Received 21 September 2015; accepted 26 October 2015; published 29 October 2015

ABSTRACT

Clinical practice remains an integral part of nursing curriculum because clinical practice provides students with an opportunity to achieve professional competence. Creating a conducive learning environment for students is responsibility of academic staff, clinical nurses and students alike. However, studies in Malawi have reported poor clinical learning environment for students. This study therefore aimed at exploring nurses’ experiences of clinical teaching environment in Malawi. The study used a qualitative research design utilizing a descriptive phenomenological approach. Participants were randomly identified from teaching hospitals across Malawi by nursing managers to attend a six week clinical preceptorship training at one University nursing college. Immediately before commencement of the training, participants were invited to voluntarily participate in a focus group discussion pertaining to their experiences with clinical environment. We conducted focus group discussions with 9 trainees in 2013 and 12 trainees in 2014 training cohorts. Findings reveal that nurses meet a number of challenges in teaching students in the clinical area. Four themes emerged from the study, namely, inadequate faculty support, poor clinical teaching environment, poor competence among nurses and unsupportive working conditions. Nurses require support from academic staff and their managers to ensure a conducive clinical teaching environment.

Keywords:

Preceptors’ Experiences, Clinical Learning Environment, Clinical Teaching

1. Introduction

Nursing is a practice based profession. Nursing education aims to develop professional clinical competencies and to enhance the quality of nursing care [1] . Clinical practice therefore remains an integral part of nursing curriculum. Clinical practice provides nursing students with an opportunity to work with patients where they develop higher level of thinking skills in order to achieve professional competence. Clinical practice setting allows students to put into practice what they have learnt during theory. A positive and supportive clinical practice setting influences integration of theory and practice [2] .

Despite a debate on whether nursing educators are supposed to take up a clinical teaching role or an educationist orientation [3] [4] , in Malawi nursing educators are expected to take students through blocks of theory and practice and clinical teaching is one of their core roles [5] . However, Malawi experiences shortage of nursing educators and clinical nurses have become the main players in students’ clinical teaching [6] . This has resulted in a call for innovative approaches to clinical teaching and learning that will see clinical nurses effectively taking up the role of teaching students in the clinical area. Globally preceptorship model is extensively being used in nursing programs to facilitate clinical learning [7] . Students require adequate support, supervision, and teaching to facilitate achievement of learning during their clinical placement [8] . There is high evidence of effective learning when students are placed in clinical settings that encourage teaching and learning during care delivery [9] .

Students have reported attainment of appropriate competency, confidence and skills that equip them to function within dynamic and complex settings when their learning involves a preceptor [10] . Clinical preceptors become experienced nurses working right in the practice setting foster independence and developing skills, competencies and confidence among students. Literature has consistently recognized preceptorship as a strategy to maximize the benefits of clinical practice in terms of promoting professional socialization [11] . However, little is known about the nurses’ experiences with the clinical teaching environment. This study therefore aimed at exploring registered nurses’ experiences of clinical teaching environment in Malawi. Findings of the study are relevant for nursing training colleges and hospital nursing managers so that they can work together to maximize students’ clinical placements. Findings reveal gaps that exist for registered nurses to effectively support students’ clinical learning. Findings give a baseline for transformative nursing education initiatives that aim at improving the clinical teaching environment.

2. Methodology

This study used a qualitative research design along the principles of the descriptive phenomenological approach. Phenomenological research aims “to capture as closely as possible the way in which the phenomena is experienced” [12] . The study aimed at exploring registered nurses’ experiences of the clinical teaching environment in Malawi.

2.1. Participants

Thirty two registered nurses attended a six week clinical preceptorship training course in two cohorts at a public nursing University college in Malawi in 2013 and 2014. Participants for the study were drawn from 15 hospitals across the country where nursing students from various nursing colleges are allocated for clinical practice. The training participants were identified by their hospital nursing managers from various departments. Before commencement of the training participants were invited to voluntarily participate in a focus group discussion pertaining to their experiences of the clinical teaching environment in their respective clinical sites. A total of 21 nurses participated in the study. Nine out of 15 trainees participated during a 2013 cohort while 12 out of 17 participated during a 2014 cohort.

