Student-Related Factors that Affect Effective Clinical Learner Support among Nursing Students in the Middle-Level Colleges in Nairobi County, Kenya ()
1. Introduction
In nursing education, clinical learning carries a large proportion of the curriculum that is carried out in a complex environment. Therefore, it is very important to identify challenges faced by students in clinical areas that negatively impact their growth and development of their nursing skills [1]. Effective clinical learner support is a compulsory requirement for nursing students in their training. However, many students report most of the challenges in these areas since they have to follow several policies and requirements in clinical settings. Clinical placements in Tanzania often fail to provide adequate opportunities for effective learner support, connecting this to the shortage of nurse tutors in clinical areas [2].
In the Kenyan context, some minimal improvement has been shown in the public/county nurse training facilities following the devolution of health care services in the year 2013. These include enhancing learner support of the student nurses by having training designed to support problem-based learning, trainees’ characteristics that portray positive characteristics, team-based coaching focus on results attainment and devolution of resources [3]. Despite some reasonable progress made towards promoting student nurses’ clinical learner support by different countries, when it comes to capacity issues in the nursing training institutions documented globally in both public and private healthcare sectors, there is still a lot more expected towards achieving quality in the trainees [4].
Gender issues in the nursing profession whereby some communities link the profession to feminine and this leads to stigmatization of the male students who choose to pursue a career that is strictly linked with femininity, affecting the male gender students’ clinical learning negatively [5].
Lack of finances and other social issues for nursing students affect effective clinical learning because these create psychological problems. Parent’s economic status affects clinical practice because lack of money causes the inability to afford payment for placement site fees, cater for learning materials, transport and other personal needs, including school fees [2]. In a study by [6], it was found that other student-related factors that include age, previous learning experiences, anxiety that comes with making a mistake leading to patient demise or complications and conflicts with relatives make it difficult for the learner to transition from one stage to another.
Challenges to effective clinical learner support among nursing students have closely been linked to poor communication with clients/colleagues and other team members in the clinical areas [7]. In the study by [8] noted that students’ attitudes are a hindrance to critical thinking, which is key to effective clinical learner support. Most of the students are resistant to competency-based or learner-centered methods but prefer the faculty to deliver the contents that make it easier for memorization and challenging in practice application.
It is, therefore, fundamental that the student-related factors are studied to determine how they affect effective clinical learner support among nursing students. The study was designed to determine the existing frequency, patterns, and background of student-related factors that affect effective clinical learner support among students in middle-level colleges in Nairobi County, Kenya.
2. Materials and Methodology
2.1. Area of Study
Figure 1. Map of Nairobi County, Kenya.
Table 1. Distribution of 12-middle-level nursing institutions.
No. |
Name of the Nursing School |
Sub-county |
1 |
Catherine McAuley Nursing School |
Starehe |
2 |
Amref Nursing School |
Langata |
3 |
Pumwani School of Nursing |
Kamukunji |
4 |
Gertrude’s Children’s Hospital School of Nursing |
Westlands |
5 |
Nairobi Women’s Hospital College |
Dagoretti North |
6 |
Mathare Mental and Teaching Nursing School |
Kasarani |
7 |
St. Francis Kasarani Nursing |
8 |
KNH Nursing School |
Kibra |
9 |
Kenya Medical Training College |
10 |
Armed Forces Nursing Training School |
11 |
Cicely McDonell College of Health Sciences |
12 |
Karen Medical Training College |
The gathered data for this study purposely targeted Nairobi County, Kenya. Figure 1 is the map for the study area. Nairobi County was the preferred area of study because of its high population, which infers the study area needs quality clinical and nursing services. Secondly, the study area is the capital city of Kenya, so there is a need to determine the effectiveness of clinical learning for nurses. In Nairobi County, there are twelve (12) clusters of middle-level nursing training institutions. These institutions are spread across the seventeen sub-counties of Nairobi. The study area categorized the twelve clusters of middle-level nursing training institutions into the following seven sub-counties: Starehe, Langata, Kamukunji, Westlands, Dagorett North, Kasarani, and Kibra. The twelve middle-level nursing training institutions considered in this study are Catherine McAuley Nursing School, Amref Nursing School, Armed Forces Nursing School, Pumwani School of Nursing and Midwifery, Cicely McDonell College of Health Sciences, Karen Medical Training College, Gertrude’s Children’s Hospital School of Nursing, Nairobi Women’s Hospital College, Mathare Mental and Teaching Nursing School, St. Francis Kasarani Nursing School, Kenya Medical Training College—Nairobi Campus, Kenyatta National Hospital Nursing School and Nairobi West College of Health Sciences. Table 1 highlights the distribution of the twelve middle-level nursing training institutions based on sub-counties in Nairobi County.
