Effective Characteristics of Iranian Nursing Students in Their Relationship with Clinical Nurses.

Introduction: The purpose of this study was to explore the characteristics of undergraduate nursing students, which may determine the nature of their relationship with clinical nurses. Relationships between nursing students and clinical nurses are critical to maximize student learning outcomes and produce skilled graduates for the future health workforce.
Methods: This qualitative content analysis study was conducted from January to August 2016. Twenty nine semi-structured in-depth interviews were conducted with 20 undergraduate nursing students in Tabriz nursing and midwifery faculty. Interviews were recorded and transcribed verbatim (in Persian), and analyzed using conventional content analysis to identify themes.
Results: Four key themes emerged: educational factors (cognitive knowledge and practical skills, and learning motivation); communication skills; perceived support (perceived support from nurses and educators); and psychological state (fear of the relationship and self-confidence). Self-confidence is an emphasized concept in nursing students' willingness and ability to relate with clinical nurses.
Conclusion: The results of the study showed that educational, communicative and psychological factors are important determinants of student communication with nurses. However, self-confidence is the most important factor in establishing such relationship. Self-confidence could be further assessed to identify nursing students who need greater support or would benefit from greater educational interventions to achieve relational skills.

Introduction

Clinical practicum is a fundamental part of nurse education and has been found to be essential for developing real-world critical thinking and reflection in nursing students.[1] Undertaking practicum in a clinical setting helps nursing students to develop their professional identity and clinical competence.[1,2] Although educators in the clinical environment can play an important role in providing clinical experiences for nursing students, in some cases they themselves may lack sufficient clinical competency across all clinical domains.[3-5] As a consequence, nursing students are often dependent on clinical nurses to support the development of clinical competency.[4] Clinical nurses’ experiences are considered a rich source for educating students worldwide.[6] So, mutual relationship with clinical nurses have many essential effects on nursing students such as: enhancing knowledge and skills;[7] improving the critical thinking and clinical reasoning skills;[8] and development of professionalism and socialization.[8,9] In many advanced countries, nurses are used as preceptors in the clinical education of nursing students.[10,11] Studies have shown that preceptors have a positive role in promoting and facilitating clinical knowledge and skills,[12] professional independence,[13] clinical competence[14] and socialization[11] in students. On other hand, numerous studies worldwide have reported registered nurses’ inappropriate behaviors toward nursing students, such as belittling and disrespecting students,[15] not engaging in the education of students,[16] not supporting student development,[17] and holding negative attitudes toward students.[18]

A recent systematic review identified lack of sufficient time and education causes nurses to poorly communicate with nursing students.[19] Similarly, it has been reported that Iranian nurses consider nursing students an inconvenience and adding work to their clinical settings.[20,21] Generating new knowledge on the characteristics of nursing students affect their relationship with clinical nurses is critical to inform and develop programs to strengthen such relationships between nursing students and clinical nurses. After an extensive review of literature, no studies on the investigation of such characteristics were identified.

However, some studies have highlighted selected characteristics related to nursing students and preceptors on the success of the preceptorship model,[22] because relationship between nursing student and nurse in the preceptorship model is the only educational relationship that occurs between them in the clinical setting. The relationship between a preceptor and nursing student that is usually a one-to-one relationship is different from clinical education with an independent clinical educator responsible for a small group of students, which is the traditional method of clinical education in Iran.

Due to the lack of general use of the preceptorship model of nursing education in Iran, having the ability to create relationship with nurses is essential for nursing student’s clinical education. Given the fact that students need nurses to have a good clinical learning experience, so students should try to establish this connection that in other studies, student relationship initiation has also been achieved.[20] In the latter situation, the objective of the clinical educator is primarily focused on the provision of education, as opposed to having clinical responsibilities. Considering the fact that the phenomenon of relationship between nursing students and clinical nurses was less studied in context of Iran, this phenomenon needs to be examined in depth. So the purpose of this study was to explore the characteristics of nursing students, which may determine the nature of their relationship with clinical nurses that conducted with content analysis.

Materials and methods

We used conventional content analysis to examine the students' relationship with nurses in the clinical setting. The study was conducted at the Tabriz Nursing Faculty affiliated to the Tabriz University of Medical Sciences, which is located in East Azarbaijan Province, the northwest of Iran. At the time of conducting the study, the faculty had a total nurse undergraduate enrollment of 800 students receiving clinical education in 11 educational hospitals.

