UNDERGRADUATE NURSING STUDENTS’ EXPERIENCES OF

THEIR CLINICAL PRACTICE

Lily Lim

Master of Nursing

2013

Faculty of Medicine and Health Sciences

Faculty of Medicine and Health Sciences

UNDERGRADUATE NURSING STUDENTS’ EXPERIENCES OF THEIR

CLINICAL PRACTICE

LILY LIM

A thesis submitted in fulfillment of the requirements for the

Master of Nursing

Faculty of Medicine and Health Sciences

UNIVERSITI MALAYSIA SARAWAK

2013

PENGALAMAN KLINIKAL PELAJAR PRASISWAZAH KEJURURAWATAN

LILY LIM

Tesis yang dikemukakan untuk memenuhi keperluan

bagi Ijazah Sarjana (Kejururawatan)

Fakulti Perubatan dan Sains Kesihatan

UNIVERSITI MALAYSIA SARAWAK

2013

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ACKNOWLEDGEMENTS

I am indeed thankful to God for His constant love and mercy in my life and journey

through this study.

The completion of this study is only made possible with the important support of

many people who really spent so much of their time and patience to guide me in this

study. My heartfelt thanks go to principal supervisor, Associate Professor Dr.

Zabidah Putit and co-supervisor, Associate Professor Dr. Chang Ching Thon. Also

not forgetting Associate Professor Dr. Chang Kam Hock and Dr. Sidiah John Siop

who had contributed to guide me in my learning as a research student. My sincere

thanks also go to members in the UNIMAS Nursing Department who have given me

the emotional support which I really need in the course of writing this thesis. The

same goes to Madam Lee Na and Madam Roselind Leong, who had shared my joys

and frustrations, in the process of completing the thesis. I would also like to

acknowledge Madam Saptuyah Hj Baki for translating the abstract in this study.

Lastly, I would like to dedicate this thesis to my husband, Mr. Chia Chiau Kio, my

mother-in-law and my children, whose loves had sustained me through this journey.

Thank you for the great support, tolerance and sacrifices.

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ABSTRACT

This qualitative research explored the nursing students’ perception of their clinical

experiences on their posting at the Malaysian health care settings. Students’

expectation, feelings, challenging experiences related to work culture, knowledge

and skills in patient care, teaching learning supports, people interpersonal

relationship, students’ role and their coping mechanism in nursing were explored.

The data were collected from interviews using purposive sampling. The participants

were undergraduate nursing students who had their clinical postings at the hospitals

and clinics in Malaysia. Data were analysed and themes emerged to illustrate the

students’ clinical experiences.

The findings were categorized into three major themes that included: 1) “Gaining

insight into the hospital setting”; 2) “Challenges”; 3) “Coping mechanism”. These

themes were then further subcategorized for easy understanding. For example, the

subthemes for “Gaining insight into the hospital setting” included: the reality of the

ward; doing ward routine; and working with other categories of health staff. The

study also identified challenging clinical experiences that students faced. Challenges

included being labelled as “degree nursing students”, theory-practice gap, problems

related to insufficient clinical practices and supervision. The students were able to

use different coping mechanism such as internal and external motivation which led

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to gain confidence as they progressed in their learning. This study proposed practical

strategies to empower students in clinical learning and increase their self-esteem and

confidence. In order to improve quality of students’ clinical education, adequate and

effective work collaboration between nursing education and health care services are

recommended. Future research should look into other aspects of students’ clinical

experiences such as students’ teaching-learning support system and patients’

perception of the care services provided by the students.

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ABSTRAK

Penyelidikan kualitatif ini mengeksplorasi persepsi pelajar kejururawatan terhadap

pengalaman klinikal semasa penempatan di institusi kesihatan Malaysia. Konteks

persepsi termasuk; ekspetasi dan perasaan pelajar; pengalaman mencabar mereka

berkaitan dengan budaya kerja, pengetahuan dan kemahiran dalam penjagaan

pesakit; sokongan pembelajaran dan pengajaran; hubungan interpersonal; peranan

sebagai pelajar; dan “coping” mekanisma pelajar untuk mengatasi masalah dalam

bidang kejururawatan. Data telah dikumpul daripada temubual dengan peserta

menggunakan “purposive sampling”. Para peserta terdiri daripada pelajar ijazah

kejururawatan yang menjalani latihan amali mereka di hospital dan klinik dalam

Malaysia. Data yang diperolehi dianalisa dan tema terbentuk untuk menggambarkan

persepsi pengalaman klinikal pelajar dalam kajian ini.

