This study explored the experiences of undergraduate nursing students during clinical practice at healthcare facilities in the Boland Overberg area in Western Cape, South Africa. Few studies have been done on experiences of nursing students during clinical practice. However, there are still inadequacies, which lead to the deterioration of clinical practice quality.
To explore and describe the experiences of undergraduate student nurses during clinical practice in healthcare facilities in Boland Overberg, in Western Cape, South Africa.
A qualitative, exploratory descriptive design was applied. Data collection was done using focus-group interviews to ascertain the undergraduate student nurses’ experiences during clinical practice in healthcare facilities in the Boland Overberg area in Western Cape Region. Thirty-eight undergraduate nursing students from Boland Campus were selected, using purposive sampling. The sample size was based on data saturation. Colaizzi’s method of coding and thematic content analysis was used to interpret the data. Ethical principles were adhered to.
After data analysis, the following themes emerged: clinical learning environment, challenges and inability to reach objectives.
During clinical practice in healthcare facilities, students were confronted with dilemmas which must be addressed with proper planning to decrease the challenges in clinical education of future nurses. The findings can be used in planning of nursing education, could provide help to develop effective clinical teaching strategies in nursing education and to support these undergraduate nursing students.
Nursing is a practice-based discipline. Hence, clinical practice is regarded as an important component of nursing education (Arpanantikul & Pratoomwan
In South Africa, different nursing programmes are offered. One of these programmes is the Bachelor of Technology in Nursing (BTech Nursing) which is an undergraduate program, governed by Government Notice No. R.425 0f 22, February 1985. The South African Nursing Council is a regulatory body that guides nursing training in South Africa (SANC). According to SANC (
In the researcher’s own experience as a nurse lecturer, when the undergraduate nurses return from their placement areas, they usually reflect on their experiences whilst they were doing clinical practice in healthcare facilities. Students mostly complained about factors at healthcare facilities that are challenging and not conducive to learning. According to Jamshidi et al. (
It has been proved that even though the clinical practice area is important, it is also challenging to the students learning (Mamaghani et al.
As a nurse lecturer, the researcher found that the students were not satisfied with their clinical learning during placement and complained about the environment not being conducive to learning. These complaints reflected in their poor performance during the objective structured clinical examination (OSCE). During the OSCEs, students are assessed on their clinical skill competencies. It was during these OSCEs that the researcher noticed that students were neither confident nor clinically skilled and competent, performing poorly. The complaints of the students, and the students’ performance during OSCE prompted an interest in formally investigating the experiences of the undergraduate nurses during clinical practice in healthcare facilities. Despite all studies done on the clinical practice of an undergraduate student nurse, clinical practice in healthcare facilities ‘in real situations’, is still a problem (Atakro et al.
In South Africa, there are a few studies that were done pertaining to the experiences of undergraduate nursing students during experiential learning. However, there are still inadequacies, which lead to the deterioration of clinical practice quality (Mabuda, Potgieter & Alberts
The research question was, ‘What are the experiences of undergraduate nursing students during their experiential learning in public healthcare facilities in the Boland Overberg area of the Western Cape?’
A qualitative, exploratory descriptive and contextual design was used to explore and understand the experiences of undergraduate nursing students during clinical practice. Qualitative methods study human experiences from the perspective of the participants, within the context in which the phenomenon takes place (Brink, Van der Walt & Van Rensburg
The researcher also chose a qualitative method as the focus was on practices, behaviour, and attitudes, all of which are part of the lived experiences of student nurses (Polit & Beck
The entire population of this study included 184 nursing students registered for the B.Tech programme at this rural campus in Western Cape. Purposive sampling was used. Thirty-eight participants, between the ages of 19–34 years were selected deliberately based on the clinical knowledge they had, as they had been exposed to clinical practice in the healthcare facilities (Gray et al.
Focus-group interviews were used as a mode of data collection to understand the experiences of undergraduate nurses during clinical practice in healthcare facilities. Focus groups interviews were conducted between 25 November 2016 and 16 March 2017. Interviews were conducted in English. The first two focus groups were conducted on 25 November 2016. Data collection was interrupted by #FeesMustFall protest prevalent on all university campuses nationally. The rest of the data-collection process was from 13 February 2017 to 16 March 2017. Each interview lasted approximately 45–60 min. Interviews were organised around a set of open-ended questions.
