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Investigación y Educación en Enfermería

Print version ISSN 0120-5307
On-line version ISSN 2216-0280

Invest. educ. enferm vol.36 no.3 Medellín Sep./Dec. 2018

http://dx.doi.org/10.17533/udea.iee.v36n3a04 

Original articles

Nursing Students' Experiences of Clinical Education: A Qualitative Study

Experiencias de la práctica clínica de los estudiantes de enfermería: un estudio cualitativo

Experiências da prática clínica dos estudantes de enfermagem: um estudo qualitativo

Leila Bazrafkan1  , Majid Najafi Kalyani2 

1 Nurse, Ph.D. Assistant Professor, Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. email: bazrafcan@gmail.com.

2 Nurse, Ph.D. Assistant Professor, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran. email: majidnajafi5@yahoo.com.(Corresponding Author)

Abstract

Objective

To comprehend the experiences of nursing students in clinical education.

Methods

A qualitative study using conventional content analysis was conducted. Data were collected using focus group interview with 16 nursing students from two public nursing schools of Shiraz and Fasa, Iran. The participants were selected by purposeful sampling. Data analysis accomplished according to conventional content analysis.

Results

From this study five categories were emerged: Theory and practice disruption (The inability to use the lessons learned in practice, Routine-oriented work, The difference between theoretical knowledge and clinical training), Shaky communications (Inappropriate behavior, Inadequate support of nurses, instructors and other caregivers), Inadequate planning (Wasting time for students in clinical training, Inadequate preparation of instructors and students), Perceived tension (Stress, Anxiety and Fear), Personal and professional development (Learning more steadily, Paying attention to the spiritual dimension of care, Increasing interest in the profession, More knowledge, greater Self Confidence).

Conclusion.

The results of this study showed that nursing students have desirable and undesirable experiences in clinical education in the process of training, which must be addressed with proper planning for reduce the students' problems in the clinical education of future nurses.

Key words: clinical education; focus groups; qualitative research; students of nursing

Resumen

Objetivo

Comprender las experiencias de los estudiantes de enfermería en la educación clínica.

Métodos

Se realizó un estudio cualitativo en el cual se utilizó el análisis de contenido. Los datos se recolectaron mediante entrevistas en grupos focales con 16 estudiantes de pregrado de dos escuelas de enfermería de carácter público de las ciudades de Shiraz y Fasa (Irán). Los participantes se seleccionaron por muestreo intencional. El análisis de datos se realizó de acuerdo con la técnica de análisis de contenido.

Resultados

De este estudio surgieron cinco categorías: Interrupción entre la teoría y la práctica (diferencia entre conocimiento teórico y el entrenamiento clínico, incapacidad para usar el conocimiento teórico en la práctica, rutinas), Comunicaciones inestables (comportamientos inapropiados, apoyo deficiente de enfermeras, instructores y otros cuidadores), Planificación inadecuada (pérdida de tiempo para los estudiantes en las prácticas clínicas, preparación inadecuada de instructores y estudiantes), Tensión percibida (estrés, ansiedad y miedo), Desarrollo personal y profesional (aprendizaje más constante, atención a la dimensión espiritual del cuidado, aumento del interés por la profesión, aumento de conocimiento y mayor autoconfianza).

Conclusión

Los resultados de este estudio mostraron que los estudiantes de enfermería tienen experiencias deseables e indeseables en la práctica clínica durante el proceso de formación, las cuales deben ser tenidos en cuenta con una planificación adecuada con el fin de reducir los problemas en la educación clínica de los futuros enfermeros.

Palabras-clave: educación en enfermería; grupos focales; investigación cualitativa; estudiantes de enfermería

Resumo

Objetivo

Compreender as experiências dos estudantes de enfermagem na educação clínica.

Métodos

Se realizou um estudo qualitativo utilizando análise de conteúdo. Os dados foram recolhidos mediante entrevistas nos grupos focais com 16 estudantes de graduação de duas escolas de enfermagem de carácter público das cidades de Shiraz e Fasa (Irão). Os participantes foram selecionados por amostragem intencional. A análise de dados se realizou de acordo com a técnica de análise de conteúdo.

