Analysis of Nursing Students Learning Experiences in Clinical Practice: Literature Review

Abstract

Learning in the clinical practice is an important component of nursing education considering that nursing is practice-based profession. The importance of clinical practice cannot be overemphasized as it prepares nurses to become competent practitioners. The aim of this study is to investigate nursing students'learning experiences in clinical education. The objectives of the study are to assess effective learning in clinical learning environment. A review of literature was performed using electronic data bases of articles from 2003-2012 that were in English. The studies revealed that effective learning takes place in a clinical learning in clinical practice occurs if students are given opportunities to practice what they have learnt in the classroom and skills laboratory supervised and supported, provided with feedback in an environment where there is good interpersonal relationships and communication. There is a need to use strategies that facilitate learning in clinical practice in addition to creating a conducive clinical learning environment.

Full text

Analysis of Nursing Students Learning Experiences in Clinical
Practice: Literature Review
N. C. Kaphagawani1 and U. Useh 2
1Department of Nursing Sciences, School of Environmental and Health Sciences,
Faculty of Agriculture Science and Technology, North West University Mafikeng Campus
2School of Research and Postgraduate Studies, Faculty of Agriculture Science and Technology,
North West University Mafikeng Campus
E-mail: nanzenkaphagawani@yahoo.co.uk
KEYWORDS Learning. Clinical Learning Environment. Clinical Education. Experiential Learning. Student Nurse
ABSTRACT Learning in the clinical practice is an important component of nursing education considering that nursing is
practice-based profession. The importance of clinical practice cannot be overemphasized as it prepares nurses to become
competent practitioners. The aim of this study is to investigate nursing students‘ learning experiences in clinical education.
The objectives of the study are to assess effective learning in clinical learning environment. A review of literature was
performed using electronic data bases of articles from 2003-2012 that were in English. The studies revealed that effective
learning takes place in a clinical learning in clinical practice occurs if students are given opportunities to practice what
they have learnt in the classroom and skills laboratory supervised and supported, provided with feedback in an environment
where there is good interpersonal relationships and communication. There is a need to use strategies that facilitate learning
in clinical practice in addition to creating a conducive clinical learning environment.
INTRODUCTION
The aim of this study is to explore nursing
students learning experiences in the clinical prac-
tice. Learning in the clinical practice is an im-
portant component of nursing education consid-
ering that nursing is practice-based profession.
The quality of nurse education depends largely
on the quality of the clinical experience that stu-
dent nurses receive in the clinical environment
(Henderson et al. 2006). The clinical practice
takes place in a dynamic social complex envi-
ronment where patient care is provided as well
as students learning (Ip and Chan 2005). Stu-
dents’ experiences in a clinical learning environ-
ment may have profound impact on their learn-
ing whether positively or negatively. Experiences,
including application of theory to practice, ef-
fective mentoring and constructive feedback
positively influence learning (Ralph et al. 2009).
Nonetheless, poor relationships with clinical
staff, lack of support from educators and lack of
challenging learning opportunities are some of
the negative experiences that may affect students’
learning (Ip and Chan 2005). These experiences
may differ from one clinical learning environ-
ment to another as organization of clinical edu-
cation differs from place to place or country to
country.
The purpose of clinical practice has been il-
lustrated in literature (Elcigil and Sari 2007;
Mannix et al. 2006). Macfarlen et al. (2007) state
that clinical practice prepares nursing students
to become competent practitioners who will be
able to provide quality health care and promote
health of the people they serve (WHO 2005).
Apart from learning the skills, students are able
to experience the real world of nursing in addi-
tion to the responsibilities of the nurse and de-
velop interpersonal relationship with others
(Benner et al. 2009; Sharif et al. 2005). Clinical
practice allows students to become socialized
into the norms and culture of the nursing profes-
sion (Fitzgerald et al. 2011). This indicates the
importance of clinical practice in nursing educa-
tion. Therefore, learning in the clinical practice
should be effectively facilitated in order to ad-
equately prepare nursing students for the work
they do after qualifying.
Learning takes place when students apply
what they have learned in classroom situation and
practiced in a simulation laboratory into the re-
ality of nursing. Evidence from literature sug-
gest that there is a gap in integrating theory to
practice which has been of concern for a long
time in nursing education which have had an
impact on students learning in clinical skills (Ip
and Chan 2005; Sharif and Masoumi 2005; Kelly
2007; Longley et al. 2007). Students become
anxious and confused if they practice something
different from what they learnt in the classroom
(Sharif and Masoumi 2005). Such emotions in
© Kamla-Raj 2013 Ethno Med, 7(3): 181-185 (2013)

