Nurse Education Today (2007) 27, 491498

Nurse Education Today

intl.elsevierhealth.com/journals/nedt

Determining problems experienced by student nurses in their work with clinical educators in Turkey
Ayfer Elcigil *, Hatice Yldrm Sar
Dokuz Eylul University, School of Nursing, Inciralti 35340, Izmir, Turkey
Accepted 29 August 2006

KEYWORDS
Clinical education; Nursing; Clinical problems


Introduction

Summary Clinical education is considered an indispensable and vital part of nursing education. Educators have an important role in the successful completion of a students clinical education. The clinical educators approach, experience and knowledge have an inuence on the students. Students encounter certain problems during their clinical practice under the supervision of educators. This study was conducted to determine the nature of the problems student nurses encounter during clinical training in Turkey. The focus-group interviews were used for this study. Three groups of 8, a total group of 24, composed of students completing their third year were included in the interviews. The students in this study had completed their practical training in the departments of internal medicine, surgery, pediatrics, psychiatry and public health. Among the problems mostly encountered by students, as established by the study, were inadequate assessment by the clinical educator, judgment, negative feedback, communication problems, inadequate guidance and overload. At the end of the research, recommendations were that educators should offer information in the direction of student expectations, increase their positive feedback and lighten the academic workload of these students. c 2006 Elsevier Ltd. All rights reserved.

Nursing education involves both theoretical and practical training processes. Clinical training is
* Corresponding author. Tel.: +90 2324 124790; fax: +90 2324 124768. E-mail address: ayfer.aydin@deu.edu.tr (A. Elcigil).

considered as indispensable and very important part of professional nursing education (Wellard et al., 1995; Lee, 1996; Dunn and Hansford, 1997). Since nursing is a discipline based on practice, it needs to be a curriculum of education that offers students the opportunity to develop their clinical skills, so important in the care of patients (Nahas et al., 1999; Becker and Neuwirth, 2002).

0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.08.011

492 Clinical training, then, comprises about 50% of the nursing school curriculum (Andrews and Roberts, 2003). The aim of clinical education is to develop in the student the professional skills and knowledge needed in life-long learning and critical thinking, to create self-condence as a nurse, and to ensure that the nurse is able to make his/her own decisions and be independent (Nolan, 1998; Lo fmark and Wikblad, 2001; Sundstrom, 2000; Papp et al., 2003). Clinical education provides the student with the opportunity to apply the knowledge, skills and concepts learned in the classroom to the actual care of the patient. Only if the student nurse can apply the theoretical knowledge she has acquired to the real environment can she provide the desired level of nursing care. In other words, nursing can only be undertaken through clinical practice, which is in effect learning through experience. Clinical education, an important part of nursing education, has always created a stress-producing situation for students (Cooke, 1996; Oermann and Standfest, 1997; Admi, 1997). The student going out into the application eld enters an unaccustomed environment which he/she nds cannot be controlled (Nahas and Yam, 2001). There have been some studies examining the effects of clinical practice on students and the problems students encounter during their training. These studies have shown that stress factors for students include worries concerning going out into the clinical eld for the rst time, the fear of making a mistake, anxiety over possible criticism from peers, communication with health personnel and patients, the approach to take toward seriously ill or terminal patients, technical skills and procedures, attitudes and expectations of clinical nurses (Cooke, 1996; Nahas and Yam, 2001). Beside the factors mentioned above, the approach, experience and knowledge of clinical educators who work with the student in the clinical environment also has an effect on the student (Nahas and Yam, 2001; May and Veitch, 1998). It is known that clinical educators are responsible for acting as a advisor to the student, being a role model, defending the student when necessary and assessing his/her competence (Chow and Suen, 2001). A good clinical educator combines the best available resources and conditions to combine theory and practical training and makes an effort to allow the student to gather clinical experience, creating learning opportunities and bringing the student to the highest possible level of competence (Neary, 2000; Nahas and Yam, 2001). The clinical educator must bring together strategies in support of the type of training that will facilitate

