How exercise nursing students experience the clinical learning environment and answer to their experiences? A qualitative study

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Abstract

Introduction On entry into the clinical surroundings, nursing students are confronted with many challenges. It is a mutual trouble throughout the world, including Iran. Although many studies have been conducted on the bug of nursing students in the clinical surround, limited information is available on nursing students' experiences of the clinical learning surroundings and the manner they respond to these experiences. Identifying nursing students' experiences is essential to develop interventions to reduce challenges.

Objective This report aimed to explore nursing students' experiences in a clinical learning environment and the way they responded to these experiences.

Design The present written report was conducted based on the qualitative inquiry design of the grounded theory methodology.

Setting This study was conducted at schools of nursing in academic settings in Iran.

Participants The participants included xix nursing students, 4 nursing instructors and three clinical nurses.

Methods The data were collected using semistructured interviews, field notes and ascertainment, and were analysed using Strauss and Corbin's approach.

Results Students, as a issue of the inadequacy of the educational environs, were faced with 'confusion of identity', stating this as their master business organization. When confronted with this concern, they employed specific strategies, some of which prevented them from getting into unpleasant conditions. These strategies did not help students solve their problems and also prevented them from accepting their professional roles and responsibilities. Conversely, some other strategies led them to advanced professional person evolution and enabled them to accept their part and the clinical surroundings.

Decision According to the results of this study, educational policymakers should focus on improving the clinical environs. Identifying professional models and increasing their influence on direction, education and clinical didactics, as well as education positive and constructive strategies, will promote positive strategies in coping with inadequate educational contexts. This is necessary for the professional development of nursing students.

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This is an open admission article distributed in accordance with the Creative Commons Attribution Non Commercial (CC Past-NC iv.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the utilise is non-commercial. Encounter: http://creativecommons.org/licenses/by-nc/4.0/.

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Strengths and limitations of this report

  • The study, by performing a grounded theory research, provided increased, indepth understanding of how nursing students experience the clinical learning surroundings and the way they respond to this experience.

  • Combining resource and using the experiences of educators, clinical nurses and students provided multiplied validity to this report and helped place a more than comprehensive paradigm of the process under investigation.

  • The information gained from this study may be useful in improving clinical environments and educational contexts.

  • Due to the sociocultural uniqueness and the context-bound relevance of the qualitative findings of this study, repetition of the study is required in other countries and cultures.

Introduction

Nursing students should employ their knowledge and skills in clinical environments to learn the required qualifications for taking intendance of patients, and their success depends to a keen extent on efficient clinical training.1 Clinical training is regarded every bit the heart and essence of learning and education in nursing.2 iii Furthermore, clinical learning environs plays an important part in turning nursing students into professionals and preparing them to function equally nurses.4

A clinical learning environs is a combination of several concrete, psychological, emotional and organisational factors affecting the students' learning and how they face up the environment.five half dozen This environment has considerable furnishings on students' positive learning and emotional well-being.7 8 Furthermore, students get acquainted with the realities of their profession and functions of nursing in this environment.9 Yet, the clinical learning environment has been referred to equally a reason for either quitting or continuing the nursing profession.10 The complication of this environment and the events involved causing tension get in difficult to exist controlled.eleven On entry into the clinical environment, nursing students are confronted with many challenges and problems which affect their learning in that surround.x Quitting the profession, fear, anxiety and defoliation have been mentioned every bit the chief reasons for nursing students' unpreparedness and concern in clinical learning environments.12 13 Bachelor nursing studies terminal for iv years in Islamic republic of iran, during which students enter clinical education and clinical learning environments. The major part of nursing education in clinical environments in Iran begins in the second term and continues until the end of the 8th term.10

The results of the study by Papathanasiou et al 14 indicated a considerable gap between students' expectations and clinical learning environments, which confronted them with bug in the clinical learning environment. Identification and elimination of the problems in clinical learning environments reduce nursing students' emotional and behavioural problems in these environments.xv 16 Despite the severe shortage of nurses and the demand for nurse training in Islamic republic of iran, there is not enough incentives to enter this profession, and many cases of leaving the profession,17 lack of motivation18 and psychological problems occur afterward entry into the clinical environs.2

The quality of clinical exercise in Iran is adamant past two main factors, namely the nursing care delivery method and the nurse to patient ratio. Within the clinical field, nursing students and nurses take care of patients from diverse ethnic groups and unlike cultures based on the case method.19 Several studies accept been conducted on nursing students' clinical preparation in Islamic republic of iran. I written report conducted by Peyrovi et al 19 demonstrated that nursing students were agape of providing care in clinical learning environments. Likewise in the research by Joolaee et al 10, nursing students reported fear and anxiety in clinical environments. Similarly, the students participating in the study carried out by Hanifi et al eighteen stated that condign a nurse was ane of their major concerns in clinical environments. Long-term experience (20–thirty years) of researchers in clinical didactics of nursing students also shows that nursing students undergo a lot of changes after entering clinical setting, causing mental and psychological problems, lack of motivation, and the decision to leave the profession.

