Hindawi Publishing Corporation

e Scientific World Journal

Volume 2016, Article ID 1846178, 7 pages
http://dx.doi.org/10.1155/2016/1846178

Research Article
The Challenges of Nursing Students in the Clinical
Learning Environment: A Qualitative Study

Nahid Jamshidi,1 Zahra Molazem,1 Farkhondeh Sharif,1

Camellia Torabizadeh,1 and Majid Najafi Kalyani2
1
Faculty of Nursing & Midwifery, Shiraz University of Medical Sciences, Shiraz 71936 13119, Iran
2
School of Nursing, Fasa University of Medical Sciences, Fasa 74616 86688, Iran

Correspondence should be addressed to Zahra Molazem; [email protected]

Received 11 February 2016; Revised 22 April 2016; Accepted 17 May 2016

Academic Editor: Kuei R. Chou

Copyright © 2016 Nahid Jamshidi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background/Aim. Clinical learning is a main part of nursing education. Students’ exposure to clinical learning environment is
one of the most important factors affecting the teaching-learning process in clinical settings. Identifying challenges of nursing
students in the clinical learning environment could improve training and enhance the quality of its planning and promotion of the
students. We aimed to explore Iranian nursing students’ challenges in the clinical learning environment. Materials and Methods.
This is a qualitative study using the content analysis approach. The participants consisted of seventeen nursing students and three
nursing instructors. The participants were selected through purposive sampling method and attended semistructured interviews
and focus groups. Results. Three themes emerged after data analysis, including ineffective communications, inadequate readiness,
and emotional reactions. Conclusion. Nursing students in Iran are faced with many challenges in the clinical learning environment.
All challenges identified in this study affected the students’ learning in clinical setting. Therefore, we recommend that the instructors
prepare students with a specific focus on their communication and psychological needs.

1. Introduction Unlike classroom education, clinical training in nursing

occurs in a complex clinical learning environment which is
Nurses’ competence is based on the knowledge and skill influenced by many factors [9]. This environment provides an
taught to them [1]. Nursing training is a combination of theo- opportunity for nursing students to learn experimentally and
retical and practical learning experiences that enable nursing to convert theoretical knowledge to a variety of mental, psy-
students to acquire the knowledge, skills, and attitudes for chological, and psychomotor skills which are of significance
providing nursing care [2]. Nursing education is composed of for patient care [10]. Students’ exposure and preparation to
two complementary parts: theoretical training and practical enter the clinical setting are one of the important factors
training [3]. A large part of nursing education is carried out in affecting the quality of clinical education [11].
clinical environments [4]. In Iran and many other countries, Since an optimal clinical learning environment has a
clinical education forms more than half of the formal educa- positive impact on the students’ professional development, a
tional courses in nursing [5]. Therefore, clinical education is poor learning environment can have adverse effects on their
considered to be an essential and integral part of the nursing professional development process [8]. The unpredictable
education program [6]. Since nursing is a performance-based nature of the clinical training environment can create some
profession, clinical learning environments play an important problems for nursing students [12].
role in the acquisition of professional abilities and train the The researchers’ experience in the nursing clinical edu-
nursing students to enter the nursing profession and become cation reveals that nursing students’ behaviors and perfor-
a registered nurse [7]. Moreover, the clinical area of nursing mances change in the clinical setting. This change can neg-
education is of great importance for nursing students in the atively affect their learning, progress in patient care, and pro-
selection or rejection of nursing as a profession [8]. fessional performance. Identifying problems and challenges
2 The Scientific World Journal