A. Elcigil, H. Yldrm Sar learning (Lo fmark and Wikblad, 2001; Nolan, 1998). There are many studies seeking to determine the characteristics of effective clinical educators in the clinical environment (Gignac-Caille and Oermann, 2001; Benor and Leviyof, 1997; Sieh and Bell, 1994; Chow and Suen, 2001). Research results in the literature point to four types of behavior in this contextsupporting, assessing, teaching and preparatory behavior (Cooke, 1996). Chow and Suen (2001) examined perceptions of the roles and responsibilities of clinical educators and found that students classify organizing learning opportunities and facilitating learning in the clinical environment in the context of a helpful role and designate this as the most important characteristic of a clinical educator. Other studies conducted with nursing students show that professional competence is dened as the most important characteristic of a clinical educator (Nahas et al., 1999; Benor and Leviyof, 1997). Lee (1996) examined effective clinical educator traits and found that the Australian nursing students disclosed that being a good role model was the most effective trait of a clinical educator.

Clinical nursing education in Turkey

The educational program would take four academic years or a total of 4600 h of education, including theory and clinical practice in Turkey. Students in the BSN program will perform 2300 clinical and 2300 theoretical hours during their length of their studies. Curriculum targets to educate nurses generalists rather than specialists. Clinical nursing education in Turkey is carried out by faculty members of nursing schools. Students at nursing schools receive practical training either after completion of their theoretical courses or in conjunction with them. In all of these applications, the faculty members of nursing schools accompany the students one-on-one in their contacts with patients. The faculty member of the nursing school who is present at the clinical application acts in cooperation with the clinical nurse, taking on the entire responsibility or most of the responsibility for the care of patients. There are a very limited number of studies in our country on the problems encountered during clinical education (Bayk, 1993). The study on problems arising in clinical nursing education carried out by Go mleksiz and Temel (1993) revealed that 56.41% of students complained of the insufcient attention and support of clinical educators. In another study seeking to establish the difculties encountered by rst-year students before and during clinical education, it has been shown

Determining problems experienced by student nurses in their work with clinical educators in Turkey 493 that 28.3% of students felt fearful of the reactions they might get from their clinical educators (Atalay et al., 1994). It is not fully known what types of problems are experienced by students in their clinical education in our country. More detailed data is needed. This research has been conducted as a qualitative study to establish the problems encountered by student nurses in their clinical education, using the method of focus group interviewing. research under the guidance of literature. The interview form included questions on the problems students encountered with their clinical educators during their clinical applications and on how these problems affected the students. Each interview took 7590 min and a voice recording was made of each.

Analysis of the data

At the end of the interviews, the records were transcribed verbatim and an analysis immediately carried out. Data was analyzed using qualitative content analysis. Two researchers conducted the content analysis independently. The data was rst separately coded by both researchers and then compared. Following coding, main themes and sub-themes were determined. During the planning for the research, three main themes had been established from the literature and according to the perception of the researchers: evaluation, communication and interpersonel relationship and guidance. The other two main themes of overload and differences were derived from the data by the two researchers. The results of the study were dened on the basis of these ve principal themes (Table 1).

Methods
Participants
All of the participants in the study were students who had completed three years of their four-year nursing education. The students in the study had, at the end of these three years, completed 1950 h of theoretical courses, 1660 h of clinical practice, fullling a total of 180 credits. By the end of their third year, the students had clinical experience in the departments of internal medicine, surgery, obstetrics and gynecology, pediatrics, psychiatry and public health. After providing 57 third-year students with verbal information on the research, written consent was obtained from the 24 students agreeing to participate in the study. Three groups of eight each were organized (Sim, 1998) and the interviews were held at the end of the academic term.

Table 1

Determined main themes and sub-themes Main themes Evaluation

Sub-themes

Focus group interviews

A focus group interview is a structured group process used to obtain detailed information about a particular topic. There are a very limited number of studies in our country on the problems encountered during clinical education (Bayk, 1993). We need to obtain detailed information about the problems encountered during clinical education in Turkey. Focus group method is particularly useful for exploring opinions, feelings and attitudes about issues of interest. It strives to produce good conversation on a given topic. So in the present study, focus-group interviews were used to obtain detailed information and students opinions, feelings and attitudes about the problems encountered during clinical education. A quiet and peaceful classroom was chosen for the focus group interviews. One of the researchers conducted the interview and the other participated by taking notes as an observer (Sim, 1998). A semistructured interview form was used. An interview form was prepared in keeping with the aim of the

