The degree of preparedness and experience of student nurses participating in the generic program during their first clinical experience

Results: The factor analysis found 4 factors that explained up to 33.82% of the variance in the experience: (1) the clinical instructor’s attitude toward the student, (2) the student’s self-confi dence in his or her abilities, (3) the department staff’s attitude toward the student, and (4) a sense of calmness and familiarity with the work environment. The students’ experience in each of the factors was above 4.33 on average (on a scale of 1-5). A strong, positive correlation was found between the support and guidance of the preceptor and between the clinical instructor’s approach toward the student; between the support and guidance of the preceptor, a sense of confi dence and ability to provide care; and between a positive relationship with staff and colleagues and the student’s confi dence in his or her personal ability.

• Student nurses' experience in fi rst clinical experience • Experience of student nurses in generic program • First experience of student nurses.

Research Article
The degree of preparedness and experience of student nurses participating in the generic program during their fi rst clinical experience groups, and feedback from students after experiencing their fi rst clinical placement, supported by fi ndings in the research literature, many students report great diffi culty, stress, and strain during the fi rst clinical experience. These experiences impair the level of attention required during this stage of learning.
According to these reports, the questions arose: • What do the students in Israel experience during their fi rst clinical placement?
• What factors can infl uence a positive or negative outcome during the fi rst clinical experience?

Background
A review of the literature found a broad consensus that a student's fi rst placement in a clinic has an important and crucial role in the training process of student nurses in the general nursing program.
Student nurses express a wide range of feelings regarding the quality of their fi rst clinical experience and learning experience. They express feelings ranging from excitement, revelation, enjoyment, and pride to confusion, anxiety, fear, apprehension, and distress [5].
Many papers indicate that students experience a high level of anxiety regarding their fi rst clinical placement, which may adversely affect the clinical learning process.
Anxiety is an emotion characterized by feelings of stress and worry among student nurses [6,7].
López-Cruz and colleagues [8] reported that initial clinical experience involves particularly high pressures, resulting from lack of knowledge and skills required of the student; fear of making mistakes and causing harm to the patient; communication with the patient and family; exposure to human suffering, disability, and death; heavy workload; and interaction with the clinical instructor and with a multidisciplinary team in the department.
Stunden and colleagues [9] conducted a review of tools and methods for reducing anxiety among student nurses in the fi rst placement and how this intervention affected the student experience. They reviewed 8 articles dealing with the subject.
The fi ndings raised several key themes, one of which was related to anxiety. Student anxiety in the fi rst placement was affected positively when the clinical instructor provided tools for students to manage stressful situations. Another theme related to the process of preparing students for their fi rst placement used simulations. Zupiria and colleagues [10] developed a bilingual questionnaire (KEZKAK) to measure stressors among student nurses in clinical practice. A total of 287 students answered the questionnaire. The factor analysis revealed 9 factors (stressors) that explained 64.4% of the variance. In the student's clinical environment: lack of competence, contact with suffering, relationship with the instructor and group members, lack of necessity and importance, lack of control over the relationship with the patient, emotional involvement, feeling vulnerable due to relationship with the patient, the patient seeking a relationship, and workload. The KEZKAK questionnaire was found to be an effective tool for measuring stressors among student nurses in clinical practice [1].
Other sources of stress reported in the literature among student nurses include: a) academic studies (workload, lack of knowledge, exam load, teaching style), (b) clinical practice (fear of making a mistake, lack of skill, fear of responsibility with patients, caring for a dying patient, dealing with death, and lack of free time), c) Relationships with others (clients, colleagues, teachers, or other health professionals), and d) Personal factors (gender, age, new environment away from home, family structure, and fi nancial burden) [11].
Alshahrani, et al. [12] examined factors that would support a positive experience in the fi rst clinical fi eld placement of 154 student nurses in Australia. The questionnaire included questions on anxiety level and coping tactics. The fi ndings revealed that most of the subjects had a moderate level of anxiety, of which the main concerns were the initial encounter with the patient and fear of making a mistake that could cause harm.
To summarize, according to the literature, student nurses in their fi rst clinical placement need a supportive environment and a better sense of readiness and capability. The preparation should be tailored to the experiences and feelings the students express.
The purposes of this study were to examine the fi rst clinical experience from the students' point of view and to determine the factors that affect it.

