It is generally accepted in education and nursing that practice experience is a vital aspect of learning (Dewey, 1944; Infante, 1975; Rogers, 1969; Wiedenbach, 1969). Learning in the contextual setting of clinical practice confronts us with challenges which are absent from the classroom. A few of these differences are: we have little control of environmental conditions; students must combine the use of cognitive, psychomotor, and affective skills to respond to individual client needs; client safety must be maintained while he or she is cared for by a novice practitioner; and faculty must monitor client needs as well as student needs.
The purpose of this study was to better understand the clinical experience from the nursing students' point of view. The research question was, "How do nursing students perceive their clinical experiences?" Specific aspects were addressed in terms of the following questions:
1. What do nursing students say they do in their clinical experience?
2. What do nursing students say they are learning in the clinical setting?
3. What do nursing students say facilitates their learning in the clinical setting?
4. What do nursing students say is detrimental to their learning in the clinical setting?
5. What makes a clinical day good for a nursing student?
6. What makes a clinical day bad for a nursing student?
7. What do nursing students worry about in clinical?
Review of the Literature
Students' perceptions and experiences were studied by sociologists Davis and Olesen (1964) in their effort to understand professional socialization of nurses. This threeyear longitudinal study utilized interviews, observations, and a questionnaire to provide data about students' progression from a lay image of nursing to a professional image. Although the results indicated that student nurses did migrate toward a more professional view before graduation, the change was not radical or consistent.
Student anxiety in the clinical setting is an area of concern for nurse educators. Because of the evidence to support an inverse relationship between anxiety and advancing human development as measured by self-actualization, Sobel (1978) studied the levels of anxiety in nursing students and compared these with self-actualization as measured by Shostrom's Personal Orientation Inventory. Sobel's (1978) results support the inverse relationship between anxiety and self-actualization and, along with a study conducted by Gunter (1969), reports that nursing students have achieved an average level of selfactualization for their age. Because most nursing students have not reached the age of emotional maturity, we can expect that they will display inefficient use of time, less inner-directed than outer-directed behaviors and dependence on views of others. Hayes (1966) reported that nursing students were no more anxious than other college students their age. After measuring anxiety levels of nursing students before lecture, before clinical, and before written examinations, Hayes (1966) concluded that there was no significant difference between anxiety levels before clinical and lecture but a significant increase in anxiety levels was documented before written examinations.
Several studies have been conducted to determine what faculty behaviors and characteristics are considered important by nursing students (Barham, 1965; Brown, 1981; Jacobson, 1966; Lowery, Keane & Hyman, 1971; O'Shea & Parsons, 1979; Wong, 1978). Interpersonal relationships characteristics, teaching abilities, and professional knowledge and behavior were reported as important in all of the studies. The order of importance varied with individual needs and level of professional development.
Naturalistic inquiry methodology was selected for this study because of the desire to understand the students' unique perceptions of the clinical experience. Nine volunteer students enrolled in their final semester of nursing school at a large midwestern public university participated in this study. Participants were compared with the entire class using sex, age, ethnic descent, residency status, and size of hometown, and, except for age, the research participants closely represented the average generic nursing student. In an effort to limit the boundaries of the study, no students over 30 years old were allowed to participate, consequently 100% of the participants were under 25 years of age, while 86% of the entire class were under 25 years old.
Data were collected by interviewing each student twice. As recommended by Guba (1981) and Glaser and Strauss (1967), data were collected until no new categorical information was ascertained. Consequently, the specific number of participants was not determined until data collection had proceeded for several months. The interviews were conducted using a focused interview approach described by Merton and Kendall (1946). This type of interview was used to direct the subject toward clinical, and yet allow the students to introduce topics which the interviewer expanded upon with the use of open ended statements like: "Iteli me more about ..." or "Give me some examples of. . ." After the first interview the audio tapes were transcribed and studied for incomplete or confusing data. The second interview was used to complete data collection from each individual and to clarify meanings.
