University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
Received Date: 29.09.2016; Accepted Date: 18.11.2016; Published Date: 29.11.2016
Aim: The aim of the research was to explore the nursing students’ opinion and their experiences about their clinical learning.
• Explore how student nurses find their initial experiences in the clinical area.
• Identify the contributory and hindering factors for effective learning in the clinical area.
• Identify teaching strategies that will enhance learning in the clinical area.
Background: Clinical learning is an important component of nursing education and takes place in a complex social contact of the clinical environment. Learning in a clinical setting creates challenges that are absent in a classroom.
Design: Qualitative research design was used and data were collected from Level II and Level III nursing students. Convenience sampling technique was utilized to collect data from the participants. Two FGDs among level III and two among level II nursing students were conducted at the Institute of Health Sciences, Botswana. There were four focus groups discussions and each had eleven participants.
Data analysis: The data were analysed by content analysis using a thematic framework approach.
Results: Focus group discussions revealed that nursing students did experience initial clinical anxiety, stress, lack of teaching and guiding support, lack of organizational support and resources, inadequate clinical supervision, and role acceptance.
Conclusion: The findings highlight the importance of clinical learning in the integration of nursing education and practice. Nurse educators and clinical nurses should strive to create a conducive environment, which maximises the nursing students’ clinical learning.
Botswana; Clinical experiences; Nursing education; Student nurses
One of the main features of nursing both as a science and a profession is integration of theory and practice. Clinical training is an important component of nursing education. Clinical learning takes place in a complex social context of the clinical environment . Learning in a clinical setting creates challenges that are absent in a classroom setting. Facilitators have control of the environmental conditions in the classroom whereas in the clinical setting, the teaching and learning are modified according to the situation of the real environment. The safety of patients that the students are assigned to care for must be maintained . Clinical experience prepares student nurses to be capable of knowing as well as doing the clinical principles in practice. Moreover, the clinical practices stimulate students to use their critical thinking skills in problem solving .
Nursing education programs in Botswana include a basic higher diploma and post-basic diploma offered in eight Institutes of health sciences of the Ministry of Health. The University of Botswana offers the Bachelor and Master of Nursing Sciences programmes. The programmes must satisfy the requirements of the Nursing and Midwifery Council of Botswana, which regulates the country’s education and practice . The basic General Nursing curriculum in operation since 1994 was revised in year 2008. The revision was recommended based on the findings of the needs assessment that showed that nursing students failed to integrate theory into practice and also lacked inadequate supervision in the clinical area. The new revised curriculum still poses many challenges to the nursing students as well as the lecturers in coping with the changes in nursing education.
Nursing education programmes in the East, South, and Central African countries share a lot of similarities. The faculty members mostly direct the clinical teaching and evaluation. Preceptors from the clinical area also contribute to the students’ learning. However, the lack of role clarity, workload, lack of knowledge among lecturers and preceptors hinder nursing students’ clinical learning [1,5].
The ward learning environment has a lot of external stimuli which disadvantages the nursing students with respect to identifying the learning opportunities. Msiska G et al. , asserts that the lack of equipment, lack of guidance, supervision, and negative attitude by the nurses influence the effectiveness of the clinical learning. Anxiety, attitude, academic level, commitment to the work and use of mobile phones by the student nurses affect the quality of learning and compromises the patients’ care . The workload, higher numbers of student teacher ratio in the clinical area, and in the classroom affect the lectures’ role in the clinical teaching [1,2,7].
Stress, anxiety, depression, and dejection were identified as an important psycho-social factor affecting the student nurses’ clinical experience. According to the available literature academic workload, unfamiliar situations in the clinical area, handling clinical emergencies, and shortage of resources negatively impact on students’ learning . Clinical nursing education is in essence learning through experience . Yet, patient needs are a primary focus and sometimes compromise students’ learning, because students are exposed to a lot of complex and challenging situations. The literature review clearly shows that the clinical learning is indeed a challenge for both the student nurses and the lecturer. The challenges are common to both developed and developing countries.
