Perception of nursing students' on clinical experience in the National Referral Hospital of Bhutan
Manikala Moktan1, Vijay Kumar Mehta2
1 Department of Community Medicine, Sikkim Manipal University, Gangtok, Sikkim
2 Department of Nursing, Faculty of Nursing and Public Health, Thimphu, Bhutan
|Date of Submission||23-Sep-2019|
|Date of Acceptance||07-Dec-2019|
|Date of Web Publication||28-Apr-2020|
Prof. Manikala Moktan
Faculty of Nursing and Public Health, Thimphu 1101
Source of Support: None, Conflict of Interest: None
BACKGROUND: This study has been carried out to study the usefulness of the clinical posting at the National Referral Hospital in Bhutan. It is important to know whether the clinical experience leads to gaining nursing skills, and nursing being a skill-oriented profession, clinical placement provides an opportunity, and education that carry a heavy weight in their wholesome nursing education.
OBJECTIVE: The objective was to explore how nursing students commonly perceive their clinical experience.
METHODS: A focus group discussion was conducted with eight to ten students/group from three levels of nursing education. The groups were 1st-, 2nd-, and 3rd-year students who expressed their clinical experiences during the focus group discussions. The data were analyzed by content analysis using a thematic analysis.
RESULTS: Four themes emerged from the focus group discussion. The themes were “good exposure,” “connect theory to practice,” “anxiety and fear,” and “learning by task participation and helping.“
CONCLUSION: The clinical environment is different to classroom. In clinical areas, the students experience stress and anxiety, and learning is through working together, moreover, it finds out that real situation is not what is taught in the classroom.
Keywords: Clinical experience, diploma in nursing, midwifery, nursing education
|How to cite this article:|
Moktan M, Mehta VK. Perception of nursing students' on clinical experience in the National Referral Hospital of Bhutan. J Edu Health Promot 2020;9:94
|How to cite this URL:|
Moktan M, Mehta VK. Perception of nursing students' on clinical experience in the National Referral Hospital of Bhutan. J Edu Health Promot [serial online] 2020 [cited 2020 May 25];9:94. Available from: http://www.jehp.net/text.asp?2020/9/1/94/283363
| Introduction|| |
This study was conducted to get the true facts from the Bhutanese students who had the clinical experience. The clinical experience being a part of nursing education is followed in this institute also; however, each cohort of students' clinical experience is different and that aspect has never been examined in Bhutan. The significance of the study is that the clinical experience would create respect for this profession and make them competent nurse. The known facts on perception of clinical experience would guide aspiring science students in selection or rejection of nursing as a profession and influence their attitude toward the profession.
| Methods|| |
Focus group discussion is frequently used to gain an in-depth understanding of social issues, and this method aims to obtain the data from a purposely selected group of individuals rather than from a statistically representative sample of a broader population.
A focus group discussion was carried out with the nursing students to understand their clinical experience. Eight to ten students from 1st-, 2nd- and 3rd-year were involved in the focus group discussion. The students were explained about the objectives of the study and those who consented to participate, signed the consent form. They were assembled in an empty classroom and explained about the focus group discussion. The two topics to be discussed were “how the clinical experience is perceived” and “knowledge/skills gained from clinical experience.” The students were allowed to discuss and give their frank views. The whole discussion took 1½ h. The permission to tape the discussion was sought, and notes were also taken. The interview was transcribed verbatim, and qualitative content analysis was used for exploring and interpreting the content of the interview text. Thematic analysis of the data identified four themes. An ethical approval was sought from the SMIMS Institution Ethics Committee and SMIMS Research Protocol Evaluation Committee in Sikkim Manipal University, Sikkim, India, and Research Ethical Board of Bhutan. This article is a part of author's thesis that is not yet published. This study is a part of the PhD study thesis.
| Results|| |
Four themes were identified after analyzing the focus group discussion of the students. The four themes are “good exposure,” “connect theory to practice,” “anxiety and fear during first posting,” and “task participation and helping.”
