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REVIEW ARTICLE
J Edu Health Promot 2020,  9:216

The challenges of supporting nursing students in clinical education


1 Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
2 Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
3 Department of Nursing, Faculty of Nursing and Midwifery, Babol University of Medical Sciences, Babol, Iran

Date of Submission05-Jan-2020
Date of Acceptance06-May-2020
Date of Web Publication31-Aug-2020

Correspondence Address:
Dr. Ali Zabihi
Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jehp.jehp_13_20

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  Abstract 


Clinical education requires creating a supportive atmosphere for learners and nursing students, who need support to be prepared for their future profession. The purpose of this study is to investigate the challenges of supporting the nursing students in clinical education. This article reviewed studies conducted between 2009 and 2019 with the keywords including support, challenge, students, education, and nursing using SID, Magiran, IranMedex, Google Scholar, Elsevier, and PubMed as databases. Among the 926 articles obtained during the two review stages, which were based on the inclusion and exclusion criteria and the first one analyzed the title and the abstract and the second one analyzed the whole article, ultimately 32 articles were selected for the study. The types of articles used in this study are as follows: qualitative (16 articles), descriptive analytical and cross-sectional (12 articles), review (3 articles), and mixed-methods (1 article). The focus of all studies was on the students' clinical education environment. The participants of the studies were undergraduate nursing students (in 22 articles), graduate students (in 2 articles), nursing instructors and students (in 4 articles), and nursing instructors and managers (in 1 article). Most of the challenges of supporting the students included violence, fear, and anxiety; socio-cultural challenges, environmental-organizational stresses; and ineffective clinical education. The findings of this study showed that nursing students face many challenges in the clinical setting. Therefore, the managers of educational and health-care centers should give a high priority to their students' support programs.

Keywords: Challenge, clinical, education, nursing, student, support


How to cite this article:
Jafarian-Amiri SR, Zabihi A, Qalehsari MQ. The challenges of supporting nursing students in clinical education. J Edu Health Promot 2020;9:216

How to cite this URL:
Jafarian-Amiri SR, Zabihi A, Qalehsari MQ. The challenges of supporting nursing students in clinical education. J Edu Health Promot [serial online] 2020 [cited 2020 Oct 25];9:216. Available from: https://www.jehp.net/text.asp?2020/9/1/216/293925




  Introduction Top


Nursing education is providing a combination of theoretical and clinical learning experiences to train students with required knowledge, skill, and attitude for postgraduate professional practice.[1] Clinical education is one of the fundamental domains in developing nursing profession,[2] which provides the opportunity for nursing students to transform conceptual knowledge into psychomotor skills and apply them to patient care.[3] Students' clinical experience is a determining factor in the quality of nursing education and has a significant influence on their learning outcomes and cultural adjustment in this profession.[4]

In clinical centers, students often encounter unplanned activities concerning the patients and other health-care staff.[5] Studies show that most students consider working in clinical centers stressful, which affects the learning process and its outcomes. Appreciating, welcoming, guiding, and alerting students to start working in the clinical setting may reduce their anxiety.[6] Ensuring that students receive the best possible support is a crucial factor in optimizing their learning experiences and enhancing their progress.[7]

Supporting students in clinical atmosphere and positive clinical experience can increase the their interest.[8] Rigorous evaluation of supportive services is essential to ensure that appropriate services are provided for students at the right time.[9] The results of the study by Msiska et al. showed that students were left alone when dealing with patients and caring for them and were not supported by nurses and educators and felt tired, humiliated, discouraged, and unconfident.[10]

In their study, Banks et al. showed that students' anxiety and depression in the clinical setting calls for a great support in such a challenging environment.[11] Another study highlighted the role of mentors and department personnel in student support.[12] Based on the study by Gidman et al., the most important areas that students need support are clinical skills, clinical placement, and self-esteem. Moreover, according to the results of this study, experienced instructors and students had a more supportive role than others.[7]

Based on the studies mentioned above, support plays a crucial role in clinical education. In recent decades, there has been much debate on support mechanisms available during nursing students' internship.[13] Over many years of experience in clinical education of nursing students in teaching hospitals, authors of this article have also witnessed numerous problems of students regarding receiving support in various aspects. Furthermore, a review of the literature indicates that, given the environmental, economic, social, and cultural conditions associated with the needs of nursing students in the areas of support in clinical education, there are numerous challenges in Iran and other parts of the world, which are in some cases unique. Thus, the purpose of this study was to investigate and identify the challenges of supporting the nursing students in clinical education.