Most of the time, the clinical learning at the Institutes of Health Sciences in Botswana is based on the dyadic approach consisting of clinical environment and supervisory relationship between students and the teachers. This approach warrants a lot of commitment from both the lecturers and students to foster effective learning. Sometimes the student and lecturer ratio ranges from 1:6 to 1:12 in the clinical area. The high acuity and increased number of the patients in the clinical area creates challenges and influences the clinical teaching and learning. The nursing students prepared at a higher diploma level are expected to be evaluated on more than twenty clinical procedures during their practicum according to their level in nursing programme . In our research lack of clinical experience, unfamiliar areas, difficult patients, fear of making mistakes and being evaluated by the lecturers were expressed by many student nurses as sources of stress during the clinical rotation.
In her capacity as a nurse educator and a researcher, the author observed and often heard nursing students expressing concern that they were not able to perform in the clinical area as expected by the lecturers, and expressed hopelessness and dissatisfaction. This concern generated a curiosity to investigate the clinical experiences of the nursing students during their clinical placement. No published studies are available on clinical experiences of the nursing students in Botswana. This study was conducted to explore the nature of clinical experience of nursing students prepared at Higher Diploma level in Botswana.
Purpose of the study
The purpose of the study was to obtain nursing students’ opinions and explore their experiences of their clinical learning.
Definition of key
Clinical experiences are planned experiences for a specific nursing educational course and experiences gained by the nursing students in hospitals, clinics, health care centres and in the community.
Nursing student is one who undergoes a three-year higher diploma course in nursing at any of the Institutes of Health Sciences in Botswana, regulated by the Nurses and Midwifes’ Council of Botswana.
Institute of health sciences is defined as the organization provides training courses for health care workers such as nurses, midwives, pharmacist and dental therapist at higher diploma level in Botswana.
A qualitative exploratory, descriptive and contextual research design was followed and Focus Group Discussions (FGD) was used to collect data.
The study was conducted in one of the Institute of Health Sciences in Botswana.
Level II and level III nursing students were targeted for participation as they had already been exposed to different clinical settings. They would therefore be able to reflect on their various experiences during clinical practice.
Forty (40) level II and level III participants were chosen by convenience sampling technique. The classroom list was utilised to obtain the required sample of participants. The inclusion criteria were: being a second and third year student in the general nursing programme; willing to participate in the study; and having been exposed to the clinical learning in the hospitals, clinics and community.
Data collection methods
Permission to conduct the study was obtained from the Ministry of Health in Botswana. A FGD was used to explore the nursing student’s views about the clinical experience. Focus group involves organised discussion with a selected group of individuals to gain information about their experiences and views of a topic and is particularly suited for obtaining several perspectives about the same topic. Using FGD in qualitative research concentrates on words and observations to express reality and describe people in natural situations. The interviews were conducted in a skills laboratory where privacy could be ensured. Since the author was the researcher, moderators who had experience in qualitative research were used to conduct FGD. There were four focus groups and each had ten students. The data were collected during August 2011. The nursing students were asked about their initial clinical experiences, factors enhancing and hindering their clinical learning and role in facilitating their own learning.
The data were analysed by qualitative content analysis . Immediately after each FGD, debriefing sessions were conducted with the moderators. Debriefing notes included comments about the FGD process, non-verbal communication, gestures and behaviour of the participants. Three levels of coding were selected for coding the data.
Level 1 coding – the researcher and the moderators examined the data line by line and made codes from the language of the participants who attended FGD.
Level 2 coding – the researcher compared the coded data and categories were created after clustering the coded data resulted from condensing the leve1 coding.
Level 3 coding – A central theme was derived from the categories that emerged during coding.
The study was conducted after obtaining approval from the institutional review board. All participants were informed about the objective and design of the study and a written consent were received. The participants were assured that the information provided would not be used against them and were informed of their rights to withdraw from the study at any stage . Confidentiality was ensured by guarding against unauthorised access to the data and was locked in a cupboard. Anonymity was maintained by allocating code numbers to all the participants.