Hasil kajian telah dikategorikan kepada tiga tema utama iaitu, 1) “Pengertian

mengenai persekitaran hospital" 2) "Cabaran", dan 3) “Coping” mekanisma. Tema-

tema ini kemudian disubkategori untuk mudah difahami. Contohnya, sub-tema untuk

“Pengertian mengenai persekitaran hospital" adalah seperti: mengenali keadaan

persekitaran wad yang sebenar; menjalankan kerja-kerja rutin di wad; dan bekerja

dengan kakitangan hospital yang lain. Kajian ini juga mengenalpasti pengalaman

klinikal yang mencabar di kalangan pelajar. Di antara sub-tema untuk “Cabaran”

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termasuk: 1) dilabel sebagai "pelajar jururawat berijazah", 2) wujud jurang di antara

teori dan praktikal, 3) praktis klinikal yang tidak mencukupi dan 4) kurang

pengawasan. Pelajar mempunyai “coping” mekanisma tersendiri seperti motivasi

“internal” dan “external” yang membantu mereka mendapat keyakinan diri di

sepanjang tempoh pembelajaran klinikal. Kajian ini mencadangkan beberapa strategi

untuk memperkasakan pelajar dalam pembelajaran klinikal dan meningkatkan

kendiri dan keyakinan mereka. Dalam usaha untuk meningkatkan kualiti pendidikan

klinikal pelajar, kerjasama yang padu di antara pendidik kejururawatan dan

pengamal perkhidmatan penjagaan kesihatan adalah disyorkan. Kajian masa depan

perlu memberi fokus kepada aspek-aspek lain seperti system sokongan pengajaran

dan pembelajaran dan persepsi pesakit terhadap perkhidmatan yang diberikan oleh

pelajar.