with which these students are faced in the clinical learning setting, individual interviews, group interviews, and observa-
environment can help stakeholders solve these problems and tion were used. Individual interviews with nursing students
contribute to them becoming professional as well as their and instructors were carried out face-to-face and in a con-
professional survival [11]. venient place based on the willingness of the participants in
Failure to identify the challenges and problems the the School of Nursing, Shiraz University of Medical Sciences.
students are faced with in the clinical learning environment Group interviews with nursing students were also performed
prevents them from effective learning and growth. As a result, to achieve a deeper understanding of this phenomenon.
the growth and development of their skills will be influenced A group interview is a way for people to express their
[4]. Studies show that the students’ noneffective exposure experiences and views with regard to a subject in a group and,
to the clinical learning environment has increased dropout instead of a researcher, members of a group are responsible
rates. Some nursing students have left the profession as a for encouraging each other to talk [19]. The individual
result of challenges they face in the clinical setting [13]. and group interviews began by asking the participants a
Many studies have been done on the clinical environment. general and open question regarding the description of their
Some relevant studies have also been carried out in our encounter with the clinical setting, and then some other
country; however, most of them have focused on clinical questions were asked based on the participants’ statements
evaluation or stress factors in the clinical training. One study and responses [17].
showed that nursing students are vulnerable in the clinical Moreover, some supplementary questions were utilized
environment and this reduces their satisfaction with the based on the participants’ comments and opinions (e.g.,
clinical training [14]. Moreover, the nursing students’ lack of “would you elaborate more on this?” or “what did you mean
knowledge and skills in the clinical environment can lead to by saying . . .?”) to search and complete information.
anxiety [15]. Yazdannik and colleagues found that nursing All the conducted interviews with the participants were
students suffered from inferiority complex after entering the recorded and immediately transcribed verbatim after the end
clinic [16]. of the interview sessions. Each interview lasted about 40 to
According to a review of the literature, few studies have 70 minutes and was 55 minutes on average. Interviews were
been done on the challenges nursing students are faced with continued with participants until the data was saturated and
in the clinical learning environment in Iran; these challenges sampling was ended with data saturation [17].
are still unknown. Identifying challenges with which nursing In addition, the observation method was used to inves-
students are faced in the clinical learning environment in all tigate the exposure of students to the clinical setting. The
dimensions could improve training and enhance the quality observer recorded the students’ activities and conversations
of its planning and the promotion of the students. We aimed for further analysis. The observation method in this study
to explain the challenges of the nursing students in the clinical focused on the relationship and the behavior of students,
learning environment. patients, staff, and instructors at the clinical setting. During
this phase of the study, field notes and reminders were used
to analyze the observations.
2. Materials and Methods
2.1. Study Design. This paper is a part of a larger grounded 2.4. Data Analysis. Content analysis was used in this research
theory study. Content analysis was used in this qualitative in order to identify and understand the challenges of nursing
research so that rich and deep information could be obtained students in dealing with the clinical setting. This method of
from the phenomenon under study [17]. Since qualitative analysis is an interpretive process that focuses on the subject
research emphasizes trust, transparency, verifiability, and and background and explores the similarities and differences
flexibility, it is considered a good method to develop insight between and within different parts of the text [20]. In this
and interpretation in the field of nursing education [18]. method, the script of the interview was read several times by
the researcher to reach an overall understanding. The parts
2.2. Study Participants. Participants in the study included related to the experiences of the participants regarding the
nursing students and instructors from Shiraz University of challenges of encountering the clinical setting were extracted
Medical Sciences, Shiraz, Iran. Clinical nursing instructors from the interviews and placed in a separate text. Then,
were selected in order to access the information of nursing words, sentences, and paragraphs relevant to each other in
students who had the experience of working at the patients’ terms of both content and context were merged and coded.
bedside. Codes and units of meaning were interpreted in the context
The population in this study consisted of seventeen of the study and compared in terms of similarities and
nursing students from different academic semesters and three differences. Finally, abstract subclasses were made based on
clinical nursing instructors. Various groups of students in the semantic line [20]. Rethinking about the codes and the
terms of age, sex, academic semester, and experience of subclasses resulted in the extraction of three main categories.
working at the patients’ bedside were used in order to achieve
deep and extensive data. 2.5. Trustworthiness of Data. In order to validate the data,
manuscripts were reviewed and data coding processes were
2.3. Data Collection. In this study, to better understand the reconducted by the colleagues and the whole process was
challenges of nursing students in dealing with the clinical peer reviewed by an outside observer. Extracted codes were
The Scientific World Journal 3

