internship program at KFMC is designed to provide the novice Saudi nurse with the knowledge base and skill set needed to transition to competence in clinical nursing practice. While providing the needed skills to meet the organization's goals and mission, the program provides nurses with the leadership skills to work collaboratively within a multidisciplinary team. The program bridges the gap between undergraduate education and "real-life" professional nursing practice, with the desired outcome being nurses delivering state-of -- the art care. During the internship period, the undergraduate nursing interns are provided with a pathway to clinical comfort, confidence, and competency, leading to active participation as a member of a clinical team. Through varied clinical opportunities in general and specialized areas they gain insight into the diversity of patient care needs and the chance to focus on a particular area in nursing leading to future specialization.

The clinical instructor, preceptor, head nurse, and the nurse Educator of the Internship continually assess the undergraduate nursing interns (KFMC Nursing Internship Program, 2013). The KFMC internship program is designed so that the interns will have opportunity to rotate through the hospital and is divided into four phases. The first phase of the program consists of 1) a two -week new internship general orientation (NIGO) followed by 2) phase II consisting of a 20-week medical and surgical rotation followed by 3) another 20-week rotation in a specialty clinical area such as critical care or emergency department and 4) finally a 10-week elective rotation where the interns selects their preferred clinical area.

Purpose of the Study

The purpose of this study is to test Benner's (1982) theory "From Novice to Expert" in relation to the perceived impact of a preceptorship (independent variable) on the competency levels (dependent variable) of undergraduate nursing interns at King Fahad Medical City (KFMC). The term preceptorship is described as a model of teaching in which an undergraduate nurse trainee or newly graduated nurse is assigned to train under the direction of a preceptor (Billings & Halstead, 2005).Clinical competence is multidimensional in complexity and is defined as the capacity in which a graduate nurse is able to provide safe, competent nursing care utilizing the core components of the nursing process within the scope of practice as defined by the state's Board of Nursing (Benner, 1984; Jerlock, Falk, & Severinsson, 2003). For the purpose of the proposed study, undergraduate nurse intern will be defined as a new nurse who completed a 12-month program of preparatory courses followed by four full years of an undergraduate nursing degree program and is undertaking a 12-month mandatory internship program in an acute tertiary hospital setting (but is yet to be licensed as a registered nurse).

Significance of the Study

Few studies have examined the factors that prevent the multinational nursing workforce in Saudi Arabia from being effective preceptors to local undergraduate nursing interns. This study may be able to identify the relationship of the perceived level of clinical competence of undergraduate Bachelor prepared nurses to Benner's Novice to Expert Theory (1982), and identify the factors that impact the multinational nursing workforce in providing effective preceptoring to local undergraduate nursing interns. Since nursing preceptors are instrumental in evaluating and adapting programs that will meet the needs of new nurse graduates, it is necessary to the perceptions of nursing interns about their clinical competence. The findings of this research will help nursing administration and nursing faculty develop and upgrade preceptorship to an effective nursing model that will result in clinically competent local nurses.

Nature of the Project

This project studies the ability to measure the effectiveness of leadership through nursing leadership.

Research Questions and Hypotheses

The research question guiding the proposed study is: What is the relationship of the perceived level of clinical competence of undergraduate Bachelor prepared nurses to Benner's Novice to Expert theory (1982)?

H0: Preceptorship provided by multinational nursing workforce will not influence undergraduate nursing interns' perceptions of clinical competence

H1: Preceptorship provided by multinational nursing workforce will influence undergraduate nursing interns' perceptions of clinical competence

Theoretical Framework

The theory used for this project is Benner's (1982) theory "From Novice to Expert" in relation to the perceived impact of nursing preceptorship and its effects on individual and organizational effectiveness and efficiency.

Definition of Terms

Undergraduate nurse interns: For the purposes of this study, undergraduate nurse interns will be defined as new nurses who are yet to be licensed as registered nurses, have completed a 12-month preparatory course followed by four full years of an undergraduate nursing degree program and is undertaking a 12-month mandatory internship program in acute tertiary hospital setting.

Novices: Persons who have had no experience of the situations in which they are expected to perform (Benner, 1984).

Advanced beginners: Those who demonstrate marginally acceptable performance and relate with recurring meaningful situational components (Benner, 1984).

Preceptee: A newly graduated RN or undergraduate nurse trainee supervised by an experienced staff RN and giving direct care to an assigned group of patients on the unit/floor of hire (Barrett & Myrick, 1998).

Preceptors: Staff RNs, who teach, inspire, role model, counsel, and support the academic growth and socialization of the new RN for a specified amount of time into his/her new position and workplace (Billings & Halstead, 2005).

Preceptorship: Defined as a process of nursing education where a partnership of teaching-learning is formed between an experienced nurse (preceptor) and newly graduated nurse or undergraduate nurse intern (Preceptee/Novice) in a patient care environment (Aaron, 2011; Bott & Lawlor, 2011; Omansky, 2010).