2.2. Data Collection

Two focus group discussions were separately conducted in 2013 and 2014. Focus group discussion was appropriate for the study because discussions provided preceptorship trainees with an opportunity to discuss their lived experiences of clinical teaching and clinical teaching environment. Researchers conducted the focus group discussions before participants commenced the training in order to have the preceptorship trainees’ real experiences that are not influenced by what they would learn during the training. Participants were briefed on the purpose and procedure of the discussion. Both focus group sessions were audio recorded after getting informed consent from participants. The focus group discussions took 45 minutes and 60 minutes for the first and second session respectively. Two general questions were used for the discussions “how is the learning environment for students at your clinical sites” and “what is your experiences teaching students in the clinical area?” Active listening, paraphrasing, reflecting and probing were used to facilitate the discussions.

2.3. Data Analysis

Data collection and analysis were done concurrently. Content analysis, a systematic coding and categorizing approach was used. The researchers listened to audio recorded discussions carefully and data was transcribed verbatim. Transcribed data was read repeatedly to gain a deeper sense of the content. Careful and repeated reading of transcribed text helped researchers to identify patterns and trends of participants’ responses. The researchers identified codes which were later categorized based on their similarities and differences. Finally the categories were grouped and four themes emerged.

2.4. Trustworthiness

The academic rigor of qualitative research is extremely significant. The trustworthiness of this study was ensured using two approaches. Firstly a “member checking” method was used. The researchers contacted five of the participants to verify and confirm the authenticity of the results. The researchers shared the summary of data analysis and results with five participants to check whether the developed concepts really reflected the insights and ideas that were discussed during the focus group discussions [13] . Secondly “peer checking” was used to check the credibility of the data analysis. Two academic members of staff were independently requested to identify concepts and codes from the data. These were compared with the researchers’ developed codes, categories and themes. Differences were adjusted and harmonized through a discussion.

2.5. Ethical Issues

The study was done as part of a larger doctorate study titled “A critical analysis of strategies aimed at improving nursing education in Malawi” whose approval was granted by Humanities and Social Sciences Research Ethics Committee of the University of KwaZulu Natal (HSS/0986/012D) and the National Health Sciences Ethics committee of the Ministry of Health in Malawi (NHSRC # 1154). During the entire research process consideration was given to non-coercion, informed consent, participants’ anonymity, freedom of participants to withdraw anytime they so wish to without being penalized. Participants were reassured that their responses would be kept confidential and their identities would not be revealed in research reports and publications.

3. Results

3.1. Demographics Characteristics of Participants

The sample consisted of 9 registered nurses in 2013 and 12 registered nurses in 2014. The study had a total of 6 males and 15 females. Majority of the participants were aged between 31 - 40 years. There were 8 registered nurses from central hospitals, 11 from district hospitals and 2 from health centres. All participants had more than 3 years of service except one who had less than 3 years of service. All participants were holders of a bachelor’s degree in nursing except for one who had a diploma in nursing.

3.2. Emerging Themes

The study findings show that registered nurses experience various challenges in training students in the clinical setting. Findings reveal that registered nurses performance in training students is affected by various that include lack of resources, poor support from academic staff, overcrowding of student and general poor working conditions. The findings of the study have been presented under four major themes; inadequate faculty support, poor clinical teaching environment, poor competences among nurses and unsupportive working conditions.

3.2.1. Inadequate Faculty Support

The study reveals that there is poor support from academic staff. Majority of the participants expressed dissatisfaction with support they receive from faculty members. Participants reported that more often students come to the clinical area unaccompanied by their college teachers. This usually leaves students with little idea of what they are supposed to do during clinical placements. Participants noted that the college teachers’ visits to the clinical area are usually infrequent. Participants said

“Students come to the clinical area without any accompaniment from their colleges… sometimes with poor or no communication about their coming”

“academic staff may come only for assessments”.

It was observed that many students report for clinical allocation without clinical objectives or personal objectives and goals. The training colleges inadequately prepare clinical nurses to receive and manage students. The participants’ excerpts include:

“the way students come for clinical allocation is as if their teachers did not know that students will be leaving for clinical practice at that time. Whether students leave the objectives by their own making… but their teachers could have made sure that before students come to clinical area, they should bring clinical objectives”.