Resultados

Deste estudo surgiram cinco categorias: Interrupção entre a teoria e a prática (diferença entre conhecimento teórico e o treinamento clínico, incapacidade para usar o conhecimento teórico na prática, rotinas), Comunicações instáveis (comportamentos inapropriados, apoio deficiente de enfermeiras, instrutores e outros cuidadores), Planificação inadequada (perda de tempo para os estudantes nas práticas clínicas, preparação inadequada de instrutores e estudantes), Tensão percebida (estresse, ansiedade e medo), Desenvolvimento pessoal e profissional (aprendizagem mais constante, atenção à dimensão espiritual do cuidado, aumento do interesse pela profissão, aumento de conhecimento e maior autoconfiança).

Conclusão

Os resultados deste estudo mostraram que os estudantes de enfermagem tem experiências desejáveis e indesejáveis na prática clínica durante o processo de formação, os quais devem ser tidos em conta com uma planificação adequada com o fim de reduzir os problemas na educação clínica dos futuros enfermeiros.

Palavras-Chave: educação em enfermagem; grupos focais; pesquisa qualitativa; estudantes de enfermagem

Introduction

Nursing is one of the key disciplines of the health care team and play many roles in various fields.1 Nursing education has two theoretical and clinical aspects. The clinical aspect of nursing education, due to the creation of conditions and the real environment, prepares learners for the role of care, education, rehabilitation and so on.2) The clinical training is the mainstay of nursing education.3,4 Nursing education faces issues in the clinical education environment, which requires special attention to the clinical environment and facilitating the context and conditions for learning the best of students' knowledge and skills.1 The quality of nursing care depends on the quality education in the clinical setting, and the qualitative clinical education is provided, the more successful and professional students will graduate, which can result in a healthier community.1,5

Training includes various components such as students, instructors, resources and facilities, hospital staff, educational materials, and clinical settings. To understand the status of education, one can use the views of stakeholders and experts.2 As stakeholders, students have a better understanding of the educational services due to their direct interaction with the clinical environment about the quality of education in the clinical setting and the problems of clinical education.1 Clinical educational environment as the first place can be effective in choosing or rejecting nursing profession by students. Students' experiences in this environment will lead to a better understanding of the conditions prevailing at the clinical environment and thus a better understanding of the factors affecting clinical education.5,6

Many factors, such as the quality of instructors' education, the quality of the monitoring of the student learning process, the educational facilities and the psychological environment affecting the clinical environment, affect education of nursing students in clinical setting.4 Identifying the problems and challenges of clinical education and timely correction facilitate the training process and improve the quality. Given the importance of clinical learning and education in nursing as well as fifteen years’ experiences of researcher in nursing education and its related challenges, and that most of the studies have only slightly evaluated the clinical teaching qualities, the researchers decided to conduct a study to get a deeper and more comprehensive view on nursing students' perception of clinical education with a qualitative approach aimed at explaining students' perceptions of this important phenomenon.

Methods

A qualitative descriptive design using a content analysis approach was used to comprehend the experiences of nursing students in clinical education. According to qualitative researchers, individuals actively participate in social interactions and have different experiences. Qualitative descriptive design is an appropriate tool for obtaining rich and deep information from participants.7) In this research, the participants (16 nursing students) were selected using purposeful sampling and were approached face-to-face, proportional to qualitative research. In this type of sampling, which is widely used in qualitative researches, the researcher is looking for those who have a rich experience in the phenomenon studied and the ability and willingness to express it clearly. Sample size criteria in this study were similar to qualitative studies to reach data saturation (by 16 nursing students), and where new data were not collected; sampling was completed.8 Sixteen nursing students from the 5th semester in two nursing schools (Iran) who had sufficient clinical experience in the hospital and wished to express their experiences and views, were selected to participate in the study. The important characteristics of participants were willingness to sharing their experiences, having experiences in clinical learning environment and were from two genders. All participants completed the interview till the final stage of the study and no one dropped out. A relationship was established between researcher and participants prior to study commencement. The participants were explained about the goal of study, reason for doing the research and they know the researcher. Subjects were interviewed by focus group method for open and semi-structured interviews. The place of conducting interview was determined by agreement between researcher and participants (in nursing school, at the office of researcher). Interviews with nursing students were conducted by corresponding author (Majid Najafi Kalyani, Ph.D, Assistant Professor at the time of study, Male, 34 years old) and recorded by voice recorder device after getting permission of participants. In the place of conducting interview there were the researcher and participants and no one else present. The researcher had 15 years’ experiences in nursing education and 5 years in conducting qualitative research. The interview was started with a general question: How did you describe one day of your clinical education? Then, based on the obtained data, more questions were asked for further explanation, and for obtaining in-depth data. This question was tested in three pilot interviews. Each focus group interview lasted from 80 to 120 minutes. There were not repeat interviews. Data analysis was performed using content analysis approach. After handwriting the interviews, each transcribed interview was read and the text was broken up in units of meaning. In the next step, the primary codes related to each other were grouped into one group. Subsequently, each of the codes obtained was adapted to the participants' statements. In the final step, based on similarity and content, subcategories were integrated to main categories.7,8) Data coding and analysis were done by two researchers.