Establishment of rigor
The method of establishing trustworthiness was adopted from the Lincoln and Guba . The credibility was maintained by following these steps. All the participants were asked same question and debriefing were conducted after each FGD. Two experienced qualitative researchers assisted in the process of peer debriefing. Member check was solicited by replaying the audio tape recordings immediately after the interviews to confirm the comments that had been made by the participants. To maintain confirmability all the research activities were carried out as per the initial research design. The thick, rich and layered information, methodology strategies followed by the researcher guaranteed transferability. Record keeping, field notes, data reduction were utilized to maintain the confirmability.
Forty students from level III and level II participated in the study and 21 (51%) were females and 19 (49%) were males between 18–23 years of age. The qualitative analysis of focus group discussion revealed the emergence of five themes.
• Initial clinical stress and anxiety
• Lack of teaching and guiding support
• Lack of organizational support and resources
• Inadequate clinical supervision
• Role acceptance
Initial clinical stress and anxiety
Stress has been identified as an important psycho-social factor in the educational process and it may influence the student wellbeing. This theme emerged from all FGD’s where all the level II and III students experienced difficulties in the beginning of their clinical rotation. The students reported the following difficulties:
# 2 I had phobia in injecting patients and thought if I give the injection in a wrong direction, the patient will die.
# 4 During the first year since we were new, I thought if I do something incorrect the patient is in danger. So we stay away from the patient to avoid the mistakes.
# 8 Learning in the class ok. But in the ward touching the dead patient gives me more anxiety. I don’t get good sleep.
# 9 I was shocked to see the dead patient for the first time. Now death has become normal to me.
The students stated that the first 2 months of their clinical placement were anxiety provoking for them. Eighty per cent of student expressed worry about the clinical rotation. Students were exposed to high level of academic stress than the clinical stress at third year and developed depression, somatic illness, anxiety that affect their performance during the clinical learning. Some events such as unsuccessful resuscitation and unexpected death, destabilize the emotions of the student nurses during the clinical practice .
Lack of teaching and guiding support
Teaching and guidance is an important component that should be provided by the lecturers and preceptors in nursing education. The theme lack of teaching and guiding support emerged from all FGD where every nursing student reported lack of support from the lecturers and preceptors during their clinical experience:
# 5 Lecturers show some attitude towards the students and project their problems to the students.
# 7 Lecturers shout and lose temper in front of the patients. Patients lose confidence in us. Some lectures are biased and attach tribalism during evaluation.
# 6 We are not focused when the lecturer come to the clinical area with an attitude.
# 10 Lecturers are procedure oriented. They do not give feedback immediately after we do the procedure without any supervision.
Support and guidance were reported as lacking from both academic staff who supervised clinical as well as the floor nurses. This student reported:
# 10 Ward nurses are also always busy with their work.
Yet another student felt the lack of support stemmed from the fact that the preceptors failed to stay abreast of the evolving science of patient care. She reported:
Some of the lecturers also don’t know the latest development in the patients care.
Nabavi and Vanaki  reported that lecturers were not accompanying students in the clinical area and students were carrying out patient care without any supervision. Clinical tutors were only seen in the clinical area when they came to evaluate the students. The clinical educator should incorporate theory into practice and facilitate the process of professionalism for their students. Timely feedback, fair evaluation and guidance would help the students to achieve better practice . In a study conducted in Malawi , the students stated that the lecturers’ interaction intimidated students and induced stress. Eighty per cent of nursing students in the current study expressed that they lack support from the lecturers during their clinical practice and the literature also support these findings.
Lack of organizational support and resources
Organization support is imperative to develop clinically competent nurse with good leadership skills. The participants expressed the following verbatim:
# 7 The delayed communication between the school and the hospital making us to suffer. Many times the nurses make us to stand outside the wards due to poor communication.
