Exploring Work-related Anxiety Among Newly Graduated Nurses in the Riyadh Region

Background: Work-related anxiety among nurses has been linked to various issues, including a heavy workload, work-related conﬂict, a lack of resources, and stress. This research aims to explore work-related anxiety among recently graduated nurses in Saudi Arabia’s Riyadh region. Methods: A descriptive, cross-sectional, and relational research design examined work-related anxiety among newly graduated nurses. A sample of 400 nurses was recruited from ﬁve Saudi hospitals in the Riyadh region. This study used the job anxiety scale ( JAS) as a study tool. The tool is a self-rating scale of 70 items for assessing job anxiety but only 25 items were applied to this research. A self-administered questionnaire was used to gather demographic information. Results: This study revealed that there was, overall, low work-related anxiety among the nurse participants. On the one hand, age, gender, educational qualiﬁcation, job experience, workplace, and work scheduling (hours per week) were found to impact work-related anxiety substantially. On the other hand, work position, nationality, unit of care, and marital status were found to play no signiﬁcant role in work-related anxiety. Conclusion: The study’s ﬁndings indicate the importance of paying more attention to workplace anxiety. As anxiety may affect nurses’ ability to attend to the needs of patients in their care units, addressing it can reduce burnout and the desire to quit. Changes in work processes, care models, and leadership may be effective in creating a supportive environment that decreases stress and anxiety, promote learning, and provides patients with optimal and safe nursing care. Health policymakers and nurse managers in Saudi Arabia should develop particular intervention programs to reduce work-related anxiety among newly graduated nurses. Managers must seek techniques that help to adapt the present environment to the needs of nurses, as well as approaches that offer newly graduating nurses essential assistance, such as clinical supervision.


Introduction
Work-related anxiety, inexperience, emotional and physical stress, nursing shortages, bullying, and lack of support have been implicated in these difficulties and the subsequent abandonment of jobs [1,2]. The Kingdom of Saudi Arabia's healthcare system is charged with the sole responsibility of meeting the basic healthcare needs of the Saudi people with high-quality services [1].
The profession is highly stressful and has a high prevalence of work-related emotional and physical burnout and anxiety [3]. This stress has necessitated rotational day and night shifts of 8 to 12 hours [4,5]. However, the shift duration is sometimes unpredictable and is determined by inpatient needs and other staff issues. This leads to unplanned overtime, resulting in mental and physical distress and fatigue [6,7].
Several other studies have shown that newly graduated nurses face difficulties in adapting to their new jobs, which require them to practice in stressful, laborious, and complex work systems [8].
Work-related anxiety has been known to have several adverse effects on nurses.
These include absenteeism, medical errors, impaired job performance, reduced mental acuity, musculoskeletal disorders, physical pain, social problems, mood changes, and mental issues [6,9].
In the study conducted in Saudi Arabia by Waled, a descriptive cross-sectional result showed that the anxiety levels of the nurses in this study ranged from 0.60 to 1.52.
The results of this study showed an inverse association between anxiety levels and critical care nurses' ages that were statistically significant. The critical care nurses in the hospitals in Albaha were only mildly anxious. Anxious mood, tension, insomnia, physical sensations, and terror are among the most frequently reported signs and symptoms of anxiety [10].
A descriptive cross-sectional study was conducted in Saudi Arabia the result revealed that the research cohort's nursing students experienced moderate stress from a variety of stressors. They frequently avoided the situation and in response, adopted a problemsolving strategy. To lessen stress among nursing students, institutions need to follow a set routine [11].
The present study aims to explore work-related anxiety among newly graduated nurses in the Riyadh region of Saudi Arabia and to measure its impact on delivering quality healthcare services. Exploring work-related anxiety amongst newly graduated nurses will furnish hospital administrators, nurse managers, and other relevant authorities with the information needed to address this situation, improve the delivery of quality healthcare services, and help achieve Vision 2030.
This study aims to explore work-related anxiety among newly graduated nurses in the Riyadh region of Saudi Arabia.

