Factors Affecting Training Efficacy in Residency Program Adopted by New Graduate Nurses in Saudi Arabia

Objective: The purpose of the studies is to analyze and identify the level of competency, which includes knowledge and skills between SCDP nurses (Residence Program) and newly graduate nurses (Non-residence) in Saudi Arabia. Methods: A survey uses an open-ended question conducted among the participant. The data is collected by using tape recording during the interview session. Newly graduate nurses and SCDP nurses were included in this study. (5) Resident nurses vs. (5) non-resident were included in this study making 10 sample size of qualitative study. Results: Findings of the study show significant differences between nonresident and resident in their journey of orientation, competency development and their learning opportunities. Residents are more likely feel less distress and more satisfied about their experience entering the residence program. Conclusion: Nursing Residency program helps in supporting nurses to build a future leader. Hence, it helps in their critical thinking, skills and knowledge, which elevate their confidence level.


Introduction
Healthcare systems are complex entities that require many functional units to be able to evolve simultaneously to confront rapid new realities taking place. Disruptive challenges involving fields such as medicine, technology, finance, management, and the like, raise concerns into delivery of health care. Being the larg-est provider of health care services, nursing is confronting with the need to transform itself constantly to align with changes occurring in other sectors. Newly licensed nurses who are trying to transition from training to clinical practice settings where they are now responsible as professional nurses must be prepared for the physical and mental challenges that go along with becoming accountable for patient care in this hectic .Thus, they must be prepared for the physical and mental challenges that go along with becoming accountable for patient care in this hectic environment [1]. Concerns for new nurses about delivering safe, efficient and effective nursing care have contributed to developing transitional support programs in healthcare settings. These "transition" or "residency" programs provide both supervision and support for new nurses or nurses who are moving to areas where they have little to no experience [1].
National Council of State Board of Nursing (NCSBN) described nursing who assist individuals or groups to attain, maintain optimal health by implementing different strategies of care and accomplishing specific goals. A nursing residency program is defined as "A planned, comprehensive period of time during which registered nurses can acquire knowledge and skills to deliver safe, quality care in clinical settings" Association for Nursing Professional Development, 2016. A nurse residency program is offered to assist newly graduated student nurses to protect time to transition into clinical practice. Programs vary, but those, which last up to 12 months have adopted by (some/many) healthcare organizations to assist newly graduated nurses to adapt an intense, complex work environment.
SCFHS is the medical licensing body responsible for certifying all medical practitioners including nurses to practice legally in KSA. Up to this date, SCFHS has exceeded 37 programs aiming to improve professional performance in different health-related field. The nursing board joined the Commission in 2002, international and training programs were formed. The nursing profession has made vast improvements in national licensing; those who have bachelor degree were categorized as "Nursing Specialist". Whereas those who hold master's degree and have at least two years' experience will be categorized as "Senior Nurse Specialist". And for those who have completed their PhD will be identified as

