Student Nurses ' Learning Needs & Expectations in the Clinical Learning Units

This paper describes and explores the clinical learning needs and expectations of student nurses. An exploratory, descriptive and qualitative design, which is contextual in nature, was used where a focus group interview was conducted with the final year basic students undergoing a four year comprehensive diploma course leading to registration as a professional nurse. Tecsh's (in Cresswell, 1994:155) method of data analysis was employed. Eight categories were identified as follows: communication; role modelling; up-to-date knowledge and experience; continuous supervision; assessment and evaluation; scientific process; management; professional practice and student status. A recommendation deduced from the conclusions made on the identified clinical learning needs and expectations of the students should enable teachers to address the long standing problem of how students should learn.


Introduction
The learning needs and expectations of student nurses need to be viewed in the light of present educational innovations taking place in the country.The nursing profession has recognised that these needs indicates a responsibility to edu cate nurses who can reflect on their prac tice to facilitate learning through interac tive, self-generated and em pow ering methods of teaching and learning.As nursing moves into more autonomous, com m unity-based practice, the chal lenge for nurse educators is to assist stu dents to develop greater reflective think ing skills, improve awareness of self and environment, and to facilitate nurse's ongoing learning from their daily clinical practice (Baker, 1996:19).Presently, the learning needs -how students learn and how this learning can be sustained to meet the rapidly changing needs in the country -is of great concern nation ally and internationally (Wong & Wong, 1987:508;P ro c te r 1989:180 andCheung 1985:40).The high student nurses' attrition rate is also causing con cern (Mashaba& Mtetwa, 1997:21).The present students are no longer sensitive to the clinical practice and therefore do not regard clinical practice as an impor tant component in their training regard less of the fact that nursing is a 'hands on' profession (Gray & Pratt, 1991).The discipline in the profession is slowly di minishing as evidenced by the increase in the number of court cases, as well as cases presented before the disciplinary committee of the South African Nursing Council as supported by Ramsden (in Klopper, 1994, monograph 2:21).These issues pose as a challenge to the professional nurses who act as clinical learning facilitators, nurse educators and stakeholders responsible for the clinical training of student nurses.Take note of the message put forth by the Minister of Education and Training (White Paper, 1995:3) which states: " ... put the learner first, and the students of this country will respond magnificently."The implication of this message, according to the re searcher, is that the learning needs, stu dents interest and the status of students should be taken into consideration when planning clinical nursing education and learning activities.Educators and train ers should be sensitive to the needs of students, and that students should be prepared to take their social roles effec tively.According to Hinchliff (1979:47) training in the clinincal learning context is not smooth due to the problems that exist which create obstacles in the clini cal learning of students such as lack of human and material resources, lack of space due to overcrowding, few offices for tutorials and the tutor-student ratio.The author states that those offices that are available are used by doctors only.Loudon (1984:8) has also identified lack of supervision and student status as cre ating obstacles to student learning in the clinical practice.These problems need to be identified

Curationis December 1999^24
and improved because the nursing pro fession has an unwritten contract with the community to provide quality nurs ing care (Searle, 1976) and therefore "safe practice" should be the watchword of all responsible for the clinical training of student nurses, hence the research question of this study is: What are the learning needs and expectations of stu dent nurses in the clinical learning units?The goal of this study is to explore and describe the learning needs and expec tations of student nurses in the clinical learning units.

