The Nursing Students' Lived Experience of Clinical Practice. AEJNE Volume 5 - No.2 March, 2000. Rose Chapman RN, MSc, Lecturer, School of Nursing, Curtin University of Technology, Western Australia. Angelica Orb, RN, PhD, Senior Lecturer, School of Nursing, Curtin University of Technology, Western Australia.   For correspondence please contact: Rose Chapman,Lecturer,School Of Nursing, Curtin University of Technology Kent Street, Bentley, Western Australia, 6102. Email: Chapmanr@nursing.curtin.edu.au Telephone: Wk: 08 92662095 Fax: 08 9266 2959   Abstract Clinical practice is an essential part of the nursing students' education. This preparation allows the student the opportunity to link theory with the practice of caring for clients. Research has demonstrated that students experience problems and difficulties throughout their clinical practice. This study used a phenomenological approach to describe the lived clinical experience of third year nursing students. The major themes identified in the study were those of clinical practice enhancement, hindrance and strategies. For the purpose of this paper only the themes of clinical practice, enhancement, and hindrance will be discussed. The findings of this study will provide clinical teachers with a meaningful understanding of the experience of clinical practice, as it is perceived by nursing students.   Introduction It has been widely recognised by those engaged in nurse education that clinical practice is a significant and essential part of a student nurses' education (Wong & Wong, 1987). The clinical setting is fundamental to the nursing students learning because it offers opportunities for them to work with 'real' clients with ìrealî problems. It is only in the clinical setting that student nurses can use knowledge in practice, develop competency in psycho-motor skills and become socialised in their future role (Reilley & Oermann, 1992).   Clinical practice is fundamental to the nursing students' learning, however, many experience problems and difficulties during their clinical practicum (Campbell, 1985; Selleck, 1982; Parkes, 1980; Parkes, 1985; Birch, 1979). There is an extensive amount of literature highlighting problems that affect the studentsí clinical learning. Stress, anxiety, the initial clinical experience and the theory-practice gap are some of the problems discussed (Campbell, 1985; Selleck, 1982, Parkes, 1980; Parkes, 1985; Birch, 1979; Beck, 1993; Lindop, 1989; Reider & Riley-Giomariso, 1993). Moreover, problems and difficulties experienced by nursing students in the clinical setting may lead to their failure to learn and rejection of the nursing profession (Pierce, 1991). The purpose of this phenomenological description was to understand the lived clinical experience of nursing students. This paper presents the lived clinical experience of third year nursing students in a Western Australian School of Nursing.   The Study The Husserlian School of phenomenology was selected for this study. This research sought to understand the experience of clinical practice as a whole, that is as a 'meaningful system of relations' (Munhall and Oiler, 1986, p.74), thereby gaining a greater understanding of how various factors of clinical practice affect the whole experience. A purposive sample was used. The study question was 'What is clinical practice like for you?' Colaizziís (1978) phenomenological method of data analysis, as described by Reimen (1986), guided the study. For Colaizzi (Streubert & Carperter, 1995), phenomenological analysis consists of several steps where the researcher has to become immersed in the data and significant statements are identified. Data collection and analysis were completed simultaneously (Omery, 1983).   The main source of data, used to understand the lived clinical experience, was interviews or ìconversationsî conducted with 14 nursing students. These interviews, using open-ended questions, were conducted to clarify, expand and confirm the emerging themes. A further source of data was a reflective journal. The journal was utilised to keep the researchers personal reflections and methodological decisions; this also ensured trustworthiness of the data. Trustworthiness was further assured by conducting prolonged interviews, repeated contacts, concurrent data collection and analysis, verbatim transcription and member checks. Ethical approval was sought, and the Ethnographic software package was used to facilitate data management and retrieval.   Using an Husserlian descriptive phenomenological methodology several themes appeared from the data and were listed. Significant statements were extracted from the transcripts and major categories were identified.   Findings Theme 1: Clinical Practice: The real world The students considered clinical practice as an essential component of their learning process. Clinical practice allowed the participants to have direct experience with the real world of nursing, to practice the clinical skills required for the job, to learn about general nursing routines and to learn about the responsibility of the nurse. Participants also considered that clinical practice allowed them to develop interpersonal relationships with others and what is more, to become aware of the political aspects of health care. Participants described this repeatedly, for example: ...I've learned nursing skills, I've learned about how a ward actually operates, the general nursing routine, I've learned different areas of responsibility that nurses have like infectious control. It's not just working on the ward, there are certain other responsibilities that go with nursing ... You learn different communication skills, dealing with people ... if you just started a procedure, there's a lot more to it then just doing a procedure, it's about developing a relationship with people, working in a team... you get a fairly good indoctrination into the politics of the ward and the politics of health care, and understand that the issues facing health care today aren't that simple, or that if you read the papers you get one side of the view but on the wards you get another view point as well'.   