Research design
The present study employed a descriptive, cross-sectional, relational research design to assess work-related anxiety in newly graduated nurses in the Riyadh region of Saudi Arabia.

Study setting
This study was carried out at five hospitals in Riyadh, Saudi Arabia: King Saud Medical City, Al-Iman Hospital, Diriyah Hospital, King Khalid Hospital, and Shaqra Hospital. In addition to serving as the nation's capital, Riyadh has a population of over 7.6 million, making it the city with the most residents in both Saudi Arabia and the Arabian Peninsula.

Sampling design
The present study employed the convenience sampling method to recruit newly graduated nurses who had given their consent and met the study's inclusion criteria. Convenience sampling is a technique adopted in many disciplines to collect research data from an available pool of participants. It has several advantages, including quick data collection, cost-effectiveness, ease of use, and readily available samples [13]. n = z 2 x p x (1-p)/e 2 where z is equal to 1.96 for a confidence level (α) of 95%, p is the proportion (expressed as a decimal) and e represents the margin of error. However, to an estimated sample size of 385, we added 5% for the attrition rate so the total should be 385 + 19 = 404, but during data collection, we found that only 400 newly graduated nurses were recruited for this study for harmonization.

Inclusion and exclusion criteria
The inclusion criteria for this study are newly graduated nurses in their first year of employment who have freely given their consent to participate in the study. Nurses who do not meet these selection criteria, other healthcare professionals, and nurses with more than three years of experience were excluded.

Research Instruments
The present study employed the job anxiety scale ( JAS) designed by Linden et al. [13]. The tool is a 70-item self-rating scale for assessing job anxiety including thoughts, feelings, and behavior, but only 25 items related to thoughts were applied to this study. The tool's retest reliability has been tested and confirmed to be r(tt) = 0.82 after 7-10 days interval of questionnaires on clinical samples in previous studies (n = 611; [13,14]. A structured interview on workplace-related anxiety (work anxiety interview, WAI) was also used to provide convergent validity criteria for the scale validity [13].

Data collection
Data were gathered using a self-administered questionnaire tailored to collect the demographic characteristics of the study subjects as well as a scale to assess their work-related anxiety. Questionnaires were used to collect data in this study because they provide a quick, efficient, and relatively cheap way of procuring large amounts of data from a large sample of participants. Ethical approval, institutional permissions, and the consent of study subjects were obtained, and data confidentiality was assured.

Data analysis
The Statistical Package for the Social Sciences (SPSS) version 22.0 was used to analyze the study's data. The qualitative data on the essential variables were provided in the form of frequencies and percentages, and descriptive statistics were used to describe the data. Meanwhile, the mean and standard deviation were used to characterize the quantitative data. The results were determined using a confidence range of 95%, and a p-value of 0.05 was chosen as the level of statistical significance. Finally, multiple linear (stepwise) regression was used to test more of the two items to assess the influence (if any) of gender, age, marital status, educational qualification, work experience, and other demographic variables on work-related anxiety, and whether recently graduated nurses in the Riyadh region of Saudi Arabia experience work-related anxiety and whether this worry affects their job performance.

Results
The findings of this study are presented in three main parts. 1) the demographic characteristics of the respondents used in this study; 2) statements related to the perceived extent of work-related anxiety among the participants; and 3) the relationship between work-related anxiety and the selected demographic variables.
Anxiety is one of the major factors responsible for newly graduated nurse turnover in Saudi Arabia's healthcare system. Therefore, there is a significant need to address workrelated anxiety for the adequate sustenance of the healthcare sector and to ensure the availability of nurses. Exploring work-related anxiety amongst newly graduated nurses will furnish hospital administrators, nurse managers, and other relevant authorities with the information needed to address this situation, improve the delivery of quality healthcare services and help to achieve Vision 2030.