Another participant emphasized the need for faculty to put clinical allocation requirements in order before students report for clinical placement. The participant stated:

“life becomes easy for clinical nurses if students bring their log books, clinical objectives, clinical diaries and possibly students clinical duty rosters. Personally when students come without clinical objectives I send them back to college to collect them from their teachers … am saying this because a nurse finds somewhere to start from when students know what they have come to do at that particular allocation … especially when they bring clinical objectives”.

Some participants indicated that they receive little guidance from faculty. They indicated that much as one might enjoy teaching students in the clinical area, little support and guidance frustrates them. One participant highlighted:

“… with the experience I have working with students, I don’t find it difficult to support students and facilitate their learning. The major problem is that the schools keep changing clinical plans without updating us or giving us adequate guidance … sometimes you look incompetent when you demand something from students and they tell you that that’s not what we are supposed to do. Honestly speaking it could be very satisfying if the colleges could give us advance guidance before students report for clinical practice”.

Another added:

“College staff should not just dump student at the clinical area. They should at least follow them up to check if they are doing what they are supposed to do. I need to say this because how do they expect them to evaluate students if the surely don’t follow and teach them regularly?” … I have personally participated in students’ evaluation with college staff who never followed the students. In such instances … they expect that you do all the students’ evaluation. Usually because we also come to work in shifts, you might have not worked with the students adequately”.

However participant also reported that some colleges provide the required support and guidance. Participants said:

“… some colleges give adequate attention to student’s clinical allocation … There is always a teacher coming with students when they are coming for the first time”.

“… colleges invite us for briefing before they send students to our clinical sites”.

These findings highlight the ineffective collaboration that exists between training institutions and clinical practice settings. Participants’ responses clearly indicate that the responsibility of training students in the clinical setting was supposed to be coordinated between the colleges and clinical setting.

3.2.2. Poor Clinical Teaching Environment

Findings of the study show that the clinical learning environment in most cases has not been to the expectation of the students and nurses themselves. The majority of participants reported lack of resources as a big problem for nurses to effectively teach student. A participant said:

“… our clinical area lacks appropriate resources for teaching students. Imagine even the mere gloves are an issue in the ward. How can students do some procedures without protecting themselves”.

Another participant agreed:

“there is too much improvising in most hospitals including my own hospital. Now what happens is that no matter how you want to teach students ideal things, you are left with no choice due to lack of resources. This issue of resources is getting out of hand. At my hospital we now ask nursing colleges to provide students with basic clinical resources when coming for the placement”.

While the problem of resources is evident, inversely the number of students is also increasing. Participants pointed out that overcrowding of students is also another disturbing factor in the clinical environment. Participants’ excerpts included:

“We have too many students in a ward at the same time. Sometimes you find number of students to be double the number of patients in your ward. … for example 23 students taking care of 15 patients. Students self interest to learn becomes important during this situation. Other students leave the allocation with very little learnt due to overcrowding”.

“… nursing colleges don’t lease with each other. You find five colleges sending so many students at the same time. This really causes overcrowding and it’s stressful for a preceptor to deal with so many students at the same time.

Generally participants agreed that the clinical learning environment is a responsibility of the clinical nurses, the college teaching staff and the students themselves. Some participants reported:

“Sometimes you meet students who are unrespectful and rude to clinical staff. Usually this type of students is not motivated to learn. With too much students in the ward, one can simply just ignore these students. However because it’s our responsibility to make these students to become real nurses you try your best to deal with such students and it becomes stressing and demanding”.

Findings show that the nurses also contribute to poor clinical environment. Participants reported that there are some nurses who just expect students to work as their pair of hands. They stated that they don’t give students time to learn but to work. Participants highlighted that nurses are also not receptive of the students in the sites. Some sentiments included:

“… some nurses have show negative attitudes to students … in such cases students don’t feel welcomed to a ward and they are not free to ask where they need help”.