2.2. Data Collection
The study employed a descriptive survey and Focus Group Discussion to collect data from the participants. A sample size of 394 participants was selected using simple random and stratified sampling techniques. The sample size was drawn from the twelve middle-level nursing training institutions based on Probability Proportional to Size (PPS). The distribution of the sample size for the study is presented in Table 2.
The sample size for this study was determined by [9] formula based on the target population size of 3368. Since the population size was known, the sample size was derived as follows:
where: n was the sample size to be determined;
N is the population as given in the sample frame (3368);
e is the sampling error (0.05).
The sample size based on the known population gave n = 357.54 participants. To cater for non-response, this sample size was adjusted by 10% non-response to a sample size of 357.54 × 1.1 = 393.3, which was rounded up to the nearest person n = 394.
Table 2. Distribution of sample size.
Name of Institution |
Number of Students |
Sample proportion |
Sample size by institution |
Cluster 1: Private institutions |
|
|
|
Catherine McAuley Nursing School |
217 |
6.4% |
26 |
St. Francis Kasarani Nursing School |
120 |
3.6% |
14 |
Amref Nursing School |
600 |
17.8% |
70 |
Cicely McDonell College of Health Sciences |
240 |
7.1% |
28 |
Karen Medical Training College |
110 |
3.2% |
13 |
Gertrude’s Children’s Hospital School of Nursing |
38 |
1.1% |
4 |
Nairobi Women’s Hospital College of Health Sciences |
68 |
2.0% |
8 |
Sample frame 1—Private institution cluster |
1393 |
41.4% |
164 |
Cluster 2: Public institutions |
|
|
|
Kenya Medical Training—Mathare Campus |
360 |
10.7% |
42 |
Kenya Medical Training College—Nairobi Campus |
1200 |
35.6% |
140 |
KNH Nursing School |
280 |
8.3% |
33 |
Armed Forces Nursing Training School |
80 |
2.4% |
9 |
Pumwani School Midwifery and Nursing |
55 |
1.6% |
6 |
Sample frame 2—public institution cluster |
1975 |
58.6% |
230 |
Total |
3368 |
|
394 |
The study established eleven Focus Groups Discussions, and the survey tool was administered in all institutions in which more than 10 students were sampled. FGDs are composed of 8 - 10 participants each except for where the total sample size in an institution was less than this number and where all students sampled were engaged. Table 3 shares the distribution of those FGDs among the targeted middle-level nursing training institutions.
Table 3. Distribution of survey participants and Focus Group Discussion.
Name of Institution |
Sample size by institution |
Survey participants |
FGD |
Cluster 1: Private/Faith-Based Institutions |
|
|
|
Catherine McAuley Nursing School |
26 |
10 |
2 (8pax) |
St. Francis Kasarani Nursing School |
14 |
14 |
- |
Amref Nursing School |
70 |
50 |
2 (10pax) |
Cicely McDonell College of Health Sciences |
28 |
28 |
- |
Karen Medical Training College |
13 |
13 |
- |
Gertrude’s Children’s Hospital School of Nursing |
4 |
- |
1 (4pax) |
Nairobi Women’s Hospital College of Health Sciences |
8 |
- |
1 (8pax) |
Sample frame 1—Private/Faith-based institution cluster |
164 |
115 |
48 |
Cluster 2: Public Institutions |
|
|
|
Kenya Medical Training Institute—Mathare Campus |
42 |
34 |
1 (8pax) |
Kenya Medical Training College—Nairobi Campus |
140 |
124 |
2 (8pax) |
KNH Nursing School |
33 |
33 |
- |
Armed Forces Nursing Training School |
9 |
- |
1 (9pax) |
Pumwani School Midwifery and Nursing |
6 |
- |
1 (6pax) |
Sample frame 2—public institution cluster |
230 |
191 |
11 FGD |
2.3. Data Analysis
The data gathered from the participants was cleaned and entered into Excel and SPSS software based on the responses of each respondent. Variables of data entered into the SPSS software are gender, marital status, age, level of study, religion, student decision to pursue nursing, skills lab simulations affect the quality of clinical support, assigned preceptors in the clinical area, students are allowed to make mistakes in the clinical area, students are always supposed to work under supervision, meeting of the training costs, family structure, motivation for a student to pursue a nursing career, and means of transport to the clinical area.