Method
An exploratory, descriptive and qualita tive design, which is contextual in nature, was used.The learning needs and ex pectations of student nurses in the clini cal learning units were better addressed through the use of a focus group inter view.According to Krueger (1994:6) a focus group interview is defined as a carefully planned discussion conducted with seven to ten people.It is designed to obtain perceptions on a defined area of interest in a permissive, non-threaten ing environment.From a population of eighty final year student nurses follow ing a course leading to registration for a diploma in nursing (general, community h e a lth , p s y c h ia try and m id w ife ry) registrable with the South African Nurs ing Council, a purposive sample of ten students who volunteered to participate in the research, was uitilised.Student nurses showed enthusiasm to take part in the research as evidenced by a cita tion: "It is hightime these issues are ad dressed and dealt w ith".A written con sent to conduct the focus group inter view using a tape recorder for data col lection was obtained from the partici pants.An expert interviewer, experi e n ce d in q u a lita tiv e re se a rch was purposively selected to conduct the fo cus g ro u p in te rvie w , w h ils t th e re searcher was collecting field notes dur ing the interview by noting the group in teraction and dynamics.Two questions were asked: W hat are your learning needs in the clinical learning units?How do you expect these learning needs to be met?A break was allowed after the first question was thoroughly dealt with.W hilst particip a nts were served with drinks and snacks, the interviewer and the researcher did a preliminary catego rization of concepts, them es and pat terns.A consensus between the re searcher and an external coder, also purposively selected, was arrived at with regard to the categories derived from the data collected.
Tesch's (in Cresswell 1994:155) proto col was used for the descriptive content 25 Curationis December 1999 analysis of data collected.Throughout the study, trustworthiness was ensured according to the principles of Lincoln and Guba (1985).The four principles related to: credibility, transferability, de pendability and confirmability were en sured.* P rolonged engagem ent: the re searcher is an experienced nurse edu cator.* T ria ng ula tion : by use o f various sources (nurse educators and litera ture), as well as utilising an external coder for content analysis of the tran scribed interviews.A concensus discus sion on the main categories was held for final interpretation purpose.A dense description of the research process was also given.

Control
The following eight categories emerged from the content analysis of data col lected, namely: comm unication; role modelling; up-to-date knowledge and experience; continuous supervision; assessment and evaluation; scientific process; management; professionalism and student status (see table one).

Com m unication
Participants emphasized the use of ef fective communication and colloboration as an important vehicle toward facilitat ing clinical learning.This is evidenced by the following quotation: "We need somebody who will be a liaison person between the college and the clinical prac tice, somebody who will be a consultant, a resource person, a counsellor and an advocate to us."To express the need for a healthy relationship in the clinical practice, the participants cited: "... a common platform to communicate our ideas, for debating issues and to solve problems is necessary.At this platform the professional nurse is able to reach e ve ryb o d y a nd subo rd ina tes can also reach her."  Wiedenbach (1969:33) believes that the a b ility to com m unicate m eaningfully within the realities of a participative clini cal area, adds a practical dimension to student learning.D ependency on the effectiveness of com m unication, Fritz et al (in Gillies 1994:183) indicates that communication climate may either facilitate or inhibit learning.
Effective com m unication will facilitate and stim ulate learning as well as put learners at ease and free to interact, whilst the adverse will hamper learning and put fear and frustration to students.Students should be afforded the oppor tunity to develop effective communica tion skills.This developm ent can be made succesful by professional nurses providing a climate conducive to effec tive communication and learning.

Role m odelling
Role modelling was identified by partici pants as one of the most important char acteristics of a professional nurse from which student nurses can learn.This statement is supported by the quotation: "Professional nurses should act as role models and be examplary in all aspects i.e. academically, professionally, socially and in their administration and manage ment style, because students imitate their activities, good or bad." This n o tio n is s u p p o rte d by Barr (1980:49) who state that nursing per sonnel in the clinical learning units are prim ary role m odels w hose attitude, whether positive or negative are quickly observed and imitated by students.In the same vein Barr (1980:49) gives a warning that negative learning is expen sive with regard to time and it is also dif ficult to reverse.It is therefore important that professional nurses reflect on their action and be real 'm irror im ages' to

Up-to-date knowledge and experience
Participants expressed the need for ex pert, relevant and up-to-date knowledge and e xp e rie n ce fro m p ro fe s s io n a l nurses, as evidenced by the following citations: "... at college we are taught book and technical knowledge but in the wards we are faced with 'real' exicting clinical knowledge.
"To gain knowledge, we want to be ac tively involved in doctors and nursing rounds, hold mini-conferences to dis cuss nursing care problems and to be in charge of the wards when we are sen ior students.This knowledge will help us not to feel inferior to the doctors." Participants expressed the notion that they need 'rea l' know ledge and not 'technical knowledge'.The word tech nical refers to mechanical, where there is little use of critical thinking.Nursing deals with human beings and therefore critical thinking is mandatory in rational decision making and problem solving.Critical thinking, according to Wilkenson (in Klopper 1994, monograph 2:24) is a disciplined, self-directed rational think ing which is necessary for students to construct their own knowledge.Klopper (1994, monograph 2:16) also maintains that the learner is not a passive receiver of knowledge but an active constructor of own knowledge.The goal being the development of critical thinking through the creation of a context conducive to learning towards deep-holistic lifelong le a rn in g .Real le a rn in g w ill com e through conceptual change where the student will be actively involved in his/ her own learning, by integrating the book knowledge taught at college with the experience gained in the clinical learn ing units through the reflective process.In the clinical learning units the profes sional nurse is responsible to create a conducive learning climate (Hinchliff, 1979:50) that will stim ulate reflective thinking by encouraging students to take part in doctors and nursing rounds, hold mini-conferences and tutorials to reflect on their experiences and be given op portunities to be in charge of the units when they are senior students, as a learning experience to gain confidence, re s p o n s ib ility and a c c o u n ta b ility .Cerinus (1994:35) has urged that 50% of student's learning experience takes place in the clinical setting, whilst Dolaz (in Palmer et al 1994:37,54) maintains that learners are expected to justify and evaluate their actions, to rationalize and articulate debate to challenge situations raised in the clinical setting.It is there fore important that to avoid being taught 'technical' knowledge students need to develop reflective thinking skills through active participation in the construction of their own clinical knowledge and expe rience to be able to solve problems in a rational manner.According to Gray & Pratt (1991), development of reflective thinking skills will be facilitated by guided reflection through continuous supervi sion, assessment and evaluation.

Continuous supervision, assessment and evaluation
The need for effective continuous super vision, assessm ent and evaluation to enhance their learning was emphasized by participants.This was clearly dis played by the citation: 'We need effi cient, effective continuous supervision, assessment and evaluation from profes sional nurses and not the traditional nag ging, policing, and to be reminded time and again that we are final year students and therefore we are expected to be per fect.Evaluation should be a learning process and not a threat or punishment to students." Student nurses perceive supervision provided by professional nurses as nag ging and policing and evaluation as pun ishment to students.The implication is that supervision, assessment and evalu ation are not effectively executed by pro fessional nurses.This hampers learn ing in the clinical practice.To correct the situation, Ramsden (in Klopper 1994, m onograph 2:20) indicated that valu able feedback on the learner's work is essential for effective and efficient guid ance.Evaluation should be congruent with the teaching and it should awaken a deep-holistic approach to learning.Addressing the issue of evaluation, Barr (1980:49) states that real grow th in learning is impossible without the right to fail, and failing should not be taken negatively but considered as influencing and stim ulating the learning clim ate, hence Reilly and Oerman (1985:297) urges that a supportive climate of mu tual trust and respect between the evalu ator and the student is essential for su pervision and evaluation to be viewed as a means of growth valued by students.Reflective methods of evaluation such as portfolios, self assessm ent and peergroup evaluation are encouraged to pro vide a cooperative student-learner rela tionship and to build confidence in them selves.Schweer (1972:168-169) main tains that scheduled formal evaluation conference with students to discuss the positive and negative aspects of evalua tion may serve the purpose for which they are designed.Use of the scientific process during supervision, assessment and evaluation is recommended.

Scientific process
Participants acknowledged and realised the importance of using nursing process as part of the problem-based approach to develop reflective thinking skills in clinical learning.This is evidenced by the citation: "... to develop reflective thinking skills in clinical learning, profes sional nurses must use nursing process to provide guidance, and use clinical problems as stimulus aimed at problem solving process." Use of the nursing process effectively to provide guidance in clinical learning by professional nurses was highlighted by participants.Recently nursing process has been under heavy criticism that, in its present form, it is limiting the creativ ity of nursing practice due to its influence of positivism, rationality and empiricism.It is said to be time-consuming, jargon laden, superfluous and static Chenitz and Swanson (in Varcoe 1996:122) and Skeet and Thompson (1985:15).
Whilst researchers are criticizing the in appropriate use of the nursing process, Gordon and Field (in Varcoe 1996:120) state that the nursing process is useful to guide clinical practice.This calls for an urgent revisit to the effective use of nursing process to develop reflective thinking skills in clinical learning.For effective clinical learning to take place, m anagem ent skills need to be devel oped.

Management
Effective management skills was high lighted by participants as one of the piv otal aspects necessary to facilitate clini cal learning.This is evidenced by the quotations: "... the climate in the clinical unit can only be healthy and conducive to learning if professional nurses play their role as leaders who use participative management in rational decision-making and problem solving." "... hospital man agement must provide inservice educa tion to update the sisters, many sisters are obsoiute with obsoiute knowledge, u sing o u td a te d p ro ce d u re m ethods, p o lic y m anuals a nd o rie ta tio n p ro grammes.Obstacles to clinical learning must be removed."According to participants, effective man agement forms a pivotal aspect and is necessary to facilitate clinical learning.Areas such as use of participative man agement in rational decision making and problem solving in the clinical learning units, staff development, closure of the policy practice gap, updating orientation programmes, the need for standardiza tion of procedures, staff and student al location were highlighted In her discussion of participative man agement, Muller (1995:16) states that a climate of openness should be intro duced to facilitate problem-solving by joint planning, consultation, consensus and negotiation.This encourages a healthy environment.One of the chal lenges of a professional nurse is to in volve student nurses in clinical decision making and problem solving, to develop their negotiation skills without relinquish ing their role as students.This will make students realize the importance of ne gotiation rather than 'toy-toying'.Stu dents must be developed towards pro fe s s io n a l a d u lth o o d .W e id e n b a ch (1969:66) quoted: "The road to learn ing is often a rocky one." Effective management should provide smooth running of the clinical learning units.Reilly and Oerman (1985:4), main tain that clinical obstacles to learning such as lack of human and material re sources, obsoiute professional nurses, outdated policies and procedures, staff allocations and orientation programmes should be attended to.This statement is supported by Ryan et al (in Gray & Prat 1992:195).Professional Practise was also identified as an important need in clinical learning.

Professional Practice
Surprisingly, professionalism was the least im portant aspect highlighted by participants in clinical practice.As evi denced by a citation: "Sisters should act professionally and teach us professional p ra c tic e to avoid pun ish m en t by the South African Nursing Council and the law." Much as participants least highlighted the importance of professional practice in clinical learning, they also realised that lack of knowledge with regard to profes sional practice will lead to malpractice leading to d iscip lin a ry action by the South African Nursing Council.Barr (1980:48) maintains that regard-27 Curationis December 1999 less of the complexity and value-laiden clinical practice, it still remains an ideal p la ce to fa c ilita te le a rn in g .Barr (1980:48) further maintains that profes sional practice takes place in a vulner able practice milieu where legal and ethi cal consideration have to be noted, as the c lin ic a l p ra c tic e m ust p ro m o te growth and protect the right of all per sons involved.Student nurses should be encouraged to take up responsibility and accountability early in training in or der to protect the patient's rights to re spect, dignity and provide safe quality care.The same notion is supported by the South African Nursing Association (1977).The question of student status was highligted as important in clinical learning.

Student status
Participants expressed their believe that to be able to develop reflective thinking skills in the clinical practice, they need to attain a full student status like other students in other professions.This was explicitly highlighted by the citations: "... it is not practical to become part of the workforce and be a student at the same time.Surely one robs the other.We need quality time for reflecting on our learning experience like other students.Routine work will be taken care o f by other mem bers of the unit.""Sisters should not re lax and shift the work to the students sim ply because they regard us as an addi tional pair of hands." Participants indicated that it is not pos sible to be part of the workforce and be a student at the same time; one robs the other.They also indicated that profes sional nurses shift their work to students so that they can relax.To solve the prob lem students expressed their feelings that, in order to be reflective thinkers, they need to attain a full student status just like other students of other profes sions.They need quality time to reflect on their experiences.For students to be able to reflect on th eir experiences, Palmer et al (1994:72) states that the work of reflection needs to be analysed critically, interpreted and compared with other perspectives.Schon (in Palmer et al, 1994:72) concurs with this aspect by describing reflective discourse where ideas are shared, debated and debrief ing done after experience.Keeping of reflective professional journals and dia ries to record the experiences immedi ately after the experiences to facilitate learning is advocated.It is highly impos sible to fulfil this role when students form part of the workforce.
Referring to quality time in the practice area, Palmer et al (1994:72) states that space and time for reflecting on experi ence need to be built into the clinical learning syllabus during the working day when nurses can be given official time to write or reflect on their experiences with the m utual purpose of learning.Therefore the issue of full student status needs consideration to develop reflec tive thinking skills in clinical learning.

Recommendation
It would be appropriate to acknowledge Rogers (in Goble, 1981:748) who takes the view that goals of democratic edu cation should include assisting students to becom e individuals w ho have ac quired knowledge relevant to the solu tion of problems and are able to adapt flexibly and intelligently to new problem situations more freely and creatively.
In this study, the concluding statements regarding the learning needs and expec tations of student nurses in the clinical learning units are justified by the nega tive perceptions of student nurses: a) Adequate communication: Commu nication between the ward staff and the college is poor due to the absence of a liaison person who could effectively liaise with the college and the ward staff on clinical learning needs of student nurses.Communication skills are developed in a free and relaxed climate that facilitate interaction.b) Adequate role modelling: Profes sional nurses do not act as role models to the student nurses and d isplay a negative attitude toward students.Role m odels are expected to dem onstrate safe clinical practice.They are also ex pected to be caring, supportive, avail able, concerned, helpful and to act as consultants.
c) Knowledge and experience: Stu dents lack knowledge and experience in clinical practice due to the inefficient teaching methods that do not facilitate correlation of theory to practice.Sisters rely on book know ledge rather than adopting teaching methods that will de velop reflective thinking skills of stu dents.

d) Continuous supervision, assess ment and evaluation:
There is lack of continuous, effective clinical supervision, assessment and evaluation due to sis ters who do not perceive these aspects as contributory towards the growth of students in the clinical learning context.

e) Scientific method of nursing:
The nursing process is used inappropriately by sisters due to a lack of knowledge and creativity in its implementation and for the teaching purpose of developing re fle ctive th in kin g skills.This can be achieved by using reflective teaching methods such as problem based learn ing and use of reflective journals in the clinical learning units.f) Management: Participative manage m ent skills are necessary for clinical learning to take place.g) Professionalism: Teaching of pro fessional practice in the wards is inad equate resulting in malpractice due to the fact that students are left to carry out procedures on their own without super vision by sisters.h) Student status: Student nurses form part of the working force in the wards, hence they are unable to reflect on their experiences to facilitate clinical learning.

Recommendations
It is recom m ended that professional nurses become sensitive to the clinical learning needs and expectations of the student nurses and encourage the use of interactive , reflective m ethods of teaching and learning.In this way the product of nursing education will be a reflective practitioner capable of making rational decisions to solve problems in the clinical learning context.A model to facilitate reflective thinking skills of stu dent nurses becom es m andatory to empower those responsible for clinical nursing education.

P
a rtic ip a n ts a c kn o w le d g e d th e .im portance of ef fe ctive co m m u n i cation as a vehicle towards facilitating c lin ic a l le a rn in g .T hey e xpresse d the need for a liai son p e rso n b e tween the nursing college and clinical learning units, the need for creating a p la tfo rm to a d d re ss p ro b le m s and debate issues arising from clinical practice.In support