Nurses' Lived Experience of Working with Nursing Students in Clinical Wards: a Phenomenological Study.

Introduction: Despite being aware of the importance of nurses' role in providing clinical training to nursing students, studies show that sufficient research has not yet been conducted on the experience of clinical nurses who are engaged in training nursing students outside their normal working hours. The present study aim to describe the experience of these nurses who are training outside their routine working hours.
Methods: This study was conducted using descriptive-phenomenology method. Twelve nurses was participated in this research. Data were collected using purposive sampling method and face to face interviews based on nurses' real life experience of students' learning in clinical settings through answering open-ended questions. Spiegel burg analysis method was used to analyze the data.
Results: The result of data analysis was the derivation of four themes and eight sub-themes. Themes included "nurses as teaching sources", "changes in the balance of doing routine tasks", "professional enthusiasm", and "nurses as students' professional socialization source of inspiration". Sub-themes included "efficient education", "poor education", "support", "interference in the role," "self-efficacy development", "inner satisfaction", "positive imaging" and "being a model".
Conclusion: It is necessary that academic centers plan for teaching nurses working on a contractual basis in the field of the evaluation method and various methods of teaching. The findings also suggested the development of individual self-efficacy in clinical nurses who train students.

Introduction

Clinical training is an essential part of nursing training at the bachelor's level.[1,2] It has an important role in the formation and promotion of values, norms and professional attitudes of students.[3] At present, teaching clinical nursing is not free from problems. Identifying the problems is the first step to resolving it.[4]

Although nursing students spend a considerable part of their training process in the clinical setting, this alone is not a guarantee for the quality of training. This is because numerous factors including the student and his personality, clinical instructor and his skills, staff of the ward and their cooperation, personal relationships, attitudes, physical structure, and other factors in the learning environment, affect learning outcomes.[5]

According to what is mentioned above, the role of nursing instructors is important in improving the quality of training nursing students. However, it appears that all nursing instructors are not necessarily faculty members. At present time, in addition to members of the faculty of nursing and midwifery, a number of nurses, most of whom having a master's and some with a bachelor’s degree, are involved in the training of students as part-time outside their clinical shift hours.

It seems that participation of nurses or, in other words, the above-mentioned nursing educators may trigger benefits or weak points as well. As an example, the questions raised here concern to what extent the presence of two different roles for the above-mentioned nurses affects the trend of their professional career, or to what extent the participation of the above-mentioned educators is appropriate and effective in the training of nursing students, and what the description of present situation is. It seems a part of puzzle solving related to the questions above, is outside the cause and effect relationships, and connected to describing the current situation. One of the best ways to describe the current situation is to identify and understand the experiences of nursing educators and the students in this field. Although understanding the experiences of the students is important, according to the researchers of the present study, an understanding of the experiences of the educators mentioned above can have a significant role in revealing the strong and weak points.

Regarding the studies carried out in this area, most studies on the experience of clinical nurses have focused on teaching students while clinical tasks were being fulfilled.[6-8] In the review of literature, no study was found on clinical nurses’ experiences offering clinical training to students out of their working hours. This study aimed to describe the experience of these nurses in Northwest Iran. The results can be effective in creating positive clinical learning environments for nurses and nursing students.

Materials and methods

This research presented questions related to identifying the experiences of nursing educators. The best method to understand the experiences of people was through qualitative phenomenology. It seemed that the most important challenge in this research concerned the selection of phenomenology as descriptive or interpretative phenomenology. In this study, the issue of cause and effect relationship was not raised, and our purpose was to understand the experiences of instructors. Therefore, it was the best type of phenomenology. On the other hand, no previous studies have been carried out in this field, so the underlying factors associated with it is not clear yet. In addition, according to the research question, an understanding of the experiences of instructors was the most important reason; therefore, the best method of the study was descriptive phenomenology.

Participants and field of study (setting): Nurses were selected using purposive sampling method from among the nurses (n = 12) working in hospital, outside their allocated clinical hours. Inclusion criteria were being employed as a clinical nurse (in clinical wards except the operating room), in the hospitals affiliated with the Tabriz University of Medical science and having cooperation with the Faculty of Medical Sciences as a clinical educator outside the routine working hours.

