first year nursing students in the clinical learning environment

The clinical learning environment creates many opportuni­ ties for student learning and the development of critical competencies in the nursing profession. The learning that takes place in this environment, however, confronts the first year nursing student with challenges that are absent from the classroom situation and causes the student to experience a significant amount of uncertainty and anxiety. The study revealed that the students experience uncer­ tainty due to the lack of opportunities to develop compe­ tence in providing nursing care. The contributing factors towards this experience are: unavailability and inaccessi­ bility of staff due to time constraints; shortage and/or ab­ sence of equipment to fulfil nursing duties and meet the needs of patients; conflict in the expectations of nursing school personnel and clinical nursing personnel in hospi­ tals, as well as a lack of awareness among senior profes­ sionals of the needs and problems of first year nursing students in the clinical health care environment. Further­ more the students experienced the nature of the clinical learning programme as disrupting the continuity in patient care learning experiences, and the guidance and support by nursing personnel in the clinical learning environment as inadequate. The aim of this study was to reflect the importance of effec­ tive accompaniment by tutors/mentors, personnel in the clinical environment and any other person involved in the education of the first year nursing student, to prepare and enable him/her to become a knowledgeable, safe, compe­ tent nursing practitioner.

The study revealed that the students experience uncer tainty due to the lack of opportunities to develop com pe tence in providing nursing care.The contributing factors towards this experience are: unavailability and inaccessi bility of staff due to time constraints; shortage and/or ab sence of equipm ent to fulfil nursing duties and meet the needs o f patients; conflict in the expectations of nursing school personnel and clinical nursing personnel in hospi tals, as well as a lack o f awareness among senior profes sionals o f the needs and problems of first year nursing students in the clinical health care environm ent.Further more the students experienced the nature o f the clinical learning program me as disrupting the continuity in patient care learning experiences, and the guidance and support by nursing personnel in the clinical learning environment as inadequate.
The aim of this study was to reflect the importance of effec tive accom panim ent by tutors/mentors, personnel in the clinical environm ent and any other person involved in the education of the first year nursing student, to prepare and enable him /her to becom e a knowledgeable, safe, com pe tent nursing practitioner.

Key words
Anxiety, clinical learning environment, accompaniment, de velopment of essential competencies, first year nursing stu dent, lack of opportunities
Die studie het aangedui dat die student onsekerheid ondervind as gevolg van die gebrek aan geleenthede om bevoegdhede in die voorsiening van verpleegsorg te ontw ikkel.Bydraende faktore tot die ondervinding is: onverkrygbaarheid en ontoeganglikheid van personeel as gevolg van beperkte tyd; tekort aan/of afwesigheid van toerusting om verpleegtake uit te voer en om in die behoefte van pasiënte te voorsien; konflik in die verwagtinge van verpleegskoolpersoneel en kliniese verpleegkundiges in die hospitaal asook die gebrek aan bew ustheid by senior verpleegkundiges van die behoeftes en problem e van e e r s te ja a rv e r p le e g s tu d e n te in d ie k lin ie s e gesondheidsorgomgewing.Verder het die studente die aard van die kliniese leerprogram as 'n onderbreking in die deurlopenheid in pasiëntsorg leerervaringe ondervind.Die leiding en ondersteuning van verpleegpersoneel in die kliniese leeromgewing is ook onvoldoende.

Introduction
In nursing education, learning opportunities for students at all levels o f the programm e have to facilitate learning and skills developm ent within the param eters o f their Scope o f Practice.
The regulations determining these parameters are devised by the South African Nursing Council (SANC).The preface to these regulations R2598 of November 1984, as amended by R260 o f 1991, determine the following as fundamental to the Scope o f Practice as a nurse or midwife: " ... or procedures,