Literature Review
The first bachelor program was established in Riyadh at King Saud University under Ministry of Education (1976), few years later King Abdelaziz University in Jeddah, and King Faisal University in Dammam had also established colleges for nursing bachelor sciences. At the beginning Nursing Programs have had low enrollment rates because of negative nursing image in Saudi Community. Today and throughout the Kingdom, Ministry of nursing colleges had reached up to 39 institutions. A total of 17,085 BSN students had enrolled to different institutions in different parts of the country [2]. Apart from this, Saudi government had provided international scholarships for more than 813 Saudi nursing students to pursue in foreign countries for education at different levels. Upon completion and in order to be eligible to practice, students are required to complete their Saudi Nursing Licensing exam, this exam is sponsored by Saudi Commission for health Specialist. SCFHS approves the necessary knowledge and competencies for students at graduate level it headquarters located in Riyadh with branches across the Kingdom. SCFHS aims to improve performance, develop skills, and sustain medical education for health-related disciplines. Furthermore, SCFHS monitors post graduate training programs, it also maintains registration and classify practitioners across the KSA. Under SCFHS there are few bodies dominating nursing profession: one, the General Nursing Department that supervises nursing daily issues under the scope of MOH; two, the Nursing Scientific Council, which provides consultation to SCFHS on nursing credentials.
Nurses hold a responsible in defining their roles in relevant to their population health needs. Nurses in KSA expected to be consistence with international definitions. This expectation draws nurses to perform autonomous care to individuals, families, communities as well as being present to advocate disabled client. According to AlDossary "there is no clear scope of practice being formalized by SCFHS". She discussed nurses in Saudi Arabia are being shaped within nursing "traditional role" in providing physical needs only, despite the interpersonal communication, and psychological aspect needed to meet patient care [3].
Physician and nurses work together in a collaborative relationship, this partnership between nurses and physician is necessary for the provision of safe patient care. Healthcare policy makers in Saudi Arabia need to empower nurses to be decision makers, additionally more research is needed to understand nature of nursing practice in the Middle East and Saudi Arabia in particular [4]. The MOH and other entities are working to attract healthcare personals by improving its education to unify Vision 2030. It is obvious that Vision 2030 are moving toward knowledge and education to contribute economic growth, thus allowing higher education institutions to forecast its demands to markets and help graduates to decide on their career paths. Freshly graduated nurses often describe their first year as "stressful and overwhelming" as they strive towards newly ac- An online survey of 282 newly graduate nurses reported satisfaction in recruitment and hiring, whereas job satisfaction after recruitment remains low.
Findings from focus groups identified several key factors that contribute in the experience of transition for newly graduate nurses. These included; nature of workforce setting, the level of support offered by managers, different cultures in workplace settings, and work of natural training and learning being offered by clinical instructors. He concluded the need to utilize evidence-based approaches that will empower nurses and enable personal professional future growth [5].
The National Council of State Board of Nursing compared performances among nurses who entered the residency program for 12 months in comparison to nurses who did not. Findings showed overall competencies improved significantly after completion (12-month program) in comparison to nurses who did not enter the program. Hence, the American Academy of Nursing released recently a policy recommending a completion of residency program for newly hired licensed registered nurses [6]. Assessment made by the impact of leadership skills among graduates who completed residency program compared to new graduates who did not entered residency program in Saudi Arabia. She concluded that residents are more likely to have higher level of leadership responsibilities by showing their collaboration, effective communication, interpersonal understanding, and clinical expertise. She also argued the importance of residency program to new graduate Saudi Nurses on job satisfaction and competencies compared to nonresident participants who received two weeks' orientation [9].
Criteria of SCDP at KFSH-D Resident Candidate(s) should be Saudi national graduate with accredited degree program and, as follows: Be registered with the Saudi Commission for Health Specialties (SCFHS) [10]. Provide evidence of degree completion with a minimum Grade Point, and provide evidence of completion of an internship in the related field. Department heads will develop and design Saudi Career Development Program (SCDP) training, based on their department needs, and provide these to the Human Resource Administration (HRA). The SCDP trainee must sign an agreement contract with the Hospital that states they will abide with the regulations of training program and other obligations. After completing the General Hospital Orientation, General Nursing Orientation, the SCDP nurse is expected to function according to job description and will follow the guidelines for the specialty pathway. SCDP nurses are required to provide at least two inservices for their assigned area. In-services will be arranged by the Nursing Education Department and clinical instructors of the specialized area.

Study Design
This is phenomenological study is to explore the lived experiences of a cohort of new registered nurses during transition in their new roles and responsibilities through understanding properties of transition and factors being identified. The number of participant not exceeds ten trainees who are collaborative nurse residency program vs. non-residency program. Nurses in this sample had been in practice for one year as interns and immersed in clinical field through entering Saudi Career Development Program since January 2019 for (12 month). The sample was convenience determined by the enrolled nurses from year 2019 till 2020.

Sampling Method
Participant was interview face to face. The questions that has been asked includes: their experiences as new hired nurses, their perspective/thoughts about the program has prepared them to meet challenges by demonstrating their professional practices as a new nurse, and the impact of non-residence towards their clinical skills, capacity and comfort filed in their clinical area.

Inclusion Criteria
Saudi bachelor Degree Holder, Completed internship program, enrolled to Saudi Career Development Program in Comparison of staff who are not SCDP residents.

Exclusion Criteria
Non-Saudi registered nurses, diploma holders. Newly hired nurses with more than 1-year experiences.

Measurement Tool
The participants were interviewed face-to-face by using the questionnaire. Their Clinical Educators was informed regarding their participation for the studies. The interview lasts from 30 -45 minutes. The interview was tape-recorded.

General Questionnaire
One question was asking during the interview "what are your transition experiences as a new graduate nurse in the collaborative nurse residency program? Participant allowed talking freely and opening ended questions such as "tell me more "will be used.