Data collection was conducted using face-to-face and semi-structured interviewing. After explaining the objectives to the participants, an informed consent was obtained for the participation in the research and recording the interviews. The interview process began with more general questions and gradually addressed more detailed issues by the simultaneous analysis of data. Some examples of the questions were as follow: Example of general questions: May I ask you to speak about your experiences of working with nursing students?

Examples of detailed questions: Can you give an example?

Can you describe in as much detail as possible……… Data collection was performed from October 2015 to March 2016. Each interview was approximately performed within 45 minutes to one hour. Type and number of questions in the interview were determined based on type of answers given by participants. In order to clarify the stated experiences, three nurses were reinterviewed, and when necessary, the researcher directed the participants toward expressing their experience, memories and perceptions of what they had expressed through the use of follow-up questions. During the interviews, researcher actively listened to the descriptions of the interviewees. During the rewriting process, the recorded interviews were frequently reviewed to extract themes.

Data were analyzed using Spielberg’s three-step process of intuiting, phenomenological analyzing, and phenomenological describing. [9]

Intuiting requires the researcher to practice complete immersion in the data while suspending criticism and evaluation by way of bracketing. During phenomenological analysis, the researcher identifies qualities of the phenomenon that make it what it is; in other words, the phenomenon does not exist without the identified qualities.

Finally, the researcher brings to written description the distinct critical elements of the phenomenon during phenomenological describing. Through this process, a comprehensive description of the experiences of instructors emerged. To enhance the rigor of our findings, several strategies were employed, including participants being asked to verify the themes that emerged following each step of data analysis. Member checking and external control were both utilized to verify the accuracy and credibility of the data analysis process.

Data credibility was established by two experts in qualitative nursing research and peer reviewers. In this regard, in order to determine the consistency of the research, Halsty indices, quoted by Rocky et al.,[10] were used. According this method, after creating the initial codes of interview transcripts, a few of these codes were submitted to another researcher and he was asked to extract the codes from the interview transcripts. Then, the degree of correspondence between the two reviewers was determined. In this study the degree of correspondence between the two researchers was 73%.

An ethical approval was obtained from the Ethics Committee of Tabriz University of Medical Sciences prior to the implementation of the study (Ethical code: tbzmed. rec 1394.15).

Results

Demographic data of participants are shown in Table 1.

Table 1

Demographic variables of nursing Students participated in this study

Variable	N (%)
Age
30-35	6 (50)
35-40	4 (33.33)
40-45	2 (16.67)
Sex
Female	9 (75)
Male	3 (25)
Times of interview
1	10 (83.33)
2	2 (16.66)

From initial interviews with 12 participants, 940 initial codes were generally extracted. After making required analysis and comparisons, themes were determined as "four main themes"and "eight sub-themes", and named more abstractly based on their nature.

Themes included "nurses as teaching sources", "changes in the balance of doing routing tasks", "professional enthusiasm", and "nurses as students' professional socialization source of inspiration". Sub-themes included “efficient education", "poor education", "support", "interference in the role," "self-efficacy development", "inner satisfaction", "positive imaging" and "being a model".

Nurses as a source of teaching

Based on the results of this study, nurses were an important source of teaching students. This indicated efficient training experience and occasional undesirable experience in clinical training. A nurse stated "... nurses engaged in the hospitals and those cooperating with the nursing faculty as an instructor (such as me), can provide a better environment for teaching students due to awareness of the intricacies of the ward … I have experienced this many times..."

Compared with the educators of the faculty, poor theoretical knowledge and lack of sufficient knowledge of teaching principles and techniques were among the factors affecting the students' unfavorable training by nurses with bachelor's degrees. Some of the nurses had the following experience: "educators employed in the nursing faculty have a higher level of theoretical knowledge compared with those working in clinical wards. I think it is necessary for nurses, who are willing to cooperate in training provision to nursing students, to pass a specific test on the relevant educational topics...Several times I've failed in the face of students' questions…  I did not feel good."