Curationis August 2003
which may be performed by scientifically based physical, chemi cal, psychological, social, educational, and technological means applicable to health care practice."The basic nursing skills required of a nurse to master in her first year will be discussed within the parameters of her Scope of Practice and the context of the basic needs of patients, inter alia, " ... the prescribing, promotion or maintenance o f hygiene, physical comfort ..." and "supervision over and maintenance o f elimination by a patient" (Regulation R.2598 in terms of the Nursing Act, 1978).
W hilst first year nursing students are performing activities re lated to patient care and nursing ie.basic nursing care, they are expected to complete a certain amount of clinical practical hours to meet programme requirements.Clinical practica involves clinical learning opportunities in health care settings under supervision o f the registered nurse or registered midwife, and where appropriate, other knowledgeable and skilled persons (South African Nursing Council Terminology List, 1994a:5).
The first year students, who have just come from a sheltered school environment with its interpersonal nature, its discipline, regular hours, and study and leisure patterns, find themselves in a com pletely different world which presents strange experi ences, and they have to adapt to the challenges inherent in clinical practica as well as in human suffering.They are sub ject to changes in mood, with heightened emotionality, which can be com pounded by coming into contact with ill persons.Hence, there are bound to be times o f emotional tension.Un derstanding on the part of the mentor, as well as other members o f the health team, can do much to reduce this tension and prevent unnecessary dropping out (Mellish and Brink, 1990:53).
The num ber of first year nursing students varies from institu tion to institution.For the purpose of this study the researcher will focus on Baccalaureus Curationis students from the Uni versity o f Port Elizabeth.

Problem statement
Within the first few months of nursing there are first year nurs ing students who resign because of the perception the student has o f what is involved in being a nurse, and what they actu ally experience in the clinical learning environment.A study by Harvey and Murray (1997:383) indicates that early aban donment o f the programme is related to unhappiness or poor performance of students.
In the experience of the researcher first year nursing students verbalized that they "did not like the practical side o f nurs ing This could be due to a num ber o f factors that have been expressed by students to the researcher.These factors include: 1. Personal perceptions about the practicals and theory re lated to nursing 2. Long practical hours in the hospitals, getting to the hospital early and leaving late at night 3. A ttitudes o f registered nurses towards students.The re searcher, being a lecturer and accom panier in the clinical envi ronment, often hears the phrases "that sister always helps m e" or otherwise "the sisters in this ward are not helpful at all./ always have to ask the senior students ..." The first year nursing students are also accom panied in prac tice by the nurse teacher as clinical nursing supervisor (the accompanier).Accompaniment is directed assistance and sup port by a registered nurse or registered midwife to a student in order to become a competent practitioner.In the case o f a student, growth occurs in relation to the level of independ ence.In the clinical practice area all registered nurses are in dispensable in the accompaniment of the student (South Afri can Nursing Council Terminology List, 1994:1).4. Diminished resources in the hospitals.There is often a short age of basic equipment and stock such as linen, liquid soap for hand washing, paper towels with which to dry hands, gloves for remaining surgically clean whilst performing nursing skills, disinfectants to spray hands 5. Communication and language barriers -the majority o f first year nursing students are fulfilling practical hours in a provin cial regional hospital where the main bulk of patients speak African languages.Students verbalize that they find it very difficult to communicate with patients especially if they want to educate them regarding their health needs, and design a plan o f care to meet the needs of these patients eg. the African speaking students find it difficult to communicate with Afrikaans speaking patients, and vice versa.The English speaking stu dents find it difficult to communicate with African speaking patients and some o f them with Afrikaans speaking patients.Due to the above-mentioned factors, first year nursing stu dents become frustrated because they cannot fulfill their prac tical requirements effectively.First year nursing students per form practical examinations in the clinical learning environment, and they are required to be evaluated on their clinical skills.These students are expected to be competent in all skills re lated to their level o f nursing practice.
Students also become very confused because of the discrep ancies between what is theoretically taught and experienced in the practical field, the so-called "theory-practice gap".This is confirmed by Forrest, Brown andPollock (1996:1258) who defined the issue of the theory-practice gap as the discrep ancy between what is taught to student nurses in the class room and what is practised in the clinical learning environ ment.
The students also experience a certain degree o f conflict be cause of the difference in the manner in which they are taught skills and the manner in which skills are actually implemented in the clinical learning environment.W hen students perform the way they are taught, they are reprimanded by ward staff.A student, who was very confused because o f this, approached the researcher and said that a nurse had told her "you are wasting our time by doing it that way".This has a definite impact on the way in which students perform and the fact that they want to render safe, effective patient care.This causes students to feel unsure and incompetent.The students also verbalized that they "become nervous when expected to p er fo rm fo r an examination or a competency where a mark is obtained fo r perform ance ".
The needs o f first year nursing students, especially within the first 3 -4 months in the clinical learning environm ent need special consideration by the registered nurse and the clinical supervisor.They have the special task of giving support and guidance to these students.They must accompany them so that they, as students, can develop on a personal and profes sional level.