sent to the participants and approved. In order to obtain the students. One of the students described how improperly the
variability criterion, the scripts of a number of interviews, department nurse treated her.
codes, and extracted classes were given to several colleagues
who were familiar with the methods of analyzing qualitative . . . One day, I was staying at the nursing station
research and were not present in the process of conducting with some of my friends. Suddenly, the depart-
this study, and the accuracy of the data coding process ment nurse appeared and urged us to get away!
was evaluated. Furthermore, allocating sufficient time to . . .you know you are making the department nurse
collect data and maintaining an objective and impartial view crowded. Quickly put the card indices back. . ., said
further added to the reliability of the research. In order to the nurse.
obtain generalizability across environments, the results of the
research were presented to a number of students who had not 3.1.2. Discrimination. Discrimination is a subcategory that
participated in the study and they were asked to judge the most students had experienced. They were complaining about
similarity between the results of the research and their own a series of discriminatory behaviors they were seeing at the
experiences. bedside that irritated them. According to what the students
claimed, the greatest discrimination in the clinical setting was
2.6. Ethical Issues. The Deputy of Research and Bioethics apparent in behaviors of nurses towards students. One of the
Committee of Shiraz University of Medical Sciences approved students said the following.
this project prior to the beginning of the study. In the current
study, in order to consider ethical principles, the purpose of . . . The head nurse of the department tells us to
the study was explained to all the participants and informed stand up and leave the nursing station whenever
consent was obtained for each interview and voice recording. we go there and wants us to let medical students
The participants were assured of the confidentiality of the sit on chairs. . .!
data. In addition, the recorded interviews were kept in a safe In addition to behavioral discrimination, some students were
place and were only accessible by the researcher. also upset and complained about discrimination in the use of
educational facilities. One of the students participating in the
3. Results study said the following.

The participants consisted of seventeen nursing students . . . Whenever we need the conference room in the
and three nursing instructors. The students were in the department and ask the nurses of the department
second, third, and fourth year of study and aged 20–23 to give us the key to that room, they simply reject
years. Moreover, three nursing instructors (two women and us and say no! This room is only for residents and
one man) participated in this study with an age range of medical students to use. . ., they answer.
32 to 38 years and a clinical training experience of 5 to 8
years. After analyzing the interviews with the participants 3.2. Inadequate Readiness. This category includes three sub-
regarding the challenges of nursing students in dealing categories of inadequate knowledge, deficient practical skills,
with the clinical learning environment, three main themes and insufficiently developed communication skills.
emerged: ineffective communication, inadequate readiness,
and emotional reactions.
3.2.1. Inadequate Knowledge. Many students did not have
sufficient knowledge to care at the bedside when dealing
3.1. Ineffective Communications. This main category con- with clinical learning environment and providing care to the
sisted of two subcategories of improper treatment and dis- patients was challenging for them. One of the students said
crimination. the following.

3.1.1. Improper Treatment. Students encounter some chal- . . . I wanted to give my patient a Pantazol
lenges in dealing with clinical learning environment and injection; however, I did not know what kind
in interaction with instructors, patients, and department of medication it was. The patient’s companion
personnel. Many students stated that they had the most asked what that medication was and to what
interactions with the instructors and believed that the way medication category it belonged. I did not know
an instructor treats a student affects their exposure to clinical to what medication category it belonged and did
learning environment. One student stated the following. not even know it was used to treat gastric issues.
The patient’s companion asked me whether it was
. . .to be frank, our instructor did not treat us well. an antibiotic and I answered I think so. . .
Once, I made a mistake and the instructor repri-
manded me right at a patient’s bed. Companions
of the patient never trusted me again. He had 3.2.2. Deficient Practical Skills. Clinical environment is a
many undue rigors. . .. suitable context for learning skills needed to care for patients.
However, some of them are considered basic health care skills
In addition to the improper treatment of instructors toward and any deficit in them affects the quality of care. In this
the students, some behaviors of nurses are also oppressive to regard, students had difficulties in performing procedures in
4 The Scientific World Journal

