Abstract
Introduction
Although clinical nursing placement is an indispensable component of student nurses' education, data on students' first clinical experiences is scarce in developing countries.
Objectives
The study aim is to uncover nursing students' first-time clinical placement experience and identify related influencing factors in Jordan.
Results
The results showed that the transition from learning with mannequins to practicing on real patients in the clinical placement involved both effective learnings through hands-on practice to dealing with clinical challenges. Students perception of nursing ranged from positive comments such as “humanistic” and “nursing almost medicine” to negative images such as “nursing is all about bedside care” and “nursing has poor social status.”
Conclusion
Students' experience in their first clinical placement is multifaceted, and incorporation of student's perspective in the first clinical placement is a crucial component of educational planning.
Background
Internationally it is widely accepted that the clinical placement is the heart of learning and education in nursing. The clinical experience allows students to apply theory into practice and to experience multiple humanistic experiences (Al-Anazi et al., 2019; Atakro et al., 2019; Ramsbotham et al., 2019). The clinical experience involves physical, psychological, emotional and organizational influences, which affects the students' learning and motivation (Haraldseid et al., 2015; Ramsbotham et al., 2019). In order for nursing students to gain the required qualifications for delivering high quality of care for patients, they should develop clinical based knowledge and skills through clinical experiences (Kalyani et al., 2019).
It is emphasized that “the clinical learning environment contains four attribute characteristics affecting student learning experiences: (1) the physical space; (2) psychosocial and interaction factors; (3) the organizational culture and (4) teaching and learning components” (Flott & Linden, 2016, p. 501). Mounting evidence shows that the first clinical placement, in particular, is the most influential for nursing students. The first clinical experience can affect attitudes and help them develop different competencies such as compassion and practical communication skills (Andrew et al., 2009; Nejad et al., 2019). Likewise, a student's first clinical placement is vital in the sense of belonging in their clinical placement and nursing education (Brady et al., 2019). However, clinical nursing practice is not free of challenges and tension. For instance, nursing students may perceive the clinical environment as non-supportive due to poor relationships between students and preceptors. Students embrace the preceptors' negative attitudes and behaviors (Ekstedt et al., 2019). Recent research confirms that students were faced with identity confusion due to limited experiences in the clinical environment (Kalyani et al., 2019). Nursing students feel isolated, especially with encounters that involve complex medical devices and complex situations when there is inadequate support (Atakro et al., 2019).
In Jordan, nursing programs span across 14 accredited facilities. Nursing students' clinical placement varies among public hospitals, university-affiliated hospitals, private hospitals, military hospitals and primary health care centers. The nature of clinical practice in Jordan and the nursing care delivery method such as the nurse to patient ratio varies between hospitals, hospital policy and the military sector. However, the ministry of higher education accredits all nursing programs.
Although it was found that a supportive clinical environment in Jordan was necessary for gaining clinical nursing skills as well as positively influencing carrier choices (Mahasneh et al., 2020; Shoqirat & Abu-Qamar, 2015), data revealed limited coordination between the clinical environment and clinical placement. There is also limited coordination between clinical placement, faculty, and student preference for clinical placement (Shoqirat & Abu-Qamar, 2013). However, these studies are now outdated and focused exclusively on fourth-year nursing students. To date, much of the international research attention is on the nursing students in the clinical environment in general, and there is a scarcity on the first time experience of the clinical placement as well as encounters with patients in particular in developing countries. Thus, this study uncovers nursing students' first-time experience of clinical placement and identifies related influencing factors. Data regarding first time clinical experience paves the way for establishing strategies and policies aimed at maximizing students' first clinical experience. Understanding the nursing students' first clinical experience may reduce challenges in their first contact with patients.
Methods
Qualitative research with the focus group discussion method was used as the method to uncover nursing students' first-time experience of clinical placement experience and identify related influencing factors. This design focuses on describing peoples' experience in a natural setting through understanding words and the way they express their reality (Krueger & Casey, 2014). A previous study demonstrated group discussion to be an effective method to explore the students experience in the clinical placement (Atakro et al., 2019).
Setting/Sampling
The study was conducted at a public school of nursing located in the southern region of Jordan. The school has 500 students enrolled in a four-year bachelor's degree program. A purposive sampling procedure was used. The inclusion criteria included only nursing students who had completed their first clinical placement in the second year of their program study (n=100). The first clinical placements occur in a hospital setting on a medical-surgical ward. Students who left the clinical placement for any reason and at any stage were excluded. We wanted to ensure that students had been exposed to a minimum number of clinical experiences.
