The “lifeworld” of Malawian undergraduate student nurses: The challenge of learning in resource poor clinical settings

Challenges of clinical accompaniment amongst undergraduate nursing students: University of KwaZulu-Natal

Background

Clinical accompaniment is an activity predominantly supervised by the clinical facilitator to develop the skills of the students. In South Africa, clinical accompaniment aims to develop the skills of the students to equip them in delivering efficient health services to the patients. Previous studies revealed that students experienced challenges and were negatively affected due to inadequate clinical accompaniment in the learning practice.

Aim

The aim was to determine the challenges faced by University of KwaZulu-Natal (UKZN) undergraduate nursing students during their clinical accompaniment.

Methods

An observational cross-sectional study design, with an analytic component was implemented. Questionnaires were used to collect data. Of the 400 registered nursing students, 245 were undergraduates; of these, 241 consented to participate in this study. Data captured into SPSS Statistics Package V28. ANOVA were used in comparing challenges amongst participants. A p-value less than 0.05 was considered significant.

Results

A total of 241 participants responded to the questionnaires, which yielded a response rate of 98.4%. This study comprised first-year (32.4%), second-year (32.8%) and third-year (34.9%) students. There was no remarkable difference in terms of challenges amongst study participants (1st; 2nd; 3rd), p=0.592.

Conclusion

This study revealed the challenges faced by undergraduate nursing students during their clinical accompaniment.

Contribution

Study results might assist in developing effective guidelines to resolve the challenges encountered by students.

The impact of clinical placement site, community clinic versus tertiary hospital, on midwifery students' clinical learning experience in Sierra Leone: a cohort study

BACKGROUND

In midwifery education, the clinical learning experience (CLE) is a critical component to gaining competency and should comprise greater than 50% of a student's education. Many studies have identified positive and negative factors affecting students' CLE. However, few studies have directly compared the difference in CLE based on placement at a community clinic versus a tertiary hospital.

METHODS

The aim of this study was to examine how clinical placement site, clinic or hospital, impacts students' CLE in Sierra Leone. A once 34-question survey was given to midwifery students attending one of four public midwifery schools in Sierra Leone. Median scores were compared for survey items by placement site using Wilcoxon tests. The relationship between clinical placement and student's experience were assessed using multilevel logistic regression.

RESULTS

Two-hundred students (hospitals students = 145 (72.5%); clinic students = 55 (27.5%) across Sierra Leone completed surveys. Most students (76%, n = 151) reported satisfaction with their clinical placement. Students placed at clinics were more satisfied with opportunities to practice/develop skills (p = 0.007) and more strongly agreed preceptors treated them with respect (p = 0.001), helped improve their skills (p = 0.001), provided a safe environment to ask questions (p = 0.002), and had stronger teaching/mentorship skills (p = 0.009) than hospital students. Students placed at hospitals had greater satisfaction in exposure to certain clinical opportunities including completing partographs (p < 0.001); perineal suturing (p < 0.001); drug calculations/administration (p < 0.001) and estimation of blood loss (p = 0.004) compared to clinic students. The odds of students spending more than 4 h per day in direct clinical care were 5.841 (95% CI: 2.187-15.602) times higher for clinic students versus hospital students. There was no difference between clinical placement sites in regards to number of births students attended (OR 0.903; 95% CI: 0.399, 2.047) or number of births students managed without a preceptor/clinician present (OR 0.729; 95% CI: 0.285, 1.867).

CONCLUSION

The clinical placement site, hospital or clinic, impacts midwifery students' CLE. Clinics offered students significantly greater attributes of a supportive learning environment and access to direct, hands-on opportunities for patient care. These findings may be helpful for schools when using limited resources to improve the quality of midwifery education.

Collaborative clinical facilitation in selected nursing and midwifery colleges in Northern Ghana

Background

Collaborative clinical facilitation converges key players to guide students individually and within groups towards achieving clinical nursing competence. However, experiences of collaborative clinical facilitation among nurse educators, clinical preceptors and nursing and midwifery students are often fragmented and have been largely unexplored in Ghana.

Aim

To describe the experiences of collaborative clinical facilitation among nurse educators, clinical preceptors and final year nursing and midwifery students in Northern Ghana.

Setting

The study was conducted at two nursing and midwifery colleges and an academic hospital in Northern Ghana.