Clinical practice also assisted students in consolidating their knowledge by getting their hands on experience and practising what they were taught in the laboratory. All participants expressed they 'loved' being on clinical practice. However, this experience often conveyed mixed feelings regarding clinical practice. While on some occasions they discussed feeling scared, nervous, stressed, intimidated, and awkward. On other occasions students found clinical practice to be exciting, interesting, important and enjoyable. For example:   ...(clinical is) nerve racking most of all, I get really nervous and uptight and don't sleep, and that's only about the day before because I donít know what to expect from the actual clinical and what my preceptorís going to be like or what my tutorís going to be like...   ÖI think clinical is the maker or breaker of everybody ... it might be quite stressful and it might not be quite what you want but itís practise of what youíre learning, and it's definitely kept me going for a long time ... even on the bad days I still want to go to prac, because that helps me learn, and that helps me practise those kind of things Iíve just learned. Putting the best into practice...   Theme 2: Enhancement of learning Another distinct theme that emerged from the data was enhancement. Enhancement was perceived as an important aspect of facilitating learning. Data revealed that the relationship that students had with their clinical teachers, the agency staff (agency staff was defined as nurses employed by the hospital), and clients was fundamental in the process of their learning. For example, participants considered that teachersí positive attitudes enhanced their learning. Participants spoke of the willingness of the clinical teachers to communicate with them and of their support and guidance, which encouraged them to engage in new learning activities. Participants also spoke of a positive learning experience at the ward level that created a congenial atmosphere in which the students were happy to work. In the words of the participants: ... that depends on the ward and the people on it. Whether they (ward staff) make you feel sort of welcome, and whether they let you do things, or if they want to do everything themselves, or if they're approachable, or if they teach you or ask you questions, or you can ask them questions ... when patients really appreciate you, and say youíve made a difference in their care ... just different tutors that Iíve had and nurses on the ward, that have taken time out to teach you things and have gone out of their way to help you... Students also stated that it was necessary for their clinical teachers and agency staff to be knowledgeable and be able to share that knowledge with them. In addition, the clinical teacher needed to be seen as ëcredibleí by the agency staff. According to the students, the clinical teacher would be credible if they demonstrated clinical expertise that included current and efficient nursing practice. For example, one participant said:   ... they (clinical teachers) know what they're doing, and they really know the area, and they have worked in the area, and they understand it, and they can explain things a lot better. Like the rationales for certain things, right the way through. Whereas if they're not really sure of themselves it's (clinical) harder ...   Another important point was learning from the role models. Participants in this study indicated that their interaction with both their clinical teachers and ward staff contributed to the development of a professional self-image. The clinical teachers and agency staff provided the students with a role model on which to emulate in their chosen career. As explained by one participant:   ... getting a good preceptor or getting a good tutor, who's a good mentor. Who shows you perfectly, well you think 'I want to do it right, they seem to be doing it right so ... I want to do it like them'...   Personal characteristics of the clinical teacher and agency staff such as, being supportive, encouraging, resourceful, confident, approachable, friendly, available, helpful, understanding, welcoming, and having the studentsí interests at heart, were all important aspects which the students perceived as enhancing their clinical performance. One participant explained how a clinical teacher made a difference:   ... she (clinical teacher) was excellent, she was so supportive and even when you did something wrong sheíd get you outside, she'd say 'Okay all is fantastic though you know you were really good but you just have to improve on this area'. She didn't make you feel really stupid that you did something wrong. She'd accentuate the good things that you did and then say 'This is what you need to improve on'. So that was good. It's good when they're supportive'.   Theme 3: Hindrance: What makes clinical harder. Hindrance was viewed in terms of what made clinical practice harder and that which hindered their learning. Hindrance was associated with personal difficulties, feeling frustrated, being tired and feeling angry (resentful) when students' needs were not recognised.   Those participants who did not have any previous hospital experience felt disadvantaged compared to those students who were enrolled nurses. Enrolled Nurses felt that their previous experience was under valued, which led them to feel frustrated and angry. One participant said:   ... I have worked in the area (clinical) before. I came into the course as an enrolled nurse. I've had lots of various experiences, in the community and various places. I've worked beforehand and it's been frustrating a lot of the time. I have learned a lot but I have found it to be almost like a waste of time. ...   