Home / Archives / Vol 47 No 3 (2021) / Research Articles

Experiences of Undergraduate Nursing Students During Their Clinical Practice in Selected Nursing Institutes in Bangladesh

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Mabel D Rozario
Department of Graduate Nursing, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.

Keywords: Undergraduate nursing student, Clinical learning, Learning environment, CLES+T evaluation scale.

DOI: 10.3329/bmrcb.v47i3.59821

Abstract

Introduction

Clinical learning is regarded as an integral and essential part of nursing education. Clinical training provides opportunities to apply theory to practice, and fosters problem-solving and decision-making skills, learn time management, collaboration with others and development of their professionalism.^1,2 This correlation of theory and practice, and the building of meaningful experience, take place during clinical practicum in the health care settings.³ Through clinical training, nurse educators facilitate students’ learning of applying theoretical knowledge into the real situation of clinical setting. It is considered as a complex process of integrating cognitive, affective and psychomotor skills.⁴ Clinical education ensures delivering information, improves students’ skills related to patient care, critical thinking and decision making and increases their self-confidence.⁵

A large part of nursing education is carried out in clinical environments. In Korea, nursing students are required to spend a minimum of 1000 hours on placements (Korean Accreditation Board of Nursing Education, 2016), which is similar to that of the USA, but far fewer than the UK and EU countries where 2300 hours are required.² In Australia pre-registration nursing students must undertake a minimum of 800 clinical placement hours as part of their undergraduate nursing education.⁶ Like Iran, in Bangladesh clinical education forms more than half of the formal educational courses in nursing. According to Bangladesh Nursing and Midwifery Council (BNMC) curriculum, 2018, the undergraduate nursing students should spend 3168 hours in clinical placements, whereas classroom and skill lab hours combine to constitute 2664 hours. According to Nabolsi M in Jordan, where the study took place, students spend 70% of the training period in clinical placements.⁴

Practice placement requires an environment which is encouraging to learner, and provides the appropriate support from skilled practitioners and educators. A clinical setting rich in learning experiences, but lacking a supportive environment, discourages learning and results in the loss of learning experience and growth opportunities.³ Unlike classroom education, clinical training in nursing occurs in a complex, clinical context which is influenced by many factors. This contextual environment provides an opportunity for nursing students to learn experimentally and to convert theoretical knowledge to a variety of mental, psychological, and psychomotor skills which are of significance for patient care.⁷

Since the nature of the clinical training environment is unpredictable, it can create some problems for nursing students. The researchers’ experience in the nursing clinical education reveals that nursing students’ behaviours and performances change in the clinical setting. This change can negatively affect their learning, progress in patient care, and professional performance. Identifying problems and challenges with which these students are confronted in the clinical learning environment can help stakeholders solve these problems and contribute to them becoming professional as well as their professional survival.⁷

According to a review of literature, few studies have been done on the challenges nursing students face during clinical learning in Bangladesh. Identifying challenges which nursing students face in the clinical learning environment in all dimensions could improve training and enhance the quality of its planning and the promotion of the students.⁷ This concern generated an interest to formally investigate the experiences of student nurses during their placement in clinical learning environments - the clinical learning environment includes hospital wards and units, the community and health clinics. Access to these experiences could only be obtained through the people who lived them, i.e. the student nurses.^3,5 Therefore, the present study was aimed to describe the perceptions and experience of undergraduate nursing students related to their clinical learning environment and factors affecting their clinical learning process.

Materials and Methods

A descriptive cross sectional study design was used to explore the experiences of Bangladeshi undergraduate nursing students during their clinical practice. Data were collected from selected government nursing college, public university and private nursing college. The nursing institutes are: Dhaka Nursing College (government), and Department of Graduate Nursing, Bangabandhu Sheikh Mujib Medical University (public) both are located at Dhaka city, the capital of the country and Kumudini Nursing College (private) which is located in Tangail district.

Data were collected during the period of July 2019 to September 2019 using Bangla version of Clinical Learning Environment, Supervision and Nurse Teacher (CLES+T) evaluation scale which was originally developed by Saarikoski et al. The questionnaire consists of background variables and statements that evaluate the learning environment, supervisory relationship and the role of nurse teacher. The respondents evaluated the statements using a five- step Likert type scale. The questionnaire also contains background variables for the professional title of the supervisor, types of supervisors, occurrence of supervision and occurrence of teacher’s interaction. Within the CLES+ T evaluation scale, the students could identify individual method of supervisory relationship from six alternatives. Based on the multinational European study, the first three alternatives were combined to form one new group of Unsuccessful supervisory experience; alternatives four and five were combined to form another group as; Group supervision; and alternative six was renamed as; Successful supervisory experience.