3.2.3. Poor Competences among Nurses

Participants highlighted the need for continuous professional development among clinical nurses who support student learning. They felt that nurses working in teaching hospitals should be clinically competent in order to impart appropriate skills to students. The majority reported:

“… how do you teach students things you are not competent yourself”.

“Honestly speaking sometimes I don’t feel confident to support students in a certain skills or procedure”. “The majority of nurses are used to shortcuts, and you can’t teach students short cuts”. What is important I think is that if you think you are not competent to do a procedure which most nurses or even preceptors do, you should be honest with the student and refer them to someone else who could appropriately do that procedure. Unfortunately most of us don’t want to look little before students”.

The discussion about competency among nurses continued:

“I like the discussion because we are really honest with each other here … personally I have met students who were taught a procedure wrongly. It was really embarrassing for me because I confronted the student that this is not the way we do this procedure. Unfortunately the student expressed with confidence … that it was how one nurse taught him the skill. At that point I realized that I needed to appropriately correct what the student was taught without degrading my fellow nurse who taught the student. … So allow me to repeat what others already said that if you think you can’t do something … refer the student to another person”.

Findings reveal that not only are skill competences lacking among nurses but also skills to teach students. Participants reported:

“… nurses shout to students at the bedside wit patients listening. This reduces the student’s confidence to approach the patient with another procedure”.

“… when students observe that the nurses are not approachable, they rather choose to consult each other for learning. In some instances they might not teach other correct things”.

Findings reveal that nurses might be knowledgeable of clinical skills and procedures but not how to handle students. Knowledge of handling student in the clinical area is critical in creating a conducive learning environment.

3.2.4. Unsupportive Working Conditions

The study shows that the majority of the participants are dissatisfied with the conditions in which they work and operate. Frequently cited issues include shortage of staff and work overload. Common reports include:

“… in our ward we agreed to seriously make a difference in teaching students. This is part of objectives for all nurses there. Unfortunately, no matter how interested you could be to help students … there are just too many tasks to be done by the same people. We were expecting that if you are assigned to facilitate students clinical teaching, the matron will take away some of your daily routines. But that’s not the case. You find yourself still doing almost everything that you usually do”.

“I was assigned to coordinate student teaching, and everybody in the ward expects me to be engaged with students all the time. … as a preceptor will I not be relieved of some of the daily tasks then? Therefore you find that the highly overloaded tasks that I perform deny me and my fellow nurses time to interact with students”.

“… My friends would agree with me that sometimes our ward could be very busy and leaves students to be my last priority”.

Findings also show that participants are demotivated and stressed by lack of clear role expectations by their unit managers. One participant indicated:

“I was nominated by my unit manager to come and do this training. However her expectations on my daily program might not change. My engagement in daily meetings and other assignments do not give me an opportunity to teach students. Allow me to give you an example of my friend who came for the first training here. Since she came back I can assure you that she only interacted with students less than a week in three months. She is always up and down in workshops and meeting sent by the same manager who identified her to take up the preceptorship role”.

Another participant said:

“We are not saying we should stop attending meetings, or be relieved of our daily tasks, but there should be clear expectations of our role. Teaching students should be part of our performance evaluation. I was once shouted at by a manager that why did you not do this and that…. The manager clearly told me that teaching students is not your primary role….She said so do your primary role first before you engage yourself in issues that will not contribute to your performance appraisal. I was disappointed and asked myself why am troubling myself”.

Findings show that nurse managers need to be briefed on roles of clinical preceptors in the clinical area in order to clarify role expectations and task distribution among nurses.

4. Discussion

Four major themes emerged from the results of this study. The themes have actually touched almost on all areas that need to support clinical learning among nursing students. These are the faculty role, the clinical learning environment, nurses’ clinical and teaching competences and nurses working conditions that included role expectations by their managers. Studies have highlighted that the preceptor role is highly satisfying, but also demanding [14] .

Registered nurses identified faculty support as paramount to their performance in teaching students. Lack of faculty support really demotivates preceptors [15] . Lack of guidance from faculty becomes stressful for preceptors. Faculty members should provide direction to the overall clinical learning. O’Driscoll et al. (2010) named lack of faculty support as deficit in leadership of practice learning. The presence of faculty to support clinical learning is not only good for the students and their preceptors but also give faculty a chance to appreciate reality of practice [16] . Not only is the need for faculty involvement in preceptorship in nursing been reported but the need to increase their involvement has also been highlighted in literature [17] .