Twenty initial face to face interviews and 9 supplementary interviews, to confirm the findings of the initial interviews or to clarify some ambiguities, were conducted with 20 nursing students. All participants were undergraduate nursing students, had experienced at least two semesters of clinical training, and had no experiences of independent nursing care as an employed nurse. Twelve (60%) were male; the mean age of the participants was 21 years. Four were the second, 8 were the third, and 8 were final year baccalaureate nursing students. The first three participants were selected purposefully, and all had extensive experience regarding the phenomenon under study. Similarly, the remainder of the participants was selected purposefully based on the analysis of the previously conducted interviews with the previous participants. In order to preserve maximum variance sampling, an attempt was made to select the samples with the highest heterogeneity in terms of gender, school year, educational status and cultural background, while observing the principles of purposeful sampling. Individual semi-structured in-depth interviews were conducted between January-August 2016. Interviews with 11 of the participants were conducted at the first author's office at the Faculty of Nursing, while the remaining interviews were conducted in private rooms in clinical settings based on participant comfort and appeal. Considering the purposeful sampling, educational affair office and clinical educator were used for introducing the students.

Interviews began with open – ended questions such as: How many semesters do you have? What lessons do you have in this semester? Which clinical sections did you attend this semester? Then, the main questions raised included: When and how do you contact with clinical nurses during clinical education programs? What factors make you feel you need to relate with a nurse? How do nurses respond to your needs in such situations? Afterwards, based on the participant responses, the following questions were asked with the purpose of probing such as: How? When? Who? What was the result? Could you explain more? Could you make some examples? Before the interview began, the objectives of the study was expressed and‏ permission for recording was taken. All interviews were conducted in Persian, then audio recorded and transcribed verbatim. Some of the participants’ statements have been translated into English to convey the meaning for this paper. Each interview session lasted for an average of 65 minutes (40-110 minutes) in the initial interviews and 22 minutes (20-35 minutes) in the supplementary interviews.

To analyze these data, the authors initially listened to the audio files of each interview several times to obtain a sense of the whole. The interviews were transcribed verbatim (in Persian) and uploaded into MAXQDA 10. The analysis of the scripts of the interviews was conducted simultaneously with data gathering and using the conventional content analysis technique.[23] While carefully analyzing the interviews, meaning units, which might have been a word or sentence, or even a paragraph, were firstly identified. These meaning units represented an important meaning for the participants in relation to the studied phenomenon. Following this, a label was chosen for these meaning units. These units were grouped according to their similarities and differences, and formed more abstract concepts. This process continued until the formation of the subthemes and themes. The process of data collection were continued until data saturation, when no new codes or categories emerged after two consecutive interviews.

To enhance the rigor of the study, the criteria introduced by Lincoln and Guba were used.[24] Credibility was confirmed by assigning a long period of time to collect data and the confirmation of study findings by three participants independently. Dependability was obtained by comparing the evaluation of three independent researchers. Moreover, confirmability was accomplished by providing a thorough description of how data were collected and analyzed. Finally, transferability was observed by confirming the findings by three nursing students who were not among the participants. This study was approved by the Regional Ethics Committee at Tabriz University of Medical Sciences with the code IR.TBZMED.REC.1395. 619. Information about the study was provided to all the participants orally and written informed consent was obtained from them.

Results

Four main themes were identified: educational factors, communication skills, perceived support, and psychological state.

Educational factors

Educational factors contain two categories: a) cognitive knowledge and practical skills; and b) learning motivation.

Cognitive Knowledge and Practical Skills

The level of cognitive knowledge and practical skills of students is an effective factor in their relationship with nurses. Although nursing students consider nurses as a valuable source of information for routine care practices, they mainly rely on their clinical educators in acquiring basic cognitive knowledge for nursing care. The level of practical skills in students is more effective in forming their relationship with nurses. This is because nursing students believed clinical nurses to be more adept and skillful at performing routine practical skills, when compared to their clinical educators. "Clinical educators have more up-to-date knowledge; but a nurse who works there knows all the routines and can better teach us how to do things." (p14) Students' underdeveloped cognitive knowledge, competency with practical skills and the concomitant fear of being humiliated or mocked by nurses was a barrier to the promotion of an effective relationship between students and clinical nurses. This concern was found to be particularly high among junior students and in intensive care units due to the perception of higher expectations. Students were found to credit strong cognitive and practical knowledge to improving their preparedness to relate to clinical nurses. "When I was the newcomer and I do not know anything about there. I'm afraid the nurse wants something from me to do. “(p1)