Clinical Competence: Clinical competence is multidimensional in complexity and is defined as the capacity in which a nurse or student nurse is able to provide safe competent nursing care utilizing the core components of the nursing process within the scope of practice as defined by the state's board of nursing (Benner, 1984; Jerlock, Falk, & Severinsson, 2003).

Scope and Limitations

The underlying assumption of the proposed study is that the competency levels of undergraduate nursing interns who receive effective and structured preceptorship will improve. The limitation of this study will be generalisability. In Saudi Arabia, a nurse's education takes nearly 6 years to complete which includes a 12-month internship. It is unknown if this additional year will favor the KSAs undergraduate nursing interns and influence the outcome of this study. In addition male and females are trained separately and this degree of difference in preparation by gender hinders the integration of the graduates into a multicultural hospital settings and functioning clinical teams. Not working in real world situations where men and women do work together tends to serve against the essence of learning and education.

Chapter Summary

This chapter introduces the background on the potential challenges within the setting of Saudi Arabia that undergraduate nurses face and how their reliance on clinical knowledge gained during schooling influences their ability to provide safe nursing care. It highlights how the success of these nurses depends on the support they receive from their preceptor and its influence on their competency levels. With growing concerns about the nursing shortage and the increasing aging population, retaining new graduate nurses in the workforce is essential to the nursing professions' ability to provide high quality patient care. The purpose of this research is to examine the impact of preceptorship on undergraduate nurse interns' perceived competency developed during the transition experience using Benner's (1982) theory "From Novice to Expert." The study will examine newly graduated nurses who are enrolled in a full 12-month nursing internship program in an acute tertiary, university affiliated hospital. The undergraduate nursing interns perceived 'competency levels' will be assessed using Benner's competencies within an instrument that is validated for evaluating the impact of nursing preceptors on the development of clinical competency. Benner's theoretical framework of the novice-to-expert practitioner development will provide the framework for the study. The research will focus on the perceived factors that provide effective preceptorship to undergraduate nursing interns. The findings of this study will help nursing administration and nursing faculty to develop and implement effective undergraduate nursing preceptorship program.

CHAPTER 2: Literature Review

Introduction

This chapter will present a review of literature of published work in the area of preceptorship and new nursing graduate competency levels. Though the knowledge gained from classrooms, simulation labs and experiences from the laboratory setting contribute significantly the development of knowledge and skills among nursing students, clinical experience remains the cornerstone of the nursing profession (Altmann, 2006). Clinical experiences not only contribute to the development of the knowledge and the skills required for nurses to function as professionals, but also the values essential to socialize them into the nursing profession (Altmann, 2006). Nursing education should prepare nursing students academically and clinically to ensure a smooth transition from being students to a practicing nurse (Myrick & Yonge, 2005). Preceptorship is one of the most effective models in clinical teaching that has the attention of many academics (Robinson & Griffiths, 2009; Altmann, 2006). The reviewed literature will discuss different aspects of preceptorship from the perspective of the nursing profession. Different sources such as peer reviewed articles, scholarly books and published reports will be used. The origin of preceptorship, the advantages and disadvantages of preceptorship, and the effectiveness of preceptorship programs as demonstrated in recent literature will be discussed.

Theoretical Framework

The theoretical framework for the study of the Saudi nursing interns' perceptions of clinical competence upon completion of preceptorship experience will be based on Benner's (1982) theory. Benner adopted the Dreyfus model of skill acquisition to explain the developmental stages of nursing practice and skill acquisition. The model describes the way in which students expand their skills in certain professions and recommended different strategies that support nurses as they move from one stage to another. There are specific characteristics and skill levels within each stage that the nurses attain throughout their nursing career (Benner, 1984).

Benner's research focused on nursing practices to discover knowledge within the practice that will broaden its base. Benner described skilled practice as implementing in actual clinical situations within the context of nursing practice integrating practice and theory together (as cited in Tomey & Alligood, 2006). Benner used Dreyfus's model in her theory with the five levels of skill achievement to fit nursing: novice, advanced beginner competent, proficient, and expert (citation).According to Benner (1984), experience is ongoing process in which changes nurses' predetermined ideas and not just passage of time. The five stages of the Dreyfus model skill acquisition to nursing are widely acknowledged as a guide to explain the ways in which nurses develop competence in the profession.

Novices are individuals with no prior experiences of the situations in which they are expected to perform. Their approach and behavior is limited and inflexible. The way they deal with clinical situations are not based on patient needs and response, rather they are self-oriented (Toomey & Alligood, 2006). Advanced beginners demonstrate marginally acceptable performance and often relate with recurring meaningful situational components. Advanced beginners while eager to learn, can be easily overwhelmed with multiple responsibilities (Kingsworth-Hinrichs, 2009).

