Ebere Omeje

UGWU, STELLA NGOZIKA

PG/M.Sc/10/55080

NURSING STUDENTS’ PERCEPTIONS OF CLINICAL NURSING TRAINING IN SELECTED NURSING PROGRAMMES IN ENUGU STATE

DEPARTMENT OF NURSING SCIENCES

FACULTY OF HEALTH SCIENCES AND

TECHNOLOGY

Ebere Omeje Digitally Signed by: Content manager’s Name

DN : CN = Webmaster’s name

O= University of Nigeria, Nsukka

OU = Innovation Centre

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NURSING STUDENTS’ PERCEPTIONS OF CLINICAL NURSING TRAINING IN SELECTED NURSING PROGRAMMES IN ENUGU STATE

DEPARTMENT OF NURSING SCIENCES

HEALTH SCIENCES AND

Digitally Signed by: Content manager’s Name

DN : CN = Webmaster’s name

O= University of Nigeria, Nsukka

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NURSING STUDENTS’ PERCEPTIONS OF CLINICAL NURSING

TRAINING IN SELECTED NURSING PROGRAMMES IN ENUGU

STATE

BY

UGWU, STELLA NGOZIKA

PG/M.Sc/10/55080

DEPARTMENT OF NURSING SCIENCES,

FACULTY OF HEALTH SCIENCES AND TECHNOLOGY

UNIVERSITY OF NIGERIA ENUGU CAMPUS

SEPTEMBER, 2015.

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TITLE PAGE

NURSING STUDENTS’ PERCEPTIONS OF CLINICAL NURSING TRAINING

IN SELECTED NURSING PROGRAMMES IN ENUGU STATE

BY

UGWU, STELLA NGOZIKA

PG/M.Sc/10/55080

PRESENTED TO THE DEPARTMENT OF NURSING SCIENCES,

FACULTY OF HEALTH SCIENCES AND TECHNOLOGY

UNIVERSITY OF NIGERIA, ENUGU CAMPUS

IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD

MASTERS OF SCIENCE DEGREE (M.Sc.) IN NURSING SCIENCE

(NURSING EDUCATION)

SUPERVISOR: DR. (MRS) N.P. OGBONNAYA

SEPTEMBER, 2015.

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DEDICATION

This work is dedicated to God Almighty and my lovely husband.

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ACKNOWLEDGMENT

I humbly express my sincere gratitude to Almighty God for His Mercies,

guidance and protection throughout the period of this programme and for

the patience and strength granted to me to carry out this project.

My special thanks go to my supervisor, Dr. (Mrs) N.P. Ogbonnaya for her

motherly advice constructive criticisms, useful inputs and also for bringing

light to this work. I will ever remain grateful to her. I am equally grateful to

all the lecturers in the Department of Nursing Sciences, UNEC for their

efforts towards the successful completion of this programme, especially my

readers Dr. (Mrs) G. Madubuko and Dr. (Mrs) A. Chinwuba for their useful

corrections to this work.

I sincerely appreciate my lovely husband Engr. Ugwu Gabriel Onyeka for his

understanding, endurance, encouragement, moral and financial support

while this programme lasted, especially for his participation during the data

collection. I also thank the HOD, principals, nurse educators and students

of the schools of nursing and department of nursing sciences in Enugu

State for their cooperation when visited for data collection.

Finally, I express my profound gratitude to my typist Miss Nkechi Nwonyi

and her boss Mr. Azubuike Ezenta for their effort and contribution toward

the successful completion of this work.

I thank you all!

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TABLE OF CONTENTS

Page

Title - - - - - - - - - - - i

Approval - - - - - - - - - ii

Certification- - - - - - - - - - iii

Dedication - - - - - - - - - - iv

Acknowledgement - - - - - - - - - v

Table of Contents - - - - - - - - - vi

List of Tables - - - - - - - - - ix

List of Figures - - - - - - - - - x

Abstract - - - - - - - - - - xi

CHAPTER ONE: INTRODUCTION

Background to the Study - - - - - - - 1

Statement of the Problem - - - - - - - 4

Purpose of the Study - - - - - - - - 6

Objectives of the Study - - - - - - - - 6

Research Questions - - - - - - - - 6

Hypotheses - - - - - - - -- - - 7

Significance of the Study - - - - - - - 7

Scope of the Study - - - - - - - - 7

Operational Definition of Terms - - - - - - 8

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CHAPTER TWO: LITERATURE REVIEW

Literature Review - - - - - - - - - 9

Concept of Nursing Education - - - - - - - 9

Clinical Nursing Training - - - - - - - 13

Clinical Placement - - - - - - - - 17

Clinical Learning Environment- - - - - - - 24

Clinical Teaching - - - - - - - - - 24

Clinical Supervision - - - - - - - - 29

Clinical Evaluation - - - - - - - - 33

Concept of Perception - - - - - - - - 41

Theoretical Review - - - - - - - - 43

Empirical Studies- - - - - - - - - 46

Summary of Literature Review - - - - - - - 53

CHAPTER THREE: RESEARCH METHODS

Research Design - - - - - - - - - 55

Area of Study - - - - - - - - - 55

Population of Study - - - - - - - - 59

Sample - - - - - - - - - - - 59

Inclusion Criteria - - - - - - - - - 59

Sampling Procedure - - - - - - - - 60

Instrument for Data Collection - - - - - - - 60

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Validity of the Instrument - - - - - - - 60

Reliability of the Instrument - - - - - - - 61

Ethical Consideration - - - - - - - - 61

Procedure for Data Collection - - - - - - - 62

Method of Data Analysis - - - - - - - - 62

CHAPTER FOUR: PRESENTATION OF RESULTS

Demographic Characteristics of Respondents - - - - 64

Objectives - - - - - - - - - - 66

Test of Significance - -- - - - - - - 78

Summary of Findings - - - - - - - - 80

CHAPTER FIVE: DISCUSSION OF FINDINGS

Discussion of Major Findings - - - - - - - 83

Implications of the Study - - - - - - - 98

Limitations of the Study - - - - - - - - 100

Summary of the Study - - - - - - - - 101

Conclusion - - - - - - - - - - 102

Recommendations - - - - - - - - 103

Suggestions for Further Studies - - - - - - 104

REFERENCES - - - - - - - - - 105

APPENDICES - - - - - - - - - 115

Appendix 1: Perception of Clinical Nursing Training

Questionnaire - - - - - - 115

Appendix 2: Calculation of Reliability of Questionnaire - - 119

Appendix 3: Pearson Correlation Coefficient (R) for Questionnaire 120

Appendix 4: Correlations for Reliability of Instrument - - - 121

Appendix 5: Informed Consent - - - - - - 122

Appendix 6: Letter of Introduction - - - - - 123

Appendix 7: Administrative Permission of Research Work - - 124

Appendix 8: Ethical Clearance Certificate - - - - 125

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Appendix 9: Means and Standard Deviations of the 70 items of the

SPCNTQ - - - - - - - 126

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LIST OF TABLES

Page

Table 1: Demographic Characteristics of Respondents - 65

Table 2: Mean and standard deviation of nursing students’ opinion

of placement into the clinical setting/learning

environment with their ranking - - - 67

Table 3: Mean and standard deviation of nursing student’ view

about clinical teaching (Instruction) with their ranking 70

Table 4: Mean and standard deviation nursing students’ view

about clinical supervision with their ranking - - 72

Table 5: Mean and standard deviation nursing students’

perceptions of clinical evaluation with their ranking 74

Table 6: Adjusted mean scores and standard deviations for

nursing students’ perception of clinical training

for each subscale - - - - - - 76

Table 7: Showing differences in perceptions of clinical training

between university and hospital-based nursing

students - - - - - - - 77

Table 8: Showing differences in perceptions of clinical training

between male and female nursing students - 79

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LIST OF FIGURES

Page

Figure 1: James Gibson’s Ecological Perceptual Cycle 45

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ABSTRACT

This study is aimed at assessing the nursing students’ perceptions of clinical nursing training in selected nursing programmes in Enugu State. Five specific objectives and two null hypotheses were formulated to guide the study. Descriptive cross-section design was adopted. Purposive sampling technique was used to select the nursing programmes and the class level of the students. A total population of 442 nursing students was used for the study. A self-developed questionnaire in 4 point modified Likert type scale with reliability of 0.970 was used for data collection. The questionnaire was distributed to the students in the classroom setting with 99.77% return rate. Information derived from the questionnaire were subjected to descriptive and t-test statistics testing at 0.05 level of significance. Results were presented in Table as frequencies, percentages, means and standard deviations. Findings revealed that nursing students had positive perceptions in clinical placement, clinical teaching and clinical evaluation but revealed that the students showed negative perception in clinical supervision. There were significant differences in perception of clinical training between the university-based and hospital-based nursing students (P-value < 0.05). There was no significant difference in the perceptions of clinical training between the male and female nursing students (P-value > 0.05), but female nursing students showed negative perception in clinical supervision. It is therefore recommended that; enough clinical supervisors should be employed and equal attention should be given to both male and female students, the university-based and hospital-based nursing students during clinical training etc. Suggestions for further studies were also made.

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CHAPTER ONE

INTRODUCTION

Background to the study

Nursing education consists of acquisition of a body of knowledge that is

partly delivered in a classroom setting which forms the theoretical basis of

nursing knowledge, and an organized and supervised clinical training

experience that takes place in the clinical setting where the nurse-patient

relationship is experienced directly or indirectly (Sheriff & Masoumi, 2005).

Clinical nursing training is the most critical step in transforming nursing

education, because that is really at the heart of getting the nurse ready for

clinical setting; and for providing safe and excellent patients care. Students

must be offered clinical experiences that are of highest quality and of

interest.

Clinical nursing training provides a practical approach for training

prospective nursing students to acquire practical skills for practice as

nurses (Emerson, 2002). The heart and soul of nursing education is the

clinical practicum where nursing knowledge is shaped into professional

practice (Diekelmann, 2004). Thus, basic knowledge and skills; and the

ability to apply knowledge into the actual practice of nursing is developed

and inculcated into the student nurses during clinical training. Barnes,

Sutphen, Leonard and Day (2009) also stated that clinical nursing education

is a fundamental part of nursing education and forms more than half part of

nursing curriculum.

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Historically, clinical training is derived through training apprenticeships as

in the era of Florence Nightingale in which an aspiring student learns many

facts of the profession from the “Master”. Even before the days of Florence

Nightingale and continuing into this century, students have learned the

practice of nursing from family members while caring for the patients.

Therefore, the clinical setting remains the most effective caring situation for

demonstrating theoretical possibilities and transforming the novice to

beginning nurse (Karen, 2013). A study carried out at School of Nursing

Oakland University on “getting the most out of students’ clinical experience”

highlighted that student nurses are provided with several opportunities for

clinical experiences. The students argued that more can be learned in these

experiences than can be taught in classroom setting though both aspects

are important and designed to complement each other (Crotty, 2011). The

benefit of clinical nursing training in nursing education cannot be

overemphasized and this is achieved through clinical placement, teaching,

supervision and evaluation (Duteau, 2012).

During clinical placement, students are posted and rotated to different

clinical learning environments such as the outpatient department,

emergency units, clinical wards, other specialist units in the hospital, other

health care institutions, health centers and communities under the direction

and close supervision of experienced personnel in nursing profession. In the

clinical learning environment, student nurses are offered an opportunity to

work directly with competent professional nurses for patients in a particular

area of expertise. Teaching in clinical learning environment presents

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educators with challenges that are different from those encountered in the

classroom because clinical setting requires different approaches to teaching

(Benis, 2000). One crucial element in students’ clinical training is the

supervision system. For student nurses, supervision is a process where the

learner is guided and supported through clinical professional knowledge and

skill (United Kingdom for Central Council, 1995). The goal of supervision in

clinical environment is to ensure that student learning occurs and that

students are safe. Evaluation of clinical performances of the student nurses

is an integral part of all programmes in nursing profession. It also plays a

major role in the society by certifying competent nurse who can render

quality nursing care to the public. Clinical evaluation is a more formal

assessment of the students’ performances in the clinical nursing training

(Raisler, O’Grandy & Lori, 2003).

As a learner in the clinical environment, the student nurse is an embodied

spirit, a union of body and rational soul. His body experiences sensation

and feels pleasure and pain. His soul is a spiritual act, the source of

intellectual abstraction, self reflection and free rational volition (Balagot,

2012). He is the central focus in clinical nursing training therefore his

perceptions of the whole process need to be ascertained. Perception is an

individual’s awareness, insight and opinion about a situation. The nursing

students are also the customers and consumers in the clinical nursing

training. Their perception is a legitimate indicator of the quality of the

training. And their benefits from the training will depend on how they

perceive the clinical training experiences. If the students perceive the clinical

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nursing training as meaningful and helping, they will be motivated to learn

and the experiences will be beneficial. If they have low perception about

them, the reverse will be the case.

However, little has been done empirically on nursing students’ perceptions

of clinical nursing education in nursing training institutions in Nigeria. The

few published ones used only university-based student nurses and did not

include the hospital-based student nurses. Thus this study examined the

nursing students’ perceptions of clinical nursing training in selected nursing

programmes in Enugu State. It also exposed areas of the clinical training

that are deficient.

Statement of problem

From the international perspective, students’ instruction and supervision in

clinical setting appear to have been shifted to clinical nurses only (Neary,

2000). Nurses who lack fundamental skills in nursing research, academic

training and experiences in preceptor-ship and supervision still constitute

the large group of nurses who often hold functions as clinical instructors,

supervisors and evaluators. From the researcher’s observation in her areas

of study too, students are sometimes left in hands of any available nurse on

duty for supervision and teaching as opposed to sound selection criteria.

Nurse educators and clinical instructors sparingly go to the clinical

environments for teaching and supervision probably due to poor planning

and busy tight academic schedule. Such things confuse the students,

inhibit learning and make clinical training disjointed and laborious (Carr &

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Schoott, 2002). Consequently many students complain of one thing or the

other about their clinical training.

Furthermore, the nursing students as learners in the clinical learning

environment are the central focus and key players in clinical nursing

training and their perception is legitimate indicator of the quality of clinical

nursing training. But workplace incivility and aggression threaten the socio-

emotional and physical safety of student nurses in the clinical environment.

This was demonstrated by students who reported ostracizing, hostile and

dismissive behavior from staff (Anthony & Yastik, 2011). They further

reported that university-based student nurses felt particularly persecuted by

non university trained nurses who believed that university trained nurses

did not know much about real practical nursing. As a result, many students

reported an adverse impact on their future careers and employment

decision. The questions are: What are the nursing students’ perceptions of

their clinical nursing training? Was it high/positive, meaningful and helping

or was it low/negative and deficient? These are some fundamental questions

the researcher wants to address in the present study. In the light of the

current demand for measures of nursing students’ perceptions of clinical

nursing training and the scarcity of focused research in this area in Nigeria,

this study is both relevant and timely. All these prompted the researcher’s

desire to investigate the nursing students’ perceptions of clinical nursing

training in selected nursing programs in Enugu State.

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Purpose of the study

The purpose of this study is to determine the nursing students’ perceptions

of clinical nursing training in selected nursing programmes in Enugu State.

Specifically, the objectives are to:

1. Determine the nursing students’ opinion on their placement in the

clinical setting (clinical learning environment).

2. Ascertain the nursing students’ view about clinical teaching.

3. Ascertain the students’ view about clinical supervision.

4. Assess the students’ perception of clinical evaluation.

5. Determine the students’ overall perception of clinical nursing training.

Research questions

The following research questions were formulated as a guide to the

researcher.

1. What is the nursing students’ opinion of their placement in the

clinical setting/ learning environment?

2. How do the nursing students’ view their clinical teaching?

3. What is the students’ view about their clinical supervision?

4. How do the nursing students perceive their clinical evaluation?

5. What is the students’ overall perception of clinical nursing training?

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Research Hypotheses

Two null hypotheses were set for this study and they include:

H01: There is no significant difference in the nursing students’

perceptions of the clinical training between the university-based and

hospital-based nursing students.

H02: There is no significant difference in perceptions of clinical nursing

training based on gender.

Significance of the study

The findings will reveal the nursing students’ opinion on the different

aspects of their clinical training. It will be of great benefit to the student

nurses, nurse clinicians/administrators, nurse educators, clinical

instructors and supervisors, other health care professionals, hospital

management and policy makers. To the student nurses and other health

care professionals in the areas of study, the findings will be a source of

reference on students’ perceptions of clinical nursing training and could

stimulate further researches among interested individuals.

To the nurse clinical administrator, clinical instructors, supervisor, nurse

educators, hospital management and policy makers, the result of this study

will help them improve and strengthen the aspects of the clinical placement,

teaching, supervision and evaluation that are deficient

Scope of the study

The study is confined to the students of Schools of Nursing UNTH Enugu;

Bishop Shanahan Hospital Nsukka and Department of Nursing Sciences

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University of Nigeria Enugu Campus, all in Enugu State of Nigeria. The

study is also delimited to determining how the student nurses perceive their

clinical placement, teaching, supervision and evaluation.

Operational Definition of Terms

Clinical Nursing Training: In this study means the sum total of the

experiences of the student nurses in the clinical setting in terms of their

placement, teaching/learning, supervision and evaluation.

Perception of clinical nursing training: In this study implies the nursing

students’ view and opinion about their placement, teaching/learning,

supervision and evaluation in the clinical setting.

Opinion on Clinical Placement: In this study refers to the students’ view

and feelings about how they are posted and rotated in the clinical setting

and the environment in which they are posted.

View about Clinical Teaching: In this context refers to students’ opinion

and feelings about their clinical teaching, those that teach them and how

they teach them.

View about Clinical Supervision: In this context means the nursing

students’ opinion about those that supervise them and how they supervised

them.

Perception of Clinical Evaluation: In the context of this study, refers to

the students’ view about how they were tested and examined for clinical

skills and those that examine them.

Selected Nursing Programme: In this study means university-based and

hospital-based basic nursing programmes.

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CHAPTER TWO

LITERATURE REVIEW

This chapter presents the review of relevant and existing literatures as they

relate to the nursing students’ perceptions of the clinical nursing education.

It was presented and discussed under the following subheadings:

Conceptual Review

• Nursing Education

• Clinical Nursing Training

• Perception

Theoretical Review

• James Gibson’s Ecological Theory of Perception

Empirical review

Summary of reviewed literatures

Conceptual Review

Concept of Nursing Education

Functionally and operationally, “education” is a process which draws out the

best in the individual with the aim of producing well balanced personalities,

culturally defined, emotionally stable, ethically sound, mentally alert,

morally upright, vocationally self-sufficient and internationally liberal

(Basavanthappa, 2009). It is also the formal process of deliberate

transmission of accumulated knowledge, skills, customs and values from

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one generation to another (May & Akikitnan, 2003). Basavanthappa (2002)

affirms that an educated person is not dependent on the information they

store in their heads because they have ability do find information, create

knowledge and develop skills when necessary. The result is an educated

person, a person who is able to perceive accurately, think clearly and act

effectively on self-selected goals and aspiration.

