Clinical Accompaniment: The Critical Care Nursing Students’ Experiences in a Private Hospital

The quality of clinical accompaniment of the student enrolled for the post-basic diploma in Medical and Surgical Nurs­ ing Science: Critical Care Nursing (Gen­ eral) is an important dimension of the educational/learning programme. The clinical accompanist/mentor is respon­ sible for ensuring the student’s compli­ ance with the clinical outcomes of the programme in accordance with the re­ quirements laid down by the Nursing Education Institution and the South Afri­ can Nursing Council. The purpose of this study was to explore and describe the experiences of the students enrolled for a post-basic diploma in Medical and Surgical Nursing Science: Critical Care Nursing (General), in relation to the clini­ cal accompaniment in a private hospital in Gauteng. An exploratory, descriptive and phenomenological research design was utilised and individual interviews were conducted with the ten students in the research hospital. A content analy­ sis was conducted and the results re­ vealed both positive and negative expe­ riences by the students in the internal and external worlds. The recommenda­ tions include the formulation of stand­ ards for clinical accompaniment of stu­ dents. the evaluation of the quality of clinical accompaniment of students and empowerment of the organisation, clini­ cal accom panists/mentors and c lin i­ cians.


Introduction
Clinical accom panim ent of the critical care nursing student is a very important dimension of the formal post-basic edu cational/learning programme.The Nurs ing Education Institution offering the pro gramme is responsible and accountable for ensuring quality clinical accompani ment of the nursing students to facilitate optimal achievement of the learning out comes of the post-basic Medical and Surgical Nursing Science: Critical Care Nursing program m e.These learning outcomes relate to both the theoretical and clinical com ponents of the p ro gramme in an integrated manner.The clinical outcomes have to be achieved in the clinical health care facilities -in this case the critical care units.A formalised system o f clinical a ccom panim ent is therefore necessary as part of the edu cational/learning programme.The postbasic Medical and Surgical Nursing Sci ence: Critical Care Nursing is offered by a Nursing Education Institution in col lab ora tion w ith the p rivate hospital, based on the approval of both the edu cational programme and the clinical fa cilities by the South A frican Nursing Council as the regulatory body for nurs ing education/learning in South Africa (Government Notice R2118, 1983).This research focuses on the clinical accom panim ent of critical care nursing stu dents in a private hospital in Gauteng.The following research question is rel evant: how do the critical care nursing students in the private hospital experi ence the clinical accompaniment?The purpose of the research is to explore and describe the experiences of the critical care nursing students in relation to the clinical accompaniment in a private hos pital in Gauteng.These experiences could provide a better understanding regarding the problems experienced by students and the type of accom pani ment required.These results could then be utilised for the improvement of the quality of clinical accompaniment of the critical care nursing student in the pri vate hospital.

Terminology And Assumptions
Experience The lived experience of the critical care nursing student in relation to clinical ac com panim ent during the educational/ learning programme in a specific private hospital in Gauteng.

Critical care nursing student
The critical care nursing student is a reg istered nurse and/or midwife enrolled for the D iplom a in Medical and Surgical Nursing Science: Critical Care Nursing (General) at the particular Nursing Edu cation Institution in Gauteng.
Clinical accom panim ent Clinical accompaniment is a formal proc ess of guidance and facilitation by a reg istered critical care nurse in the clinical units to facilitate and ensure achieve ment of the clinical outcomes of the edu cational/learning programme.

Assumptions
The following assumptions are applica ble:

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The critical care nursing student is a spiritual being (body, mind and spirit) functioning in an inte grated biopsychosocial manner.

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The experience of clinical accom paniment by the critical care nurs ing student is influenced by ex ternal and internal environmental factors.

