Casey-Fink Graduate Experience Survey for Nurses and Preceptors in the Kingdom of Saudi Arabia

Background: Preceptors play an essential role in supporting new nurses during the transitional period in professional roles. Moreover, graduated nurses experience several challenges during their transitional role from students to professional nurses, despite of the considerable relationship between nurses and preceptors. Purpose: The study aims to evaluate the relationship between the experiences of nurses using Casey-Fink Graduate Nurse Experience Survey and the number of preceptors in Saudi hospitals. Methods: A cross-sectional study design was adopted, and Casey-Fink Graduate Nurse Experience Survey was used to collect data from 84 newly graduated nurses. Descriptive and regression analysis was used for data analysis. Results: Results showed that there was no statistically significant relationship between the responses of 5 factors of Casey-Fink Graduate experience survey and the number of preceptors. Based on the survey, (33.8%) had stress whereas significant causes of stress were student loan (41.9%), personal relationships (13.5%), living situation (27%), and finances (10.8%). Conclusion: No statistically significant relationship was found between variables including; support, patient safety, communication/leadership, professional satisfaction and job satisfaction. The significance of preceptorship programs should be considered by the primary health care corporation to support and prepare preceptors of newly graduated and recruited nurses.

relationship between nurses and preceptors reflects caring expressed through kind words and actions. Supportive and caring preceptor workforce can help in the transition of student nurses into experts by improving their sense of belonging in the nursing profession (Omer & Moola, 2019). The transition of graduated nurses is importantly handled in preceptorship programs that are able to provide safe and competent patient care, leading towards the increase in retention of newly graduated nurses, and improve the quality of care (Arbabi, Johnson, & Forgrave, 2018). Kim and Kim (2019) outlined that the preceptor's personality attributes such as self-efficacy, and leadership qualities as significant characteristics that help in the successful transition of new nurses into professional nurses.
The health sectors around the world are experiencing a shortage of healthcare workforce (Haddad & Toney-Butler, 2019). This is evident from the report of the World Health Organization (WHO) which estimated a shortage of 12.9 million by 2035 (World Health Organization, 2013). Despite of significant relationship between nurses and preceptors, graduated nurses experience several challenges during their transitional role from a student to a professional nurse. Similar issues are encountered by experienced nurses when entering to new workplace to be oriented to an unrecognized work environment. It is assumed that the role of preceptors is vital to support new nurses during the transitional period in professional roles (Borimnejad, Valizadeh, Rahmani, Shahbazi, & Mazaheri, 2016). Wong et al. (2018) conducted a study to identify the challenges encountered by the nursing graduates during their transition period. Rush, Adamack, Gordon, Lilly, and Janke (2013), on the other hand, highlighted that increased support from peers, mentors and preceptors are significant in positively influencing the transition period of nurses. Trained preceptors were also identified in creating a positive influence on the newly graduated preceptor relationship. The role of the preceptor is expanding from facilitation to support, coaching as well as positive role modeling for the formation of a constructive environment. The corresponding relationship between nurses and their preceptors provide them the opportunity to guide and encourage fresh nurses to efficiently perform their respective roles and responsibilities, leading towards improvement in skills and ultimate satisfaction in their jobs. Kamolo, Vernon, and Toffoli (2017) outlined that team collaboration, communication, and an increase in individual confidence are the ultimate benefits of preceptorship. The implementation of the nursing preceptor has proved to be beneficial for the nurses' retention, contributing to the increased rate of 90% (Rush et al., 2013).
Certain factors such as the difference in focus, level of independence in practice, and structure, and the experiences of the graduated nurses' preceptors can be different from those of experienced nurses, since most of the fresh nurses experience professional isolation, lack of support from experienced staff and professional discrimination (Alboliteeh, Magarey, & Wiechula, 2018). It has been suggested to assist students with increased preceptorship and professional support, to make them confident enough for their acquired knowledge along with decision-making skills.
Recently, changes in the healthcare system are increasingly made, as new methods and technology of care delivery are continuously developed. The burden of these changes on staff, especially on nurses is observed by healthcare managers, along with the increased safety risks to introduce new graduates (Schultze, 2017). Nursing schools fall upon healthcare institutions for providing continuing education according to the need of new graduates and fundamental skills of nursing care. They also provide a nurturing and supportive environment to assure those newly graduated nurses become safe and competent members of the healthcare team. This gives rise to the researchers' interest in investigating the topic concerning different domains.
Preceptorship needs to be explored as an essential phenomenon in the nursing profession to improve their knowledge and perceptions regarding the preceptor's roles. According to Casey, Fink, Krugman, and Propst (2004), mostly graduated nurses do not have the appropriate skills and competence which makes them incompetent in fulfilling their responsibility to provide safe patient care based on several factors. These factors include increasing turnover of the experienced graduated nurses, burnout, high-acuity level, increasing workload demands, excessive use of contract labour, and decreasing graduated nurses' orientation. The overall discussion indicates that the problem is highly critical and is associated with multiple factors. Therefore, investigation of the topic concerning certain regions is crucial to improve healthcare quality.
Therefore, the study intends to evaluate the relationship between experiences of nurses and preceptors using Casey-Fink Graduate Nurse Experience Survey in Saudi Arabian hospitals. Rationale behind the selection of the region is based on its reported high turnover rates. The study results are assumed to be helpful for nursing leaders in the development of an effective transitional program, improving newly graduated nurse's satisfaction as well as providing a meaningful experience. One of the main contributions of this study is the use of the Casey-Fink graduate experience questionnaire to determine the relationship between nurses' experience and preceptors in Saudi Arabian hospitals. To the best of the author's knowledge, this is the first study to explore this objective using the Casey-Fink Graduate Experience questionnaire.