Nurses as a source for student’s inspiration

This theme included two sub-themes of being a positive imager and a model. Based on the experience of educators, they were a positive imager for nursing students. In fact, students saw their future career in these nurses and this could contribute to the feeling of students towards their professional future. On the other hand, the educator had the role of a model. As far as a nurse’s role as a model is concerned, a nurse said, "my students communicate with the staff just like me. When they see that I respect all the staff of the ward, they realize that they should treat them similarly. The concept of being a model is not merely considered in connection with the communicational dimension; but it includes scientific knowledge and students’ efforts toward acquiring knowledge. A nurse said, "the students look at us differently …. My scientific knowledge is very important to them.

In connection with positive imaging, a nurse said, "I remember once when a student told: When I look at you, I am proud that maybe in the future I will be like you."

Imbalance in daily life

In most cases, families of the majority of the mentioned nurses had initially accepted their professional role as a nurse; or even in some cases, they had somehow coped with irregular and long working hours in the nursing profession; but working for more than expected hours could lead to imbalance in their daily lives. A nurse said, "When I am working in the evening shift, I have to get the nursing students to the hospital in the morning shift; and when I go home at night, I have to handle my kids’ homework. The fatigue caused by such workloads affects me considerably; and I should preserve my spirit for the sake of my students. Another nurse said, "Now we are approaching the New Year; my mother is alone and in need of someone to help her. Well, I have to manage my situation... ". This can affect the way the students are educated or trained. A nurse said, "Sometimes I feel really tired. When after a night shift...I am to work with students, it is really hard; when during the same day you have to work with students who are all doing well, and are highly motivated to work with high spirit..., in those situations, I somehow have to act; it is really a role playing. I try my best to actually show a positive spirit, be happy and give them energy; because they do not know that I have had a night shift the day before ... These put me under a lot of pressure... both physically and mentally ... ... "

The existence of support systems such as spousal support or the system support could be effective in coping with the changes in the balance. For example, a nurse said, "Thank God I am supported by my spouse ... they have coped with this issue" Another nurse said, "Fortunately, I receive a good support from the nursing system and the superintendent. For example, the superintendent tries to coordinate the shifts with me in a manner that makes me more comfortable."

Professional enthusiasm

For nurses, working as an educator creates a double enthusiasm about their professional life. This includes understanding their capabilities (improvement of self-efficacy), and on the other hand, creates a kind of inner satisfaction. A nurse said, "When students entered the ward for the first time, in my opinion, their score was zero in terms of clinical aspect. During the training period that we were together, I taught some materials and I saw the outcome in students’ behaviour. This motivated me; and in fact made me realize that teaching students is useful. I sensed that I could teach them. It was a good feeling. In connection with the sense of satisfaction, a nurse said, It was very important to me that I learn myself, and on the other hand, I educate students. This is very important to me. Over these years, teaching had been very positive for me. The energy that I am given by the students had been very important to me ...with teaching, I always feel that I begin a new day; and I am in a very happy mood in the ward after teaching the students.

Discussion

Nurses’ experiences in this study, as a source of teaching, indicated the self-esteem of nurses who were educators as well. However, nurses, based on their experiences, came to the conclusion that their training could be efficient or undesirable. Most of the nurses in this study believed that their familiarity with specific details needed to work in any ward was a merit. However, based on the results of this study, the feeling of incompetence in nurses arising from training the students was not related to their sense of empowerment. However, most of them believed that their lack of familiarity with teaching and evaluation methods play a role in this field. Such results are not far-fetched, since there is no specialized subject related to teaching methods in the curriculum of undergraduate courses, and on the other hand, most nurses cooperating in the field of education have a bachelor's degree, and do not receive specialized training during the period of their activity in clinical practice. In a study conducted in Iran in 2012, the students’ lack of answer to some questions in clinical practice, lack of adequate supervision on the clinical performance of students, lack of appropriate criteria for evaluation, and the effect of personal preferences on evaluations, were among the disadvantages of mentorship training based on the experiences of nursing students, which corresponded with the results of the present study.[1]