Ethical Considerations
The ethics committee approved the study at the Faculty of Nursing. Written informed consent was collected from each participant before data collection. The current authors were not involved in training or evaluating any students in the study in a way that might affect their responses.
Data Collection
After approval from the university ethics board, the second author NS who has a PhD degree conducted four focus group discussions. The participants' demographic data were obtained in written form. This included: age, gender and the university grade point accumulative average. Participants were sequentially assigned to focus groups. The number of participants in each group included eight, seven, eight, nine, respectively, which was adequate for interactions among participants (Krueger & Casey, 2014). At the end of the fourth focus group discussion, the moderator decided no further discussions were needed because the main themes repeated, such as personal images of nursing.
The total sample was 32 participants. The group discussions were held in the faculty meeting room, which had space for group discussions away from clinical activity. All participants were encouraged to engage in the discussion by using a semi-structured format enabling two-way communication. Relevant published literature on student placement guided the discussion (Jack et al., 2018; Pitkanen et al., 2018; van de Mortel et al., 2017). The questions included:
Tell me about your experience? What were the best and worst parts? Can you provide some examples or stories? What were the influencing factors, or were there any factors that can affect their placement? What do you suggest for improving the experience of clinical placement?
The average time for the digitally recorded discussions was 45 minutes. The moderator (NS) obtained handwritten notes about non-verbal data. The moderator made a summary at the end of each discussion. The focus group discussions took place between May and June 2019 immediately following the clinical experience.
Data Analysis
Discussions were recorded and transcribed for thematic analysis using qualitative data analysis software NVivo 12. This software works strictly from left-to-right, and discussions were translated from Arabic to English texts. To rule out the possibility of mistranslation, the translation was independently carried out by the second author (DM) and other nursing colleagues (n=2), who are fluent in both Arabic and English languages.
Strauss and Corbin's method was utilized to discover concepts and understand relationships in raw data (Strauss & Corbin, 1990). All authors took part in the analysis, coding and categorizing of the data through discussion and debate. Analysis of open coding required rereading of each transcribed discussion to identify essential ideas/concepts. Then, similar codes were put together in one theme. Constant comparisons determined the relationships among the themes, subthemes and related meanings. Supporting extracts from the transcripts illuminates the evolution of each theme. All the analysis outcomes were discussed by all authors, and in case of any disagreement, evidence from data was required to support disagreeing viewpoints. Only minor disagreement related to the labelling of some themes and subthemes occurred in relation to the phrase “hands-on learning” or only “learning”. Taking into account participants' narratives, “hands-on learning” is the appropriate theme. Decisions about each theme or subthemes revolve around a high degree of agreement among researchers involved in the analysis. Regarding the trustworthiness of the data, member checking method was used with randomly selected participants (n=8) to enhance the credibility. Indeed, bilingual translation and independent analyses process contributed to the overall dependability. The transferability of the findings is enhanced by providing adequate descriptions about the study context, setting and data collection (Shenton, 2004).
Findings
The total sample was 32 full-time nursing students, 18 females and 14 males. The average age is 19 years. The majority of students clinical placement was on medical wards (68%, n=22). In the current study, the ratio of each preceptor to students was 1:15. The mean of their accumulated grade point average was 77.3%. The qualitative analysis of students' narratives about their first experience of clinical placement revealed two themes. First, the transition from learning on mannequins to practicing on patients comprising two main subthemes: hands-on learning and dealing with difficulties. The second theme pertains to the nursing profession, which is divided into two main subthemes: Personal images of nursing and future plans.
Theme 1: From Learning With Mannequins to Practicing on Patients
Subtheme 1: Hands-on Learning
When participants were asked about their first clinical placement experience, participants stressed the importance of shifting the learning from training in the lab to the hospital. The shift was in the application of a newly learned clinical skill. In particular, the analysis showed that the hands-on learning involves several meanings but always was associated with the word “Real” for example “being a real nurse”, “meeting real patients” and “dealing with real equipment.”
“…during my lab training, we were trained on mannequins you know they are not real now for the first time; for example, I took a blood pressure on a real patient” (Male Participant 2).
“yes it was the first time of life I started the IV fluid I felt like a real nurse…the real placement is different you learn by practicing and not only listening as the case in the classroom or even sometimes nursing labs” (Female Participant 8).
“…it was the first time in my life to remove a dressing on a diabetic foot and assist senior nurses in applying a sterile one…real stuff and types of equipment” (Female participant 5).