Although the above-mentioned studies have addressed nursing students' problems and challenges in clinical environments, none of these has investigated how students experience the learning surroundings and the way they respond to this experience. Considering the problems of Iranian nursing students later entering the clinical surround, the effects of this environment on students' professional learning and future, and the existing gap in the literature, and given that no comprehensive research has been conducted in this regard, this report was performed using a grounded theory approach for profound understanding of how students experience things (behaviours, events and interactions) on entering clinical environments and attending clinical departments. This would pave the way for improvements in clinical preparation and reduction of probable bug in the clinical surround.

Methods

Written report pattern

Qualitative research with the grounded theory approach was used as the appropriate method to respond the enquiry question. Grounded theory approach is a deep written report of clinical practices, behaviours, and attitudes of individuals and groups. Since grounded theory focuses on social processes and is related to the context, it is a suitable method to respond the inquiry question and to draw the social processes lying in the data.xx

Participants

In this research, 19 nursing students as key informants were start selected based on purposive sampling (table i). So, to complete the connections between the categories that emerged and to extract the process in the data, four instructors (table 2) and three clinical nurses (tabular array 3) were interviewed based on theoretical sampling until information saturation was achieved. The selection criteria for nursing students included internship feel in clinical learning environments and willingness to participate in the research and to limited their personal experiences. Information technology should be noted that the instructors and nurses had at least five years of work experience.

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Table 1

Characteristics of the students participating in the written report

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Table 2

Characteristics of the instructors participating in the written report

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Table 3

Characteristics of the nurses participating in the study

Information collection

Semistructured personal interviews were used to collect data from the students, instructors and nurses from October 2014 to May 2017. The interviews were decided to be conducted at Shiraz Kinesthesia of Nursing and to last between 40 and 70 min, every bit agreed past the participants. It should be noted that five nursing students were interviewed twice.

The interviews began with the following questions: 'What did you experience after entering the clinical leaning environment', 'What happened during your clinical do', 'How did you experience at that fourth dimension', and 'What did you practice'. The instructors and nurses were besides asked to share their experiences about exposing students to the clinical learning surround. The interviews were recorded and transcribed. Field notes and observations were employed as well.

Data assay

Data collection and assay were performed simultaneously using Strauss and Corbin's approach. In this method, the data were examined several times and analysed (as in the instance in table four) using the three steps of open up, axial and selective coding until theoretical saturation was achieved. The data were collected by the authors (ZM, NJ and MNK). All authors participated in the data analysis; they talked most the codes and categories and reached an agreement. Data analysis was conducted during the data collection process as follows. At the beginning, the audio files of the recorded interviews and observations were transcribed. In the analysis for open coding, the texts of the interviews and observations were read several times and the principal concepts were extracted and coded. After this, similar codes were placed in 1 category by constant comparison. In axial coding, the initial categories formed in the open coding were compared, and those that were like to each other were rooted in a common axis. At this phase, the categories were related to their axial categories in order to provide more precise and complete explanations of the miracle. In the third step or the selective coding, constant comparison was used to determine the relationships amid the categories and to search for the process involved in the data. The researchers likewise looked for the core variable and the existing process in the data.21 Memoing and diagramming were used as well.

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Tabular array 4

An example of data analysis

Rigour

Regarding the trustworthiness of the data, brownie was established through member bank check, data drove triangulation and prolonged engagement. In this regard, the texts of the interviews and the derived codes were returned to the participants (northward=x) and they were asked to comment on the researchers' perceptions of their statements and to correct any variations. Indeed, peer check was performed by v expert supervisors of nursing and experts in qualitative inquiry. They also supervised the process of interviewing, coding and categorisation. Moreover, maximum variation of sampling (in terms of sexual practice and academic term) enhanced the confirmability and credibility of the data.21

Patient and public interest

Patients were non involved in this written report. The report participants included nursing students, instructors and clinical nurses.