Method of data collection
The objectives of the study were to: • explore and describe the experiences o f first year nursing students related to their exposure to the clini cal learning environment.• develop guidelines to ensure optimal accompaniment o f first year nursing students in the clinical learning environment.

Accom panier
This individual is the person who accom panies the student at any given time.It is/ could be the lecturer, the clinical supervi sor, or the w ard/unit registered nurse.

Clinical learning environm ent
The clinical learning environment is the environm ent in which students perform skills related to needs o f patients and pro vide physical, psychological, spiritual and social support (uti lizing a holistic approach) to patients, in order to promote and maintain safe, effective patient care (researcher's definition based on reviewed literature).

Student
An individual who is following the four year Baccaulaureus Curationis programme in the Department of Nursing Science of the University o f Port Elizabeth.

Accom panim ent
Accom panim ent is the planned and deliberate intervention by the accompanier, and includes all those activities that occur in a planned fashion according to the needs of the student, and are aim ed at inducing self-reliance in the dependent person (in the context of this study, the first year nursing student) (Kotzé, 1998:10).

Research design
This research study was a qualitative, explorative, descriptive, contextual study, reflecting experiences o f first year student nurses in the clinical learning environment.

Research method
The collection of data and the analysis of data was implemented and divided into two phases.
Phase 1 jnvolved the exploring and describing o f the experi ences of first year nursing students whilst exposed to the clini cal learning environment.
Phase 2 followed the interpretation of data and involved the developm ent of guidelines to ensure optim al accompaniment o f first year nursing students in the clinical learning environ ment.This will assist the clinical supervisor and all staff mem bers working with first year nursing students in making the clinical learning environment less threatening for the first year nursing student and optimize their experience o f the clinical learning environment.

Sampling
R andom -purposive sam pling was used.Burns and Grove (1999:233) state that from a sampling point o f view each indi vidual in the population should have an opportunity to be selected for the sample.One method of providing this oppor tunity is referred to as random sampling.
Purposive sampling is judgm ental sampling that involves the conscious selection by the researcher of certain subjects or elements to include in a study (Bums and Grove, 1999:475).
Cases selected by the researcher were believed to be able to give some specialized insight on an experience (Yegidis and Weinbach, 1996:122).

Sample Population
The population in this study were the first year nursing stu dents who had had no previous exposure to the clinical learn ing environm ent (ie.had not nursed previously).

Sampling criteria
The sample population selection criteria were as follows: The participants: • were 18 years and older.
• had attended the complete orientation programme as designed by the Department of Nursing Science, Uni versity o f Port Elizabeth.
• were English (Xhosa speaking participants included) or Afrikaans speaking to avoid loss o f information dur ing the process of interpreting interviews.
• had fulfilled practical hours in the clinical learning envi ronment for at least 8-12 weeks prior to the interview.
• had been allocated to at least 2 different areas in which they had fulfilled practical requirements e.g surgical unit, medical unit.
• represented different gender groups (ie.male and fe male first year nursing students).

M ethod of data collection
Data was collected by means of unstructured phenomenological interviews.The data gathering was done by the researcher.An audiotape recorder was utilized to capture data in the inter views and they were transcribed verbatim.A separate personal journal was kept for process documentation.Directly follow ing each interview, field notes were made about the interview situation.The central question asked o f each student was: "Tell me how you experience your practicals in the hospital." A pilot study was conducted with a first year nursing student who met all the criteria as mentioned.This was done to identify potential research problems during the first phase.