Type of study: A research -survey
The sample includes all 103 nursing students in the academic retraining program and the academic nursing program at the university, who had their fi rst clinical experience in adult nursing, participated in the study in 2019 (There are no exclusion criteria).

Ethical approval
The Meir Medical Center Ethics Committee approved the study (25.07.2019). Informed consent was not required.
The research tool was based mainly on studies on this subject and included central categories taken from Boostel and colleagues, 2018 [1]; López-Cruz and colleagues [8]; and Zupiria and colleagues [10]. Participants were asked to rate each item on a Likert scale from 0 (do not agree at all) to 5 (strongly agree).

Statistical methods
A pre-study test was conducted to evaluate the questionnaire's reliability. The questionnaire was found

Characteristics of the study population
Most of the 103 study participants were women (80.2%), at an average age of 29.3±7.5 years. About half were Muslims Of the participants in the academic retraining program, 49% had a bachelor's degree and 51% had a graduate degree.
Most participants (62.5%) had attended an academic college and 37.5% had graduated from a university.

Research variables
The dependent variable was student nurses' experience during their fi rst clinical experience.
The factor analysis included 4 factors that explained 33.82% and 20.11%, 9.38% and 6.58% of the variance in the experience: (1) the clinical instructor's attitude to the student, (2) the student's confi dence in her/his personal ability, (3) the department staff's attitude to the student, and (4) feeling calm and familiar in the work environment. The students' experience in each of the factors was above 4.33 (on a scale of 1-5).
The independent variables -factors that infl uence the feelings regarding the clinical experience.
An analysis of the infl uencing factors found 8 factors that explained 13.07%, 9.78%, of the variance in the factors infl uencing the clinical experience: 1. Assistance, support, and guidance from the instructor -13.07% (Cronbach's alpha = .92).

7.
Adapting to the atmosphere of the department -6.64% (Cronbach's alpha =.54). Differences between the research groups -It was found that the students in the April cycle rated the relation of the clinical instructor to the student, the relation of the department staff to the student, and the support and guidance of the instructor, as better than those in the September cycle did, and reported less school workload.
The Jewish students felt less success in connecting with the patient and her/his environment than the Arab students did.
Students who studied at a university prior to nursing studies felt calmer and more familiar with the work environment and reported better contact with staff and colleagues than students who attended an academic college.   confi dence in his/her personal ability. That is, the more assistance, support, and guidance from the instructor, the more the student has a sense of security and ability to provide care, and the better relationship with the staff and colleagues, the greater the student's sense of confi dence in his/her personal capabilities.
No other signifi cant correlations were found Table 3. The regression fi ndings showed that there are signifi cant     Table 5.

Summary of fi ndings of the open-ended questions (97% response rate)
To the question: What were the most helpful factors in your fi rst clinical experience?
The leading areas were the character of the instructor (88%), and the department in which the experience took place (41%).
To the question: What were the most inhibiting factors in your fi rst clinical experience?
The leading areas were: the fi eld of study (65%), and the load of theoretical studies combined with tests and the assignments of the experience during the clinical experience made it diffi cult for them to focus on the clinical experience (58%).
To the question: What would make it easier for students in their fi rst clinical experience?
The students reported that a clinical instructor who is supportive, inclusive, directing, not stressful, coordinates expectations, and works systematically, would be the most signifi cant factor.