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The critical care nursing student is exposed to different clinical units in three different hospitals within the private group in Gau teng during their year of educa tion and learning.(Thomas, 1990:93) was done to include all the nursing students due to their small number.The interviews were conducted one month after completion of their studies to ensure retention of their lived experience, but to avoid with holding of information due to fear of vic timisation during the clinical examination period.Although these students were em ployees of one particular hospital, they were exposed to critical care units in three other hospitals, resulting also in three different clinical accompanists dur ing the period of learning and education.The interviews were tape-recorded, vali dated (sections thereof) with the inter viewee on completion of the interview and transcribed thereafter.Data-analysis was performed in accordance with the principles of content analysis as de s c rib e d by Tesch (in. C re sw ell, 1994:153).An experienced independ ent coder (with a doctorate in Nursing Science) was also used.Although the principles of open coding were applied during the data-analysis, the results were classified under external and internal world/environmental experiences.Trust worthiness of the study was ensured by applying the principles as described by Guba (Lincoln & Guba, 1985:300) as follows:

Research Design
• the researcher is a registered criti cal care nurse with experience as a clinical accompanist of critical care nursing students in the re search hospital; • an independent coder was used to ensure objectivity of dataanalysis; • the results were discussed with the participants to ensure mem ber checking; • the results were exposed to a lit erature control; • an audit trail on the research method, raw data and final results are available.
Ethical considerations included the ob taining of informed consent from the hospital authority as well as from the in terviewees.General research-related human rights were also adhered to in relation to the following: privacy, ano nymity and confidentiality of participants (South A frican N ursing A ssociation, 1991).

Results
A total of ten individual phenomenologi cal interviews were conducted.The re sults are grouped into two main themes: internal and external environmental ex periences (see table one).These expe-