Research design
The cross-sectional study design was employed to determine the relationship between experiences of nurses and preceptors in the hospitals of Saudi Arabia. In this context, a survey approach has been used to collect data prospectively from graduated nurses. The study was conducted in 9 different hospitals of Al-Bahah region, Saudi Arabia.

Samples
The study targeted graduate nurses working with the experience of minimum 6 months and a maximum of 2 years in Saudi Arabian hospitals. Since the researcher is a resident of Al-Bahah region, the study was conducted in 9 general and public hospitals of Al-Bahah region of Saudi Arabia. These hospitals include King Fahad Hospital, Prince Mishari bin Saud Hospital, Almakwah Hospital and Al Mandaq General Hospital, Al Aqiq General Hospital, Buljurshi Psychiatric, Gilwah General Hospital, Naqaha Hospital, and Al Qara General Hospital. Limited nurses were working in these hospitals so a sample size of 80 was achieved based on 104 as population, 95% confidence level, and 5% confidence interval. The selection of the graduated nurses was based on their correspondence to the inclusion criteria.

Instrument
A prospective data collection approach was used to collect data from the targeted graduated nurses. Casey-Fink Graduate Nurse Experience Survey was used in the study. The selection of the tool is based on its utilization in previous research (Cline, La Frentz, Fellman, Summers, & Brassil, 2017;Rush et al., 2013). This tool was originally proposed by Kathy Casey and Regina Fink to measure newly licensed registered nurses' comfort with skills over time (Casey et al., 2004). The Cronbach alpha coefficient for the overall questionnaire (24 items) was 0.89. This questionnaire comprises of 5 factors, which include support (α=0.90), communication/leadership (α=0.75), patient safety (α=0.79), stress (α=0.71), and professional satisfaction (α=0.83). A 5-point Likert scale was used to measure the factors from very unlikely to very likely.