Learning motivation

Learning motivation was found to be an influential factor in students’ relationship with clinical nurses. This relates to students' willingness to become familiar with clinical ward routines, including the desire to learn care instructions and approaches, and become familiar with new care equipment. Students considered clinical nurses to be a valuable source of information on these issues. "I had a great desire to learn the places of equipment during the first days; I would like to quickly learn from nurses." (p 8) Learning motivation was intrinsic in some cases and is related to the inherent curiosity of students in acquiring new knowledge. However, in most cases, such motivation has an extrinsic source, the source related to the willingness of students to prepare for entry into an independent work environment or gaining a better score in relevant clinical exams. Interestingly, if learning motivation is extrinsic, the willingness to learn is diminished by acquiring the desired skill or score, clinical nurses’ lack of response to students’ questions, humiliating students, or abusing students by assigning tasks that are considered not worth learning. Motivation for learning is usually higher in critical care units due to more care instructions and technical equipment in such environments. "When you ask some nurses, they immediately take advantage and ask you to measure all blood pressures. That is why I'd rather not ask for anything." (p8)

Communication skills

Communication skills are regarded as one of the most important factors in building relationships. Many of these skills are formed prior to entering the university. Place of residence was found to be an important perceived factor in relation to communication skills with students from rural environments or small towns more likely to indicate they had greater communication problems after entering the university. Furthermore, female students were more likely to report communicating proficiently. "I didn’t know about these things, but some peers learned about them in the family; well, small cities are different from here as a formal environment and big city." (p 20) Previous experience of students from clinical education is an important factor in determining the level of their communication skills, and these skills in most cases are promoted over time and through familiarity with the culture in clinical wards. However, early experiences have a key role in this regard, with some students' reporting a decline in self-confidence in developing effective communication skills if these experiences are negative. A number of students indicated that the lack of development of communication skills can negatively impact learning motivation and lead to a poor professional attitude. "I remember so many inappropriate and unfriendly encounters that I don’t want to talk to nurses anymore. Why should it be like this?" (p13)

Perceived support

The support that students receive in clinical consists of two subcategories including perceived support from nurses and perceived support from clinical educators.

Perceived support from nurses

Students believe the support received from the clinical nurses is one of the most important factors in establishing a relationship between them. Many clinical nurses were reported to be unwilling to support nursing students for a variety of reasons including: the presence of an independent clinical educator; high workload and insufficient time; lack of interest in education; negative attitudes toward nursing students, and concerns about students’ potential medical errors. Students said that this reasons are the Barriers to supporting‏ nursing students in the clinical settings which nurses themselves have told the students. Lack of support from clinical nurses was found to significantly reduce students' interest in relating with nurses and thus, decrease students’ learning motivation and even their interest in the nursing profession. "Altogether, nurses do not trust students and think that students are solely responsible for all the errors in the ward. Keeping such an attitude in mind, how can one take the initiative to contact?" (p9) In contrast, some students reported nurses to have a strong desire to support students, in particular junior students and students who lacked knowledge and skills. In some cases, clinical nurses invited students to learn nursing procedures and respond positively to a students' learning request. Adorned appearance, admiration and possession of appropriate care knowledge and skills were found to be key attributes of clinical nurses who responded well to student requests for information. Overzealous support was sometimes found to conceal students' errors and reduce patient contact. The perception of clinical nurses’ support appears to be very important especially in intensive care units. Such support, in addition to its educational outcomes, was found to lead to the emergence of a positive professional identification in students. "There was a nurse who did not let anyone know about our mistakes. “She is a good student; gives her a high score”, she once told my educator." (p13)