  Materials and Methods Top


The present research is a review study conducted based on Broome[14] in three stages of literature search, data evaluation, and data analysis.[14],[15] As a result of searching in IranMedex, Magiran, SID, Google Scholar, Elsevier, and PubMed using nursing, education, students, challenge, and support as keywords, 926 articles and abstracts were gathered. This study was conducted after approval in the ethics committee of Babol University of Medical Sciences with the code: IR.MUBABOL.REC.1399.160.

All review or original articles on the challenges of supporting nursing students in clinical education, conducted between 2009 and 2019, were studied, if the full-text version of the article was available.

Studies that did not address the challenges of supporting the nursing students in clinical education were excluded. The articles were selected in two stages. In the first stage, the articles that were not relevant to the challenges of supporting nursing students in clinical education were excluded from the review and in the second stage, all relevant articles were thoroughly studied, which eventually led to the selection of 32 full-text articles published either in Iran or abroad.

In the first stage, 926 articles were selected. At this stage, the title and, if necessary, the abstracts of the articles were reviewed and finally, 135 articles were selected. In the second stage, the full text of the articles were studied, and 103 articles were excluded from the review because of their lack of focus on the challenges of supporting nursing students in clinical education, which left us with 32 published articles. At the analysis stage, the information collected from the studies included the author(s), year of publication, purpose of the study, main study results, study methodology (study design, data collection, and research method), research setting, and sampling method of the study. This information was regularly gathered in files and applied as the raw data for this review study. During the data collection process, the information was not interpreted, and the exact terms and expressions used by the authors in their articles were extracted. The validity of the data analyses was confirmed in two ways: (1) using two researchers who were working independently during data analysis procedure and (2) the two researchers agreed on the results of data analysis and if they faced a problem, they discussed until an agreement was reached.


  Results Top


Articles used in this study were qualitative (16 articles), descriptive and cross-sectional (12 articles), review (3 articles), and mixed-methods (1 article). Content of majority of the studies (24 articles) focused on students' experiences, views, and perceptions of the clinical education atmosphere. There were three articles on violence against nursing students in workplace and two on challenges of master's nursing students' clinical education. The study samples in these articles were nursing undergraduate students (in 22 articles), graduate students (in 2 articles), nursing instructors and students (in 4 articles), and nursing instructors and managers (in 1 article).

Data collection instruments selected for the reviewed studies include interview (in 12 articles), questionnaire (in 12 articles), and focus group (in 5 articles). Regarding statistics, the studies adopted descriptive statistics methods (i.e., frequency and percentage, mean and standard deviation) and analytical statistics methods (i.e., logistic regression analysis, Chi-square, t-test, ANOVA, Kristal–Wallis, and Pearson's correlation coefficient). Moreover, qualitative studies applied content analysis methods (11 articles), thematic analysis (3 articles), and Colaizzi's seven-step qualitative analysis (2 articles).

Violence

The reviewed studies mainly highlighted violence of nurse educators, staff, patients, and patient companions. In a qualitative study, nursing students' experiences regarding vertical violence in clinical settings showed that as one of the major challenges of student support, this kind of violence has numerous and varied evidences including humiliating and blaming students, rejection, exploitation, discrimination, bullying, and poverty of student supporting.[16] Furthermore, a review introduced the following factors as the challenges of clinical education: lack of access to educators, inappropriate behavior of ward staff, lack of student and educator support, and student bewilderment in the absence of educator.[17] Nursing students' experiences of emotional challenges during clinical education in Malawi (East Africa) showed that due to the insufficiency in nursing staff, students are often left alone at the bedside, not receiving support from nurses and/or educators. Inappropriate behavior of nurses and educators and humiliation of the students by educators at the bedside and in the presence of the patients, lead to patients' permanent distrust of students and students' discouragement and loss of self-confidence.[10]

The results of a cross-sectional study conducted in Hong Kong showed that 30.3% of students experienced clinical violence during education. The prevalence rate of verbal abuse was 30.6%, which was mostly committed by patients (66.8%), hospital staff (29.7%), educators (13.4%), and patients' relatives (13.2%), while this rate was reported to be 16.5% for physical violence, the perpetrators of which were mainly patients themselves (90.1%).[18] In another study, 42.18% of the students confronted with violent behaviors in the clinical setting during the past year, while one-third of them witnessed bullying against other students, all of which led to the decision of leaving their profession in 19.8% of the students.[19] In addition, 34% of the nursing students who participated in a study in Italy said that they experienced at least one case of physical or verbal violence at the workplace.[20] A study which investigated bullying in clinical education in Canada showed that it is to a large extent present in nursing education settings.[21] Use of mentors in clinical education of nursing students, which is constantly emphasized, can minimize the violence and stresses of clinical setting.[22]