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TABLE OF CONTENTS

Acknowledgement i

Abstract ii

Abstrak iv

Table of Contents vi

List of Table xii

List of Figures xiii

Key to transcriptions xiv

CHAPTER 1: INTRODUCTION

1.0 Introduction to the chapter 1

1.1 The impetus to this study 1

1.1.1 Students’ experiences 2

1.1.2 Reflecting on my past experiences

in nursing as a nursing student 4

1.1.3 Reflecting on my past experiences in

nursing as a nursing staff 6

1.1.4 Reflecting on my past experiences in

nursing as a nursing instructor 7

1.2 Studies on nursing students’ clinical experiences 8

1. 3 Contexts of the study 10

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1.4 Problem Statement 12

1.5 Aim of the study 14

1.6 Research Question 14

1.7 Research Objectives 15

1.8 Significance of this study 15

1.9 Operational Definition of Terms 16

1.10 Organization of the thesis 16

CHAPTER 2: LITERATURE REVIEW

2.0 Introduction 18

2.1 Clinical education 18

2.2 Factors affecting students’ socialization 19

2.2.1 Students’ knowledge and skills in

patient care 20

2.2.2 Inadequate clinical practices 23

2.2.3 Clinical supervision 26

2.2.4 Clinical instructors’ and educators’

commitment 30

2.2.5 Communication and interpersonal

skills 35

2.2.6 Conducive learning environment 38

2.2.7 Theory-practice link 40

2.3 Coping strategies 44

viii

2.4 Summary 51

CHAPTER 3: METHODOLOGY

3.0 Introduction 53

3.1 Justification for using qualitative research

method 53

3.2 Sampling the study participants 55

3.3 Research ethics 56

3.4 Setting 58

3.5 Data collection 59

3.5.1 The interview question guideline 59

3.5.2 Interview process 60

3.6 Pilot study 63

3.7 Data analysis 64

3.7.1 Transcribing interview records and

sorting field notes 66

3.7.2 Coding and thematic analysis of data 67

3.8 Trustworthiness and authenticity of the study 76

3.8.1 Self awareness 77

3.8.2 The reflecting process 78

3.8.3 Internal coherence 79

3.9 Summary 81

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CHAPTER 4: STUDY FINDINGS

4.0 Introduction 83

4.1 The participants 83

4.2 Gaining insight into the clinical environment 83

4.2.1 The reality of the ward 84

4.2.2 Aware that patients were different 86

4.2.3 Doing ward routine 87

4.2.4 Working with other categories of health

staff 91

4.2.5 Working with other students 96

4.2.6 Learning by observing nurses’ and doctors’

behavior 98

4.2.7 Mixed feelings 99

4.2.7.1 Excitement 100

4.2.7.2 Anxiety 101

4.2.7.3 Fear 102

4.2.7.4 Stress 103

4.3 Challenges 104

4.3.1 Inadequate clinical practices 104

4.3.2 Inadequate clinical supervision 107

4.3.3 Perceived wrongly 108

4.3.4 Theory-practice gap 110

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4.4 Coping mechanism 112

4.4.1 Internal motivation 113

4.4.2 External motivation 114

4.4.3 Gaining confidence 120

4.5 Summary 121

CHAPTER 5: DISCUSSION AND RECOMENDATIONS

5.0 Introduction 123

5.1 Gaining insight into the clinical environment 123

5.1.1 Work based environment 124

5.1.2. Interpersonal relationship among

people at the work place 126

5.1.3 Inadequate knowledge and skill about

the nursing work 132

5.2 Challenges during clinical posting 135

5.2.1 Perceived wrongly 135

5.2.2 Inadequate clinical practices 137

5.2.3 Clinical supervision 139

5.2.4 Theory-practice gap 141

5.3 Coping mechanism 145

5.4 Summary of major findings of this study 147

5.5 Recommendations for the study 148

5.5.1 Nursing Education 148

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5.5.1.1 Role of the university 148

5.5.1.2 Collaboration between nursing

educators and clinical nurses 150

5.5.2 Future research 151

5.6 Limitation of the study 152

5.7 Conclusion 153

REFERENCES

Appendices

Appendix A Ethical clearance 173

Appendix B Information about the research study:

Undergraduate nursing students’ clinical experiences 174

Appendix C Informed consent form 177

Appendix D Consent to participate in this study 180

Appendix E Question guideline 182

xii

LIST OF TABLE

Table 3.1: Sample of coding for a transcript 69

xiii

LIST OF FIGURES

Figure 3.1: Sequence of data analysis 65

Figure 3.2: Sample of a category 72

Figure 3.3: Sample of a theme 73

Figure 3.4: Diagrammatic sample, code, category

and theme 74

Figure 3.5: Nursing students’ clinical experiences 122

xiv

KEY TO TRANSCRIPTIONS

Keys or

symbols

Meaning(s)

Name Pseudonyms are used for the study participants to

maintain confidentiality throughout the study.

Excerpt(s) The excerpts of the study participants are in the form of

words, phrases or sentences.

“Phrase” This symbol appeared in excerpts to represent students’

findings, and is written either in English or Bahasa

Malaysia language.

…//… This symbol in the excerpts indicates next event that are

stated by the same participants at different times during

interview.

… This symbol represents unrelated words, phrases or

sentence in the excerpts by the participants, and/or a pause

during interview.

[ ] This symbol refers to the third party mentioned in the

conversation.

(Zabidah, 2010)

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CHAPTER 1

INTRODUCTION

1.0 Introduction to the chapter

Section 1.1 in this chapter provides an introduction to the impetus of the study.

Section 1.2 provides information on nursing students’ clinical experiences in local

and foreign countries. Section 1.3 describes the context of the study. Section 1.4

states the problem statement, while Section 1.5 defines the aim of the study. This

is followed by section 1.6, the research question, Section 1.7, the research

objectives and the significance of the study in Section 1.8. Section 1.9 presents

the operational definition of terms found in the study, while Section 1.10

describes the organization of the thesis.