Methods

A qualitative, descriptive, exploratory design was utilized. Forty-six participants comprising 16 nurse educators, 10 clinical preceptors, 10 nursing students and 10 midwifery students were purposively sampled. Focus groups and in-depth interviews were used to gather data and analysed thematically.

Results

Three themes revealed facilitative experiences of collaborative clinical facilitation: team-based clinical mentorship and supervision, personalised preceptorship, and clinical conferences. Two themes emerged inhibitory to collaborative clinical facilitation: staff shortages and lack of timely communication.

Conclusion

This study found that team mentorship, preceptorship and conferences fostered collaborative clinical partnerships for students' clinical learning. However, failure to engage in timeous communication in the midst of staff shortages hampered its smooth practice. Orientation workshops need to be organised for key players to share relevant updates and explore ways to navigate the challenges often experienced within the clinical training environment.

Contribution

This paper provides insight into the collaborative nature of clinical facilitation; and highlights the need for coordinated clinical placements to enhance students' clinical learning.

A Model for Effective Nonverbal Communication between Nurses and Older Patients: A Grounded Theory Inquiry

Nonverbal communication is an inevitable art to be effectively mastered by nurses. Nurse nonverbal communication has many benefits when it is effective. For instance, nonverbal communication is important to convey affective and emotional information, and demonstrate respect for and build therapeutic relationships with older patients. As the older population is growing fast worldwide, effective nonverbal communication with older patients is an essential skill for nurses and will improve patients' satisfaction and the quality of care. Therefore, this article presents a model to guide effective nonverbal communication between nurses and older patients. A Grounded Theory approach guided the study. Data were collected between July 2018 and January 2020 through overt participant observations and individual interviews. Purposive and theoretical sampling were used to select 13 clinically experienced nurses, 4 nursing students, and 8 older adults. Data analysis encompassed open coding, axial coding, and selective coding. The results showed that effective nonverbal communication emerged as the co-phenomenon hinged within context and/or environment and is influenced by certain factors. This model, which is in support of person-centered communication and care, advocates for effective nonverbal communication between nurses and older patients.

Nursing and Midwifery Students’ Perspectives of Faculty Caring Behaviours: A Phenomenological Study

Aims:

The study aimed at exploring faculty caring behaviours from the perspectives of university students enrolled in Nursing and Midwifery programme at one of the public universities in Malawi.

Background:

The concept of caring has to a larger extent been defined in the context of nursing practice and rarely in the context of nursing education. Caring for students and nurturing a caring attitude in nursing education is the first place for students to learn about the most significant values of their profession.

Objective:

The objective of this study was to describe faculty caring behaviours from the perspectives of university students who were studying for a degree in Nursing and Midwifery programmes at one of the public universities in Malawi.

Methods:

A qualitative approach utilising descriptive phenomenology as a study design was used in this study. Data was collected through semi-structured interviews at a public university in Malawi from ten (10) nursing and midwifery students who were purposively selected. All ethical considerations were followed. Data were analysed using Colaizzi’s (1978) method.

Results:

Five themes emerged that defined faculty caring behaviours from the student’s perspective: (1) Being available, (2) Being respectful, (3) Seeing the person in the student, (4) Being fair and (5) Communication.

Conclusion

Findings have shown that nursing and midwifery faculty display both caring and uncaring behaviours. The study recommends the establishment of a curriculum with caring as one of its defining philosophies; the establishment of educational faculty - student interactions based on moral and human caring principles, and advocating for faculty to embrace faculty caring to improve nursing and midwifery student's professional socialisation.

Challenges faced by student nurses and midwives in clinical learning environment - A systematic review and meta-synthesis

OBJECTIVES

This systematic review aimed to offer insight and understanding, through synthesis of findings from studies that report on perspectives of student nurses/midwives, clinical instructors, clinical nurses/midwives on the challenges faced by student nurses/midwives in the clinical learning environment (CLE).

DESIGN

All primary qualitative research studies published in the English language that reported on the views of student nurses/midwives, clinical instructors and clinical nurses/midwives on the challenges faced by student nurses/midwives in the CLE were included.

DATA SOURCES

The electronic databases of Medline EBSCO (1946-), CINAHL (1970), Embase Ovid (1974-), ScielO, WHOLIS (2002-), ASSIA (1985-), Web of Science (1956-), PsycINFO (1800s-) and Maternal and Infant Care (1970-) were searched in November 2019.