Data on student-related factors affecting effective clinical learner support were subjected to analysis using SPSS, data analysis software. Chi-square analysis was performed to determine the degree of several associations considered in this study at a significance level of p = 0.01.
3. Results
3.1. Demographics
The response rate for the study was 98%, with 380 respondents successfully participating out of the study sample size of 394. Table 4 and Figure 2 present the social-demographics of the participants in the study, and based on the analysis, the majority of the participants were female, Christian, 21 - 30 years old, second year of study, and had basic diplomas.
Table 4. Socio-demographics characteristics of the participants.
Category |
Variable |
Frequency |
Percentage |
Gender of participant |
Female |
219 |
58% |
Male |
127 |
33% |
Other Sexual Groups |
34 |
9% |
Age |
<20 |
54 |
14% |
21 - 30 |
253 |
67% |
>30 |
73 |
19% |
Marital status |
Single |
145 |
38% |
Married |
127 |
33% |
Separated |
54 |
14% |
Others |
54 |
14% |
Religion |
Christian |
326 |
86% |
Muslim |
54 |
14% |
Level of study |
Higher diploma |
145 |
38% |
Basic diploma |
235 |
62% |
Year of study |
First |
108 |
28% |
Second |
199 |
52% |
Third |
73 |
19% |
Figure 2. Socio-demographics.
On cross-tabulation of demographic results with effective clinical learner support, it was found that the gender of the participant was significantly associated with effective support. The female gender was more likely to learn effectively than the male and other sexual groups. All the other variables were not significant, as indicated in Table 5.
Table 5. Association degree between socio-demographics and level of effective clinical learning.
Variable |
Category |
Level of effective clinical learning |
df |
P value &
Chi-square |
Moderate |
High |
Sex of the participant |
Female |
34 |
185 |
2 |
P = 0.006 ꭓ2 = 10.40 |
Male |
38 |
89 |
Other Sexual Groups |
6 |
28 |
Age |
<20 |
10 |
44 |
2 |
P = 0.352 ꭓ2 = 10.40 |
21-30 |
57 |
196 |
>30 |
11 |
62 |
Marital status |
Single |
35 |
110 |
3 |
P = 0.453 ꭓ2 = 2.08 |
Married |
21 |
106 |
Separated |
10 |
44 |
Other |
12 |
42 |
Religion |
Christian |
66 |
260 |
1 |
P = 0.739 ꭓ2 = 0.111 |
Muslim |
12 |
42 |
Level of study |
Higher diploma |
35 |
110 |
1 |
P = 0.171 ꭓ2 = 1.875 |
Basic diploma |
43 |
192 |
Year of study |
First |
20 |
88 |
2 |
P = 0.352 ꭓ2 = 10.40 |
Second |
39 |
160 |
Third |
19 |
54 |
3.2. Student-Related Factors that Determine Effective Clinical Learner Support
All the students reported that they had chosen nursing as their career of choice. None were reported to have been influenced by family, friends or parents. However, 19.2% (n = 73) had consulted their parents for them to make an informed decision, with 80.8% (n = 307) made a personal choice. The findings indicated that the majority of students’ (66.6%, n = 253) clinical learner support was affected by skills lab simulations, they did not perfect the skill before proceeding to the clinical area, therefore, felt incompetent to learn the skills on real patients. However, in the clinical area, 81.1% (n = 308) reported that they had been allocated clinical mentors. Despite the allocation of the clinical mentors, some students had never seen or met their clinical mentors.
Since the clinical area is a learning site, 76.1% (n = 289) of the students reported having made mistakes while handling the patients. It was reported that the majority (85.8%, n = 326) of the students were working under supervision from a qualified nurse. During the clinical placement, the clinical site fee was catered for by students. Relatively, some students paid for the clinical area on their own, some were paid for by their parents and others by their guardians at 33.4% (n = 127), 33.4% (n = 127) and 33.2% (n = 126), respectively. The study found that the majority of the students (85.8%, n = 326) came from monogamous families.
The students reported being motivated to pursue the nursing profession so that they could work abroad, while others were motivated by the fact that after training, they would get a ready job market for themselves. The findings presented in Table 6 indicated that the nursing career pays well and has an employment guarantee, as indicated by 33.2% (n = 126) and 33.4% (n = 127), respectively. On the means of transport to the clinical area, the majority of the students (57.1%, n = 217) reported being dropped at the clinical site by the college bus, while others were either using public means (23.9%, n = 91) and motorbikes (18.9%, n = 72), respectively.
Table 6. Student-related factors.