Data analysis
Data collected were analyzed using the Statistical Package for Social Sciences (SPSS) IBM version 20.0. Descriptive statistics such as mean, standard deviation, frequencies, and percentages were employed for describing and categorizing the variables. Along with it, regression analysis was applied for quantifying the relationship between Casey-Fink Graduate Nurse experience survey factors and the number of preceptors. The pvalue of <0.05 was determined for demonstrating results' significance statistically.

Ethical considerations
The deanship of postgraduate studies at King Saud University approved this study. The Institutional Review Board (IRB) for the College of Medicine at King Saud University granted the approval for conducting this study. Before the performance of the research, a written letter and a copy of the sample were submitted to the clinical administration for providing relevant information about the study. Along with it, study objectives, confidentially and anonymity were also communicated to the participants followed by the gathering of the written consent. One week's time period was provided to the participants for completing and submitting the survey to the nursing directors. The completed surveys were then collected by the researchers.

RESULTS
Results showed that out of 80 participants, 41 were males and 39 were females with a mean age of 26.48. Each nurse has mostly 1-2 preceptors (69%) during their orientation (Table 1). The responses of nurses towards the five factors of Casey Fink Graduate Nurse Survey which was measured on 5-point Likert scale response indicating that "1" represents "very unlikely" and "5" is used for "very likely" showed the mean values ranges from 2.53 to the factor of organizing prioritizing patient safety and 3.27 to the factor of professional satisfaction. The average number of preceptors in our study subjects was almost 2 (Table 2). Towards the acceptance of experiencing stress in their life and its cause, 15 (15.8%) agreed, 25 (33.8%) had strongly agreed, whereas, 49 (51.6%) were neutral, and 21 (22.1%) and 10 (10.5%) disagreed and strongly disagreed that they were experiencing stress in their life. The significant causes of stress were student loans (41.9%), finances (10.8%), living situation (27%), personal relationships (13.5%), and job performance (8.1%) ( Table 3). The relationship between the responses of 5 factors of Casey-Fink Graduate experience survey by the nurses and the number of preceptors was assessed by using linear regression analysis. The regression coefficients of each of the five factors (support, patient safety, stress, communication/leadership, and professional satisfaction) indicate no statistically significant linear relationship. The R-square values of these five factors indicate no effect on the dependent variable (number of preceptors) ( Table 4).