Results

The findings of the present written report (effigy ane) showed that, due to the inadequacy of the clinical environment, nursing students were faced with defoliation of identity and stated this every bit their master business organisation. Students in confrontation with this concern used ii sets of strategies according to the condition. Some of these strategies prevented them from getting into unpleasant situations. These strategies did not help students solve their problems and prevented them from accepting their professional roles and responsibilities. On the other hand, another strategies promoted the students' professional person development and helped them better embrace their clinical surround and professional responsibilities. Supportive systems in this process would also facilitate students' professional evolution.

Inefficient educational context

When in clinical training environs, nursing students realised that information technology lacked the required efficiency. Inefficient educators, unfavourable educational plans and inappropriate clinical environs were the components of this inefficient educational context.

Inefficient educators

According to students' experiences, some instructors and nurses did non have acceptable efficiency to educate students and transfer knowledge to them. Some instructors' failure to provide sufficient details on medications, procedures and required intendance was among the items mentioned by the students.

…In one of the internships, the teacher provided us with no explanations on what the medication was, how it was to be dissolved, and what complications it had… (S13)

Some instructors' improper assessment of students, inflexibility, lack of feel, lack of clinical skills and failure to respond to students' questions were other items stated by the students.

…Main students are now ready every bit instructors. They neither have sufficient cognition, nor do they know how to communicate and teach… (S5)

Furthermore, some nurses in clinical environments were not able to respond to students' questions properly.

Unfavourable educational planning

Lack of correspondence between the length of internship courses and the specified objectives, as well every bit between the times of theoretical and applied courses, resulted in students encountering challenges when in the clinical environment.

In the same term that we have orthopedics, we accept to attend internship at that department. Before learning about the diseases and care, we are encountered with patients at the ward, which causes us not to acquire well… (S18)

Based on the students' experiences, educational focus on performing routine tasks and repetitive departments in dissimilar internships restricted the opportunity to learn more.

…We haven't seen many cases at all; we go to the department and everything is repeated… (S4)

From the students' perspective, limitations in the curricula deprived them of the requirements for entering the clinic in terms of knowledge and clinical and communication skills. Furthermore, admission in nursing profession with no regard to the correspondence betwixt the students' characteristics and the field, or its mandatory or blind option by some students, made them spiritually unprepared to attend clinics and receive the required instructions.

Inappropriate clinical environment

Some nurses' negative attitudes towards the students' presence in the department, lack of support, and nurses' and patients' mistrust caused an unsupportive atmosphere in clinics, which was very unpleasant to the students.

…Well, they (nurses) are biased, saying 'oh, students are there once more!'…Then, they e'er seek for problems with our work… (S10)

Students observed unpleasant interactions in clinical departments that challenged them. They kept complaining well-nigh the nurses' neglect or indifference towards them, also as the staff's non-cooperation.

…Department nurses deport and then badly, just equally if you're saying something bad to them. They don't cooperate at all. (S16)

Furthermore, educational injustice and discrimination betwixt nursing and medical students were major problems in clinical learning environments.

…I was reviewing a patient'due south tape when the nurse took information technology away from me very roughly. She would say nothing to a medical student though… (S5)

Moreover, lack of facilities and unavailability of the needed equipment led to waste of time and delay in patient care; such an educational environment was unpleasant to the students. Nurses too plant the concrete space inappropriate to the number of students in the section.

Defoliation of identity

There was no clear clarification of tasks for nurses and students, which was why they did not know what they were responsible for. Non-professional tasks performed by nurses, for instance, caused a negative mental attitude towards nursing and confusion about its functions.

…We practice things at the department that attendants are responsible for; for example, when patients want u.s.a. to clean their beds…. (S4)

Furthermore, the mismatch betwixt expectations and reality and the difference between what they have been taught in classrooms and what they notice in clinical environments intensified the confusion. Instructors' and nurses' different expectations also increased the defoliation and conflicting roles.

…We instructed a educatee how to communicate with the patient and go through the nursing process. The pupil was explaining to the patient, but the nurse said there was no need for too much caption… (I2)

Nurses with negative attitudes towards their career brought this mental attitude to the students and doubted them in accepting their function as a nurse.

… Nurses themselves keep telling me 'what a pity you selected this field'. They speak sick of it…They are by no means motivated, they continue groaning at departments. Then, how tin can I have a positive attitude towards nursing… (S17)

…I feel that nurses are treated like servants, which is not at all the example. A nurse also studies, as in all other fields, and what she does is scientific… (S10)

These factors caused nursing students in clinical environments to change their attitudes towards nursing and be dislocated in accepting their professional identities.

