Theme 1:
managerial challenges:
This
theme included 4 subthemes, namely “workload and time management”; “shortage of
nurse supervisor”, “absence of clinical instructors in some wards” and
“shortage of hospital stock”.
-
Workload and time management:
Participants
in this study declared that the workload prevents effective clinical
supervision of nursing students. Registered nurses had limited time to
supervise students and they expressed the following regarding the heavy
work-load:
“We try to
supervise students but patients are too many and their care prevents us to
concentrate on students, we prefer to give time and effort to our patients.”
“We do not
always have time to guide and teach nursing students to our ward properly
because of the work load.”
Student
nurses expressed their experiences regarding workload as follows:
“Sometimes
supervisors have no time to teach students who try to learn through experience
without guidance and it is not always easy.”
“I met a
lot of problems with supervision in the ward as registered nurses are too busy
with patient care.”
“Most of registered
nurses are overloaded with patient care and they do not have time to help
students in doing procedures.”
The
sentences above indicated that participants in this study experienced
challenges with supervision, caused by the too heavy workload. In agreement
with this, Natalie (2007) concluded that the presence of students in the ward
was seen as an additional burden by ward nurses. Students, due to the heavy
workloads, were regarded as part of the staff or workforce and not as students
who need to learn their practical skills (Magobe et
al., 2010). As a result, registered nurses in wards directed their effortd to
the patient care rather than to supervising students. Supervising nursing
students results in further increasing the workload of nurse educators who are
required to supervise a large number of students. Such challenging situations
can harm their emotional health leading to stress, burnout and feelings of
dissatisfaction for their own performance (Younasa,
2019). Therefore, nurses who are allocated to supervise students should
have reduced workload for proper supervision of nursing students. (Magobe et al, 2010; Moeti et al. 2004)
-
Shortage of nurse supervisor:
Shortage
of staff added to the workload of registered nurses who had little time to
supervise students. Registered nurses mentioned the following during the
interview regarding the shortage of staff:
“There is
a large number of students regarding the number of registered nurses. This may
have negative effects on student learning as it hinders the assistance given to
them.”
“We cannot
supervise student nurses properly because our number is small regarding the
number of students that we cannot cope.”
“Wards are
overloaded with student nurses who are too many to be supervised by the
available registered nurses in the wards.”
Nursing
students responded to the challenge about the shortage of supervisor by stating
the following:
“Supervisors
try to teach us but they do not have time for all of us to practice because we
are too many.”
“Sometimes
during supervision some students are left unattended while supervisors are
attending to some others because the number allocated to them is too large.”
“Some
students do not learn anything because we are too many and supervisors are too
few.”
Teaching
and learning opportunities should be provided by adequate human resources for adequate
supervision. When student nurses are allocated in a large number to the same
clinical area, teaching and learning could be affected negatively since
registered nurses would not be able to support them in the adequate manner. (Magobe et al., 2010; Neshuku and
Justus, 2015) Increased number of student nurses in clinical practice brings an
additional strain to the already short-staffed and overworked registered
nurses. They may cause negative attitudes towards clinical supervision. Therefore,
the number of student nurses allocated to any unit at a time should be
controlled to achieve effective supervision. (Hlongwa,
2009; Klerk, 2010; Landmark, 2003).
-
Absence of clinical instructors in some wards:
The
absence of clinical supervisors in some wards represented an important
managerial challenge mentioned by the participants that was associated with a
negative effect on the clinical supervision of student nurses.
Registered
nurses opinions regarding the absence of clinical supervisors were:
“It is
very difficult for us to help students allocated to our wards and there is
nobody helped us how to supervise those students allocated in our wards."
“Clinical
instructors in this hospital have duties like other registered nurses, they do
not get time to supervise student nurses."
Student
nurses on the other side commented in the following:
“We have
to go back to our old style whereas clinical instructors were present in each
ward and responsible for practical teaching of students.”
“I only
see clinical instructors when they come to do clinical assessments, I do not see
them on a daily basis, sometimes they are not supervising student nurses.”