REVIEW METHODS

Retrieved papers were reviewed independently by two authors for selection by title, abstract and full text, and two authors agreed for inclusion of the papers. The COREQ criteria checklist was used for assessment of methodological quality of the included studies.

RESULTS

The review included 32 studies published over 22 years between 1997 and 2019 involving 853 nursing/midwifery students, clinical instructors, and clinical nurses/midwives from 14 countries. Three key themes emerged: 'The support structure', 'Personal factors', and 'Planning and organisation - influence of extrinsic factors'.

CONCLUSION

Attitude of clinical staff, instructors, and significant others had a major influence on students' clinical learning. Lack of a sense of belongingness and self-motivation to learn, and perceived fear of doing errors were some of the demotivating factors. Lack of resources to facilitate need-based training, staff shortages, workload and inconsistencies between theory and practice were other key challenges in the CLE. Understanding the challenges faced by students in clinical practice can help overcome the barriers leading to development of competent and confident nurses and midwives.

A "Co-CREATES" framework to foster a positive learning environment for nursing students' professional development in Rwanda

AIM

The future of the nursing profession in Rwanda in large part depends on the students who join the workforce and the education they have received. Preparing students with the necessary knowledge, values and judgement requires practice settings to be learner-centered. This study aimed at exploring strategies that might improve the current practice-based learning environment.

DESIGN

A focused ethnographic approach was used.

METHODS

Nursing students, staff nurses, clinical instructors and nurse leaders from three hospitals and an educational program participated in individual interviews.

RESULTS

Five key areas of improvement emanated from study data: 1) strengthening institutional support; 2) improving school-hospital collaboration; 3) building the capacity of nurses and clinical instructors; 4) restructuring clinical placement; and 5) reviewing the current supervision model. Based on these findings a "Co-CREATES" framework grounded in the actions of collaboration, care, recognizing, empowering, actively engaging, transforming, enhancement and support was developed. The framework offers a collaborative approach that engages every stakeholder in "cocreating" conditions that build positive practice environments which are conducive to preparing students as professional nurses.

CONCLUSION

The positive outcomes stemming from such a collaborative approach can further enhance a positive culture of collaboration in nursing education and practice.

Graduate Midwifery Education in Uganda Aiming to Improve Maternal and Newborn Health Outcomes

Background:

Maternal and newborn health outcomes in Uganda have remained poor. The major challenge affecting the implementation of maternal and newborn interventions includes a shortage of skilled midwives. In 2013, Lira University, a Ugandan Public University, in partnership with Seed Global Health, started the first Bachelor of Science in Midwifery (BScM) in Uganda with a vision to develop a Master of Science in Midwifery (MScM) in the future.

Objective:

Evaluate results of Lira University’s Bachelors in Midwifery program to help inform the development of a Masters in Midwifery program, which would expand midwifery competencies in surgical obstetric and newborn care.

Methods:

Lira University and Ministry of Health records provided data on curriculum content, student enrollment and internships. The internship reports of the graduate midwives were reviewed to collect data on their employment and scope of practice. Interviews were also conducted with the graduates to confirm the added skills they were able to apply and their outcomes.

Findings:

The critical competences incorporated into the Bachelor in Midwifery curriculum included competences to care for pre- and post-operative caesarian section patients or assist in a caesarean section, newborn care (e.g. resuscitation from birth asphyxia), anesthesia, and theatre techniques, among others. Overall, 356 students (40.2% male, 59.8% female) enrolled in the BScM program over the period 2013–2018. Annual data shows an increasing trend in enrollment. Of the 32 graduates in January 2019, 87.6% were employed in maternal and newborn healthcare facilities, and 12.4% were employed in midwifery private practice. Follow-up interviews revealed that the graduate midwives reported positive maternal and newborn outcomes and the ability to practice advanced obstetrics and newborn care skills they acquired from the training.

Conclusion:

There is growing interest in a graduate midwifery education program in Uganda for both male and female students. The retention of the graduate midwives in healthcare facilities gives a renewed hope for mothers and newborns, who benefit from their extra obstetrics and newborn care competences in settings where there are neither medical doctors nor obstetricians and gynecologists.