Study population was undergraduate nursing students. A total of 400 nursing students studying at the level of 2^nd year, 3^rd year and 4^th year were included in the study. Non probability purposive sampling technique was applied to select the sample. The sample size of the study was estimated by using G* power analysis. The accepted minimum level of significance (a) .05 with a power (1-b) .95 and the effect size .25.

All the filled in questionnaires were checked and edited to ensure consistency and accuracy, and transferred to dummy tables for processing and subsequent statistical analysis using the software, SPSS. Descriptive statistics such as frequencies, percentage, mean, and standard deviation were calculated. Moreover, inferential statistics: ANOVA, Independent Samples t test, Pearson Correlation and Post-hoc tests were performed to examine the relationship. The study was approved by the IRB of the American World University before starting the study. The participants were explained the purpose of the study, given assurance to maintain anonymity and confidentiality of their information and obtained informed written consent from the participants before data collection.

Results

The present study explored the perceptions and experiences of Bangladeshi undergraduate nursing students of their clinical learning environment. The findings were presented under three broad headings:

i) Participants’ socio-demographic and clinical characteristics ii) Nursing students’ perceptions and experiences of their clinical learning environment and

iii) Relationship between socio-demographic characteristics and participants’ experience of clinical learning environment and relationship between participants’ clinical characteristics and participants’ experience of clinical learning environment.

i) Participants’ socio-demographic and clinical characteristics

It was revealed that most (69.8%) of the participants were in the age group of more than 20 years and the mean age of the participants was 21.15 years. Eighteen percent of the students were from public university, 46.3% from government nursing college and 35.8% from private nursing college (table I).

Forty seven percent reported ward in-charge as principal supervisor title, 34.8% reported they had situational supervisor, 83.5% of the participants reported clinical placement duration 7 weeks or longer. Forty four percent reported they had supervision 1-3 times, whereas 24.5% reported they never had any supervision during clinical practice. Equal percentage of participants (36.8%) mentioned that they had interaction with nurse teacher 1- 3 times, and more than 9 times and 3.5% told that they never had any interaction with nurse teacher during clinical practice.

The study indicates 33.0% of the students were satisfied with their clinical learning experience, 41.8% students reported they had group supervision, while 24.5% students expressed dissatisfaction with their clinical learning experience. The occurrence of supervisory relationship was linked to the students’ level of satisfaction (table II).

i) Nursing students’ perceptions and experiences of their clinical learning environment

The students evaluated their clinical learning experiences positively. The mean values of the sub- dimensions varied between (3.57 ± 1.12) and (4.05 ± 1.01). The highest mean value (4.05 ± 1.01) was in the sub-dimension leadership style of the ward manager followed by role of the nurse teacher (3.92 ±

.97), pedagogical atmosphere on the ward (3.87 ±

.96), premises of nursing on the ward (3.85 ± 1.08). The lowest mean value (3.57 ± 1.12) was in the sub- dimension supervisory relationship. Students reported higher satisfaction with leadership style of the ward manager, role of the nurse teacher, pedagogical atmosphere on the ward, than premises of nursing on the ward and supervisory relationship (table II).

ii) Socio-demographic and clinical characteristics and experiences of clinical learning environment.

Results showed students’ experience of clinical learning environment is negatively correlated with increasing age. Students from private nursing college had more positively evaluated clinical learning environment compared to public university and government nursing college. The perception of the students of their clinical learning environment varied according to their study level. Second year students evaluated clinical learning environment more positively compared to third year and fourth year students (table III).

Students who had their last practice in medicine, surgery and paediatric wards were more satisfied than students who had their last practice in gynae &obstetrical ward and critical care unit (p = .007). It was to be found that significant differences in mean overall scores of CLES+T scale for both variables: principal supervisor title (p = .000) and organization of supervision (p = .000). Association was found between mean overall score of CLES+T scale and occurrence of supervision (p = .000). Positive correlations were found between mean overall score of CLES+T scale and duration of practice (p = .000), frequency of supervision (p = .000) and interaction with nurse teacher (p = .000).