Fear of not passing the class Judgment No empathy from advisors Body language Feedback Insomnia Fatigue Problems in private life Stress Believing that clinical educator will not provide answers Anxiety about being evaluated as incompetent Differences between advisors Differences between theory and practical application

Communication and interpersonal relationships Overload

Seeking Guidance

Differences

494

A. Elcigil, H. Yldrm Sar nursing schools. There is no mentorship system in our country, that is, the nurses working at the clinics are not directly responsible for the students clinical education. Faculty, perhaps, place their roles as educators in front of their roles as nurses and this may be the reason why students feel more anxiety about evaluations. In addition, faculty members working in clinical education take on the full responsibility of all the patients cared for by the students. The responsibility of educators encompasses not only training and evaluating students in a study by Li (1997), evaluation has been established as the most effective behavior of clinical instructors. Lee et al. (2002) showed in their research on the effective traits of clinical educators that while evaluation was cited by students as the second most effective behavior, educators themselves marked this as the third effective behavior. In their study, Viverais-Dresler and Kutschke (2001) determined that nursing students considered evaluation as the most effective behavior among the different clinical educator behaviors and that fairness and constructive criticism were conducive to learning.

Research ethics
The study was approved by the ethics committee of the Nursing School. Written consent was obtained from the students participating in the research and the Dokuz Eylu l University Nursing School Directorate where the study was carried out. All participants were informed of the purpose and design of the study. The interviews were held at the end of the academic term after students grade was announced to the students.

Findings and discussion

Evaluation
The problem that almost all students pointed to was evaluation by the clinical educator. Students asserted that they were aware that the clinical environment was an environment of learning but said that their anxiety over how they would be evaluated by their educators led to their focusing on getting good grades and passing their clinical training rather than concentrating on learning. They expressed a belief to the effect that educators were taking on the role of evaluators rather than teachers and that for this reason the clinical environment became for them only a place where higher grades had to be attained. They said that at the end of the clinical term, they were very stressed in the fear of not passing and that this affected them negatively. Students feel that evaluation was necessary but this evaluation should be constructive. One of the students expressed this in the following way: The clinical environment stops being an area of learning and after a short time becomes just a place where you are graded. I try to learn so that my instructor doesnt evaluate me negatively, so that she doesnt give me a bad evaluation. If I cant learn, I get anxious.. . .. In other words, the instructor is always with us. The smallest mistake and my grade drops. We do actually want to learn but of course we have to think of our grades too. How the educator evaluates the student in the clinical environment and how she gives feedback is an important aspect of clinical education. The literature shows that students take evaluations much more seriously than educators do (Lee et al., 2002). The evaluation touches upon the students self-respect, affects her self-condence and motivation (Li, 1997; Gignac-Caille and Oermann, 2001). In Turkey, clinical educators who work with the student 8 h a day are faculty members at the

Judgement
Students state that they feel judged by educators in the clinical environment. They say that educators sometimes ask so many and so detailed questions that it makes students feel as if they are being judged. They assert that when they are unable to answer the questions, their motivation suffers a blow and they experience anxiety. Students say that younger educators generally pose questions that pass judgment and that the older the educator is, the more the questions seem to be directed toward learning. Students have made the point that younger educators continually ask irrelevant questions because of their own inexperience. The instructor sometimes asks some very detailed questions. We shouldnt be learning something by just repeating them to the teacher. The higher the level of competence of the instructor, the better is her approach to us. My worst experiences, for instance, were the experiences I had with the young clinical educators. They kept asking me, Did you do this? Did you do that? The clinical environment is at the same time the place where the student transfers her theoretical knowledge to the eld. Educators believe that a students knowledge of the reasons for the interventions she engages in will in the long run prepare

Determining problems experienced by student nurses in their work with clinical educators in Turkey 495 the student nurse to work as an independent and self-condent nurse. This is why educators in the clinics ask students the reasons for their intervention and their decisions. This questioning is perceived by the student as a stress-creating interrogation. It may be that in our country the reason students are questioned to a greater extent is because faculty members so closely accompany the students in their clinical work. In the literature the researches show us that students are not this disturbed with this particular factor in Europe or the United States. Due to the mentorship practice in those parts of the world, clinical education is offered by the nurses. Nurses are responsible for both patient care and training student nurses. It may be that because of this, nurses may not be able to nd the time to evaluate a particular students knowledge. the body language used by educators particularly affects them negatively when the educators do not answer students questions during discussions of patient care plans. The slightest mimic, the smallest difference in tone of voice affects us immensely.