The goal of the data analysis was to organize the data into categories to provide structure for better understanding the clinical experience. The categories were appraised for completeness in three ways described by Guba and Lincoln (1981). First they were checked for internal and external plausibility. Internal plausibility was established when each individual category appeared to be internally consistent. External plausibility was established when the entire set of categories related to one question reflected a complete picture ofthat question. These decisions were made by the use of logic and knowledge about the phenomenon being studied. The second check for completeness was that of inclusiveness. Inclusiveness was established when there was a relative absence of unassigned data and when the data in each category appeared to logically cover the subject. The final check for completeness was an audit provided by a second competent judge.
The four major criteria defined by Guba (1981) for establishing trustworthiness while conducting naturalistic inquiry were used in this study. The four criteria are credibility, transferability, dependability, and confirmability. Credibility (internal validity) was tested by using repeated interviews and member checks. Repeated interviews were accomplished by interviewing each participant twice to obtain a rich supply of data. Member checks were achieved during the second interview by asking the participant to verify interpretations from the first interview.
Ttests for transferability (external validity) are concerned with generalization of the findings. Although naturalistic inquiry is not greatly concerned with generalization, some transfer of results between similar situations may have some relevance. Transferability was provided by the use of thick descriptions as described by Geertz (1973). Dependability (reliability) was tested by using an audit provided by a second competent judge who verified that the categories were appropriate and data were assigned logically. Confirmability (objectivity) was provided by proper training of the researcher and a final audit by three competent judges to verify that the data supported the interpretations.
The categories which emerged from the data are listed in the lable. Students clearly recognized the practice of nursing skills as a major function and area of learning in clinical experience. Skills discussed include assessment, therapeutic communication, and psychomotor skills. Students also devoted considerable time to studying and organizing cognitive material to facilitate their learning and nursing care. This involved "hitting the books and journals" and "pouring over charts for hours"; consulting other health care providers; and writing papers. Some of this was preparation before clinical experience and some was accomplished during clinical experience.
Time management was a major source of frustration for students. They often felt disorganized and explored a variety of ways to resolve this problem. One solution was to prepare a schedule of activities the day before clinical. Although this worked well, students found it necessary to remain flexible because "Many things change when you actually get to clinical. You have to learn to think on your feet."
Students progressed in their professional socialization by observing nurses and participating in nursing functions to "learn how to act like a nurse." The more they felt a part of the profession, the better they felt about clinical experience. Although relating to staff nurses was difficult at first, it was valued as an important part of learning. By the last clinical course, eight of the students felt like "real nurses" and one did not.
The students accepted responsibility for the quality and quantity of their learning through their willingness to prepare for clinical practice. Preparation included meeting patients, reading charts, studying patients' health needs, and consulting staff. Adequate preparation for clinical was credited with "making all the difference in the world," particularly during beginning and intermediate level courses.
Supervision during clinical was provided by the instructor and staff nurses. The students wanted their instructor to "challenge them" by "expecting a lot" and "asking good questions." They also wanted to know what the instructor expected of them and they wanted frequent, honest feedback about their performance. The students felt they learned more from knowledgeable instructors and staff who were willing to share their knowledge and experience but they did not want the instructor or staff nurse to do their work because "that ruins my confidence." The students also reported that a pleasant clinical instructor and staff helped them learn. This pleasant atmosphere helped the student relax and increased the likelihood that the student would approach the instructor or staff nurse to ask questions or discuss clinical issues.
A wide variety of clinical experiences, with "lots of different patients with different diseases," "different kinds of floors," "a variety of instructors" and "working with different equipment" all increased learning. Although variety was valued, students believe they "need more than one day with patients to learn to work with them instead of just doing skills."
Personal problems were cited as detrimental to learning. Personal issues can "distract me in clinical or interfere with my preparation." Since the participants were all close to graduation they often mentioned "worry about being out on my own" and "worry about getting a job" as occasional distractions.