Many
studies supported the previous statements by stating that students appreciate
the presence of supervisors in the wards. Therefore, in absence of preceptors/instructors
practical learning was very difficult. (Ohaya, 2010;
Brown et al., 2004; Mabuda et al., 2008). Student
nurses felt that clinical teachers should be available in most clinical
situations. Instructors are key components for effective clinical training. (Andrew et al., 2006; Sharif and Msoumi, 2005).
-
Hospital stock shortage
The
results of this study revealed that there is a shortage of materials needed for
training of nursing students during their supervision in clinical practices.
One
student nurse stated that
“It is
difficult to learn some procedures because of a lack of materials needed;
students are not able to learn how procedures are done if there are no
necessary equipment.”
The
following quotations are evidence of the above findings from registered nurses:
“Shortage
of equipment is a problem; We are willing to teach students but there is a
shortage of the necessary equipment.”
“We
frequently order the materials needed to provide student training, but we do
not get them. We are not able to teach students if we do not have the necessary
materials.”
“It is
difficult to teach some procedures due to lack of materials, hence, students
are not able to learn the technique of certain procedures.”
In
a similar study carried by Magobe et al., (2010),
registered nurses declared that shortage of equipment was preventing them from
training effectively the student nurses. In Kuwait equipment support to health
care settings is not a problem, but it seems that participants considered the
equipment allocated for clinical training of student nurses. Logically,
registered nurses could not use equipment that were allocated for patients in
the sake of student training. There should be co-operation between nursing
school and health care settings regarding the training equipment support.
Theme 2: Educational
challenges:
The
findings of this study revealed many educational challenges to clinical
training that were categorized under three subthemes namely “outdated
supervisors with lack of knowledge of their role”, “gap between theory and
practice” and “ineffective clinical supervision”
-
Outdated supervisors with lack of knowledge
of their role:
Registered
nurses expressed their experiences as follows:
“Practice programs
for student nurses are not always clear for us in the wards.”
“I was
just selected to be a supervisor but I was not prepared for that.”
“Some
items included in the course requirement are new to us; therefore, we need to
be updated through workshop on supervision to continue supervising students."
“Most of
us are not up-to-date with the latest requirements for the supervision of
students.”
On the
other hand, student nurses expressed the following:
“Some
registered nurses do not want students to practice some procedures as drawing
of blood samples.”
“Registered
nurses do not allocate students according to their year of study and they send
us to do tasks of first-year of our study.”
“I only walk
after the supervisors and observe them work. They do not know what to teach
us.”
“Courses
have been changed and not all registered nurses are aware of them.”
Lack
of knowledge of ward nurses lead to ineffective training of nursing student. Some
ward nurses are not prepared enough for the supervision role. This has been
identified as one of the causes to increase frustration and confusion for
registered nurses working with students. Preparing ward nurses for supervision
improves student performance and helps the registered nurses to evaluate this
performance. (Ip and Chan, 2005; Van Rhyn and Gontsana, 2004). Oermann (2016) indicated that registered
nurses showed minimal interest in the student learning process and were unable
to provide knowledge to students. They need to develop essential skills and
experiences needed for teaching and supervising trained nursing students.
Outdated
nurses in providing clinical supervision could be attributed to lack of
continuing education for the registered nurses. (Magobe
et al. 2010; Searle et al. 2009). On the other hand, some hospitals lacked
trained staff to carry out supervision and used unexperienced staff for
supervision. (Pillay and Matshali,
2008) This goes with Younasa (2019) who
reported that the challenge supervisors face while teaching students in the
clinical settings is the lack of qualified preceptors or mentors and that
most of the hospital staff are diploma holders and they do not have the skills
and knowledge to facilitate nursing students training. The practicing nurses
lack education and knowledge about the roles and responsibilities of nursing
students, their learning needs, and set different expectations from students
which interferes with students' learning.
-
Gap between theory and practice
Previous
researches done on clinical supervision reveal that there is a gap between what
is learned in classrooms and the real practice in wards that was considered an
obstacle for clinical training. (Kelly, 1997; Longley et al. 2007). The same
picture was found in the present study.
One
registered nurse said that:
“A student
told me that the way of nursing practice in ward is not the same as was taught
in classroom. I answered her that was the way we do a long time and no patient
died because of that.”