1.1 The impetus to this study

The impetus to this research began when I listened to the stories from two nursing

students about their experiences at a hospital. The students’ stories revealed that

they faced challenging learning experiences at the clinical area1. Clinical

experiences help students to become socialized into the nursing profession and

1 Clinical area refers to the health care setting, ward(s) in the hospital(s) or clinical

learning environment.

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the health-care system. Windsor (1987) found that the quality of clinical

experiences was affected by a variety of clinical opportunities to which the

students were exposed. The students can only learn when they are able to adapt to

their clinical experiences. As a clinical instructor2, I need to understand the

nursing students’ perception of their clinical experiences to improve their clinical

learning, and thus, this study was conducted.

1.1.1 Students’ experiences

The first incident was about student Liza. She encountered a problem with a

senior nurse when she was asked to accompany a ward staff to send a patient for a

right eye cataract for the first time. Liza was instructed to wait for the patient to

finish the operation. After the operation, a nurse asked Liza to escort the patient

to the toilet. On the way to the toilet, Liza met with a senior nurse. Liza was

reprimanded for sending the patient to the toilet right after the cataract operation.

The second incident was about student Aminah, a first year nursing student who

shared her experience in communicating with an ill and dying patient. Aminah

was asked to empty the urinary bag in that particular shift. When she entered the

patient’s room, she found a dyspnoeic, thin and pale looking old man who

2 Clinical instructor refers to clinical teachers or nursing educators from the university.

They teach the students on patient care and clinical skills in the university. They also

supervise the students when they are posted to the clinical area for learning.

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suffered from terminal illness. He was groaning in pain with each breath. He was

on oxygen therapy and was unable to talk. His relatives were not around at that

time. On seeing that the patient was so dyspnoeic, she recalled what she had

learnt about breathing exercise, so she told the patient to try and breathe in

deeply. The patient did not respond to her. Soon after that, Aminah had to leave

the room because a staff had called her to attend to another patient. Ten minutes

later, after Aminah had completed her task, she returned to monitor the patient’s

condition, but was horrified to find that the old man had died. Aminah felt very

bad and guilty because she had asked the patient to perform deep breathing

exercise without realizing that he was dying. She felt sad because she did not

know how to comfort her patient. She felt that she had failed as a nurse.

In the third incident, a patient’s relative reported to the students that her mother

had just undergone a major operation a day before, and had vomited. The

patient’s relative asked one of the students for help to clean her mother. The

student went to look for a trolley to prepare the requirements. However, they

returned to inform the patient’s relative that they could not clean the patient

because there was no trolley available at that moment.

Reflecting on the above stories as a clinical instructor, I wondered how each of

these nursing students felt or perceived the problem that they had encountered?

What did they think after those moments of encounters with the nursing staff,

patient and relative? How did they feel about their experiences? How did they

perceive the health care and teaching-learning support system during the clinical

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posting? What had they learnt from these incidents? Schon (1987) also challenged

teachers to reflect-in action and “move into the center of the learning situations,

into the center of their own doubts” (p. 83). Reflection began once the teacher

could recognise a problematic situation and think about the problem encountered

in a new way. It also involved the teacher asking and answering questions to find

out the meaning of a situation for her and to the students that he or she serves.

Reflecting on the above incidents also triggered me to recall my past experiences

as a nursing student, staff and teacher in the nursing profession.

1.1.2 Reflecting on my past experiences in nursing as a nursing student

I enrolled as a nursing student in the School of Paramedic, Kuching, Sarawak. As

a student, I obtained my clinical experiences through postings to various wards in

the hospital and community health clinics. I spent about 80 percent of my training

at the clinical areas. I remembered some of these clinical postings lasted two to

three months before we went back to study theory in the classroom.

During the initial clinical posting, I also faced many challenging clinical

experiences. I did not know how to communicate with patients, their relatives and

health care staff at the work place. Nursing students in other studies also reported

about experiencing interpersonal relationship problem with people at the clinical

area (Halarie, 2006; Higginson, 2006; Mackintosh, 2006; Bradbury-Jones,

Sambrook, & Irvine, 2007; Chou & Lee, 2007; Ranse & Grealish, 2007; Bowden,

2008; Cheraghi, Salasli, & Ahmadi, 2008). I took some time to adapt to the work

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culture, patients, health care staff and the learning environment. We had longer

clinical posting and the nurses in the ward were familiar with us and knew our

learning needs. They created learning opportunities for us to learn in patient care

activities, supervised, guided us, and discussed patient care with us. We learnt

from the nurses’ experiences. I remembered these nurses were efficient in their

work, established good rapport with patients, and were well versed with patients’

health needs and problems. They explained patients’ health conditions and

management, and helped us to link between theory and practice. They would also

allow us to perform patient care activities by ourselves once they assessed and

confirmed that we had reached the expected competency level. That had

significantly increased our self esteem and confidence in performing patient care.

