Student nurses ’ experiences during clinical practice in the Limpopo Province

Key w ords : C linical learning environment, clinical learning experience, clinical teaching, clinical practice, clinical preceptor. Abstract: Curationis 31(1): 19-27 A qualitative, exploratory, descriptive and contextual study was conducted to explore student nurses’ experiences during clinical practice at a nursing college in the Limpopo Province. Purposive sampling was used and phenomenological interviews were held with eleven (11) student nurses who were in their final year of the four year basic nursing programme. The interviews were analysed by using Tesch’s method of data analysis for qualitative research. The findings indicate that there are aspects which impact negatively on student nurses’ clinical learning experiences, such as lack of teaching and learning support, lack of opportunities for learning, poor theory-practice integration, and poor interpersonal relationships between the students, college tutors and ward staff. Recommendations to enhance the clinical learning experiences of student nurses were outlined.


Introduction
Clinical teaching is the means by which student nurses learn to apply the theory of nursing, facilitating integration of theoretical knowledge and practical skills in the clinical setting which becomes the art and science of nursing.This correlation of theory and practice, and the building of meaningful experience, take place during clinical practice in the health care services.According to Reilly and Oermann (1992:133), it is through experience in the clinical setting that student nurses acquire the knowledge, skills, and values essential to professional practice and become socialised into the nursing profession.This is where students encounter the human side of nursing (Mellish.Brink & Paton 1998:207).
The South African Nursing Council's (SANC 1992:9) minimum requirements and guidelines relating to clinical learning states: the overall objective of clinical practice is to provide student nurses with meaningful learning opportunities in every area of placement according to the level of training, to ensure that on completion of the program the student nurses is able to nurse efficiently.This implies that student nurse should be able to demonstrate the ability to solve problems effectively and apply a scientific approach to nursing from the initial assessment to the rehabilitation of the patient or client.
A conducive and supportive learning environment for student nurses depends on the availability of placement support systems, such as supervision, mentorship, preceptorship and relationships between the faculty, student nurses and clinical staff.Learning 19

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in practice placement requires an environment which is conducive to learning, and provides the appropriate support from skilled practitioners and educators.A clinical setting rich in learning experiences, but lacking a supportive environment, discourages the learners in seeking experience and results in the loss of learning and growth opportunities.On the other hand, a setting with limited experiences but rich in support, may provide opportunities for student nurses to examine new health needs and ways of addressing them.Thus, regardless of where clinical practice is taking place, the learning climate influences student nurses' achievement and satisfaction with the learning experience (Reilly & Oermann 1992:117;Quinn 2000:425).
Student nurses from one of the nursing campuses of the Limpopo College of Nursing are placed in four hospitals for their clinical learning experience, as well as a number of clinics within one of the districts of the Limpopo Province.During this placement, they are expected to learn and become professionally mature and competent practitioners of nursing.According to Masarweh (1999:44), clinical learning is regarded as an integral part of nursing education.It provides opportunities to apply the theory to practice, and fosters problem-solving and decision-making skills, collaboration with others and development of legal and ethical morals.

Background and Problem statement
Despite the many references to the importance of effective student learning during clinical practice, many nurse researchers repeatedly report on the negative experiences of student nurses in the clinical setting.Lipinge and Venter (2003:10) found in their study that (a) expectations of the student nurses were not met, as the staff are sometimes not aware of the student nurses' learning objectives; (b) frustrations were experienced during daily practice due to poor integration of theory and practice; and (c) there was a lack of tutorial support and guidance by tutors.
Lita, Alberts, Van Dyk and Small (2000:30) reported that workload and shortage of personnel limited the opportunities for properly teaching and guiding student nurses allocated to the wards.These findings are supported by Quinn (1995:187) who cites Fish and Purr (1991), who found that supervisors had heavy workloads and that their roles were not properly defined.In a study of perceptions of the clinical competencies of newly registered nurses in the North West Province done by Moeti, Van Niekerk and Van Velden (2004:72), it was found that a shortage of staff, equipment and supplies affected the competency of newly registered nurses negatively.
The findings of Mhlongo (1996:30) and Netshandama (1997:105), revealed that a shortage of staff and equipment affects the conduciveness of clinical learning environments.Moeti et al (2004:82) share similar views, in that financial constraints on healthcare, high bed occupancy, and shortage of staff and equipment, exacerbate the situation, as staff become frustrated and depressed by the lack of resources, leaving them with little energy and time to effectively attend to the needs of student nurses.It therefore appears that there are a variety of factors which have a negative influence on student nurses' learning during clinical practice.
The researcher, in his capacity as a nurse educator, observed and often heard student nurses expressing concern and dissatisfaction with their clinical learning experiences.This concern generated an interest to formally investigate the experiences of student nurses during their placement in clinical learning environments -the clinical learning environment includes hospital wards and units, the community and health clinics.Access to these experiences could only be obtained through the people who lived them, i.e. the student nurses.Against this background, the researcher found it necessary to explore the experiences of student nurses to come to a better understanding, so that student nurses can be assisted in achieving their educational goals during clinical practice.No similar study has been done at the particular nursing campus under study in the Limpopo Province, on the clinical practice experiences of student nurses registered for the four-year diploma programme leading to registration as a nurse (general, psychiatry, community) and midwife (SANC Regulation 425,22 February 1985, as amended).This study will therefore seek to answer the following question:

Research design
A qualitative, exploratory, descriptive and contextual design was followed using the phenomenological method to explore the lived experiences of student nurses during clinical practice.The richness and depth of the description gained from a qualitative approach, provides a unique appreciation of the reality of the experience (Munhall 2001:106;Streubert & Carpenter 1999:18).

Setting
The study focused on the clinical practica experiences of student nurses on one of the nursing campuses of the Limpopo College of Nursing and its clinical facilities.The study was restricted to one of three nursing campuses and the clinical facilities included general-, community-and psychiatric nursing, and midwifery.

Population
Student nurses who were registered for the four-year diploma programme for education and training as a nurse in general-, community-and psychiatric nursing and midwifery, on one of the three nursing campuses of the Limpopo College of Nursing, formed the target population.Students who were in their fourth year of study were targeted for participation as they had already been exposed to different clinical settings, ie both in hospitals, clinics and the community.At this level they have also covered almost all study disciplines for the four-year programme (SANC 1985).They would therefore be able to reflect on their various experiences during clinical practica.

Sample
A purposive sampling method was used.The participants were selected based on their particular knowledge of the phenomenon, for the purpose of sharing their knowledge and experiences with the researcher (Brink 1996:141;Streubert & Carpenter 1999:58).The researcher personally recruited participants.The purpose of the study and voluntary participation were explained to the fourthyear students.Not every one of the forty seven final year students were willing to participate but consent was obtained from those who were willing to participate The inclusion criteria were: being a final (fourth) year student in the basic nursing programme; willingness to participate in the study; and having been exposed to the clinical learning environment in the hospitals, clinics and community covering all four disciplines (general-, community-, psychiatric nursing and midwifery).The performance of students in the clinical learning environment (whether good or poor) was not included as a criterion as it was not relevant to the purpose of the study.A total of eleven participants were interviewed, and at that stage, data saturation appeared to have been reached by means of repeating themes.Those interviewed were four males and seven females, with the age range of 23-30 years.Participants were requested to give written consent for the interviews to be audio-taped.All participants conformed to the sampling criteria.

Data collection
Phenomenological interviews were used to collect the data because it provides participants with the opportunity to fully describe their experiences (Munhall 2001:156;Streubert & Carpenter 1999:59).
The researcher made use of bracketing to enter into the interviews without any bias.The interviews were tape recorded, and verbatim transcriptions were made.
The following question was asked: "Describe your clinical learning experiences during placement in a clinical learning environment?" The interviews were conducted at a venue in the nurses' hostel where privacy could be ensured.The researcher used communication skills such as reflection, nodding, questioning, clarification, and maintaining eye contact, to facilitate and encourage participants to talk, until there were no new themes or issues emerging from the participants.Field notes were taken during the interviews.A follow-up interview was done with five of the participants, after first listening to the tapes.This was done to verify and allow the participants to expand on inadequate descriptions, or add descriptions to the phenomenon.

Data analysis
Data was analysed using Tesch's method of analysis for qualitative data (Tesch 1992:117).Utilizing this method the researcher listened to and transcribed the audiotapes, and read and re-read the verbatim transcripts, to get a global understanding of the interviews and to familiarize himself with the data.Thereafter, the researcher randomly picked each verbatim transcript, and started analysing them one by one.An independent co-coder, a colleague of the researcher, assisted with the coding process of a few interviews and after a consensus discussion between the researcher and co-coder, the researcher continued with coding.Similar topics were grouped together into categories.
From each category, a number of themes emerged.The researcher went back to five of the participants to validate the analysed data.