Recommendations:

Further, larger tracer studies of the graduate midwives to identify the kinds of obstetric surgeries and newborn care services they ably performed and their corresponding maternal and newborn health outcomes is recommended. Also recommended is advocacy for recognition of extra skills of graduate midwives by health authorities in Uganda and the region.

Factors influencing high absenteeism rate of student nurses in clinical areas at a nursing college in the Lejweleputswa District

BACKGROUND

Student nurse attendance during training is mandatory, and the South African Nursing Council (SANC) stipulates that students must attend 80% of hours for both theory and practice during their training. Unauthorised student nurse absenteeism, especially in the clinical areas, has become an increasing problem in nursing education institutions and in the universities. This study explored student absenteeism with the aim of generating solutions that are specifically relevant to the context of the Free State College of Nursing.

OBJECTIVES

The objectives of the study were to describe perceived personal reasons and reasons related to clinical areas that contribute to student nurses' absenteeism from the clinical areas and to explore the relationship between demographic data and reasons for absenteeism.

METHOD

A quantitative research design with descriptive and exploratory strategies was used. Data were collected by means of a self-administered questionnaire. Data analysis was performed using SPSS version 23.0. One hundred and fifty-two student nurses were sampled after permission to conduct the study was requested and obtained.

RESULTS

The results showed that 72.4% of respondents agreed that students are absent because of physical illness. The majority of students (97.3%) at the selected campus are absent from clinical areas because they are covering staff shortages. The findings showed no particular relationship between gender and absenteeism as absenteeism was present throughout.

CONCLUSION

Student nurses at a selected campus are generally absent at the clinical areas because they are physically ill and are funded for studying but not paid for working. It was recommended that accurate records of attendance should be kept and absenteeism rates be calculated at frequent intervals.

Transforming Nursing Education to Strengthen Health System in Malawi: An Exploratory Study

Background:

Malawi made great strides to increase the number of nurses through the Emergency Human Resource for Health Program. However, quantity of health workforce alone is not adequate to strengthen the health system. Malawi still reports skill mix imbalance and geographical mal-distribution of the nursing workforce. Health systems must continuously adapt and evolve according to the health care needs and inform health professionals’ education to accelerate gains in health outcomes. The Lancet Commission reported that health professionals’ education has generally not lived up pace with health care demands.

Objectives:

The aim of this study was to describe the strategies being implemented in Malawi to improve nursing education. Specifically, the objectives of the study were to explore strategies being implemented, identify stakeholders and their targets in order to share practices with countries experiencing similar nursing education challenges.

Methods:

This was a cross sectional descriptive study with a concurrent mixed method design. One hundred and sixty participants including nurse practitioners and educators responded to a questionnaire. Fifteen nurse practitioners and eight nurse educators were also engaged in one to one interview.

Results:

Respondents showed varied opinion on how nursing education is being implemented. Six themes as regards strategies being implemented to improve nursing education emerged namely- capacity building, competency based curriculum, regulation, clinical learning environment, transformative teaching and infrastructure/ resources.

Conclusion:

Findings of this study show that the strategies being implemented to improve nursing education are relevant to closing the gap between health care needs and nursing education.

Clinical Supervision and Support: Exploring Pre-registration Nursing Students' Clinical Practice in Malawi

Background:

Supervised clinical practice plays a significant role in the nursing profession, as it has an influence on the students’ clinical learning.

Objectives:

The aim of this study was to explore how the pre-registration nursing students find their experience on clinical supervision in the clinical placements.

Methods:

The study used both quantitative and qualitative approach to collect data through focus groups (n = 144) and self-administered questionnaires (n = 590) from nursing students of various programmes in selected colleges in Malawi.

Results:

About 75% (n = 443) of the participants indicated that they received supervision from both clinical staff and Nurse Educator. However, qualitative results indicated that students received inadequate clinical supervision. Themes that emerged from the discussion included lack of human resources, learning support, availability of instructors yet not supporting learning, job insecurity and lack of remuneration as reasons for lack of supervision, role models and student guidance despite pressure and self-directed.

Conclusion:

There is a need for clear policies regarding clinical supervision as well as a structured and well monitored process.

