Barriers to Practical Learning in the Field: A Qualitative Study of Iranian Nursing Students' Experiences.

BACKGROUND: Clinical training is an integral part of nursing education; however, some studies have shown that it is not always efficient.
OBJECTIVES: This study aimed to find out the factors that can impede nursing students' clinical learning.
MATERIALS AND METHODS: In this qualitative study, data were collected via reflective journal writing. Purposeful sampling was used, and 12 senior nursing students were recruited to the study. The data were analyzed using a content analysis method.
RESULTS: Three main categories were derived, including inappropriate communication, ineffective role models, and theory-practice gaps. Students perceived that inappropriate communication between instructors, staff members, and students had the greatest impact on student learning. The competence of clinical instructors and staff is an important factor affecting students' training. The clinical learning environment does not always integrate theory and practice together.
CONCLUSIONS: Nursing students did not experience effective clinical learning. Having expert instructors and supportive communication are important factors in creating a clinical learning environment.

1. Background

Clinical training is an integral part of nursing education (1). Clinical practice gives students the opportunity to make decisions, apply theories, prioritize those decisions, learn time management, and provides them with a chance to practice their clinical skills (2, 3).

In a supportive learning environment, clinical teachers encourage students to be independent in their learning and they advise them to be self-reliant (4, 5). However, some earlier studies conducted in Iran have shown that clinical learning is usually ineffective for nursing students (6), students experience high levels of anxiety (6), nursing instructors are mostly inexperienced, and clinical learning fails to integrate theory and practice (7). However, few studies are available on the reasons behind the ineffectiveness of clinical learning in nursing education.

2. Objectives

This study aimed to find out the factors that can impede nursing students’ clinical learning.

3. Materials and Methods

This qualitative research study used reflective journal writing as the main data collection method. Content analysis was used to identify categories in participants’ descriptions.

3.1. Participants and Data Gathering

Participants were purposively selected among the nursing students who were studying in their seventh semester of the baccalaureate program in 2014 and who had clinical rotations in the hospitals affiliated to Bushehr University of Medical Sciences. After the researchers explained the objectives of the study to the participants, 12 students, out of 30, volunteered to participate and to keep reflective journals. In a briefing session, the first researcher gave them a notebook and presented them with a verbal description of how to complete the journaling task. The students were asked to write in their journals about their own experiences, important learning events, attitudes, feelings, and their own opinions on their clinical learning experiences in after passing a week of their practical course in each ward. They were asked to return these anonymous journals to the researcher at the end of each week.

3.2. Ethical Considerations

The research committee (ethics No. 46327) and review board of Bushehr University of Medical Sciences approved and granted the proposal of this study. All of the participants signed a written informed consent form and were assured that their written texts would not be shown to any persons other than the researchers and would not affect their clinical evaluation scores.

3.3. Data Analysis

The content analysis approach was used to analyze the collected data. Thus, the researchers received each journal from the participants, and then they considered them carefully. The researchers used coding procedures in order to transcribe the data. Analyses consisted of identifying, coding, and summarizing themes according the approach suggested by Graneheim and Lundman (8).

In order to evaluate the data’s trustworthiness, the researchers gave summarized results to a few participants to confirm the credibility of the data analysis. The established relationship between the researchers and participating students facilitated a trust-based relationship between the parties in relation to data generation and treatment. Credibility was also enhanced because of the prolonged engagement of the researchers with participants and having experience in the practical field as an instructor. There was no academic relationship between the researchers and the participants during the study.

4. Results

All of the participants were in in their seventh semester of studies. All were female, and ranged in age between 21 and 24 years. Data analyses revealed three main categories, as outlined below.

4.1. Inappropriate Communication

The participants believed that interpersonal communication between students, nurses, teachers, physicians, and patients was one of the most important factors affecting clinical learning. From the students’ point of view, a positive and friendly relationship between students, nurses, and instructors affects the clinical learning environment and increases their self-confidence and learning. Students described that communication with their classmates in the educational environment was positive and satisfying. One student wrote: “My friend and I always are together, and ask each other questions that we have, and this is good.” However, relationships were not respectful from the side of the qualified nurses, and this affected the students’ motivation to learn. One of the students commented: “Some nurses frowned at me, when I asked them a question.” From the participants’ point of view, some nurses did not trusted the students' work, and they blamed them when anything bad happened in the ward.

4.2. Ineffective Role Models

Participants emphasized that the competence of the clinical instructors and staff nurses -as a role models- was a crucial factor affecting their learning in the clinical field. To the students, their instructors’ kindness, knowledge, clinical skills, expertise, and self-efficacy were among the main characteristics that made them good role models. One of the students commented: “Some instructors have sufficient knowledge and skills, so they have a higher self confidence level, and they help us (students) to understand how to do our duties. Some of them say to follow whatever staff do. In this ward (NICU), the staff respects our instructor. Because of this, they are kind to us, too.” However, the majority of the students believed that the lack of clinical experience among instructors was the main barrier that decreased their competency to train students effectively.

Participants recognized staff members as role models, too. Nonetheless, although they were technically skillful, they did not always have a caring attitude and sometimes performed procedures without upholding any standards.

4.3. Theory-Practice Gap

Participants revealed that there is a theory-practice gap in the clinical setting, and this hindered their clinical learning. The participants indicated that they confronted problems such as confusion about how to do procedures based on theoretical knowledge or like nurses in real situations. One student wrote: “We didn’t see many things that we have learnt in theoretical class. It is a difference between real and ideal practice. Many of nurses do not follow established nursing standards. If we follow standards, the nurses may laugh us and I dread this.”

Participants wrote in their journals that the nurses were often unaware of educational objectives and the students’ learning needs; further, their expectations of the students were not the same as the teachers’. One of them wrote: “The staff nurses demand that we do their routine tasks, such as checking vital signs and changing linens. These are not useful for us, because these are repeated each day and we learnt them well, but we didn’t learn some special procedures, like CPR.

5. Discussion

The current study has shown that, despite the crucial role of appropriate relationships in students’ clinical learning experiences, it is not enough. This has negatively affected the students’ clinical learning and self-confidence. This finding was in line with findings of Jahanpour et al., who studied clinical decision‐making in senior nursing students (2).

According the participants in this study, the competence of their clinical instructors and the theory-practice gap were among the most important factors affecting them and their learning in clinical settings. Some earlier studies have also pointed out the role of clinical instructors and staff nurses as role models for nursing students learning in clinical setting (6, 9, 10). In Iran, many experienced nursing instructors who hold Master’s or PhD degrees are reluctant to participate in clinical education, and so this role is mostly assigned to inexperienced, newly graduated nurses with Master’s degrees, or those who are still Master’s degree students. These people are not ready to fulfill their role as competent role models. On the other hand, as Cheraghi et al. (7) reported, due to the domination of task-oriented work in clinical settings, nurses’ clinical behaviors cannot support nursing students’ efforts to integrate theory and practice.

This study was only conducted in one nursing school, and this might limit the generalizability of the results. However, based on out findings, we can say that nursing students lack sufficient clinical learning due to unsupportive and inappropriate communication running throughout clinical settings, they lack effective role models, and they are harmed by the theory-practice gap. Restructuring the healthcare setting so that experienced nursing instructors are encouraged to enter and participate in clinical settings, establishing appropriate workshops for preparing inexperienced nursing instructors for their roles as clinical instructors, and implementing appropriate strategies to motivate staff nurses to take part in the education of nursing students might help in decreasing the barriers to effective learning in clinical settings.