According to the authors of the present study, since most nurses acquire their skills clinically in their specific field, they could be helpful in training nursing students. However, the need for specialized theoretical knowledge associated with each procedure is very important, and overlookingit can be influential in the training of nursing students and their skills. It can also have a negative effect on the professionalization of nursing. This is despite the fact that, fortunately, nursing educators feel the need to raise their theoretical base and subsequently attempt to resolve it. Certainly, the cooperation of academic systems in support of and specific training for the mentioned nurses will be better. Studies have shown that receiving academic educational programs by the mentorship nurses has been welcomed by them.[2] It is suggested that a practical program be organized in these fields.

A question is raised in connection with the changes in the balance of doing routine tasks: "is it possible to provide the possibility for the nurses to train students while doing clinical tasks in the wards?" Although preceptor ship model seems appropriate, it has not been confirmed by researchers. For example, the results of a study has shown that, in most cases, following the use of preceptor ship model, the employment of students for doing basic nursing measures prevents the possibility of allocating time to perform more complex actions (such as intravenous catheterization and fluid therapy); or the time needed for training students is not provided because of the workload.[11] Therefore, it seems that allocation or non-allocation of time to work with students in separate shifts is a challenge in relation to clinical education, and more research is required to determine the most favorable practices in this field.

An important part of professional nursing behavior is shaped as a student.[12] Socialization is a process during which individuals learn the roles, values, attitudes and social conditions necessary for activity in social organizations.[13] In the present study, nursing educators felt, based on their experiences, that they were a symbol for the students.  On the other hand, nurses and nursing educators as a model and mirror for their students has been confirmed in some other studies.[2,14] In a study regarding the factors affecting students' self-esteem, nursing educators have been identified as a mirror for their students.[14] Self-esteem includes nursing student's sense of honour about themselves which can impact academic failure, dropping out, or vice versa (their academic achievements.[15] However, no study was found to be specifically on the need for clinical nursing educators’ awareness about their influence on students' self-esteem. Doing further studies in this field is recommended. There are various definitions for job satisfaction, such as a positive and pleasant emotional state resulting from the assessment of job or job experiences[16] or the reflection of individuals’ attitude towards liking or disliking the job.[17]

In the present study, nurses insisted that working with students had created a sense of calmness. In the present study, development of a sense of self-efficacy, or in other words, nurses' perceptions of their ability have been listed as an outcome of the experience of teaching the students. In a study in China in 2010, a sense of personal satisfaction and self-enrichment were reported based on the preceptor ship nurses’ experiences, which is consistent with the results of the present study. In the above-mentioned study, nurses insisted that their participation in the processes of teaching[18] has been effective in the development of their sense of learning. Based on the results of the present study, nurses’ engagement in training students has been effective in developing a sense of understanding in relation to their capabilities. Now the question is "how can the ability of nurses in teaching students be used to develop self-efficacy in nursing educators?" No specific study was found in the literature in this field. Further studies in this field are required.

Conclusion

Nurses’ experiences indicated that some factors were effective in acquiring positive experience including development of believing of them about their capability or negative experience, such as overcoming fatigue and the need to support, lack of familiarity with teaching and evaluation practices.

Based on the results of this study, it is necessary for academic centers to plan to offer training to clinician nurses about evaluation methods and different ways of teaching. On the other hand, the results of the present study point to the development of self-efficacy in clinical nurses who train students. Plans need to be developed by authorities to provide support to the mentioned nurses.

Among the limitations of the study is the research limitation in Tabriz University of Medical Sciences; however, with further investigation in other universities, valuable experiences of other clinical educators can be gained, and development of nursing knowledge, more comprehensive planning and provision of a more favorable environment for the clinical learning of nursing students can be achieved. Furthermore, only the experiences of teachers have been extracted in this study, so it is recommended that the experiences of students be extracted in this field as well.

Acknowledgments

Authors would like to express their gratitude to all participants in this study as well as authorities in Tabriz University of Medical Sciences for their financial support.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.