INTRODUCTION:

Clinical education is an important part of nursing education. Clinical experiences provide students with the opportunity to apply knowledge from theory courses to supervised clinical situations¹. Nurses place value on clinical education because they believe it presents students with opportunities to apply what is learned in the classroom, expose students to various patient conditions, and present students with opportunities to learn organization and prioritization skills². A good relationship between the nurse, student, and faculty is essential for the most positive clinical experience.

The learning experience of students in the clinical setting can be impacted by several factors including the type of unit, clinical expectations, clinical supervisor, and clinical course³. Nursing students often first experience the healthcare work environment during clinical rotations.⁴ Clinical experiences are influenced by the staff, the instructor, the patient, and the unit.

Nursing staff had positive (enabling) and negative (hindering) effects on students' clinical learning⁵. Hostile or dismissive behavior from staff can make students disappointed in clinical experiences and can have a negative impact on patients³. This behavior may limit students' understanding of the patient situation or discourage them from asking questions. Learning environments where the staff is described as unresponsive or unreceptive to the students' needs were detrimental to the student’s learning experiences⁶. Students are often sensitive to the interactions between staff during their first clinical experiences.

Nurses in the clinical environment often work with students on multiple days of the week, have students of varying skill levels, and may work with a variety of students, instructors, and programs⁷. Nurses may be overwhelmed by nursing students, or they may be experiencing burnout. Students may have unrealistic expectations of the nurse. Nursing students may increase the workload of the nurse even when faculty are present. Nursing students are aware and respect that the nurses’ primary duties were related to patient care, but students also expect that the nurse facilitate and allocate time for talks, reflection, and guidance⁸. The nurse cares for multiple patients whereas the student is often focused on one patient. Beginning nursing students are often unfamiliar with the environment and the charting system. In addition, they are still learning assessment, nursing skills, communication, and medical conditions. Nurses may feel unprepared for teaching and the added time a student requires⁹.

There is also a lack of reward and recognition for nurses who work with nursing students⁹. Sometimes students may increase the workload of nurses. Nursing students may be slower at skills, may have questions or require assistance. Nursing tasks may take longer when helping a student. There may not be any compensation for a staff nurse when working with a student. Expectations may be unclear for students and nursing staff. However, nurses’ actions, attitude, and willingness to teach are influential factors on the experience of nursing students⁵.

Direct care nurses are often disrespectful toward nursing students¹⁰. Previous researchers have found that in many cases “nurses’ eat their young”¹¹. This may perpetuate a cycle. This type of negative nurse-student interaction hinders communication, leaving the student feeling intimidated and insecure which ultimately compromising quality client care. Students may choose to leave the nursing profession due the incivility that is experienced in the clinical setting¹². The students first experience in the hospital setting is often the most anxiety producing experience for them¹³.

Nurses' actions may have a negative effect on students including decreasing their confidence, learning and desire to continue in the profession⁵. Students’ experiences of negative or bad attitudes from the mentors can result in learning, however, including how to handle students when they become a practicing nurse⁸. Nurses may have little experience on the unit which can affect education and evaluation¹⁴. This could be related to new graduate nurses, nurses floating to the unit from another unit and travel nurses.

Conversely, nursing staff may be encouraging and excite students when they behave as positive mentors⁵. Nurses also have positive experiences with students who are motivated and committed⁹. Nursing students value feeling welcome and a student friendly environment⁵. Learning environments that included approachability, accessibility and caring by the faculty lead to more positive experiences⁶. Registered nurses who work with students cite an enhancement of their professional development as a benefit, but an increase of the demands on time and workload as a drawback¹⁵.

A good clinical experience can help promote student outcomes, critical thinking, communication, self-confidence and reduce anxiety and stress¹⁶. Students, nursing instructors and nurses need to be able to work together to provide care for patients. Each interaction with a nurse influences a nursing student’s perception of the experience, the unit, the facility, and nursing. Positive relationships and discussion in the clinical environment help motivate clinical learning¹⁷. Clinical experience is an integral part of nursing education as it allows students to transform theoretical knowledge into practice¹⁸. By evaluating what nursing students are experiencing, interventions can be determined to improve the experience for nursing students and nurses. The following research questions will be explored. What type of experience does the nursing student have during the clinical experience? Does the nursing student experience during clinical vary based on unit or shift?

METHODS:

Sample Information:

This study involved second semester nursing students in a small midwestern nursing program. This was a convenience sample to assess beginning medical/surgical clinical experiences of bachelor’s degree students. The students are primarily Caucasian females between the ages of 20 and 24. One male was eligible to participate. There were 28 potential participants. No specific demographics were obtained from the participants because of the homogeneity of the population. Demographics could have linked the surveys to a specific student.