According to Benner (1984), competency is being reliable, predictable, and timely. Nurses are considered competent if they stay in a same job for two to three years and are able to develop long-range goals for patient care (p.233). Gained experiences and knowledge enables these nurses to move from advanced beginner to competent with a sense of mastery. Competent nurses are no longer relying on abstract concepts, but commit fully to the situation. They feel confident and are able to cope and mange a different clinical situations. Unlike advanced beginners, these nurses are more organized, but still need more time for decision making in complex patient situations (Benner, 2001).

The fourth stage of Benner's theory is proficient; at this stage nurses view and understand situations as whole parts. The fifth and the final stage of Benner's theory is expert. These nurses are no longer relying on principles, rules, or guidelines to connect situations and determine actions. They have intuitive grasp of each clinical situations and their performances are now fluid, flexible, and highly proficient (Benner, 1984).

This adaptation of Benner's stages between novice and advanced beginner are more reflective of the new graduate nurse. The supports Benner (2001) described for the novice and advanced beginner nurses reflects the supports needed by the new graduate nurse. These supports include an orientation by a preceptor who can help the new nurse, resources such as support forms, experienced nurses to provide safe patient care, assistance with priority setting, and time management and support from their nursing programs. Benner's model can assist preceptors to address the skill set of nursing interns. The evaluation tools that are based on this model could illustrate nursing interns' progress during their internship program.

The Historical Development of Preceptorship in Nursing

The concept of preceptorship can be traced back during Florence Nightingale's treatise in 1882 which highlighted the need for newly graduate nurses to obtain clinical and skills education through ongoing interaction with senior nurses who were trained to teach, mentor and guide inexperienced nurses (Robinson & Griffiths, 2009). Nurses were receiving hospital-based training up until the end of the 20th century. In the U.S.A. this tradition changed in the 1960s; this was due to the move from nursing education based in hospitals to higher education institutions and to licensure . Many countries including New Zealand (1973), Australia (1984-1993), the United Kingdom (1989), and Canada (2000) followed same trend (Ohriling & Hallberg 2001, Udlis, 2008; Usher et al., 1999).

The utilization of preceptorship programs varies by country and nursing's developmental sophistication. In North America preceptors are unit-based staff nurses who in addition to their regular duties provide one-to-one teaching of new employees or nursing students (Shamian & Inhaber, 1985). In Australia preceptorship is considered an integral component of new nursing programs that consists of a three-year nursing degree program followed by a one-year transitional period (Hayman, Happell, Charleston & Ryan, 2007). In the United Kingdom though preceptorship is not mandatory; it is viewed as essential in ensuring a smooth transition from student nurse to practicing nurse. "Fitness for Practice" stipulates that all newly qualified nurses and midwives receive adequate support for induction and preceptorship when they commence their employment (Department of Health, 2008).

As nursing education moved from the hospital to higher education institutions several challenges were created. In academic settings, typically one clinical instructor supervises eight nursing students; this makes individual student clinical teaching by faculty difficult. As a result of this faculty to student ratio, many newly graduate nurses complained of lack of preparation and clinical exposure during their training (Udlis, 2008). When these novice nurses with no prior or limited practical training in hospitals entered the workforce they experienced the so-called "reality shock." In their first of year of practice, they struggled to cope with the demands of their daily tasks (Myrick & Yonge, 2005; Suzuki, et al., 2006; Udlis, 2008). It was for this reason that the concept of preceptorship was introduced and became prevalent in the nursing profession as a model to guide and support future nurses (Altmann, 2006; Myrick & Yonge, 2005).

Positive Aspects of Preceptorship

The reviewed literature identified various models and methods of preceptorship programs. Positive and negative aspects associated with preceptorship programs were reported (Liu, Lei, Mingxia & Haobin, 2010). Among the identified positive aspects were: the majority of newly graduate nurses wanted preceptorship; the programs provided the skills and the knowledge necessary to move into their new roles and the view of preceptors were generally positive; they regarded the preceptorship program as key for their successful transition from student to a professional nurse (Dilbert & Goldenberg 1995; Farrell & Chakrabarti, 2001; Hyrkas & Shoemaker, 2007; Pfeil, 1999). The preceptors reported satisfaction in helping the new nurses' transition into their new role and affording them the opportunity to further their knowledge and competency in teaching (Giriji, Raghda & Shreedevi, 2014).