Several participants identified that outside factors made clinical experience harder, these were mainly personal factors. For example, lack of transport, financial difficulties, relationships, finding child-care, and the distance they had to travel to get to their clinical placements were all factors which hindered students' clinical experience. However, there were also other learning factors that made clinical more difficult. For instance, students felt strongly that what they had been taught in the classroom was too ideological and not functional in the 'real world':   ... what we get taught at university is too ideological, not the real world, once you get working out there, lots of nurses think we don't live in the real world...   The students observed quite early in their education that what they were taught in theory did not always equate in practice. Initially, this led to conflict until the students were able to accept the differences. Accepting the differences required the students to be versatile in how they performed on clinical practice. The data revealed that how the students adapted to the theory-practice gap was dependent on whom they were working with. They would behave one way for the agency staff and another way for their clinical teachers. The students identified the dichotomy as the University teaches them ìwhat is right and what is wrongî, whereas in the clinical setting they are taught ìwhat they should doî. One said:   ... a lot of things they teach us at uni just doesn't happen when you're out there, like they say to us 'you don't give a drug till you know what it is' and one of the nurses said to me 'you know there's heaps of drugs that I give and I don't know what they are' ... in a course you get taught about what's right and what's wrong, but when you're out there you sort of get taught what you should do ...     Other factors that had a significant impact on the difficulties that participants experienced during their clinical placement were the attitudes of agency staff towards tertiary education for nursing. Some participants expressed that some agency staff considered that tertiary educated nurses were incompetent and they lack knowledge and experience:   ... I think I've had a lot of negative experience against the university way of learning, some nurses don't want to know you because you're from the university and that's that ...   ..people (agency staff) say things about university trained nurses, how they're useless and don't know anything.   The students described this experience as unfair discrimination against them because the choice of where to gain their education was not available; the only option to become a Registered nurse was through the tertiary system.     Discussion:   The aim of this study was to describe the lived clinical experience of students completing an undergraduate nursing program. It was concluded that participants perceived clinical practice to be an essential component of their nursing education. Clinical practice provided the students with the opportunity to link theory with the practice of caring for clients. Participants considered that there were many factors that enhanced the students' clinical experience. It is not surprising that one of these factors was the positive relationship with their clinical teachers and agency staff. Ferguson (1996) also identified the importance of the relationship between the clinical teacher and their students. On the other hand, there were also factors that hindered their clinical experience. Several authors (Hewison & Wildman, 1996; Hopton, 1995; Wilson-Thomas, 1995; Ferguson & Jinks, 1994; Wilson-Barnett, Butterworth, White, Twinn, Davies & Riley,1995) have identified the discrepancy regarding the theory-practice gap as a cause of anxiety among students. Participants in this study recognised that there was conflict between what is taught in the classroom and what happens in the real world. Unlike other studies which have focused on aspects of the students clinical experience (Windsor, 1987; Yong, 1996) this current study provided a holistic picture of the studentsí lived experience from commencement to completion of their course, thereby, gaining a broader understanding of the their experience of clinical practice.     Implications   Clinical practice is the real-life, face-to-face contact with clients, work settings, and other health professionals. This practice exposes the students to the work of the nursing profession and assists them in adopting professional ideologies and behaviours (Mundt, 1990). The main function of nurse education is to graduate Registered Nurses who have the ability and knowledge to care for clients in a variety of settings. The act of caring for ìrealî clients can not be simulated in a laboratory setting, nor can the practice of communicating with people who are sick, distressed, afraid and anxious. Students of nursing can only gain these experiences by attending clinical practice. As the clinical component of nurse education is crucial to the future practice of the graduate nurse, the quality of this experience is paramount. Clinical teachers and agency staff can enhance students learning by creating a positive learning environment and participating as role models. In the clinical setting, agency staff must orient themselves to include students as members of the health team and support them in the achievement of their nursing degree. This study shows that clinical teachers and agency staff make a valuable contribution to the studentsí learning process. Collaborative relationships between clinical teachers and agency staff can be a critical component of studentsí ongoing learning. 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