There is a ‘below the surface’ tension between clinical staff of training institutions and nursing students from Limpopo College of Nursing. The clinical accompaniment, guidance and support process in a rural hospital was questioned by the students, who are unhappy about professional nurses’ attitudes and behaviour. The training of nurses includes both theory (classroom learning) and clinical practice for successful application and integration of new learned knowledge (Bezuidenhout 2003:19). Nursing students should be allowed and supported to interact with clients and their families in any clinical practice environment, to stimulate and acquire critical-thinking, decision-making, psychomotor and affective skills (Stokes & Kost 2009:283).

There seems to be uncertainty about the responsibility for clinical accompaniment, guidance and support of nursing students within the South African context. The Nursing Act 2005 (Act No. 33 of 2005) (Republic of South Africa 2005) empowered professional nurses and midwives to assist, guide and support nursing students throughout their training, with the aim of developing competent, independent nurse practitioners by creating a conducive environment for learning (Bastable 2003:13; Republic of South Africa 2005:34). That professional nurses have an educational role to facilitate development of nursing students both academically and personally is supported by Bond and Holland (1998:12). Stokes and Kost (2009:287) assert that the clinical tutor as a role model plays a crucial role for the successful clinical understanding of nursing students by sharing their clinical experience and knowledge of theory for the practice of nursing and the profession.

Four different levels of nursing students (levels I–IV) are placed at the hospital, with one clinical tutor responsible for a group of about 50 students, allocated in different disciplines. The nursing students do not receive adequate accompaniment, guidance and support during their clinical learning and practice due to the shortage of professional nurses at the rural hospital (Rikhotso 2010:51). The rural hospital where the nursing students obtain clinical exposure and learning posed a challenge to the professional nurses, due to the imbalance of work between patient care and providing guidance and support to nursing students. Lekhuleni, Van der Wal and Ehlers (2004:9) are of the opinion that clinical accompaniment, supervision, guidance and support for nursing students should be shared by a multidisciplinary team including nurse educators, peer group, professional nurses, doctors, dieticians and other allied health professionals.

The clinical professional nurses feel that providing guidance and support for the students is an extra workload which is burdened by understaffing, the impact of poverty and debilitating diseases such as HIV and/or AIDS, tuberculosis and malnutrition. Due to the shortage of professional nurses in the wards, nursing students’ guidance and support becomes less important, and they become incompetent employees with inadequate skills as they are tasked to cover the shortage in patient care (Mhlongo 1996:29; Rikhotso 2010:51).

Nursing students are trained by Limpopo College of Nursing and allocated for clinical exposure at accredited hospitals within Limpopo. When this study was conducted the college was using the block system for students to rotate between theoretical and clinical learning settings. During clinical placement the nursing students find themselves in an unfamiliar environment and location on a monthly basis, and some suffer psychologically as the hospital and surroundings are new, with little or no guidance and support within the hospital.

This article reports on a study conducted in a rural area surrounded by underdeveloped villages dependent on farming, 30 km from the nearest town, with taxis and buses the only mode of public transport. The area is dominated by two cultural, ethnic groups (Tshivenda and Xitsonga), and is traditionally conservative. According to literature reviewed by the researcher, limited research has been conducted in Limpopo regarding guidance and support during clinical exposure of nursing students from the Nursing College in this setting. This article explores the perceptions of nursing students in a specific rural hospital, and proposes guidelines for effective clinical guidance and support in similar settings.

The findings were analysed and discussed according to the process of qualitative content analysis as described by Graneheim and Lundman (2004:106), including condensed meaning units, subthemes and themes.

The themes and subthemes identified from the transcribed data are listed in Table 1.

Ethical approval was obtained from North-West University (Potchefstroom Campus). The Ethics Committee of the Limpopo Provincial Government's health department issued a permission letter for entry into the institution where the study was conducted (the institution gave verbal permission on the basis of approval by the Ethics Committee of Limpopo Provincial Government). Participants gave informed consent after thorough explanation of the nature and extent of the study by the researcher. The audio tape-recordings were kept under lock and key by the researcher after verbatim transcription of the interviews.

In this study the evaluation of data quality was ensured by using Lincoln and Guba's (1985:290) methods, which include credibility, confirmability and transferability. The researcher ensured credibility by prolonged engagement with the participants, planning the study with experts and use of a similar question for all participants. Confirmability was assured by the second researcher, who assisted with analysis and coding, audio-recording of interviews and records kept for the audit trail. Thorough descriptions of the findings were provided to ensure transferability.

According to the constructivist approach to teaching and learning (Klopper 2001:103–104; Bruner 1996:42), nursing students should take responsibility for their own learning through active participation and constructing new knowledge. The clinical environment in which nursing students are placed for clinical learning through exposure and experience should have an invitational, positive attitude, create a mutual trusting relationship with all staff members, including students, and accept responsibility for the success of the learning process.