Nursing education can be referred to as the formal learning and training in

the science of nursing, which includes the functions and disciplines that

accelerate the patient’s return to health and helps maintain it. It is the

theoretical and practical training provided to student nurses with the

purpose to prepare them for their duties as future nursing care

professionals. This education is provided to nursing students by experienced

nurses and other medical professionals who have qualified for educational

tasks (Adah, 2012). Adah (2012) further stated that all nursing education

programmes have a clinical component in which students are supervised by

clinicians in the clinical setting.

Nursing education therefore is all about impacting the integral nursing

knowledge of theories, principles, facts, concepts and acquisition of

necessary and appropriate skills and proficiency to practice the profession.

That is why nursing is seen as a science and an art. Thus, the two are

inseparable. They must go together in order to train a well balanced nurse

who will perform proficiently in the clinical area anywhere in nursing field.

While the acquisition of theoretical knowledge, principles, facts, concepts

occur in classroom setting during the teaching - learning interaction

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(process), the acquisition of the required skills and proficiency to practice

occur during clinical training which occur in the hospital setting,

community setting or else where outside classroom setting.

American Nurses Association (2012) stated that the aims of nursing

education include: Provision of opportunities for both in and out of hospital,

continuing education programmes that increase knowledge and skills

thereby enhancing quality care; Provision of resource materials which are

evidence based in order to keep all personnel informed and updated on

current practices in health care; Supporting research council; Providing

changed nurses and managers with leadership development programmes;

Provision of framework and support for mentors and clinical ladder nurse

and Provision of necessary orientation and training to all our new

employees. Basavanthappa (2009) further stated the general aims of nursing

education as thus: Nursing manpower development; Leadership; Personality

development; Professional development of each individual nurse; Ongoing

research; Knowledge.

According to Nursing and Midwifery Council of Nigeria (NMCN) (2008), the

two forms of nursing education in Nigeria include: Non University-based

Nursing Programme and University-based Nursing Programme. Non

University-based Nursing Programmes are the diploma certificate based

programmes done in schools of nursing and they include:

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General Basic Nursing Diploma Programme: The duration of the training

is three calendar years and is done in hospital based schools of nursing. The

school exams for this programme are: introductory block/Preliminary

Training Section (PTS) exam, junior block, intermediate block, senior block,

hospital final and final council qualifying exams. Each exam is accompanied

by a practical and viva voce aspect of the exams. The registration obtained is

“Registered Nurse” (RN).

Advanced Post Certificate Diploma Nursing Programme: Some of these

programmes include orthopedic, ophthalmic, pediatric, burns and plastic

nursing programmes etc. The duration of training is one calendar year with

the exception of the advanced post basic diploma programmes (nurse

anesthetic programme and midwifery etc) that last for 18 months. The

school exams for these programmes include first semester, second semester,

hospital finals and final council qualifying exams. These programmes are

done in post basic schools of nursing.

The University Based Nursing Programmes include:

Baccalaureate Nursing Programme: It is the generic nursing programme

done in the department of nursing science in some of the Nigeria

universities. It is done for five years for candidates that came in through

jamb examination and four years for direct entry student in pursuit of

Bachelor of Nursing Science (B.N.Sc) Degree. The school examinations here

are the university semester exams from the first to the final year and

Nursing Council final qualifying examination during their fourth year for

B.N.Sc students, midwifery final qualifying examinations by the NMCN

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during their fifth year, then the university degree examinations at the end of

5th year.

Higher Degrees in Nursing:- The programmes here are Master of Science

(M.Sc.) in nursing (from one year to eighteen months) and Doctor of

Philosophy (Ph.D) in nursing (from 3 years and above). These are offered in

some Nigerian universities. The modes of evaluation here are the course

work exams, clinical posting and thesis.

In all these forms of nursing education programmes, clinical nursing

training forms an integral part of their programmes and this starts with

clinical placement, clinical teaching, clinical supervision and ending with

clinical evaluation. Thus students’ perception of the clinical training is of

paramount important.

Concept of Clinical Nursing Training

Clinical nursing training is a combination of three words; clinical, nursing

and training. The Macmillian English Dictionary for Advanced Learners

defined clinical as relating to “working with people who are ill”, nursing as

the “professional training that a nurse receives” and training as “the process

of being trained for a particular profession”. The combination of these three

words therefore results to the professional training that an aspiring student

nurse receives in the clinical area. Clinical nursing training is the education

of students in the clinical setting. Most notably, clinical training is derived

through training apprenticeships, in which an aspiring student learns many

aspects of the profession from the “master” (Schen in kozier, 2008). National

Athletic Training Association Education in 2002 also defined clinical training

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as the portion of the students’ professional preparation that involves the

formal acquisition, practice and evaluation of clinical proficiency through

clinical experiences in the hospital care environment. In the clinical

situation, nursing care becomes a reality and the student nurse can observe

the responses of patients to the care given (Melone, 2010). Contacts with

patients are important elements in learning in clinical practice. Here,

students are exposed to authentic life stories for example people with

serious illness and these experiences can arouse strong emotion and yet

they also offer meaningful learning experiences. These kind of clinical

situations are important impulses to students’ profession development

(Turumen, 2002).

In discussing the goals of clinical nursing training, Schindly, (2012) stated

that students gain real life experience by working in the clinical setting and

that clinicals move students from textbook theories to patient bedside care.

The primary drivers of transformation in clinical nursing education are

society’s need, increased patients’ awareness about health and nursing

practice, accountability for efficient and effective use of education resources

which include best clinical teaching practices based on research evidence

(Shariff & Masoum, 2005). The increased demand for quality care by the

public and increased struggle for quality assurance and quality

improvement by nursing profession have been confronting the theoretical

and clinical training of nursing students during the past decade. Thus,

Ehiemere, (2009) concluded that clinical training based on sound nursing

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education is the only option to equip nurses with the current trend in

nursing practice.

Patterns of clinical training in nursing education

These refer to the ways in which the practical experiences of nursing

students are planned and organized in the clinical setting. The pattern

varies from school to school depending on each schools schedule of

programme and according to the curriculum. The pattern also varies

according to the type of school, that is, whether the school is hospital based

or generic nursing programme. The NMCN has a stipulated number of days

which each student must attend clinical experiences in the clinical

sites/wards for the period of training. For hospital based program, the

student must complete a minimum of 204 days or 4,400 hours in the

clinical areas before being qualified for the nursing council final qualifying

exam (Nursing and Midwifery Council of Nigeria Curriculum for General

Nursing Program, 2001). The patterns for clinical nursing training include:

Consolidated clinical training; Study day’s clinical training and Block system

of study clinical training

Consolidated clinical training: This is the pattern of clinical training

where the periods for student’s clinical experiences are scheduled to be at a

stretch towards the end of a semester. These periods ranges from 3months

for some schools of nursing to 6months in the universities.

Study day’s clinical training: This starts from the introductory class

where preliminary training students are introduced early to the wards to

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practice what they have learnt on weekly bases. Students attend classes on

some days in a week and still go for clinical experiences on weekly

bases/or the same week. In some schools, two days in every week are

mapped out for this exercise.

Block system of study clinical training: Many schools of nursing practice

block system of study whereby there are periods allocated in the yearly

school programme for each set of students to be in the classroom and

periods for them to be in the practice area. Students are assigned to specific

area of experience during each period of about 3 to 4 weeks after classroom

learning of about six to eight weeks.

Components of Clinical Nursing Training

Component as defined by Macmillan English Dictionary for Advanced

Learners is the different parts or essential feature of something. It is used

synonymously with basic element which means an important basic part of

something. Component of clinical nursing education is the important basic

or essential feature (element) of clinical nursing education. Basavanthappa

(2009) identified some of the basic elements of clinical training in nursing

education as: Planning and organizing (placement), Teaching, Supervision

and Evaluation. Duteau (2012) in addition, opined that the benefit of clinical

training in nursing education is achieved through adequate clinical

placement, teaching, supervision and evaluation.

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Clinical placement

The challenges confronting nurses in today’s rapidly changing health care

environments have highlighted the necessity for graduating students to be

prepared for practice. This necessity has in turn highlighted the increasing

significance of the nature and quality of student clinical learning experience

(Adams, 2002 & Chan, 2002). Graduate students will be required to have

adequate knowledge and skills to be able to transform competences into

effective performance. It is during their clinical placement that students are

expected to develop the relevant knowledge, skills and competence (Chan,

2002) to develop their capacity for “knowing how” as well as for “knowing

that” and to expand their perceptions of their future role as registered

nurses.

Placement is the act of putting someone into a place/position where he can

do a temporary job that is part of a course of study and gives experience of

the work he hopes to do at the end of the course (Rundel, 2006).

Commenting on this, University of Liverpool Online Programme (2013) noted

that clinical placements involved supervised practice in approved clinical

situation including teaching hospital, private hospital and clinics,

community health centre and specialist areas including early childhood and

women’s health services. They went further to state that clinical placement

may be undertaken during semester or in semester breaks and can vary

from regular one-day placement to block periods of several weeks.

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Clinical placement can also be defined as any arrangement in which a

student nurse is present in an environment that provides health care or

related services to patients or the public. The placement can take place in

primary, secondary, community health centre or social care setting and

these are the places in which nursing students see the art of nursing

applied and begin to develop their unique style (Tobin Communications,

2005). Therefore, clinical placement is the process of posting or sending

students to the various clinical sites or environment for quality clinical

learning experiences that will help them develop relevant knowledge, skills

and competencies for their future role as registered nurses. It is usually

taken in a facility external to the university offering nursing sciences or

school of nursing and where the clinical education and supervision is

undertaken by a member of the school of nursing or university staff (nurse

educators, clinical educator preceptors) in accordance with guideline agreed

between the school or universities and the placement facility or sites

(University of Queensland, 2005).

This school went on to say that clinical placement site (facility) refers to the

workplace, organization, service, agency or practice that agree to provide

clinical education and supervision to the students and to oversee their

professional development and progress throughout the placement. During

this placement the students are rotated through various working services.

These facilities include out patient department, family planning units,

medical wards, surgical wards, theatre and CSSD, Orthopaedic unit, public

health unit obstetric and gynecological unit and community placement

33

facilities like health centre, school health visits, home visits, visit to the

community’s source of water supply, visit to market arbertuer. The schools

and hospitals must coordinate and schedule these rotations to clinical services

According to Australian Government Initiative (2012), the elements relevant

to quality in clinical placement are enablers and barriers. Enablers are

factors known to improve the quality of the clinical placement experience

and they include: A culture of quality comprising relationships, learning and

best practices; Effective supervision founded on a good supervisory

relationship; Learning opportunities largely supported by

participation in direct patient care; Effective communication and collaborati

on between students’ academic institutions and placement sites to ensure

adequate placement preparations and Resources and facilities to conduct

placement activities. And barriers are factors known to reduce the quality of

the clinical placement experience and they include:

Occupational stress: Psychological stressors such as high workload,

problematic working relationship, lack of supervisors support and low level of

recognition and reward are all too commonly reported in health service

delivery environments. These induce states of anxiety, inhibits learning,

impair performance and compromise health and wellbeing.

Workplace incivility and aggression: These threaten the socio-emotional and

physical safety of students in the placement environment. Incivility is defined

as intimidating and disruptive behaviours that are “low intensity deviant

behavior with ambiguous intent to harm the target, in violation of workplace

norms for mutual respect”. In a study exploring nursing students’ experience

34

of incivility in clinical environment, co-workers and supervisors can be a

source of stress (Anthony and Yastick, 2011).

Preparation/Guidelines for clinical placement:

According to Sobralske and Naegele (2001) clinical educators, staff, client,

students and faculty must all prepare for the students entry into the clinical

setting. Plans should be made to know the students very well, find out how

each of them learn best, orient them to the clinical and clarify expectations

and responsibilities of the education programme, to the student and the

clinical preceptor. Guidelines on how to do these as stated by Sobralske and

Naegele (2001) were similar in the field of midwifery and advance practice

nursing and they are summarized as thus: The school should do the

following: Provide learning objectives; Provide tools for feedback and

evaluation; Clarify grading criteria and responsibility; Initiate student and

clinical educator and preceptor contact; Resolve clinical problems in

collaboration with preceptor and students; Provide to preceptors/clinical

nurse educator with student bio-program objectives curriculum and

evaluation forms and Provide to students with description, location and

contact information for the practice and preceptor clinical objectives,

evaluation tools and grading criteria.

The preceptor/clinical educator should do the following: Be able to

demonstrate safe, evidence-based practice; Hold current licensure; Be aware

of curriculum, learning objectives and evaluation/grading criteria; Orient

students to site; Create optimal learning opportunities; Provide timely,

35

constructive feedback and Evaluate student performance fairly and

accurately. The students should do the following: Dress professionally;

Know their learning needs; Be familiar with clinical objectives, evaluation

forms and personal learning objectives; Know how to contact clinical area

and preceptors; Follow clinical area policies (Osler, 2013).

Providing monetary compensation to clinical sites may be necessary. Other

types of compensation that are offered include free or reduced-price,

continuing education programme, internet-e-mail accounts and library

privileges. In some programmes students fill out a clinical preferences form

before clinical assignments are made. They detail their prior experience,

personal constraints (for example family, travel constraints) and desires for

next clinical rotation for example patient population, volume, risk and

preceptor style that is most helpful to them (Turnbull, 2013).

It is helpful to have a class discussion about clinical survival skills before

the beginning of the clinical rotation. During this session, students

appreciate hearing from more advanced students or recent graduate who

recently completed similar clinical rotations. Some education programmes

have created a clinical coordinator position to link the academic programme

and clinical sites more effectively. The clinical coordinator has a key role in

recruiting and retaining preceptors and clinical sites and arranging student

placement. She/he may also provide teaching and learning resources to

faculty preceptors and supervisees’ clinical activities. This multifaceted role

requires clinical and academic competence, creative flexibility and good

communication skills. It is helpful to let other staff know that the student

36

will be coming and to involve them in welcoming and orienting the students

to the clinical setting (Corrin, 2015).

Nursing and Midwifery Council of Nigeria (2008) in discussing some of the

items needed for clinical experiences requires that each student must have a

schedule book which contain things learnt in the classroom and also things

learnt during clinical experiences in different aspects of care units. They

went on to say that schools must have a procedure manual which should be

reviewed every five years. This serves as a guide to both the students and

the teachers for clinical training. This procedure manual is developed by

each school to reflect their philosophy which must be in line with the NMCN

curriculum. Schools must also have a good library and demonstration

rooms with relevant charts, models, equipment, bones etc to help the

student practice. A total placement periods of 1530 hours in the basic

nursing curriculum for clinical training in nursing education is

recommended (Nursing and Midwifery Council of Nigeria, 2001).

Clearly, clinical placement environment not only plays an important role in

the development of students’ competency but also students’ confidence,

organizational skills and preparedness for practice. There has also been

recognition of the influence that individual ward or unit environments have

on students’ experiences and career intentions (Clare, White, Edward &

Van-Loon, 2002).

Furthermore, given the inadequate preparation of nursing graduates for

rural practice together with the concentration of clinical placements within

37

large metropolitan hospital, it would not be unexpected that most graduates

have little understanding of rural issues and generally do not choose rural

nursing as a career option. However research findings indicate that rural

placement programmes improve the clinical skills necessary for rural work,

increase appreciation of the variety of experiences offered in rural practice

(Talbot & Ward, 2000) and increase awareness of the multiple opportunities

to practice clinical skills during rural placements (Peach & Bath, 2000). By

undertaking rural placements, nursing students especially those with no

prior experience of a rural lifestyle-could be expected to gain an appreciation

of the rural practice environment as well as the employment options

available in these settings. Moreover, this strategy should also facilitate the

gaining of knowledge and the variety of skills required to practice effectively

in a rural environment.

A recent national study conducted in Australia as indicated by Clare et al,

(2002), found that nursing students and health care staff both desire clinical

placements which provide students with quality learning experiences that

meet the growing demands placed upon graduates on completion of their

studies. In addition, graduates are expected to demonstrate all the

attributes of caring considered essential by the relevant nursing authority.

These experiences cannot be successfully simulated in a laboratory setting

(Boxer & Kluge, 2000).

38

Concept of Clinical Learning Environment

Clinical learning environment is a group of stable characteristics unique to a

particular clinical setting and impacting on the behavior of individuals

within that setting. The settings encompass a wide range of health care

services and in the wider meaning of term; include all psychological, social

and cultural factors of the clinical placement (English National Board (ENB),

2001a). Clinical learning environment is also the interactive network of

forces within the clinical setting that influence students’ learning outcomes.

The clinical learning environment of the ward atmosphere incorporates

items like how easy the staff members are to approach, the spirit of

solidarity among nursing staff and encouragement of students to participate

in the discussion. The ward premises includes the nature of care delivery,

the wards nursing philosophy, the documentation of nursing using the

nursing care plans and the daily recording of nursing procedures

(Saarikoski, Leino-kilpi & Warne, 2002). The related concept of learning

climate also emphasizes the importance of the physical, human,

interpersonal and organizational properties and mutual respect and trust

among teachers and students.

Clinical Teaching

Clinical teaching as defined by Basavanthappa (2009) is a type of group

conference in which a patient or patients is (are) observed and studied,

discussed, demonstrated and directed towards the improvement of nursing

care. In nursing, clinical teaching may be given by the doctors and nurses in

order to discuss the medical aspects of a patient condition more vividly than

39

can be done in the classroom. It may also be given by other members of the

health team like the dietician, physiotherapist, psychologist etc.

Alternatively, clinical teaching may be given by any faculty members ie

clinical instructor or tutor or ward staff and will concentrate on a particular

patient’s needs as a person and how doctor’s treatment orders can be met

by the right understanding and nursing care (Basavanthappa, 2009).

[[

Teaching in the clinical environment is the teaching and learning focused on

and usually directly involving patients and their problems (Spencer, 2003).

This often takes place in the course of routine clinical where discussion and

decision-making take place in real time. Often the teaching will centre on

analysis of actual patient care that the student has undertaken. Irby and

Papadakis (2001) summarized the skills that make a clinical teacher

excellent as thus: Share a passion for teaching; Organized, accessible,

supportive and compassionate; Are able to establish rapport, provide

direction and feedback, exhibit integrity and respect for others; Demonstrate

clinical competence; Utilize planning and orienting strategies; Process broad

repertoire of teaching methods and scripts; Engage in self-evaluation and

reflection and Draw upon multiple forms of knowledge; they target their

teaching to the learners’ level of knowledge.