Being a preceptor also has added benefits such as stimulating one's commitment and motivation to the nursing vocation (Hyrkas & Shoemaker, 2007). Working alongside the interns in developing their clinical skills also helped preceptors maintain their own clinical skills and competencies and reflected on their leadership role (Burns, Beauchesne, Ryan-Kraus, & Sawin, 2006). The interaction and sharing that occurs between the preceptor-preceptee provided opportunities for reflection and a venue for intellectual stimulation (Lynn & Redman, 2005).Preceptors developed a sense of accomplishment and achievement by participating in the development of future nursing leaders and administrators (Robinson & Griffith, 2009). The fact that preceptorship programs helped raise the standards of the nursing profession, preceptors found their participation in precepting interns rewarding (Elisabeth, Christine & Ewa, 2009).One of the benefits of preceptorship programs for the institution is that those who have a positive preceptorship experience may seek employment in that same institution (Young & Paterson, 2009). Preceptorship programs may reduce the duration of orientation and competency development for the newly graduate nurses thus reducing cost (Robinson & Griffith, 2009). The development of more competent and informed nurses will ultimately contribute to the provision of high quality patient care (Robinson & Griffith, 2009; Young & Paterson, 2007).

The preceptorship model provides several advantages not only to the students, interns but also to the preceptor and the healthcare institution. (Omansky, 2010).Nursing interns reported feeling nurtured through preceptorship programs (Wieland, Altmiller, Dorr, & Wolf, 2007). Preceptorship programs provide opportunities for developing socialization; competence and professionalism which will help preceptee reduce "reality shock" in their first year of experience (Wieland, Altmiller, Dorr, & Wolf, 2007). The level of confidence and sense of empowerment of interns may also be increased as a result of preceptorship (Gleeson, 2008).The positive relationship of preceptors-preceptee and the guidance of an experienced and seasoned nursing professional imparts independence and empowerment (Delaney et al., 2007; Gleeson, 2008). Preceptorships help interns to become professionally mature and become aware of the way in which the nursing profession functions (Kim, 2007). Interns need to be supported emotionally as they are exposed to emotions and frustrations that are associated with the nursing profession on a daily basis (Billay & Myrick, 2010).Nursing interns need to be oriented to the bureaucratic conflicts attached to their vocation (Mohide & Matthew-Maich, 2007).

Negative Aspects of Preceptorship

The reported negative aspects that are associated with preceptorship programs include that they are not always available; there were inconsistencies allocating a preceptor and actually receiving preceptorship (Hancook, 2002). The relationship between preceptor-preceptee can sometimes be problematic which can lead to a frustration to both. This is more common when the preceptor is assigned to the preceptee randomly (Pfeil, 1999). Lack of formal training for the preceptors into their new role was identified as negative aspect of the role (Dibert and Goldenberg 1995; Fox et al., 2006; Hyrkas and Shoemaker, 2007; Lee 1997; Pfeil 1999). Lack of time for both preceptor and preceptee to work together was identified as a key constraint in delivering effective preceptorship (Huybrecht, Loeckx, Quaeyhaegens, De Tobel & Mistiaen, 2011). Giriji et al., 2014 conducted a descriptive quantitative study to examine preceptors' perceptions of the clinical teaching-learning process of final year undergraduate nursing students and found that 70% of surveyed preceptors reported work load and lack of time as hindering factors.

The relationship between preceptor and preceptee does not always result to be positive and may create hostility that will hinder the learning experience of the preceptee (Delaney et al., 2007; Gleeson, 2008). Lack of preparation of the preceptors about their roles is another problem (Myall, Levett-Jones, & Lathlean, 2008). Preceptor's inability to find sufficient time to build a relationship and become effective is a very common constraint among preceptorship programs (Robinson & Griffith, 2009). To be a preceptor involves added responsibilities and requires time and dedication (Hautala, Saylor, & O'Leary-Kelly, 2007). There are reported cases where preceptors failed their role of supporting and creating a positive learning environment for the preceptee creating additional stress and frustration among interns and exhaustion and unpleasant experiences for preceptors (Young & Paterson, 2010; Hautala, Saylor, & O'Leary-Kelly, 2007). Much of the reviewed literature highlighted the factors that can facilitate and ensure the success of the preceptorship program. Leadership and organizational commitment to ensure proper workload planning that gives the preceptors ample time to provide preceptorship, developing and attending programs and training; ensuring the appointment of a senior nurse in each clinical area to assure that each new nurse is not only allocated a preceptor, but receives one; assuring preceptors are prepared for their role, and able to support students in their skills development; addressing the difficulties that may arise in the relationship between preceptors-preceptee (Hickey, 2009; Smedley & Penny, 2009; Wilson et al., 2009).

Preceptee-Preceptor Relationships

Newly graduated nurses who are paired with preceptors with high levels of leadership skills reported being engaged and more satisfied with their relationship (Giallonardo et al., 2010; Morton et al., 2011; Maxwell et al., 2011). There are certain preceptors' behaviours that can either facilitate or hinder the nursing students' experiences. Being flexible and respectful are identified as facilitating behaviours, whereas role confusion, constraints, lack of opportunity to question and lack of safety being identified as hindering behaviours (Wilson et al., 2009). Precptee's healthy relationship with their preceptors can lead to a greater growth in their confidence, competence and adaptation in their roles as nurses (Giriji, Raghda & Shreedevi, 2014). Though both preceptors and preceptee were satisfied with their overall relationship during their interactions, the preceptee viewed the relationship more positively (Currie & Watts 2012). Study conducted by Zilembo & Monterosso, (2008) highlighted the importance of preceptor-preceptee relationships. The preceptor's leadership skills and ability to provide an environment that is conducive to learning is a cornerstone for preceptee success (Zilembo & Monterosso, 2008). Zilembo & Monterosso, (2008) proposed a preceptor-preceptee relationship model to explore the interaction between preceptors and nursing students that can also be applied to a newly graduated nurses and interns.

Cost effectiveness of Preceptorship Programs

There are mixed reviews in regards to the cost benefit ratio of preceptorship programs (Hickey, 2009; Wilson et al., 2009; DeWolfe et al., 2010; Giallonardo et al., 2010).The reviewed articles by Currie and Watts 2012 did not show any benefit of preceptorship program on cost or clinical outcome in the UK. They noted that the current studies are mostly descriptive and based on self-reports. Studies done in the UK showed little evidence that preceptorship programs improved retention in new graduate nurses (Sharon, Robert, Malcolm, Ann, Paul, & Andrew, (2010). In contrast studies done in USA, preceptorship programs were associated with improved recruitment and retention of new graduate nurses as well as preceptors (DeWoolfeet al., 2008; Sherrod et al., 2008; Aoron, 2011).

Competency

Several studies have demonstrated the effect of preceptorship on competencies (Pfeil 1999). Kimberly, 2007 conducted a descriptive correlational study to explore the perceptions of senior nursing students about their clinical preceptorship program and found that the preceptorship programs increased the overall perceived competence of nursing students. The importance of preceptor-preceptee interactions was demonstrated by Kimberly,( 2007). Student nurses who reported positive interactions with their preceptors had the perception of increased competence in nursing evaluation skills. There is consensus among reviewed articles that traditional nursing education does not adequately prepare nursing students to practice in the rapidly changing health care environment (Mabeen & Griffiths 2008).

Several studies, Bradley's 1998; Gerrish's2000; Farrell & Chakrabarti's2001; Pfeil's1999, reported preceptorship as key contributing factor to their smooth transition from student to registered nurse. Confidence building, providing emotional support and empowering decision making are a few attributes of the preceptorship role that was emphasised in a study conducted by Farrell and Chakrabarti's (2001).It is worth noting that the writer did not find any studies that examined the impact of preceptorship on improving the quality of patient care. Robinson 2008 argued that it would be difficult to isolate the effects of a particular preceptor on providing better care since nursing students can receive clinical support from other sources than preceptorship. There were several studies demonstrating that increased competency levels were reported by preceptee during the preceptorship period (Pfeil, 1999).

Differences Between Preceptorship and Mentorship

The term preceptorship and mentorship are often used interchangeably but to remove the theoretical ambiguity, nursing tries to distinguish between the two terms (Turner, 2007). Preceptorship is described as a teaching model that has established periods of time and is specific to health care settings where an experienced nurse or other health care providers are designated as preceptor and are paired with nursing students in their final year of their educational program (Altmann, 2006; Young & Paterson, 2007).Most of the literature indicated that a preceptorship model provides the best opportunity for a one-to-one relationship between preceptor and preceptee (Flynn & Stack, 2006; Young & Paterson, 2007). Unlike mentorship, preceptorship provides support to the preceptee and new graduates during their transition period into the clinical setting (Morton-Cooper & Palmer, 2005).

In the U.S.A. And Canada preceptorship programs are utilized for nurses in the pre-licensure phase, whereas the UK and most European countries use preceptorship programs for nurses post licensure (UKCC 2001). In the UK, preceptorship is defined as the time when a newly qualified staff nurse is assigned to a qualified nurse who works in a same clinical area, who will provide support, guidance and advice (UKCC 2001). Most of the reviewed literature often used the term "preceptorship" in studies that focused exclusively on support provided to student nurses during their studies. Researchers in North America used the term mentorship and preceptorship interchangeably for support provided to both student nurses and practicing nurses (DeWoolfeet al., 2008; Sherrod et al., 2008; Aoron, 2011). In Scandinavia, studies mainly focused on preceptorship in the context of nursing student trainees (Hayman-White et al., 2007).