Interviews were conducted in one of the study halls at this campus. This was the choice of the participants. Eight focus groups were made, of which six of these groups consisted of five participants each. The other two groups comprised of four participants only as some students did not arrive for the interviews. According to Gray et al. (
These focus groups consisted of female and male students from the second, third and fourth-year levels of study. In this study, focus groups were used to understand the experiences of undergraduate nurses during clinical practice in healthcare facilities. An Olympus digital voice recorder was utilised to do all the recordings. Each interview lasted approximately 45–60 min.
Data analysis was done following Colaizzi’s (
Throughout the study, the researcher adhered to the four basic frameworks to ensure rigour. Regarding the trustworthiness of the data collected, credibility was used to judge the accuracy and correctness of the research findings (Polit & Beck
In this study, peer checking was done by the researcher’s colleagues, and the researcher kept a journal of reflection in order to cross-reference and minimise personal bias during data analysis (Anney
Regarding confirmability, the researcher used the audit trail technique to check whether conclusions and interpretations could be traced to the source. All raw data were audiotaped with the permission of participants and then transcribed verbatim before analysis was done. The supervisor also assisted with the coding of the data (Brink et al.
Approval to conduct the study was received from the Cape Peninsula University of Technology Faculty of Health and Wellness Sciences Research Ethics Committee: NHREC: REC- 230408-014.
The researcher started collecting data as soon as approval from the Ethics Committee of the university was granted. Permission and support were also granted by the head of the College. The researcher complied with the following ethical principles as out lined by Polit and Beck (
The results of this study revealed that undergraduate students were faced with challenging experiences. After coding, experiences of undergraduate nursing students were categorised. One theme and nine sub-themes were identified (see
Themes and subthemes.
Theme | Subthemes |
---|---|
Unhealthy interpersonal relationships | |
Poor communication | |
Integration of theory and practice | |
Anxiety | |
Students were neglected | |
Violence | |
Discrimination | |
Inability to reach objectives | |
Congestion of students in a clinical setting |
This main theme consists of seven sub-themes which are poor interpersonal relationships, poor communication skills, theory-practice gap, anxiety, students were neglected, violence and discrimination against student nurses.
During interviews participants repeatedly mentioned the issue of poor interpersonal relationships between clinical staff and students:
‘I will say the greatest experiences are that you had to deal with the attitudes of the permanent staff because a lot of times where I had moments where I just felt like quitting the course. It had something to do with the permanent staff’s attitude and the way they do things, the way they talk to you; they talk down to you like you don’t matter, you can’t even think. They down-size you so much that you don’t even feel human, you feel useless.’(Participant 29, year 4, focus group 7)
‘Actually, the staff is the main reason why I don’t want to work in a hospital. That energy that they give off is just negative. You don’t feel that you’re learning anything.’ (Participant 9, year 2, focus group 2)
Communication between clinical staff, clinical educators and student nurses was a challenge. The following confirm ineffective communication:
‘The thing that was very negative was the staff. They think you are students you, you speak English? They aren’t really interested in you but as much as you speak Afrikaans they would say oh, and they willing to teach you everything you need to know but English – they won’t say much to you. They are not willing to show you, to teach you how things are done in a hospital setting so that’s the only negative thing to me.’ (Participant 31, year 4, focus group 7)
‘[…
‘The physios use these water bottles where the people have to blow in, but they didn’t explain to us what is that bottle for, I told the people who had the bottles that they must drink the water.’ (Participant 25, year 4, focus group 6)
The nursing students are placed in healthcare settings in order to correlate theory and practice. Whilst in clinical practice, students were confused because what they learn in the classroom was not being practiced in clinical settings. The ward staff also contradict each other when doing some procedures in the clinical area, affecting the learning of students negatively.