Phenom enological strategy of enquiry
The phenomenological approach focuses on individual's in terpretations o f their lived experiences and the ways in which they express them (Parahoo, 1997:395).Phenomenology is an approach to human inquiry that em phasizes the complexity of hum an experience and the need to study that experience holistically as it is actually lived (Polit and Hungler, 1997:442).

Data analysis
Interviews were transcribed verbatim and analyzed by the re A complete description of methodology, including litera ture control to m aintain clarity will be used.G uidelines developed will also be discussed in detail The use o f an independent coder skilled in the field o f re search will analyze the study and discuss findings with the researcher The data will be left for tw o weeks after initial analysis and the recorded.Identified themes will be compared Consensus discussion between the researcher and the in dependent coder

Reflexivity
Please see above Objectivity will be maintained throughout the study, no names of participants will appear anywhere (Compare Krefting, 1991:214-222) searcher and an independent coder.Interviews were analyzed for the em ergence of themes that were prevalent amongst all participants.D ata was reduced until the central storyline, as told by the student, emerged clearly from the raw data.A meet ing was held between the researcher and the independent coder to reach consensus on the storyline and them es.The data was then analyzed by making use o f the descriptive analysis tech nique by Tesch in (Creswell, 1994:155) and identified themes were formulated.

Literature control
The findings o f the research was discussed by consulting rel evant literature obtained from similar studies conducted as a source o f verification o f findings o f the study and other related research.
Trustworthiness G uba's M odel in Krefting was utilized for ensuring trustw or thiness in this study.This model defines different strategies of assessing the criteria mentioned below.These strategies are important to researchers in designing ways of increasing the rigor of qualitative studies and for readers to use as a means of assessing the value o f the findings o f qualitative research (Krefting, 1991:215).

Truth Value
This asks how confident the researcher is with the truth of the findings based on the research design, informants and con text.Truth value is obtained from the discovery of human experience as lived and experienced by the informants.The strategy for establishing truth value is credibility (Krefting, 1991: 215).
Actions to improve the credibility of the study include prolonged involvement, persistent observation, trian gulation and peer debriefing.

Applicability
Applicability refers to the degree to which the findings can be applied (fitted) to other contexts and settings or with other groups.The criterion against which applicability is assessed is fittingness or transferability (Krefting, 1991:216)

Consistency
Consistency of data refers to whether the findings would be consistent if the enquiry were replicated with the same sub jects or in sim ilar context this is based on the criterion o f de pendability (Krefting, 1991:217).

Neutrality
This refers to the degree to which the findings are a function solely o f the informants and the conditions of the research and no t o f o th e r b ia s e s , m o tiv a tio n s an d p e rs p e c tiv e s .Confirm ability is the criterion against which neutrality can be measured (Krefting, 1991:217).

Ethical considerations
The ethical principles stated by Crabtree and M iller (1999:83) were considered throughout the research study.These are: discomfort and harm, informed consent, confidentiality, pri vacy and anonymity.The right to full disclosure was also considered as an ethical principle.This means that the re searcher fully described the nature of the study.The student had the right to refuse participation and withdraw from the study at any time.However, all students persevered through out the study.Informed consent was obtained from the stu dent prior to commencement o f the interviews.

Identified themes / results of the study
One central theme identified that the student experiences un certainty due to the lack o f opportunities to develop com pe tence in the providing o f nursing care.

Discussion of themes
Central them e: The student experiences uncertainty due to the lack of opportunities to develop com petence in providing nursing care In education and nursing it is a known phenomenon that prac tice experience is a vital aspect o f learning.Studies done by Parkes (1985:950), and Jones and Johnston (1997:476) on the distress, stress and coping o f first year student nurses, found that initial placement in a clinical environment produces greater anxiety for students than at any other stage o f their training.Sub-themes identified from the central theme are discussed as follows: Table 2 : Identified them es related to the experiences of first year student nurses in the clinical learning environm ent

Central theme Sub-themes
The student experiences uncertainty due to the lack o f opportunities to de velop com petence in providing nursing care Sub-them e: Students felt insecure in their practising of nursing skills, because they are not developing adequate skills, due to unavailability and inaccessibility of staff The factors which contribute towards the students feeling in secure because they are not developing adequate skills, are:

Time Constraints
The student must become familiar with the general functioning of the ward, which means that an orientation programme should be available in the nursing unit.One o f the main functions of an orientation programme is to reduce fears and uncertainties.
During the interviews most o f the students said that profes sional personnel in the clinical area do not have time to orien tate them when they are in the clinical area for the first time.
The insecurity experienced by students however, is mainly re lated to staff shortage and time constraints.A student verbal ized the following: "The first day when we arrived, they were very short-staffed and didn't have time to show us around where the sluice-rooms were or where anything was.We were told to get or fetch things and we didn't even know, everyone was so busy, it was the worst day I've ever had in the hospital so far."

Students experience a reality shock due to lack o f sufficient orientation and induction to the new learning environment
Reality shock is described by Shin (2000:261) as the impact of the realization by the students that practice in the clinical set ting is quite different from what they had expected or even imagined.The reason for this being, that students have prac tical skills dem onstrated to them in a simulated environment before they are placed in the actual patient setting.A factor contributing to the insecurity that students experience is that he/she has to rapidly learn to cope with realities surrounding life and death situations with which they are confronted in the clinical environm ent, and at most times unexpectedly, as the students have verbalized:

Attitudes o f professional personnel towards first year nursing students
The attitudes of the professional personnel influence the per ception the students have o f themselves.One of the biggest challenges the student nurse has in her first year of training is to "fit in" with the social environm ent of the clinical field, and to be accepted by personnel in the wards where they are doing practicals and participating in patient care.In this research study it was observed that first year students feel rejected and isolated.They felt as if they were a nuisance and a waste of time.This can be seen in the following quotation: This is evidenced by the following extract from an interview: "Like we get taught to p u t the patient with dyspnoea in Fowl er !s position, hut some beds are broken, and cannot wind up.
/ fe e l totally helpless... " Sub-them e: Students expressed confusion because of the conflict in the expectations of the nursing school lecturers versus those of the hospital s ta ff, related to the perform ance of first year nursing students in the clinical environm ent Throughout the interviews students indicated that there was a lack o f awareness am ongst senior professionals of the needs and problem s of first year students in the wards.They verbal ized that everyone in the wards assumed that they knew what to do.
It became clear that there is a lack of understanding o f first year students' needs for unconditional guidance and support be cause everything is so new to them.

Lack o f awareness amongst senior professionals o f the needs and problems o f first year students
The lack o f awareness o f the needs and problems o f first year students is substantiated by the following extract from an in terview: " ... everyone in the ward expects me to know ... I thought it would be easier, it was mind-blowing ... you go to the ward and they expect you to know why ..." -Christiansen (1988:15) supports this by stating in his study that students enter nursing with an idealism most of us have forgotten, yet with a fear of being expected to know what to do before they have ever given them selves a chance to learn, or before a chance has been given to them to learn.

Furthermore, students experience confusion because of the discrepancy between what is taught to them in the classroom
and what is actually being implemented in the clinical environ ment.They become very nervous when their clinical tutors/ mentors approach them to practise skills related to nursing care.This is because they try to recall what they were taught, whilst being used to the way nursing care is done in the actual clinical setting.
" / try to rem em ber how we are ta u g h t... because I 'm now used to doing like they do in the hospital, and I 'm always shaking and confused when M r s ... and M r s ... (clinical tutors) come to see m e ." When clinical tutors arrive, it is a m atter of survival on behalf o f the student, because of the experience o f trying to remember the way they were taught by academic mentors (compare Nolan 1998:626).A study done by Craddock (1993:219) maintains that students are more likely to adopt hospital rituals to reduce anxiety levels, and Melia (1987:334) states that the student may abandon many goals in favour o f meeting the require ments of the moment, if it means she will be seen as part o f the team.
Students verbalized that they receive no guidance from per sonnel in the wards as to their method of nursing care skills.
"They don't tell us i t ' s different, they ju s t sort o f laugh at us and think there go the little fo o ls again ... I fe e l quite em bar rassed." Students experience little support from personnel when they try to practise as they have been taught at the nursing school.This is evident in the following statement: "The sisters say i t ' s fu n n y when we do things, some ju st shout and others ignore us." Students stated that because of the break in between contact days with patients, they are unable to develop a nurse-patient relationship or follow through a disease pattern from the initial onset through to the end/final stages.