The view on “good exposure” was as follows
“We get exposure in clinical posting and we are exposed to setting, environment, people around, learn lots of things about management system, we go through the system and we follow and through that we adapt the system and environment. We enhance learning and we socialize with staff and patients and deal with them. When we socialize we get more knowledge and boast our skills as people help us.”
Chesser-Smyth study in 2005 mentioned that novice nurses found a clinical environment as facilitating task-rearing, personality-rearing, knowledge-rearing, and profession-rearing roles of clinical work. Manoochehri et al. in 2015 identified four elements in a clinical setting, and these are as follows: the appreciation and support the students received, the quality of mentoring and patient care and students' self-directedness. The added elements are clinical nurses, physicians, patients, carers, support staff and availability of equipment.
Student nurses' valued clinical practice and the possibilities it offered to become a nurse and a professional. A good clinical learning environment was established through good cooperation between the school and the clinical staff, therefore it was concluded that the school should be able to provide a suitable clinical learning environment at the right time. The nursing students found a clinical learning environment as supportive, provide well-organized learning activities, extensive learning opportunities, and involve student in practice.,,
Connect theory to practice
“Practical posting helps to remember the theory and experience are not taught in the classroom. After learning theory in class, we are posted to wards and there we can practice procedure and see the patient as cases. Practical-improve knowledge and get opportunity to apply. In surgical ward, we have different cases and some are pre-operative and some post-operative case and through this we can learn about surgery and after care of patient.”
“The theory taught in classroom is applied to practice in clinical areas. The nursing skills learnt during clinical posting makes us competent to practice confidently as clinical nurse after training. At the beginning of our training, there is not much difference between theory and practice as we learn theory in classroom and then practice in lab. Moreover, it is not risky to practice on mannequins. However in some subjects, theory taught and posting in clinical setting does not match. In case of midwifery, theory is taught followed by practice and therefore, it is easy to integrate.”
“ Posting in District hospital is very important as we can relate theory to practice and won't be able to apply if not posted there. This is useful when we are in job after completion of training. We are able to practice the simple skill e. g. vital sign, caring for patient, however due to physician not performing advanced procedure on patients, we lack those skills. Nonetheless, there are clinical nurses who supervise us however, sometime we don't get time and opportunity to learn from them.”
The gap between theory (taught in the classroom) and the practice (in the clinical area) is discussed a lot, nonetheless, a study mentions that appointing a nurse practitioner in ward would aid in bridging the gap between theory and practice. Literature suggests that the most commonly accepted solutions by the students to bridge the gap were to provide parallelism between the practicing field and the students' needs, the compliance between the theoretical information and the applications in practice, to perform the practicing classes in the rooms that are provided in the practicing field, to focus on improving the skills before practicing, and to inform students about the practice.
Safazadeh et al. s' study in 2018 carried a qualitative study on reducing the theory-practice gap in emergency nursing education that was divided into six primary categories, two main categories, and the one theme of action to change. The participants felt necessary to have reform and developmental actions in line with care, supervision, evaluation, and educational processes to reduce the gap in emergency nursing education.
Anxiety and fear
“The feeling in first clinical posting is fear and nervousness and feel mentally challenged. When we come back to our residence then get nightmares and feel haunted thinking about incidences from clinical areas. We have heard from most senior saying that in-charges are strict and we observed that they are fast in doing their work and don't have time to teach us while handling emergency cases. As in beginning, we are novice and we don't learn anything however, we get through nonetheless, we sometime don't like it as we know less. Slowly, I could overcame the fear after experiencing the pain, depression, then as time passed, all went well”. “The thought that I did wrong used to hurt me and could not concentrate for long time and this happened in my first posting, 6 months ago. The sudden exposure to clinical areas with lots of people who are sick and physicians, carers that are around patients, intimidates us.”