The
following statements are accounts by student nurses of this issue:
“Things
that are learned in class are not done the same in practice. At practice nurses
have their own style of doing things; this makes me confused because I do not
know who is correct and who is wrong.”
“I
experienced confusion in the wards because of discrepancies between what is
taught in class and what is actually implemented in the clinical environment.”
“I am
confused because when I tried to apply theory in practice, I found that I am
unable to do so.”
“Within
clinical education I encounter situations which I have not been received enough
information about in the curriculum, therefore I lacked the skills needed for
handling this clinical situation.”
Previous
studies found that students also compliant from difference between what was
learned ideally inside the classroom and the real practice in hospital ward.
(Safadi et al., 2011; Sharif and Masoumi, 2005; Van Rhyn and Gontsana’s, 2004; Moghadam et al., 2017). Underdeveloped nursing curricula
and inconsistencies in the application and implementation in practice is one of
the greatest challenges in training of nursing students. (Younasa, 2019). Over the years and across countries, theory
practice gap has remained consistent. However, the strategies to manage and
bridge this gap are few and far between. Since the gap is mainly attributed to
the tensions between academic and practice settings, more continued and
collaborative efforts are required to address this gap (Råholm
et al., 2016).
-
Ineffective clinical supervision to student
nurses:
In
their study, Moghadam et al (2017) found that nursing students felt themselves
as uninvited guests, which according to the staffs’ views they had not any
responsibility in providing patients care especially in the first days of their
training. Registered nurse expressed their opinion regarding the effectiveness
of the training in the following sentences:
“I doubt
about the effectiveness of the training for nursing students, with their large
number.”
“We cannot
concentrate in our heavy duties regarding patients and training of student.”
Student
nurses also commented on the effectiveness of clinical training:
“Nobody
supported me, I did not learn anything. I was just doing tasks.”
“Registered
nurses are not interested in teaching students; some tell students that they
are tired and some answered by saying that they are not for student teaching
but for work.”
“Most of the supervisors did not have a particular lesson
plan. We did not know what we should learn on this ward.”
This
was explained in a previous study conducted by Shin in 2000 whereas the participating
student nurses experienced ineffective clinical training by registered nurses
who leaved them unsure and frustrated. This is because they feel abandoned
without any role in patient care in the ward. (Shin, 2000)
Aliafsari Mamaghani et al (2018) reported that supervisors did not
explain the plans of teaching the practical course to students. This was
attributed to the short duration of the clinical course of training and the
large numbers of students allocated for training in a group
Theme 3:
Non-conducive environment:
This
study revealed that most of the participants indicated that the environment for
supervision of student nurses was not conducive due to poor guidance, poor
interpersonal relationships, and poor communication during the process of
clinical supervision.
-
Poor guidance of student nurses by registered
nurses:
In
this regard, only one statement was recorded from registered nurses and the
majority on comments were from nursing students.
Registered
nurses’ comment was:
“I need
guidance on how to supervise student nurses effectively.”
Student
nurse participants for this study raised their concerns by stating the
following:
“Some
supervisors do not want students to practice difficult procedures; how will
students learn these procedures.”
“We are
not properly supervised during clinical practice; they only leave us alone to
do the work on our own.”
“Some
supervisors do not care about student differences; they end up doing demonstrations
and explaining things in their local language, not caring about those who do
not understand them.”
According
to Pillay and Matshali (2008),
some participants in their study viewed their negative experiences regarding
guidance by reporting that they were seen as a burden by unit staff and they
were left to function independently, even when they required some guidance. Similar
findings were obtained by Carlson et al (2003), where it was reported that
student nurses were left unattended, with nobody checking whether what they are
doing is right or wrong. The same study reported a lack of guidance and support
of student nurses by nursing personnel in clinical practice. In another study, participants
were confused as a result of the different and inconsistent educational methods
used by clinical supervisors and the lack of established guidelines for clinical
education. Participants believed that the ultimate reason for this educational
confusion was the lack of a systematic approach for clinical education by the
nursing faculty (Aliafsari Mamaghani
et al., 2018).