Measures for trustworthiness
The method of establishing trustworthiness was adopted from that of Lincoln and Guba (1985:290-294), also cited in Krefting (1991:24) and Mouton (2001:227).To ensure credibility, dependability, confirmability and transferability, the following procedures were followed: To ensure credibility, the researcher employed the following measures.All participants were taken through the same main question, debriefing with informants, and any additional information was taken into consideration during analysis (member checks).The participants were interviewed to the point at which there was data saturation (prolonged engagement) and the interviews were tape-recorded and transcriptions were made of each interview (referral adequacy).The researcher went back to some of the participants, to ascertain whether the transcribed data was a truthful version of their experiences.
Dependability was achieved through a 21 Curationis March 2008 dense description of the methodology used to conduct the study, and a dense description of the data.The data was organised in categories and subcategories.All interview materials, transcriptions, documents, findings, interpretations, and recommendations, were kept, to be available and accessible to the supervisor and any other researcher, for the purpose of conducting an audit trail.Confirmability was ensured by audit trail of the verbatim descriptions, categories and subcategories (Krefting 1991:215-222).The researcher provided a dense description of the research methodology, the participants' background, and the research context to enable someone interested in making a transfer, to reach a conclusion about whether transfer could be possible or not.Purposive sampling was also used (Krefting 1991:214;Lincoln & Guba 1985:316;Mouton 2001:277).Transferability was ensured by a literature control after the collection of the data where similar findings of other research studies were reported.The research methodology and context of the research were described thoroughly.

Ethical considerations
As the research was involving human participants, it was necessary to follow strict ethical principles.The participants were asked to give their consent, and they were assured that participation or information provided would not be used against them.They were also assured of their right to confidentiality and anonymity.Anonymity was maintained by numbering the participants and by destroying the names attached to the numbers after the researcher went back to a few participants to validate the transcriptions.Confidentiality was ensured by guiding against unauthorized access to the data, the data was locked in a cupboard and the types destroyed after completion of the research.Participants were informed of their rights to withdraw from the study at any stage (Bums and Grove (2001:196 -201).

Discussion of the findings and literature control
Four main categories concerning the experiences of the student nurses in the clinical learning environment emerged from the data analysis.The categories and sub categories are displayed in table 1.The findings are discussed together

Category 3: Integration of theory and practice
Three subcategories emerged from this main category (see table 1).Students indicated that some aspects of the curriculum were only taught after they had been exposed to the clinical setting.They were allocated to the maternity ward in their 1st year of midwifery in which case the theory of abnormal labour was not yet given to them and yet most of the deliveries in the hospital were the abnormal ones as normal deliveries were done at the clinics.They therefore lacked the theoretical background: ...we were allocated in maternity it was for the first time and we were blank as we were not having theoretical background.Lita et al (2002:31) found a lack of guidance and correlation of theory and practice in a study done in the primary health care setting.
There were discrepancies between theory taught at the college and the actual practices in the clinical setting.Students' level of training or scope of practice was not considered when delegation of tasks were done, which compromised the integration of theory and practice.This might be due to the fact that student nurses were merely seen as a pair of hands, without recognition of their student nurse status and learning needs: ...for instance as fourth year students they will allocate to do vital signs instead of taking blood or doing doctors ' rounds, I know that vital signs can be done by every nurse but I must be allowed to do things in our scope of practice as a fourth year student;...you will find that non-nursing duties are done by student nurses, like dusting... Chabeli (1999:27) in her study confirmed that students nurses were used as a pair of hands or working force in the wards.

Category 4: Interpersonal relationships between college tutors, student nurses, and clinical staff
Four subcategories were identified (see table 1).Interpersonal relationships were a problem.There were poor interpersonal relationships between the ward staff and the student nurses.Student nurses were called names, harassed, and were in most instances used as scapegoats for any wrong-doings in the wards.However, the student nurses had good interpersonal relationships with the clinic managers, most of whom had qualified from the same programme (four year diploma) that the student nurses were following, as compared to the single qualified professional nurses who were mostly in the hospital wards.There might be an element of an inferiority complex amongst the unit manager/ward sisters who were single qualified, which might have influenced the nature of their relationships with the student nurses.
Poor interpersonal relationships amongst the ward sisters themselves was a cause of concern to student nurses, as they found themselves not knowing who to report to or side with, and when they had problems, they were tossed from one supervisor to another.

Limitations of the study
The study focused only on student nurses from one of the three nursing campuses of the Limpopo College of Nursing and its clinical facilities, the findings could therefore not be generalised to all campuses and their clinical facilities within the Limpopo Province.
Data was only collected from the student nurses who were in the final year of study (fourth year), requiring them to reflect on their past experiences.

Category 1: Clinical teaching and learning support
were left to rely on ward sisters, who also could not offer the necessary guidance, clinical teaching and supervision, due to heavy workloads and shortage of staff.A participant made the following remark: Accompaniment is the biggest problem, we do not have it.They only do accompaniment when they are coming to evaluate you.. student nurses and did not have time due to heavy work loads:., the other thing is we were asking something from one sister and she said that they are not getting paid to teach students;... other nursing staff end up telling us they do not have nursing education bar and they are not paid for teaching so they won' t find any time allocated for teaching the student nurses;...she was not having time to teach us and she was worried that she wanted to teach us but she has also to consider patient care as she was the only professional nurse in Ante natal ward.