IRB approval was granted through the university Institutional Review Board. Students were invited to participate in the research during class. Students were asked to complete the survey after their first four medical/surgical clinical experiences. Participation was voluntary and consent was implied by the student completing the questionnaire. Inclusion criteria included being a second semester nursing student completing medical-surgical clinical and the willingness to complete the survey.

Each clinical experience was set up similarly. Students provided total care to one patient during the 8.5-hour experience. Students could have a clinical on the acute care unit or the surgical unit. The first and fourth clinical was dayshift. The second and third clinical were evening shifts. The response rate was 35%. There were 39 responses from students out of a possible 112. Students were sent email reminders during the six weeks of the semester that these clinicals took place.

Instrumentation:

This study utilized the Nursing Student Perception of Civil and Uncivil Behaviors in the Clinical Learning Environment (NSPCUB). The instrument consisted of 12 questions. Four questions were reverse coded. Students’ self-reported on 12 statements regarding their clinical experience and the staff nurse/nursing student relationship. The student rated the statements strongly agree, disagree, agree, and strongly agree. The previous Cronbach’s ɑ was found to be .930⁴. The survey had been utilized in few other studies.

Procedures:

Students were informed of the study and asked to participate during class by reading a script. Each student was given four surveys with four return envelopes addressed to the investigator. Students had the opportunity to complete the survey during each of the first four medical/surgical clinical experiences. Surveys returned to the investigator’s mailbox. The researcher did not receive any completed surveys directly from students. The staff and preceptors at the clinical site were not aware of the research study. Permission was obtained from the authors of the NSPCUB to utilize the survey.

Data Analysis:

Data was analyzed using SPSS v27. This included frequencies, descriptive statistics, independent t-test and Anova tests. Reverse coding was done questions 3, 6, 7, and 9. Surveys included the number of the clinical experience, the unit, and the shift.

Table 1. Completion rates of survey

		Number of students Completing survey
Clinical	1st Clinical	10
	2nd Clinical	10
	3rd Clinical	9
	4th Clinical	10
Unit	Acute	25
	Surgical	14
Shift	Days	17
	Evenings	22

The data was found to be normally distributed by Q-Q plots. The Levene statistic was not varied. The data had a skewness of .378 and a Kurtosis of .741. The independent t-test and Anova was conducted to determine the significant mean difference between the shift and unit.

The original survey had three constructs, mutual respect, guided participation, and student centeredness. The mutual respect construct including “RN was approachable”, “RN was disrespectful to me”, “RN acknowledged by introduction.” and “RN embarrassed me in front of others”. The mutual respect construct had a Cronbach’s alpha of .637 in this study. The original study had a Cronbach’s alpha of .704 in regard to mutual respect. Guided participation included “RN included me in his or her decision-making process”, “RN invited me to actively participate in my patient’s care.”, “RN did patient care without including me.” and “RN talked about ways to improve my nursing care.”.

This study found the construct of guided participation to be .882 compared to .882 in the original study. Student centeredness included “RN ignored me during my clinical shift.”, “RN helped my anxieties”, “RN went out of his or her way to help me meet my learning needs.” and “RN encouraged me to ask questions.” The last construct, student centeredness, was found to have a Cronbach’s alpha of .912 which is comparable to the original study of .875. The overall Cronbach’s alpha for the original study and this small replication study was found to be .930. The Cronbach’s Alpha if the item was deleted ranged from .917 to .935. The three constructs were disregarded from the original scale as the Cronbach’s alpha was found high for the overall scale.

RESULT:

Overall, the students rated the clinical experience positively on both units and both shifts. Most questions had an average rating above 3. Four statements were rated below 3.00. This question included “RN included me in his or her nursing decision making process”, “RN helped calm my anxieties”, “RN went out of his or her way to help me meet my learning needs” and “RN talked to me about ways to improve my nursing care.”. These could be rated lower because these clinical experiences are faculty led. Students participate in preceptor led clinicals with nurses at the end of the semester. The instructor often passes medication and has the most interaction with the student during faculty led clinicals. Staffing may also play a role in this question. The nurses often had 5 or more patients and did not always have adequate support staff. The staffing ratios, patient census and other variables were not included in this study.