Demographic characteristics of the respondents
This section includes data about the respondents' gender, age, marital status, educational qualification, work experience, and other demographic variables.
In this study, 92.5% of the participants were Saudi nurses, and the mean age of the sample was 27.30 ± 5.28 years. More than half the participants (75.5%) were between 20 and 29 years old, while only 3.8% were 40 years old or above. About half the participants (51.2%) were single, while only 41% were married. Concerning the respondents' educational level, 49.2% of the participants had a diploma, while 38% had completed a bachelor's degree. The vast majority of the participants (80%) had worked for less than 1 year. More than half the respondents (86.5%) worked less than 50 hours and 37% worked in critical care units in the hospital. Approximately 87% of participants had a work schedule of fewer than 50 hours per week, and the workplace with the most participants in this study was King Saud Medical City (39%).

The second deals with statements related to the perceived extent of work-related anxiety among the participants.
Overall, the participants summary of the Likert score showed that the anxiety level per questionnaire of all respondents was 2.10, demonstrating that the respondents exhibit low overall anxiety.
The third shows the relationship between work-related anxiety and the selected demographic variables.
The results also showed that age, gender, educational qualification, work experience, workplace, and work scheduling (hours per week) significantly influenced work-related anxiety. However, work position, nationality, unit of care, and marital status did not significantly affect work-related anxiety.

Discussion
Work-related anxiety among nurses has been linked to a variety of causes, including overburdening workloads [15], conflicts with other healthcare providers [16], a dearth of resources [17,18], exposure to death and dying, demographics, and workplace stress [19,20]. Studies have shown that these factors (among others) contribute to increased anxiety levels among newly graduated nurses [21,22]. The time between nursing school and becoming a registered nurse is fraught with anxiety, tension, and even dread [23,24]. In a study conducted among recently hired nurses in Taiwan, the first year of a two-year residency course was associated with moderate anxiety and work stress [25]. al. [28] on the anxiety levels of newly hired nurses at a Jordanian cancer hospital. The authors found that the anxiety levels of newly employed nurses consistently increased from the start to finish of the general nursing orientation program (GNO) and that these levels began to fall after three months [28].    In comparison to a study conducted in Saudi Arabia by Waled with a similar design a descriptive cross-sectional result showed that the anxiety levels of the nurses in this study range from 0.60 to 1.52 was considered a very low level of anxiety [10].
The present study also found that the level of education a nurse possessed substantially influenced their level of work-related anxiety. According to Rambur et al. [29], who used a different study design, "The RN Job Analysis and Retention Study" ( JARS nurses with a bachelor's degree (BSN)" were better able to handle occupational stress-a potential cause of anxiety-than their associate degree-holding counterparts. To better equip freshly graduated nurses and help them cope with the stress and anxiety of the nursing profession, it may be necessary to establish a structure that promotes the gradual advancement of all levels of nursing education to a minimum of BSN.
This is comparable to the advice given in a 2019 study on stress and coping mechanisms for student nurses in clinical training in Saudi Arabia, which suggests employing regular avoidance of circumstances and the use of problem-solving techniques in response. Institutions must adhere to a predetermined schedule to reduce stress among nursing students [11].
According to the present study's findings, work hours per week also contribute significantly to work-related anxiety. This is consistent with several studies that have found a correlation between shift work and increased stress on the job. According to a cross-sectional epidemiological study in Eastern Saudi Arabia, nurses who experienced work-related stress and anxiety were more likely to have worked in shifts [30]. Moreover, a similar cross-sectional study design showed that longer shifts or work hours led to more work, such as the manual handling of equipment or patients, which was strongly linked to work-related stress [31].
The present study also indicated that demographic parameters such as work experience and age influenced the perception of work-related anxiety. This result is consistent with Abu-Feddeh and Darawad [32], a quantitative descriptive cross-sectional design with a similar sampling technique that found a strong correlation between age and workplace stress. The workloads of newly licensed nurses may increase as they age and take on more responsibility in the field. Moreover, registered nurses in hospitals report that excessive workload is a significant source of stress in their profession [33]. Ang et al. [34] a mixed-method sequential explanatory study corroborated these findings, reporting that nursing became more emotionally draining for respondents as they got older. Indeed, the emotional and physical demands of providing complex patient care can prove taxing for nurses (such as lifting and moving patients, rearranging duty schedules, and working longer hours [35]. In comparison to descriptive crosssectional designs, patients' illnesses and deaths raise nurses' awareness of their aging and mortality, which may lead to higher emotional stress and anxiety [36]. In comparison with different designs of qualitative research, the fact that most of the participants in this study (75.5%) were still relatively young (20-29 years) may also help explain the lack of a noticeable trend toward work-related anxiety.
Based on the findings of this study, neither a work position nor a unit of care played a significant role in predicting work-related stress. However, this observation is at odds with the results of Alhroub et al. [28], who found that newly hired nurses in a general hospital unit reported much higher work stress than those in an emergency or operating room. Keskin et al. [37] showed a similar effect of work stress and anxiety: increased workload and the number of patients in general care units contributed to feelings of anxiety and depression amongst nurses. These variations in occupational stress and anxiety are attributed to the larger number of patients in the general ward, the higher complexity of their treatment, the greater likelihood that the nurses will work overtime [38,39]. A possible explanation for the present study's contrary finding may be that most participants (37%) worked in critical units. Nevertheless, the results of this study are consistent with those of Blomberg et al. [40], a cross-sectional design that found that recent nursing graduates had similar stress levels regardless of their placement.