-
Poor communication and interpersonal relationships
between supervisors and students:
Interpersonal
relationships can be defined as any relationship that exist within each
individual, and between individuals and groups of people and the greater
community. (Rew, 2004). If interpersonal relationships
between registered nurses in the hospital wards and student nurses during
training is not good and encouraging, the efficiency and success of the
training process may be negatively affected.
Registered nurses
complained about the attitude of students towards them in wards and expressed
their experiences as follows:
“Student attitude is one of the challenges. They
are not interested in practicing nursing or even in their learning. That is why
interpersonal relationship between students and supervisors is not as it should
be.”
“There is poor communication between
supervisors. They do not report to each other problems encountered during
student supervision.”
“Through communication supervisors will learn
and be aware of what students know and what they do not know and will be able
to help them with what they need.”
“Registered nurses in the wards are not
helping each other by discussing the role of each of them in the training
process.”
The following
statements from student nurses were reported:
“I am discouraged by the relationship between
me and supervisors during practical training because they are only
concentrating on the mistakes done by the students without saying anything for
correcting us.”
“Supervisors are not sharing their experience
during supervision. I believe that if they want to help us better they should share
their feedback of training.”
“Regarding the relationship, I feel that some
registered nurses are not willing or interested to work with students. They
just want to keep students in the unit but if they are doing something they do not
want to work with students or they do not answer student questions.”
“I experience a lot of problems with the
supervisors in the ward because not all registered nurses are friendly.”
In a similar previous
study, participants reported an inadequate interaction and communication among
supervisors on one hand and unfriendly communication between supervisors and
student nurses on the other hand. (Van Rhyn and Gontsana, 2004)) Respect and positive feedback from
registered nurses towards student nurses during clinical supervision increase
the levels of interaction and open communication between them which support the
process of training. (Kapucu and Bulut,
2011; Maxwell and Wright, 2016) In spite of the
positive effect of good communication in forming relationships between nurses
and students, nurses use inappropriate forms of communication during supervision
of trained students, making them feel rejected and unwanted which in turn negatively
affects nursing student training and performance. The nursing students
expressed a deep concern that restricted access to their supervisors may lead
students to form alternative learning relationships with non-qualified
personnel. (Harrison-White et al., 2018)
Conclusion
It was
clear from this study that student nurse did not receive effective clinical
supervision from registered nurses in wards due to managerial and educational challenges
as well as non-conductive environment that were encountered with during the
execution of the clinical supervision. The challenges experienced should be considered
in planning and improving of future clinical educational program for student
nurses.
Conflicts
of interest: No conflict of interest.
References:
Aliafsari Mamaghani E, Rahmani A, Hassankhani H, Zamanzadeh V,
Campbell S, Fast O, Irajpour A. (2018). Experiences
of Iranian Nursing Students Regarding Their Clinical Learning Environment.
Asian Nurs Res (Korean Soc Nurs Sci). 12(3): 216-22.
Andrews
GJ, Brodie DA, Andrews JP, Hilian E, Thomas BG, Wang
J, Rixon L. (2006). Professional roles and
communications in clinical placement. A qualitative study of nursing student
perceptions and some models for practice. International Journal of Nursing
Studies. 43(7): 861-74.
Archibald
MM, Radil AI, Zhang
X, Hanson W. (2015). Current Mixed Methods Practices in Qualitative Research: A
Content Analysis of Leading Journals. International journal of qualitative
methods; 14(2): https://journals.sagepub.com/doi/pdf/10.1177/160940691501400205
Begat I., Ellenfsen B., and Serevinsson E.
(2005). Nurses’ satisfaction with their work environment and the outcome of
clinical nursing supervision on nurses’ experience of well-being. A Norwegian
study. Nurs Manag; 13(3):
221-3.
Brown L,
Herd K, Humphries G, Parton M. (2004). The role of the lecturer in practice
placement: What do students think? Nurse Educ Pract; 5(2): 84-90.
Brunero S, Stein-Parbury J. (2008). The effectiveness of clinical
supervision in nursing. An evidence based literature review. AJAN; 25(2):86-94.
Carlson S,
Kotze WJ and Van Rooyen D. (2003). Accompaniment needs of first year nursing
students in the clinical learning environment. Curationis;
26 (2): 30-39.
