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Transitional Shock of Multi-Nationality Newly Graduate Nurses in Kuwait

Introduction The transitional period of newly graduate nurses became more stressful, different coping mechanisms are essential. Therefore, effective coping with transition-related stress and anxiety is important for the life and professional of those nurses. Objectives To examine the transitional shock through assessing the occupational stress and coping mechanism of multi-nationality newly graduate nurses in Kuwait. Methods A descriptive correlational design was used to identify the occupational stress of the newly graduate nurses (NGNs) and their coping mechanisms during the transitional period to their professional life. All the NGNs were recruited. The total number of participants was 152 nurses. Results Highly significant correlations on almost all stress domains with p-values P < 0.01. We found that “Death and dying” was ranked as the highest stressor with a mean score of 6.20, followed by “uncertainty concerning treatment” with a mean score of 5.59, and in the “Inadequate preparation” was the least stressor with a mean score of 1.64. Conclusion “Religious coping” was the highest-ranked coping mechanism. In conclusion, NGNs have to adjust quickly to the new practical atmosphere encountered in the health care settings by using the proper coping mechanisms techniques.


Introduction
The transitional period from student life to becoming a registered nurse is rewarding but challenging and could be distressing (Bronstein, 2019). The transition process is entitled as a reality shock (Powers et al., 2019). Schott et al. (2019) defined reality shock as "the shock-like reaction that occurs when an individual who has been reared and educated in that subculture of nursing that is promulgated by schools of nursing suddenly discovers that nursing as practiced in the world of work is not the same -it does not operate on the same principles". Newly Graduate Nurses (NGNs) need time to cope with the changes in the new environment, particularly when switching from a protected environment where they were supervised by their instructors to an authentic world where they need to take care of the afflicted (Phillips et al., 2014).
When NGNs enter the new work environment, they experience stress, mainly because of their limited clinical experience and skills, difficulties in adjustment and a sudden increase in responsibilities (Labrague et al., 2020). In this regard, Kakemam et al. (2019) emphasized that the sources of occupational stress are lack of knowledge, and confidence to give safe and independent care to patients, fear of setting medical apparatus, inability to carry out the procedure using machines or test, dealing with ambiguous orders and unfamiliar diagnosis.
Furthermore, the inability to communicate appropriately with other nurses, physicians, patients, and their families are the main stressor for NGNs (Mercado & Pham, 2019). In addition, organizational and managerial skill deficits and dealing with new situations as major factors also causing stress (Basu et al., 2016;Yeboah-Kordee et al., 2018).
As the transitional period of NGNs becomes more stressful, different coping mechanisms are essential. Effective coping with transition-related stress and anxiety is extremely important to NGNs life and professional development. The coping strategies that had been used between individuals are influenced by ethnic, cultural, and socioeconomic characteristics (J€ orgensdotter Wegnelius & Petersson, 2018).
In Kuwait, a student nurse must successfully undertake four years of Bachelor Degree in nursing or two and a half years of Associate Degree in nursing or three years of nursing Certificate to be prepared as a registered nurse. On completion, all the NGNs have to undergo nine months rotation program in a general hospital, rotate in three different areas for a period of 3 months each. At the end of every rotation, a procedure checklist will be checked and signed by the nurse experts like a head nurse or clinical instructor or senior nurse. After completion of nine months of rotation, NGNs should report to the nursing department in the Ministry of Health (MOH) along with the evaluation and checklist for the confirmation of the area assignment (MOH, 2009). The purpose of this study was to examine the transitional shock through assessing the occupational stress and coping mechanism of multi-nationality newly graduate nurses in Kuwait.

Design
A descriptive correlational design was used to identify the occupational stress of the NGNs and their coping mechanisms during the transitional period to their professional life.

Population and Sampling
All the NGNs with Nursing Certificate (NC), Associate Degree of Nursing (ADN), and the Bachelor of Science in Nursing (BSN) programs were recruited for this study. All of the participants were working in the governmental sectors and undergoing the nursing rotational program. The total number of participants was 152 nurses. The participants who were under the bridging courses were excluded. Bridging courses mean that the candidates are working under the MOH and they decided to complete their study either the ADN or the BSN degree. This means that they have possibly overcome the stressful period for years and they will be posted after their graduation into their previous area of work without passing through the rotation period.

