Navigating Bachelor (generic) graduate nurses' views about a one-year internship program: A qualitative descriptive study related to role transition

Background: On completing the graduate study, nurses require to be posted for a one-year internship program (IP). In other words, it is a form of ‘transition or a change in a role.' As health care professionals, role transition is an inevitable, constant and dynamic process. The journey from student to a registered nurse is exciting as well as complex phenomena. The study was conducted to ‘explore the views of nurse internee, who have completed their one year internship period, about their experiences related to that important phase of transition. Methodology: A qualitative descriptive study with purposive and convenience sampling method was conducted. Data was collected through interviews and analyzed through a method proposed by Colorafi KJ & Evans B (2016). Results: Eight interviews were conducted. The main theme identified was “Internship as a professional endeavor”. Four subthemes as ambiguity in understanding objectives of the internship, administrative and communication problems, supportive environment and ethical practice environment were also identified. Conclusion: It was concluded that the internship period is a very essential component for achieving professional growth and skill acquisition, but it was also stressed that it can only be made effective, if objectives of internship be made clear to interns and communication and administrative problems solved on priority basis as to create an ethically sound and professionally favourable conditions for interns. Role Transition.


Introduction
One year internship programs (IP) for new graduate nurses are formalized to recognize a need for change among those graduates because they are to embark on a new journey of becoming a registered nurse. This phase of the internship is developmental as well as situational. Developmental is in the sense that it brings a sense of responsibility and situational as it provides a path for finding new dimensions. It is a transitional phase that is totally separated from being a student 1 .
To be a competent nurse, IP is a valuable tool to ease graduate nurses' (GN) transitional process from a student towards a registered nurse 2 . The journey through the days of the IP is an exciting venture as peer supportive behaviours is a source of availing doors of further career enhancement opportunities for GNs 3 . If GNs are supported and motivated during this phase it will create more learning opportunities and contribute them to attain professional autonomy and independence. The GN interns will be more confident and their self-esteem will increase, ultimately, leading them to be valued as productive team members 4 . IPs could be counted as resources to ease the transition period of new GNs. Those IPs must be reflective of long-term and viable solutions rather than temporary and immediate goals. The main aims of that IPs must be to ease the transition process of novice nurses from student to registered nurse practitioner 5 . Consequently, nursing shortage problems could be effectively tackled, if IPs are scheduled in a way that they increase not only retention of nurses, but also embody novice nurses with caring features that are a hallmark of nursing profession 6 .
New GNs' have different perspectives about the nature of arrangements for IPs, the role of preceptors during the orientation phase and their particular experiences about the IP. Most of the new GNs wished to continue their professional bonding with their preceptors once their orientation phase comes to end 7 . This research had explored new GNs' positive as well as negative aspects of their orientation phase 7 . Participants of this research identified differences and imbalances in orientation programs. They wished for more formal orientation programs for future nurses 7 . Experienced nurses lacked the knowledge and skills to support GNs during the IP. This gap in knowledge and skills was a hindrance because GNs found themselves in distress when they were not supported professionally by their seniors and mentors 8 .
The above discussion discovered that transition from student nurses to registered nurses is not a tranquil pathway. It has its own problems, issues, and solutions. Therefore, Role transition is another concept needing prompt attention. One way to get to the point is to listen to the interns' experiences about one-year IP. In Pakistan, Nursing education moved from diploma in General nursing to 04 years Bachelors of Nursing in Science (BSCN) degree program in 1997 at Aga Khan University (AKU-Karachi) 9 . Then, some public sector universities also started this unique nursing degree program under their domain of different nursing institutions. Higher Education Commission of Pakistan (HEC) with the collaboration of Pakistan Nursing Council (PNC) set a national curriculum for this degree program in 2006 for the first time in Pakistan. The curriculum was revised in 2011 10 .
The objectives of the program are in accordance with HEC's policy of: "1) prepare competently, committed, knowledgeable nurse clinicians (hospital and community settings); 2) produce nurses who will integrate evidencebased study into clinical practice for the care of individuals, families, and communities; 3) enable nurses to meet future challenges, including changes in technology; 4) educate nurses with appropriate knowledge, skills, and attitudes with clinical competency; 5) produce nurses who can provide preventive, curative and rehabilitative health care to populations in rural and urban settings; and 6) develop human resources such as teaching faculty for existing nursing programs 8 . At the end of 04-year regular studies, it is mandatory for each candidate to join the one-year IP before applying licensure from PNC to practice as a registered nurse. Upon efficacious registration, a nurse becomes able to play a role as a change agent in nursing practice and education in any healthcare setting in Pakistan 11&12 . According to PNC (2014), the IP is designed for only the BSN (04-years) degree program. It must be completed in a tertiary care hospital (in patient's departments). The main objectives of the internship program are to identify and prepare GNs for skill enhancement and made them able to provide holistic care to the clients under the close supervision of a senior registered nurse 13  Still, there are various questions that need consideration. One of those questions is to know about their IP experiences. "How much internship duration has helped them to prepare for the big challenge to be a registered nurse?" This is not documented yet, at least for our institute. There is a lot of internationally conducted literature available on the problem discussed above, but the phenomena failed to attract Pakistani nurse scholars to look at the prevailing issue around the corner. Only one study on the theme could be found. This study was conducted at a well-established private university teaching hospital of Karachi 17 . Going through the study, it became domineering that conducting this study was a necessary step because the evidence on the theme is lacking from this part of the world 17 . Secondly, aforementioned study was conducted in a deep-rooted private university teaching hospital of the country, whereas, this research was conducted in a less developed public sector, university attached teaching hospital of a rural area of Sindh, province 16 . Thirdly, the study population of the aforementioned study was three-years nursing diploma passed nurses. It meant that they were not entitled to go through a one-year IP. Whereas, this study was proposed to explore views and opinions of g GNs of 04-years degree program, who had also completed their one-year IP. Fourthly, three other public sector university in Sindh, and numerous private institution of Sindh and public and private sector universities and Institutions are offering BSN (04-years) degree program, but they have not yet initiated work on the topic under consideration 16 . Therefore, this study was conducted on much-felt need in the area. Aims and objectives of this study was to explore views and opinions of BSN (abbreviation) (generic) graduates about one-year internship program, to describe GNs experiences about one-year internship program, to explain the effects of a one-year internship program for their role transition process, to generate suggestions to improve current standings in the internship program.