As a general rule, the students enjoyed clinical experience. They considered it extremely valuable and felt personally fulfilled by the contact with patients. Clinical went well when students felt they functioned as a health team member and contributed to the team work. Positive feedback about their performance from instructors, staff, and patients was highly valued even when they knew they had done well. Students reported that they do not worry much about clinical experience now but remembered being very nervous before previous clinicals. They expressed the desire to provide good patient care and had some concerns that they would be unable to accomplish that goal.
STAGES OF DEVELOPMENT: This study also revealed that student nurses move through different stages of professional development in clincial. During the first stage students were very nervous and reported not sleeping well before clinical. They perceived clinical as "just doing skills like baths" with everything being new and scary to them. During this stage students felt very dependent on the instructor and unsure of themselves.
The second stage was called the "make you or break you stage" by one student. The students became less obsessed with psychomotor skills and began to explore other aspects of the nursing profession. Some students felt very confused at this stage because they were unsure what nurses do besides the psychomotor tasks.
During the final stage the students became more confident and less dependent on the instructor. They felt more comfortable about not knowing everything because "I know I can find the answers." They studied less for clinical and began to feel like a nurse - not just in school, but all of the time."
RELATIONSHIPS: Students indicated that their relationship with instructors, staff nurses, students, and patients was important in their clinical experience. In addition to helping the students learn, these people helped provide a pleasant atmosphere in which to work. Instructors and staff nurses and patients were reported to occasionally provide a negative atmosphere while other students were consistently supportive and helpful. Although physicians were mentioned, they were not perceived as important to the students.
Thirty percent of the total responses were about the clinical instructor. The data indicated that the instructor was an important resource person for the many questions students had about clinical situations. They wanted to feel free to ask these questions without being embarrassed or harassed by the instructor.
Students expressed the need for knowledgeable clinical instructors who were willing to share their knowledge and past experiences with the students. Although they did not want the instructor to do their work, their respect for the instructor increased if they saw the instructor interact well with patients and demonstrate good nursing skills. "I need the instructor to think of things that never occur to me. No matter how much you prepare, you can't know everything and an experienced instructor or nurse helps me prevent mistakes," responded one student. Students reported that they often did not know if they were doing well, especially during the beginning clinical courses, unless the instructor provided both positive and negative feedback. Feedback that was given in private and at frequent intervals was appreciated most by students. When instructors criticized students in front of patients, other students, or staff they felt embarrassed, angry, and "I lose my confidence." This was degrading to the students and left them with very bad feelings about clinical and the instructor.
The amount of supervision that the instructor provided was important to the students. Students indicated that they wanted to develop independence from the instructor as they progressed toward graduation and disliked being watched too closely when they felt they had adequately mastered such skills as giving injections. On the other hand, when they were performing a procedure for the first time they expressed the desire to have an instructor present because "Fm not sure what I'm doing."
None of the participants expressed the desire to have an easy-going instructor. They indicated that an instructor should have high expectations of them by assigning difficult patients, asking questions, and requiring students to work at solving problems. If the instructor was too casual or relaxed about the students' performance, the students were less likely to feel good about their clinical experience because "a difficult assignment shows that she trusts you and tough questions help me learn."
The instructor was expected to demonstrate professional behavior for the students. Behaviors which were reported were confidence, thoroughness, neatness, respect, and supportiveness. Professional behavior also included ethical behavior such as not talking about other instructors or students inappropriately. The responses demonstrated that students felt a need for colleagial support within nursing which the instructor could help provide.
Personality characteristics, such as honesty, humor, warmth, respect and enthusiasm, were considered desirable in the instructor. The students said that they wanted the instructor to be "human and friendly, a nice person who cares about me as an individual." A nervous instructor is "terrible for students, we are anxious enough doing all this new stuff."