Furthermore, the pattern/ forms of clinical teaching according to Ende

(1997) in Ramani & Lister (2008) are in-patient and out-patient teaching. In-

patient teaching refers to the clinical teaching of the student nurses in the

various wards where the patients are admitted including the environments

of the ward with or without the patients’ presence. The role of the inpatient

40

teacher is one of the most challenging in medical/nursing education and

that of a master, mentor, supervisor, facilitator (Ende, 1997 in Ramani &

Leinster, 2008). Some of the challenges of inpatient teaching as stated by

the above authors are: Difficult to set teaching goals; Unanticipated events

occur frequently; Ward team usually composed varying level of learner;

Patients too sick or unwilling to participate in the teaching encounter;

Patient stays are too short to follow natural history of disease; Teacher could

compromise trainee-patient relationship. Trainees and teachers feel insecure

about admitting errors in front of the patient and the rest of the medical

team; Tendency by many clinical teachers to lecture rather than practice

interactive teaching; Engaging all learners simultaneously can be difficult

and Teachers need to pay close attention to learners fatigue, boredom and

workload.

In-patient teams also need to behave as a teaching community where each

member respects the other in order to maximize their learning. Teachers

should learn to challenge their learners without humiliating them and

provide support so that learning can be furthered.

According to MAHEC Officer of Regional Primary Care Education (2009),

bedside teaching is part of in-patient teaching and it is a specialized form of

small group teaching that takes place in the presence of the patient. It

involves teaching in the presence of the patient. In addition, Ramani (2003)

noted that there are many skills that cannot be taught in a classroom and

requires the presence of a patient, real or simulated. Jenkins, Page,

Hewamana and Brigley (2007) also added that bedside teaching can improve

41

students’ history taking, examination skills, knowledge of clinical ethics,

professionalism, can foster good communication and role modeling skills.

The practical tips that promote effective bedside teaching according to

Ramani (2003) are:- Preparation; Planning; Orientation; Introduction;

Interaction; Observation; Instruction; Summarize; Debriefing; Feedback;

Reflection and Preparation for the next encounter.

Out-patient teaching according to Prideaux, Alexander, Bower, Tallett,

Dacre, Haist, et al (2000), involves the clinical teaching of the learner by the

clinical educators at the outpatient department either during or after patient

consultation in the clinical. The above authors identified some of the

challenges of outpatient teaching as thus: busy clinical setting, teaching

time often too short ie no time for elaborate teaching, attending to several

patients at the same time with multiple learners, brief teacher-trainee

interaction, multiple patients problems must be addressed simultaneously,

so teachers cannot focus on one problem to teach. Learning and service take

place concurrently.

Teaching styles used during clinical teaching

Multiplicity of clinical teaching styles of nurse teachers were modified

according to situations, skill (course content) and learner level. This means

that the clinical teachers might use one or more teaching styles to ensure

student learning. These teaching styles as identified by Brown (2003)

include: Teaching by doing where clinical educators are involved in doing

tasks in real environments and conditions; Teaching by supporting where

reinforcing students and giving feedback to them will increase their

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responsibility for learning; Teaching by being a role model where nurse

educators believed that being a role model in clinical education is the most

effective and right way for transmitting professional experiences and

attitudes; Teaching by creating learning context which involves creating a

suitable scenario and good condition for teaching; Teaching by monitoring

where the teachers constantly monitor the students’ attributes.

But Basavanthappa (2009) affirmed that in nursing, commonly used clinical

teaching methods include: Bedside clinic which utilizes the presence of a

selected patient as its focus for group discussion; Nursing round which is an

excursion into patient’s area involving the students. Students respond to

this method of teaching with enthusiasm; Nursing assignment which is part

of learning experience where the students are assigned with patients or

other activities concerning to patient in clinical laboratory; Nursing care

conference which consists of a group discussion using problem-solving

techniques to determine ways of providing care for patients to whom

students are assigned as a part of their clinical nursing experiences;

Morning and afternoon reports which summarizes the services of the nurse

and or the agency; Team nursing conference which refers to the use of two

or more teachers each having special competencies and knowledge in the

cooperative planning, teaching, supervision and evaluation of a given group

of students; Health team conference which is a group of professional

persons involved in accomplishing common goals for the purpose of

interchange of ideas and solving problems which are centered around the

client; Individual conference which involves a “conversation with a purpose”

43

or more simply put as an interview and process recording- which is an

exact report of the conversation between the nurse and the patient during

the time they were together.

Clinical Supervision

The concept of supervision is used here as an overarching concepts which

refer to the guidance, support and observation of nursing students by

clinical staff (Pires & Ferreira, 2012). The relationship is evaluative, extends

over time and has the simultaneous purpose of enhancing the professional

functioning of the junior member(s); monitoring the quality of the

professional services offered to the client. Secondly, it is the formal process

of professional guidance, support and learning which enable individual

practitioners to develop knowledge and competence, assume responsibility

for their own practice and enhance consumer protection and safety of care

in complex clinical situations. It is an interaction among two or more

professionals with the aim of improvement of the care quality rendered to

the customer in a safe and supportive atmosphere. From the above

definitions, clinical supervision in nursing education is therefore the process

of guiding, supporting and directing the nursing students in the clinical site

or during clinical posting by nurse educator to ensure that the theory-

practice gap is closed.

According to Kavani and Stillwell (2000), the nursing school and health

provider’s relationship at clinical site is crucial in providing ongoing support.

The school has a responsibility to give the health provider information about

its nursing curriculum and familiarizes them with the clinical components of

44

the programme so that appropriate levels of supervision can be provided.

They are also responsible for informing the health provider (clinical areas)

about the individual students attending the clinical placement, their level of

attainment and the clinical facilitator responsible for the placement.

The importance of clinical supervision cannot be overemphasized. Clifton

(2002) opined that health care organization have a responsibility to ensure

that their workforces are sufficiently developed to enable practitioners to

provide an appropriate standard of service. Clinical supervision must be

regarded as part of clinical governance that emphasizes the importance of

improving patient care and maintaining high standard of service and clinical

delivery.

In discussing the necessity for clinical supervision in nursing education,

Benard and Goodyear (1998) stated that effective supervision in clinical

nursing training will produce positive outcomes beneficial to all the

students, nurse educators, nurse practitioners and the patients. He

considered good supervision fundamental in producing a relationship which

is committed, adequate and in some important sense spontaneous for the

patients and nursing student. Through clinical supervision in nursing

education, nursing students are aided to build confidence in clinical

practice. Moore (2000) also added that clinical supervision in general is

fundamental in the safeguard of quality improvement, development of

professional expertise and delivery of care. Supervision in clinical nursing

training enhances the implementation of evidenced based practice, inputs to

research and development agenda and is a leading implement in monitoring

45

the delivery of quality care to patient through supervised learning, staff

support and development.

In planning for effective clinical training, the tasks and skills of supervision

considered basic to successful clinical teaching as highlighted by Newman

(2013) include: The importance of establishing and maintaining an effective

working relationship with supervisee; An atmosphere where learning is

supported should be provided and Open and ongoing communication

between the supervisor and the supervisee. This is central to the success of

the supervisory relationship. He further stated that, it is important for

clinical educators to meet with each supervisee prior to initiating the clinical

assignment/experience. For placements that are off-campus, the university

will: Typically establish a contract, which should outline the responsibilities

of the university and the clinical site and should serve to protect all parties;

Have a coordinator (or similar title) who will then follow through in setting

up the details of the student’s experience; Establish placements up to a year

in advance of the assignment and Determine start and end dates and review

any requirement of the particular setting.

Linfield (2012) also stated that the preceptor performs the following roles

during clinical supervision: Provides faculty and the student with a copy of

preceptor’s work schedule to assist in scheduling student clinical days;

Coordinates the student’s orientation to the facility including staff roles and

client expectations; Ensures the student is identified as a student while in

the clinical area and is not regarded as staff for the clinical site; Foster

students’ integration into the work place culture and health care team by

46

involving student in the meetings related to client care and other

appropriate professional matters; Arranges for a substitute preceptor when

absent; Facilitates learner centered education through collaborative

identification of the students learning needs, open communication,

informing students about learning resource; Serves as a role model for the

student, demonstrating professional roles and behaviors such as caring

integrity, effective interpersonal communication, critical thinking and

conflict management to assists the student to cope with stress and reduced

consent associated with clinical practice and Stimulates development of

the students’ clinical judgment and critical thinking ability through

reflective practice and the application of evidence based practice.

The faculty (schools, department of nursing) also performs the following

roles: Notifies the student of the preceptor’s name and phone number;

Facilitates scheduling of the student’s clinical days; Orients students to the

course, including clinical outcomes and requirements of the course;

Orient them to the role expectation of the student faculty and the preceptor;

Orient the preceptors to the nursing curriculum, the course including

clinical outcome requirement of the course and Orient the preceptors to the

evaluation methods and role expectations of the preceptors, faculty and the

student.

Format for clinical supervision

Newman (2013) in differentiating clinical training from classroom education

stated that clinical training is generally one supervisor with one graduate

student clinician or one supervisor with a small group of graduate student

47

clinicians. Sometime, the supervisor will be assigned one graduate student

to spend an extended period of time working with the supervisor (a

semester). Sometimes a graduate student will be assigned for part of a day

once or twice a week. In a university setting, the supervisor may be assigned

to supervise general students but will generally spend sometimes working

individually with each graduate student.

Clinical supervision according to Newman (2013) can be delivered in a

variety of formats namely: Individual format where a clinical supervisor is

providing supervision to one supervisee and is probably the most common

format in nursing; Group format where a group of between four and six

supervisees is guided by a clinical supervisor (Price & Chalker, 2000) and

Triad format where a clinical supervisor usually offers supervision for two

supervisees when using this format (Sloam & Watson, 2002).

Clinical Evaluation

This deals with making judgment about the value or quality of clinical

placement, teaching and supervision after they have been carefully thought

of. Wren and Wren (1999) stated that evaluation of clinical performance is

an integral part of all programmes in nursing profession. In addition,

Raisley, O’Grandy and Lori (2003) stated that evaluation is a more formal

assessment of students’ performance. It is an assessment of whether a

learner has adhered to the educational outcomes expected. Assessment

plays a major role in the process of nursing education and in the society by

certifying competent nurse who can render quality nursing care to the

public. The public or society need to know that nurses that graduate from

48

nursing schools are competent enough and can practice their profession in a

compassionate and skillful manner (Shumway and Harden, 2003). As earlier

stated, clinical evaluation is therefore the process of eliciting the extent to

which the student nurses in the clinical learning environment have achieved

their clinical training objectives.

Wren and Wren (1999) assert that evaluation requires the preceptor to make

observations of performance and collect other types of data, then, compare

this information to a set standard. In additions, O’Connor (2006) developed

an evaluation process that can be applied in the clinical setting for nursing

students and this includes: Identifying the goals of evaluation; Clarifying the

standards for evaluation; Analyzing the results; Reporting the results;

Making decisions using the results and Evaluating the evaluation process.

The goals of evaluating students’ clinical practice according to Wren and

Wren include: Protecting the public; Satisfying students’ expectations;

Meeting institutional requirements; Ensuring graduates adhere to standards

and are clinically competent example professional socialization,

responsibility, certification, safety, critical thinking, communication ration

as they relate to patient safety and clinical supervision control as they relate

to patient safety student knowledge and ability.

Oermann and Gaberson (2009) stated that some of the evaluation strategies

in clinical nursing training include: Written assignment like use of case

study, evidence-based practice (research) papers, development of nursing

care plan and writing articles for journal publications using cases picked

from the ward; Practical assignment and examination which deals with

49

assessing the students’ ability to demonstrate the skills which they learnt in

the classroom and during clinical instruction and Oral questions which

deals with asking the students oral questions based on the clinical

instructions and practical procedures demonstrated in the clinical learning

environment.

Types of Evaluation

Different types of evaluations are used to assess clinical performance (Wren

& Wren, 1999 & O’Connor, 2006):

Formative evaluation: Is ongoing and leads to specific plans for

improvement. Its purposes include to: Enable students to develop clinical

knowledge skills and values; Indicate areas in which learning and practice

are needed; Provide a basis for suggesting additional instruction to improve

performance and Provide feedback to learners about their progress in

meeting the outcomes of the clinical practicum course or in developing

required clinical competencies. Wren and Wren (1999) and O’ Connor (2006)

went further to summarize that the purpose of formative is for judgment. In

terms of timing, the formative evaluation is ongoing and generally given at

the midpoint of the rotation and is used to guide the students in their

learning process. In terms of use, the formative is used to give feedback,

identify strengths and weaknesses while summative is used for grading. In

terms of competence, the formative evaluation develop plan while summative

evaluation judges competencies.

50

Summative Evaluation: Is designed for determining clinical grades

because it summarizes the competencies student has developed in clinical

practice. The grade resulting from the evaluation usually reflects a joint

determination by the preceptor and programme faculty (school) of whether

(and how well) the student has met the objectives of the rotation (Raisler,

O’Grandy and Lori, 2003). Summative evaluation also reflects progress over

a complete time period. That is, it is done at the end of a period of time to

assess the extent to which learners have achieved the clinical outcomes or

competencies.

Self evaluation: Is another type of evaluation mentioned by Wren and Wren

(1999) during clinical placement, training and supervision. Most students

have a realistic assessment of their progress, can be done daily and at the

end of a semester and should be specific and describe exact limit of

achievements.

The overall purpose of clinical evaluation of students includes to: Identify

existing competencies; Identify learning needs during clinical rotation;

Assess progress towards achieving competencies; Make judgments of

competencies met at the end of clinical experience. Evaluation of the

supervisee typically follows a schedule provided by the university setting

and the schools of nursing. The pattern of examination for clinical training

consists of: Continuous practical assessment in each unit of practice during

every period of experience and End of semester/block and yearly practical

examination which are conducted in the wards. The promotion to another

51

class or for certification depends on positive performance of the students on

clinical training examination (NMCN, 2008). Points to consider when

evaluating students progress in the clinical setting as stated by O’Connor

(2006) include: Establishing a nurturing and trusting relationship with

students; Knowing the course theory and clinical objectives thoroughly;

knowing what the expectations are for the students; Observing the students

while they carry out their assignment; Being responsible and objective;

Ensuring adequate time to respond to students questions and Being opens

minded.

Giving feedback:

Feedback regarding performance and how to improve it is essential for

clinical evaluation to be effective in the clinical environment. It is essential

to provide feedback to trainees as without feedback their strengths cannot

be reinforced nor their errors be corrected. It is a crucial step in the

acquisition of clinical skills. Omission of feedback can result in adverse

consequence, some of which can be long term especially relating to patient

care. Feedback can be formal or informal, brief and immediate or long and

scheduled, formative during the course of the rotation or summative at the

end of a rotation (Branch & Paranjape, 2002). Feedback is essential for a

student to gain an insight into what they did well or poorly and the

consequences of those actions. It tells the learners where they are in

comparison to where they ought to be and where they should go. Feedback

when well done, also promotes self-reflection and self assessment which are

valuable traits for lifelong learning (Ramani & Leinster, 2008).

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Opportunities available for student nurses in clinical site-based

learning

In discussing clinical site-based learning, American Association of Clinical

Nursing (2002) stated that clinical site-based learning provides opportunities

to: Provide care along a continuum; Work with interdisciplinary teams; Work

within and across diverse health care delivery environments communities;

Provide care for diverse populations, including diverse ages, gender,

ethnicity healthy-ill, and acute-chronic health states; Exercise

delegation/Management skills: Students manage the delivery of care

provided by others; Practice case management; Manage health-related data;

Use information technologies to provide nursing care; Participate in nursing

research; Deal with the allocation and management of fiscal and human

resources; Work with role models and preceptors; Practice in the advanced

practice nursing role and Work with an agency staff committed to the

advanced practice nursing role.

Factors Influencing Students experience of clinical Training

Sass and Dama (2011) argued that in clinical nursing education, clinical

learning environment, behaviors of the clinical educators and learning of

appropriate clinical knowledge and skills have been found to influence

students’ perception. According to Nahas and Yam (2001), studies have

shown stressors associated with going out into the clinical fields as fear of

making mistakes, anxiety over possible criticisms from peers, being able to

communicate with health personnel and patients, providing care for the

seriously ill or terminal patients, attitudes of staff towards the students and

53

staff expectations of the students. The above source stated the facilitating

factors in clinical nursing training as thus:

Good physical conditions- These had a positive influence on the students’

clinical learning and include providing room to leave books, materials and

having meetings. If the environment is unpredictable, unstructured and

overwhelming, students can be left with feelings of vulnerability and anxiety

(Papp, 2003).

New Educational Environment- Here, students are exposed to different

practices and have opportunity to perform different interventions when they

attend practices in different hospitals. These different experiences help them

get ready for work after graduation.

Acceptance – Relationship with staff of the units and staffs’ attitude

towards students are the most two important factors that affect clinical

learning. Students are more motivated and eager to attend clinical when

they feel that they are part of the health- care team.

Communication and relationship –Students learn more from nurses that

demonstrate effective communication skills.

Feedback from nurses- Positive feedback from nurses generates high

motivation for students’ clinical learning. Feedback from mentors allows the

students to recognize their deficiencies and helped them improve their

knowledge and skills.

Teaching ability and nursing competence of mentors – Students learn

better when mentors present knowledge, demonstrate new interventions and

help them to perform these interventions.

54

Patients with severe illnesses- Nursing care for patients with severe

illnesses help them to gain experience and prepare them for professional

life.

Patients’ attitude – Student nurses have increased motivation for

learning when patients let the students care for them.

Shame in the clinical learning environment is another factor and a concept

that negatively influence students’ perception of their clinical nursing

training (Bond, 2009). He went further to say that negative behaviors such

as grilling the students with questions and watching them like a “hawk”

contribute to the students’ anxiety; make them develop feeling of

incompetence and insecurity which are manifestations of shame. Bond

(2009) also suggested that when students experience shame, socialization in

the nursing profession and with other professionals as well as the learning

experiences are compromised. Recognition of these shaming behaviors by

the instructors and making effort to correct them can therefore make great

difference in the quality of clinical learning environment and the clinical

nursing education for the students.

In addition, the four types of staff nurses that proved “toxic” to students

learning in the clinical environments according to Gray and Smith (2000)

are the avoiders, dumpers, blockers and criticizers. The avoider is suddenly

not around when it is time to have anything to do with students. The

dumpers do not take any responsibility for students learning in the clinical

site. The blockers may absolutely refuse to help the student, withhold

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knowledge or over supervise the student. The criticizer belittles and

undermines the student.