Dale B,
Leland A, Dale JD. (2013). What factors facilitate good learning experiences in
clinical studies in nursing: Bachelor Student’s Perceptions. ISRN Nursing. Retrieved
at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3877600/pdf/ISRN.NURSING2013-628679.pdf
De Vos AS
(ed). Strydom H, Fouche, CB, Delport
CSL. (2002). Research at Grass Roots: For the social sciences and human
services professions. Published by Van Schaik Publishers, Pretoria
Doane GH, Varcoe C. (2015). How to nurse: Relational inquiry with
individuals and families in changing health and health care contexts.
Lippincott, Philadelphia, Williams &
Wilkins.
https://www.crihhi.nursing.ubc.ca/hartrick-doane-g-varcoe-c-2015-how-to-nurse-relational-inquiry-with-individuals-and-families-in-changing-health-and-healthcare-contexts/
Encyclopedia.
(2020). https://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/clinical-supervision
Ghafourifard M.
(2015). Guidelines for quality improvement of clinical conferences in nursing
education. Iranian Journal of Medical Education; 15: 497-500.
Harrison-White
K. Owens J.
(2018). Nurse link
lecturers' perceptions of the challenges facing student nurses in clinical
learning environments: A qualitative study. Nurse Educ Pract; 32: 78-83.
Hlongwa E.
(2009). Diplomate’s perceptions of their psychiatric nursing component of the
four-year comprehensive programme. Retrieved 25 / 8 /
2009 at: http://hdl.handle.net/10500/2502
Ion R,
Smith K, Moir J, Nimmo S. (2016). Accounting for actions and omissions: A
discourse analysis of student nurse accounts of responding to instances of poor
care. JAN; 72(5): 1054–64.
Ip WP, Chan
DCK. (2015). Hong Kong Nursing Students’ perception of the clinical
environment: a questionnaire survey. International Journal of Nursing studies;
42: 665-6.
Jamshidi L.
(2012). The challenges of clinical teaching in nursing skills and lifelong
learning from the standpoint of nursing students and educators. Procedia Soc Behav
Sci; 46, 3335-8.
Kapucu S, Bulut H. (2011). Turkish nursing students’ view of their
clinical learning environment: a focus group study. Pak J Med Sci; 27(5),
1149-53.
Kelly C.
(1997). Theory of Experiential Learning. The internet Test Journal; 3(9). http://iteslj.org/Articles/Kelly-Experiential/
Klerk K.
(2010). Clinical supervision in selected hospitals; Cape Town. Reflection on
registered nurses live experiences Magister Curationis
University of Western cape South Africa. Retrieved 28.7.2014 at:
http://hdl.handle.net/11394/1761
Landmark BTH,
Hansen GS, Bjones I. Bohler A. (2003). Clinical
supervision factors defined by nurses as influential upon development of
competence and skills in supervision. JCN; 12: 834-41.
Löfmark A, Thorkildsen K, Räholm M, Natvig GK. (2012). Nursing student satisfaction from
preceptors and teachers during practice. Nurse Educ Pract; 12(3):164-9..
Longley M,
Shaw S, Dolan G. (2007). Nursing: Towards 2015. Alternative Scenarios for
nursing Health Education in UK in 2015. DOI: 10.13140/RG.2.1.2821.3209
Mabuda BT, Portgieter E, Albert UU. (2008). Student nurse experiences
during clinical practice in the Limpopo Province. Curationis;
31(1): 19-27.
Magobe NBD, Beukes S, Muller A. (2010). Reason for student poor
clinical competence in the Primary health care; clinical nursing diagnosis
treatment. Journal of Interdiscipplinary Health
Science; 15(1): 1-6.
Maxwell
KL, Wright VH. (2016). Evaluating the Effectiveness of Two Teaching Strategies
to Improve Nursing Students' Knowledge, Skills, and Attitudes About Quality
Improvement and Patient Safety. Nurs Educ Perspect; 37(5): 291-292.
Moeti MR, Van Niekerk SE, Van Velden CE. (2004). Perception of the
clinical competence of newly registered nurses in the North West Provence. Curationis; 27(3), 72-84.