Fear and anxiety

A qualitative study was conducted on nursing students' readiness for clinical education, the main themes of which being student rejection of the profession, fear, and anxiety. They are confused, feel alienated, and extremely need support specifically from educators in the clinical education setting, especially in the first days of internship and starting to work in a new ward.[23] The results of another study showed that one of the causes of students' negative experiences in clinical learning was their fear during the internship because they did not have any supporters and ward staff and educators' information was not up to date.[24] Another study found that fears of harming patients, being ridiculed by peers, being criticized by educators, and educators' insufficient trust in students during their performance lead to the reduction of students' self-confidence.[25] As Killam and Heerschap stated, junior students feel more frightened and stressed in clinical settings, which shows their severe need for ward staff and educators' support.[26] Furthermore, in a qualitative study in Indonesia, students reported that they feel pressure and deal with communicative challenges at bedside.[27] Most studies in a review study indicated that the clinical learning setting causes stress for students.[28]

Sociocultural challenges

Discrimination between nursing students and those who study in other medical fields is a problem which has made many students stressed out. In a qualitative study, experiences of students and nurses in the emergency department showed that the clinical learning setting is unprofessional and ineffective, students are not well supported, and there is discrimination among students of different fields of medical science.[29] In a study, discrimination between nursing students and other students in the field of medical sciences, as well as the reluctance of staff to collaborate with nursing educators, have been suggested as supportive barriers for students.[30]

In another study, exploitation, discrimination, and bullying by educators and treatment staff were cited as challenges, which need support.[16] Regarding identity problems of nursing profession, a study in South Africa indicated that male students confront with more challenges at the bedside, simply because nursing is a female-dominated profession, and there are few male nurses.[31] Concerning culture, patients' lack of cooperation and trust in students, even in teaching hospitals, is another problem of clinical education which requires support from the system and educators.[32]

Environmental and organizational stresses

A study on clinical education problems from nursing students' point of view indicated that the most important problem of clinical education was depriving students of being involved in making decisions on planning, inadequate attention to hospital amenities, improper placement in the ward, insufficient collaboration of ward staff with the student, and the staff who do not possess up-to-date information to train students in the absence of the educator.[33] In a review and analysis of nursing education challenges in the clinical setting, most nursing students announced that instructors, educational supervisors, and ward staff did not provide them with sufficient support.[34] In another study, inadequate physical space and educational classrooms of the ward, physicians and nurses who does not support students, and a large number of students in comparison to a smaller number of patients on the ward were pointed out as challenges regarding the effectiveness of clinical education and shared concerns of students, nurses, and educators.[35]

Another study introduced the large number of students in internship groups, nonteaching hospitals, lack of adherence to scientific principles at work in clinical settings, and subjective evaluation methods as barriers of clinical education from educators and students' viewpoint.[36] In addition, another study reported that due to the inadequate supply of nurses on the ward, nursing students are not sufficiently supported by nurses.[37] As Papathanasiou et al. highlighted, in order to provide nursing students with psychosocial support, policymakers have to move toward reorganizing clinical education, providing more opportunities for student innovation, reducing the number of interns that an educator can teach, and striving for effective clinical education.[38] In their systematic review, Qanbari Qalehsari et al. referred to appropriate learning environment and collaborative learning as significant themes in the effective learning of nursing students.[39]

Ineffective clinical education

In addition to problems related to organization and environment, lack of student support from clinical educators is considered the most important problem regarding student education. Educators do not provide sufficient motivation for being employed in this profession.[34],[40] A qualitative study identified nursing students' support needs in different physical, competency, informational, and psychological domains. This study also highlighted the educator as the first source of student support and the guide of support process. Moreover, in the same study, patience, calmness, friendliness, possessing professional knowledge, ability to communicate effectively, and targeted management of education were introduced as characteristics of a supporter educator.[41] In another study, disqualified educators and unsupported learning environment were introduced as challenges of nursing students' learning in clinical settings. Weakness in practical skills, especially among novice educators, inadequate supervision, and weak approach to educational strategies were noticed in disqualified educators.[42]