Feedback
Students say that the words and tone of voice used by educators during feedback affects them to a great extent. The students said that they would like to get some positive feedback but that they mostly get negative feedback about what they have not done. Were not saying that there shouldnt be feedback but it should be without judgment, it should be delivered with a different body language. We get most of our positive feedback from patients and from our families. This of course does motivate us but we inevitably want the same positive feedback from our educators. It is known that the communication achieved between the educator and the student in clinical education inuences the success of the clinical implementation. Feedback offers the student the opportunity to be aware of deciencies and provides the chance for self-development. That is why it is recommended that feedback be constructive and not destructive. It may be the effort to discover deciencies and urge the student to correct these that cause educators to more frequently give the student negative feedback. In a qualitative study by Lo fmark and Wikblad (2001), students asserted that receiving positive feedback made students more condent of themselves. Lee et al. (2002) have indicated that offering feedback without hurting the students feelings is among the ten most important characteristics cited in this context. In the qualitative study by Papp et al. (2003), students express the need to be appreciated. Kotzabassakis study (1997) has stated that not being able to offer constructive criticism is among the worst characteristics an educator can have. In the study by Evans and Kelly (2004), being evaluated in front of the patient takes third place in the list of factors causing nursing students stress in the clinical environment.

Communication and interpersonal relationships

Students state that they cannot always communicate easily with their educators, pointing out that they nd their instructors inaccessible. They said that the educators ask too many questions and that they felt bad when they could not answer the questions. They felt that instructors do not empathize as much as they would like them to and that they could be more understanding. Our instructors communicate with the patients very well. Sometimes I wish I could be a patient during clinical practice. We cannot reach our own instructors, to the ones who are our primary educators, because we feel like we have to hold back. In the study by Suen and Chow (2001), students have found the friendly behavior played out in the mentorship relationship inadequate. Lee et al. (2002) stated that students have singled out maintaining good relationships as the most important characteristic of an effective clinical educator, pointing also to the fact that the most effective clinical educator is the one who is a good role model. Viverais-Dresler and Kutschke (2001) have stated that student nurses have ranked relationships as the third most important category. Being accessible was rated as the most important factor.

Body language
Students said that they are very much affected by their educators body language. They assert that

Overload
Students said that during their clinical education, they nd it difcult to nish the tasks related to

496 patient care but that the educator expects them to complete all they have been assigned to do. They state that when they come to the clinic in the mornings and have to plan more than one patients care, they nd this difcult and experience stress. They also express the fact that their course load in conjunction with their clinical work brings additional burdens on them. They say that they spend all their time in the library and have no time for social activities. Students particularly note that preparing nursing care plans takes up much of their time and on clinic where there is a great deal of patient circulation, this preparation is particularly difcult. They say that they cannot sleep properly and experience a great deal of stress for this reason. We have no time to rest. We always have to be studying. Third-year students may sometimes start off with one patient during their clinical training and then, depending upon the patient situation and the particular student, have to deal with two or three patients. During clinical training, a student is expected to prepare a program of care for her patient and provide complete care. Sometimes students care for the patient on the basis of priorities and have difculty providing the needed care. They may not be able to manage their time well and they may be stressed when the educator offers feedback in this context. In addition, the students course work goes on during the period of their clinical training. Sometimes they are unable to allot enough time for studying because of their clinical work. Lo fmark and Wikblad (2001) indicated that students did not have the time to talk to their patients because of their work load. Lindop (1999) claimed that the reason students feel tired stems from the extreme physical workload that clinical training brings.