Msiska, Smith [18] reported that students often complain of being used to cover shortage. This is true when students are not given adequate time to interact and learn from preceptors. Other studies have also agreed that high bed occupancy, shortage of staff and lack of resources exacerbate frustration and depression among nurses resulting into poor commitment and interest to spear time to teach students [19] . Preceptors expressed dissatisfaction with their inability to give students adequate engagement time. Registered nurses reported experiencing conflict between primary demands of providing patient care and performing of the preceptor role [15] . Findings clearly indicate that without proper planning and assignment of tasks within the ward, performing dual roles of both a practitioner and a preceptor could be stressful usually resulting into ineffective student teaching and supervision. The quality of clinical learning environment and the interactions between students and academic staff and preceptors directly impact on the acquisition of competences [20] . Croxon and Maginnis [21] highlighted that a constructive clinical learning environment with adequate opportunities for the development of confidence and competent is essential.

The role of clinical preceptors has universally been accepted as an approach to strengthen students’ clinical learning [22] . However more studies have also reported that being a registered nurse in itself is not adequate to teach students. [23] indicates that there is a general lack of competence among some registered nurses.

The dual role of being a preceptor and a care giver is described as a serious hindrance to the fulfilment of the preceptor role [24] . In a study to investigate nurses’ commitment in Finnish, findings showed that 85% of the respondents reported being committed to their profession. A number of factors tend to reduce nurses commitment and they include feeling that one’s work is not meaningful or important, low level of confluence, dissatisfaction with the ways one’s own abilities were being put into use, poor atmosphere at work and low quality of leadership. Preceptors would effectively discharge their role of preceptoring if nursing administrators also played their role. In view of this, preceptors would be relieved of some tasks to enable them provide an effective teaching role and student support [7] .

Budgen and Gamroth [25] identified poor working conditions leading into poor retention among preceptors in their wards. Unclear role description of preceptors affects their role performance [4] . Shortage of staff is forcing the same few nurses available in the wards to be prepared as preceptors. The findings of the study show that there is a higher preceptor ? student ratio than the ideal 1:10 ratio due to increased students’ enrollment in colleges. This is increasing burden on the nurses.

5. Study Limitations

Focus group discussions were done with nurses coming from different clinical settings. In as much as registered nurses reported similar experiences, focus group discussions with participants from the same clinical setting would be more representative of their clinical settings.

6. Recommendations

Experiences of registered nurses of clinical teaching environment would help in the provision of appropriate learning environment for students’ nurses. Registered nurses should be engaged in the improvement of clinical learning environment. Regular clinical learning and clinical teaching environment reviews should be conducted in an attempt to bring solutions to problems facing clinical environment. Clinical teaching is stressful for most registered nurses and appropriate support should be given to the nurses to maximize the benefits of students’ clinical practice.

7. Conclusion

The results of the study indicate that registered nurses meet a lot challenges in clinical teaching of students. Much as the primary role of nurses in the clinical area is care provision, they acknowledge that teaching students is also a necessary role. Findings show that working as a clinical teaching and working as a clinical nurse are both stressful and demanding due to the nature of the clinical environment. It is evident that clinical nurses require adequate support from both their managers and faculty staff. Infrequent interaction between clinical nurses and faculty staff during clinical teaching fosters a sense of demotivation and lack of recognition among nurses. Lack of competence to handle students among nurses affects their willingness to manage students. Provision of clinical resources and adjustment to workload could improve the role performance of nursing during clinical teaching of students.

Acknowledgements

We extend our gratitude to all who participated in the study.

Conflict of Interest

There is no conflict of interest for this study

Cite this paper

ThokozaniBvumbwe,AtupeleMalema,MepChipeta, (2015) Registered Nurses’ Experiences with Clinical Teaching Environment in Malawi. Open Journal of Nursing,05,927-934. doi: 10.4236/ojn.2015.510098

References

NOTES

^*Corresponding author.