This is what the participants had to say in this regard:
‘Sister shows me, for example how to put in a nasogastric tube. During the demonstration they told us to wear sterile gloves, then when the Sister does it, they use normal gloves, and the whole procedure for that is not aseptic. Then you feel this is not the right way, but this is how the Sister does it, then you don’t want to speak up or tell the Sister they are doing it the wrong way.’ (Participant 27, year 3, focus group 6)
‘Sometimes in certain procedures, one nurse will tell us something and another will tell us something else, and then we don’t know what to do because one says this and another one say this then you don’t know what to do who is right who is wrong.’(Participant 9, year 2, focus group 2)
During clinical practice students went through a lot of stress and anxiety. According to the participants, the real situation is not like being in the simulation class. In the clinical setting they are dealing with real people; the patients’ lives are in their hands:
‘I was just so scared that I might kill a patient by doing something wrong; or doing something so wrong that I am asked to just stop training and leave.’ (Participant 29, year 4, focus group 7)
‘[…
‘I was a first-year, I had no clue what to do with an open wound. I opened the wound and there was maggots inside. I was screaming all the way and the Sister asked me what the racket was.’ (Participant 28, year 3, focus group 6)
Most of the students felt they were left alone whilst in clinical placement. They had to do the work all by themselves, without supervision of the ward staff and this had a negative impact on their learning. This was evident in the following statements from undergraduate student nurses:
‘We are a working force; the other day
‘The staff nurse was just like she and the Pen students (Hospital students nurses) were friends, were talking showing them the stuff they already know, even if you stand next to her she will call that Pen student to come and help her, and didn’t want us anywhere near her.’ (Participant 30, year 4, focus group 7)
‘They think you can do everything, so they will sit there and leave you on your own to do everything … do the vital signs, everything on your own, whilst they just sit there.’(Participant 36, year 2, focus group 8)
According to undergraduate student nurses’ experiences, they were exposed to different types of violence in clinical settings. These students were sexually and mentally abused.
‘I was working in (operating) theater and the doctor threw gauze that was blood stained on my chest. She just threw it up in the air and it landed on my chest the bad thing she never even apologised.’ (Participant 9, year 2, focus group 2)
‘I was sexually harassed in my second year by a security guard of the hospital when we were alone. I don’t know if you know the Hospital H set-up, but it is the hospital and then across the road is the psychiatric wing. I was delivering the keys to the wing and I was alone with the security guard and he picked me up and pinned me against the wall and then he started feeling my body. That was also very emotional for me because I didn’t know how to handle it or who to go to.’(Participant 23, year 3, focus group 5)
Students mentioned that they were being discriminated against by hospital nurses:
‘The hospital students get the most support in the hospital if they want to do a procedure, but if our college students want to go and do a procedure, they don’t get the same support.’ (Participant 6, year 2, focus group 2)
‘There is a constant comparison between us and the Pen students (Pen students are nurses enrolled for Auxiliary nursing and enrolled nursing), which I think is ridiculous. You cannot possibly expect of us to be able to do those things, and first of all, nobody takes us by the hand, not even half the time that they work, so obviously, they will know the tricks of the trade. We are there for several days and just when you start getting comfortable with the staff in that particular ward, you have to leave already.’ (Participant 12, year 3, focus group 3)
Students were unhappy that they were not assigned those activities that would enable them to fulfil their objectives. According to the participants they were not delegated the responsibilities wisely, and that hindered their learning:
‘In the hospital where I worked, whether you are first, second, third or fourth year, when you come to services you are expected to do vitals and to fix. You are not being allocated specifically to the area where you need to be to achieve those objectives.’ (Participant 29, year 4, focus group 7)
‘Most of the timewe as students are allocated to do observations. I am now a third-year [student] and when I go to the hospital now I will be expected to do observations. You will never get a chance to do medications or something which you have to do on a year of practice in the third year to do certain assessments.’ (Participant 11, year 3, focus group 3)
Large numbers of students in one placement area decreases the learning opportunities for student nurses. Below are the comments of the participants:
‘I haven’t had a good experience in the hospital. It’s like we had two types of students, the Pen students (Pen students are nurses enrolled for Auxiliary nursing and enrolled nursing) and us. I was about to do a procedure on one of the patients when another student said, “No, that’s my patient.”’ (Participant 19, year 3, focus group 4)
‘In the hospital, we are up to seven students in a ward from first to the fourth year, so there is one or two Sisters in the ward, excluding the Operational Manager, of course, so it’s difficult for her to teach a first-year and a second year at the same time, because it’s two different things.’ (Participant 1, year 2, focus group 1)
The aim of this study was to explore and describe the experiences of the undergraduate nursing students during clinical practice in Boland Overberg area, in Western Cape. The results of this study revealed that students experienced different challenges whilst in various clinical settings. According to the study participants, these challenges led to a non-conducive learning environment, which hindered the student learning. These findings support those of Jamshid’s (
Most of the students experienced inappropriate, interpersonal relationships with clinical staff. The findings of the current study revealed that, the ward staff were disrespectful and mean to the student nurses. This negative attitude of ward staff towards nursing students undermined the student nurses’ trust and respect for professional nurses. These findings concur with those of Matshotyana et al. (
The current study revealed that the staff’s attitudes and perceptions had a negative impact on the learning of these nursing students. Both parties, student nurses and clinical staff, failed to set goals and make decisions together. Students were ignored by the clinic staff, even when they asked for help and were instead ridiculed by them.