Internal environmental experiences
The internal environmental experiences relate to the physical, mental and spir itual dim ensions of which there were both positive and negative experiences.The s tu d e n ts (N = 10) e xpe rie nce d physical tiredness as a major stumbling block due to increased workload and the dem ands of both the theoretical and clinical program m es sim ultaneously.
The following direct quotations underpin this experience by the students: " It was extremely tiring with immense physical strain throughout the year" ; "The physi cal demands were very exhausting" ; " I was very tired throughout the year." The mental experiences focused mainly on satisfaction with the clinical accom paniment, intrapersonal conflict due to contradicting theoretical principles and expectations by the Nursing Education Institution and clinical realities in the units (N = 10).They were of the opinion that the theory and clinical realities were in conflict and that many of the clinical reg istered critical care nursing practitioners were outdated in both knowledge and s k ills .They th e re fo re expe rie nce d (N=8) inadequate clinical accompani ment by the majority of the rolemodels, unit managers, m ulti-disciplinary team members and even by the clinical ac com panists themselves: "The theory and practice are too far apart and differ ent" ; "The rolemodels are just absentmany of the sisters are too outdated and even unwilling to teach us" ; "The clini cal tutor couldn't be everywhere at the same tim e" ; "The university expects too much in too little tim e" .The students expressed an urgent desire to be as sisted with this co nflict between the theory and reality and that the group (students, clinical practitioners, unit man agers and clinical accompanist) should have the opportunity to reflect on cer tain clinical practices and theoretical education: "We need to bridge the gap between theory and practice" ; "The aca demic expectations by the university and clinical realities need to be m atched" ; "The doctors are good -very good, but the sisters don't know what and how to teach us -they need to help us to un derstand why are we doing what." Most of the students (N=8) were satis fied with the quality of clinical accompa niment offered by the clinical tutor of their base hospital: "She was excellent -al ways ready to challenge you" ; "She was always there for us" ; "She went out of her way to assist us and to make you feel comfortable" ; "She can drill infor mation out of you until you get it right" ; " I enjoyed most of the clinical accompa niment -it was great" ; "On a bad dayjust seeing her made you feel better -it calms you down" ; "She was always sup portive" ; "She made you feel safe -I trusted her knowledge and ability" ; "She made me gain confidence." Whilst the students were very motivated when they commenced the course, they experienced a sense of dem otivation and neglect during the course due to reality shock and the level of stress in the units and a general lack of caring (N = 10).
A n o th e r reason fo r dem otivation was due to the fact that they were not also treated as adults dur ing clinical education (N=5) as con firmed by some of the direct quotations: "They treated us as children -1 had many years of experience which was just ig nored" ; " I was very motivated when I started -but gradually became dem oti vated because of the shock I experi enced in the units" ; "You really felt not cared for" ; " People are just too busyno one cares about you"; " I only saw the clinical tutor twice a month which wasn't enough" ; "You need to initiate your own learning -be self-driven" ; "You must ask what you don't know" ; " It de pends how w illing you are to learn" ; "You need to be self-driven; have inner motivation" ; "You need to also rely on yourself -it is up to you to find your way" ; "You have to be able to stand on your own feet." All the students experienced immense emotional stress during the programme emanating from a lack of knowledge, inability to meet the mental, emotional and physical demands in the units, and the great responsibility delegated to them to nurse very seriously and com promised patients.They were of the opinion (N=6) that the stress levels have a negative influence on their ability to acquire the necessary clinical abilities (knowledge, skills and attitudes).The pace was also too fast, resulting in im patience and intolerance by the nursing unit managers and other professional practitioners.They were therefore frus trated with the whole setup and lack of an adequate educational structure as substantiated by the follow ing direct quotations: "There are times that you really felt frustrated nursing very sick patients; " In the beginning it was nerve racking; " I in itia lly experienced the course as very traumatic" ; "Very stress ful with inadequate guidance by the clini cal tutor; "You felt the pressure all the tim e" ; "One clinical tutor is not enough -there must be more than one, espe cially in the beginning of the course" ; "Often you felt intimidated by the sisters -rather than being able to ask them to help you, you just don't" ; " I would like to be accompanied more frequently" ; " I would have liked to be accom panied more often" ; "Students must be accom panied all the time." Insecurity was therefore experienced by all the students and the clinical accom panist couldn't meet their demands in this regard -she just couldn't be every where at the same time.This also re sulted in experiences o f being very scared w hilst nursing the seriously ill patient.They therefore experienced the clinical situation as awful in the begin ning with a feeling of being neglected by the clinical accompanist and the lack of an allocated clinical mentor in each unit for each student to give the necessary on-the-spot guidance/accom panim ent and e m o tion al support." I fe lt very scared -not knowing what to expect and what to d o " ; "These equipment -very scary; " It was frightning to work there" ; " I felt very neglected at times" ; " Patients are very sick and you feel very incapa ble" ; "You are thrown into the deepvery scary" ; " I felt awful not knowing what to do." The clinical accom panim ent was also experienced as a happy and joyful oc ca sio n w hen th ey w ere a ssisted in achieving the objectives/outcom es re s u ltin g in a sense o f tre m e n d o u s achievement and excitement." It was very exciting to know you can now do it" ; " It was nice to tick off the items on the register" ; "There is a lot of art that she can get across to you that yo u 'll never learn theoretically -she has a lot to offer and you must just tap that" ; "She is the person to help you to put theory and practice together." As they progressed in the acquiring of skills, they experienced more confidence (N=6) and could enjoy the challengesboth intellectual and clinical skills." I felt that sense of achievement and it was great" ; " I had more confidence and en joyed being challenged by her" ; "They started giving me a chance to nurse more complicated and the very sick pa tients."Some of the students (N=2) experi enced interpersonal co nflict with the clinical accompanist that was overall in charge of their clinical accompaniment.These students were therefore of the opinion that there should be more than one accompanist/mentor with the option of self selection by the students."She and I had a personality clash -we just couldn't fit" ; " I had the feeling that she didn't like me" ; "You should be able to choose your own clinical tutor to match your personality" ; "She didn't want to take responsibility for the clinical teach ing." A lthough a positive trust relationship between the students and the accom panist was initially absent, they were of the opinion (N=5) that this trust rela tionship gradually increased and they felt trusted and m otivated to do their best." I experienced more trust and was allocated to the very sick and com pli cated patients" ; "The clinical tutor chal lenged me -1 could trust her on this."