Concept of Perception

Various scholars have defined perception in different ways. According to

Schacter (2011) perception is the organization, identification and

interpretation of sensory information in order to represent and understand

the environment. In addition, Goldstein (2009) puts forward that all

perception involves signals in the nervous system which in turn result from

physical or chemical stimulation of the sense organs. It depends on both the

psychological and physical characteristics of the perceiver in addition to the

nature of the stimuli.

Perception is also seen as our sensory experience of the world around us

and it involves both the recognition of environmental stimuli and actions in

response to these stimuli. This means that perception not only creates our

experience of the world around us but it allows us to act within our

environment. From the foregoing, perception can be summed up to be our

sensory experiences and interactions within our environment and our ability

to make good judgment from those experiences. Nursing students’

perception of clinical nursing education is therefore their sensory

experiences of the clinical training, their interaction with the clinical

learning environment and their ability to make good judgments based on the

experiences and interactions. It is the way in which they regard, understand

and interpret their clinical training experiences (Goldstien, 2009).

56

Perception can be positively or negatively influenced by a variety of factors

(Alam & Gary, 2011) . These factors are the personal characteristics of the

individual that heavily influence the way he interprets something and they

are grouped under the following:

Factors influencing the perceiver: The perceiver is the person who

becomes aware about something and come to a final understanding. These

factors include experience, motivational state, emotional state, attitudes and

expectations. In different experiences, motivational and emotional states, the

perceiver will react to or perceive something in different ways. The influence

of expectation on perception is the idea that what we see is at least to some

extent influenced by what we expect to see. In other words, if

expectations are met, the individual will have high/positive perception and if

not met the individual will have low/negative perception.

Factors in the target: The target is the person, object or event being

perceived or judged. The factors here include the motion, size, proximity,

similarity. Ambiguity or lack of information about a target leads to a greater

need for interpretation and addition.

Factors in the situation: Examples here are time, work setting, social

setting. Situation also greatly influences perceptions because different

situations may call for additional information about the target being

perceived. The time and setting at which an object or event is seen can

influence attention thereby influencing the individual’s perception of that

event or object.

57

Theoretical Review

James Gibson’s Ecological Theory of Perception

Gibson’s theory of perception was developed in 1950. According to Goldstein

(2009), Gibson was an American psychologist. His psychology of perception

is referred to as an “ecological approach” based on the interactive

relationship between the perceivers and their environment. Critical to

Gibson’s model is that perception is an active process and that meaning is

added through higher mental processes such as cognition or memory. He

argued that meaning is external to the perceivers and lies in what the

environment affords him. Gibson’s theory assumes the existence of stable,

unbounded and permanent stimulus information in the ambient optic array.

And it supposes that the visual system can explore and detect this

information.

Gibson argued that perception was crucial as it allowed humans to adapt to

their environments. His theory of perception is information-based rather

than sensation-based. And to that extent, an analysis of the environment (in

terms of affordances), and the concomitant specification information that

the organism detects about such affordances (environment) is central to the

ecological approach to perception (Noe, 2004). In order to receive

information from the actual environment, human beings are equipped with

sense organs. Each sense organ is part of a sensory system which receives

sensory input and transmits sensory information to the brain. According to

McLeod (2007), sensation detects the presence of an event or objective in the

environment and perception forms a mental representation of that event.

According to Gibson’s theory, perception of the environment inevitably leads

58

to some course of action. Ecological understanding of perception derived

from Gibson’s early work include: “perception-in-action” and “affordance”.

“Perception-in-action” is the notion that perception is a requisite property of

animate actions, that without perception, action would serve no purpose.

Gibson increased his focus on the environment through development of the

“theory of affordance”. “Affordance” is the real perceivable opportunities for

action in the environment that are specified by ecological system. The

affordance of the environment is what it offers the organism (human), what

it provides or furnishes either for good or ill. He regarded affordance as a

property of whatever the person interacts with.

59

Figure 1: Gibson’s Ecological Perceptual Cycle

Source: Neisser .U. (1976) in Kim, J. and Jens, R. (2010) Cognition and

Reality.

Application of the theory to this study

Gibson’s notion that perception is a requisite property of animate action and

that without perception, action would be unguided implies that student

nurses have the property/ability to perceive their clinical training. It is how

The Independent variable Clinical training (clinical placement, teaching,

supervision and evaluation).

The Intervening variable The activities, condition, nature, situation of the clinical training (how the training is being carried out)

Actual Environment, Available information event/object

Perceptual Exploration(overt Perception- in-action)

Knowledge of environment Schema (mental

Representation)

Modifies Samples

Direct

The Dependent Variable Nursing students’ perception (Negative/Positive)

in –action)

60

they perceive the training (positively/negatively) that determines how the

training is carried out. Without the student perceiving the training, there

may not be need for change and continuous quality improvement in the

training. The dependent variable is the perceptual exploration that is the

overt perception –in- action. That is the student’s (perceiver) perception of

the clinical training which may be positive or negative. The independent

variable is the available information and event in the actual environment

(target) being perceived. That is the clinical training (placement, teaching,

supervision and evaluation) being perceived. The affordance is the

intervening variable. That is the characteristic, nature, condition of the

training and the characteristics in the environment (experiences) that affect

the emotional and motivational state of the student nurses. The nursing

students sample information about their clinical training experiences from

the outside visual world through their knowledge of the environment from

mental representation (higher mental processes). If the timing, setting,

condition of the training and the experiences of the student nurses are poor,

the students will have negative perception about the training, and the

reverse is the case.

Empirical studies

There is a gross scarcity of literature on students’ perceptions of clinical

nursing training in Nigeria.

A study carried out in Cyprus and Finland using Schools of Health Science

Department of Nursing Cyprus, University of Nicosia Cyprus, University of

61

Applied Science Health Care Education Finland and University of Turkey

Finland, on student nurses experience of learning in the clinical

environment was by Leino–Kilpi, Haritini, Saarikoski, Lambrinous and

Papastavrous (2009). The research instrument used was a questionnaire

consisting of the English version of Finnish (Finland) Clinical Learning

Environment and Supervision scale tested in earlier studies. The reliability

of their instrument was established with the Cronbach’s reliability

coefficients. The total scale was 0.95 which is extremely satisfactory.

Software package SPSS was used for their statistical analysis. The total

sample of 645-students participated in their study. The supervisory

relationship was found problematic, since 30% of the students had “failed

supervisory relationship. Students were supervised by a variety of people,

ranging from staff nurses, to managers, doctors, fellow students or they

were not assigned to a supervisor. They perceived their clinical placements

as “good”. Nevertheless Cypriot students gave ward managers a low

evaluation score.

Another study carried out by Odunukwe (2015) in Nigeria was titled

perspective of clinical posting experience among undergraduate nursing

students of UNEC. Students in 500 level who met the inclusion criteria were

used and a descriptive survey was used too. Questionnaire was the

instrument for data collection which yielded a Cronbach alpha reliability co-

efficient of 0.87. The data were analysed using frequencies, percentages and

mean. Major findings of the study include: many of the students (66.7%)

perceived that the timing of their clinical posting is late; 59.4% perceived the

62

duration of the posting as short; the students perceived inadequacies in

56% of supervisory skills of their supervisor in the clinical area; 50% of the

student nurses perceived that 83% of activities in clinical supervision were

not carried out and that their achievement test in basic nursing tasks was

poor.

Sumari-Ayo (2006) in a quantitative study in Tanzania investigated on

“factors influencing clinical teaching of midwifery students” using three

schools of midwifery. Their study revealed that clinical instructors and

preceptors were overworked due to shortage of staff, the schools’ skill

laboratory and the hospital wards lack basic equipment and necessary

supplies, there were no clinical accompaniment guideline, teachers in the

classroom and supervisors in the clinical areas do not cooperate with each

other in training the students and that both the professional and

educational qualifications of the clinical instructors were low.

Another study carried out in Tehran University of Medical Science Iran by

Ziaee, Ahmadinejad and Morravedji (2000) was titled “Evaluation of

medical students’ satisfaction with clinical education and its effective

factors”. The research design used was a cross sectional descriptive

analytical study. Subjects were medical students during their medical

internship (the last two years of sixth and seventh year medical students). A

questionnaire based on job satisfaction was used for data collection. In this

study clinical education was classified into outpatient, bedside and

theoretical teaching in addition, the students’ satisfaction of the way they

63

were tested for clinical skills (clinical evaluation) was also assessed. Two

hundred and fifty (250) medical students were surveyed in their study. The

statistical package for the social science (SPSS version 9) was used for

statistical analysis. The mean age of the students was 36.5 years (23-

35year) and 216 (86.4%) of them were male. In their study, the overall

satisfaction was 38.8% (97/250). 61.2% (153/250) were not satisfied with

their clinical education. There was no statistically significant relationship

between age and gender. Satisfaction with the way through which they were

tested (methods of evaluation) was 64% (161 subjects). In their study, there

was no relationship between satisfaction and gender.

Odunukwe (2015) in a qualitative study in Nigeria investigated on perception

of students about factors influencing clinical training using students of

Department of Nursing Sciences UNEC. The research design was cross

sectional descriptive analytical study. Purposive sampling technique was

used to sample 161 fourth and fifth year students. The instrument for data

collection was a close ended questionnaire with 4 point Likert scale. Data

were analysed using SPSS version 16 and presented using descriptive

statistics such as percentages, means and standard deviations. The study

revealed that inadequate supervision of the students was the institutional

factor affecting clinical training of students. Unconducive clinical

environment was the clinical factor affecting clinical training of students.

Large class size was the individual factor affecting clinical training of

students.

64

Saarikoski, Leino-Kilpi and Warne (2002) carried out a study in Finland and

UK on the comparative analysis of the experiences of Finish and English

student nurses in clinical learning environment and supervision instrument.

The data were collected from a total population of 558 student nurses from

four nursing colleges in Finland and UK. Data were statistically analysed

using ANOVA. The findings showed that Finish students evaluated their

clinical placements and supervision more positively than students in UK.

Another study by Chapman and Angelica (2000) in Husserlian School of

Phenomenology in Western Australia titled “The Nursing Students’ Lived

Experiences of Clinical Practice”. A purposive sample was used and the

study question was “what is clinical practice like for you?”. The main source

of data used to understand the study was interviews conducted with 14

nursing students. The findings showed that participants perceived clinical

practice to be an essential component of their nursing education. Clinical

practice with functional teaching and learning materials provided the

student with the opportunity to link theory with the practice of caring for

clients. Data also revealed that the relationship that students had with their

clinical teachers, the agency staff and client was fundamental in the process

of learning.

A non-experimental qualitative descriptive study by Okoronkwo, Onyia-Pat,

Agbo, Okpala and Ndu (2013) evaluated students’ perception of effective

clinical teaching and teachers’ behavior in UNEC. A descriptive design was

employed using questionnaire to collect data. Respondents comprised of

65

direct entry and university matriculation examination students in their 400

level who had completed their six months consolidated clinical experiences,

totalling 101. Specifically, frequencies, percentage, mean and standard

deviations were used for descriptive analysis of scores. Their results showed

that having both clinical and teaching knowledge were the most important

teaching skills for effective clinical teaching. Five qualities ranked by

students as teacher behaviours important for effective clinical teaching

include being honest with students, motivation to teach, willingness to listen

and using good communication skills, supervising students effectively and

being positive role model.

Papathanasiou, Tsaras and Sarafis (2013) assessed students’ views and

perceptions on their clinical learning environment in a Greek nursing

school. In their study design, 196 students were included. A published

questionnaire of “Clinical Learning Environment Inventory (CLEI)” was used.

In their result, the lowest mean score of 19.21 was observed for the actual

clinical environment while the lowest mean score of 26.82 was observed for

preferred clinical learning environment. This study showed a noticeable gap

between the expectations and reality of the clinical learning environment for

students in nursing.

A qualitative study carried out by Rafiee, Moattari, Nikbakht, Kojuri and

Mousavinasab (2012) at Shiraz Nursing and Midwifery School Iran was on

the views of nursing students and trainers about problems and challenges of

nursing students’ clinical evaluation. A sample size of 8 nursing instructors

66

and 40 nursing students were used. Data were collected through semi-

structured deep interviews. Content analysis was employed in order to

analyze the data. The results showed that from the students and instructors’

point of view, inappropriate clinical evaluation methods, problems of clinical

evaluation process and problems related to clinical instructor were

considered the important evaluation problems.

Papastavrou, Lambrinou, Tsangari, Saarikoski and Leino-kilpi (2009)

assessed student nurses’ experience of learning in the clinical environment

using 645 undergraduate nursing students of the only public school of

nursing (Ministry of Health) in Cyprus. The research instrument used was

the Finish Clinical Learning Environment Supervision (CLES) instrument.

SPSS package was used and frequencies on the items of the scale were

found. Statistical tests such as ANOVA and Bonferoni were also performed.

Their result showed that the most unsatisfied nursing students were the

ones with a failed supervisory experience while the most satisfied students

were those with a successful mentor relationship. The Bonferoni tests

showed that students who had more frequency sessions with their

supervisors were more satisfied. The ward atmosphere and the leadership

style of the ward managers were rated as less important factor for clinical

learning (rated with lower scores with means of 3.44 and 3.43 respectively).

A study carried out by Esmaeili, Cheraghi, Salsali and Ghiyasvandian (2013)

in School of Nursing and Midwifery, Tehran University of Medical Sciences

Iran was titled “Nursing students” expectations regarding effective clinical

67

education: A qualitative study”. In this study, a semi-structured interview

process was utilized with 17 nursing students. Content analysis was

employed to analyse the data. Data analysis led to identification of three

main themes: (i) appropriate communication and interaction between

instructors and students (ii) incorporation of both theory and practice in

clinical teaching including the presence of the instructor in the clinical area

and evaluation based on appropriate criteria and (iii) having specialized

instructors with a specific emphasis on the instructor’s knowledge and

motivation as important factors in learning.

Summary of Reviewed Literature

Clinical training in nursing education comprise of placement/ posting of

student nurses to the clinical areas/sites where formal acquisition, practice

and evaluation of clinical proficiencies through experiences in hospital care

environment take place under the supervision of a qualified clinical nurse

educator, clinical instructor or preceptor. Nursing students’ perceptions of

the clinical training is of paramount importance because it has been

associated with their later professional attitudes, career commitment and

retention. The conceptual review was on nursing education, clinical nursing

training, clinical placement, clinical learning environment, clinical teaching,

supervision, evaluation and perception. James Gibson’s ecological theory of

perception was reviewed to provide a framework for this study.

68

Majority of the empirical studies were done outside Nigeria and they covered

both university and hospital-based student nurses. They centered mainly on

clinical learning environment and very few were on clinical evaluation

teaching and supervision. However there is paucity of indigenous studies in

this topic. The very little empirical studies that were done in Nigeria used

only university-based students and did not assess the views of the hospital-

based student nurses in all the subscales. The aspects of clinical placement,

supervision and evaluation were not well covered too. This is considered a

serious gap as this study included nursing students from both the

university and hospital-based nursing programmes and also exposed the

areas of clinical placement, teaching, supervision and evaluation that are

deficient. And as earlier stated, the student nurses’ perception of clinical

training is a legitimate indicator of the quality of the training. It is this gap

that informs the researcher’s choice of topic, nursing students’ perceptions

of clinical training in selected nursing programmes in Enugu State.

69

CHAPTER THREE

RESEARCH METHODS

This chapter presents the following: research design, area of study,

population of the study, sample and sampling technique, instrument for

data collection, validation of instrument, reliability of instrument, ethical

consideration, the procedures for data collection and methods of data

analysis.

Research Design

A descriptive cross-sectional design was adopted for the study. This design

was considered appropriate for the present study because it allowed the

investigator to describe the current and prevailing information about

nursing student’s perception of clinical training and reveal areas that need

change. The design was successfully used by Okpala, Iheanacho,

Okoronkwo and Stephens (2014) in a study of Students’ Perception of

Environment Sanitation: a study of a Nigerian university.

Area of study

The area of study is in Enugu State located in the South East geopolitical

zone and is one of the thirty- six states constituting the Federal Republic of

Nigeria. Enugu state derives its name from the capital city Enugu (top of the

hill) which is regarded as the oldest urban area in the Igbo speaking area of

south-east Nigeria. The city owes its geopolitical significance to the discovery

of coal in 1909 by a team of British geologists. The state shares borders with

Abia State and Imo State to the south, Ebonyi State to the east, Benue state

70

to the northeast, Kogi State to the northwest and Anambra State to the west

(Federal Republic of Nigeria Population Census, 2006). Economically, the

state is predominantly rural and agrarian. In the urban areas, trading is the

dominant occupation followed by services, mostly the public service.

Administratively, the state is administered at two levels of government the

state and local government. There are 17 Local Government Areas with

council headquarters located in each, some of which include: Enugu North,

Enugu South, Nsukka etc (Nigeria National Bureau of Statistics, 2008).

In Enugu state, health care services can be obtained at several institutions-

state government for example, Enugu State University Teaching Hospital

(ESUTH), federal government for example University of Nigeria Teaching

Hospital Enugu, private hospitals for example Niger Foundation Hospital

and Diagnostic Centre and mission hospitals for example Bishop Shanahan

Hospital Nsukka. Most of the nurses working in these health care

institutions were trained in the nursing schools situated in the state.

Majority of the nursing education programmes in the state are situated at

UNTH Enugu, ESUTH Parklane Enugu, University of Nigeria Enugu Campus

(UNEC), National Orthopedic Hospital Enugu, and Bishop Shanahan

Hospital Nsukka.

There are two schools of nursing offering a 3- year basic nursing

programmes in the state and one university offering a 5- year generic

nursing science programme with NMCN accreditation. These are School of

Nursing, UNTH Enugu, School of Nursing BSH Nsukka and Department of

71

Nursing Science, Faculty of Health Science and Technology in University of

Nigeria Nsukka, Enugu Campus respectively, and they are selected for this

study. The school of Nursing ESUT Hospital Parklane had their accreditation

status withdrawn by the NMCN in 2013 therefore will not be used in this

study.

[

Department of Nursing Sciences, University of Nigeria, Enugu Campus

(UNEC) came into existence in 1983 and commenced with a 3 year post

basic degree programme in three areas of specialty namely Nursing

Education, Nursing Administration and Public Health Nursing. In

2004/2005 academic session the department started a 5 year generic degree

programme in nursing sciences leading to the award of B.N.Sc degree. The

department is located at North-East region of the university which is located

in Enugu South Local Government Area of the State. It has 3 standard

classrooms, library, hostels, demonstration room etc. The department also

has about 20 teachers with other guest lecturers and 445 students. The

department was chosen because it is the only programme in the state that

offers generic nursing programme with NMCN accreditation. Their clinical

sites are located at UNTH Ituku Ozalla, at the health centres in the

communities within Enugu and Federal Neuropsychiatric Hospital Enugu.