This article reports that the institution where the main study was done lacks the characteristics of the teaching-learning relationship, based on the nursing students’ perceptions of clinical guidance and support. The relationship which exists between students and professional nurses does not provide guidance and support for learning due to mutual disrespect and mistrust, resulting in offensive behavioural patterns by both students and staff.

The first author of this article worked in the same rural institution where the study was conducted for many years, and the findings and reports from the literature are true as discussed. The experience of nursing students in the context is true, although somewhat exaggerated. Some district hospitals (level 1) are understaffed (in terms of both doctors and nurses), and have a shortage of clinical equipment as well as drugs due to challenges beyond the scope of the particular hospital's professional nurses.

These challenges adversely affect patient care by causing substitution of safe and effective nursing care and medication with alternative treatments; compromising nursing and medical procedures; or resulting in medical errors as students ‘work’ without guidance (Hart & Rotem 1994:31; Ventola 2011:740). Most hospital wards are managed by one professional nurse per shift, and thus it becomes difficult for them to take full responsibility for students’ guidance and support in learning.

District hospitals are the catchment centres for poor communities, who suffer from chronic and debilitating illnesses, operating with constrained budgets and with a lack of clinical equipment and expert professionals. That rural hospitals or district hospitals try to provide patients with the optimal quality of care whilst simultaneously tackling challenges due to their often remote geographical area and limited resources (human, financial and equipment) is supported by American Hospital Association Trendwatch (2011:2).

Students enjoy learning and working under the guidance and support of a knowledgeable professional nurse for their effective professional development (Beukes, Nolte & Arries 2010:4). A shortage of staff, high bed occupancy, high student ratio and lack of clinical equipment burdens the overstretched professional nurse, thus giving little or no opportunity to provide attention to guide and support nursing students (Mabuda et al. 2008:20).

Jirwe, Gerish and Emami (2009:23) allude to the fact that lack of communication and cross-cultural care encounters are problematic in care of patients from a different background to the professional nurses. This communication problem between cultural and ethnic groups may be transferred to nursing students, and they can experience difficulties in communicating with patients with whom they do not share a common language (Boykins & Carter 2012:2), putting patients at risk in their care.

Interpersonal communication skills should be practised and implemented by all nurses throughout the training of students to embrace the cultural diversity of the South African rainbow population; this has a therapeutic effect on an individual and the clinical environment. The clinical learning opportunities and clinical guidance and support of nursing students, hampered by limited clinical equipment and other resources, poor interpersonal relationships and ineffective communication, may be complicated by ethnocentrism in some hospitals. For effective communication, professional nurses, nursing managers, clinical tutors and the college management should involve the nursing students, as a form of learning guidance in preparation of future competent professional nurses who care for diverse patients within society.

Many articles have been written about the experiences and perceptions of nursing students regarding clinical placement and accompaniment in the clinical setting. The study on which this article is based explored and described the experiences of nursing students in a specific rural hospital. The researcher proposes guidelines, supported by the literature, for the clinical guidance and support of nursing students during their clinical exposure and learning in hospitals. The proposed guidelines include: Creation of a context conducive to a learning environment in the clinical practice by means of clarity on mutual expectations; and the provincial government to launch an enquiry about the status of hospitals’ physical infrastructure, maintenance and availability of essential patient equipment.

The findings of the literature review showed that students perceive clinical guidance and support differently, namely negatively or positively. The nursing students experienced lack of support, inadequate mentoring and guidance, isolation from clinical activities, an inhumane attitude by clinical staff, a poor clinical environment and many other aspects as hindering students’ learning. Stokes and Kost (2009:283) describe clinical practice for nursing students as any place where they interact with the patient and his or her family or community. During this learning by interaction with the clients the nursing students integrate theory into practice. Support and guidance in this regard should be given by the professional nurses and other health professionals within the hospital (Bezuidenhout 2003:19).

The study which this article reports on was explorative in nature and held in a specific setting; therefore the results cannot be generalised. Evidence from literature and this study demonstrates the need for the college and hospital management of all training institutions to provide placement and accompaniment, guidance and support guidelines for effective learning in the clinical setting.

The findings as described here demonstrate the need to implement the proposed guidelines as soon as possible to avoid nursing students from forming a negative attitude towards clinical placement in this setting. The nursing students should also be supported throughout their training during the rotation amongst the hospitals, to gain more knowledge and skills with or without adequate clinical resources.

This article will assist readers (health professionals – i.e. nursing students, college tutors, professional nurses and hospital and college managers) to be aware of the impact that the clinical setting, guidance and support have on the education and learning of nursing students. This article contributes to the understanding of why nursing students taking part in the current research were reluctant when allocated to certain hospitals. The management of the college and hospitals should be aware of and understand the behaviour of nursing students in this setting, assist them to develop professionally and provide ways to deal with challenges at the hospital. Good interpersonal relationships should be promoted amongst staff, irrespective of the status of the nurse that acts as facilitator, mentor and supporter in the clinical environment.