Preparation of Preceptors

The success of the preceptorship experience mainly depends on how adequately the preceptors are prepared so they can maximize preceptee clinical experiences (Altman, 2006). Despite the introduction and the implementation of preceptor preparation courses internationally, many preceptors do not receive adequate preparation for their role (Phillips et al., 1996, Allen & Simpson, 2000; McCarthy, 2006). The requirements for nurses to become preceptors vary internationally. In the United States (U.S.) and Canada, nurses who wish to be preceptors are required to complete a minimum of one year post-registration nursing experience by some hospitals, but the majority require 2 years (Altmann, 2006).In the United Kingdom (UK), nurses are required to complete 1 year post registration nursing experience, an average of five study days and theoretical assessment and obtain a recognized teaching qualification (Mallik & Aylott, 2005). In Australia, preceptors are required to have 5 years post-registration nursing experience, a baccalaureate degree in nursing and completion of 2-day workshop on clinical teaching and assessment (Mallik & Aylott, 2005).

Preceptorship programs do not always provide clear information about the role and responsibilities of preceptors (Byrd et al. 1997, Allen & Simpson 2000, Chow & Suen 2001). Zilembo and Monterosso, 2008 suggested ongoing support and training for preceptors and recommended this training to be mandated for all registered nurses. The reviewed articles revealed that there was no minimum of preparatory training required for the preceptors and that in some cases there was no training at all (Kemper, 2007). Lack of teaching experiences necessary to function effectively as a preceptor is reported among Canadian preceptors and many preceptors reported having to learn on the job (LeGriss & Cote, 1997).

Clinical Environment

Facilitating health and healing by meeting the preventative, curative, and palliative health needs of the population is the primary function of health care settings (Monique and Harris 2012). To achieve this, health care sectors need adequately prepared nursing workforces that will provide competent patient care. It is very important to provide a clinical environment that will allow undergraduate nursing interns to gain practical, real-life experience that will integrate their knowledge while developing the clinical skills needed for successful professional practice. Education Institution Environment: According to Monique and Harris (2012) the single most important resource in the development of competent, capable and caring nurses are adequate clinical learning environments.

Supervising Faculty: Yonge, Ferguson, Myrick & Haase (2011) identified the need for faculty involvement in the preceptorship experience. Four supervisory faculty competencies necessary for preceptorship experiences were identified: awareness of student's knowledge, skill, preferred learning style, and expectations. Given that many faculties do not receive a formal educational preparation of "how" to teach students in a preceptored experience this lack of training would pose a barrier in the delivery of an effective preceptorship program.

Preceptor Role: According Luhanga, Billay, Grund, Myrick & Yonge (2012) the close relationship between a student and preceptor is crucial in ensuring students' smooth transition to safe and competent practice. They also identified multiple factors such as multiple preceptors, higher preceptor-student ratios, workplace and workforce stresses and inconsistent preparation that can hinder the preceptor's ability to facilitate this close relationship (Luhanga et al.; 2012).

Preceptors: There is little attention given to the experience of preceptoring for those registered nurses who volunteer to become preceptors compared to those who are assigned.

Nursing Interns: The experiences of students during preceptorship is an important aspect to consider when evaluating the over preceptorship program.

Summary

There are many challenges and barriers in the provision of professional development for nurses. Traditional nursing education alone cannot effectively meet these challenges or the ever increasing demands due to the expansion of health care (United Kingdom Central Council (UKCC) 1992b). If a higher standard of care is to be attained, new staff nurses need to be supported by education and training (Ward & Wood, 2000). These findings were supported by Younge et al., (2002) who described the transition from being a student nurse to becoming staff nurse more stressful compared to other transitions during the academic period. Discussing and clarifying students' roles during the transition period will enable them to function more effectively in initiating nursing tasks (Kimberly, 2007).

CHAPTER 3: METHODS

Introduction

A non-experimental quantitative, descriptive research design will be utilized to test Benner's (1982) theory "From Novice to Expert" in relation to the perceived impact of preceptorship on the competency levels of undergraduate nursing interns at King Fahad Medical City (KFMC) in Riyadh, Saudi Arabia. According to Creswell (2012) the researchers' underlying assumptions and the nature of the subject or the phenomenon to be studied will determine what research methodology to be employed. The identified research problems and the questions that will be asked will help the researcher determine which research methodology to use. The author identified three important factors such as matching the researchers' approach to the research problem. Considering how the approach and the research report will fit your target audience and finally the need to factor your own personal experience of how your approach the research problem (Creswell, 2012). The researcher is interested in assessing a research problem using information that is expressed entirely in number, percentages, frequency and numbers that can be worked easily. Quantitative methods will allow the researcher to answer questions such as "how many" or how much?' Or How often?' This data may also be used to compare and contextualize with other studies.