Variable |
Category |
Frequency |
Percentage |
Do you consider nursing as your career of choice |
Yes |
380 |
100 |
What informed your decision to do nursing |
Parents decided |
73 |
19.2 |
Personal choice |
307 |
80.8 |
Skills lab simulations affect the learner support |
Yes |
253 |
66.6 |
No |
127 |
33.4 |
Students are assigned mentors/ preceptors while in the clinical area |
Yes |
308 |
81.1 |
No |
72 |
18.9 |
Students are allowed to make mistakes in clinical practice |
Yes |
289 |
76.1 |
No |
91 |
23.9 |
Students always work under supervision |
Yes |
326 |
85.8 |
No |
54 |
14.2 |
Who meets the training cost at the clinical area |
Individual student |
127 |
33.4 |
Parents |
127 |
33.4 |
Guardians |
126 |
33.2 |
Family structure |
Monogamous |
326 |
85.6 |
Polygamous |
54 |
14.2 |
What motivates the student to pursue nursing |
Better pay |
126 |
33.2 |
To work abroad |
54 |
14.2 |
To help people |
73 |
19.2 |
Job guaranteed |
127 |
33.4 |
Means of transport to clinical area |
College bus |
217 |
57.1 |
Public means |
91 |
23.9 |
Motorbikes |
72 |
18.9 |
On calculation of Chi-square test of independence, it was found that quality of skills lab simulations, students working under supervision, means of transport to clinical area site were significantly associated with effective clinical learner support at ꭓ2 (1, N = 380) = 14.68, p < 0.001, ꭓ2 (1, N = 380) = 22.07, p < 0.001, ꭓ2 (2, N = 380) = 8.14, p = 0.017 respectively. The other factors were not statistically significant, as shown in Table 7.
The significant factors: quality of skills lab simulations, students working under supervision, and means of transport to the clinical area after cross-tabulation were entered into a binary logistic regression, and the results are indicated in Table 8.
Table 7. Primary institution-related factors.
Variable |
Category |
Level of learner support |
df |
P value &
Chi-square |
Moderate |
High |
|
|
What informed student decision to do nursing |
Parents |
16 |
57 |
1 |
P = 0.743 ꭓ2 = 0.11 |
Personal choice |
62 |
25 |
Skills lab simulations affect the quality of clinical support |
No |
41 |
89 |
1 |
P < 0.001* ꭓ2 = 14.68 |
Yes |
37 |
213 |
Assigned preceptors in the clinical area |
No |
16 |
56 |
1 |
P = 0.692 ꭓ2 = 0.16 |
Yes |
62 |
246 |
Students are allowed to make mistakes in the clinical area |
No |
23 |
68 |
1 |
P = 0.198 ꭓ2 = 0.165 |
Yes |
55 |
234 |
Students are always supposed to work under supervision |
No |
24 |
30 |
1 |
P < 0.001* ꭓ2 = 22.07 |
Yes |
54 |
272 |
Who meets the training costs |
Individual |
21 |
106 |
2 |
P = 0.299 ꭓ2 = 2.42 |
Parents |
31 |
96 |
Guardians |
26 |
100 |
Family structure |
Monogamous |
68 |
258 |
1 |
P = 0.693 ꭓ2 = 0.16 |
Polygamous |
10 |
44 |
What motivates a student to do the nursing profession |
Better pay |
28 |
98 |
3 |
P = 0.399 ꭓ2 = 2.95 |
To work abroad |
10 |
|
To help people |
19 |
54 |
Employment guaranteed |
21 |
106 |
Means of transport to clinical area |
College bus |
37 |
181 |
2 |
P = 0.017* ꭓ2 = 8.14 |
Public matatu |
28 |
62 |
Motorbike |
13 |
59 |
Table 8. Placement-related factors.
Variable |
Category |
B |
Wald |
df |
Adjusted odds ratio AOR |
Lower boundary |
Upper boundary |
Gender |
Female |
1.774 |
7.90 |
1 |
5.89 |
1.71 |
20.29 |
Male |
1.935 |
5.49 |
1 |
6.92 |
1.37 |
34.90 |
Other Sexual Groups |
Reference category |
Quality of skills lab simulation affects clinical area learning |
No |
0.895 |
2.55 |
1 |
2.44 |
0.817 |
7.32 |
Yes |
Reference category |
Students always need supervision while working in the clinical area |
No |
2.47 |
28.92 |
1 |
11.89 |
4.82 |
29.32 |
Yes |
Reference category |
Means of transport to clinical area |
College bus |
−0.200 |
25.92 |
1 |
.82 |
.39 |
1.72 |
Public means |
0.082 |
0.04 |
1 |
1.09 |
.47 |
2.51 |
Motorbike |
Reference category |
From the above results, only the gender of the student, quality of skills lab simulation, and students always working under supervision were significant and were entered into multivariate logistic regression to adjust for confounding factors. After adjusting for confounding factors, only the gender of the student and the student always working under supervision were found to determine effective clinical learner support. The students who were supervised while practicing were 11.89 times more likely to learn effectively compared to those who were not supervised. The female gender was 5.89 times more likely to be supported in clinical areas than the male gender. During group discussion, a group member reported the following
“while working in the ward the patients are used to calling the nurse ladies ‘sister’ they fear calling the male nurse students, they only call them ‘daktari’ this mentality makes even the male nurses to feel like nursing is for ladies”.