Emotional flares

When confronted with the problems and challenges in educational opportunities and clinics, students were faced with psychological problems, fear and stress. Their fright and stress in clinical learning environments could exist rooted in the unknowns, equipment and fear from harming the patients.

…There were lots of dressings and lots of things connected to them (the patients). I had never seen these; information technology's scary…I have no idea how to operate them; it'southward then bad… (S16)

Another source of students' fright in clinical learning environments was receiving negative feedback from instructors, patients' companions or nurses.

…Information technology has happened to me a lot…They shiver…I asked some and they replied 'we're afraid of being told that we are making mistakes'… (N2)

Hopelessness was another psychological reaction created under the influence of nurses' attitudes. Discriminatory behaviours and an unsupportive atmosphere in clinical environments, as well as the negative attitude towards nursing students and nursery in clinical departments and the society, caused an inferiority complex, a sense of humiliation or deficiency in self-conviction in students. Furthermore, some nurse instructors' unfriendly behaviours intensified these feelings.

…When instructors don't talk to us and don't treat us properly, we have no self-confidence to exist able to serve patients; we are upset to the extent that we take no incentive to work… (S14)

The unsupportive, unfriendly atmosphere sometimes caused the students to cry or jitter.

Fluctuation of escape and promotion

Nursing students used two sets of strategies based on their weather condition in the clinical environment every bit an inadequate educational context. Some of these strategies made it possible for them to escape from unpleasant situations. These strategies did not help students solve their problems and prevented them from accepting their professional roles and responsibilities. On the reverse, some other strategies promoted students' professional development and helped them embrace their clinical surround and professional responsibilities and reduce negative emotional responses. In this written report, fluctuation of escape and promotion was recognised equally the core variable.

Escape

Sometimes, the students tried to deal with unpleasant behaviours past neglecting or staying silent in order to reduce tension and stress and to avoid the increase of such behaviours.

…Whenever we enter the department, nurses say 'the clumsy are there once more,'…We said nothing, kept silent, and just stopped and looked… (S8)

Some students tried to avoid the nurses' unpleasant, destructive behaviours. They also tried not to become stuck in situations that required noesis and skills to preclude stress and irritation.

…I can't perform electrocardiography and get stressed when I need to do it…I don't select a patient for whom I have to do so; I avoid these opportunities in order non to get stressed… (S18)

However, the students sometimes chose a different method; they denied the reality, that is, lack of knowledge and skills, and tried to pretend that they held high skills or the required knowledge for caretaking.

…I never admit that I don't know something…either to a teacher or to a patient…never…I don't know, in fact, and I'm also stressed… (S1)

Escaping from responsibleness was some other strategy, which was sometimes adopted by the students. Lack of correspondence between the students' personalities and the field as well resulted in escape from responsibilities. This was manifested as a waste product of time or failure to do the assignments through which the students tried to encounter the unpleasant conditions in the clinical environments.

…Students really come up to the section and don't work willingly; they e'er seek for a way to escape…They nourish the section conference, only they aren't prepared; they make excuses… (I1)

Efforts for promotion

Some students used a strategy to grow and promote due to a sense of internal delivery as well every bit the need for agreement and improving their practical skills. In this mode, support from nearby people, including peers and instructors, was helpful. They tried to find themselves in the environment and to understand who they are, what their duties are, and how they can establish a relationship and gain the trust of patients and nurses. In this manner, the students tried to improve understand their roles and responsibilities and to increment their practical cognition and skills. Therefore, they identified some nurses and educators with loftier care and skill levels and good relationships equally their models to improve their performance and reduce the stress acquired by their lack of knowledge and skills.

…I definitely choose the instructor with proper beliefs as my office model, and try to learn from her… (S16)

Furthermore, some students tried to be responsible towards the patients due to their intrinsic sense of commitment and made efforts to gain patients' trust and satisfaction and provide amend intendance. Thus, they overcame their lack of interest and incentive, and they satisfied themselves and promoted their own performance.

…even if I'g not interested in nursing, I try to do my job properly to satisfy the patients since I feel responsible now; this makes me interested at least… (S1)

Search for information was some other important measure taken by the students to manage the stress that resulted from unpreparedness and fear.

The students stated that they used support from their friends, peers and some instructors to reduce their psychological problems and overcome their fear and negative feelings towards clinical environments, and then that they could announced with confidence and perform the assigned tasks.

Discussion

The findings of this written report expanded nursing students' main concern in the clinical education environs and the overall strategies used to deal with information technology.