Summary of fi ndings
The Regarding the differences between the study subgroups, it was found that the students in the spring semester rated the relation of the clinical instructor to the student, the relation of the department staff to the student, and help, support, and guidance from the counselor better than those in the fall semester did. In addition, they reported a lighter academic work load. The Jewish students felt less success in connecting with the patients and their environment than the Arab students did. Also, students who studied at a university prior to nursing school felt calmer and more familiar with the work environment and reported better relations with the staff and fellow student than those who had studied at an academic college did. And adapting to the atmosphere of the department 0.05 0.05 .08 1.00 .32 Table 5: Regression fi ndings to predict a feeling of calm and familiarity in the work environment. Regarding the academic workload: The variable was composed of the burden of tasks, seminars, study days with words for the experience and load testing. Surprisingly, no correlation was found. However, in the open question that related to inhibiting factors, 58% of students indicated that the burden of theoretical studies combined with tests and assignments during the experience made it harder for them to concentrate on the experience. In addition, during the internship the students felt pressure "due to the load of tests and assignments during the internship". Study load may be a mediating factor infl uencing the experience, as reported in most of the studies reviewed [6,11,13].

Variable B SE Beta t p-value
The most prominent factor having a positive or negative relationship with the fi rst clinical experience on each component was the help, support, and guidance of the clinical instructor. The clinical instructor is also referenced in the literature as being a central fi gure in the outcomes of the student's clinical experience.
The clinical instructor has a major impact on the general interaction of the clinical experience [6,7,9]. There is no doubt that the clinical instructor has a signifi cant impact on the students' clinical experience, because every clinical experience is led and guided by the knowledge that begins with the orientation to the department and setting expectations, and not providing feedback and formative assessment. At the end of the fi rst clinical experience, the instructor's evaluation has an important weight in the student's grade and in shaping his or her ability for the continuing clinical experience.
Cooper and colleagues [14] examined which factors have a positive or negative effect on the fi rst clinical experience, among 361 students. The questions were divided into 3 categories: (a) how much the students felt wanted in the department, (b) the individual approach versus the staff approach, and (c) the students' expectations of supervision by the department nurses. The fi ndings suggested that methodology for preparing the students for the clinical training, and preparing the environment for the students' clinical experience need to be improved. Building professional trust and encouraging learning will support achieving positive learning in the fi rst clinical experience.
Cantrell and colleagues [6] in their review, found that students report that the common causes of stress are the academic requirements during the experience, the relationship in the clinical environment, and the care of the patient and family. Clinical placement, tests, exercises, and the student's level of competence were found to engender high levels of stress.
Reference was also made to the clinical instructor in the open-ended question in which the students were asked to indicate what are the factors that contribute to a positive experience from the clinical experience. 88% of the students answered that the clinical instructor is the most helpful factor. Regarding the question "what can make it easier for the student in their fi rst clinical experience?", the students indicated that The students indicated that the clinical instructor as a very signifi cant factor for them: supportive, inclusive, directing, not stressful, coordinates expectations, and works systematically.
In addition, students were asked to consider how they would ease the demands of the clinical experience.
With the help of the instructor, his or her support and guidance, a signifi cant positive connection was also found to the other components of the fi rst clinical experience: the student's confi dence in his or her ability, the attitude of the department staff, and the sense of calm in the work environment. In addition to the instructor's assistance, a positive relationship with the staff and colleagues also had a positive impact on these factors.

Conclusion and limitation
The current study conducted a regression to predict the main factor in the students' experience among the factors found in the literature to infl uence the fi rst clinical experience.
In conclusion, the human factor that accompanies the training: (clinical instructor, staff, and colleagues) is of the utmost importance for a positive experience for the student in the fi rst clinical experience. The academic work load that is not directly related to the clinical experience should be reduced as much as possible and should focus on the learning tasks that are relevant to the clinical experience.
However, further studies are necessary to support this fi nding as the most signifi cant predictor of the students' experience, in light of the range of factors found in the literature to infl uence the students' fi rst clinical experience.
Another limitation of the current study is the need to establish the results using a control group.