some situations, due to the lack of necessary skills. One of the The presence in the clinical setting and exposure to new
participants said the following. events cause emotional reactions in students. Such reactions
have a significant effect on their learning process. One of the
Our professor urged us to care for a patient. students participating in the study said the following.
However, I did not know how to take his blood
pressure. The reason was that I could not recognize . . . When I went to the department, I saw a patient
the sound. . .. to whom some devices were attached. I was full
of stress, as I had never seen such a situation.
Deficiency in practical skills in caring for patients was a My hands and legs were shaking. I could not
concern of many students in the clinical setting. One of the concentrate at all. . ..
students stated the following.
. . . The first time I took the blood pressure machine 3.3.2. Inferiority Complex. Inferiority complex was more
and intended to take a patient’s blood pressure, I evident among female students than male ones. In this regard,
had the blood pressure cuff upside down around one of the students said the following.
his elbow. . .it was really my fault. I got embar-
rassed in front of the patient. . .. . . .once I wanted to place an IV cannula inside an
old man’s vein who was hospitalized. I am not a
lab rat, the patient shouted. Since then, I feel I have
3.2.3. Insufficiently Developed Communication Skills. Many
lost my self-confidence every time I want to insert
students mentioned the lack of communication skills as the
an IV cannula. . .I have that old man’s image in
reason for deficiency in communicating with the clinical
my mind all the time, and I’m worried of making
learning environment. One of the students participating in
another mess. . ..
the study said the following.
Students in lower semesters experienced greater inferiority
. . . Once we wanted to visit a patient who had a
than students in higher semesters. In this regard, one of the
shunt along with our professor. There was a bulge
instructors said the following.
on his hand. I asked him what that bulge was
in front of the patient. The patient became upset . . . Students often do not have enough confidence
and I myself regretted. The professor told me that early in their internship. . .they gradually become
I shouldn’t have asked that question in front of the more confident as they get used to the hospital and
patient and he could explain it to me. . .. its environment. . ..
Insufficiently developed communication skills sometimes
cause disruption in providing care for patients. One student 4. Discussion
participant said the following.
The findings obtained from the study demonstrated that inef-
. . . the nurse said that she wanted to take blood fective communication, inadequate preparation, and emo-
and urged us to go and watch. She pricked the tional reactions are Iranian nursing students’ challenges in the
patient several times because she was unable to clinical learning environment.
find the vein. I got tormented! The patient was It is one of the teachers’ major responsibilities to treat
screaming out of pain. I told the nurse that she nursing students properly in the clinic, causing higher enthu-
should act gently toward the patient. She got angry siasm and motivation for learning as well as increasing
and told me not to interfere and not to talk their self-confidence [4]. Nabolsi et al. [2] demonstrated
like that in front of the patient and to control in their study that proper treatment and establishment of
ourselves. . .. a communication with students are an important item for
nursing teachers to be a role model for students. Training that
3.3. Emotional Reactions. This class includes the following involves value and respect facilitates the teaching-learning
two subcategories of stress and inferiority complex. process and socializes the students into the nursing profes-
sion [2]. The results of the studies conducted by Baltimore
3.3.1. Stress. Many of the students participating in this study and Sharif and Masoumi demonstrate that conflicts and
became distressed and overwhelmed in dealing with new improper treatment between the staff and students negatively
experiences within the clinical learning environment. From affect the clinical teaching trend [15, 21]. Hanifi and colleagues
the perspective of these students, providing care for patients found that proper communication with students increased
is stressful to them. One of the students said the following. their motivation [22].
Many of the students participating in the study com-
. . . Once I wanted to examine a patient, I was plained about the staff ’s discrimination between them and
so stressful. . .I was afraid of doing something students of medicine. The result of the study conducted by
that causes harm to the patient. I was giving his Mohebbi and coworkers in Iran demonstrated that a high per-
medication with a great fear and was praying for centage of nursing students reported discrimination between
him to stay safe. I was hoping for my internship to them and students of other fields [23]. In Baraz-Pordanjani et
be just finished as soon as possible. . .. al.’s study, discrimination in the use of educational facilities
The Scientific World Journal 5