During this preparatory process, student's at all educational levels within all kinds of undergraduate nursing programs (i.e. diploma, associate, and baccalaureate) report high levels of stress and anxiety in the clinical learning environment. The lack of experience, being evaluated by nursing mentors and handling patients, leads to stress and anxiety in clinical environment. Moreover, the nursing students' lack of knowledge and skills in the clinical environment could lead to anxiety.,,
The lack of nursing skills and knowledge and the queries from patients make students' feel low.,,, The most common factors include the first clinical experience, fear of making mistakes, performing clinical skills, faculty evaluation, lack of support by nursing staff, and theory-practice gap. Rajeswaran study in 2016 elucidates that beginner in nursing field has fears with the clinical environment; therefore, the first exposure to caring for life is overbearing for them.
Task participation and helping
“When we go to wards, we are asked to clean patients then we do not know. We ask seniors to teach us. Sometimes, we go with staff nurse to give medicine; there we watch staff giving medicine, next time, we do same. In wards, I sometimes go with staff as she tells me to carry intravenous set and normal saline. She asks me to hold patients' arm, I do and learn to give next time.”
Students learn to care patients in the clinical environment by observing clinician, their teachers and peers., Another way to acquire skills offer through task participation with peers that provides opportunities to learn. Task participation and accomplishment facilitate learning, as it leads to the development of clinical skill and confidence. The students are assigned patient and nursing procedures to be carried out related to the patient's care. Certain tasks are listed for students that require skill to perform the task. Learning only occurs if the experience is use productively.,
| Discussion|| |
Students are posted in clinical areas according to the duty roster and objectives. The objective is aligned with the nursing procedures, students have learned in the classroom and practiced in the nursing laboratory. The theme “connect theory to practice” is one objective that is explained to incorporate in clinical areas. The next theme “good exposure” is with the first time posting as mentioned with orientation to the physical setup of hospital or ward. Stress felt for the first time in clinical areas is mostly mentioned by 1st year. These themes are expected due to lack of complete knowledge, skills as only a few subjects/skills are taught before the clinical posting. Learning skills through helping and assisting are mentioned by a study, and this trend is still being practiced in all nursing education.
Only three groups of students were interviewed due to time constraints. A few students may have been not frank enough to put forward their opinion, as the interviewer was their teacher. On the contrary, as it was explained that this study would be put forward to the administration and management for improvement, most students were honest to give their views.
The perceptions of 1st-year students' gave insight to develop an orientation program before sending them to hospitals. This issue was also discussed in the coordination meeting with adjunct faculty and other nurses who were working with the students.
The facts reveal that the students posting in clinical areas are productive. The students did express that they did not expect to be stressful in clinical posting; on the contrary, as patients mostly are not aware of their level of knowledge and skills, therefore, students anticipate all white uniform nurses to be knowledgeable and skillful to give care. A few nursing staff reads the objective sent along with a duty roster of students, rest assume that students already knows all nursing procedures and would help them in wards.,,,,
| Conclusion|| |
The result depicts positive as well as negative themes encountered during clinical posting. The perception of students on clinical experiences was elaborate and truthful. The focus group discussion did save time, and analysis could be done immediately after each session. The drawback being students not being too candid and frank in expressing while in groups. Conducting discussions with three different levels of students gave rich data on the experiences of clinical areas. As the topic was not sensitive, most students were truthful about the clinical experiences.
I would like to thank the Dean, Faculty of Nursing and Public Health, for his great support throughout the study. My most appreciated thank goes to my supervisor who provided insight and expertise that greatly assisted the study. My heartfelt gratification goes to the Diploma students who participated in my study. My good luck wishes for their bright future.
I would also like to show my gratitude to the anonymous reviewers for their insights and for sharing their pearls of wisdom and their comments.
The study was approved by the Royal Ethical Board of Health in Bhutan, concurrent approval given by the hospital, and it was self-financed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nyumba OT, Wilson K, Derrick CJ, Mukherjee N. Qualitative methods for eliciting judgments for decision making, the use of focus group discussion methodology: Insights from two decades of application in conservation. Methods in Ecology and Evolution. British Ecology Society. 2018; 9:20–32.
2. Chesser-Smyth PA. The lived experiences of general student nurses on their first clinical placement: A phenomenological study. Nurse Educ Pract 2005; 5:320-7.