For trustworthiness of data several methods were used: Prolonged engagement, a review of the analysis performed by Peers check and reviewing the entries by the participants in the member check.7 The objectivity of data, which is important in qualitative research, means that the two researchers had the same results from handwritten notes and reports. Objectivity of the data was done through continuous involvement and investigation, appropriate treatment and accuracy in all stages of the research and clarity of the research method.7 The regional ethics committee of Shiraz University of Medical Sciences approved this study (IR.SUMS.REC.1395.S976). Before data collection, participants informed about the objective of the study and their written informed consent was obtained. The participants were assured that their information would remain confidential and were allowed to leave the research process at any time. Moreover, each quotation was identified by participants’ number in the results.

Results

Three hundred forty-eight initial codes were extracted from research data. After classification, the experiences of nursing students were divided into five general categories including theory and practice disruption, shaky communications, inadequate planning, perceived tension and personal and professional development (Table 1).

Table 1 Categories and Sub-categories derived from the experiences of nursing students from clinical education 

Theory and practice disruption

From the viewpoint of the students participating in the study, the disruption of theory and practice in nursing was part of their perceived experiences of clinical training. This class has implications of the inability to apply the lessons learned in practice, the routine, and the difference of clinical training with theoretical knowledge. Participants in the study believed that their lessons in the classroom could not be used in clinical training and in work with patients. The majority of students experienced this problem. Participant 12: In your lessons, principles and techniques tell us something about dressing up saying that you have to step in the steps ... but in the ward, there is nothing like that... they do it as they wish and tell us you do not need to act like practice. Participating students saw the contradiction between theory and practice as a source of confusion. Participant 7: In the ward, some staff is working very different from what we read. These makes me confused and not know exactly what to do. In addition, personnel routine leads to a greater disruption of theory and practice from the students’ perspective. Participant 3: We went to different wards, the nurse and the instructor who taught us when we did not have a student and we were with them, the routine and misleading ones, who themselves knew what they were doing wrong, themselves admit to non-sterile effects.

Shaky communications

Participants in this study believed that the fragile and insecure communication with them by nurses, educators and other staff in influences clinical training. Inappropriate behavior and lack of support from instructors and nurses were the constituent concepts of this class. Students who participated in the study said that in the face of the problems and the questions they had faced, the staff had an inappropriate behavior with them, which affected their clinical training. Participant 15: I was asking about the penicillin injection ... I went to ask the nurse. “Go and ask your instructor,” she said with an offensive and ridiculous behavior ... I tried not to ask them again if I had a question. The lack of adequate support from trainers in clinical training was another one that was experienced by students. Participating students believed that lack of support from instructors would reduce their eagerness to learn and pursue training. Participant 2: On the sick side, I wanted to have an angiocath, the instructor told me you cannot; let your friend do so. If I make a mistake, the instructor should support me to learn." This lack of support makes me lose my confidence and unable to learn. Inappropriate behavior with the student causes his lack of follow up and his interest in clinical training. Participant 13: I was by a patient whose doctor came with the medical students for a visit ... I greeted them but they did not answer. Although I wanted to stay and see what I was doing, I came to the sick room but with this behavior, I went out.