Data Collection
The data collection period took one month. Arrangements for the data collection visits were done with the regional nursing directors, hospital, and PHC nursing directors. Explanations were given to them regarding; the research aim, the significance of the study to nurses' work environment, and the time of around 30 minutes to fill the questionnaire. The participants signed the consent form before they completed the study questionnaire. Two of the researchers were present during the data collection procedures to answer any inquiries. The researchers' contact information, such as e-mails and mobile numbers, were available for all the participants during the data collection period.

Ethical Consideration
The approval was obtained from the research committee/MOH-Kuwait. Permissions were taken from the directors of the seven health regions. The hospitals/ clinics directors and the heads of nursing departments in the same health organizations also approved the visits. As a participant in this study, each NGN received a cover letter that explained the aim, significance of the study, the content and instructions about the instruments, and the duration of completion of the instruments. The informed consent form was signed by each participant who agreed to participate in the study after reading the cover letter.
A list of code numbers for the participants with their names and contact numbers were kept with the main researcher only and they were entered as a soft copy in a word document with password protection on the researcher's laptop. Participation in the study was completely voluntary and the participants were able to withdraw at any time without any consequences or harm to their occupation as nurses.

Measures
In addition to the demographic data, the study used two scales: The Nursing Stress Scale (NSS): This scale was developed by Gray-Toft and Anderson in 1981. It intended to measure the frequency and the main sources of stress experienced by nurses on hospital units (Gray-Toft & Anderson, 1981). This instrument consists of 34 items, which describes conditions that have been recognized as producing stress for nurses in the performance of their works. These 34 items distributed into seven subscales as follows: death and dying (7 items), conflict with physicians (5 items), inadequate preparation (3 items), lack of support (3 items), conflict with other nurses (5 items), workload (6 items), and uncertainty concerning treatment (5 items). This scale includes four-point Likert rating scales: never (0), occasionally (1), frequently (2), and very frequently (3). The summation of scores of each subscale is used as a tool for interpretation of the results alternatively with the total scores of all nursing stress scale. The reliability of the original questionnaire in the test-retest coefficient for the total scale was 0.81 and it is valid as empirically it was investigated in other studies. A Cronbach alpha test was carried out to determine the reliability and internal consistency of the nursing stress scale, which was 0.899. A bivariate correlation was carried out between the nursing stress subscales and the total nursing stress score to determine the validity of the Nursing Stress Scale. The results showed that all of the domains are highly correlated with total stress score where p-values of P < 0.001 were recorded thus indicating the tool as valid.
The Cope Inventory Scale (CIS): It is a multidimensional coping inventory to evaluate the different coping techniques, was developed by Carver et al. (1989). This scale contains 60 items categorized in 15 subscales. Each item is scored on a four-point Likert rating scale. The subscales are: positive reinterpretation and growth, mental disengagement, focus and venting of emotions, use of instrumental social support, active coping, denial, religious coping, humor, behavioral disengagement, restraint, use of emotional social support, substance use, acceptance, suppression of competing activities, and planning. According to our culture and religion, one sub-scale (substance use) was removed. A Cronbach alpha score in this study was 0.88.

Statistical Analysis
Data were coded, entered, and analyzed using the IBM Statistical Package for Social Sciences (IBM SPSS Statistics) version 25.0 for Windows (IBM SPSS Statistics for Windows, Version 25.0, 2017). Descriptive statistics and correlation analyses were used in this study.