# 8 Many times there is no equipment, trolleys. This delays our procedures. Lecturers don’t understand the situation. They cancel the procedures if we don't keep the equipment (student was in tears).
# 5 Dressing materials and packs are not available. Many times sterility is compromised.
# 9 Sometimes we don’t even get N95 mask in the wards. We always work under fear.
# 14 In the class we are taught about the privacy and confidentiality. In the wards many times the nursing activities are carried out without the curtain.
Ward atmosphere directly influences student learning as it determines their perception whether the clinical area is suitable for their learning. Insufficient equipment, theorypractice gap, confusion causes, stress, anxiety and may encourage the students to practise ‘short-cut’ methods to complete their tasks quickly . Lack of harmony, communication, and interpersonal relationship between the educator and the student negatively affect the clinical learning . The attitude, approach, interpersonal relationship, and neutrality, of the lecturer create trust among the students [5,16]. 75% of students raised concerns that their learning was compromised due to lack of organizational support.
Clinical supervision is an important component in facilitating learning in the clinical setting . The heavy workload and attitudes of the nurses compromise the clinical learning of the student nurses.70% of the students expressed concern about the nurses’ attitudes towards students.
# 1 Nurse’s think student nurses are burden to them. Nurses should know that we are learning from them. The ward nurses are not concerned about what students learn.
# 3 Nurses use the student nurses to carry out their responsibilities. Documentation is not done as per the standards. They are unable to carry out the educational and service role.
# 7 Younger nurses are not committed to the profession. They are interested in earning money. Many nurses lack professional accountability. They sign in the file before giving the medication.
# 12 Nurses should be called for workshop and explained about the changes in the curriculum by the educators.
The literature suggests that the clinical nurses should be a role model for the student  nurses and individualised guidance, mentorship facilitates nursing students learning. Clinical nurse educators take a role of evaluation than supervising the students. Lack of resources, shortage of nurses and attitude of the nurse educators has impact negatively on students teaching .
Role acceptance emanates from professional socialization. The desired outcomes of professional socialization are the acquisition of a professional identity, ability to cope with professional roles, professional and organizational commitment, which assists to improve the quality of care, provided by the student nurses . The students expressed the following verbatim:
# 3 During first year we were not serious in studies. But now we know what is expected t obecome a nurse.
# 8 We learnt to be assertive during our 3rd year when we did our management practicum. Learning and practising the procedure well ahead helps to reduce the anxiety.
# 10 We spend 3 years and have developed necessary knowledge and skills to be a professional nurse. Now it is our responsibility to give it back to the community.
# 11 We feel after 3 years we have grown professionally and society expects more from us.
The study findings suggest that the nursing students accepted the professional dimensions and developed necessary knowledge and skills during their clinical rotation. The findings are congruent with the study conducted in Iran where the student nurses expressed positive attitude and devotion towards the profession . Independent, selfmotivated learning, could be considered as a positive attitude and the similar opinion echoed by the student nurses from Malawi .
The clinical experiences of the nursing students’ showed that they did experience challenges during their clinical rotations. The nursing students clearly expressed that the initial clinical experiences were stressful for them. Students in the level II experienced more anxiety compared to level III students. Three categories of concern for students are: fear of hurting the patient, not fully competent on certain procedures and over load of class room work. Nursing students’ received instructions totally different from what they are taught in the class room. The gap between theory and practice creates conflicts and influence the students learning negatively. Studies conducted in Iran [5,8] Malawi and in South Africa  supports these findings.
Fear of doing mistakes and harming the patients, academic workload and less time allocation for the procedures was anxiety-producing moments for the student nurses. Developing competent and confidence among student nurses is the important component of the nursing practice and the nurse educators should facilitate the process. Positive clinical experiences can affect positively on student nurses feelings .