External environmental experiences
The w orkload was seen as the m ost negative external environmental experi ence (N=10) with a high ratio of patient allocation and the fact that the student does not have supernumary status in the u n its -s/h e is p a rt o f th e n orm al workforce and this inhibits optimal clini cal learning.The critical care units also have an unpridictable bed occupancy resulting in too high working demands at times or inadequate learning oppor tunities and boredom when there is too little to do.The following direct quota tions are applicable: "There is just too much work to d o " ; " Patients allocated to you were uninteresting for learning p urpo ses" ; "A llocation did not meet learning needs" ; "Wrong allocation of patients, not meeting my learning needs -very boring at tim es" ; "They allocated the demanding and unpopular patients to us -not meeting our learning needs;" "Too busy -no time for learning."Time constraint was also experienced as a major limitation by all the students, to such an extent that some were of the opinion that the duration of this course/ programme should be extended to a two year diploma.The specified time to ac quire a particular clinical skill was inad equate, resulting in consistent pressure by the clinical accom panist and thus not allowing for self pace by the student."There was too little time to meet all the learning dem ands by the university" ; "The time is too little -should be done over two years m aybe" ; "Too much pres sure and too little tim e for all of it." There is also a lack of adequate orienta tion by the unit managers in relation to the physical layout of the units, the gen eral policies and procedures applicable to that particular unit, as well as to the equipm ent used.This was especially experienced by the students (N = 10) when they commence duty in a new unit where they have never worked beforethis unit could also be in another hospi tal within the group, depending on the available clinical learning opportunities in their "own" hospital, necessitating a rotation system in different hospitals w ithin the private g ro up in Gauteng.There was also a lack of role clarifica tion between that of the student, the clini cal accompanist and the unit managers, resulting in frustration experiened by the students." It would be nice to be intro duced into the new units by your tutor on the first day" ; "The equipment is com plicated -you need someone to guide you on how they work" ; "They need to show you the geography of the unit" ; " I was not orientated -no one showed me around -it is a new unit and you defi n ite ly need so m e on e to sh ow you around." The students (N=6) expressed a high level of gratitude for being able to do this course in a private hospital setup.They also expressed positive feelings towards the high standard of critical care prac tice in their hospitals in comparison to other units where they had to spend some time on certain learning opportu nities.This experience made them real ise to appreciate their own working cir cumstances." I feel very grateful to man agem ent fo r allo w in g me to do this course" ; "After having seen other units in ... I am happy and grateful to work here" ; "We have the best -both in equip ment and doctors" ; " I feel privelaged to work here and to do the course."Some students (N=4) expressed frus tration with the lack of correlation be tween theory and practice.When a spe cific system was dealt with in theory, they were placed in another type of unit due to the logistics of student allocation." It would have been nice to work in the unit when you were doing the theory" ; " I sometimes did the theory but worked in another unit and lacked the knowledge for that unit."It is not unusual for the nursing student to experience stress during a form al post-ba sic e d u catio na l/lea rn ing p ro gramm e (Bailey & Clarke, 1989:73).Mahne (1987) also confirmed the in tensity of stress experienced by the criti cal care nursing practioner in South Af rica.Negative emotions, such as frus tration and fear/insecurity are regularly experienced by critical care practioners (White & Ewan, 1991:144).
They also stress the presence of interpersonal and intrapersonal stress and conflict experi enced by critica l nurse practitioners when theory and practice d on 't corre late.The educators needs to be sup portive, facilitative and empathetic in their educational relationship with students (Knowles, 1980;Klopper, 1994a/b).Mahne (1987:77) confirmed the need for coping mechanisms by the critical care nurse practitioner and the need for support systems and stress m anage ment programmes.The importance of c o n tiu a l p ro fe s s io n a l d e v e lo p m e n t (clinical, educational and research abili ties) was confirm ed by Dannenfeldt (1988).The post-basic nursing student requires a support system in relation to the management of a clinical education/ accompaniment programme with a for malised approach to the planning, or ganisation, implementation and evalua tion of such programmes (Mellish, Brink & Paton, 1998:77;Muller, 1998:336-341).The clinical accom panim ent of post-basic Medical and Surgical Nurs ing Science students therefore requires a formalised approach: the organisa tio n a l stru c tu re , d e lin e a tin g all the roleplayers -from the nursing service manager, the nursing unit manager, the clinical accompanist, the clinical nurse practitioners and the multi-disciplinary team members -need to be described.A role clarification by means of written job descriptions for each roleplayer is necessary.A formal clinical education programme, developed in consultation with the Nursing Education Institution, should be place.The students need to be supported physically, mentally and spiritually.The commitment of the health care organisation and nursing service towards formal education is reflected in this support programme.