Moghadam YH, Atashzadeh-Shoorideh F, Abbaszadeh
A, Feizi A. (2017). Challenges of PhD Graduated
Nurses for Role Acceptance as a Clinical Educator: A Qualitative Study. Journal
of Caring Sciences; 6(2): 153-61.
Natalie J
Kemper. (2007). Win-win strategies help relieve preceptor burden: Nurs Manage; 38(2): 10. Doi:
10.1097/00006247-200702000-00004.
Ndawo MG.
(2015). Challenges experienced by nurse educators on the delivery of content
laden curriculum at a nursing college in Gauteng. Journal of Nursing Education
and Practice 5 (11), 103–12.
Neshuku H, Justus
AH. (2015). Experiences of registered and student nurses regarding the clinical
supervision in medical and surgical wards: Develop an educational programme to support registered nurses. International
Journal Medicine; 3(2): 87-97.
NMC. (2008).
Nursing and Midwifery Council. Standards to support learning and assessment in practice. London:
NMC.
https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-to-support-learning-assessment.pdf
NMC. (2020).
Nursing and Midwifery Council. Standards for education and training. London:
NMC. https://www.nmc.org.uk/standards-for-education-and-training/
Oermann
MH, Lynn MR, Agger CA. (2016). Hiring intentions of
directors of nursing programs related to DNP-and PhD prepared faculty and roles
of faculty. J Prof Nur; 32 (3): 173-9.
Ohaya M.
(2010). Support for Learning in the Clinical Area: The Experience of
Post-Registration Student Midwives. AISHJ; 2(1): 14.1-14.14.
Pillay P, Matshali NG. (2008). Clinical supervision and support for
the bridging programme student in the great Durban
area South African Nursing Association. Curationis;
31(4): 46-56.
Raholm MB, Lofmark A, Henriksen J, Slettebø Å. (2016). Nurse education role complexity and
challenges. International Journal for Human Caring; 20 (2), 76–82.
Rew L. (2004).
Adolescent health. A multidisciplinary approach to theory, Research and
Intervention. University of Texas, Austin, SAGE Publications: Thousand Oak,
London, New Delhi.
Safadi RR,
Saleh M, Nasser OS, Amre HM Froclicher
ES. (2011). Nursing students’ perception of nursing: a descriptive study of
four cohorts. Int Nurs Rev;
58: 420-7.
Searle C,
Human S, and Mogtlane SM. (2009). Professional
practice: a South Africa nursing perspective. Johannesburg: Heinemann.
https://www.worldcat.org/title/professional-practice-a-southern-african-nursing-perspective/oclc/467221910
Sharif F,
and Masoumi S. (2005). A Qualitative Study of Nursing
Students‟ Experience of clinical Practice. BMC Nursing; 5
https://bmcnurs.biomedcentral.com/articles/10.1186/1472-6955-4-6
Shin KR.
(2000). The meaning of clinical experiences of Korean nursing students. Journal
of Nursing Education; 39(6): 259-65.
Sutton
J and Austin Z. (2015). Qualitative Research: Data Collection,
Analysis, and Management. CJHP; 68(3):
226-31.
Tesch R.
(2013). Qualitative research: Analysis types and software tools. DOI: https://doi.org/10.4324/9781315067339
Van Rhyn WJC, Gontsana M. (2004).
Experiences by student nurses during clinical placement in psychiatric units in
a hospital. Curationis; 27(4): 18-27.
Welman C, Kruger
F, Mitchell B. (2013). Research Methodology. Oxford University Press: South
Africa.
https://www.loot.co.za/product/c-welman-research-methodology/rbmy-2655-g680
Wilson JL.
(2016). An exploration of bullying behaviours in
nursing: a review of the literature. BJN; 25(6): 303–6.
Younasa A, Zebc H, Azizd SB, Sanae S, Alberte JS, Khand IU, Inayatf S, Khand FH, Rasheedg SP. (2019).
Perceived challenges of nurse educators while teaching undergraduate nursing
students in Pakistan: An exploratory mixed-methods study. Nurse Education
Today; 81: 39-48.