Inadequate planning

Participants in this study experienced poor training planning, wasting time in clinical education, and inadequate skills of instructors and students in clinical education, and considered it a factor in poor clinical training. Nursing students believed that poor training and planning in clinical training affect their motivation and their interest in learning in the learning environment. Participant 6: Some of the trainings we go to are not at all clear which goal we are seeking, as if it was just going to take a course. As such, there's no interest and motivation for us. Some students said their apprenticeship planning and their clinical training would waste their time in clinical training. Participant 9: Some units of the theory are not practical, and we just waste time. From morning to noon, we go to the ward and in the end, we see losing our time today. In addition, participating students believed that their lack of knowledge and skill and their instructors were effective in clinical training. These students considered their scientific readiness and scientific and practical training of instructors as a prerequisite for clinical training. Participant 4: Some trainers' information is not up-to-date, such as what is happening or what is new or what is new in the clinic or drug information, sometimes the instructors do not know much (they were student 30 years ago). A trainer who cannot, for example, use Foley catheter how can he teach his students.

Perceived tension

One of the classes related to the experiences of nursing students was the perceived tension. Nursing students experienced clinical training with stress and anxiety and believed that the clinical training environment and the nature of clinical training would cause them problems. Participants in this study considered the clinical training as stressful and believed that doing work on the patient caused their stress and anxiety. Participant 11: I am stressed when I want to go over the head of the patient and do angiocath. All of this I think that I will ruin and the patient's veins. The majority of participating students expressed their stress in the clinical training by presenting their work in the presence of the trainer. Participant 6: I was in the emergency ward that I went to angiocath for one of the patient. The professor came up to me and told me that if you did it right, I would give you a score of twenty if I do not do more than fifteen if you do it right ... I could not do the right thing, because the master made me stressed out.

Participating students mentioned the fear of unknowns, the fear of not doing the job and the fear of scores by the instructor as sources of stress. Participant 8: When the instructor tells me to go over the sick and do the sick work ... I have a lot of fear and stress not to make mistakes, and if the instructor understands will reduce the score from me. The experience of teaching practical skills for the first time was another reason for the stress and anxiety of nursing students. Participant 15: The first time our trainer wanted to teach us how to stitch, he was a sick person who was torn. I was very stressed, even though our trainer did it, but my hands and feet and the rest of the kids shook.

Individual and Professional Development

One of the positive experiences of nursing students from clinical training classes is the individual and professional development. In this study, the participants referred to more sustainable learning, attention to the spiritual dimension of care, increased interest in the profession, more knowledge and self-confidence. According to students participating in the research, clinical training improves the learning and sustainability of their learning. Students believed that the use of learning in clinical training would make them learn deeper. Participant 10: What we read and understand the thing we read in theory here objectively, which makes learning better and stabilized. The nursing students participating in the study believed that clinical training would further increase their attention to the spiritual dimension of nursing and caring for the patient. Participant 1: We did not notice much about the issues of the class we were in. Now that we have come to the hospital and we are educating the sick, we just found out how spirituality of nursing is high. The very doing of something for the patient itself is of general spiritual value. This is my spiritual dimension, which increases my interest in the field and ignores many of the problems. Clinical training from the perspective of students has made them more aware of the nursing profession. Participant 5: When I came to see hospitals, received training, and worked on the patients, I just realized what the nursing was, what I did not know exactly at the time. Now, it is completely clear to me what kind of career it is, what place I am, what I have to do. In general, I know much more. Another positive aspect of clinical training, from the perspective of nursing students, was increasing their self-confidence. Participating students believed that work on patients and training in the hospital's real environment increased their self-confidence. Participant 14: When you do something some times for your patient, you yourself are confident that you are doing it yourself, you learn, you will learn more, for the next time you want to do it, you do not worry, you are sure that you have done the right thing as you did it right before.

Discussion

The results of this study showed that nursing students have a number of desirable and undesirable experiences during clinical education. Theoretical and practical disconnection, shaky relationships, inadequate planning, and perceived stresses were classified in the domain of undesirable experiences, and personal and professional developments were classified in the domain of desirable experiences. The disconnection of theory and practice in nursing was part of the experiences perceived by the students from the clinical education. Participants in this study believed that what they learn in the classroom is not applicable to clinical education and working on the patients. In their study, Salehiyan et al.9 mentioned the existence of a gap between theory and practice. The studies carried out show that the disconnection of theory and practice, in addition to learning and educational problems, causes stress and do not received good support in students as well.10,11

The experiences of the majority of students in this study indicated the inconsistency of theory and practice in nursing. Besides this, the personnel were being routine oriented leads to the disconnection of theory and practice being noticed more from the perspective of the students. These results are consistent with the results obtained by other studies and show that the gap between theory and practice in nursing has its roots in the history of nursing education, and solving this problem requires the coordination and collaboration of instructors, nurses, students, and managers.10-13