Discussion

The key finding of this study was that Bangladeshi nursing students’ overall evaluation of their clinical learning environment was found more positive compared to Slovak students and in line with a previous study from nine Western European countries where the students evaluated their clinical placement experience positively.^{8, 9} In the present study, the highest mean score was found in the sub-dimension, ‘leadership style of the ward manager’, whereas Slovak students reported highest mean score in the sub- dimension, ‘ premises of nursing on the ward’ and in the study by Warne T et al, the highest mean value was reported in the sub-dimension, ‘supervisory relationship.’ The lowest mean score was found in the sub-dimension, ‘supervisory relationship’ both in Bangladesh, and Slovakia study which is completely opposite to Warne T et al study. The reason behind might be that most of the Bangladeshi and Slovak students reported they had experienced group supervision model whilst in Warne T et al study most of the students experienced individualized successful mentorship relationship during their clinical placement. This study also revealed 59.8% students met their nurse teacher 4 or more times which is almost double than previous study in Western European context.¹⁰

In the present study the culture, the complexities of care (facilities and resources for nursing, ‘common spirit’ of the ward), nurse teachers ability to integrate theory and practice, their support to students’ learning, their relationship to students and mentors and ward environment were identified by the students as very important since they rated highly these three sub- dimensions: ‘ leadership style of the ward manager’, ‘ role of nurse teacher’ and ‘ pedagogical atmosphere’. This result is partially in line with previous study with Slovak students and nine Western European country students where they identified ‘premises of nursing care on the ward’ and ‘leadership style of the ward manager’ as important and pedagogical atmosphere as an important aspect of the clinical learning environment by rating high.^8,9

This study revealed students evaluated mutual respect and approval highest in the sub-dimension, ‘supervisory relationship’ like Pitkanen et al.¹¹ This means mutual respect and approval is very important for effective supervision and students’ learning. The results also revealed that 41.8% students reported they had experienced group supervision model where as it was 57.9% in Slovak students and only 25% in the study by Warne T et al.⁹ This result indicates group supervision model is more common model of supervision used in Bangladesh and Slovakia. Thirty three percent of Bangladeshi students reported they had experienced successful supervision during their clinical practice, whereas it was only 16.3% in Slovak nursing students and 57% in nine Western European countries study. The findings in the present study revealed that there is an association among nursing students’ perceptions of clinical learning environment and all the clinical characteristics. Likewise other studies the present study identified duration of practice was also related to students’ perceptions of clinical learning environment, which was not found in Slovak study.⁹ An interesting finding of this study was that 4^th year students were more satisfied with their clinical learning experience than 2^nd year and 3^rd year students (p = .000). The possible explanation might be that as the students become more mature with their level of study, they become more skilled and confident and can provide care to the patients independently which increases their satisfaction level.

In this study, the students evaluated the sub- dimension, the role of nurse teacher as the second highest aspect for their clinical learning (mean = 3.92), whereas in Finland the students evaluated the aforesaid sub-dimension as the poorest which is the consequence of decreasing resources for teachers to supervise students due to organizational changes in Finland and also elsewhere in Europe.^11-13 Like Slovakia, the traditional role of nurse teacher in Bangladesh is teaching nursing students both in clinical practice and in classroom setting in the college and university. An increase number of patients in the hospitals might be the reason of unavailability of named personal supervisor. Preceptorship is a new concept in the context of the country which has been started to a limited extent. The analysis of qualitative data collected in the study revealed that students feel more supported and learn effectively during clinical placement if they have preceptors to instruct and teach them during clinical practice.

Conclusion

Clinical learning experiences vary from country to country as the design of nursing education is also different. In spite of the importance of clinical practice in preparing nursing students for the work they do as practicing nurses after graduation, this study has shown that clinical practice inadequately prepared students for the nursing profession in selected institutions in Bangladesh. Development of clinical learning environment and individualized supervision is a way to ensure the clinical competencies of future nursing workforce. Therefore, appropriate policy and strategy needs to be undertaken by competent authority to improve the clinical learning environment for effective clinical learning of the nursing students.

Acknowledgments

I would like to acknowledge all the students who took part in the study and shared their experiences, opinions and perceptions by giving their time to provide the information. I also acknowledge the contribution of Professor Chung Yale Lee and Mr. Hasan who shared their expertise, valuable suggestion, and advice to do the analysis.

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