The School of Nursing, UNTH Enugu, was initially established as a specialist

hospital school of nursing but later approved for training of general nurses

in 1971. On April 1st 1973, the school became the school of Nursing UNTH

Enugu. The school is located at the South-West region of the old site UNTH

72

Enugu which is located at Enugu North Local Government Area of the state.

The school was chosen for the study because it is the only teaching

hospital’s basic school of nursing in the state with NMCN accreditation. The

school has 3 standard classrooms, library & hostels both for the male &

female students all within the school premises. It has about ten teachers

with many guest lecturers and a total of about 175 students. But most of

their clinical sites are located at Ituku Ozalla in Nkanu West LGA of Enugu

State, the various health centres within the communities in Enugu and

Federal Neuropsychiatric Hospital Enugu.

[

The School of Nursing, Bishop Shanahan Hospital, Nsukka was established

in 1962 for training Nigerian registered nurses under the private mission

hospital built by His Grace Most Rev. Dr. Charles Henry CSSP of blessed

memory. It was closed down during the war and was reopened again in 1970

after the war. The school was chosen for this study because it is the only

mission owned school of nursing in the state accredited by NMCN. It is

situated towards the North West region of the hospital in Nuskka metropolis

Nsukka LGA of Enugu State. It has standard classrooms, students’ hostels,

about 10 teachers with several guest lecturers. Their clinical sites are

located within their hospital, at UNTH Ituku Ozalla, National Orthopaedic

Hospital Enugu, Federal Neuropsychiatric Hospital Enugu and the various

health centres within the various communities at Nsukka.

73

Population of study

The target population for the study included all the 4th and 5th year generic

nursing students in the Department of Nursing Sciences, UNEC, totalling

two hundred and twenty two (222) and all the 2nd and 3rd year nursing

students from the two basic nursing schools (UNTH Enugu, one hundred

and twenty-two (122) students and BSH Nsukka- ninety-eight (98)) giving a

total target population of four hundred and forty two (442) students. These

groups of students have had up to six months to one year or more clinical

training and can give better account of their experiences in the clinical

learning environments.

s

Sample

The total population of four hundred and forty two (442) student nurses was

used for the study because of its small size. However, because all the

subjects may not be around at the time of data collection, only those who

met inclusion criteria were used thus:

Inclusion criteria

1. Students in 4th and 5th year of study in the Department of Nursing

Sciences, UNEC.

2. 2nd and 3rd year student nurses in the 2 selected hospital-based

schools of nursing (UNTH, Enugu and BSH, Nsukka).

3. Physical presence of students at the time of data collection.

4. Willingness of the students to participate in the study.

74

Sampling procedure

Purposive sampling technique was used to select class level of the students;

the two hospital- based schools of nursing and one university-based nursing

programme with NMCN accreditation in the state. And because all the

nursing students in the selected years of study were used, there was no

sampling procedure used for the selection of the number of subjects.

Instrument for data collection

The instrument used for data collection was the researcher’s designed

questionnaire. The items in the questionnaire were generated from the

literatures reviewed based on the objectives set for the study to elicit

information from the students on the topic of study. The instrument has two

sections, A and B. Section A comprises the respondents’ demographic

characteristics. Section B contains items designed to address the research

objectives, questions and hypotheses. Items 6-75 were presented on a 4-

point Likert type scale ranging from strongly disagree (1) to strongly agree

(4). There are four subscales namely: clinical placement (18 items), clinical

teaching (25 items), clinical supervision (17 items) and clinical evaluation

(10 items). Negative items were scored in reverse manner. A copy of the

questionnaire is attached in appendix I.

Validity of instrument

The face and content validity of the questionnaire was carried out by project

supervisor and two senior lecturers in the Department of Nursing Science,

University of Nigeria, Enugu Campus and Department of Statistics, Nnamdi

75

Azikiwe University, Awka, who are experts in Nursing Education and

Measurement and Evaluation respectively. They examined the items in line

with purpose, objectives and the hypotheses set for the study. They also

assessed the language used in developing the instrument, made necessary

modifications and their input and suggestions were effected. Items were re-

arranged according to the item response group. The final draft of the

instrument was submitted to the researcher’s supervisor who approved it

after effecting the due corrections.

Reliability of Instrument

In order to establish the reliability of the instrument, a pilot survey was

carried out. Copies of questionnaires were administered to 40 student

nurses at School of Nursing Amachara, Ministry of Health Umuahia Abia

State and Department of Nursing Sciences Ebonyi State University using

test-retest method within two weeks interval. These nursing students are

similar to the group under study. The instrument was re-administered to

the same group of students after two weeks. The two sets of scores were

correlated using Pearson Product Moment Correlation statistics and the

coefficient of reliability of 0.970 was obtained which showed a high value.

This made the instrument reliable for data collection. (See appendix II).

Ethical considerations

Ethical clearance was obtained from the ethical committees of the University

of Nigeria Teaching Hospital Ituku Ozalla Enugu. Further permission was

also obtained from each school’s authority after presenting the introductory

letter from the head of Department of Nursing Sciences UNEC and

76

explaining the nature and purpose of the research to them. All participants

were fully informed of the objectives and design of the study. Copies of the

informed consent, introductory letter from the head of Department of

Nursing Sciences UNEC, permission letter to the principal of School of

Nursing Bishop Shanahan Hospital Nsukka and ethical clearance certificate,

are attached in appendices V, VI, VII and VIII respectively.

Procedure for data collection

The data collection was done by the researcher with the help of six trained

research assistants. The assistants were trained on the purpose of the study

and on how and whom to administer the questionnaire. Questionnaires were

administered to students on the spot in the classroom setting and were

collected immediately students reacted to them. It took about 15 to 20

minutes to react to the questionnaire. Data collection lasted for 7 weeks.

Method of Data Analysis

The data obtained from the instrument were collated, tallied and analyzed

using Statistical Package for Social Science (SPSS) version 17. Using

descriptive statistics, the means and standard deviations of the responses

were determined item by item and subscale by subscale. The total value of

the modified four point Likert scale for perceptions of clinical nursing

training is 10. The criterion (average) mean is 2.50. Mean scores of 2.50 and

above denotes acceptance of assertion, while the mean score below 2.50

denotes rejection of assertion. The higher the mean score for each item, the

better the perception and the reverse is the case. The inferential statistics,

specifically multiple t - test was employed for testing of the hypotheses at

77

0.05 level of significance. The mean standard deviations and t-test were

extracted and presented in Tables which answered the objectives.

78

CHAPTER FOUR

PRESENTATION OF RESULTS

The results of the data analysis are presented in this chapter. Out of the

four hundred and forty-two (442) copies of the questionnaires administered

to the respondents, four hundred and forty-one (441) were returned,

properly filled in and fit for analysis. This gives a 99.77% return rate. The

results of the data analyses were presented in Tables according to the stated

objectives and hypotheses that guided the study.

Demographic Characteristics of Respondents

Descriptive statistics involving frequencies and their percentages were used

to analyze data on demographic profiles of the respondents. The results of

the analysis were presented in Table 1 below.

79

Table 1: Demographic Characteristics of the Respondents

n = 441

S/N Variables f % 1. Name of institution Department of Nursing Science, UNEC 222 50.3

School of Nursing, UNTH 122 27.7

School of Nursing, Bishop Shanahan Nsukka Total

97 441

22.0 100

2. Type of programme University-based Nursing Students 222 50.3

Hospital-based Nursing Student 219 49.7 Total 441 100 3. Year of study Year 2 Year 3 Year 4 Year 5

100 (SON) 22.6 119 (SON) 27.0 123 27.9 99 22.4

4. Age (years) <20 181 41.0 20-24 203 46.0 25- 29 39 8.8 30 – 34 18 4.1

Mean age 25.6 (+ 2.7) years 5. Gender Male 59 13.4 Female 382 86.6

The results on Table 1 showed that 222 (50.3%) of the nursing students

used in this study were from Department of Nursing Sciences, UNEC which

constituted the university-based nursing students, while 122 (27.7%) and

97 (22.0%) of them were from School of Nursing, UNTH Enugu and School of

Nursing, Bishop Shanahan Hospital, Nsukka respectively which constituted

hospital-based nursing students. 100 (22.6%) and 119 (27.0%) of the

80

respondents were 2nd and 3rd year hospital-based student nurses

respectively, while 123 (27.9%) and 99 (22.4%) of the respondent are 4th and

5th year university based student nurses respectively. Majority 373 (84.6) of

respondents were within the age range of 20-29 years. The mean age of the

students was 25.6 (± 2.7). Majority of the respondents 382 (86.6%) were

females while 59 (13.4%) were males.

Objective 1: To determine the nursing students’ opinion of their

placement into the clinical learning environment/setting.

Students’ responses to the 18 items generated to realize this objective were

subjected to descriptive analysis using means and standard deviation. Data

were analyzed item by item and the mean scores and standard deviations for

each item presented on Table 2 below.

81

Table 2: Mean score and standard deviations of nursing students’

opinion of their placement into the clinical learning environment/

setting with their ranking.

n = 441

S/N Items Sum Mean Stdev Rank

6

Students opinion of their clinical placement

Students are actively involved in planning for the clinical placement

969

2.20

1.04

18

7 The orientation I received for the placement was adequate

1181 2.68 0.83 5

8 The duration for each clinical placement and exposure was adequate

1137 2.58 0.99 8

9 All the placements were timetabled 1331 3.02 0.90 1

10 The placement period was put to good use 1261 2.86 0.89 4

11 The placement gave me the opportunity to learn with students from other discipline

1308 2.97 0.88 2

12 Rotation to necessary specialist clinical units were adequate e.g. theatre, obstetric and gynae, med-surg, etc.

1190 2.70 0.98 5

13 Clinical setting (environments) were well organized

1146 2.60 0.95 7

14 Reasonable accommodation was made available for the student during outstation posting

984 2.23 1.01 17

15 Transport arrangements during the placement were adequate

1020 2.31 1.04 15

16 Aesthetic aspects of the physical infrastructure were adequate

1053 2.39 0.90 14

17 Access to leisure activities during the clinical posting was always allowed

1010 2.29 0.96 16

18 Reasonable steps were taken to ensure that the health of the students were not jeopardized during placement

1061 2.41 0.96 13

19 There was a positive atmosphere for learning throughout the period of the posting

1130 2.56 0.88 10

20 The clinical sites and faculty provide me with procedure book and movement scattergram during placement

1132 2.57 0.90 9

21 It improved my interpersonal relationship and skills

1303 2.95 0.84 3

22 Clinical learning environment was conducive in all clinical setting

1108 2.51 0.84 11

23 The nurses at the clinical setting were friendly and easy to approach throughout the period posting and rotation

1109 2.51 0.83 12

Subscale mean 2.57 0.51

82

The result on Table 2 shows the means scores and standard deviations of

each of the 18 items on nursing students’ opinion of their placement into

the clinical learning environment/setting. The item mean scores and

standard deviations for the 18 items on clinical learning

environment/setting ranged from 2.20 (SD = 1.01) to 3.02 (SD = 0.90).

The result shows that twelve (12) items had mean scores above 2.5 which is

the scale critical mean ranging from 2.51 (SD = 0.83) to 3.02 (0.90) while the

remaining six (6) items had mean scores below 2.5 ranging from 2.20 (SD =

1.04) to 2.41 (SD = 0.96). The findings that “All the placements were

timetabled” (Mean = 3.02; SD = 0.90); “The placement gave me the

opportunity to learn with students from other discipline” (Mean = 2.97; SD =

0.88); and “It improved my interpersonal relationship and practical (clinical)

skills” (mean = 2.95; SD = 0.84) were the three highest scored items in

placement into the clinical learning envrionment/setting subscale. The

items, “Students are actively involved in planning for the clinical placement”

(Mean = 2.20, SD = 1.04), “Reasonable accomodation was made avaliable for

student’s during outstation posting” (Mean = 2.23; SD = 1.01); and “Access

to leisure activities during the clinical posting was always allowed” (Mean =

2.29; SD = 0.96) were the three least scored items. The higher the item

mean score, the higher or more positive the students perception about their

placement into the clinical learning environment/setting and the reverse is

the case.

83

Objective 2: To ascertain the nursing students’ view of clinical teaching

The responses to the twenty five (25) items generated to realize this objective

were subjected to descriptive analysis using means and standard deviations.

The data were analyzed item by item and the means and standard

deviations for each of the 25 items in the clinical teaching subscale were

presented on Table 3 below.

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Table 3: Mean scores and standard deviations of nursing students’ view about clinical teaching with their ranking.

n = 441 S/N Items Sum Mean Stdev Rank 24

Students view of clinical teaching The clinical instruction was student centered

1119

2.54

0.84

16

25 The instruction was stimulating 1150 2.61 0.84 9 26 The clinical teaching contents were well organized 1074 2.44 0.85 21 27 The instructor challenged me to understand ideas and

concept 1133 2.57 0.87 13

28 The instructor encouraged me to ask questions 1295 2.94 0.83 1 29 The instructor communicated concept clearly 1166 2.64 0.86 5 30 The procedure and log books were accurate and useful

during the teaching 1165 2.64 0.93 6

31 There was a good coverage of the clinical instruction curriculum

1086 2.46 0.90 18

32 The teaching and learning materials were always provided

962 2.18 0.89 25

33 The facilities were always in good condition (adequate) 986 2.24 0.91 24 34 The clinical instructors were adequate in number 991 2.25 0.90 23 35 Varied teaching tips like preparation introduction,

interaction and summarization were used by the clinical instructor.

1063 2.41 0.88 22

36 Varied clinical teaching styles (methods) were used by the instructors

1082 2.45 0.89 19

37 I was taught by a number of difference clinical instructors

1137 2.58 0.94 12

38 The clinical teachers had good bedside manner 1111 2.52 0.86 17 39 Patients were involved during clinical teaching when

necessary 1128 2.56 0.92 14

40 In my opinion, all the clinical instructors were capable of integrating theoretical knowledge and the practical knowledge

1082 2.45 0.86 20

41 I felt socially comfortable in teaching sessions 1147 2.60 0.86 11 42 Opportunities are given to express my opinion and

develop interpersonal skills during teaching sessions 1152 2.61 0.88 10

43 I was encouraged and allowed to participate actively in the teaching and learning sessions

1282 2.91 0.87 3

44 Opportunities were given to me for demonstration of clinical skills learnt like carrying out basic nursing tasks

1286 2.92 0.89 2

45 I was able to constantly use the learning materials provided for practical demonstration

1205 2.73 0.89 4

46 I was able to participate in the clinical professional development events like research

1128 2.56 0.94 15

47 I was opportuned to develop collaboration and communication skills with members of other disciplines during the teaching.

1162 2.63 0.90 8

48 In my opinion the quality of clinical teaching and learning was good

1165 2.64 0.86 7

Subscale mean of means. 2.56 0.53

85

The results presented on Table 3 above shows the mean scores and

standard deviations of each of the 25 items on students’ view about clinical

teaching. The item mean scores and standard deviations for the 25 items on

this subscale ranged from 2.94 (0.83) to 2.18 (0.89). The result shows that

majority (17) of the items in this subscale had mean scores above 2.5,

ranging from 2.52 (SD = 0.86) to 2.94 (SD = 0.83) while the remaining eight

(8) items had mean scores below 2.5 ranging from 2.18 (SD = 0.89) to 2.46

(SD = 0.90). The 3 highest scored items in this subscale were “The instructor

encouraged me to ask questions” (Mean = 2.94; SD = 0.83); “Opportunities

were given to me to demonstrate clinical skills learnt like carrying out basic

nursing tasks” (Means = 2.92; SD = 0.89); and “I was encouraged and

allowed to participate actively in the teaching and learning session” (Mean =

2.91; SD = 0.87). The three (3) lowest scored items were “The teaching and

learning materials were always provided” (Mean = 2.18; SD = 0.89); “The

facilities were available and in good condition” (2.24; SD = 0.91); and “The

clinical instructors were adequate in number” (Mean = 2.25; SD = 0.90). The

higher the items mean score, the better the students’ view of their clinical

teaching experience.

Objective 3: To identify the nursing students’ view about clinical

supervision.

The responses to the seventeen (17) items generated to realize this objective

were subjected to descriptive analysis using means and standard deviations.

The data were analysed item by item and the means and standard

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deviations for each of the 17 items in the clinical supervision subscale were

presented on Table 4 below.

Table 4: Mean scores and standard deviations of nursing students’ view

about clinical supervision with their ranking

n = 441

S/N Items Sum Mean Stdev Rank

49

Students’ view of clinical supervision The clinical instructor and supervisors have adequate training knowledge and skills to supervise

1216

2.76

0.88

1

50 The supervisors were transparent 1139 2.58 0.82 3 51 The supervisors were friendly 1115 2.53 0.85 4 52 The supervisors evidenced a personal interest in

my success 1097 2.49 0.85 7

53 The clinical supervisors do not belittle and intimidate students

1069 2.42 0.97 10

54 The supervisor takes responsibility 1164 2.64 0.87 2 55 Supports from clinical supervisors were adequate 1080 2.45 0.81 9 56 Supports of teachers from the school were

adequate 1113 2.52 0.89 5

57 There was good support system for student who encountered difficulties

1056 2.39 0.90 12

58 The supervisory relationship was characterized by a sense of trust and mutual relationship

1050 2.38 0.88 14

59 The staff were generally interested in students supervision

1102 2.50 0.91 6

60 I received group supervision which was adequate 1059 2.40 0.87 11 61 I received individual supervision which was

adequate 1056 2.39 0.93 13

62 The supervisors were always available 998 2.26 0.91 17 63 The supervisors were always accessible 1044 2.37 0.89 15 64 The supervisors show respects for students 1033 2.34 0.87 16 65 The supervisors had good rapport with students

Subscale mean 1087 2.46

2.46 0.89 0.54

8

The result on Table 4 shows the mean scores and stand deviations of each of

the 17 items on the nursing students view about clinical supervision

subscale. The item mean scores and the standard deviations of the 17 items

in this subscale ranged from 2.26 (SD = 0.91) to 2.76 (SD = 0.88). The result

also show that 6 out of the 17 items in this subscale had mean scores of 2.5

and above which is higher than the scale critical mean of 2.5 ranging from

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2.5 (SD = 0.91) to 2.76 (SD = 0.88). The 3 highest scored items in this

subscale were “The clinical instructors and supervisors have adequate

training knowledge and skills to supervise “(Mean = 2.76; SD = 0.88); “The

supervisor takes responsibility” (Mean = 2.64; SD = 0.87); and “The

supervisors were transparent” (Mean = 2.58; SD = 0.82). The remaining

eleven (11) items had mean scores below 2.5 ranging from 2.26 (0.91) to

2.49 (SD = 0.85). The 3 lowest scored items were “The supervisors were

always available” (Mean = 2.26; SD = 0.91). “The supervisors show respect to

students” (Mean = 2.34; SD = 0.87); and “The supervisors were always

accessible (2.37; SD = 0.89). The average mean score for the clinical

supervision subscale was 2.46 (SD = 0.54). The higher the item mean score,

the better the students’ view of their clinical supervision experience and the

reverse is true.