Table 2: Descriptive statistics of survey (Questions 3, 6, 7, and 9 are reversed coded)

	Minimum	Maximum	Mean	Standard Deviation
1. RN was approachable	2	4	3.5128	.64367
2. RN included me in his or her nursing decision making process	1	4	2.9744	1.03840
3. RN was disrespectful to me	3	4	3.7692	.42683
4. RN invited me to actively participate in my patient’s care	1	4	3.3333	.89834
5. RN acknowledged my introduction	1	4	3.4359	.75375
6. RN ignored me during my clinical shift.	1	4	3.1795	.91398
7. RN did patient care without including me	1	4	3.3077	.86310
8. RN helped calm my anxieties	1	4	2.8974	.96777
9. RN embarrassed me in front of others	3	4	3.8205	.38878
10. RN went out of his or her way to help me meet my learning needs.	1	4	2.9744	.93153
11. RN talked to me about ways to improve my nursing care	1	4	2.8974	1.04617
12. RN encouraged me to ask questions	1	4	3.1026	.88243

Question 3 “RN was disrespectful to me” and Question 9 “RN embarrassed me in front of others” were only rated by students as strongly disagree or disagree. The other two questions that were negative “RN ignored me during clinical shift” and “RN ignored me during my clinical shift” were rated strongly disagree, disagree, agree, and strongly agree. All other questions were rated on all categories except for “RN was approachable” which did not include strongly disagreeing as a rating.

There was one statistically significant finding. The ANOVA test was used to determine the mean significance difference between unit, shift, and clinical. The unit was significant for question 4, “RN invited me to actively participate in care.” The Acute unit mean was 3.56 and the Surgical mean was 2.92. This could be related to several factors. Surgical is a newly opened unit and has a higher number of travel nurses and new graduate nurses. The demographics of the nurse was not included in this study. This is similar to other studies that found that in some nurses taught students a lot and other nurses did not pay attention to students¹⁹.

Table 3. ANOVA Test between clinical number, unit and shift.

	Clinical	Unit	Shift
1. RN was approachable	0.465	0.081	0.492
2. RN included me in his or her nursing decision making process	0.273	0.701	0.652
3. RN was disrespectful to me	0.719	0.414	0.510
4. RN invited me to actively participate in my patient’s care	0.295	0.007	0.338
5. RN acknowledged my introduction	0.423	0.863	0.164
6. RN ignored me during my clinical shift.	0.791	0.194	0.159
7. RN did patient care without including me	0.648	0.756	0.487
8. RN helped calm my anxieties	0.216	0.626	0.629
9. RN embarrassed me in front of others	0.788	0.949	0.522
10. RN went out of his or her way to help me meet my learning needs.	0.231	0.898	0.898
11. RN talked to me about ways to improve my nursing care	0.167	0.152	0.530
12. RN encouraged me to ask questions	0.390	0.449	0.850

DISCUSSION:

Limitations of this study include the small sample size, the use of a convenience sample from one semester at one nursing program at a one clinical site. Specific demographics of age and gender were not collected. Specific demographic information could allow for identification of students. The study was initiated to see what students felt and experienced in the clinical setting in beginning medical/surgical clinical. No interventions were completed during the data collection to affect student perceptions. Each of the clinicals was faculty led which did lead to a more limited experience with the nurse. Specific information about the nurse the student interacted with was not collected. Factors such as experience and if the nurse was a traveler could impact the student experience. Specific data about the shift including the number of patients the nurse had or acuity of the patients was also not collected.

Future research could include the demographic of the nurse and factors of the unit such as staffing and acuity. This includes the experience of the nurse including the time as a nurse and on the unit. Several hospitals utilize travel nurses and their impact on students' experience has not been studied. Nursing students may have better or worse experiences with travel nurses. Often travel nurses are knowledgeable and experienced. Some have been at the clinical site for close to a year and some only stay for a 13-week contract. Medical-surgical units are often starting units for new graduate nurses. Newer nurses may remember what it is like to a nursing student but may be more stressed by having students. Experienced nurses may experience burnout.

Other factors of the clinical environment could influence the student experience including the number of patients the nurse has and the acuity of the patients. Overall staffing including the resource staff available such as aides can influence the experience. Different schools utilize this facility for clinical experience. The frequency of having a student was not included in this study which could also affect the student experience. Studies could also be expanded to include all clinical experiences in each semester of the nursing program.

CONCLUSION:

Overall, students had positive experiences during the clinical experience. This was a small single site study. The nursing student experience does vary by shift and unit but was only significantly significant for one question. The average rating for the student was 3.26 on a scale of 1 to 4. The student experience did not vary significantly based on shift. Only one statement did vary significantly on unit but was still rated high overall. More research needs to be done to evaluate the impact of the student-nurse relationship.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

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Received on 08.12.2021 Modified on 18.02.2022

Int. J. of Advances in Nur. Management. 2022; 10(4):307-311.

DOI: 10.52711/2454-2652.2022.00069