Manoochehri H, Imani E, Atashzadeh-Shoorideh F, Alavi-Majd A. Competence of novice nurses: Role of clinical work during studying. J Med Life 2015;8:32-8.
Papp I, Markkanen M, von Bonsdorff M. Clinical environment as a learning environment: Student nurses' perceptions concerning clinical learning experiences. Nurse Educ Today 2003;23:262-8.
Chuan OL, Barnett T. Student, tutor and staff nurse perceptions of the clinical learning environment. Nurse Educ Pract 2012;12:192-7.
Serena P, Anna B. Italian nursing students' perception of their clinical learning environment as measured with the CLEI tool. Nurse Educ Today 2009;29:886-90.
Ousey K. Bridging the theory–practice gap? The role of the lecturer/practitioner in supporting pre-registration students gaining clinical experience in an orthopedic unit. J Orthop Nurs 2000;4:115-20.
Tanriverdi G, Ozyazicioglu N, Atay S, Sivrikaya SK, Gursoy MY, Cetin A. The recommended solutions of nursing students to bridge the gap between the school and practice areas. Int J Caring Sci 2017;10:199.
Safazadeh S, Irajpour A, Alimohammadi N, Haghani F. Bridging the theory-practice gap in Iranian emergency nursing education. ARYA Atheroscler 2018;14:105-14.
Carlson S, Kotzé WJ, van Rooyen D. Accompaniment needs of first year nursing students in the clinical learning environment. Curationis 2003;26:30-9.
Cook LJ. Inviting teaching behaviors of clinical faculty and nursing students' anxiety. J Nurs Educ 2005;44:156-61.
Elliott M. The clinical environment: A source of stress for undergraduate nurses. Aust J Adv Nurs 2002;20:34-8.
Hayden-Miles M. Humor in clinical nursing education. J Nurs Educ 2002;41:420-4.
Sharif F, Masoumi S. A qualitative study of nursing student experiences of clinical practice. BMC Nurs 2005;4:6.
Shipton SP. The process of seeking stress-care: Coping as experienced by senior baccalaureate nursing students in response to appraised clinical stress. J Nurs Educ 2002;41:243-56.
Cowen KJ, Hubbard LJ, Hancock DC. Concerns of nursing students beginning clinical courses: A descriptive study. Nurse Educ Today 2016;43:64-8.
Rajeswaran L. Clinical experiences of nursing students at a selected institute of health sciences in Botswana. Health Sci J 2016; 10:.6:471.
Adamski M, Parsons V, Hooper C. Internalizing the concept of caring: An examination of student perceptions when nurses share their stories. Nurs Educ Perspect 2009; 30:358-61.
Aston L, Molassiotis A. Supervising and supporting student nurses in clinical placements: The peer support initiative. Nurse Educ Today 2003;23:202-10.
Henderson A, Cooke M, Creedy DK, Walker R. Nursing students' perceptions of learning in practice environments: A review. Nurse Educ Today 2012;32:299-302.
Smedley A, Morey P. Improving learning in the clinical nursing environment perceptions of senior Australian bachelor of nursing students. J Res Nurs 2010;15:75-88.
Roberts D. Learning in clinical practice: The importance of peers. Nurs Stand 2008;23:35-41.
Zentz SE, Kurtz CP, Alverson EM. Undergraduate peer-assisted learning in the clinical setting. J Nurs Educ 2014;53:S4-10.
Ashworth P, Morrison P. Some ambiguities of the student's role in undergraduate nurse training. J Adv Nurs 1989;14:1009-15.
Palmer D, Burns S, Bulman C. Reflective Practice in Nursing. Carlton: Blackwell Science; 1994.
Shields E. Reflection and learning in student nurses. Nurse Educ Today 1995;15:452-8.
Battersby BB, Hemmings L. Clinical performance of nursing graduates. Aust J Adv Nurs 1991;9:30-4.
Bartlett HP, Simonite V, Westcott E, Taylor HR. A comparison of the nursing competence of graduates and diplomats from UK nursing programmes. J Clin Nurs 2000;9:369-381.