students in addition to learning on what may not
be ideal may negatively affect their performance
in the clinical learning
In order to become competent practitioner,
student nurses need to be guided and supervised.
Supervision of nursing students in clinical prac-
tice plays a significant role in nursing profession
as it has an influence on the students learning of
the knowledge and skills (Häggman-Laitila et al.
2007). Lack of supervision may lead nursing stu-
dents learning incorrect procedures as they lack
guidance become incompetent and lose interest
in nursing profession as they feel frustrated in
their work due to incompetence.
It is suggested that students have to be given
opportunities to practice different tasks to gain
confidence, become perfect and learn from the
mistakes they will make (Löfmark and Wikblad
2001). As much as this suggestion is ideal, the
number of students in the nursing colleges has
increased in such that students are not given ad-
equate opportunities to learn. The increase of
students’ numbers may lead to students not be-
ing competent to some tasks when completing
their training hence unable to provide quality care
(Heller et al. 2005).
Learning in clinical practice takes place if stu-
dents know what they are doing is right or wrong.
This is done through feedback that is provided
to students from clinical nurses. Mentors, pre-
ceptors and nurse educators during clinical learn-
ing (Clynes and Raftery 2008) Feedback helps
students to gain confidence as through feedback
students know their progress
Furthermore, good interpersonal relationship,
communication and support between staff and
students create a conducive environment which
is essential for students learning in the clinical
setting. Such behaviours reduce anxiety and fos-
ter socialisation process, confidence and self-
esteem thus promoting learning.
METHODS
A wide range of data search was conducted
by the authors to identify studies on nursing stu-
dents’ experiences of learning in the clinical prac-
tice. Electronic data research was done data en-
gines included; Academic research premier,
CINAHL, ERIC, Health source/ nursing/ aca-
demic edition, Master file premier, Medline,
Psych Articles and Psycinfo, thesis and disserta-
tions. The inclusion criteria were research articles
and reviews published in English in scholarly
peer reviewed journals with abstracts and full
texts published from 2003 to 2012. The search
included studies with all types of methods and
yielded 58 articles.
Review of literature was done by answering
the following question. What are the nursing stu-
dents‘ learning experiences in the clinical prac-
tice? Key words used in the search were: Learn-
ing, clinical practice, clinical education, clinical
learning environment, experiential learning and
student nurse.
RESULTS AND DISCUSSION
Despite a wealth of research on clinical edu-
cation learning in clinical practice is still a prob-
lem (Croxon and Maginnis 2008). The studies
had different purposes and used different meth-
ods making analysis and comparison difficult.
Nevertheless, findings from the studies provided
insight into the experiences of nursing students
learning in the clinical practice on what impacts
effective clinical learning.
Theory Practice Gap
The theory-practice gap has been described
as the disparity between what has been learnt in
the classroom setting and what is practiced in
the clinical environment. Evidence from litera-
ture suggest that there is a gap in integrating
theory to practice which has been source of con-
cern for a long time in nursing education. Ac-
cording to Sharif and Masoumi (2005) in Iran,
Elcigil and Sari (2007) in Turkey and Safadi et
al. (2012) in Jordan, students reported dispari-
ties between what was learnt in class and simu-
lation laboratory and the actual practice in clini-
cal practice. Theory forms a basis for learning
which students have to apply in the clinical prac-
tice in order to make meaning from the theory.
Conflicting practices between the ideal nursing
taught and that of clinical setting results in
students being confused, stressed and anxious
may indicate that students are not effectively
learning to prepare them for work they do after
qualifying (Evans and Kelly 2004; Sharif and
Masoumi 2005). Learning takes place when
students apply what they have learned in
classroom situation and practiced in a simulation
laboratory into the reality of nursing.
Several studies have illustrated measures to
try and close the theory-practice gap. Studies
suggest the use of pedagogical approaches such
N. C. KAPHAGAWANI AND U. USEH
182