Participants' Characteristics
The results showed that among the 15 nationalities who participated in this study, nearly one third (32.9%) of the participated nurses were Syrian (n ¼ 50), Jordanian nurses (13.8%), and in the third rank was Kuwaiti nurses (11.2%). Almost two-thirds of the nurses (65.1%) were females. The participated nurses' ages ranged from 21 to 44 years with a mean age of 24 years. We found that 77% of the participants were single. Table 1 illustrates details regarding the sociodemographic of the participated nurses.
Descriptive analyses were carried out to examine the occupational stressors that the participated nurses were facing in their workplace for all sample and for female nurses with diploma only. The results showed for all sample that "Death and dying" was ranked as the highest stressor with a mean score of 6.20, followed by "uncertainty concerning treatment" with a mean score of 5.59, and in the "Inadequate preparation" was the least stressor with a mean score of 1.64. However, the means of stress for female nurses with diploma was higher in all aspects than means for all sample. The rankings of the stress scale domains are presented in Table 2.
The coping mechanisms are ranked in descending order for all participants. The "Religious coping" was the highest-ranked coping mechanism with a mean score of 13.5, followed by "Positive Reinterpretation & growth" with a score of 12.32. While, "denial," "humor," and "Behavioral disengagement" had the lowest mean scores among the coping mechanisms. The means of coping for female nurses with diploma were almost very close to the whole sample as shown in Table 3.
Correlation analysis was carried out to examine the relationships between the demographic data and the total score for both the occupational stress scale and the scale of the coping mechanisms. The results showed that the stress scale has a significant negative correlation with age (r ¼ -0.22, p < .01) and a positive correlation with the levels of education (r ¼ 0.27, p < .001). Furthermore, significant positive correlations were noted between the total coping mechanism scale and the levels of education (r ¼ 0.23, p < .01). Gender did not show any significant correlation with both stress and coping scales.
Pearson's correlation was conducted to examine the relationships between the nursing stress scale domains and coping mechanisms for all participants and for female nurses with diploma only. The results for all sample showed highly significant correlations on almost all stress domains with p-values < 0.01), except on the level of "planning" and "religious coping" as a coping mechanism where no significant correlation was recorded with any of stress scale domains (Table 4). However, for female nurses with diploma, the correlations were almost less in all aspects than all participants. Female nurses use less 'humor', less 'instrumental social support', and they had 'less mental disengagement' as coping mechanisms with stress.
To examine if there are differences on stress and coping mechanisms based on nationality, Analysis of Variance was conducted. Only Kuwaiti nurses showed less stress than other nationalities. No differences were found on coping mechanisms among nurses from different countries (Table 5).
A comparison between NGSs on stress and coping mechanisms based on the rotation period was conducted. The only significant result was for nurses in the first rotation who shown less stress than the other