Conclusions and Recommendations
The following conclusions are made: • there were both internal and external environmental experiences by the stu dents; • the internal environmental experiences relate to satisfaction with the clinical ac c o m p a n im e n t; p h y s ic a l tire d n e s s ; intrapersonal conflict due to inconsisten cies in theory and practice; initial moti v a tio n w h ic h p ro g re s s e d to w a rd s demotivation; emotional stress, frustra tion and insecurity; gaining of confidence and a sense of achievement; • the external environmental experi ences focused on high workload, too lit tle time and too much pressure, interper sonal conflict and positive trust relation ships; • most of the students (N=8) were satisfied with the quality of clinical ac companiment received by the appointed clinical accom panist/m entor, but they were dissatisfied with the quality of clini cal a cco m p a n im e n t received by the other critical care nursing practitioners in the units; • the students (N=6) expressed grati tude towards their management for be ing able to do the course; • the formulation of standards on clini cal accompaniment on least the follow ing: the pre-requisites of clinical accom paniment, the management of clinical accompaniment in a health care organi sation, responsibilities of the different roleplayers and the process of clinical accom panim ent in relation to Medical and Surgical Nursing Science; • a role clarification of the different roleplayers in clinical accom panim ent with written job descriptions for each; • a formal programme on continual clini cal e m p ow e rm en t of all the clin ica l roleplayers concerned to enable quality clinical accompaniment; • inservice education to the unit man agers, clinical practitioners and clinical accom panists/mentors on their role of clinical accompaniment of students and the general principles of adult education; • inservice education to the clinical ac c o m p an ists/m en to rs on co ntingency leadership and the relationship thereof in clinical education/accompaniment; • active involvement of the medical practitioners/intensivists in the clinical edu cation programme; • the development and implementation of a formal orientation programme for post-basic Medical and Surgical Nurs ing Science students in each clinical unit; • the establishement of a formal com munication system between the Nursing Education Institution and the clinical ac companists to address the theoretical and clinical inconsistencies; • the development, implementation and evaluation of a support and stress man age m e nt pro gram m e fo r post-ba sic Medical and Surgical Nursing Science students; • research to determine the relationship between internal motivation of the stu dent and the external motivating factors; • revision of the staff establishment of crititical care units and policy formula tion to allow for supernumary status of post-basic students; • the evaluation of the quality of clinical accompaniment of students enrolled for Medical and Surgical Nursing Science post-basic courses/programmes.

Concluding Remarks
Quality education is necessary to facili tate the achievement of the outcomes of the educational/learning programme in Nursing Education.This implies that both the theoretical and clinical com po nents of the educational/learning pro gramme need to be of a high standard.An integrated theoretical and clinical educational approach is necessary to facilitate critical/analytical reflective think ing/reasoning by the post-basic student in Medical and Surgical Nursing Sci ence: Critical Care Nursing (General).

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The students had both positive and negative experiences in relation to clini cal accompaniment during their clinical learning/educational programme.The fo llo w in g reco m m en d atio ns are 35 Curationis June 2000 made: : internal and external world experiences by critical care nursing students on clinical accom panim ent during the educational I learning programme (N=10) High workload and non-supernumary status Time constraint Inadequate orientation in the units Inadequate role clarification Inadequate correlation: theory and practice