Methodology
A descriptive qualitative research design was implemented. We selected a descriptive qualitative methodology because its purpose was 'to describe and understand unremarkable

Results
Notes were read multiple times by all researchers with the aim to develop better understanding of the written content. The themes and categories were identified during this process. In the end, all the themes and its categories were inductively constructed to present the results of data systematically. This method of qualitative data analysis was Main theme: Internship Program as a Professional Endeavor All the participants expressed that their one year IP was a professional endeavor as there were many gaps in applying and learning clinical skills during clinical rotation (during regular BSN studies) such as time-limitations. Secondly, during clinical rotations, they could not focus on learning clinical skills due to study pressure. During the study, they mostly focused on passing examinations and securing good grand percentage average (GPA) in the results. Study-related subject assignments were the biggest problem, which barred them to learn clinical skills and manage a patient. The continuity in learning clinical skills enabled them to regain confidence and they believed that they were in a more satisfactory position to manage a patient on their own, at the end of one-year IP. Subthemes: 1) Ambiguity in Understanding the Objectives of the Internship Program: All the study participants termed the 'understanding of IP objectives' as a fundamental principle of a professional endeavor'. As one participant told that "I was totally unaware of the objectives of the internship at the time of the internship start. No one cared to satisfy me. Even, my teachers never told me what are my role and responsibilities during the IP. I was only informed that I have to perform duty from 08:00 am to 02:00 pm every day except Friday and Sunday.' Moreover, I only knew that Friday was reserved for licensure examination preparation classes and Sunday as an official holiday".

2) Administrative and Communication Problems:
Four out of eight research participants identified administrative and communication problem; as no specific place selected for morning and evening attendance and admiration's direction for posting.
One intern verbalized as "there were no specific spot selected for the morning (shift start) and evening (shift end) attendance. Sometimes, we were asked to run for the office of the medical superintendent to mark attendance and sometimes, to chief nursing superintendent office for the same purpose'. It was a very confusing and uncomfortable situation. No one was there to realize the gravity of the situation".
Another intern told, "I was working in ……ward. Suddenly, one person (female) from the administration came and told me that I should go to ……ward because there was heavy emergence and I was supposed to fill the gap of shortage of staff. That was very annoying as I was not prepared to do so. I think that it was against the spirit of the internship and professional endeavor."

3) Supportive Environment:
Under this subtheme, positive as well as negative experiences were duly shared.
One internee shared her experiences as "It was very encouraging and motivating when a senior colleague of you supports you during this initial period. One female staff nurse helped me whenever there was any problem that I faced related to patient's care. During the first days of the internship, I was not able to pass the catheter to a female patient. She came and taught me the procedure in a very professional way. Not only this, but she didn't criticize me before the patient and their relative." Another internee informed her experience in a different mood as "I was not accepted as internee but dealt as a student of a diploma level. One senior female staff nurse blamed me not doing work according to her directions. She misbehaved me several times. She said to me that I was careless. It was a very bad situation as I felt powerless to prove myself innocent. I lost my confidence and felt low self-esteem".