Objective 4: To assess the nursing students’ perception of clinical

evaluation.

Students’ responses to the ten (10) items generated to realize this objective

were subjected to descriptive analysis using means and standard deviations.

Data were analyzed item by item and the means and standard deviations for

each item in the clinical evaluation subscale were presented on Table 5

below.

88

Table 5: Mean scores and standard deviations for nursing students’

perceptions of clinical evaluation and their ranking

n = 441

S/N Items Sum Mean Stdev Rank

66

Students’ perceptions of clinical evaluation I was evaluated in each unit of practice

1105

2.51

0.91

9

67 My clinical performance was evaluated only at the end of each semester

1181 2.68 0.90 4

68 I was given opportunity for self assessment 1112 2.52 0.95 8 69 The clinical evaluators were able to use

assorted techniques (strategies) like continuous assessment, assignment and examination

1230 2.79 0.96 2

70 The clinical evaluators were good at providing constructive criticism and feedback

1168 2.65 0.86 6

71 Through feedback, my strengths were reinforced and errors corrected

1173 2.66 0.91 5

72 The faculty informed me of the grading methods in practical exam

1117 2.53 0.98 7

73 I was duly informed of the duration and period of clinical evaluation

1282 2.91 0.93 1

74 The evaluator consistently informed me of my progress

1024 2.32 0.90 10

75 Assignment that required critical and creative thinking were provided or given Subscale mean

1185 2.69 2.63

0.95 0.54

3

The results on Table 5 show the means and standard deviations of each of

the 10 items on nursing students’ perception of clinical evaluation. The item

mean scores and the standard deviations ranged from 2.32 (SD = 0.90) to

2.91 (SD = 0.93). The result indicated that all the 10 nursing students’

perceptions of clinical evaluation statements, except item 74 (“The evaluator

consistently informed me of my progress” with item mean of 2.32; SD = 0.90

which is below the mean criterion value of 2.50) were scored above 2.50. The

3 highest scored items were, “I was duly informed of the duration and period

of clinical evaluation” (Mean = 2.91; SD = 0.93); “Assorted techniques were

used for clinical evaluation” (Mean = 2.79; SD = 0.96); and “Assignments

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that required critical and creative thinking were given” (Mean = 2.69, SD =

0.95). The 3 lowest scored items were, “The evaluator consistently informed

me of my progress” (Mean = 2.32; SD = 0.90); “I was evaluated in each unit

of practice” (Mean = 2.51; SD = 0.91); and “I was given opportunity for self

assessment” (Mean = 2.52; SD = 0.95). The averages mean score (mean of

means) for the clinical evaluation subscales was 2.63 (SD = 0.54) while the

total subscale mean was 26.25 (SD = 5.40). The higher the item mean

scores, the better the students’ perception of their clinical evaluation

experience.

Objective 5: To determine the students overall perception of

clinical nursing training.

To realize this objective, data collected from 441 nursing students were

analyzed item by item using descriptive statistics to indicate the mean

scores of students to each items with their corresponding standard

deviations in each subscale at 95% confidence interval (C.I.). The students’

total mean score on the “Students’ Perception of Clinical Nursing Training

Questinnaire (SPCNTQ) was 178.56 (SD = 37.86). Comparisons of the four

subscales, each with a different number of items, was facilitated by the use

of an adjusted mean derived by dividing the total mean score of each

subscale by the number of items in that subscale. The item means of the 70

students’ perceptions of clinical nursing training statements ranged from

2.18 to 3.02 (SD = 0.89 – 0.90)

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Table 6: Adjusted mean scores and standard deviations for students’

perceptions of clinical nursing training for each subscale

Subscale Number of items Mean Stdev 95%CI

Placement to clinical learning environment/setting.

18 2.57 0.51 2.53-2.62

Clinical teaching and learning 25 2.56 0.53 2.51-2.61 Clinical supervision 17 2.46 0.54 2.41-2.51 Clinical evaluation 10 2.63 0.54 2.57-2.68 Grand mean Mean

10.22 2.55

2.12 0.53

10.02- 10.42 2.51 – 2.61

The result on Table 6 showed the adjusted mean scores and the standard

deviations of the nursing students’ perceptions of clinical nursing training

for each subscale. The mean scores and the standard deviations for the 4

subscales ranged from 2.46 (SD = 0.54) to 2.63 (SD =0.54). The highest

scored subscale is “Perception of Clinical Evaluation” (Mean = 2.63, SD =

0.54) while the lowest one is “Views about Clinical Supervision”. (Mean =

2.46, SD=0.54). The result also showed that only 1 out of the 4 subscales

had the mean scores that is lower than the critical mean of 2.50. The grand

mean and mean of means score and standard deviation are 10.22 (SD =

2.12) and 2.55 (SD = 0.53) respectively.

Test of Significance

Hypothesis 1: There is no significant difference in the perceptions of

the clinical training between university-based and hospital-based

nursing students.

The mean scores of nursing students’ perceptions of the 4 subscales in

clinical training of university based and hospital based nursing students

91

were computed using multiple t-tests. The results of the t-test analysis were

presented on Table 7 below.

Table 7: Showing differences in perceptions of clinical training between

university and hospital-based nursing students.

Type of Institution t-test for Equality of Means

Subscale University-based Hospital-based t-test df p-value Nursing Students Nursing students (n=222) (n=219) Mean SD Mean SD

Opinion about placement to clinical setting/environment

2.29 0.37 2.86 0.47 - 14.02 439 0.000

Views about clinical teaching/learning

2.33 0.43 2.80 0.51 -10.439 439 0.000

Views about clinical supervision

2.28 0.48 2.66 0.53 -7.977 439 0.000

Perception of clinical evaluation Mean

2.44 0.45 2.35 0.37

2.82 0.57 2.78 0.45

-7.696 -11.246

439 439

0.000 0.000

From the result shown on Table 7 above on the perception of the clinical

training between the university-based and hospital-based nursing students,

the university-based nursing students had mean and standard deviation of

2.29 ± 0.37 while the hospital-based nursing students had mean and

standard deviation of 2.86 ± 0.47 on their opinion of placement to the

clinical setting/environment. This result is significant. On their views about

clinical teaching (instruction) /learning, the university-based nursing

students had mean and standard deviation of 2.33 ± 0.43 while the hospital-

based nursing students had 2.80 ± 0.51 and the result is also significant.

On their views about clinical supervision, the university-based nursing

students had mean and standard deviation of 2.28 ± 0.48 while the hospital-

based student nurses had 2.66 ± 0.53. This is also significant. The

university-based nursing students also had mean and standard deviation of

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2.44 ± 0.45 while the hospital-based nursing students had mean and

standard deviation of 2.82 ± 0.57 on their perception of clinical evaluation.

This is significant.

On their overall average perception of clinical training, the university-based

nursing students had an average mean and standard deviation of 2.35 ±

0.37 while the hospital-based nursing students had mean and standard

deviation of 2.79 ± 0.45. This result is significant. The hypothesis is rejected

(P < 0.05, t-value = -11.246) and therefore, there is significant difference in

the nursing students’ perceptions of the clinical training between the

university-based and hospital-based nursing students. This implies that the

hospital-based nursing students have positive perceptions of the clinical

training while the university-based nursing students have negative

perceptions of clinical training.

Test of Significance

Hypothesis 2: There is no significant difference in perception of the

clinical training based on gender.

The mean scores of nursing students’ perceptions of the 4 subscales in

clinical training of the male and female nursing students were computed

using multiple t-tests. The results of the t-test analysis were presented in

Table 8 below.

93

Table 8: Showing differences in perceptions of clinical training between

male and female nursing students.

Subscale Gender t-test for Equality of Means

Male (n=59) Female (n=382) t-test df p-value Mean SD Mean SD Opinion about placement to clinical setting/environment

2.61 0.52

2.57 0.51

0.600

439

0.549

Views about clinical teaching/learning

2.65 0.55 2.55 0.52 1.292 439 0.197

Views about clinical supervision

2.59 0.55 2.45 0.53 1.924 439 0.055

Perceptions of clinical evaluation Mean

2.73 0.57 2.65 0.46

2.61 0.55 2.56 0.46

1.509 1.390

439 439

0.132 0.165

From the result shown in Table 8 above on the perceptions of the clinical

training between male and female nursing students, the males had mean

and standard deviation of 2.61 ± 0.52 while the females had 2.57 ± 0.51

respectively on their opinion of placement to clinical setting/environment

subscale. This result is not significant. The males also had mean and

standard deviation of 2.65 ± 0.55 while females had 2.55 ± 0.52 respectively

on their views about clinical teaching (instruction)/learning and this is also

not significant. On their views about clinical supervision, the male nursing

students had mean and standard deviation of 2.59 ± 0.55 while the female

student nurses had mean and standard deviation of 2.45 ± 0.53

respectively. This result is significant. On their perceptions of clinical

evaluation, male student nurses had mean and standard deviation of 2.73 ±

0.57 while the female students had 2.61 ± 0.55 respectively and this is not

significant.

94

On their overall perceptions of clinical nursing training, the male nursing

students had an average mean and standard deviation of 2.65 ± 0.46 while

the female students had 2.56 ± 0.46 respectively. This is not significant. The

hypothesis is accepted (P > 0.05, t-value = 1.390) and therefore, there is no

significant difference in perceptions of the clinical training based on gender

among the nursing students.

Summary of Findings

The following findings were made from the analysis of the data presented in

chapter four.

• The three highest mean scored items on placement into the clinical

setting were “All the placements were timetabled” (Mean 3.02); “The

placement gave me the opportunity to learn with students from others

discipline” (Mean 2.97) and “It improved my interpersonal relationship

and skills” (Mean 2.95).

• The three lowest mean scored items on placement into the clinical

setting were “Students are actively involved in planning for the clinical

placement” (Mean 2.20); “Reasonable accommodation was made

available for the students during outstation posting” (Mean 2.23) and

“Access to leisure activity allowed” (Mean 2.29).

• The three highest mean scored items on clinical teaching were “The

instructor encouraged me to ask questions” (Mean 2.94);

“Opportunities were given to me for demonstration of clinical skills”

(Mean 2.92) and “I was encouraged and allowed to participate in the

teaching and learning sessions” (Mean 2.91).

95

• The three lowest mean scored items in the clinical teaching and

learning were “The teaching and learning materials were always

provided” (Mean 2.18); “The facilities were always in good condition

(adequate)” (Mean 2.24) and “The clinical instructors were adequate in

number” (Mean 2.25).

• The three highest mean scored items in the clinical supervision are

“The clinical instructors and supervisors have adequate training,

knowledge and skills to supervise” (Mean 2.76); “The supervisors take

responsibility” (Means 2.64) and “The supervisors were transparent”

(Mean 2.58).

• The three lowest mean scored items in the clinical supervision were

“The supervisors were always available” (Mean 2.26); “The supervisors

show respects for students” (Mean 2.34) and “The supervisors were

always accessible” (Mean 2.37).

• The three highest mean scored items in clinical evaluation were “I was

duly informed of the duration and period of clinical evaluation” (Mean

2.91); “The clinical evaluators were able to use assorted techniques

(strategies) like continuous assessment, assignment and examination”

(Mean 2.79) and “Assignment that required critical and creative

thinking were given” (Mean 2.69).

• The three lowest mean scored items in students’ perceptions of clinical

evaluation were “The evaluator consistently informed me of my

progress” (Mean 2.32); “I was evaluated in each unit of practice” (Mean

2.51) and “I was given opportunity for self assessment (Mean 2.52).

96

• There were significant differences in the nursing students’ perceptions

of the clinical training between the university-based and hospital-

based students.

• The university-based nursing students had negative perceptions about

their clinical training in all the subscales, while the hospital-based

student nurses attracted positive perceptions about their clinical

training in all the subscales.

• There was no significant difference in the perception of clinical

nursing training based on gender.

• Female nursing students had negative views about clinical supervision

(Mean 2.45), while the male students had positive views about clinical

supervision (Mean 2.59).

97

CHAPTER FIVE

DISCUSSION OF FINDINGS

This chapter presents the discussion of the major findings of the study,

implications for nursing education and practice and limitations of the study.

The conclusion drawn from the findings, a brief summary of the entire work,

recommendations based on the findings, as well as suggestions for further

researches were also highlighted. The findings were discussed in line with

the research objectives and hypotheses that were formulated to guide the

study.

Nursing students’ opinion about placement into the clinical learning

environment/setting

The findings indicated that “All placements were timetabled” (Mean 3.02);

“The placement gave the nursing students the opportunity to learn with

students from other discipline” (Mean 2.97) and “It improved their

interpersonal relationship and skills” (Mean 2.95). The possible explanation

for these three highest scored items could be due to the effort of the school

to ensure that students posting and rotation to different specialist clinical

units are covered and the students offered the opportunity to work directly

with competent professional nurses for patients in a particular area of

expertise, develop their interpersonal skills with and learn from staff and

students from other discipline. This findings support the findings in the

study done by Saarikoski, Leino-Kilpi and Warne (2002) that Finnish

students evaluated their clinical placement more positively than students in

98

UK. The above findings and explanations are supported by Chan 2002 who

stated that, it is during clinical placement that students are expected to

develop the relevant knowledge, skills, competence and expand the

perceptions of their further role as registered nurses. American Association

of Clinical Nursing (2002) also supported this by stating that clinical site-

based learning provides the students opportunities to work with

interdisciplinary teams, role models and preceptors while students develop

coordination, collaboration and communication skills when working with

members of other disciplines for the purpose of improving the health status

of clients.

The findings clearly portray that, the students were not involved in planning

for their placement into the clinical setting (Mean 2.20), reasonable

accommodations not provided during outstation posting and access to

leisure activities during the clinical posting (Mean 2.23) was not always

allowed (Mean 2.29). The possible explanation for this could be lack of

knowledge of and inability to follow strictly the guideline for clinical

placement, improper arrangement by the school and the clinical setting for

the accommodation of the students during outstation posting. The findings

were supported by a study carried out by Papathanassiou, Tsaras and

Sarafis (2013) which showed a noticeable gap between the expectations of

the students and the reality of the clinical learning environment. The result

also affirms the statement of Papp (2003) that if the environment is

unpredictable, unstructured and overwhelming, students can be left with

feelings of vulnerability and anxiety. It also affirms the statement made by

99

University of Queensland (2005) that the placement should be in accordance

with the guideline agreed between the school, the placement facility (clinical

setting) and the accrediting body (NMCN). The result also differs from that of

the study of Leino-Kilpi et al (2009) in Cyprus and Finland on student

nurses experiences of learning in the clinical learning environment which

showed that students perceived their clinical placement as good, though the

Cypriot student nurses evaluated their ward environment with lower scores.

In relation to the type of programme, university-based nursing students had

low perceptions of placement to clinical setting (Mean 2.29) while the

hospital-based nursing students had higher perceptions of placement to the

clinical setting (Mean 2.86). The possible explanations for the low or negative

opinion of the university-based nursing students may be attributed to late

exposure to clinical experiences which starts towards the end of their 3rd

year of study compared to the hospital based student nurses. This could

have resultant negative effects on other aspects of their clinical training.

This finding is in agreement with the findings of the study carried out by

Odunukwe (2015) in UNEC, Nigeria using undergraduate 500 level nursing

students on perspective of clinical posting experience. The result showed

that many of the students perceived that the timing of their clinical postings

is late and the duration of the posting as short. Anthony and Yastik (2011)

also supported the above findings in their statement that clinical student

nurses are relatively powerless in health care setting and therefore

vulnerable targets for incivility. The higher/positive opinion of the hospital-

based student nurses towards clinical placement may be attributed to the

100

fact that they have early exposure (from their first year) to the clinical

setting, get acquainted to the staff nurses, activities in the clinical setting

earlier and develop good relationship with the nurses. This is in agreement

with Nahan and Yam (2001) who stated that relationship with staff of the

units and staff attitude towards the students are the two most important

factors that affect clinical learning. Students are more motivated and eager

to attend clinical posting when they feel that they are part of the health-care

team.

Nursing students’ view about clinical teaching and learning

The findings in Table 3 clearly portray that the instructor encouraged the

students to ask questions (Mean 2.94); opportunities were given to the

students for demonstration of clinical skills learnt like carrying out basic

nursing tasks (Mean 2.92) and the students were encouraged and allowed to

participate actively in the teaching and learning sessions (Mean 2.91)

respectively. These are commendable and may be attributed to the fact that

the instructors want to encourage the students to understand and

consolidate what they learnt in the classroom with what is on ground in the

clinical setting. This finding supports the study of Chapman and Angelica

(2000) in Hussserlian School of Phenomenology Western Australia titled

“The nursing students lived experiences of clinical practice which revealed

that the relationship students had with their clinical teachers was

fundamental in the process of learning This result is also in line with the

statement of Benis (2000) which says that for clinical training to be effective

and to bring about positive and skillful result, the things taught in the

101

classroom must be repeated and practiced in the wards for students to

understand them better. The findings are also in agreement with the

statement of Ramani and Leinster (2008) that in preparation for effective

ward teaching, the teachers should ask themselves a set of questions like

how will the learner be engaged and how will they meet the needs of each

learner. Hewamana and Brigley (2007) also supported this finding by noting

that bedside teaching can improve students’ history taking and examination

skills.

The findings still emphasized the fact that the clinical teaching and learning

materials were not always provided (Mean 2.18); the facilities were not

always in good working condition (Mean 2.24) and the clinical instructors

were not adequate in number (Mean 2.25). These results may be due to non

maintenance of the available materials, workload, shortage of staff and

clinical instructors in the clinical setting etc. The clinical instructors not

being adequate in number implies that the few available ones may not cope

with the large number of students to be taught in the clinical area and the

clinical training curriculum may not be covered. These may lead to poor

attention to students fatigue and workload leading to poor learning of the

clinical/practical skills. The lack of teaching and learning materials implies

that what is taught and learnt in the classroom may not be practiced in the

ward thereby encouraging theory-practice gap. Furthermore, all these could

jeopardize teaching and students’ learning in the clinical setting.