It is one of the instructors' and nurses' important obligations to provide nursing students with training and support on entry in clinical environments and help them have their roles equally nurses. However, the findings of the present research, also as those of some other studies, have indicated that nurse instructors and nurses lacked the required efficiency, knowledge and skills for training students.22 23 Furthermore, the results of the present study demonstrated that defects in educational planning reduced the students' preparedness to enter the field. The wide gap betwixt theoretical and clinical teaching results from educational planning methods in the field.24 The results of the research by Pourghane23 indicated that repetitive topics in clinics resulted in negative clinical experiences, and this had to be taken into consideration.

Students enter clinics with insufficient preparedness and with their ain conceptions of clinics and nursing. They notice disharmonize between their expectations and learnt subjects and the reality in clinics once they are encountered with an unsupportive atmosphere, nurses' negative behaviours and attitudes, and and so on. This finding is in line with those of other studies.xiv 25 Abazary et al 26 stated that nursing students' entry into clinical environments caused interference between their and nurses' responsibilities and the resultant issues. Factors causing problems between students and the department staff include lack of correspondence between instruction and treatment, rejection of criticism, insufficient equipment provided to students and failure to consider the students' list of responsibilities.

Improper clinical work environments and lack of correspondence between reality and the students' preconceptions resulted in nursing students' negative view of their career and the decision to quit.17 This is a major reason for quitting the career and withdrawing from the field after entering clinical environments.27 Nonetheless, well-nigh students enter nursing profession with positive attitudes towards the values of caretaking and expect to learn it as a caretaking career.28 Of course, students' personality traits are of keen importance with regard to their preparedness to piece of work in clinical environments and their part as nurses. Iranian university entrance exam just assesses participants' theoretical knowledge and educational talent. A study conducted in Islamic republic of iran demonstrated that 44% of students did non hold personality traits appropriate to the nursing career, and most 77% of them had footling knowledge of the field when selecting information technology.29 Therefore, an important betoken for admitting students to this field is to assess its correspondence with their personality traits. Another important cistron in the students' accomplishment of nursing purposes and proper professional performance is to establish expert relationships with the handling squad. However, students inappreciably have such experiences and consequently encounter conflicts in accepting their profession.30

The interpersonal human relationship between the instructors and clinical nurses and the students plays an important office in the evolution of students' personal and professional person identities.31 Furthermore, instructors' and clinical nurses' negative relationships with and behavioural and verbal aggression towards students are a major factor in the development of stress in students, creating a sense of inefficiency and disqualification.32 Establishing proper relationships with students and supporting them in clinical environments both facilitate the learning process and result in professional person socialisation.33

When confronted with stressful, unpleasant factors in clinical environments, students try to utilize coping strategies.34 Some studies have demonstrated that students tended to use positive35 or avoidance strategies.36 37 Coping strategies including transference, staying optimistic and trouble-solving were other solutions to reduce students' stress.34 Gaining support from friends has also been 1 of the most important strategies employed past students.37 According to the results of the study by Vaghee et al 38, training in communication skills reduced the employment of the 'escape from troublesome situations' and avoidance strategies, and could enforce the 'seeking for social support' strategy, increase efforts to obtain information and emotional support from others, and increase the employment of 'responsibility' and 'problem solution' strategies, also equally analytical efforts to solve problems in stressful situations.

Information technology is essential that wellness and instruction policymakers have a special focus on improving clinical environments and educational contexts. Identifying professional models and increasing their influence on management, education and clinical educational activity, also as teaching positive and effective strategies, assistance strengthen and promote positive strategies in coping with inadequate educational contexts.

Limitations of the study

This study just focused on discovering the experiences of Iranian nursing students, clinical nurses and instructors. Thus, further studies in other cultures are needed to make the results more generalisable.

Decision

The present written report showed that continued attention is required to minimise unsupportive atmosphere in the clinical surround, also every bit negative attitudes towards nursing students and nursing profession in clinical departments and the society. In this context, educators and nurses should exist enlightened that they, as proper role models, can motivate students and raise their clinical knowledge and skills. In addition, educators and nurses can be effective in helping nursing students properly confront the challenges of the clinical environs. Apply of constructive strategies that lead to professional person development of nursing students should exist enforced with the necessary instructions, and at the same time faculties and clinical environments are coordinated. In this way, clinical regime are informed about students' expectations and clinical environments are improved, eventually enhancing students' preparedness and capabilities before entering the clinics.

Acknowledgments

This article was extracted from the PhD dissertation written by NJ. The authors would similar to thank Ms A Keivanshekouh at the Research Improvement Center of Shiraz University of Medical Sciences for improving the use of English in the manuscript.

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