as guided reflection and Problem Based Learn-
ing can close the gap (PBL) (Sharif and Masoumi
2005; Ehrenberg and Häggblom 2007; Dlamni
2011). PBL and Reflective process which focuses
on both cognitive and affective aspects allow stu-
dents to learn from their practice experience
through discussions and meetings with other stu-
dents under the guidance of the preceptor. Stu-
dents become independent self-learners thereby
developing the critical thinking and problem
solving skills (Ehrenberg and Häggblom 2007).
Task Involvement, Participation and
Opportunities for Learning
Learning also takes place if nursing students
are given the opportunity to practice real nurs-
ing by doing. Task participation can be referred
to as students offered opportunities to learn and
getting involved in providing holistic patient care
and not merely doing a list of tasks (Henderson
et al. 2012). Grealish and Ranse (2009) argue
that task participation and accomplishment fa-
cilitates learning than mere application of theory
to practice. However, if students are able to par-
ticipate and accomplish a task that is challeng-
ing then theory is been translated into practice
therefore, learning takes place.
Responses from students that they were do-
ing routine tasks and sometimes non-nursing
duties (Sharif and Masoumi 2005; Mntambo
2009; Hickey 2010) suggest lack of challenging
opportunities for students to be able to learn criti-
cal and clinical judgment skills. According to
Chuan and Barnett (2012) students reported a
variety of learning opportunities which facilitated
their learning. However, these learning opportu-
nities were compromised if there was increased
workload. This suggest that learning in the clini-
cal practice for student nurses to become com-
petent is depended on availability of challeng-
ing opportunities which encourages students to
ask questions and reflect on their experience
hence becoming critical thinkers and be able to
make clinical judgement.
Task participation and accomplishment facili-
tate learning as it leads to development of clini-
cal skill and confidence (Smedley and Morey
2009; Scully 2010; Henderson et al. 2012).
Clinical Supervision and Support
Clinical supervision is an important element
in facilitating learning in the clinical setting
(Hickey 2007; Saarikoski et al. 2007; Papas-
tavrou et al. 2010). Effective supervision by clini-
cal teachers in clinical environment is vital for
students learning (Papp 2003; Lambert and
Glecken 2005). Clinical nurse educators‘ role is
to enhance learning through provision of oppor-
tunities for learning. Supporting, guiding and
conducting timely and fair evaluations. However,
in the studies students felt that this role is not
fulfilled as clinical nurse educators take more a
role of evaluation than supervision which is
mainly done by nursing staff who lack teaching
experience and may not know the needs of the
students (Sharif and Masoumi 2005). In addi-
tion, heavy workload and attitudes of staff com-
promised supervision (Maben 2006; Chuan and
Barnett 2012). Clinical performance increases if
students are given necessary support in the clini-
cal environment (Elcigil and Sari 2007).
It was evident in the literature that there were
variations on supervisory models from country
to country for example a study conducted in Eu-
ropean countries (Warn et al. 2010) showed these
variations. Students are satisfied with regular
supervisory discussions and mentorship which
provide individualised supervision (Papastavrou
et al. 2010; Warn et al. 2010). Individualised
supervision facilitates learning on the premise
that one to one relationship with the mentor or
preceptor allows students to express about their
learning experiences and feelings in the practice
thus leading to self-confidence, promote role
socialization, professional development and in-
dependence thereby attain clinical competency
(Sharif and Masoumi 2005; Warne et al. 2005;
Papastavrou et al. 2007; Saarikoski 2007). Nev-
ertheless, it has also been reported that students
prefer group supervision and cluster facilitation
as it promotes their personal and professional
growth (Croxon and Maginnis 2009; Holmlun-
dum et al. 2010; Walker et al. 2012). This sug-
gests that students have different preferences in
clinical learning.
Apart from clinical supervision, the studies
have revealed peer support and social support as
a vital elements in facilitating students learning
(Kellys 2007; Roberts 2008). Students perform
better both academically and clinically if they
have social support from peers and significant
others (Ip and Chan 2005; Elcigil and Sari 2007).
According to Chuan and Barnett (2005) lack of
peer support in the clinical environment was
manifested by conflicts, tensions and competi-
ANALYSIS OF NURSING STUDENTS LEARNING EXPERIENCES IN CLINICAL PRACTICE 183