A. Elcigil, H. Yldrm Sar like this and push ourselves into different methods of learningwe approach the assistants, we approach the nurses, we approach everybody but our advisors. I have difculty with this because of this. Clinical educators have an important effect on the clinical experiences of the nursing students. An important function of the educator during clinical practice is to give support to nursing students (Andrews and Roberts, 2003). If the clinical education does not provide the student with the support needed for the planning and fulllment of the students tasks, the clinical learning period may be ineffective (Papp et al., 2003). Oermanns study (1998) indicates that clinical educators are perceived by students as their biggest stress inducers. Referring the student to relevant literature (Lee et al., 2002) or the educational skills of the clinical educators are not indicated as important categories in the studies carried out. In the present study, the students wanted the clinical educators to be knowledgeable and competent in their own elds. Students said that they wanted to spend their clinical training with specialized educators and more experienced instructors. The reason students want to work with more knowledgeable and experienced teachers may be because they feel themselves to be more secure in the clinical environment in this way. Studies have shown that professional competence is set out as an important trait (Papp et al., 2003; Viverais-Dresler and Kutschke, 2001; Nahas et al., 1999). Nahas et al. (1999) explains this result by saying that students accustomed to the traditional educational model prefer to see the educator in the role of information provider. In the study by Chow and Suen (2001), students have accepted the mentor role as the most important assistance role. Students feel that advisors, in the assisting role, set up learning opportunities and facilitate learning in the clinical environment.

Guidance and advising

Students complain that they are not sufciently guided by their educators during their clinical work. They say that they refrain from asking questions because they are afraid that educators will assess them to be decient and incompetent. The students state that because they cannot ask their advisors enough questions, they are forced to look up the answer in books or try to nd out the answers from the clinical nurses or doctors. When I think Im weak in some aspect of the work, Im afraid to ask questions for fear I will be evaluated as decient. Yes, we create our own barriers

Existence of differences
Differences between educators
Students state that there are differences among educators and that this adversely affects their learning. They say that particularly during the planning of the patients care program, different educators will have different expectations and criteria. They stress that advisors have different ideas about which topics are important. One instructor will place importance on one aspect whereas another

Determining problems experienced by student nurses in their work with clinical educators in Turkey 497 will place importance on something entirely different. Students have said that there are also certain differences in clinical skills among educators and that this affects their learning as well. They say that differences are more pronounced between young and experienced instructors. The students complained that they are not sufciently guided by their educators during their clinical work. When guidelines for nursing practice are lacking, the students will not continue to ask questions for learning. To eliminate the problems encountered by students, clinical educators may provide the information the student expect. They may, during the clinical applications, explain topics more concretely and share with the students their own expectations at the start of the clinical experience. The students also complained that they have many tasks to do in practice. If students experience stress and lack of time, they have feeling of losing control and doubt their choice of profession. So students studying loads should be reduced during clinical training and increased in proportion to their capacity to cope. The results of this study will be helpful in dening what the clinical educator must consider in order to provide a productive clinical education.

Differences between theory and practice

Students have said that they experience difculty in transposing the theoretical knowledge they study in their courses to the clinical setting. They say that the clinical environment is more different than what is described in class. They have also indicated that some clinical skills that they had learned in the skills laboratory are not practiced quite in the same way in the hospital. I believe that our clinical training is a learning experience, both in terms of practicing the theoretical and in terms of professional skills. We have great difculty in putting theory into practice. We would like this to be acknowledged. This situation gives us a lot of stress. We have the theoretical knowledge, in other words, but we have difculty putting it into practice. In a study by Evans and Kelly (2004), student nurses said that the greatest stress for them during their clinical training was to ll in the gap between theory and practice.

References
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Conclusion and recommendations

Nursing is a profession based on application. Clinical education is a major component of nursing curriculum (Lee, 1996). It provides nursing students with the opportunity to develop competencies in the application of knowledge, skills and attitudes to clinical eld situations. The clinical educator has an important role in providing an effective clinical education. At the end of the study, it was found that the problems most encountered by student nurses were anxiety over the way they were evaluated by the clinical educator, being interrogated, receiving negative feedback and communication problems. If students do not get feedback, they are not aware of others perspectives of their strengths and weaknesses.When students succeed and receive positive feedback, this gives them occasion to reect on their own development. This may contribute to increased self-condence (Lo fmark and Wikblad, 2001). So educators may increase their positive feedback in order to increase student motivation.

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