(Participant 4, group 2)
This was supported by another participant in another group discussion who reported that
“…nursing is a ladies profession….according to the uniform nurses should be wearing nurse caps which cannot be worn by male nurses….”
(Participant 2, group 1)
4. Discussion
The study findings indicated that being supervised during their clinical practices improved their clinical learning. All the students reported that they had made personal choices to join the nursing profession, unlike in the previous study, where the students did not make individual choices and hence had challenges in clinical learning support. In the previous study, it was reported that it was important to carry out the interviews and select suitable candidates for nursing training. This selection should be utilized to examine the suitability of the nursing students during clinical learning and identify challenges that need to be worked on [10]. In another study, it was found that nursing students who had their nursing career chosen for by parents and their financial supporters had challenges in getting support in the clinical areas because of a lack of motivation [11].
In the current study, the female gender was associated with effective clinical learner support, this is congruent with the results previously reported by [5], who found that the nursing profession has suffered greatly from public stereotyping and being strictly linked with femininity and non-masculinity. In some countries, the male students who choose nursing as their career end up being stigmatized in the area of practice, which they term as feminine, hence affecting the male gender students’ clinical learning negatively [5]. In another study, it was found that gender tailoring by allocating students and mentors to the same gender category proved to increase learning experiences [8].
Socio-economic issues of nursing students affect effective clinical learner support and create psychological problems as well as social climate of the school is an important factor in enabling students’ effective learner support. Majority of nursing students agree that parent’s economic status affects clinical practice. Lack of money causes the inability to afford learning materials and other personal needs [2]. However, in the current study, socio-economic status of the parents or guardians was assessed and did not significantly affect the student’s clinical learning. During the students’ placement, the current study found that most of the parents paid placement fees together with the college fees, and then it became the responsibility of the college to pay the students for the clinical site fee. Now that the students were not involved directly with the payments, they were not psychologically tortured about the payments.
The current study also found that the students who were always supervised for their practice became more competent compared to those not supervised. During supervision, the mentor can correct the mentee and this improves their skills. Unlike where the students are not supervised, they learn through the trial and error method, and in this case, patient care is compromised, and it may take longer for the student to learn the right practices. Students are required to practice under supervision as this ensures both patient safety and effective clinical learning [12]. In another study, it was reported that the students who worked hand in hand with the mentors supervising them always became competent in the nursing practice [13].
5. Conclusions
The demographic characteristics for the study indicated that the majority of the students had a mean age of 23.49, with the majority aged between 20 to 30 years old. Among the students’ characteristics that were assessed, including gender, level of training, year of study and religion, only the gender of the student was found to significantly affect effective clinical learner support.
Chi-square analysis was done to determine the significant association between effective clinical learner support and the following factors: what the student considered to choose a nursing career, what informed their decision, how skills lab simulations affect their clinical learner support received from the mentors, level of supervision, training costs and who caters for the costs, their family structure and what motivates them to do nursing. Out of all these factors, only supervision of the students while practicing in the clinical area was found to significantly affect the effective clinical learner support. The students who were supervised gained more competencies compared to those who were not supervised.
This recommends sensitization through the community leaders, nurses, and senior secondary schools career day that either gender can practice as a nurse to mitigate the gender stigma that affects the morale of nursing students during clinical placements. Secondly, all the clinical practice site supervisors, clinical instructors, and faculty should ensure proper supervision for effective clinical learner support.
Further study needs to be conducted on students’ attitudes toward clinical learner support and other healthcare provision cadres to determine if the study will give the same results.
Acknowledgements
Special thanks to the students of the 12 middle-level nursing institutions in Nairobi County who volunteered information for the study. Thanks to my supervisors and the entire team of AMREF International University, Department of Public Health, for the technical and moral support.