tions for opportunities for practice which is det-
rimental for learning. Students’ relationships are
important for learning. Students support each
other, discuss about their practice, share knowl-
edge, skills and experiences thus, being socialised
in the profession (Bourgeois et al. 2011).
Feedback
Feedback is a prerequisite for effective learn-
ing. Clynes and Raftery (2008) defines feedback
as a collaborative process of providing insight
to learners about their performance. Students
expressed concern that feedback was always
negative with poor communication or no feed-
back at all that lead them feeling demotivated
(Elcigil and Sari 2008).
Negative feedback with poor communication
and lack of it may have negative impact on learn-
ing. It is believed that when students know their
progress and deficiencies on their practice and
improve on the weaknesses, they get motivated
and become confidence hence optimizing learn-
ing, leading to growth (Clynes and Raftery 2008;
Komaratat and Oumtanne 2009). Feedback will
also assist students to reflect on their practice
thereby learning from experience.
Conducive Clinical learning environment
The clinical learning environment can influ-
ence nursing students learning positively or nega-
tively (Frankel 2009). A conducive clinical learn-
ing environment is one that is supportive with
good ward atmosphere and good relationships
and is perceived to produce positive learning
outcomes (Papp et al. 2003; Edwards et al. 2004).
An environment that positively influences learn-
ing have been reported as where staff are happy,
friendly with good morale and attitude, coopera-
tive and willing to teach and guide students pro-
vide quality patient care (Papp et al. 2003;
Edwards et al. 2004; Lewin 2006; Papastvrou et
al. 2010; Chuan and Barnett 2012). Students feel
confident and motivated to learn in an environ-
ment where they are respected. Recognized, sup-
ported and regarded as part of the team (Chesser-
Symith 2005; Ip and Chan 2005; Hickey 2007;
Kellys 2007; Levett-Jones and Lathlean 2008;
Henderson et al. 2010).
In contrast relationship problems have been
highlighted including staff being unfriendly, with
bad attitude, hostile and denying the students
opportunities to learn (Mntambo 2009; Cheraghi
et al. 2012) Poor relationship may lead to frus-
tration and demotivation thus, negatively affect-
ing students learning in acquisition of knowledge
and skills to become competent practitioners
CONCLUSION
There is evidence from literature that students’
experiences in the clinical practice can either
positively or negatively impact on their learn-
ing. The similarities and differences in the find-
ings of the studies have shown that clinical learn-
ing environments are unique which may be at-
tributed to differences in cultural, socio-eco-
nomic and political factors in addition to cur-
ricula and organization of clinical nursing edu-
cation. Therefore, research has to be conducted
to explore nursing students’ learning.in the clini-
cal practice across cultures in different countries.
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