A study on the clinical education challenges of masters students of nursing revealed that the main challenges are divided into internal and external factors. Internal factors included lack of professional identity, lack of motivation, and previous experience, whereas external factors were professional interactions, unconformity between theoretical and clinical education, inefficient educators, and not supporting educators and nurses on the ward.[43] In another study, students' confusion caused by different supervision methods provided by ward nurses and educators, uncertainty of the student about the validity of practice or routine ward performance, irresponsibility of ward staff in student education, and educators' subjective educational performance were referred to as the existing challenges in the clinical education of nursing principles and techniques.[44] Furthermore, in a review study, inaccessibility of educators; inappropriate behavior of ward staff, students, and educators who are left unsupported; and students' confusion which is caused by the absence of the educator were mentioned as clinical education's challenges.[17] A qualitative study highlighted the significant role of educators' communication with students in their clinical learning. Though in some cases, this communication is weak and students are not supported.[1]


  Discussion Top


A review of studies has shown that the most important challenges that the nursing students face in clinical education include violence, fear and anxiety, socio-cultural challenges, organizational-environmental stress, and ineffective clinical education.

The majority of the studies which were reviewed, were either descriptive or qualitative. There were only few or in some cases no analytical, empirical, and/or mixed-methods articles. Moreover, because most studies did not investigate this concept thoroughly, there is a need for such research studies. Reviewing the studies on the challenges of supporting nursing students in clinical education showed that most studies highlighted the presence of such challenges, while few studies dealt with their causes and in most cases, they are dealt with superficially. However, to ensure the validity of the results of these studies, further analytical, empirical, and/or mixed-methods researches are required in order to discover causal relations more precisely in the subject of the study and using the results of extensive and in-depth research, devise appropriate strategies to prevent the challenges of supporting nursing students in clinical education. Considering the issues discussed and the findings of the reviewed studies, the present study suggests the following points to reduce the challenges of supporting the nursing students in clinical education:

  1. One of the support challenges for clinical learning was lack of coordination between faculties and treatment staff as well as the existence of some nonteaching hospitals. Therefore, taking the nature of the problems into account, consultation and cooperation between nursing faculties as well as medical and educational departments of medical universities are needed to increase coordination, change nonteaching hospitals to teaching ones, and overcome the challenges of nursing clinical education
  2. Educator–student relationship plays a crucial role in student's support and learning. Studies indicated that in most cases, this relation is weak. Thus, more support can be provided if good relationship is built with students
  3. To provide more psychosocial support to students, policymakers have to reorganize clinical education, reconsider acceptance rate which has to be in accordance with the capacity of the educational environment, make internship groups with the same size, distribute the same number of units to each clinical educator, provide more opportunities for students' innovation, and attempt to reach qualified clinical education
  4. Shortage of amenities and necessary facilities in hospitals, insufficient space on the ward, lack of educational tools and facilities, and inadequate training classes were significant challenges in clinical education environment. Therefore, the authorities have to take necessary actions to compensate for the deficiencies
  5. Counting internship period as work experience of nursing students can increase their motivation and ability during clinical education and create a positive attitude toward their future career
  6. Discrimination between nursing students and other medical students has been one of the major challenges in clinical education setting. Therefore, authorities have to take necessary actions to overcome this challenge
  7. Other challenges of clinical education are nurses, educational supervisors, and doctors, who do not support the student; bewilderment of student in the absence of the educator; and ward staff's reluctance to cooperate with nursing educators. One important reason might be the limited number of nurses on the ward and their overwhelming tasks. Thus, crucial steps have to be taken to provide support for ward staff
  8. Clinical environment, especially the one which the student experiences for the first time, is stressful. Creating an educational environment which is based on caring and humane relationships, as well as attempting to reduce students' stress, anxiety, and confusion in unfamiliar environments, can provide them with a better support
  9. Another influential factor in student support is the existing injustice in the clinical environment, for instance the use of students as ward staff, bullying, and use of physical and psychological violence against them. Repressing such injustices requires a fundamental reform in the organizational culture of academic medical centers and greater coordination between the managers of nursing faculties and hospitals
  10. Using the supportive role of master's and senior students for the clinical education of junior students can improve their efficiency and self-confidence.



  Conclusions Top


The findings of this study showed that the most important supportive challenges that nursing students face in the clinical environment include violence, fear, and anxiety; sociocultural challenges; environmental and organizational stresses; and ineffective education. Further attention to these challenges can improve clinical learning and ultimately the quality of nursing care. Therefore, the managers of educational and health-care centers should give a high priority to their students support programs.

Acknowledgment

The authors would like to thank all the authors of those books, articles, and journals that were referred in preparing this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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