A middle-range model for improving quality of nursing education in Malawi

Background

Despite a global consensus that nurses and midwives constitute the majority and are a backbone of any country’s health workforce system, productive capacity of training institutions remains low and still needs more guidance. This study aimed at developing a middle-range model to guide efforts in nursing education improvements.

Objective

To explore challenges facing nursing education in Malawi and to describe efforts that are being put in place to improve nursing education and the process of development of a model to improve nursing education in Malawi.

Method

The study used a qualitative descriptive design. A panel discussion with eight nursing education and practice experts was conducted guided by core concepts derived from an analysis of research report from a national nursing education conference. Two focus group discussions during two quarterly review meetings engaged nurse educators, practitioners and clinical preceptors to fill gaps from data obtained from a panel discussion. A qualitative abductive analysis approach was used for the development of the model.

Results

Transforming and scaling up of nursing education emerged as the main concept of the model with nursing education context, academic practice partnership, regulation, competent graduate and nursing workforce as sub concepts. Key main strategies in the model included curriculum reforms, regulation, transformative learning, provision of infrastructure and resources and capacity building.

Conclusion

The model can be used to prioritise nursing education intervention aimed at improving quality of nursing education in Malawi and other similar settings.

Through the eyes of the student: Best practices in clinical facilitation

Background

Clinical facilitation is an essential part of the undergraduate nursing curriculum. A number of studies address the issue of clinical facilitation in South Africa, but there remains a lack of knowledge and understanding regarding what students perceive as best practice in clinical facilitation of their learning.

Objective

To determine what type of clinical facilitation undergraduate students believe should be offered by clinical facilitators (nurse educators, professional nurses and clinical preceptors) in the clinical area in order to best facilitate their learning.

Method

A qualitative, exploratory and descriptive study was conducted. Purposive sampling was performed to select nursing students from the second, third and fourth year of studies from a selected nursing education institution in Johannesburg. The sampling resulted in one focus group for each level of nursing, namely second, third and fourth year nursing students. Interviews were digitally recorded and transcribed verbatim, thematic data analysis was used and trustworthiness was ensured by applying credibility, dependability, confirmability and transferability.

Main findings

The data revealed that participants differentiated between best practices in clinical facilitation in the clinical skills laboratory and clinical learning environment. In the clinical skills laboratory, pre-contact preparation, demonstration technique and optimising group learning were identified as best practices. In the clinical learning environment, a need for standardisation of procedures in simulation and practice, the allocation and support for students also emerged.

Conclusion

There is a need for all nurses involved in undergraduate nursing education to reflect on how they approach clinical facilitation, in both clinical skills laboratory and clinical learning environment. There is also a need to improve consistency in clinical practices between the nursing education institution and the clinical learning environment so as to support students’ adaptation to clinical practice.

Challenges in Neonatal Nursing Clinical Teaching to Nurse-Midwife Technicians in Malawi

BACKGROUND

Practice-based learning is important in clinical teaching of nursing and midwifery as students develop the necessary competencies and confidence aligned by the outcomes of their learning programs. However, in Malawi, research shows that clinical teaching in neonatal nursing has not been given adequate consideration. This article reports on challenges faced by educators and students in clinical teaching and learning in neonatal nursing for nurse-midwife technicians.

METHOD

An explorative qualitative study was conducted. Data were collected through 23 focus group discussions with 140 students and 31 clinical teachers from eight nursing colleges. Audiorecorded data were transcribed verbatim and analyzed using Hennink's content analysis stages.

RESULTS

Challenges faced by clinical teachers and students were short duration and variation in clinical placements, lack of emphasis in clinical teaching, and lack of skills among clinical staff.

CONCLUSION

Nursing training institutions should maximize student learning opportunities in neonatal nursing practice by creating more practice-based learning opportunities that meet the students' needs. [J Nurs Educ. 2017;56(4):215-221.].

Iranian Nursing Students' Experience of Stressors in Their First Clinical Experience

The first clinical experience is a turning point in the educational journey of nursing students as it marks the beginning of their professional development. This experience is often stressful for students. This study was conducted mainly to research, describe and interpret nursing students' perceptions of stressors in the clinical environment in their first clinical experience. The present phenomenological study selected seven nursing students through purposive and snow balling sampling and questioned them in semi-structured interviews. The data acquired were analyzed by Colaizzi's method. The following themes emerged in this study: 1- the sense of inadequacy, 2- being ignored, 3- ineffective communication, 4- prevailing sadness and 5- ambiguity. The results of the present study showed that nursing students experience several sources of stress in their first clinical experiences. Hence nursing administrators should diligently evaluate and rectify nursing students' clinical stressors.