There were studies which also reported about nursing students’ learning from

their clinical posting (Stockhausen & Sturt, 2005; Tsai & Tsai, 2005; Halse &

Hage, 2006; Henderson, Happell, & Martin, 2007; Wieland, Altmiller, Dorr, &

Wolf, 2007; Bowden, 2008; Cheraghi et al., 2008; Kerridge, 2008; Chan, So, &

Fong, 2009; Hung, Huang, & Lin, 2009; Levett-Jones, Lathlean, Higgins, &

Mcmillan, 2009). I felt I had closer work relationship with the staff compared to

the tutors in the school. I could still remember sharing clinical situations more

with the clinical staff than with the tutors. My tutors would come to visit us at the

clinical areas a few times in a year or whenever the needs arose. Usually, the

main objective for their visits was to discuss with the staff about the students’

learning outcomes during the clinical posting. Other than that, they would only

come when the ward staff informed them about students’ misconduct in the

clinical area.

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As time passed by, gradually I understood what it meant “to work as a nurse” and

developed a liking for nursing. I realized that learning to be a nurse is more than

learning the theory in patient care. It was also learning to develop the appropriate

attitude to provide safe care for the patients. I learnt to observe how the

experienced nurses performed their work. By engaging myself in clinical

practices on patient care, I learnt how to interact with the patients from different

walks of life. Through all these I learnt how to socialize with people and the work

environment. My clinical experiences at different postings were different from

each another. Although some of the experiences were difficult and challenging,

they were meaningful and contributed to my personal growth and professional

development. These experiences had provided a platform on which my nursing

career had developed and progressed until I become a nurse teacher today. There

are studies which reported that nursing students also gained confidence after a

period of time of learning in the clinical areas (Jackson & Mannix, 2001;

McVicar, 2003; Walsh & DeJoseph, 2003; White, 2003).

1.1.3 Reflecting on my past experiences in nursing as a nursing staff

As a staff, I realized that the nurse’ role was tougher than I had imagined. There

were more responsibilities and work challenges. My experience when I worked

with the nursing students was encouraging. Most of the students were quite

helpful and were willing to learn during their postings to my ward. These students

shared with me their learning problems and interesting clinical experiences. I also

learnt that it was important to know the students before I could help them with

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their learning needs. There are studies that reported that nursing students are keen

to learn during their clinical posting (Grindel, Bateman, Patsdaughter, Babington,

& Medici, 2001; Begley & Brady, 2002). However, there were also students who

were not interested in nursing, thus, did not adopt a positive attitude towards

learning. I had difficulty to manage these students during their clinical posting.

There are studies which also reported about nurses’ difficulty to work with the

nursing students (Grindel et al., 2001; Matsumura, Callister, Palmer, Cox, &

Larsen, 2004; Sharif & Masoumi, 2005; Hathorn, Machtmes, & Tillman, 2009).

1.1.4 Reflecting on my past experiences as a nursing instructor

When I worked as a clinical instructor in the same hospital that I was posted to as

a nursing student, I had the opportunities to observe the changes within the

hospital setting. I noticed that the clinical scenario was very different. The wards

were crowded with students from various government and private nursing

schools. At the same time, students from the post-basic nursing programme also

utilized the same wards for learning, and had created problem for nursing students

to obtain adequate practices in patient care.

As a clinical instructor, I observed that the students were usually busy and need to

complete the routine work in the ward during the shift duty. They faced learning

problems such as inadequate clinical practices in patient care, use of inappropriate

equipments in patient care and inadequate clinical supervision. At the same time,

I observed that most of the ward nurses were too busy with their work and could