Design

The purpose of this study is to test Benner's (1982) theory From Novice to Expert in relation to the perceived impact of a preceptorship on the competency levels of undergraduate nursing interns at King Fahad Medical City (KFMC). A cross-sectional descriptive / correlational research design will be used for this study. A probability sampling technique will be used to recruit undergraduate nursing interns from King Fahad Medical City, Saudi Arabia who will be asked to complete the tool. This sampling technique will enable the researcher to make statistical inferences (i.e., generalizations) from the sample being studied to the population of interest and assess how confident the researcher is about such inferences. The reason the researcher decided to use the probability sampling technique is to help minimize sampling bias (Creswell, 2011). These interns have completed a five-year full time nursing training educational program including a 12-month foundation year followed by 12-month structured nursing internship program. It is the 12-month internship program that is the focus of this study. A survey questionnaire will be administrated to undergraduate nursing interns in the clinical setting of KFMC who are being precepted by employed multinational nurses. The data gathered from the questionnaires will enable the undergraduate nursing interns to identify and rank, according to their importance, those factors that they perceive to contribute to their competency levels and their perception of the effectiveness of their preceptorship program. For the above mentioned reasons, the researcher decided to use a quantitative, descriptive research methodology and adopted a validated and reliable survey instruments to test Benner's (1982) theory "From Novice to Expert" in relation to the impact of preceptorship on the performance / competency levels of undergraduate nursing interns at King Fahad Medical City (KFMC).

Setting

The sample for the research will be recruited from KFMC which is a tertiary care center which supports health services research. It consists of a general hospital, maternity hospital, pediatric hospital, rehabilitation center, and primary care clinics with a total of 1,160 beds. The current nursing workforce at KFMC is approximately 3500, which 500 of them are trained preceptors that precept from 100 to 130 nursing interns in any given time.

Sample

The participants of this study will include undergraduate nursing interns from university affiliated, acute tertiary hospital in central Riyadh. The site was selected based on the need for a diversity of nursing workforce and participants. Creation a sample that is representative of the population is critical component of probability sampling. The more representative the sample is of the population, the more confident the researcher can be when making statistical inferences (i.e., generalizations) from the sample to the population of interest. Sample size has a significant impact on the quality and the outcome of research. Sample size that is too small or too large can potentially lead to incorrect findings (Creswell, 2011). Using a G. power data analysis, a sample size calculation to determine how large the researcher's sample size to be was performed. Inputting following parameters (effect size of 0.5, P value of 0.05 and power of 0.95) yielded a sample size of 54. Undergraduate nursing interns that are completing their internship program, and are about to be employed as staffs nurse will be selected. The participants will be recruited through their programs; designated clinical instructors and program coordinator will distribute the study information to their students. Participants will also be recruited through messages posted to KFMC post master and electronic mailing list.

Survey Instrument

Many researchers use surveys to gather data from different sources. Well written surveys allow the researchers to collect consist and accurate data that produces results that answers specific research question (Cindy, Alison, Michael and James, 2002). The researcher developed (used)a paper and pencil instrument that is comprised of three parts: demographic questions that will describe the sample; a skills competency section with 20 of questions; and a section that asks the respondent to evaluate their perceived competency comprised of 40 questions.

The sections on skills and competency, the researcher will use a Clinical Competency Questionnaire and self-assessment instruments tools tested with Cronbach's alpha, inter-item correlation, and item-total correlation. The Cronbach's alpha for the entire CCQ was .98. Content and known-groups validity was also confirmed Kimberly, (2007. The undergraduate nursing interns' preceptorship questionnaires will be used to collect data from undergraduate nursing interns. The questionnaires will be divided into two categories: the first category consist 20 opinion statements that evaluate the interns' perception of the effectiveness and the relationship with their preceptor, whereas the second category consist 40 competence-oriented statements that indicate the interns perceptions about their ability to perform nursing tasks in clinical settings. This instrument is a self-administered 61-item questionnaire that uses a five-point Likert scale (Shwu & Ching, 2014; Kimberly, 2007).

A Likert scale is one of the most popular (and reliable) ways to measure someone's attitudes or behaviors. Likert scale uses answer choices that range from one extreme to another (for example, not at all likely to extremely likely). It measures a level of agreement or disagreement with the statement you are asking from the respondent's own opinion and allows you to uncover degrees of opinion (Kellar & Kelvin 2013).

Instrument Reliability

The reliability of the Clinical Competency Questionnaire and self-assessment instruments tools were tested with Cronbach's alpha, inter-item correlation, and item-total correlation. Scale validity was assessed using content validity with expert panel reviews, concurrent validity for criterion-related validity, and factor analysis for construct validity. According to Kellar & Kelvin 2013, factor analysis is most often used as part of instrument development process by nursing and other health care professionals.