Subtheme 2: Dealing With Difficulties
While hands-on learning was the heart of the theme from learning on mannequins to practicing on patients, the transition was beyond just clinical knowledge and skills. A number of factors influence the transition from lab to clinical. The analysis of students' narratives implies that the first clinical experience is not free of difficulties. However, dealing with such difficulties even at the personal level provides a rich learning experience. According to the analysis, three types of difficulties emerged during the first clinical placement. These include “dealing with the difficult patient”, “dealing with difficult relatives”, “dealing with difficult health care professionals”. The following extracts encapsulate the themes:
“… I met a difficult patient at the surgical ward. He refused to see any student and started shouting at me … despite the fact that he was angry because of pain. In the second day, I visited him and reintroduced myself while smiling then, and we had a nice chat together” (Participant 9)
“…some [patient' relatives] are impolite and do not respect us and keep saying you are just students do not look after my dad you could make a fatal mistake…I told my clinical instructor and she, in turn, informed the family that the students are all well supervised ….eventually, I hated to see any patients while relatives around” (Female Participant 2).
“…our clinical instructors ask us to provide them with a personal reflection during Pre-Clinical and Post-Clinical Conferences and in case of any problems we are asked to report in writing for the faculty deanship for further actions or solutions” (Male Participant 8).
“…for me as it is said in the Jordanian culture I was a blind cat (laughing) [An Arabic expression which means the absence of any experience in general life] one day the ward supervisor was very impolite and told me loudly never touch anything in the ward because I was a first-year student … I felt embarrassed, but then I reported her to the nursing coordinator who communicated the issue with the hospital management, and then things got better” (Female Participant 4).
Second Theme: Nursing Profession
Subtheme 1: Personal Images of Nursing
An overwhelming number of participants (n= 25) were divided about the public image of nursing after their first clinical placement and the impact of the experience. The analysis of transcripts showed two opposing personal images of nursing as experienced for the first time by participants. The first was positive and grounded in the idea of nursing is “humanistic”, “nursing is science” “nursing is not easy”, “nursing is almost medicine”. On the other hand, the negative perceived images were guided by the idea: “nursing is all about bedside care”, “nursing has the poor social status”. These images of nursing are illuminated below:
“…it was the first time for me with real patients to take care of …you know nursing is science that needs knowledge and skills and not as I was thought as a routine profession” (Female Participant 3)
“…after seeing what nurses really do at the surgical wards, I think nursing is almost medicine, and I feel happy to work with patients. Before studying nursing I thought it is all about bedside care “(Male Participant 7)
“….the first clinical experience for me has taught me that nursing is not easy and needs lots of reading and training and this makes me even more determined to complete the program” (Female Participant 1)
However, others (n= 10) perceived nursing following their first clinical placement in a negative way:
“ you know I spent a full semester in the clinical placement, and I feel disappointed…I found nursing is all about bedside care: changing sheets and feeding patients frankly do not like that “ (Male Participant 6)
“yes I agree even I saw the visitors looking at nurses as housemaids I felt nursing has poor social status and I did not enjoy any training”(Female participant 3)
Subtheme 2: Future Plans
The analysis of data found that participants' plans are influenced by the first clinical placement. Three types of plans were identified in the transcripts. First, many students (n= 21) stressed that they would continue their placement and then work in Gulf countries where the pay rate is higher than that in Jordan. Second, others (n=7) were more interested in completing their postgraduate studies in the future. Third, some participants (n=4) were indecisive about whether to complete the program or select another speciality.
“….you know I started thinking about my future career from the first placement ….frankly, I have chosen to study nursing hence after graduation I will move to Gulf countries and work there …the salary is four times or more than that in Jordan” (Male Participant 3)
“ well for me I think about doing my MSc and PhD abroad immediately . my parents advised me about studying nursing . frankly I hate bedside care and love teaching in the university” (Female Participant 8).
“….since I started my first clinical placement, I feel a bit confused and not sure whether to complete the degree or just start new speciality such as medical laboratories” (Male Participant 4).
Discussion
The study uncovers nursing students' first-time experience of clinical placement and identifies related influencing factors in Jordan. The overall results showed that the transition from learning on mannequins to practicing on real patients in the clinical areas involved both effective learning through hands-on practice and dealing with challenging situations. The importance of clinical instructor' role in addressing students clinical learning needs facing “real patients” and helping them to deal with organization-related problems such as uncooperative nursing staff cannot be underestimated. As confirmed earlier nursing students need various degrees of support including, supervisors' commitment and logistics provisions not only to gain knowledge and skills needed for nursing process in their placement (Atakro et al., 2019), but also helping them accept their roles as future nurses (Kalyani et al., 2019).