Limitations
When interpreting the findings, it is essential to keep the study's limitations in mind.
First, the current study relied on convenience sampling, which could reduce the results' generalizability. Second, the use of self-reported questionnaires is another limitation, as it depends on the study participants' honesty and may thus lead to under-reporting of anxiety. Third, the researcher's capacity to collect sensitive data on work-related anxiety among the study participants may have been limited by the use of quantitative methods.
Fourth, 20% of the nursing participants had experience of more than a year. This may have led to lower anxiety and work stress levels than if all participants had less than a year of experience.

Conclusion
The current study explored the significant factors contributing to work-related anxiety among newly graduated nurses in Saudi Arabia. Overall, there was low perceived anxiety at work among the participants. However, some demographic characteristics, including gender, education level, work experience, and scheduling, were linked to anxiety; these characteristics were found to play a significant role in the perception of work-related anxiety. The study's findings suggest that it is necessary to pay more attention to workplace anxiety, which may affect nurses' capacity to attend to the requirements of patients in their care units. To provide safe patient care, nursing administrators must be involved in efforts to adjust nursing programs and implement the necessary techniques to lower anxiety and stress levels among newly graduated nurses, helping them settle into their new responsibilities without difficulty. The study implies that Saudi Arabian health policymakers and nurse managers should create specific intervention programs to lessen work-related anxiety in recently graduated nurses.
Managers must look for methods that assist in adapting the current environment to the demands of nurses as well as strategies that provide recently graduated nurses with crucial support, such as clinical supervision. The researcher suggests that additional research on anxiety be done using a different sampling strategy.

Recommendations
More attention must be paid to work-related anxiety and stress among newly graduated nurses in order to reduce burnout and the intent to quit. During their orientation phase, newly graduated nurses should attend training classes on how to react effectively to challenging work situations, which may help reduce the detrimental effects of stress. In addition, mindfulness-based stress reduction (MBSR) programs and online peer support [41] can help new nurses transition better into their nursing careers. Such programs could be included as part of nursing residencies.
Nurse managers should put in more effort to guarantee that newly hired nurses will have more suitable job responsibilities and nurse-to-patient ratios. Managers must look for methods to adapt the current environment to nurses' needs and strategies that provide newly graduating nurses with essential assistance, such as clinical supervision.
Nurse supervisors must consider that these nurses are new and inexperienced and work in an environment that places significant expectations on them. A change in workflows, care models, and leadership may help create a supportive environment that reduces stress and anxiety, promote learning, and offers the best and safest nursing care for patients. It is challenging to change the nature of hospital practices and patient care to make the environment less stressful.