DISCUSSION
The present study has depicted the relationship between responses of 5 factors of Casey-Fink Graduate experience survey by the newly graduated nurses and the number of preceptors. Excessive work load, lack of basic as well as advance professional knowledge, communication, individual expectations, change of role, work atmosphere, support from peers and other professional training programs, blame or complaining culture, and personal attitude are some common challenges faced by the nurses during their period of transition.
The results depicted that there was no statistically significant relationship between the responses of 5 factors of Casey-Fink Graduate experience survey by the newly graduated nurses and the number of preceptors. The factors that support the newly graduated nurses during their transition period include improved orientation, increased support, unit socialization and improved work environment. Results also showed that peer support, patient and families, ongoing learning, professional nursing role and positive work environment increased their satisfaction with the work environment. However, factors contributed to the least satisfaction in their working environment include the nursing work environment, working system, interpersonal relationship, and orientation.
More than half of the participants in the present study agreed towards experiencing stress in their life that was caused due to financial issues, living situation, personal relationships, and job performance. However, a previous study conducted by Hayes et al. (2006) stated that intention to leave was associated with dissatisfaction with the work environment (including staffing, support, professional development, responsibility, quality of care, and physical environment). These results are also consistent with the study of D'ambra and Andrews (2014) stating that work environment factors play an important role in experiencing stress and dissatisfaction among the newly graduated nurses. Besides, work readiness (organizational acumen dimension) of newly graduated nurses was associated with intention to remain in the current job and this relationship was mediated by job satisfaction; though, the relationship has not been shown quantitatively (Walker, 2013). Moreover, Osmo and Landau (2006) stated that job satisfaction among newly graduated social workers was predicted by the extent to which respondents felt their degree had prepared them for their job (measured after workforce entry).
The relationship between preceptor and graduates is a two-way learning and growth process. Moreover, the newly graduated nurses were expected to take on an active role in their learning. Results depicted that the relationship between responses of the study participants about five factors of Casey-Fink Graduate experience survey and the number of preceptors was not statistically significant. A previous study conducted by Carlson, Pilhammar, and Wann-Hansson (2010) stated that preceptorship is a strategy that help in preparing the newly graduated nurses for the reality of practice, where the integration of theory and practice occur to gain a sense of professional identity in nursing. The role of preceptorship and preceptor is observed as dynamic, complex, rewarding, engaging and consuming strategy. Preceptorship not only depends on preceptors themselves, rather it depends on peers and managers that contribute to the workplace environment.
The clinical learning among newly graduated nurses is likely to be perceived as a process that takes place within the existing practices and social relations. Moreover, the preceptors are responsible for inviting the newly graduated nurses into the community of practice and help them in navigating these relations and practices. A similar study was conducted by Yonge (2012) and stated that nurse preceptors serve as influencers, role models, teachers, friends, assessors, evaluators and supervisors. Therefore, they need to acknowledge the fact that nursing was their primary responsibility, while precepting and patient safety was their foremost priority.
The findings of this study can influence academic and clinical education practice. The level of support, feedback, and encouragement provided by preceptors can enable educators to utilize these methods as a part of their curriculum. Feedback and encouragement can be delivered through a pre-licensure curriculum to nursing students as an approach to instill confidence and validation of practice accuracy. The graduated nurses should be offered a training program to help them understand their important role as an evaluator, educator, and role model. The short-term association established between graduated nurses and preceptors provides attention on learning needs of the graduated nurses and to develop their confidence in performing their expected roles. The quality improvement project should be conducted in Saudi Arabian hospitals and compared to all the graduated nurses' responses for obtaining generalizability. The clinical practice of the graduated nurses should be expanded in other clinical nurses of the hospitals such as the recovery room, wound care department, operating room, and intensive care unit.
Findings of the present study can be implied to understand the difficulties of transition for newly graduated nurses to reduce the turnover rate and to support the retention of a qualified workforce to meet future healthcare needs. Moreover, developmental, role transition, relational and organizational strategies are likely to enhance the critical thinking ability, confidence and support of newly graduated nurses. It might also contribute towards transition, relational and organizational components that are critical to the transition. Moreover, newly graduated nurses, with their preceptor, should spend time in the simulation lab putting their hands-on equipment and performing skills.
This study is limited since only certain factors were focused that are associated to the relationship between nurses' experience and preceptors. However, due to the small number of participants, findings of this study cannot be generalized.

CONCLUSION
The results depicted the factors related to the difficulties experienced by the newly graduated nurses, include role expectations, lack of confidence, workload, fear, and orientation issues. In the transition period, these nurses must be prepared for the entrylevel practice. The results therefore, concluded that there was no statistically significant relationship between the responses of 5 factors of Casey-Fink Graduate experience survey by the newly graduated nurses and number of preceptors. Around half of the study participants agreed towards experiencing stress in their life. Moreover, the leading cause of stress among nurses was associated with financial issues, living situation, personal relationships, and job performance.
Nurse educators and nurse managers have the opportunity for designing an orientation program that fulfills the needs of the new graduate nurse. It might be essential for considering how preceptors are used in the program as nursing leaders strive to explore the most authentic way. Nursing administration must continue to develop competent nurses as well as retain these nurses for several years of recruitment throughout the organization.
Future studies should consider mixed-method or longitudinal designs for examining this phenomenon further. New insights can be obtained through a discussion group with fresh graduates after the initial interviews related to their experiences, as it may allow them to share their observations and experiences with the preceptors. Future studies should also explore the effectiveness of nursing educators to prepare newly graduated nurses to enter the clinical environment.