Perceived support from clinical educators

The support students receive from their clinical educators is an important factor in establishing communication between students and nurses. Interestingly, in many cases, receiving support from clinical educators caused students to rely on them and reduce the need for student contact with clinical nurses. In some cases, students thought clinical educators actively prevented the development of a relationship between them and clinical nurses. The most important reasons proposed for this included the fear of students’ learning inappropriate procedures, decreasing the educator's dominance, and fear of generating tension between students and clinical nurses. In particular, students believed educators did not encourage the establishment of a relationship between clinical nurses and students with lower grades or in the case of students perceived to have a low cognitive and skills base. "Once I was supposed to give two antibiotics to a patient. “Mix together and inject" the nurse said. I went to the educator and told him about the issue; he got angry and argued with the nurse." (p7) In some cases, however, educators themselves were reported to facilitate a relationship between students and clinical nurses. This was found to be mostly true for educators who were also nurses at the internship site. Such educators usually asked students to be consistently in touch with clinical nurses regarding coordination of caring practices for patients and they sometimes actively encouraged nurses to help students in performing care practices. The educator’s willingness to establish relationships between clinical nurses and students was found to play a very important role in students' perceived sense of belonging to the clinical environment and their learning motivation. "Some educators take students to the ward and introduce them to the nurses, and also require students to stay in touch with the nurse responsible for the patient." (p 16)

Psychological factors

Psychological factors consist of two sub-categories of (a) fear of relationship and; (b) self-confidence.

Fear of relationship

Fear of the relationship with clinical nurses was found to be an experience shared by all participants. The main reasons for this fear included clinical nurses’ misuse of students through the assignment of trivial care duties; fear of being humiliated by clinical nurses; fear of violence, and fear of unjustly attributing medical errors to students. Interestingly, participants stated that at the beginning of the clinical education period, they regarded clinical nurses’ misuse of them as a form of collaboration and provision of educational opportunities, and were even happy with it. "In some wards, nurses do not properly treat us. You are worried not to do anything for the patient so that you are not humiliated by nurses in front of others." (p16) The source of some student’s fears and concerns was generated by the students themselves. The fear of occupational injuries, the fear of committing medical errors and the fear of lacking sufficient knowledge and skills, and the fear associated with unfamiliarity with the ward culture seemed to be independent of any external influence. These fears were found to be more pronounced in lower level students and also in intensive care units where the clinical educator had limited ability to control the environment. This fear of relating, especially when associated with students' previous unpleasant experiences with clinical nurses, was found to be one of the most important factors in preventing a positive relationship with nurses in clinical settings. "Of course, you might make errors when you do not know things well. One’s afraid not to cause any problems to the patient; these all make it harder to go and talk to nurses." (p11)

Self-confidence

Students’ self-confidence in their ability to relate with clinical nurses was identified as a key concept in the initiation and continuity of relationship between students and clinical nurses. The most important factor found to create this self-confidence was students’ possession of knowledge and skills necessary for carrying out nursing care. Self-confidence was more likely to be greater in higher-level students, especially males. "I was not so much confident at first semesters. [at that times] I was afraid of making mistakes; but now I’m less frightened and have a boosted up self-confidence." (p 10) Another important and influential factor in students' self-confidence is the degree of educators’ support to establish the relationship between students and clinical nurses; students’ perceptions of the quality of relationship between clinical educators and clinical nurses; educators’ clinical competence, and educators’ level of education. This was especially important in the case of female and junior students."We had an educator who constantly asked nurses about different things; “what an inexperienced educator you have”. One of the nurses once told me." (p 19) We identified that other factors contributing to perception of self-confidence by students included the psychosocial environment of clinical settings; the level of clinical nurses support from students, and students’ previous experiences of relationships with clinical nurses. The positive nature of the environment and the presence of previous positive experiences can enhance the feeling of self-confidence in students and vice versa. We discovered that self-confidence is the outcome of many variables affecting the relationship between students and clinical nurses. Some students suggested that the degree of a positive relationship with clinical nurses was a direct result of self- confidence. "When a student knows something, his confidence is boosted and he can more easily relate with nurses; nurses also accept the student more easily and trust the student." (p 4)

Discussion

This study was conducted with the aim of exploring characteristics of nursing students which may determine the nature of their relationship with clinical nurses.