Inappropriate utilization o f practice time
Sub-them e: Students feel insecure because of the lack of guidance and support by nursing personnel in the clinical learning environm ent The students in the study believed that they are not adequately informed o f the daily responsibilities required o f them to de velop nursing skills and practice.They arrive on duty and there is little or no communication between the ward personnel and the student as to where they must begin the daily practical tasks and patient care activities.

Patient allocation
Patient allocation ensures that the workload o f the ward and the patient care activities are equally divided am ongst staff members and that prescribed nursing care is effectively imple mented.The patient allocation is the responsibility o f the reg

Communication
The bulk of the information concerning the patients' condition and treatment plan is discussed in a ward round each morning and afternoon when shifts change.Ward rounds may take place more often, depending on the condition of the patient.
The information is usually shared by utilizing a m ulti-discipli nary team approach.The reason for this approach is the re quirement of total patient care and sharing o f observations, "W hen you go on rounds they speak like in morse code really, and they speak so f a s t... they never explain to us ..."

Lack o f supervision
Supervision is an interpersonal process whereby a skilled/ex perienced individual assists, educates and supports a less ex perienced person to achieve professional abilities (compare M agg in Fowler, 1996:476; Barber and Norman in Rodriguez andGoorapah, 1998:663).
Students shared in the interviews that because they were new, they needed somebody to "check" them whilst rendering pa tient care and practising skills.A student verbalized:

Guidelines to optimize accompaniment of first year nursing
Students in the clinical learning environm ent Data analyzed from the interviews indicated that students feel insecure due to the lack o f guidance and support by nursing personnel in the clinical learning environment.The guidelines form ulated which will optimize accom panim ent o f first year nursing students were discussed under the headings o f table 3.

Limitations of the study
The following limitations o f the study were identified: ■ Interviews were conducted with students from a single state hospital in the Nelson M andela Metropole.

■
The study does not include the experiences o f students allocated to other state hospitals or private hospitals for clinical practice.

Recommendations Recom m ended Research
The limitations o f the study have been indicated.In the light o f that and the findings of the study, the following is recom mended for future research in this regard: empowering nursing students in their mastering of health care knowledge, nursing skills and the socializ ing into the role of the professional nurse.

Recom m endations related to Nursing Education
To ensure that improved strategies are in place for quality clini cal teaching the following areas need to be addressed: ■ Agreements between nursing schools and health service authorities must include assistance with accompaniment o f nursing students in the clinical health environment.
■ Agreements between nursing schools and health service authorities should make provision for formalizing the nature o f the contribution o f clinical nursing personnel in the nursing programme.

Recom m endations related to Nursing Practice
The research results indicate that students are receiving very little, if any, support and guidance from personnel in the clini cal learning environment.

Conclusion
The study produced evidence that there are definite reasons why the first year students experience the clinical learning en vironment as anxiety-provoking.The quality of learning in the first academic year is crucial as a foundation for the rest o f the basic nursing programme.Particular attention should there fore be given to content and strategies to secure adequate learning opportunities, as well as a learning environm ent con ducive to the attainment of outcomes expected o f the nursing student.
The nursing student is the future provider of competent, safe nursing care and needs to be empowered through effective accom panim ent to reach the basic nursing programme out comes, namely that o f -

•
Students felt insecure because they were not developing adequate nursing skills due to unavailability and inaccessibility o f staff • Students expressed helplessness and frustration due to the shortage and/or absence o f equipment to fulfil nursing duties and meet the needs o f the patients • Students expressed confusion because o f the conflict in the expectations of the nursing school lecturers versus those o f the hospital staff, related to the performance o f first year nursing students in the clinical environment • Students experienced the nature o f the clinical learning programme as disrupting the continuity o f patient care learning experiences • Students felt insecure because of the lack o f guidance and support by nursing personnel in the clinical learning environment

"
N obody e v er checks on us -they still don't check on us, if w e're doing everything the right w ay ... because I 'm so new a n d very conscientious, I lack the confidence an d I 'd like to be checked b y som ebody com petent, to see if I 'm on the right tr a c k ..."