A nurse-led intervention improves detection and management of AKI in Malawi

BACKGROUND

Acute kidney injury is common and has significant impact on mortality and morbidity. There is a global drive to improve the lack of knowledge and understanding surrounding the recognition, diagnosis and management of patients with AKI in resource poor healthcare systems.

OBJECTIVES

We propose a nurse-led education programme to medical and nursing staff of the Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, will improve the overall care and understanding of patients with AKI that will still be effective 3 months later.

METHODS

This was a three phase, prospective interventional pilot study which evaluated base line knowledge and clinical practice amongst healthcare workers, provided a comprehensive combination nurse-led class room and ward based teaching programme and evaluated the change in knowledge and clinical management of patients in the high dependency areas of the hospital immediately, and 3 months, after the teaching intervention.

RESULTS

The nurse-led intervention significantly improved the healthcare workers attitudes towards detecting or managing patients with suspected AKI (p < 0.0001). There were also significant improvements in the completion of fluid charts and recording of urine output (p < 0.0001), corner stones of AKI management. Knowledge and clinical intervention was still present three months later. There was however little change in the understanding that AKI could be a significant clinical problem in QECH and that it may have a major impact on mortality and working practice and this needs to be addressed in future teaching programmes.

CONCLUSIONS

A low cost, nurse-led AKI educational intervention improved the knowledge and management of AKI at QECH, which was still evident 3 months later.

Enhancing students’ moral competence in practice

Background:

Nurses and student nurses in Malawi often encounter challenges in taking a moral course of action. Several studies have demonstrated a need for increased awareness of ethical issues in the nursing education.

Objective:

To explore the challenges experienced by nurse teachers in Malawi in their efforts to enhance students’ moral competence in clinical practice.

Research design:

A qualitative hermeneutic approach was employed to interpret the teachers’ experiences.

Participants and research context:

Individual interviews (N = 8) and a focus group interview with teachers (N = 9) from different nursing colleges were conducted.

Ethical considerations:

Ethical approval was granted and all participants signed their informed consent.

Findings:

Two overall themes emerged: (1) authoritarian learning climate, with three subthemes: (a) fear of making critical comments about clinical practice, (b) fear of disclosing mistakes and lack of knowledge and (c) lack of a culture of critical discussion and reflection that promotes moral competence; and (2) discrepancy between expectations on learning outcome from nursing college and the learning opportunities in practice comprising three subthemes: (a) gap between the theory taught in class and learning opportunities in clinical practice, (b) lack of good role models and (c) lack of resources.

Discussion:

Our findings indicated that showing respect was a central objective when the students were assessed in practice. A number of previous studies have enlightened the need for critical reflection in nursing education. Few studies have linked this to challenges experienced by teachers for development of moral competence in practice. This is one of the first such studies done in an African setting.

Conclusion:

There is a clear relationship between the two themes. A less authoritarian learning climate may enhance critical reflection and discussion between students, teachers and nurses. This can narrow the gap between the theory taught in college and what is demonstrated in clinical practice. Moral competence must be enhanced in order to ensure patients’ rights and safety.

Perceptions of nursing students trained in a new model teaching ward in Malawi

This study aimed to investigate the perceptions of nursing students trained in a new model teaching ward in Malawi. A total of 90students from five nursing colleges were randomly assigned to one model ward and two ordinary wards in a single teaching hospital. The students were administered a revised version of the Student Evaluation of Clinical Education Environment questionnaire. Significant differences among the three wards were found in all items in the communication/feedback subscale, with the exception of the item "nursing staff provided constructive feedback" (P=0.162). Within the learning opportunities subscale all items showed significant differences among the three wards, whereas 50% of the items in the learning support/assistance subscale had significantly different responses among the three wards. Within the department atmosphere subscale, no significant differences were found in the items assessing whether an adequate number and variety of patients were present in the ward (P=0.978). The strategies that are being implemented to improve the educational environment showed positive results. Students scored the model teaching ward highly. Students who underwent precepting in the model teaching wards reported having more learning opportunities and a positive learning environment.