Result
The finding of the study shows significant differences between nonresident and resident in their journey of orientation, competency development and their learning opportunities. Resident are more likely feel less distress and more satisfied about their experience entering the residence program (Table 1). This result contributes a clearer understanding from nurses who participated in nursing residency where there was a significant increase in nursing ability skills and being comfortable in their work field during the 12 months' residency program [10]. Whereas nonresident faces disappointment especially in their first five months after orientation ( Table 2). As they must be prepared for the physical and mental challenges that go along with becoming accountable for patient care. These findings fit with Duchscher theory; transition shock comes from multiple underlying premises allowing contraindication presents between knowledge, roles, responsibilities and relationships.
National Council of State Board of Nursing in United States, has conducted a comparison studies in accessing the performance among nurses who entered the residency program for 12 months compare with the nurses that has not enroll for the residency program. The studies indicate, the nurses who participated in the residency program has 100% satisfaction in terms of professional development compare to those nurses who did not participate in the residency program. The findings indicate that residency program does not only help in professional development but it also builds core abilities for fulfilling one's role (Table 3). Nursing profession need to stay UpToDate with the latest developments, continuing to update their skills and competencies to meet health needs.
Nurses in KSA is expected to be consistence with International Council of Nurses (ICN) this expectation draws nurses to perform autonomous care to individuals, families, communities as well as being present to advocate disabled client. Therefore, we have done comparison studies nurses from residency program and nurses that has not attended residency program. From the survey conducted, the feedback obtained from the residency-trained nurses stated, they have sufficient time to learn which shows (100%), whereby, the non-trained residency program indicates, and they needed more time to learn (100%) ( Table  3).
However, when looking at the aspect of leadership skills and management, both the residency and non-residency program trainee nurses, has identified that they needed more in-depth knowledge to enhance their professional development skills. Thus, this contraindicates, with the studies conducted by Aldossary as the researcher has mentioned, for those who has completed their residency program gives an astonishing impact in their leadership skills and knowledge. Apart from that, when focusing on career development, the non-residency program nurses are more keen in moving forward to leadership and visualizing themselves in the position of managerial, unlike the residency program, they are more focused in pursue their career development by further studies which could enhance their capabilities, knowledge and establishing their career pathway (Table  4).  Further, most resident had supplement classes to improve their professional development. Finding showed more classes needed in both programs and involving trainee to be a part in research and evidence based. Residency program can offer new graduate nurses to be involved in research committee.

Discussion/Conclusions
The Saudi Career Development Program will function according to the hospital standard of practice and it will proceed to Human Resources Administration. Thus, the trainee will be signing an agreement contract with hospital, and they should abide with the regulations of training program and other matters related to their training. Apparently, they need to attend the General Hospital Orientation and General Nursing Orientation, before they are able to perform their duties in the respective units based on their job description. While they are on duties, they will be guided on certain guidelines, based on the criteria of the unit specification.
In order for the Saudi Nurses to perform as trained Registered Nurse (RN), they need to undergo a mandatory residency program for 6 months in order for their employment in other hospital. Thus, they will be acknowledged based on their clinical practice and evaluation from the course attended. Besides that, with the current advancement of technology in hospital settings, exposure to clinical setting by nurses will prompt their confidence and knowledge towards patient care.
Structured residency program focused on clinical settings of specialized area will help to promote quality and safety practices. Nursing transition is important because it addresses the skill development, preceptors training, and provides support through 6 to 9 months' post hire period. Therefore, with the conducive working environment, it encourages the newly graduate nurses to pursue higher studies. From the studies conducted, the nurses have mentioned, this training helps them to analyze their capabilities, abilities to perform in stressful situation, enhances their critical thinking and most importantly it develops good interactions among their colleagues, patients and relatives. Therefore, I would highly recommend that, the structured transition program to practice should be designed with 9 months in length focused on competency profile for each nurse, and identify his or her gaps by using performance gap analysis. In addition, the residence should attend leadership course and training to enhance their skills and be empowered.

Statement of Ethics
Institutional Review Board (IRB) approval was obtained from all studied (IRB approval number: NED0321). The paper is expedited from ethical committee approval. Informed Consent taken from the participant before the studies conducted. Potential subjects will be identified by the educator /instructors. You may refuse to participate and shell not be loss of benefits. Use the information provided by you in this questionnaire for research purpose. Your participation will be strictly confidential. Participant was informing that they are allow to withdraw themselves at any point during the studies. Confidentiality of participants and data maintained.

Funding Sources
I declare this research did not receive grant from any funding agency in the public, commercial or not for profit sectors.

Data Availability Statement
All data generated or analyzed during this study are included in this article and its supplementary material files. Further enquiries can be directed to the corresponding author Ms. Sarah Mohammed Qannas.