■
Courses and workshops to improve the quality o f clinicalteaching, clinical accompaniment and clinical assess ment should form part o f the annual personnel devel opment programme of clinical health service staff, with nursing school personnel contributing to such pro grammes.■ Clinical teaching, assessment and accompaniment of students should officially be part o f the responsibility schedule and job description of registered nurses in training hospitals.
be implemented regarding the nature o f student/health service personnel relation ships, its im pact on student learning, and means of

Table 1 :
Criteria to ensure trustworthiness

Opportunities for students to assist each other to acquire/practise skills are not allowed to be utilized
"We do things together and the sisters get upset, and think we are loafing around and socializing all the time, actually we are ju st helping each other, not doing anything wrong, som e times I get the feeling that they don 7 trust u s ... like we are not doing what they want us to do ... hut we are." Tim e constraints is considered as one o f the reasons for this.Another reason is that the value o f the "buddy system " as a support system is underestim ated and not considered as a possibility for acquiring o f nursing skills.Students verbalized that they are not getting the opportunity to practise skills with each other because the wards were either too busy, or the staff would say they are taking too long.At times when the wards are quiet, students are also not allowed to assist each other, because they are expected to fulfil other functions in the ward.

"
The sister thinks you are a nuisance in her eyes, and doesn't want anything to do with students ... some don't like students ... sometimes I can understand why they don't have time for us, or don't like us because we have just started, they have been nursing for many years and we are new." "/ fe e l frustrated and helpless.You stand there, you see this patient who really, really needs something and you can't help ... you have to do a dressing, it h a sn ' t been changed fo r two days, i t ' s absolutely necessary because you can take the dressing off, but you can p u t nothing on ... th ere' s no dressing packs, ... nothing sterile ... " .. the flo o rs are washed with water, 1 fe e l helpless, be cause I know the risk o f infection in a h o sp ita l..."Students are unable to meet the needs o f patients which is contradictory to expectations of the programme where students are taught to maintain basic hygiene and care for patients with unique disease conditions.
Clinical practica hours are hours during which the student is placed in health service areas and exposed to the clinical learn ing opportunities with the aim of developing nursing skills and rendering patient care.Students indicate that they spend a lot of this time performing non-nursing activities which prohibit them from developing adequate nursing skills.Students stated that it was almost expected o f them to assist and carry out functions that are not within the scope o f the academic or the practical programme.W hen they were unwilling to perform these non-nursing duties they were ostracized leading to feel ings o f hurt.One student stated: "A t the moment the general assistants ju st want us t o ... there' s a whole big thing about taking plates to the kitchen, and ... um, dishing up food.I f we are busy with something else, they get cross because they think we should lik e ,... um, be helping them dishing up fo o d and, I mean, it is hectic in the wards.One o f them said to us, "these children are lazy, thev d o n ' t want to help us, they want to do their own thing ".We were actually busy, I was actually doing an enema at the time ... " "I t ' s really fu n n y going from one ward to a n o th er.. um .. also the ward systems change, the routine, not the whole routine, like you have to shift around i t ... i t ' s really scary because you have to learn new things all over again ... "

Table 3 :
Guidelines to optim ize accom panim ent istered nurse in charge of the ward for the day.This is not materializing as verbalized by a student: " ... I still don't know some places existed when they ask me to do things in the ward, hut also today / never fo u n d out that I was supposed to he working in a specific ward and I ju st saw my name on the hoard.No-one told me.I fe lt like no-one was communicating to us, especially me because I was supposed to be in that ward.Someone shouted that there was som e thing, som ething w a sn 't done and I was in charge o f that ward.I didn 7 see my name anywhere." Involvement o f personnel in the accom panim ent of students interpretations and advice by persons with the expertise and relevant experience.This serves as a vital learning opportu nity for the first year nursing student.Com m unication, how ever, appears to be a stumbling block in the process, because professional personnel often do not take time to explain the treatment plan and condition o f the patient.A student verbal ized: