Practices of caring for nursing students:A clinical learning environment

Jennifer Subke,Charlene Downing ,Irene Kearns

Department of Nursing,University of Johannesburg,Johannesburg,South Africa

Keywords:Clinical learning environment Empathy Nursing students Nursing education

ABSTRACT Objective:The purpose of this study was to explore,describe and illuminate nursing students’ best encounters of caring in the clinical learning environment.Caring for nursing students was emphasized and recommendations provided to enhance caring for nursing students within their clinical learning environment.Methods:Qualitative data was collected by the researcher using semi-structured individual interviews and an Appreciative Inquiry (AI)methodology.Ten second year nursing students undertaking the bridging course leading to registration as general nurses in terms of Regulation 683 of the South African Nursing Council (SANC)were purposively sampled from 3 private hospitals within the Western Cape.Data was analysed using Giorgi’s method.Results:The main theme included the best and‘least best’caring practices embedded in the centrality of the heart.The subthemes comprised of the nursing students’ experiences of caring literacy and caring illiteracy.The second theme included the creation of best caring practices within a conducive clinical learning environment.Within this theme,the subthemes comprised of the caring attributes required in reflecting best caring practices,as well the creation of a clinical learning environment to optimise caring.Conclusions:The significance and necessity of caring for the nursing student were clearly illustrated and confirmed by participants.Caring was equated to the heart as the core to the nursing students’ being.Recommendations for nursing education,management,practice and research were therefore specifically formulated to enhance caring towards nursing students.

What is known?

· It is known that caring is essential to nursing and many studies have documented‘caring’,‘caring moments’and‘the promotion of caring’,however no statistics were found by the researcher,specifically regarding ‘caring’ and ‘caring practices for nursing students’.

What is new?

· This study identified that nursing students are faced with challenges within their clinical learning environment which directly effects them.

· Emphasis is thus placed on the importance of‘caring’and‘caring practices’ for nursing students within their clinical learning environment.

· Recommendations were suggested to achieve best caring practices for nursing students within their clinical learning environment.

1.Introduction

Within the nursing profession,caring is mostly aspired to,yet it is under threat of disintegration in the 21st century [1].Clinical practice is an essential aspect of nursing education [2]and this is where nursing students are exposed to a complicated world that is influenced by many factors;socially,economically and politically.It can,therefore,appear that caring becomes lost within the existing healthcare milieu [3].

Emphasis is placed on caring as being fundamental to nursing[4].Lekalakala-Mokgele and Caka however mention that there is a lack of care displayed in caring for nursing students within their clinical learning environment where nursing students have described their clinical learning environment as unsupportive and a stumbling block,creating within them feelings of dread and apprehension [4].

As caregivers,nursing students are faced with challenges while spending significant time in the clinical learning environment [5].These challenges include acquiring clinical skills,integrating theoretical knowledge,adapting to a new environment,and other health personnel [6].It is important to note that stress has been recognised as a psycho-social factor in the clinical learning environment which may affect the well-being of nursing students[2].It is therefore essential that consideration be given to caring for nursing students and that a caring environment be created[7].

Watson’s Theory of Human Caring was viewed as the theoretical background for this study because it embodies characteristics of caring and emphasises the following processes;1)improving loving-kindness and composure to self and others,2)being truly in attendance,3)developing one’s spirituality,4)cultivating and maintaining caring and helpful relationships,and 5)being available and showing support of positive and negative feelings.This theory relates to the nursing student as it explains what constitutes ‘caring’,the way in which caring is displayed,as well as positive effects of caring,and caring for each other and the self within the clinical learning environment [8].Similarly,caring was also viewed as a way of connecting to someone,encouraging growth,development,and fulfilment [9].In agreement,Al-Banna [10]states that caring includes compassion for,as well as connection with others.Caring requires action and is viewed as a sentiment that displays understanding and responsiveness towards others [1].

Within the nursing students’ world,the clinical learning environment is required to be an environment that is caring and supportive [11].Arkan,Ordin and Yilmaz [12]state that the clinical learning environment should provide nursing students with individual and professional development.The clinical learning environment has a direct effect on the nursing students’ performance and their learning.It is thus imperative to consider the clinical learning environment in which care is given [13].

Desmond,Horn,Keith,Kelby,Ryan and Smith [14]emphasize caring in the clinical learning environment by stating that in caring cultures,nursing students feel accomplished,purposeful,grateful,and satisfied with their work.Similarly,Flott and Linden [15]mention that when nursing students feel physically and emotionally safe as part of the health care team,they experience a sense of belonging.Additionally,it is noted that when a clinical learning environment is experienced in a positive way,learning is enriched[16].

Within the clinical learning environment,‘practices’ of caring refer to the processes,behaviors’ and attitudes by which caring is demonstrated towards the nursing student[17].

Contrastingly,the nursing student may be exposed to stress,compassion fatigue and discourteousness [6].In such an uncaring clinical learning environment,the nursing student may become hardened,depressed,and worn down [16].Sanvik,Eriksson and Hill [17]also noted that in the clinical learning environment the focus is often entirely on acquiring clinical skills,executing tasks,and achieving learner outcomes.Minimum attention is given to the nursing students’ emotional and psychological development;the caring factor that recognises the nursing student as an individual is neglected [18].Finally,according to Lekalakala-Mokgele and Caka[4],the clinical learning environment may be stressful,causing anxiety and fear,and affecting learning negatively.Emphasis is placed on caring as being fundamental to nursing;however,a lack thereof is displayed in caring for nursing students within their clinical learning environment[13].A conclusion is thus drawn that caring for nursing students within their clinical learning environment is a necessity.

Caring and uncaring practices are referred to in this study as caring literacy and caring illiteracy.The terms ‘caring literacy’ and‘caring illiteracy’are used to demonstrate and clarify the difference between caring and uncaring.The meaning of literacy is usually associated with reading and writing abilities.The Cambridge Academic Content Dictionary(2018)however refers to literacy as being proficient or having expertise in a subject matter [19].In this context,the meaning of caring literacy is defined as possessing illumination in caring at professional and personal levels,including insightfulness,awareness and deliberateness,coming from the heart.Caring illiteracy or uncaring would therefore reveal the opposite of caring or caring literacy.

2.Methodology

The research design used was a qualitative,exploratory,descriptive and contextual design to describe and give meaning to the nursing students’ world of caring encounters within their clinical learning environment.The researcher focused on identifying,portraying,exploring and understanding caring encounters experienced by nursing students in their clinical learning environment in order to form a holistic picture of this phenomenon.The 4D-cycle of the Appreciative Inquiry method was employed for this study and consisted of the following phases:Discovery,Dream,Design and Destiny [20].

2.1.Study setting and sampling

The study setting consisted of three private hospitals belonging to one healthcare institution situated in the southern suburbs,northern suburbs and central business district of the Western Cape region.The private hospital in the southern suburbs was the smallest private hospital with a bed status of eighty-eight patients;in the northern suburbs the private hospital had a bed status of one hundred and forty-five patients whilst the private hospital in the central business district had the largest bed status of two hundred and sixty patients.These private hospitals housed various disciplines such as;medicine,surgery,and intensive care units and provided medical attention to patients locally and internationally.

Participants pursued their clinical practice at these private hospitals,which at the time of the study trained a total of twentyone second-year bridging nursing students in meeting their clinical training requirements.In order to meet their clinical training requirements,second-year bridging students were required to spend a total of one thousand clinical hours within the clinical learning environment.During this time,skills such as management of the various units were taught by clinical facilitators.Interviews were conducted by the researcher in private consultation rooms within these private hospitals,at times and dates that were suitable for the participants.

A purposive sampling method was employed ensuring that the researcher purposely selected ten,second-year nursing students who were knowledgeable in providing data of the phenomenon under study [21],and were willing to participate in the study.The final number of participants,i.e 10 s-year nursing students were determined at the point when data saturation had been reached.Saturation of data occurs at the point when no new information can be gleaned from the participants and redundancy is achieved[22].

2.2.Participants’ demographic characteristics

Participants were second-year bridging nursing students leading to registration as general nurses in terms of Regulation 683 of the South African Nursing Council.Second-year bridging nursing students were chosen,due to their previous experience of and exposure to clinical practice in the clinical learning environment.Of the ten participants,there were seven females and three males with Black,Coloured,Indian and White ethnic backgrounds.Ages varied from the youngest participant of 27 years to the oldest participant of 48 years.The inclusion criteria included participants who had successfully completed 75% of their theoretical and practical components of the curriculum.As the English language was the medium used for instruction during the participants’clinical training,interviews were conducted in English,which was understood by all the participants.

2.3.Data collection

A pilot study was conducted and confirmed the adequacy of the interview questions in providing data of the phenomenon under study.The researcher then collected data by conducting individual semi-structured interviews until data saturation was reached.Data saturation occurred when the data shared was unvarying,became repetitive and no new data emerged from the participants[21].The semi-structured interviews were audio recorded and of a duration of 45-60 min.Field notes were recorded immediately after the interviews had taken place and described the emotional context of the interviews as well as relevant observations,behaviors and experiences [21].Data collection took place over the period of May 2017 until March 2018.

2.4.Interview questions and description of Appreciative Inquiry phases

(1)What are the best caring moments that you have encountered in your clinical learning environment? (Discovery -Phase 1).This is a critical phase focusing on identifying and‘a(chǎn)ppreciating the best of what was and what is’[23].During this stage,nursing students’ most meaningful encounters and best experiences of practices of caring within their clinical learning environment are illuminated.This phase also stimulates dialogue regarding future possibilities.

(2)What would be the best or ideal way of caring for you as nursing students in your clinical learning environment?How do you wish it was? (Dream -Phase 2)This is the phase when the participants describe their dreams,desires and the possibilities of what might be.At this time,aspirations and a sense of the practices of caring for nursing students in the future,are identified [24].

(3)How should caring be improved in creating the ideal clinical learning environment? (Design -Phase 3)The focus of this phase is about creating processes to support the ideal envisioned image of practices of caring for nursing students by dialoguing how the ideal should be within the clinical learning environment [23].

(4)What can be recommended,developed,and maintained to optimise caring in a clinical learning environment?(Destiny/Delivery -Phase 4)This fourth phase involves implementing,evaluating and maintaining processes of what was envisaged in striving for the ideal practices of caring for nursing students within their clinical learning environment[24].Within this phase,new plans can surface and be developed [24].

2.5.Data analysis

Data were transcribed and analysed by the researcher using Giorgi’s five-step method to obtain the crux of the participants’experiences [18].The researcher transcribed the interviews verbatim from an audio recorder.Thereafter the researcher read and reread the complete descriptions in their entirety,engaging with the words of the participants in order to recognise and categorise ‘units of meaning’ [18].Data was then divided and the meanings condensed in order to process and group the content.All similar meanings were assembled and arranged under main themes and categories [18].An independent coder,qualified as a well-known researcher with a PhD degree in Psychiatry analysed the data.Consensus occurred after two rounds of discussions were held between the independent and the researcher.

2.6.Trustworthiness

The trustworthiness of this study was assessed by using the four criteria of credibility,transferability,dependability,and confirmability [25].During this study credibility was demonstrated by prolonged engagement as the researcher spent sufficient time with participants.Within this time rapport was established and a deeper understanding of the practices of caring for nursing students in their clinical learning environment was gained.Persistent observation of the gathered data also provided credibility as well as data triangulation.This occurred by collecting data from field notes and interviews from triangulated sources,i.e.participants from different groups of second-year bridging nursing students in varied hospital clinical learning environments[26].The researcher used a purposive sampling method,a detailed description of the study results in achieving transferability as well as an audit trail of all research activities in enhancing dependability and confirmability.Furthermore,the researcher consulted an independent coder to ensure the trustworthiness of the study,by checking and confirming that accurate units of meaning were derived from the collected data.

2.7.Ethics considerations

Before the commencement of this study,permission was requested and approval was obtained from the Faculty of Health Sciences’Research Ethics Committee(REC-241112-035)and Higher Degrees Committees of the University of Johannesburg (01-67-2016)as well as the Research Operational Committee of the Health Care Institution (UNIV-2016-0072).Permission was also requested and approval was obtained from persons in authority to gain access to study participants and the three institutional sites wherein research was conducted within the Western Cape.The ethical principles used by the researcher were:the right to selfdetermination,the principle of beneficence,and the principle of justice[25].

It is important to note that nursing students may be viewed as a vulnerable population or group as they may be susceptible to coercion and exploitation;as such,they may need added protection[27].The participants therefore were seen as autonomous individuals,having the right to decide voluntarily to participate in the study without the risk of discriminatory treatment or coercion.Participants gave written consent and confidentiality and anonymity was assured as pseudonyms were used.The participants did not receive clinical instruction from the researcher and were therefore unknown to the researcher.Assurance was given to the participants that they could withdraw from the study at any time without being penalised in any way[26].

3.Results

3.1.Emerging themes

Two main themes and four subthemes emerged from the data.The themes and subthemes developed from the interviews with participants in accordance with the questions asked.Best and‘least best’ caring practices embedded in the centrality of the heart was the main theme and consisted of subthemes exploring the nursing students’ experiences of caring literacy and caring illiteracy.The second theme comprised of the creation of best caring practices within a conducive clinical learning environment.Herewith the subthemes consisted of the caring attributes required in reflecting best caring practices,as well the creation of a clinical learning environment to optimise caring for nursing students.

3.2.Best and‘least best’caring practices embedded in the centrality of the heart

The main theme emphasized that caring was essential to the nursing student and described as‘love’;associated with the‘heart’;allowing for wholeness and a sense of completion.Best practices of caring are thus embedded in the centrality of the heart.This is confirmed by the following verbatim quotes:

“Caring as I said is love.If you are cared for then you feel whole,you are complete.”(Participant 5,female,41 years)and“So if there is caring,you have the students’ best interest at heart.Caring is something that comes from the heart.” (Participant 10,male,31 years).

The subthemes comprised of the nursing students’ experiences of caring literacy and caring illiteracy

Within the subthemes participants noted that caring literacy engenders a host of positive emotions.When caring literacy prevailed and was experienced by participants,the following was stated:“I feel confident.” (Participant 6,female,29 years).Participants relayed that their peers were supportive and assisted each other.This is described by the following quotes:“We come together,unite and form a solid bond.We need to care for ourselves and for each other.”(Participant 8,male,27 years).Furthermore,all participants experienced caring and shared a supportive relationship with clinical facilitators.They were viewed as ‘motherly’:“In a way it feels like we are at home and cared for.She assists us with everything we need.It can be practical procedures…it can be personal issues that we need to deal with.” (Participant 8,male,27 years).

Caring interactions with hospital staff were perceived as varied.Interactions were positive when caring was revealed,while other interactions were uncaring or caring illiterate.Some nursing managers and unit managers were good role models and a supportive presence to nursing students.They were perceived as‘student-friendly’ and therefore available to the nursing students.

Contrastingly,when caring illiteracy,such as disrespect and ill treatment was displayed by unit managers a breakdown of caring occurred.Nursing students expressed feelings of exclusion and non-acceptance by hospital staff as uncaring practices;‘professional jealousy’ was experienced by some.Uncaring encounters experienced by nursing students were communicated to the nursing students in the manner of approach,communication,body language and unhelpful attitudes According to the participants,a common perception arose within the clinical learning environment that when errors occurred,the nursing student was solely to blame.This is described as:“I feel students are being used as a scapegoat for everything that happens wrong in the hospital.They’ve got that perception that whatever wrong that is happening,students are to blame for it.I feel they need to give everyone a fair chance to do their work,without a pre-judgemental view.” (Participant 10,male,31 years).

Other uncaring practices were described in terms of ‘professional jealousy’.These practices are explained as:“Because they know that you are going to study further or going to complete the course,the four-year degree course or diploma,you’ll get one feeling very much intimidated.That is caused by age,sometimes because you get to be exposed when you’re a young nursing student,you get to work with senior people,so now they feel very much uneasy with you,it might happen that you may be as young as their first daughter or son.Then they can’t understand being led by youngsters.”(Participant 1,male,30 years).

In this example,the participant explains that staff members feel threatened by nursing students who are improving their career prospects and acquiring knowledge.Age also plays a factor in professional jealousy,as staff do not want to have to follow orders or be challenged by someone younger than themselves.

The study findings also show that participants felt that they were regarded as a‘workforce’.They believed that they were seen merely as extra pairs of hands to do the work required.In other words,they experienced not feeling valued as nursing students in a learning role.For example:“… load is so much heavier than normal personnel…need to understand that students are not supposed to be your working force…they do not really care,because the reality is it is very much work driven.” (Participant 10,male,31years).

3.3.Creation of best caring practices within a conducive clinical learning environment

Participants acknowledged that they feel vulnerable when entering the clinical learning environment due to an unfamiliar environment.This second theme emphasises that it is important that best caring practices are created to ensure a conducive clinical learning environment.Feelings of insecurity,fear and fragility were expressed by participants and revealed as follows:“…as a student you don’t know everything.It might be your first time in a particular ward and the procedures there are completely different.It’s a stressful environment and that stressful environment goes on to the student.”(Participant 4,female,29 years).

3.3.1.Caring attributes required in reflecting best caring practices

The study findings showed that nursing students agreed that caring was shown by support,guidance and teaching.These qualities were regarded within this subtheme as essential caring attributes required by nursing students that assisted their personal and career growth.Being mentors to the nursing students was an important aspect which enabled a sense of security.A supportive presence was vital to the nursing student as this suggested being in close proximity and therefore physically and emotionally available to the nursing student.This also meant that the nursing student felt heard,was listened to,acknowledged,recognised and included.These caring attributes,together with a feeling of belonging to a team,was fulfilling to the nursing students.

Participants also shared that being part of a team,being oriented and accompanied enabled a sense of security and belonging within the clinical learning environment.Effective communication,specifically the manner in which nursing students were spoken to,was fundamental to their well-being.Non-verbal body language impacted on the nursing student,also portraying caring.All these factors increased the nursing students’ levels of confidence,motivation and self-esteem.Receiving guidance and support is thus critical and expressed as:

“I would’ve liked to have received that holistic care that we give our patients … the emotional,physical,all-round support and guidance.” (Participant4,female,29 years).

Findings of the study show that nursing students require encouragement and motivation and have expressed the need to have a support structure in attendance and accessible to them.Nursing Students require that support in the form of an individual who can be physically present and connect emotionally to them.This is illustrated by the following quote:

“…all round interactiveness…be available to go and talk.You need to know that no matter what,that there is somebody that you can go and talk to about it.And that it’s going to help you and not just throw you into the lion’s den.…you have to have that,a surety that there is somebody there for you.”(Participant 4,female,29 years).

Not only do nursing students want to belong and be accepted by the team within their clinical learning environment,they also have a need to be acknowledged.Nursing students require positive recognition,praise and acknowledgement of their strengths.Participants stated:

“I mean as human beings we all want to be acknowledged in a sense that we’ve done well or that people see what we’re actually doing.It’s not just going unnoticed.” (Participant 3,female,32 years).“Acknowledge my strengths … say something nice and acknowledge what I do right.Everybody needs that credit for what they do best.” (Participant 6,female,29 years).

3.3.2.Creating a clinical learning environment to optimise caring for nursing students

The clinical learning environment is known as the area of clinical practice where nursing students are expected to spend time in order to qualify as professional nurses.It encompasses a physical area in which nursing tasks are performed.However,the clinical learning environment also includes an emotional ambience.

Participants mentioned:

“Environment is of utmost importance to show you care.Create a conducive environment for your student.You want them to excel and give excellent care you need to show them respect and show them that you create an environment that says that.”(Participant 10,male,31 years).

4.Discussion

It is noted by the study findings that the caring displayed made a lasting impression on the nursing students.As shown in the main theme of the study,caring was equated to the heart as the core to the nursing students’ being,as participants shared that they felt loved and complete when cared for.

Watson [28]claims that being fluent in caring enables one to become aware of the deeper meaning of caring,as well as to refine and enlighten one on how to‘be caring’.This applies specifically to having an awareness of caring,being in the presence of caring,displaying caring,and knowing how to care.In other words,to be aware of caring would require that one is primarily cognisant and knowledgeable about the concept and meaning of caring and all it entails.Likewise,to be in the presence of caring means to be within an emotional or physical environment where caring is displayed.Labrague,McEnroe-Petitte,Papathanasia,Edet and Arulappan[29]add that practical caring behaviours relate to task-oriented activities,preservation of the clinical learning environment,teaching,guidance and problem resolution.Emotional caring behaviours consist of establishing trust,displaying emotional support,empathy and sensitivity [29].

According to Monsen,Le,Handler and Dean[30],when there is awareness and understanding of the insecurities nursing students are faced with,support can be given to enhance their growth and develop their emotional intelligence.This will also lead to the development of beneficial relationships and engagement with their patients.Sensitivity to nursing students’ emotions and needs,is thus essential to their well-being.Nursing students are also in a period of transition,from being learners to becoming registered nurses.Due to this transition,nursing students are in a vulnerable position and feel insecure.They may,therefore,be emotionally exposed and at risk of experiencing ungraciousness from staff members as well as stress and emotional fatigue,[4].This can be challenging but can be managed by providing more support during this transitional period.Similarly J?rvinen,Ekl¨of,and Salminen[31]state that some nursing students may feel anxious and insecure about entering the clinical learning environment.

To become caring literate and fluent in caring,hospital staff should be present and aware of nursing students’insecurities.It is noted from the participants’ verbatim quotes,as well as D’Souza,Karkada,Parahoo,Venkantte and Saperumal’s study that caring interactions with ward staff are significant in creating the nursing students’clinical experience.Similarly,support from ward staff,coworkers and unit managers have a positive influence on jobsatisfaction [32].Within this study,the clinical facilitators and the caring roles they played were frequently mentioned by participants and as mentioned by Muthathi,Thurling &Armstrong [33],the clinical facilitator plays an essential role in supporting,teaching and guiding the student.Peers are also important initiators of emotional support to fellow nursing students during their clinical practice and a channel whereby caring relationships can be experienced [34].

Nursing students also agreed that caring attributes such as support,guidance and teaching together with a feeling of belonging to a team was found to be fulfilling to the student.Notably effective communication,specifically the manner in which nursing students were spoken to,as well as non-verbal body language impacted on the nursing student portraying caring and increasing their selfesteem,motivation and levels of confidence.

In conclusion Watson[8]mentions that nurses become fatigued by caring for others without attending to the care required for themselves.Nursing students,therefore,need to be kind and engage in caring behaviours that contribute to the wholeness of their lives.In doing so,they can replenish their inner resources and this,in turn,will be extended to others within the clinical learning environment[35].There is value in self-care practices which is not only crucial to the nursing students’well-being but also in teaching nursing students to take care of others [36].

5.Conclusion

Best caring practices for nursing students are imperative to the nursing students’ world.When caring practices are portrayed,the clinical learning environment becomes a positive and caring one,conducive to the personal and career development of the nursing student.

In conclusion,the study findings showed that as nursing students practice in clinical learning environments that can be physically and emotionally demanding and strenuous,it is therefore imperative that caring for nursing students also encompasses teaching them to care for themselves.

6.Recommendations

Caring for the nursing students is essential therefore best caring practices need to be emphasized and a student-friendly environment established by all clinical staff,portraying guidance and support.Caring for the nursing student allows for increased confidence,motivation and general well-being,and therefore impacts on relationships within the clinical learning environment as well as patient care.As awareness of caring is developed,training and skills workshops about caring practices and all aspects of caring may be introduced.Nursing students may also be frAppendix A.Supplementary data

equently reminded of ‘self-care’ and the importance thereof to prevent compassion fatigue by the introduction of in-housetraining programmes.Furthermore,it is imperative to have nursing managers who are effective role models and who display professionalism and care for their subordinates.‘Caring’ and ‘best caring practices’ may be introduced by nursing educators at nursing education institutions as subjects within the nursing curricula.Models of caring and caring philosophies can be employed by nursing educators as part of the curriculum.

Funding

The research study was financially supported by the researcher and the partial funding of Supervisor bursaries as awarded by the University of Johannesburg.

Declaration of competing interest

The authors declare no potential conflicts of interest in respect to the research,authorship and/or publication of this article.

CRediT authorship contribution statement

Jennifer Subke:Conceptualization,Methodology,Data curation,Investigation,Validation,Writing-original draft,Writing -review&editing.Charlene Downing:Conceptualization,Methodology,Validation,Supervision,Writing -review &editing.Irene Kearns:Conceptualization,Methodology,Validation,Supervision,Writingreview &editing.

Appendix A.Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2020.03.005.