Our findings revealed that student-nurse relationships are influenced on different levels by nursing students’ cognitive knowledge and practical skills. Although previous literature has reported weakness in knowledge and clinical skills as critical stressors for nursing students,[25,26] we found only one study that have examined the association between this phenomenon and nursing students' willingness to relate with nurses.[27] In addition, it was revealed in this study that nurses also had high expectations from students, especially lower-year students that disrupt the relationship between them. Allocation of excessive responsibilities to nursing students has also been reported in previous studies.[17,28]

Learning motivation was another influential factor in students’ relationship with clinical nurses. we found only one study studies have only addressed learning motivation among nursing students as an effective factor in the relationship of students with nurses;[29] however, there are some studies that indicate the effect a proper relationship between nurses and nursing students on increasing learning motivation in nursing students.[30,31] Another interesting finding of this study is that assignment of routine and simple care practices to nursing students reduces their learning motivation. This finding reported in previous Iranian study.[5] According to the findings, students' communication skills are an important factor in shaping their relationship with nurses. However, the results of previous researches are not contradictory in this regard.[32,33] On the one hand, nursing students have been reported to have proper communication skills in some European countries.[34] On the other hand, the results of studies in Portugal[35] and China[32] require nursing students to be educated on communication skills.

Whilst the support of clinical nurses is one of the essential factors in establishing a relationship between students and clinical nurses, most nurses are reluctant to support nursing students. The medical personnel’s lack of support for nursing students has also been reported in Western countries such as Italy[36] and Ireland.[17] This is concerning when examined alongside the evidence which shows the importance of clinical nurses support to students in making them feel valued.[37,38] Another novel finding from this study is that clinical nurses’ support for students often involves clinical nurses being complicit in the students’ mistakes and implausibly defending them. The relationship between clinical nurses and clinical educators is an interesting finding in this study. Clinical educators generally, were perceived as hindering the relationship between students and clinical nurses. Although there are many studies in the literature addressing educators’ support as a key factor for nursing students' clinical learning.[6,39] no study was found on the impact of clinical educators on establishing a relationship between students and clinical nurses.

Among other findings of this study was the nursing students’ excessive fear of relating with nurses. This issue has been well documented in previous studies.[15,25] Similarly, some researches carried out in the Middle East have highlighted students’ fear of nurses' criticisms and insults,[40,3] and reported relationship with the medical staff as the second source of stress for nursing students.[25] Although, the results of this study indicate that the source of such fear is sometimes rooted in the nursing students’ weaknesses, such as lack of knowledge and skills or unfamiliarity with the environment. Self-confidence was identified in this study as a more emphasized concept in building relationships between students and clinical nurses. Students’ possession of sufficient clinical knowledge and skills, clinical educators’ clinical support and competencies and nurses' support were the most influential in the formation of students’ self-confidence according to findings of this study. In previous studies, the role of knowledge and skills[27,29,41,42] and nurses' support[31] has been highlighted in the formation of nursing students’ self-confidence and in the performance of nursing care. This study is among the few studies that introduce self-confidence as a fundamental concept in shaping the relationship between students and clinical nurses and describes the factors that contribute to establishing such self-confidence.

The results of present study have some limitations. In present study, the experiences of nursing students was investigated and we did not collected and analyzed the experiences of their clinical educators or clinical nurses. In addition, this study was conducted in one university in North West of Iran.

Conclusion

The findings of this study can be used to facilitate relationships between nursing students and nurses in clinical setting. As revealed, the level of cognitive knowledge as well as practical and communication skills of nursing students is essential in their ability and willingness to relate with nurses. This study highlighted that students’ fear of relating with nurses was to some extent rooted in students' unfamiliarity with clinical settings.

Therefore, monitoring and promoting such skills in nursing students and furthering their familiarity with clinical settings play an important role in enhancing students' self-confidence in relating with nurses. Further, it was observed that the perception of clinical nurses’ support is a major indicator of students' self-confidence and preparedness to relate with clinical nurses.

Unfortunately, however the majority of clinical nurses were perceived as reluctant to relate with and support nursing students. So, educating nurses in the clinical area of the importance of building positive relationships with nursing students would assist in the facilitating these relationships. Finally, it was identified that nursing students' self-confidence is a key concept in shaping the relationship between nursing students and nurses. Further studies could investigate the concept of self-confidence further and identify strategies to develop nursing students’ self-confidence

Acknowledgments

This article is derived from a PhD dissertation in nursing at the Tabriz Nursing and Midwifery Faculty. The authors would like to appreciate from Tabriz University of medical sciences funding and all the nursing students that participated in the study.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.