4) Ethical Practice:
At least, five participants valued their contribution in creating an environment for ethical practice. One internee examined her value belief thoughts as, "It was very good that the ideas learned during nursing ethics subjects such as respect for patients' value and belief system, fidelity and veracity promoted a system of ethical care in between me. One patient was a Hindu (non-Muslim) and I didn't offer him meat in the dinner. I suggested him to eat the food brought by his family member from home. This was very encouraging and patients thanked me with closed lips and lovely gestures. Patient's feelings of satisfaction were instrumental for me that I felt convinced that the right thing to do is bring peace of mind to the patient".
One overarching theme of 'Internship program as a professional endeavor' and four subthemes, ambiguity in understanding the objectives of the IP, administrative and communication problems, supportive environment and ethical practice were identified. The results of this study revealed that a 'professional endeavor' can be enhanced if the objectives of internship are clear to nursing director/faculties and administration at clinical posting places, reducing and addressing administration and communication issues, providing students as supportive working environment plus developing professional and ethical practice behavior among students during academic period.

International Journal of Endorsing Health Science Research
Int. j. endorsing health sci. res.

Discussion
Role transition is an intriguing issue and a difficult process 20 . New GNs face daunting challenges while their transition process from a student to a registered nurse continues. One way to ease their transitional experiences is a structured IP. These structured IPs must model them into a competent registered nurse as they can handle challenges of providing professionally sound and ethically viable clinical care to their assign patients. Without this, internship experiences cannot be termed as 'professional endeavor' and all the intern can benefit from their internship experiences in a positive manner 21 .

1) Ambiguity in understanding the objectives of the Internship Program:
This showed that students were not explained the objectives of the one-year IP. The finding is supported as ambiguity in understanding objectives of IP leads internee to functional disability and a victim of poor communication problems. This confusion was evident in the starting days of the IP. This confusion arose many questions in the minds of the intern. It is very essential that the time available to the intern must be utilized in a way that they can master required nursing skills effectively to improve patients care as a whole 22 .
2) Administrative and Communication problems: IPs are a valuable resource for signifying work experience to future nursing force and providing them with breaks of professional growth and autonomy. Nevertheless, the role of effective communication is difficult to deny. One of the main strategies to motivate them for continuous learning is to appreciate them as a valuable workforce. Although, it is a fact that patients' acuity and nurses' shortage is a reciprocal phenomenon that leads to increased workload. But, it must not lead to denying the internees' opportunity of learning, putting an excuse of shortage of nurses and utilizing the interns as a cover up for staff shortages. It can lead to dangerous outcomes as new graduates may not fully benefit from internship programs 7 .

3) Supportive Environment:
The supportive environment is a basic right of each working person. This becomes more important for GNs during the IP. They need continuous support from seniors and peers. They must be accepted as a valuable team member. Discrimination of any kind leads them towards frustration and they may make care-related errors. Secondly, the socialization process of GNs remains low in the initial stages. They feel shy and remain isolated. It was also reported that GNs faced many difficulties to tell the senior doctors about the condition of the patients. These findings are very important insights for policymakers including teaching institutes in general and particularly PNC, to initiate innovative strategies for constructing clear and simple objective guidelines to promote knowledge and skills among nurses during their IP. To achieve objectives of developing competent nurse practitioners, it is mandatory to listen to their problems and issues during their educational period and IP. The guidelines based on the suggestions in the research will provide guidance for future nurses. Which is why the research in this area is highly indispensable. Although, this study is conducted in a single nursing institute, so the generalizability of the results is limited.

Conclusion
This study is a first step to understand and examine the utility and importance of the oneyear IP for the GNs before joining the nurse workforce as a registered nurse. Their pretransition period is a critical phase to convert them from a student to professional nurse. The internship period is no doubt a period of professional endeavor. But, it is not free of problems. In light of the findings of this study, we recommend that one-year IP needs more formal reviews. This responsibility falls on the shoulders of PNC (abbreviation) in particular and the Institutions in general. It is also in sighted that clearance in objectives of the internship must be a priority as without this an atmosphere of uncertainty and confusion will prevail. This will be a big hindrance in achieving aims and objectives of IP and ultimately improving the qualities and competencies of the GNs to handle the complex situation of patients' quality care requirements.

Conflicts of Interest
None.