Discussion
Recognizing the NGNs stressors is the initial step in overcoming shock during the transitional period. Between all the stressors in the stress scale, death and dying, uncertainty concerning treatment, and conflict with other nurses were considered to be the main work stressors that the NGNs are suffering from. "Death and dying" was the highest significant stressor that experienced by the NGNs in Kuwait. This result was congruent with the findings of many studies in other countries (Chatzigianni et al., 2018;Galdikiene et al., 2014;Qiao et al., 2011;Saleh et al., 2013). This can be explained as death and dying considered as an upsetting experience that encountered the NGNs novel professional life. They have limited skills and knowledge on how to deal with the real situations of death and dying with the patients and their families. Chatzigianni et al. (2018) explained that the stress behind death and dying also comes from the great demands regarding the care that needs to be provided for terminally ill patients. Qiao et al. (2011) added that death and dying is a process where the NGNs can not control or express their feeling and emotion correctly when confronting this type of stressor. The NGNs considered uncertainty concerning treatment as the second-highest stressors that they faced during their transitional period. This stressor is related to a lack of communication between the physician and the nurse about the patient's condition due to physician failure to communicate the information or the absence of the physician in the medical emergency condition (Gray-Toft & Anderson, 1981). Furthermore, inadequate inter-professional communication was found to Correlation for all sample each first rows and for females with diploma second row. *P .05, ** P .01, *** P .001. increase uncertainty in medical responsibility and form a barrier to a better care process (Flierman et al., 2020). That stressor consequently leads to a lack of communication between nurse and patients or their families in relation to how to explain the patient's medical condition, treatment and then what to communicate, when, and how to communicate the information. Furthermore, Fitzpatrick and Gripshover (2016) mentioned that, transitional shock period can be reduced by finding proper preceptorship and mentors, creating a solid knowledge base, developing positive workplace relationships, connecting with a novice nurse group, and asking for regular evaluations.
Knowing and understanding the coping mechanisms for the NGNs are essential to overcome stressful situations in the transitional period. Kurki (2018) revealed that coping mechanisms are existing in three categories as follow: nursing management and organizations, individual sources, and social support. In the part of individual strategies; planning and emotional focused coping, that include religious coping, and positive reinterpretation and growth, are found as components of these strategies. These individual strategies assist nurses in adapting with stress effortlessly because they include optimistic feelings and emotions, which in response uphold physically and mentally the coping practice by helping the NGNs to explain the problem in different ways and helping the NGNs in making changes in their ways of thinking (Kurki, 2018).
In this study, religious coping, positive reinterpretation and growth and planning were found to be the first three coping strategies that the NGNs were practicing when they pass through stressful situations. Choosing the religious coping to be the first management strategy is due to the Islamic cultural instructions, which advise us to practice praying at any time when confronting challenging or stressful events in our lives and to seek help from "Allah" (Ahmad & Dardas, 2016). Carver et al. (1989) reported the reasons behind choosing religion as one of the coping strategies. Religion might work as a basis for emotional support, as a tool for positive reinterpretation and growth, or as an approach for active coping with stressful situations.
The results of this study revealed that in general, there are significant positive correlations between the total stress scores and the total coping scores, which indicates that when the stress increases the coping mechanisms increase too in order to restore the state of equilibrium in the NGNs' professional lives. Furthermore, the results showed that the mean scores for the stress and the coping during the second transitional rotational period increased which approved Kramer's theory of "reality shock". This theory contains four phases: the honeymoon phase, shock phase, recovery phase, and resolution phase (Wakefield, 2018). The first three months are called the honeymoon phase, where the NGNs' characterized to be idealistic, optimistic, and excited toward their profession.
The second phase from the reality shock theory is named the shock phase, which is happening in the second three months from the NGNs' professional lives. In this phase, the NGNs' suffering usually from the emotional withdrawal, rejection, possible hostility, fatigue, and illness (Wakefield, 2018). These characteristics support the results of this study, where the NGNs' stress results elevated during the shock phase and as adaptation the coping mechanisms raised too. In the third three months, the recovery phase takes place and the NGNs' started to increase their coping mechanisms and reduced their anxiety (Wakefield, 2018). In this study, the results of stress and coping for the NGNs' were standing in line with the characteristics of the recovery phase where the stress level started to be in the peak and the coping mechanisms increased more to accommodate the stress level.
The demographic data is an essential part to focus on and interpret in the lives of the NGNs in the light of stress and coping. Age in this study was related negatively to stress. This result is congruent with the study of Purcell et al. (2011) but not in line with the results of Chatzigianni et al. (2018), which showed that age was associated with the total stress score. In terms of levels of education, the findings of this study revealed that there are positive relationships between the levels of education on one hand and stress and coping mechanisms on the other hand. The level of knowledge is increasing when the level of education increases. These results are in harmony with the findings of other studies (Chatzigianni et al., 2018;Qiao et al., 2011).
The analyses of the 73 female nurses who have a diploma degree revealed almost similar scores on the coping mechanims to all participants, but higher stress scores in all aspects than means for all sample. This could reflect that those female nurses with diploma degree experience higher levels of stress. Furthermore, female nurses with diploma showed lower correlations between stress and coping in all aspects than all sample participants. This result is similar to another study conducted in Saudi Arabia (Alammar et al., 2020) and could be attributed to the smaller sample size for female nurses with diploma degree.
When the NGNs from different nationalities were compared on stress and coping scales, only Kuwaiti nurses showed a lower level of stress. This could reflect that nationality has little effect on the variation in how nurses handle stress or use coping mechanisms, which is consistent with another study conducted in a similar region (Alammar et al., 2016).
Having that only the NGSs with less stress than nurses in the second and third rotation is a surprising result. It is expected that nurses with less experience show a higher stress level than nurses with more experience (Alhurani et al., 2018). The explanation for this result could be attributed to the perception of the NGNs as fresh graduates with less responsibility on them. However, once they start to get closer to the finish of the rotation periods, then they will start to handle the responsibilities for their work.

Implications for Practice
A formal orientation program could be one way to overcome the stress of the transitional period. Moreover, a comprehensive and well-structured program can reduce transitional shock for novice nurses, minimize turnover, and establish a solid foundation for a productive and lengthy career. The NGNs need frequent support, supervision, and reward by the supervisors and the managers to grow up and overcome the stressful situations during this period. Knowing and understanding the causes of the stress will help the policymakers, managers, and educators in the field of nursing to coordinate with each other's to establish a platform to deal with the transitional shock that influences the NGNs' practice and professional development. A longitudinal study to assess the student's growth and development in terms of their knowledge and skill and the effect of stress management education and training on their future professional life is needed.

Conclusion
The transitional period of the NGNs' from the academic side as students to work in the health care sectors as staff nurses is considered a shock and stressful period. Newly graduate nurses' have to adjust quickly to the new practical atmosphere encountered in the health care settings by using the proper coping mechanisms techniques. The findings of this study blaze a trail for more studies as it is the first study in Kuwait that focuses on firstly; the transitional shock period during the first year of work, secondly; NGNs' occupational stress, and lastly; their coping mechanisms. The stressors with the highest scores in the transitional period (Death and dying, Uncertainty concerning treatment, Conflict with other nurses, & Workload) should be studied in more depth. This will help the policymakers and managers in the nursing field as well as the nurses' educators in discovering a better image of this period and overcome the obstacles confronting these NGNs'.