Another undesirable experience of nursing students was shaky relationships. In addition, insufficient support by the educators in the clinical education was another case that was experienced by the students. The participating students believed that the lack of support from educators would reduce their eagerness to learn and pursue education. The results of a study performed by Chan et al.14 in Hong Kong showed that lack of adequate support for the students by the educators leads to stress in nursing students in the clinical education environment. In his study, Salehiyan and Armat 9 showed that the lack of the support of the educator from the students would discourage them. In their study, Rahimaghaee et al.15 pointed out the unsupportiveness of the clinical environment and they also mentioned the personnel as the negative learning patterns. These students were complaining about the rejection by the personnel and their undesirable relationships, which they introduced these cases as the subtheme of unsupportive atmosphere. Shen and Spouse16 in their study have pointed out the bad and harsh treatment of students in the clinical environment. In the research of Saifan et al.11) more than half of participants complained that they were treated improperly by their instructors in clinical learning environment. Poor educational planning, wasting the time of students in the clinical education and inadequate preparation of educators and students in clinical education was another undesirable experience of nursing students from clinical education in nursing. Kermansaravi et al.17 in their study, showed that the job description of the students in some sections are not clear and the educational planning is not in a desirable condition. Some of the participating students in the study stated that the undesirable planning of their apprenticeship and clinical education wastes their time in the clinical education environment.

Another category related to the experiences of nursing students from the clinical education was the perceived stress. Nursing students experienced the clinical education with stress and anxiety and believed that the clinical education environment and the nature of the clinical education would cause problems among them. Students struggle with various problems in the clinical environment. These problems cause stress among the students and will entail psychological problems such as anxiety and depression.18 Studies have shown that the clinical experience is one of the most stressful components of the nursing education program. Lack of sufficient clinical experience, unfamiliar environments for the students, difficult patients, fear of making mistakes, and concerns about the evaluation by instructors, have been mentioned as stressful situations in the clinical experience.19-21 The majority of the participating students expressed the source of their stress as performing their work in the presence of an educator. The participating students mentioned the fear of unknowns, the fear of not doing their job properly and the fear of reduced score by an educator as the sources of their stress. The clinical environment is inherently stressful, and factors such as new situations, uncertainty about the results of caring practices, the fear of providing the wrong care, changes in the patient's natural conditions, lack of sufficient knowledge and skills in care, lack of familiarity with the clinical environment, work with unwell patients, and the feeling of being under supervision cause the incidence of stress in the students.22-24

One of the desirable experiences of nursing students from the clinical education was the individual and professional development. In this study, participants pointed out the more sustainable learning, attention to the spiritual dimension of the care, increased interest in the profession, higher knowledge, and self-esteem. Clinical education can lead to more sustainable learning in nursing students.25 Another positive aspect of clinical education, from the perspective of nursing students, was the increase in their self-esteem. The participating students believed that work on patients and training in the hospital's real environment increased their self-esteem. In their study, Heshmati et al.26 found that the self-esteem of the students increased in the clinical education environment and it consequently caused the promotion of their learning. From the perspective of the nursing students, the clinical education, and along with it the support of nursing staff in teaching new situations, causes an increase in their self-esteem.27

Conclusion

The results obtained in this study showed that the undesirable experiences of nursing students from clinical education, such as the disconnection of theory and practice, shaky relationships, poor educational planning, and the perceived stress, have an important and influential role in the education of these students. Nursing students believe that the reduction of the gap between the theory and practice, and practice along with the support of nursing staff and educators in their clinical education, leads to their better education. Additionally, proper planning and sufficient preparation reduce the students' problems in the clinical education. Considering the role of clinical education in the development of individual and professional skills of the nursing students, the results of this study could be helpful in the fundamental planning of nursing education and its qualitative improvement.

Acknowledgment

This paper was extracted from an approved research project (No. 11986) in Shiraz University of Medical Sciences. The authors appreciate the cooperation of participants for sharing their experiences.

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Received: March 20, 2018; Accepted: September 19, 2018

Conflicts of interest:

none.

How to cite this article:

Bazrafkan l, Kalyani MN. Nursing Students' Experiences of Clinical Education: A Qualitative Study. Invest. Educ. Enferm. 2018; 36(2):e04.

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