and amenities and also in interpersonal communication caregiving processes. Improper treatment, discrimination,
was reported as a factor distorting the nursing students’ inadequate knowledge and skill, and lack of communication
professional identity in the clinic [24], which is in line with skills in these patients lead to stress and inferiority complexes
the results of our study. The comparison between nursing in them. In view of the students’ challenges in confrontation
and medicine and regarding medicine as a superior major with the clinical learning environment and the necessity
violates nursing students’ personal dignity and gives them of learning and providing patients with care in a peaceful
a sense of professional inferiority [25]. Students’ inadequate environment free of any tension, educational authorities and
preparation for entering the clinical environment creates nursing faculties are required to pay particular attention
problems for them and nursing teachers [26]. Even though to these issues and try to facilitate the nursing students’
they learn the fundamentals of nursing in classrooms and learning and professionalization. Hence, the following can be
practice rooms, nursing students do not have sufficient concluded:
time to practice and repeat these skills to completely enter
(1) Based on the results of the study, many students
the clinic. Killam and Heerschap found that the students’
lack the communication skills necessary for effective
insufficient practice and lack of skill before entering the
communication in the clinical environment. It is
clinical environment created problems for them with respect
suggested that the effective communication skills
to learning in the clinic [27]. Moreover, the students’ lack of
are taught to students before they enter the clinical
skill in confronting the clinical environment and dealing with
environment with the emphasis on the differences
actual patients is evident [11]. Students’ lack of knowledge
between the clinical environment and the classroom
and skill and inadequate preparation for entering the clinical
environment.
environment disturb their learning processes and make
them anxious [28]. Acquisition of communication skills in (2) In view of the results of the study, many students
nursing students creates a guiding atmosphere in the clinical mentioned lack of theoretical knowledge and prac-
environment, followed by an increase in their motivation tical skills as one of the problems involved in care-
[22]. Nursing students’ lack of practical skills is considered giving. Therefore, before students enter the clinical
as a challenge in entering the clinical environment [29]. environment, it should be ascertained that they are
Nursing students’ stress in confronting the clinical envi- theoretically and practically prepared as they take
ronment affects their general health and disturbs their learn- tests and give care in the skill lab.
ing processes [30]. According to one study, stress is one of (3) In light of the presence of stress and inferiority
these students’ experiences in the clinical environment [11]. complexes in students in confronting the clinical
In Changiz et al.’s (2012) study, it was revealed that the causes environment, it is suggested that while they receive
of nursing students’ stress in the clinical environment fall psychological consultation on the nursing profession,
into three types of stress due to the educational plan, stress caregiving, and the hospital environment plans be
due to the educational environment, and factors concerning made for them to visit the hospital and to get
the students [31]. In Chesser-Smyth’s (2005) study, stress and acquainted with the clinical learning environment
anxiety were one of the students’ experiences in the clinical before they begin the actual internship.
environment [8]. Nursing students’ young age when entering
the clinical environment and their social and emotional lack The innovation of this study was that we studied how the
of experience lead to stress and psychological problems [32]. nursing students were faced with the clinical learning envi-
An inferiority complex is another challenge mentioned by ronment and all components of this process by a grounded
the students participating in the study. The results of Edwards theory study (this paper is a part of a larger grounded
et al.’s [30] study showed that low self-confidence is one of theory study). In addition, in this study, the challenges
the nursing students’ problems. Adequate self-confidence is of nursing students were deeply assessed with respect to
one of the nursing students’ requirements in providing good educational, behavioral, emotional, and practical aspects,
care [33]. In Joolaee et al.’s (2015) study, lack of self-confidence which differentiates this study from other previous studies.
has been referred to as a major cause of fear and anxiety in
nursing students. The researcher demonstrated in his study Competing Interests
that lack of self-confidence also disturbs communication
in nursing students [11]. Moreover, having adequate self- The authors declare that they have no competing interests.
confidence for caregiving is one of the most important factors
affecting the students’ learning [34]. In Begley and White’s Acknowledgments
(2003) study, self-confidence was an important part of a
nurse’s personal and professional identity [35]. We found that The present paper was extracted from the Ph.D. thesis
nursing students in Iran are faced with many challenges in written by Nahid Jamshidi and financially supported by
the clinical learning environment, which affect their profes- Shiraz University of Medical Sciences (Grant no. 93-7126).
sionalization and learning processes. Many students are not The researchers would like to thank all nursing students and
mentally prepared to enter the clinical environment leading instructors who contributed to the study. The authors would
to higher rates of psychological problems. Moreover, lack of like to thank the Center for Development of Clinical Research
adequate knowledge and skill along with lack of mental and of Nemazee Hospital and Dr. Nasrin Shokrpour for editorial
psychological preparation disturbs the learning and patient assistance.
6 The Scientific World Journal

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