These findings are consistent with those of Lee, Clarke and Carson (
Communication is the cornerstone of nursing services (Jooste
According to Jooste (
According to Mikkonen et al. (
The literature revealed a gap in integrating theory with practice. This has been a problem for a long time in nursing education (Kaphagawani & Useh
These findings support those of Jahanpour et al. (
Participants in this study reported that clinical staff were task-oriented and did not care for patients in accordance with their needs (as they had been taught before being placed in these clinical settings). These findings were similar to those of Zenani (
Sun et al. (
This study revealed that clinical practice was stressful. Some of the participants were anxious because they were dealing with patients’ lives. They feared something might go wrong, resulting in the death of the patient. These findings correspond with those of Sun et al. (
The participants in this study reported that students were left alone to do work without supervision. This put a lot of pressure on students because they were frightened of making errors. The literature reveals that on many occasions, students are left alone to struggle with unfamiliar tasks (Moghaddam et al.
Tee, Özçetin and Russell-Westhead (
Discrimination against nursing students in clinical settings is one of the challenges that nursing students encountered during their placements. This discrimination occurs in healthcare systems and unfortunately, nursing staff are involved in exacerbating this discrimination against nursing students (Mamaghani et al.
The
Participants in this study reported that large numbers of students in one placement area limited their learning opportunities. Similar findings were also found in the study of Ahmadi et al. (
The current study revealed that undergraduate students had challenging experiences during clinical practice in the healthcare settings. The outstanding challenges were integration of theory and practice, anxiety, students neglect, violence, congestion of students and discrimination of students; interpersonal relationships, poor communication and inability to reach objectives. These challenges affected learning of undergraduate student nurses negatively. The participants of this study believe that change of clinical staff attitudes and reduction of the gap between theory and practice can lead to a conducive learning environment.
Findings of this study can be used in planning of nursing education clinical curricula; could provide help to develop effective clinical teaching strategies in nursing education as well as to support these undergraduate nursing students.
One nursing school was included in this study, hence no generalisation.
Recruitment process and data collection were made easy by the fact that students who were the participants of this study, were eager to take part in the study.
All categories of staff involved with the experiential training of students need regular updates on all nursing procedures. This includes lecturing staff, so that all persons involved are aware of the correct way in which nursing care should be rendered and how procedures should be managed and executed. This will help to bridge the gap between theory and clinical practice.
Regular interpersonal skills training for staff should be arranged, in order to reduce poor attitudes and behaviour towards students in training.
Large numbers of students in one unit make it difficult for the clinical staff to supervise students. Therefore, when placing students, the number of students should be controlled.
Effective communication skills can be taught when nursing students are doing interpersonal skills, before they go to the clinical environment. Before the nursing students go to the clinical environment, the difference between the clinical environment and classroom environment must be emphasised. Before the nursing students go for their clinical practice to the real environment, they must get psychological counselling and visit the clinical environment prior to their placement, in order to familiarise themselves.
The researchers would like to acknowledge all undergraduate student nurses who participated in this study.
The authors declare that they have no financial or personal relationship that may have inappropriately influenced them in writing this article.
F.P.F. is a Masters’ student; she conducted the study from inception, data collection, analysis and report writing. H.F.V. was the supervisor to the student from inception; assisting in data collection, analysis, report writing and finalising of the article.
This research received no specific grant from any funding agency in the public, commercial or not for profit sectors.
Data may be requested from the corresponding author, F.P.F.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy position of any affiliated agency of the authors.