The students' feelings about the staff nurses changed considerably from the first to the last clinical course. At first the students tended to fear the nurses and felt ignorant in comparison to them. The responses indicated that students rarely interacted with staff nurses during the first clinical course except to "report off." As the students progressed through the clinical courses they tended to interact increasingly with staff nurses. The students indicated that as their interaction with the staff nurses increased, their fear of the staff nurses decreased.
The majority of the responses about staff nurses were overwhelmingly positive. The students generally perceived them as knowledgeable, helpful, and understanding. The staff nurses "were the ones who knew the patient best; now I usually ask them my questions." Occasionally the students would ask staff nurses a question because they did not want the instructor to realize that they did not know the answer. The staff nurses also served as resource people when the instructor was busy and the staff nurse was more available at the moment. Two students reported feeling that staff nurses had been particularly supportive of them when they were nervous about new procedures, and had helped them relax and feel more confident.
Negative experiences with staff nurses included nurses making derogatory comments about students and looking at them in disparaging ways, telling students to ask their instructor for help instead of asking staff nurses, and frequently checking on the students to see if they were doing their work. The negative feelings were conveyed more by the manner of the staff nurse than by overt behavior. The students indicated that the more they talked with staff nurses the better their relationship became. Some students reported that they deliberately made efforts to be respectful, friendly, and helpful to develop a positive relationship with the staff nurses.
The most frequent response about other students was that they provided essential emotional support. The students perceived that only nursing students "really understand what they go through in school" and, therefore, they talk with nursing students about school-related problems and issues. Most of their close friends were in one or more clinical groups with them and were often their close friends socially. They indicated that competition between nursing students in clinical was rare and generally not encouraged by the students. The responses demonstrated that student nurses frequently help each other in clinical. They often ask questions of their peers rather than the staff nurses or instructor. Other students are consistently supportive and provide no threat by making their peers feel bad "because I don't know something." The students frequently work together as colleagues to accomplish difficult tasks or to complete the necessary work. One student mentioned that the instructor might not like for them to help each other so they tend to conceal this activity from the instructor.
The value of this study lies in the resulting implications for nursing education and future research. Nursing curriculum and course development are often executed by nurses who know little about education. Few nurses are taught how to teach in the clinical area but are considered competent because of clinical expertise and educational achievements. A better understanding of what constitutes quality clinical education would be valuable in providing better educational experiences.
This study indicated that many aspects of the clinical environment affect the quality of the students' experience. The instructor emerged as an important variable in clinical. The characteristics and behaviors of the instructor desired by nursing students have been studies with consistent results. More rigorous studies would help clarify categories but there is already information available that would be valuable in helping nurse educators to better meet the needs of the students.
Staff nurses and peers also emerged as important people in the clinical environment. It would be helpful to acknowledge the importance of these relationships and help the students and the staff nurses to take full advantage of the positive aspects of their interdependence. Nurses need to be encouraged to work more closely together in supportive relationships. Fostering this activity at an undergraduate level may help establish closer bonds.
Students need to learn how to organize their time in clinical and prepare well for the clinical experience. This is often learned by trial and error and could be less traumatic if assisted more directly by faculty and peers. Standard principles or organizing time could be studied by students for application in the clinical setting.
A clearer understanding and acknowledgment of the professional developmental stages of nursing students would help faculty and students to cope with the feelings and needs of the student more constructively. As the students learn about nursing, they often feel confused and doubtful about themselves and the profession. The close alliance between nursing student and clinical instructor is an ideal opportunity for students to vent these thoughts and feelings. Lack of understanding from the instructor may cause increased dissonance rather than provide the needed support for the troubled student.
Clinical experience for nursing students is a very important aspect of their professional education. Research in clinical nursing education is needed to help develop optimum learning opportunities for the nursing student. The lack of research-based planning and implementation of clinical education is a disturbing deficit in the nursing profession. This study reveals many questions which need to be systematically answered.
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