While the importance of the physical space, psychosocial and interaction factors of organization is acknowledged, our data uncover a new dimension affecting nursing students' first experience of clinical placement. That is, students' images of nursing itself and their conceptualizations are examined in their first clinical placement. The study showed that nursing students' own conceptions of nursing in the first year of clinical placement in Jordan range from positive as nursing as “humanistic “and “nursing almost medicine” to a negative image such as “nursing is all about bedside care” and “nursing has poor social status”.
What makes this internal perceptual conflict even more complex and negative was the perceived low social status of nursing realized by students in the placement and then confirmed by patient relatives. For instance, some students had a negative clinical experience when a patient's relatives or visitors looked at nurses as housemaids. Earlier research found that some patient relatives and their poor communication with nursing staff affect the work pattern negatively at the ward level (Shoqirat, Mahasneh, Singh, Al Hadid, et al., 2019; Shoqirat, Mahasneh, Singh, Al‐Sagarat, et al., 2019). Although nursing worldwide and in Jordan has gained increasing social respect, it seems that students' image has a profound impact on students' first clinical placement and thus, professionalism. It is argued that having positive experiences and attitude toward a profession has been associated with having competency in a profession, satisfaction and sustaining a productive work life (Nejad et al., 2019; Taskın Yılmaz et al., 2014). This study further highlights that the way the nursing student experience the first clinical placement may shape their plans. For instance, some students either anticipate changing profession or travelling after graduation to the Gulf countries. Therefore, nursing students tend to choose nursing profession to secure a job easier (Elibol & Seren, 2017; Wilkes et al., 2015).
However, choosing nursing based on job security instead of wanting to care for people needs careful interpretation. Although selecting the nursing profession might be a reflection of the high unemployment in Jordan, this might be a negative situation, in terms of viewing nursing as job security. The core of nursing which encapsulates loving humanity and helping others pales by the future economic job prospects. With this being the case for some students, the importance of economic overshadows the potential for successful and enjoyable clinical placement directed by clinical experience.
Taking all the above points together, education policymakers, nursing deans, in particular, need to pay significant attention to improve clinical placement for those students in their first clinical placement. There is a need to recognize the significant impact of interactions with patients and their relatives on nursing students. Likewise, clinical instructors need to pay significant attention to minimize the stressful atmosphere of the first clinical placement. Negative attitudes towards nursing students and their future career require early interventions.
Hospital nurses, together with the clinical instructors, are role models; hence they play a vital role in maximizing students' satisfaction of the first clinical placement. It seems that induction days about nursing profession need organization around the students' first clinical placement. Having an induction or orientation would enable students to share their experiences and expectations about future career opportunities, which better informs their future career plans. Finally, we agree with international scholars that there is a need for nurses and other stakeholders to project the image of the nursing profession (Oyedele et al., 2015). However, this is not enough, and there is an urgent need to assess admitting students to the nursing profession and its correspondence with their personality traits along with their future expectations from the being a registered nurse. It is clearly emphasizing the value of nursing before the first clinical experience affects career trajectory.
Limitations
Before the study findings are to be interpreted, a few limitations need to be acknowledged. The study only looked at first years' placements, and thus students' experiences and plans might be different for those in the advanced years of the program. Therefore, the next study needs to focus on the students at an advanced level of clinical placement and thus compare and contrast their experiences and related factors with the first-time experience.
The current study only explored the students' interpretations, and hence clinical instructors and lecturers are crucial stakeholders of the students' clinical placement, their views on the clinical learning development are worth exploration. Further studies would include larger samples, and more nursing schools are needed to verify the current results. In particular, it would be interesting to explore what happens to students' perceptions and plans for future career paths over time as well as comparing different cohorts. Finally, given that nursing is an international profession, the reason behind nursing students' decision to choose the nursing profession needs to be updated and uncovered in different countries in the light of dramatic changes in the socio-economic and political environment.
Conclusion
The study illuminated how nursing students experience their first clinical placement and how certain factors contributed to clinical learning in a positive or negative way. Although hands-on practice and dealing with difficulties are vital benefits for student's first-time clinical placement, the study highlighted other complex dimensions. It seems that students own conceptualizations and images of nursing as a profession at an early stage play a crucial role in shaping not only the experience of first placement but importantly, their future career path. Consequently, clinical educators, hospital stakeholders and nursing staff need to be informed about students' expectations, personal images of nursing and career plans to incorporate them into their first clinical and educational experience planning.
Footnotes
Authors’ Contribution
DM: Study Design, Analysis and Manuscript Writing; NS: Data collection, analysis and Manuscript Writing; AS: Data analysis and Manuscript Writing; CS: Analysis and interpretation; LT: Critical revision of the manuscript. All listed authors meet the authorship criteria and that all authors are in agreement with the content of the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Deanship of Scientific Research at Mutah University, Jordan.