This result supports the result of the study of Chapman and Angelica (2000)

which showed that clinical practice with functional teaching and learning

102

material provided the students with the opportunity to link theory with the

practice of caring for client. It is also in line with one of the findings

identified in the study of Odunukwe (2015) that large class size was the

individual factor affecting clinical teaching of students. It also agreed with

some of the findings in the study of Sumari-Ayo (2006) which pointed out

that clinical instructors and preceptors were overworked due to shortage of

staff and that the hospital ward lack basic equipment and necessary

supplies. The findings also agreed with Ramani and Leinster (2008) and

Prideaux et al (2000) who stated some of the challenges of inpatient teaching

as thus: not paying close attention to the students fatigue, boredom and

workload, busy clinical setting, no time for elaborate teaching and brief

teacher students interaction.

In relation to the type of institution as reflected in Table 7, the findings also

revealed that university-based nursing students have a negative view of their

clinical instruction (Mean 2.33) compared to the hospital-based nursing

students (Mean 2.80). This may be related to their different experiences,

motivational and emotional state with clinical nursing training. University-

based student nurses may also have a better understanding of their clinical

training curriculum therefore may know when it is covered. They are better

exposed in the university community relating with students and teachers

from other departments and comparing the qualities and skills of those

teachers with that of their clinical instructors which might have contributed

to their negative view about their clinical teaching. This is in line with the

findings of the study carried by Okoronkwo et al (2013) on students’

103

perception of effective clinical teaching and teachers’ behavior using nursing

students in their 400 level at Department of Nursing Sciences UNEC. Their

result revealed that having both clinical and teaching knowledge were the

most important teaching skills for effective clinical teaching. That five

qualities ranked by students as teacher behaviors important for effective

teaching include being honest with students, motivation to teach,

willingness to listen and using good communication skills.

Nursing students’ views about clinical supervision

The finding shown in Table 4 indicated that the nursing students have

low/negative perceptions of their clinical supervision. This implies that they

are poorly supervised. The three highest scored items in this subscale (“The

clinical instructors and supervisors have adequate training, knowledge and

skills to supervise” (Mean 2.76), “The supervisor takes responsibility” (Mean

2.64) and “The supervisors were transparent” Mean 2.58) may be attributed

to the fact that some of the supervisors may have demonstrated dedication

and qualitative skills during the students’ clinical supervision and may have

certificate of clinical competence. This result supported the report of

Linifield (2012) and Newman (2013) which indicated that some of the tasks

and skills of supervision considered basic to successful clinical nursing

training include the importance of establishing and maintaining an effective

working relationship with supervisee, ongoing and open communication

between the supervisor and the supervisee, provision of the faculty and the

students with a copy of preceptor’s work schedule to assists in scheduling

students clinical days and arranging for a substitute preceptors when

104

absent. This result disagreed with one of the findings in the study of

Odunukwe (2015) on perception of students about factors influencing

clinical training which revealed that inadequate supervision of the students

was the institutional factors affecting clinical training of students.

Further interpretation of the findings showed that some of the supervisors

were not always available (Mean 2.26), accessible (Mean 2.37) and that the

supervisors did not show respect for the students (Mean 2.34). One could

probably say that the above findings may be due to selection of

inexperienced and unqualified clinical supervisors/educators and preceptors

by the school. Any available nurse on duty in the clinical area acts as

clinical supervisor. Heavy workload, poor remuneration, difficult transport

system to the clinical site (distance) and unavailability of materials to work

with, may have contributed to these.

This result agrees with that of the study carried out in Cyprus and Finland

by Leino-Kilpi, et al (2009) on “student nurses experience of learning in the

clinical environment” which showed that supervisory relationship was

problematic. This finding is also in line with some of the findings of the

study of Odunukwe (2015) which revealed inadequacies of about 56% of

supervisory skills of their supervisors in the clinical area. That most of the

student nurses used in the study perceived that most of the activities in the

clinical supervision were not carried out. This is also supported by Neary

(2000) who poised that students’ instruction and supervision appear to have

been shifted to clinical nurses only. That nurses who lack fundamental

skills in nursing research, academic training and experiences in preceptor-

105

ship still constitutes the large group of nurses who often hold functions as

clinical instructors, supervisors and evaluators. The results of this study

disagreed with that of the study of Saarikoski, Leino-Kilpi and Warne (2002)

which showed that Finish students evaluated their clinical supervision more

positively than students in UK.

The findings in Table 7 also revealed that university-based nursing students

have a negative view (Mean 2.28) about their clinical supervision compared

to the hospital-based student nurses (Mean 2.66). This may be related to the

fact that some of hospital-based trained nurses who mostly work as the

clinical supervisors do not relate well with the university-based student

nurses because of the current reform in nursing education which

emphasizes B.Sc. Degree in nursing. The hospital-based non B.sc trained

nurses have the fear and jealousy that the university-based student nurses

will take over the leadership position from them when they graduate thereby

resulting to the tendency of having more frequent supervisory sessions with

the hospital-based student nurses than the university-based student

nurses. These may result to failed supervisory experiences thereby

contributing to the negative view of clinical supervision by the university-

based nursing students. This findings support that of the study of

Papastavrou et al (2009) which revealed that the most unsatisfied nursing

students were the ones with a failed supervisory experience and that

students who had more frequent sessions with their supervisor were more

satisfied.

106

The negative views (Mean 2.45) of female nursing students in clinical

supervision as shown in Table 8 may be attributed to the popular saying

that females have more domineering and strict attitudes towards life

situations than males. They are in a position to give true/ better

interpretation of life situations and they are also the majority in this study.

This is in line with the statements of Alam and Garry (2011) which included

attitudes as one of the factors that influence perception.

Nursing students’ perception of clinical evaluation

The fact that the evaluators do not consistently inform the students of their

progress (Mean 2.32) as shown in Table 5 may be attributed to the facts that

results are not released individually to the students. Rather it is released by

the school pasting it on the notice board after addressing the students as a

group about their general performance. This result was supported by Wren

and Wren 1999) who stated that evaluation of the supervisee nursing

students typically follows a schedule provided by the university setting and

the school of nursing.

The high/positive perception of the clinical evaluation (Mean 2.63) by the

nursing students as revealed in this study in Table 5 may be attributed to

the fact that the evaluators selected by the school and NMCN are well

trained knowledgeable, attend examiners workshop and are experienced in

clinical evaluation, its goals and strategies. They follow the guiding rules

and practice the evaluation process in clinical evaluation as stipulated by

NMCN. This result supports the study of Esmaeli, Cheraghi, Salsali and

Ghiyasvandian (2013) which reported evaluation based on appropriate

107

criteria as one of the important factors in clinical education. This result is

also in line with goals and purposes of clinical evaluation of nursing

students as identified by Wren and Wren (1999) and some of them include:

identifying existing competencies and learning needs during clinical

rotation, assessing progress and making judgments of competencies met at

the end of clinical experience thereby protecting the public, satisfying

students’ expectations and meeting institutional requirements. But the

finding here differs from that of the study of Rafiee et al (2012) which

identified that from the students and their instructors point of view,

inappropriate clinical evaluation methods, problems of clinical evaluation

process and problems related to clinical instructor were considered the

important evaluation problems.

Furthermore, despite the above result, university-based nursing students

had a low perception (Mean 2.44) of the clinical evaluation compared with

hospital-based nursing students (Mean 2.82) as shown in Table 7. The

possible explanations for this may be that they are not always exposed to

continuous practical assessment in each unit of practice during every period

of experience, far distance of their clinical setting from the school and

workload of their clinical instructors. The result of this study is in line with

one of the results of the study of Odunukwe (2015) on perspective of clinical

posting experience among 500 level university-based nursing students

which showed that the achievement test in basic nursing tasks was poor.

This result and explanations also disagreed with the stipulation of NMCN

(2008) that continuous practical assessment in each unit of practice is one

108

of the patterns of examination for clinical nursing training and should be

enforced.

Nursing students overall perceptions of clinical training

The finding shown in Table 6 portray that the nursing students have an

averagely high (positive) overall perceptions (Mean 2.55) of their clinical

training. It also revealed high/positive perception of the clinical placement

(Mean 2.57), teaching (Mean 2.56) and evaluation (Mean 2.63) with the

clinical evaluation ranking the highest. But there is low or negative

perception of clinical supervision (Mean 2.46). This implies that the students

are poorly supervised.

This may be attributed to selection of inexperienced and unqualified clinical

supervisors/educators and preceptors by the school, which may bring about

poor planning and gross inefficiency on the parts of the supervisors. There

may also be non sponsorship and attendance of seminars and workshop by

the supervisors to acquaint themselves with their roles on clinical

supervision, clinical supervision formats and importance of effective clinical

supervision. The above agrees with the common saying that “one cannot give

what he or she does not have”. The poor supervision may also be as a result

of poor relationship between the clinical setting staff and the school and

“when two elephants fight the grass suffers”. So the students suffer and

when they are not well supervised, they may not give what they do not have

therefore the patients suffer.

109

These finding contrast the findings in the study of Saarikoski, Leino-Kilpi

and Warne (2002) where Finish students evaluated their clinical supervision

more positively than students in UK. This finding agrees with the statement

of Kaviani and Stillwell (2000) that the nursing school and health provider’s

relationship at clinical site is crucial in providing ongoing support. The

school has a responsibility to give the provider information about the

nursing curriculum and familiarizes them with the clinical components of

the programme so that appropriate levels of supervision can be provided.

They are also responsible for informing the nurses in the clinical setting

about the individual students, their level of attainment and the clinical

facilitators responsible for the placement. Moore (2000) also supported the

above findings by stating that supervision in clinical nursing training

enhances the implementations of evidenced based practice, inputs to

research and development agenda and is a leading implement in monitoring

the delivery of quality care to patient through supervised learning, staff

support and development.

The average overall high or positive perception of the clinical placement,

teaching and evaluation by the nursing students may be attributed to the

efforts of the schools in trying to meet up with the public demands for

quality nursing care. This result is commendable but needs quality

improvement for better quality assurance in clinical nursing training and

nursing education in general. This finding disagreed with that of the study

of Ziaee, Ahmadinejad and Moravedji (2000) where 61.2% of the medical

students showed negative satisfaction with their clinical training. But the

110

aspect of their satisfaction with clinical evaluation (the way they were tested)

agreed with the result of this study. The above finding was also supported

by Karen (2013) who stated that effective clinical setting remains the most

effective caring situation for demonstrating theoretical possibilities and

transforming the novice to beginning nurse. Duteau (2012) also supports

this finding by commenting that the benefit of clinical nursing training in

nursing education cannot be overemphasized and this is achieved through

clinical placement, teaching, supervision and evaluation.

Differences in the perceptions of the clinical training between

university–based and hospital–based programme

In comparing the results from university-based and hospital–based nursing

students in this hypothesis, the findings in Table 7 revealed that there is

significant difference in the perceptions of the clinical training between the

university-based and hospital-based nursing students (P<0.05). Significant

differences are noted in the aspects of perceptions of placement to clinical

setting, clinical teaching/learning, clinical supervision and clinical

evaluations. This result implies that the hospital-based nursing students

have a higher/positive perception of the clinical training than university-

based nursing students.

The high /positive perception of the hospital-based student nurses could be

attributed to the early exposure of hospital-based nursing students to

clinical setting from their first year during the introductory class to cover for

the stipulated number of days or hours by the NMCN and this placed them

in a better position for early assessments of and acquaintances with the

111

activities in the clinical setting. This is in line with the view of the Nursing

and Midwifery Council of Nigeria Curriculum for General Nursing

Programme (2001) which stipulates that hospital-based nursing students

must complete a minimum of 204 days or 4,400 hours in the clinical areas

before being qualified for the NMCN final qualifying exams. This takes the

patterns of study day and block system of study clinical training.

Difference in perceptions of clinical training between male and female

nursing students

The findings showed that there is no significant difference in the perception

of clinical training between male and female nursing students (P>0.05).

There is also no difference in perception of clinical training based on gender

noted in the aspects of perceptions of clinical placement, clinical teaching,

supervision and clinical evaluation. This portrays that there is no significant

difference between the way male nursing students perceive their clinical

nursing training and the way female nursing students perceive it. This

could be attributed to the fact that there is no separate and special clinical

placement, teaching, supervision and evaluation organized for male or

female nursing students. They are trained together. This result is similar

with that of the study carried out in Tehran University of Medical Science

Iran by Ziaee, Ahmadinejad and Morravedji in 2000 on “Evaluation of

medical students’ satisfaction with clinical education and its attending

factors’ which showed that there was no relationship between satisfaction

and gender.

112

The negative views of female nursing students in clinical supervision as

shown in Table 8 may be attributed to the popular saying that females have

more domineering and strict attitudes towards life situations than males.

They are in a position to give better interpretation of life situations and they

are also the majority in this study. This is in line with the statements of

Alam and Garry (2011) which included attitudes as one of the factors that

influence perception.

Implications of the study

The findings of this study have some implications as follows:

• Making adequate timetable for clinical placement will help the

students cover their postings and rotations to the various clinical

units, widen students required experiences, improve their practical

skills, and the students offered the opportunity to work directly with

competent professional nurses for patients in a particular area of

expertise.

• Offering the students opportunity to learn with students from other

discipline and improving their interpersonal relationship and skills

during the placement will help the students develop collaboration,

coordination and communication skills they can apply in patient care

during and after the training.

• Not involving the student nurses in planning their placement into the

clinical setting may lead to lack of interest and motivation in the

actual carrying out of the plan.

113

• Lack of reasonable (enough, comfortable on the closeness to clinical

setting) accommodation and access to leisure activities during

outstation posting will expose the students to feelings of anxiety and

vulnerability and then poor social development which interfere with

the clinical training and learning.

• Encouraging students to ask questions, giving them opportunity for

demonstration of clinical skills and allowing them to participate

actively in the clinical teaching and learning sessions will help them

develop proficiency in those skills and become competent trained

nurses after the training.

• Non provision of the clinical teaching and learning materials (like

bedsheets, trolleys, dressing packs, B/P apparatus etc), the available

ones not being in good working condition and the clinical instructors

not being adequate in number will not allow the students to do proper

practice of the clinical skills thereby preventing the students from

linking theory with the practice of caring for clients.

• Having adequate training, knowledge, responsibility and transparency

by the clinical supervisors will help them demonstrate qualitative

skills beneficial to students during the clinical supervision.

• The supervisors not being available, accessible and not showing

respect to the students will make them not to carryout adequate

supervision of the students, permit the students to work on their own

and learn wrongly thereby exposing the students and the patients to

serious danger.

114

• Informing the students of the duration and period of clinical

evaluation, use of assorted technique and giving assignments that

require critical and creative thinking will help the students to be well

prepared for the clinical skills being evaluated on.

• Not consistently informing the students of their progress individually

will deny them the opportunity for self-assessment and effort for self

improvement.

• Because there are significant differences in the perceptions of clinical

nursing training between the university-based and hospital-based

nursing students, there may be differences in the quality of clinical

skills acquired by the students of the different programmes leading to

inadequate or adequate quality of care rendered to patients.

• Finally, because there is no significant difference in perception of

clinical training between the male and female student nurses, there is

no separate or special clinical placement, teaching, supervision and

evaluation organized based on gender.

Limitations of the Study

There is a great limitation of literatures for this work. Time constraints

prevented this study from covering the nursing students in other basic

nursing programmes in the southeast geopolitical zone.

115

Summary

This study was carried out to assess the nursing students’ perceptions of

clinical training in selected nursing programmes in Enugu State. The

objectives that guided the study were to:

• Determine the nursing students’ opinion of the placement into the

clinical learning environment/setting.

• Ascertain the nursing students’ view about the clinical teaching

(instruction).

• Identify the nursing students’ views about clinical supervisions.

• Assess the nursing students’ perceptions of clinical evaluation.

• Determine the students overall perception of clinical nursing training.

Relevant literatures were reviewed to cover the objectives. The research

design used was descriptive cross-sectional survey. 441 out of the 442 2nd

and 3rd year hospital-based and 4th and 5th year university-based nursing

students in the NMCN accredited basic nursing programmes in Enugu State

were used. A validated structured questionnaire constructed by the

researcher with the help of experts was used for data collection.

• Data obtained were presented in Tables, percentages, mean, standard

deviation and hypotheses tested using multiple analysis of variance at

0.05 level of significance. Major findings of the study revealed that:

• Majority of the students were females.

• Majority of the nursing students involved in this study demonstrated

high perception of their clinical training especially in the aspects of

116

the placement into the clinical setting and clinical teaching

(instruction).

• Some of the nursing students also demonstrated low perception of

their clinical training.

• Majority of the nursing students showed low perception of their

clinical supervision.

• There was a high perception of clinical evaluation though the students

were not constantly informed of their progress.

• There exists a significant difference in the perceptions of the clinical

training between the university-based and hospital-based nursing

students (P<0.05).

• There was no significant difference in perception of clinical training

between males and female nursing students (P>0.05), though female

nursing students had negative views about their clinical supervision.

Conclusion

The nursing students involved in this study generally demonstrated positive

perceptions of clinical training. A positive perception was shown on clinical

placement, teaching and evaluation, while negative perception was shown

on clinical supervision. University-based nursing students showed negative

perception in all the subscales, while hospital-based student nurses

showed positive perception in all the subscales. Also, the fact that there was

no significant difference in perceptions of clinical training between the male

and female student nurses indicated similarities in all the activities of

clinical training.

117

The nursing students are the customers and consumers in the clinical

nursing training. Their benefits from the training will depend on how they

perceive the clinical training experiences. But since clinical nursing

education is not meaningful without qualitative clinical placement, teaching,

supervision and evaluation, it becomes essential for the schools of nursing,

faculties, clinical setting and the policy makers to be highly committed to it

and work together towards giving the students the required qualitative

clinical nursing training.

Recommendation

In view of the findings and educational implications of the study it is

therefore recommended that:-

1. Nursing students should be actively involved from the planning stage

of their placement and adequate accommodation made available for

outstation posting.

2. Access to leisure activities during the clinical posting should be

allowed to permit the students to also develop socially during the

clinical nursing training.

3. Adequate and functional teaching and learning materials example blood

pleasure apparatus, trolleys, nursing process charts etc. should be

provided at the clinical setting.

4. More qualified clinical instructors, supervisors and enough ward staff

nurses who are experienced and are capable of integrating theoretical

knowledge with practical procedure should be employed for clinical

teaching, supervision and facilitation during clinical nursing training.

118

This will also help to ease off the heavy workload of the nurses thereby

providing enough attention to the student nurses.

5. The clinical instructors and supervisors should do adequate planning

of their supervision and duty roster made available so that they can

always be available and accessible to the students.

6. There should be equal attentions should be given to university-based

and hospital-based nursing students during clinical placement,

teaching, supervision and evaluation.

