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Giving students the confidence to take part

VOL: 98, ISSUE: 35, PAGE NO: 36

Raph Morgan, MSc, RGN, SEN, is a nurse lecturer, Trinity College, University of Dublin

Learning within the clinical environment can be a frightening experience for any nursing student. However, this can be exacerbated on the student's first clinical placement.

Learning within the clinical environment can be a frightening experience for any nursing student. However, this can be exacerbated on the student's first clinical placement.

Clinical experience is important in nurse education and many factors influence the way that students learn. Olsson and Gullberg (1987) say that being able to derive maximum benefit from a placement is a complex process, involving a lot more than merely allowing oneself to be influenced by the environment. Student nurses must be able to be active participants within their clinical setting if they are to optimise their learning potential.

A study of nursing education in Ireland (Simmons et al, 1998) suggests that staff in clinical areas can contribute to a positive learning experience for nursing students by involving them in a range of clinical procedures. However, other authors believe that true learning requires the students not only to be actively involved in clinical procedures but to understand why they are taking place so that they can implement their new experience appropriately in future situations (Ashworth and Morrison, 1989; Palmer et al, 1994; Shields, 1995).

Literature review
According to Hyland et al (1988), there are several reasons for the stress associated with a student's first clinical placement. One factor may be that the student is starting work for the first time and is entering an unfamiliar working environment.

Nolan (1998) found that initially, students were unsure of what to do but they became more certain of their role over time. Once accepted by the qualified nurses, they felt part of the team. The fear of harming patients is a major stress factor for students, yet it motivates them to become proficient in clinical skills. Time spent in the clinical environment teaches them how to carry out clinical procedures efficiently and so gain confidence (Wilson, 1994).

Dunn and Hansford (1997) contend that the student's attitude to learning is vital and to maximise learning opportunities, students need to have confidence. Knutenson and Wielchowski (1994) found that the length of the clinical placement can affect the level of confidence reached by students. They claim that short-term clinical placements leave little time for reflection and insufficient time to explore new practices. A short clinical placement limits a student's ability to become a member of the team, resulting in superficial learning (Knutenson and Wielchowski, 1994; Nolan, 1998).

Method
This study was designed to investigate how diploma-level student nurses experienced their first clinical placement. Six participants were randomly selected from the first-year nursing students attending one large Dublin teaching hospital. Students repeating their first year and those being taught by the researcher were excluded.

Data was collected using a semistructured in-depth interview and evaluated using the Giorgi (1985) method of analysing phenomenological data. Each interview took place in a quiet, private room, allowing the participants to feel relaxed and comfortable. Although ethical approval was not required by the hospital for this study, the researcher was aware that students do need to be protected during a research study. Therefore, each participant was assured of confidentiality and anonymity.

Results
Students embarking on their first clinical placement can often feel very nervous. The feelings of one of the participants in this study were fairly typical: '[I felt] really scared. I almost fainted on my first morning on the ward. I had to be taken out. It was very embarrassing.' Another said that the first few days were nerve-racking. 'I had only left school recently and it was a totally new experience.'

The students' supernumerary status can also make them feel surplus to requirements. One told the researcher: 'I felt the nurses thought I was in the way. Most of the time when I asked if I could do something, they told me: 'Oh no, we'll do it.'' Another student said: 'I felt a bit of a nuisance some of the time, as I did not know what to do.'

Other nursing students felt nervous about asking to be shown how to carry out specific tasks. 'For the first couple of weeks I felt out of place,' one responded. 'I wanted to see certain procedures, but I was afraid to ask if I could go and see them.'

Students embarking on their first clinical placement often do not know what to do or what is expected of them. One, whose response was typical of the study sample, said: 'I felt I was standing around an awful lot. I was watching things and not getting in there and doing things, which is what I wanted to be doing.'

After a settling-in period, however, the students generally felt that the staff nurses gave them the necessary support by showing them what to do. One student said: 'I did not know whether I was going to like my placement or not. I clung to a staff nurse, and then the staff nurse I was linked to took me under her wing and showed me how to do things.'

Another reported: 'I think the staff nurses became more used to me. Some of them would teach me and go into detail about what they were doing, why they were doing it and the consequences of what they were doing.'

Being shown how to carry out a procedure, and getting to know the ward routine, helped students to become aware of what needed to be done. 'As time went by the nurses realised I was keen to learn,' said one participant. 'Some things were shown to me a few times and done over and over, for example bed baths and observations, so after a while I knew how and when to do them.'

Knowing how to do things helped the students to become more confident in applying their skills to routine tasks. 'As the weeks went by I began to relax, and I felt more comfortable and confident,' said one. 'I became more familiar with what had to be done, like dressing changes and other procedures.'

Another stated: 'After the first couple of weeks, I felt more self-assured as I knew what had to be done. After a while, I showed that I was capable of doing things.'

Once the nurses accepted the students on the ward, the students began to feel part of the team. For instance, one student described the heartening feeling of being addressed as a nurse: 'I was acknowledged as a member of the team.'

Students often found that it took the nurses a couple of weeks to accept them. 'All the nurses were really good at including me in the team. I felt I was not alone,' said one student. Another reported: 'As the weeks went on, I began to feel part of the team. The staff got to know me, and communicated better with me.'

Discussion
It is important that permanent ward staff are aware of the anxiety a student may be feeling on entering the ward for the first time. Although students embarking on their first clinical placement may initially be unaware of what to do, they become more confident once the technique has been demonstrated sufficiently by nurses. As one student said: 'Initially, I was standing around doing nothing, just observing. However, as time went by I was shown how to do things such as bed baths.' Nolan (1998) also identified that as time went by the students became aware of what was expected of them.

Once students know what they are meant to be doing they can begin to grow in confidence. This is extremely important during the first clinical placement if they are to be able to develop to the next stage of training. It is vital that qualified nurses have an interest in ensuring students become part of the ward team. They should make space to allow the students to be active participants. Condell et al (2001) found that nurses who were friendly and helpful towards students had a positive impact and contributed to the students' confidence levels. As one student in the present study said: 'I felt part of the team after the first couple of weeks. All the nurses were really good at including me. I felt I was not alone.'

The duration of a first placement is of crucial importance. A short clinical placement may limit the student's chances of becoming part of the team (Knutenson and Wielchowski, 1994). It is vital that the first placement is long enough to allow students to build confidence and learn their clinical skills.

The first placements for students in this study lasted seven weeks, which most students thought was long enough to begin to feel part of the ward team.

Limitations of the study
The size of the study was limited owing to academic constraints and, although all the participants identified pertinent issues, the accuracy, consistency and transferability of the study would be enhanced by more data. In addition, the study sample was selected from one hospital, which restricts generalisation of the findings.

Although the study has its limitations, the researcher believes it identifies important issues for nursing students undertaking their first clinical placements.

Recommendations and conclusion
Nurse educators must consider the length of the first clinical placement. It should be long enough to ensure it gives students enough time to feel part of the team and become familiar with clinical procedures.

It is also vital that nurses develop students' confidence during their first clinical placement by working with them and allowing them to participate actively in holistic patient care. Students should also gain an understanding of the role of every member of the multidisciplinary team.

Students are initially frightened of the clinical learning environment because they are on unfamiliar ground: they do not know what to do and how to do it. However, active participation in patient care, in conjunction with experienced nurses, encourages students to gain confidence. This participation in patient care also allows students to feel part of the ward team.

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