Data Collection and Management

Participants of this study will be recruited from KFMC through the nursing education department. The first phase will be meeting with the nursing department director to describe the purpose and aims for the research. A memorandum will be sent from the nursing department director to nurses. The purposes of this memorandum are to explain the purpose of this study and confirm management's approval to conduct this study. The investigator will go to each nursing unit where nursing interns are assigned at different time intervals that are mutually convenient for the interns and researcher. Research questionnaires will be distributed using a large envelope with an index card attached to the questionnaires asking them to provide name, address and email address if they are interested in the findings. The index cards will be collected in a separate envelope. Anonymity of participants will be assured by removing all identifying details such as names and any other information that can help to identify participants for example: university attended. Geographical information, combined with the type of institution attended can give away identity quite quickly. The researcher will take as many precautions as possible to protect participants' anonymity.

Research Question #1:What is the relationship of the perceived level of clinical competence of undergraduate Bachelor prepared nurses to Benner's Novice to Expert Theory (1982).

To address Questions # 1, descriptive statistics will be used to describe the undergraduate Bachelor prepared nurses' perceptions of their level of clinical competence. The descriptive statistics will include measures of central tendency (mean, median, and mode) and dispersion (range, variance, and standard deviation) for continuous variables and frequency distributions for the categorical variables.

Analysis of frequency (chi-square test) will be used to determine the relationship between the categorical variables. This compares the expected frequencies with the observed frequencies. If these differences are big enough to generate a chi-square value that exceeds the critical value, the null hypothesis will be rejected (Kellar & Kelvin, 2013). If the parametric assumptions are met, Pearson correlation coefficient will be utilized to determine the relationship between variables measured on ratio or interval scales; otherwise, the Spearman correlation coefficient will be used. Higher order effects for the continuous factors and interaction effects among factors will be considered. There are several ways to measure correlation to express the relationship between two or more variables. The standard Pearson correlation coefficient (r) measures the extent to which two variables are related. It quantifies the relationship between two variables (Kellar & Kelvin, 2013). In the predicting the outcome dimensions, step-type regression analysis will be used to obtain the optimal models. In addition, to determine the strength of the overall relationships between preceptorship and outcome dimensions, multiple regression analysis will be used. Multiple regression analysis allows one to assess the relationship between a dependent variable and a set of independent variables (Kellar & Kelvin, 2013).

Protection of the Rights of Human Subjects

All the potential ethical aspects that may arise from conducting a quantitative research study will be considered. Clearly, there is a substantial threat to privacy, power imbalance and ensuring the basic ethical principle for quantitative researchers (Creswell, 2012).Protecting the inherent worth, dignity and human rights of every individual is the underlying fundamental principles of all nursing practice. (American Nurses Association, 2001). All participants will be given full information regarding the purpose of the study and the implications of participation. Participants will be informed that they could choose to withdraw from the study at any time without consequences, and every effort will be made to maintain the confidentiality of the participant's identities through the data collection process.

Data will be e recorded without personal identifiers and all data and data derivatives will be stored, managed and disposed according to KFMC's IRB policies. In quantitative research design, researcher need to consider issues such as seeking permissions, safe guarding the anonymity of respondents, minimizing the site interruptions and informing the participants the purpose of the study (Creswell, 2012).The researcher will avoid alienating any specific groups and will give utmost care for those vulnerable groups in his study report. The researcher will avoid demeaning attitudes, biased assumptions and will be aware own personal bias towards specific topics and will be neutral to the topic under study. The researcher will avoid discriminating participants based on their ethnic groups, disability, sexual orientation, gender or age, and will present a report that uses a research language that is specific and sensitive to stereotyped labels. The researcher will acknowledge the participation of people in the study and will produce a report that is free of plagiarized and not influenced by personnel interest (Creswell, 2012).

Summary

The purpose of this chapter was to describe the research methods of this study, explain the sample selection, describe the procedure used in designing the instrument and collecting the data, and provide an explanation of the statistical procedures used to analyze the data. The remaining two chapters will address the findings and the implications of the study. The SPSS program (version 18.0) will be used for statistical analysis for the quantitative study. Descriptive (mean, frequency and standard deviation) and inferential analysis will be used in this study. A p values < 0.05 will be considered statistically significant. The final chapter will address the implication and the application of the results to practice. It will provide brief restatement of the problem, the main features of the methods used and the most important findings of the study. The researcher will indicate whether or not the hypothesis of the study was supported. Finally the researcher will make recommendations if a further research if necessary. The intended audiences for this study are nursing and hospital administrators, nursing faculties, policy makers and hospital-based nurse educators. These audiences have an obligation for nursing students and newly graduate nurses; they play an important role ensuring that these nurses receive adequate clinical exposure and environment that are conducive to learning. Faculties are equally important in providing the theoretical background that enables these nurses to integrate theory into practice. Determining how a multinational nursing workforce perceives the role of a precepting local undergraduate nursing interns are instrumental in evaluating and adapting a program that will meet the needs of these new nurse graduates. The findings of this research will help nursing administration and nursing faculty develop effective undergraduate nursing preceptorship model. The researcher is hoping that the findings of this research will help the development of effective undergraduate nursing preceptorship model.