7. Proper feedback on the students’ progress should be given to them

individually and as groups after clinical evaluation to enable them

work harder in areas they are having problems.

Suggestions for further studies

This present study and its findings opened up avenues for other areas that

could be explored, for example;

1. Further study is suggested to investigate the nursing students’

perceptions of clinical supervision.

2. A comparative study on perceptions of clinical training between the

university-based and hospital-based student nurses should be carried

out.

3. Similar study should be extended to other basic nursing programmes

in the other states of the federation for better generalization.

4. Since replication studies could provide empirical support for this

study, it should be carried out as scientific empiricism demands that.

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129

APPENDIX 1

QUESTIONNAIRE

Department of Nursing Science, Faculty of Health Science and, Technology, University of Nigeria,

Enugu campus. 2nd June, 2014. Dear Respondent,

QUESTIONNAIRE ON NURSING STUDENTS’ PERCEPTIONS OF CLINICAL NURSING TRAINING IN SELECTED NURSING PROGRAMMES IN ENUGU

STATE

The researcher is a post graduate student of the Department of Nursing Sciences, University of Nigeria, Enugu Campus. This questionnaire is designed to obtain information on the nursing students’ perceptions of clinical nursing training in selected nursing programmes in Enugu State.

The research work is purely an academic exercise and information obtained will be treated with utmost confidence. You are requested to be as honest and objective as possible in answering the questions. Your sincere opinion on each question will be highly appreciated. Do not write your name or registration number. Thanks for your anticipated co-operation.

Ugwu Stella Ngozika

Instruction: Tick (√) in the appropriate box in section A Tick (√) at the column that represents your opinion against the statement in section B

Section A: Demographic characteristics 1. Name of Institution: (a) Department of Nursing Science UNEC (b) School of Nursing UNTH Enugu (c) School of Nursing Bishop Shanahan Hospital Nsukka 2. Type of Nursing Programme (a) University-based nursing programme (b) Hospital-base nursing programme 3. Year of study (a) Year 2 (b) Year 3 (c) Year 4 (d) Year 5 4. Age last birthday (a) < 20 years (b) 20-24 years

(c) 25-29 years (d) 30 -34 years

130

5. Gender: (a) Male (b) Female

SECTION B:

Students’ Perceptions of Clinical Nursing Training

Use the following scale to answer questions 6 to 75.

4 – Strongly Agree “SA”, 3-Agree “A”, 2-Disagree “D” and 1 – Strongly Disagree “SD”.

S/n Items SA A D S D

Opinion about Placement to Clinical setting/ environment

4 3 2 1

6 Students are actively involved in planning for the clinical placement

7 The orientation I received for the placement was adequate 8 The duration for each clinical placement and exposure was

adequate

9 All the placements were timetabled

10 The placement period was put to good use 11 The placement gave me the opportunity to learn with

students from other discipline

12 Rotations to necessary specialist clinical units were adequate e.g theatre, obstetric and gynae, med-surg etc

13 Clinical settings (environments) were well organized

14 Reasonable accommodation was made available for the student during outstation posting

15 Transport arrangements during the placement were adequate

16 Aesthetic aspects of the physical infrastructure were adequate,

17 Access to leisure activities during the clinical posting was always allowed

18 Reasonable steps were taken to ensure that the health of the students were not jeopardized during placement

19 There was a positive atmosphere for learning throughout the period of the posting

20 The clinical sites and faculty provide me with procedure book and movement scattergram during placement

21 It improved my interpersonal relationship and skills

22 Clinical learning environment was conducive in all clinical settings.

23 The nurses at the clinical setting were friendly and easy to approach throughout the period of posting and rotation.

Views about Clinical Teaching (Instruction)/learning

24 The clinical instruction was student centered

25 The instruction was stimulating 26 The clinical teaching contents were well organized.

27 The instructor challenged me to understand ideas and

131

concepts

SA A D SD 4 3 2 1 28 The instructor encouraged me to ask questions

29 The instructor communicated concept clearly

30 The procedure and log books were accurate and useful during the teaching

31 There was a good coverage of the clinical instruction curriculum.

32 The teaching and learning materials were always provided.

33 The facilities were always in good working condition (adequate).

34 The clinical instructors were adequate in number 35 Varied teaching tips like preparation introduction,

interaction and summarization were used by the clinical instructor.

36 Varied clinical teaching styles (methods) were used by the instructors.

37 I was taught by a number of different clinical instructors.

38 The clinical teachers had good bedside manner.

39 Patients were involved during clinical teaching when necessary.

40 In my opinion, all the clinical instructors were capable of integrating theoretical knowledge and practical knowledge.

41 I felt socially comfortable in teaching sessions.

42 Opportunities are given to express my opinion and develop interpersonal skills during teaching sessions.

43 I was encouraged and allowed to participate actively in the teaching and learning sessions.

44 Opportunities were given to me for demonstration of clinical skills learnt like carrying out basic nursing tasks.

45 I was able to constantly use the learning materials provided for practical demonstration.

46 I was able to participate in the clinical professional development events like research.

47 I was opportuned to develop collaboration and communication skills with members of other disciplines during the teaching.

48 In my opinion the quality of clinical teaching and learning was good.

Views about clinical supervision 49 The clinical instructor and supervisors have adequate training,

knowledge and skills to supervise.

50 The supervisors were transparent. 51 The supervisors were friendly.

52 The supervisors evidenced personal interest in my success. 53 The clinical supervisors do not belittle and intimidate students.

132

SA

A

D

SD

4 3 2 1 54 The supervisor takes responsibility for students learning. 55 Supports from clinical supervisors during supervision were

adequate.

56 Supports of teachers from the school during clinical experiences were adequate.

57 There was good support system for student who encountered difficulties.

58 The supervisory relationship was characterized by a sense of trust and mutual relationship.

59 The staff was generally interested in student’s supervision. 60 I received group supervision which was adequate.

61 I received individual supervision which was adequate. 62 The supervisors were always available.

63 The supervisors were always accessible.

64 The supervisors show respect for students.

65 The supervisors had good rapport with students. Perception of Clinical Evaluation

66 I was evaluated in each unit of practice. 67 My clinical performance was evaluated only at the end of each

semester.

68 I was given opportunity for self assessment.

69 The clinical evaluators were able to use assorted techniques (strategies) like continuous assessment, assignment and examination.

70 The clinical evaluators were good at providing constructive criticism and feedback

71 Through the feedback, my strengths were reinforced and errors corrected.

72 The faculty informed me of the grading methods in practical exam 73 I was duly informed of the duration and period of clinical

evaluation.

74 The evaluator consistently informed me of my progress.

75 Assignment that required critical and creative thinking were provided or given.

133

APPENDIX II

CALCULATION OF RELIABILITY OF QUESTIONNAIRE

Respondent Pre-Test Scores (X) Post-Test Scores (Y) XY X2 Y2

1 178 180 32040 31684 32400

2 201 204 41004 40401 41616

3 222 221 49062 49284 48841

4 198 200 39600 39204 40000

5j 176 178 31328 30976 31684

6 200 198 39600 40000 39204

7 245 243 59535 60025 59049

8 101 120 12120 10201 14400

9 99 110 10890 9801 12100

10 219 224 49056 47961 50176

11 156 175 27300 24336 30625

12 143 165 23595 20449 27225

13 138 143 19734 19044 20449

14 178 180 32040 31684 32400

15 188 183 34404 35344 33489

16 167 154 25718 27889 23716

17 127 129 16383 16129 16641

18 187 185 34595 34969 34225

19 199 201 39999 39601 40401

20 201 209 42009 40401 43681

21 220 225 49500 48400 50625

22 264 264 69696 69696 69696

23 243 245 59535 59049 60025

24 189 190 35910 35721 36100

25 178 180 32040 31684 32400

26 99 104 10296 9801 10816

27 110 112 12320 12100 12544

28 152 145 22040 23104 21025

29 139 140 19460 19321 19600

30 140 141 19740 19600 19881

31 165 152 25080 27225 23104

32 178 154 27412 31684 23716

33 192 189 36288 36864 35721

34 204 202 41208 41616 40804

35 239 211 50429 57121 44521

36 218 201 43818 47524 40401

37 169 172 29068 28561 29584

38 159 165 26235 25281 27225

39 178 170 30260 31684 28900

40 165 154 25410 27225 23716

Total 7124 7118 1325757 1332644 1322726

134

APPENDIX III

135

APPENDIX IV

CORRELATION FOR RELIABILITY OF INSTRUMENT (USING SPSS 17.0 OUTPUT)

Correlations

Pre Test Post Test

Pre Test Pearson Correlation

1 .970"

Sig. (2-tailed) .000

N 40 40

Post Test Pearson Correlation

' .970" 1

Sig. (2-tailed) .000

N 40 40

Correlation is significant at the 0.01 level (2-tailed). From the above Tables, the Spearman's rank correlation coefficient is 0.97. This indicates a strong positive correlation. Therefore, the research instrument is very reliable.

136

APPENDIX V

INFORMED CONSENT Introduction: My name is Ugwu Stella Ngozika, a post graduate student of Department of Nursing Science, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus. Voluntary nature of participation: Subjects participation in this study is entirely voluntary. You have the right to withdraw consent and discontinue participation in the study at any given time. Study procedure: I am carrying out a study on nursing students’ perceptions of clinical nursing training in selected schools in Enugu State. In this study, you will be required to fill the questionnaire. Please feel free to ask for clarification on any question you do not understand. Risk: The process of filling the questionnaire will not cause you any harm or injury. Confidentially: Please note that information you give will be kept confidential. Your name will never be used in connection with any information you give. Feed back: In case of any clarification, you can contact me: 07032361295 Response: The study has been explained to me and I understood the consent of the study process. I will be willing to participate in the study described above. …………………………….. ………………………… ………………………….. Signature of participant signature of witness signature of researcher

…………………………… ………………………… …………………………… Date Date Date In case of enquiries/complaint, contact Dr. Okolie Uche HOD Department of Nursing Sciences Faculty of Health Sciences & Technology University of Nigeria, Enugu Campus

137

APPENDIX VI

138

APPENDIX VII

Department of Nursing Sciences, Faculty of Health Sciences & Technology, University of Nigeria, Enugu Campus, 28th July, 2014 The Principal, School Nursing, Bishop Shanahan Hospital, Nsukka, Enugu State. APPLICATION FOR ADMINISTRATIVE PERMISSION TO USE SECOND AND THIRD YEAR STUDENT NURSES FROM YOUR SCHOOL FOR RESEARCH STUDY I wish to apply for your permission to use the second and third year student nurses from your school for my research study. I am a post graduate student of the above department carrying out a research study on nursing students’ perceptions of clinical nursing training in selected schools in Enugu State. The research project is under the supervision of Dr. Mrs. N.P. Ogbonnaya of Department of nursing Sciences. Information obtained would be treated with utmost confidentiality. Thank you. Yours sincerely, Ugwu Stella Ngozika

139

APPENDIX VIII

1

APPENDIX IX

Means and standard deviation of the 70 items of the SPCNTQ

n = 441

Subscales S/N ITEMS SA A D SD n Sum Mean

Stdev

Nursing students’

opinion of their

placement into the

clinical learning

environment /setting

6 Students are actively involved in planning for the clinical placement

63 102 135 141 441 969 2.20 1.04

7 The orientation I received for the placement was adequate

69 196 141 35 441 1181 2.68 0.83

8 The duration for each clinical placement and exposure was adequate

88 151 130 72 441 1137 2.58 0.99

9 All the placements were timetabled

152 174 86 29 441 1331 3.02 0.90

10 The placement period was put to good use

111 195 97 38 441 1261 2.86 0.89

11 The placement gave me the opportunity to learn with students from other discipline

134 187 91 29 441 1308 2.97 0.88

12 Rotation to necessary specialist clinical units were adequate e.g theatre, obstetric and gynae, med-surg, etc.

108 151 123 59 441 1190 2.70 0.98

13 Clinical setting (environments) were well organized

81 165 132 63 441 1146 2.60 0.95

14 Reasonable accommodation was 60 108 147 126 441 984 2.23 1.01

126

2

made available for the student during outstation posting

15 Transport arrangements during the placement were adequate

68 125 125 123 441 1020 2.31 1.04

16 Aesthetic aspects of the physical infrastructure were adequate

43 167 149 82 441 1053 2.39 0.90

17 Access to leisure activities during the clinical posting was always allowed

50 134 151 106 441 1010 2.29 0.96

18 Reasonable steps were taken to ensure that the health of the students were not jeopardized during placement

56 159 134 92 441 1061 2.41 0.96

19 There was a positive atmosphere for learning throughout the period of the posting

57 194 130 60 441 1130 2.56 0.88

20 The clinical sites and faculty provide me with procedure book and movement scattergram during placement

62 187 131 61 441 1132 2.57 0.90

21 It improved my interpersonal relationship and skills

113 229 65 34 441 1303 2.95 0.84

22 Clinical learning environment was conducive in all clinical setting

58 153 187 43 441 1108 2.51 0.84

23 The nurses at the clinical setting were friendly and easy to approach throughout the period posting and rotation

47 184 159 51 441 1109 2.51 0.83

subscale mean 2.57 0.51

Nursing students’ views about clinical teaching (instruction)

24 The clinical instruction was student centered

54 176 164 47 441 1119 2.54 0.84

127

3

25 The instruction was stimulating 56 203 135 47 441 1150 2.61 0.84

26 The clinical teaching contents were well organized

47 157 178 59 441 1074 2.44 0.85

27 The instructor challenged me to understand ideas and concept

54 201 128 58 441 1133 2.57 0.87

28 The instructor encouraged me to ask questions

105 236 67 33 441 1295 2.94 0.83

29 The instructor communicated concept clearly

68 191 139 43 441 1166 2.64 0.86

30 The procedure and log books were accurate and useful during the teaching

81 181 119 60 441 1165 2.64 0.93

31 There was a good coverage of the clinical instruction curriculum

56 161 155 69 441 1086 2.46 0.90

32 The teaching and learning materials were always provided

36 115 183 107 441 962 2.18 0.89

33 The facilities were always in good condition (adequate)

43 118 180 100 441 986 2.24 0.91

34 The clinical instructors were adequate in number

44 116 186 95 441 991 2.25 0.90

35 Varied teaching tips like preparation introduction, interaction and summarization were used by the clinical instructor.

42 173 150 76 441 1063 2.41 0.88

36 Varied clinical teaching styles (methods) were used by the instructors

51 165 158 67 441 1082 2.45 0.89

37 I was taught by a number of difference clinical instructors

69 187 115 70 441 1137 2.58 0.94

38 The clinical teachers had good bedside manner

47 195 139 60 441 1111 2.52 0.86

128

4

39 Patients were involved during clinical teaching when necessary

59 199 112 71 441 1128 2.56 0.92

40 In my opinion, all the clinical instructors were capable of integrating theoretical knowledge and practical knowledge

44 176 157 64 441 1082 2.45 0.86

41 I felt socially comfortable in teaching sessions

55 211 119 56 441 1147 2.60 0.86

42. Opportunities are given to express my opinion and develop interpersonal skills during teaching sessions

60 207 117 57 441 1152 2.61 0.88

43 I was encouraged and allowed to participate actively in the teaching and learning activities

110 218 75 38 441 1282 2.91 0.87

44 Opportunities were given to me for demonstration of clinical skills learnt like carrying out basic nursing tasks

120 202 81 38 441 1286 2.92 0.89

45 I was able to constantly use the learning materials provided for practical demonstration

90 183 128 40 441 1205 2.73 0.89

46 I was able to participate in the clinical professional development events like research

76 159 141 65 441 1128 2.56 0.94

47 I was opportuned to develop collaboration and communication skills with members of other disciplines during the teaching

71 193 122 55 441 1162 2.63 0.90

48 In my opinion the quality of clinical teaching and learning

66 196 134 45 441 1165 2.64 0.86

129

5

was good

Subscale mean 2.56 0.53

Nursing students views about clinical supervision

49 The clinical instructor and supervisors have adequate training knowledge and skills to supervise

82 217 95 47 441 1216 2.76 0.88

50 The supervisors were transparent

51 198 149 43 441 1139 2.58 0.82

51 The supervisors were friendly 53 177 161 50 441 1115 2.53 0.85

52 The supervisors evidenced a personal interest in my success

47 176 163 55 441 1097 2.49 0.85

53 The clinical supervisors do not belittle and intimidate students

73 123 163 82 441 1069 2.42 0.97

54 The supervisor takes responsibility

67 197 128 49 441 1164 2.64 0.87

55 Supports from clinical supervisors were adequate

38 174 177 52 441 1080 2.45 0.81

56 Supports from teachers from the school were adequate

58 177 144 62 441 1113 2.52 0.89

57 There was good support system for student who encountered difficulties

51 147 168 75 441 1056 2.39 0.90

58 The supervisory relationship was characterized by a sense of trust and mutual relationship

47 146 176 72 441 1050 2.38 0.88

59 The staff were generally interested in students supervision

59 172 140 70 441 1102 2.50 0.91

60 I received group supervision which was adequate

47 150 177 67 441 1059 2.40 0.87

61 I received individual supervision which was adequate

54 149 155 83 441 1056 2.39 0.93

130

6

62 The supervisors were always available

48 110 193 90 441 998 2.26 0.91

63 The supervisors were always accessible

44 153 165 79 441 1044 2.37 0.89

64 The supervisors show respects for students

39 150 175 77 441 1033 2.34 0.87

65 The supervisors had good rapport with students

51 171 151 68 441 1087 2.46 0.89

Subscale mean 2.46 0.54

Nursing students’ perceptions of clinical evaluation.

66 I was evaluated in each unit of practice

60 172 140 69 441 1105 2.51 0.91

67 My clinical performance was evaluated only at the end of each semester

79 191 121 50 441 1181 2.68 0.90

68 I was given opportunity for self assessment

71 160 138 72 441 1112 2.52 0.95

69 The clinical evaluators were able to use assorted techniques (strategies) like continuous assessment, assignment and examination

110 182 95 54 441 1230 2.79 0.96

70 The clinical evaluators were good at providing constructive criticism and feedback

71 184 146 40 441 1168 2.65 0.86

71 Through feedback, my strengths were reinforced and errors corrected

81 182 125 53 441 1173 2.66 0.91

72 The faculty informed me of the grading methods in practical exam

75 165 121 80 441 1117 2.53 0.98

73 I was duly informed of the 130 182 87 42 441 1282 2.91 0.93

131

7

duration and period of clinical evaluation

74 The evaluator consistently informed me of my progress

47 131 180 83 441 1024 2.32 0.90

75 Assignment that required critical and creative thinking were provided or given

92 180 108 61 441 1185 2.69 0.95

Subscale mean 2.63 0.54

132