Greener Journal of Medical Sciences
Vol. 11(1), pp. 13-21, 2021
Copyright ©2021, the copyright of this article is retained by the author(s)
Nursing application for students of
the second level of internal and surgical nursing
Nursing Tutor, Kuwait Nursing Institute
Article No.: 011421008
Background: A poorly trained nurse may lead to low quality health care. Usually registered nurses supervise nursing students for clinical training in wards.
Objective: The aim of the present study is to describe the opinion of registered nurses and nursing students regarding training in hospital wards.
Methods: This study was carried out in three hospitals in Kuwait. Thirty-five registered and student nurses were selected by a purposive sample. Data collection tools consisted of open-ended questions. Data were collected by interviews. Participants answers were also recorded. Data were analyzed qualitatively using Tesch‟s method. Data transcription followed by data reduction resulted into 3 main themes and 9 sub-themes.
Results: Participants responses were presented and grouped under the titles of the 3 main themes (Administrative challenges, educational challenges and non-conducive environment), and 9 sub-themes.
Conclusion: 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.
Radia M Bahman
E-mail: radianurse @ yahoo.com
Nowadays the main goal of nursing schools is to prepare professional and competent nurses for clinical practice. Clinical education has long been considered as an important component of nursing education. A poorly trained nurse may hinder the medical team effectiveness and lead to low quality health care. Clinical teaching and learning help to prepare student nurses for the kind of work they will have to do as practicing nurses. (Doane and Varcoe, 2015; Ghafourifard, 2015) Despite substantial improvements in nurse education over the last 20 years, literature from the UK suggests that many students still describe their clinical practice as being accompanied by negative experiences. (Ion et al. 2016; Wilson, 2016)
Clinical supervision is the term used to describe an educational relationship between an experienced registered nurse and nursing students. (Encyclopedia 2020) Clinical supervision is seen as important tools because it enables the students to understand, improve and maintaining standard of patient care. (Brunero and Stein-Parbury, 2008; Begat et al., 2005)
The registered nurses must supervise and demonstrate how theoretical knowledge can be intergraded into practice. (Löfmark et al. 2012; Dale et al., 2013) They also need to develop essential competencies and skills which are needed for teaching in different fields of nursing. (Oermann, 2016) Despite the importance of clinical teaching to the nursing profession, student nurses are often taught by clinical nurse educators who usually have little or no prior formal teaching. Indeed, there are no guidelines to assist clinical nurse educators on how to effectively teach and supervise student nurses. (Ndawo, 2015; Råholm etal.,2016)
There is a need for clinical nurse educators in particular and the health system in general to identify and address the challenges faced by clinical nurse educators. An understanding of these challenges could provide a template for the clinical nurse educators to be empowered with teaching skills and thus improve teaching outcomes. A critical understanding of the current challenges will support clinical and academic staff in operating the new Standards of any program. (NMC 2018; Jamshidi (2012); Ndawo (2015) The aim of the present study is to describe the lived experiences of registered nurses and nursing students about clinical supervision of nursing students in medical and surgical wards in Farwniya, Sabah and Amiri hospitals in Kuwait.
This study was conducted in Farwniya, Sabah and Amiri hospitals (three of the nursing training hospitals in Kuwait), where student nurses are practiced their clinical training for medical and surgical nursing. A number of the registered nurses who serve as supervisors of those student were recruited from these hospitals.
The study population were all the students in the second or third year of the Diploma in Nursing Science, Nursing Institute in Kuwait who were practiced their medical and surgical training in Farwniya, Sabah and Amiri hospitals (60 students) as well as registered nurses who are supervising them. A purposive sampling was used to select the participants in this study to select the most legible participants and those with an enough related valuable information, so that the maximum information required for qualitative research will be available. The sample size was determined by saturation of the collected data. This was obtained as repetition of already mentioned answers without adding new information. (Welman et al. 2013) Accordingly, the sample in this study consisted of 27 student nurses and 8 registered nurses.
Data was collected by means of face to face interviews between the researcher and participants. The participants were informed to be open answer the questions and to ask if there was something they did not understand. Questions included experiences regarding clinical supervision of student nurses in medical and surgical wards. All participants’ interviews were digitally recorded for analysis; however, interviewees had the opportunity to refuse the recording. (De Vos, 2002; Sutton and Austin, 2015)
A pilot study was carried out on 2 student nurses and a supervisor registered nurse to test the clarity and applicability of the study tool as well as determining the time needed to answer the questions.
All the necessary approvals for carrying out the research were obtained. The Ethical Committee of the Kuwaiti Ministry of Health approved the research. A written format explaining the purpose of the research was prepared and signed by the participant before filling the questionnaire. In order to maintain confidentiality, questionnaires were anonymous.
Tesch’s method was used for qualitative data analysis. This involves descriptive examination of the participants’ responses and opinion regarding question in the data collection tool, followed by grouping and categorization of the collected data. (Tesch, 2013; Archibald et al., 2015)
Recorded responses were transcribed verbatim. Then, all of the transcripts from gathered data as raw fields were red thoroughly several times. The researcher listened to the recorded answers and read the transcripts to familiarize herself with the data and get an overall understanding of the whole. This was followed by making a list of all topics Similar topics were gathered together to form main groups (themes). Under each theme, few items were determined (subthemes).
RESULTS AND DISCUSSION:
Analysis of the collected data revealed that 3 themes and 9 sub-themes were identified as illustrated in table 1.
Table 1: Themes and sub-themes of data collected from student nurses and supervisor registered nurses regarding training experience in medical and surgical wards.
1. Managerial challenges
1.1. Too much work load and time management
1.2. Shortage of nurse supervisor
1.3. Absence of clinical instructors in some wards
1.4. Shortage of hospital stock
2. Educational challenges
2.1. Outdated supervisors with lack of knowledge of their role.
2.2. Theory-practice Gap
2.3. Ineffective clinical supervision
3 Non-conducive environments
3.1. Poor guidance of student nurses by registered nurses
3.2. Poor communication and interpersonal relationship 3.3
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).
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)
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.
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Cite this Article: Bahman RM (2021). Nursing application for students of the second level of internal and surgical nursing. Greener Journal of Medical Sciences, 11(1): 13-21.