Lack of teaching and guiding support were one of the main themes identified in this study. According to the participants, the lecturers play a major role in moulding the student nurses to attain the excellence in the profession. The majority of the students had the perception that their lectures focus more on the procedure than on the clinical teaching. The attitude and biased opinion of the lecturer affects the focus of the nursing students in the clinical area. It is the responsibility of the lecturers to develop the students with sufficient knowledge and information in professional education that would allow them to manage the work situation with fewer problems .
The nursing students expressed concern about the lack of support by the organizations both by the training institutes and by the hospitals where they practice. In this study majority of the students mentioned that non-availability of the necessary equipment, sterile packs impact their clinical practice and force them to improvise in providing care for the patient. The lack of communication between the school and the clinical setting affect or curdles the effectiveness of the clinical learning. Poor interpersonal relationship, lack of communication frustrates the student nurses not knowing who to report when they were new to the units .
The findings are consistent with a study by Magnussen and Amundson  whereby insufficient hospital resources, unprepared work environment, financial constraints are the most stressful experiences to the nursing students. Inadequate clinical supervision and guidance by the nurses in the clinical area raised concern among nursing students. Clinical nursing supervision is an on-going systematic process that encourages and supports the student nurses’ professional practice. In this study, majority of the students had the perception that their preceptors need to be oriented about the changes in the curriculum. The preceptors’ educational preparation and attitude contribute to the students’ learning . The students identified a supportive and ideal mentorship as a vital role of the nurses in the clinical area. According to Begat and Severinsson  clinical nurses may have positive effect on the professional growth of the student nurse.
In spite of the challenges experienced by the student nurses in the clinical area, most of the nursing students accepted their role positively and highlighted that self-evaluation o fknowledge skills and attitudes would contribute to the professional growth. The nursing students value the contribution of supervisors, lectures and preceptors and emphasised that their role increase their self-confidence, socialization and professional independence . 80% of the student nurses felt they need to take active role in their own learning.
In Botswana and in Sub-Saharan African countries the nursing students face different challenges during their training since they are expected to provide nursing care to the patients with HIV and AIDS, Tuberculosis, Cancer and different other medical and surgical conditions. In this study, student nurses showed professional socialization by accepting their roles and exhibited commitment to the society. The view is a combination of the internal and external motivation to create a sense of generosity and responsibility in the individual to care about others [18,24]. Nursing as a profession has various concepts/dimensions in different cultures. Cultural beliefs of a society play an important role to value the profession. The philosophical approach of “Botho” which promotes the common good of society and humanness is inculcated in every individual from childhood in Botswana and other African countries. The finding on role acceptance supports this philosophy to some extent.
The findings of this study support the importance of clinical learning and help to integrate the nursing education and practice. Nurse educators and nurse managers should strive to create conducive environment that will maximise the learning experiences of the student nurses. The following recommendations are based on the findings and if implemented, would enhance student learning in the clinical environment.
- Periodic debriefing and counselling sessions could assist the students to socialize to become a professional nurse. This will also allay their anxiety level during their clinical practice. Pre-clinical conference and explaining the expectations of the clinical area prepares the student nurses psychologically.
- The lecturers should create a conducive non-threatening and creative environment for the students.
- Faculty practice should be implemented which allows the nurse educator to learn the latest trend in the clinical practice.
- The teaching hospital and the management should strive to provide necessary equipment and resources for the student nurses.
- The professional organizations could organize workshops on preceptorship, latest development in the teaching and learning methods to the register nurses.
- The policy makers would strive to create collaboration with the other health care sectors to meet the need of the student nurses.
- Further research also can be conducted on the process of professional socialization of the student nurses, sources of social support in the clinical milieu and the experiences of lecturers and the preceptors in assisting the student nurses learning in the clinical area.
Relevance to clinical practice
The health training institutes and the teaching hospital should collaborate together to enhance the student nurses clinical learning. Nurse educators should conduct regular inservice education to the clinical nurses about their role in mentoring the nursing students. Pre-clinical conference and debriefing could allay the anxiety among student nurses.