Title : Lived Experiences of Graduating Nursing Students: A Phenomenological Focus Group Study

 Lived Experiences of Graduating Nursing Students: A Phenomenological Focus Group Study

 

Abstract:

Student nurses enter nursing as a novice with limited understanding of the profession; they learn skills in their four years. For all of them nursing education is a life transforming. The researchers were keen to understand the experiences associated with this transformation. Phenomenological focus group techniques with audio- and video-taped interviews were used to collect the data. The early counselling and guidance, constant mentoring by the same teachers in theory and practical learning and constant positive motivation, a generous amount of exposure to extra-curricular activities and strict student status have contributed to their positive outlook for future professional nursing. This study provides insights in understanding the experiences of student nurses and helps the nursing institutes to enhance positive experiences in their students.

 


Nursing is a complex, demanding profession and Nursing Sciences is a difficult professional study. Baccalaureate Nursing Sciences is a four years undergraduate study focused on the care of individuals, families, and communities to help them attain, maintain, or recover optimal health and quality of life till last. During the course, a student is taught theory and practice in real life situations to work independently and as a part of a team to assess, diagnose, plan, implement and evaluate care based on nursing and allied sciences and evidence- based practice. The student is required to study pure sciences like Anatomy, Physiology, Biochemistry, Microbiology, behavioural sciences like Psychology, Sociology; Research, Statistics, Administration & Management, Basic Economics and all medical sciences in detail from Genetics, Pharmacology, Dietetics, Medicine and Surgery, Mental Health and Community Health. As main subject they study Foundations of Nursing, Community Health Nursing, Medical Surgical Nursing, Mental Health Nursing, Paediatric Nursing, Obstetrics & Gynaecological Nursing.

 

The whole teaching-learning process is multifaceted; it requires multitasking ability and involves lot of physical and mental work. But at the end becoming a professional nurse is an honourable and noble job, which gives great satisfaction to its members. Patients look to you for hope and understanding and they respect and depend on your skills. Laura said, “Life as a student nurse is a mix of highs and lows. But you can do it if you remain realistic, keen and you don’t underestimate yourself. You are worthy of having that badge and that tunic. And it will be the best feeling ever as you step from student to staff nurse.”

Indian student often chooses nursing by persuasion of somebody, parents or relatives, who have an idea that at the end of education one can be immediately employed. This ignorant novice then undergoes changes under pressure to learn the knowledge, skills and attitudes to become a professional nurse. It would be interesting to hear their experiences of undergoing this transformation.

A model of teaching called the “four stages of teaching” later described as “Four Stages for Learning Any New Skill”, was given by Martin M Broadwell in February 1969. This model suggests that a learner is initially unaware of how little he/she knows, or unconscious of their incompetence. As they recognise their incompetence, they consciously acquire a skill, and then use it. Eventually, the skill can be utilised without it being consciously thought through; the individual is said to have then acquired unconscious competence.

In today’s age of professionalism, nurses have to be well trained to face the challenges of day to day professional activities. “Nurses undergo rigorous professional training before they join the stream of professionals in health care” (Soans, 2018). It is a challenging task for an uninformed and ill prepared nov-ice nurse to undergo this rigorous training. 

Review of Literature

 

Tan-Kuick & Keith (2010) studied the factors affecting nursing students’ choice towards nursing. They found that education, career aspiration, personal ability, socio economic status and peer encouragement influenced the choice in ascending order. After joining the professional studies students undergo stress- filled transformation.

In spite of all the hard work of learning graduat- ing nurses do not have warm and happy experience with the transition of becoming professional nurses. Lynn Soppeland Assimacopoulos (1962) says, “Oh yes, we complained about too many hours on the floor and there were too many reports, too many exams and too many hours of labs that we thought would never come to end. But as it has been said, ‘All good things must come to an end’ and it did. What we nursing students received at the end was a gift of a life time. Did we realise… probably not at first”.

Bonsall (2010) in Lippincott Nursing Centre on Memories from Nursing School states that connecting with people of similar goals, knowledge from anatomy, physiology to pathology and pharmacology, communication skills, helped her in everyday life, topics on death and dying, nutrition and human sexuality were all the good memories with nursing education. She did not like heavy books, medication er- rors, continuous learning at clinicals starting from 7 am and care plans, these were her bad memories.

Tiwaken et al (2018) states that “The most critical experiences for the student nurses are their exposure to patients in the clinicals. It is where they encounter the human side of nursing”. Porteous & Machin (2018) stated that tutors and mentors who were empathetic, caring and respectful, positively role modelling nursing values and behaviour facilitated student support, engagement and empowerment. With positive supportive experience, the students developed resilience, beginning to feel more confident and competent. In Indian setup we have no qualitative studies studying the experience of nursing students with their clinical learning.

Duchscher (2001) found the graduate nurses to express disillusionment with what they perceived as inconsistencies between their expectations of a professional nurses role and what they actually observed in practice. Whitehead (2001) observed that sudden increase in responsibility and accountability were the concerns of the graduating nurses. Casey et al (2004) observed that graduate nurses experienced feelings of inadequacy, and conflicting feelings of needing to be independent and yet being dependent on others were their source of stress. Krammer (1974) developed a theory called “Reality Shock”, which stated that nursing students with university instilled values faced reality shock with the real world of practice of nursing. Boychuk-Duchscher (2009) proposed a theory called “transition shock” experienced by the graduate nurse, when faced with real world of practice. They state that University education does not prepare the nursing students adequately for the real world practice.

This study explored the lived experiences with nursing education and the changes they have perceived in selves. A qualitative phenomenological design was chosen. An increasing number of nurse researchers have been drawn to phenomenology possibly because it considers the whole person and values their experience (Lauann & Deborah, 2006). Nursing is concerned with understanding people, being perceptive and sympathising with them. It recognises the validity of individuals’ experiences and supports them in exercising control over their own health care (Oiler, 1982).

Methodology

It was a qualitative, explorative, descriptive study employing the phenomenological focus group.

Population: The 22 4th year students of MKSSS BTINE were the target population. They had completed their final year theory and practical examinations of nurs- ing and were exposed to all the theoretical and clinical learning that a Baccalaureate degree require. Their willingness to participate in the study was ensured.

Sampling: Non–probability purposive sampling was used. The participants were selected for sharing their knowledge and experience with the researchers on certain broad areas. A total of 22 students in three focus groups consisted of seven students in two groups and eight in one. They were interviewed on three settings till data saturation appeared to have been reached by means of repeating themes. All the participants were women of age group 21-22 years. The interviews were audio- and video-taped.

Data collection: The lived experience of the graduat- ing student nurses on their nursing education was facilitated through a semi-structured interview ques- tionnaire followed by observation, informal and un- structured interviewing to allow the researchers to develop a clear understanding on the depth of the information required for developing a relevant and meaningful discussion. Participants were interviewed until data saturation appeared by means of repeating themes.

 

The interviews that lasted for 60-90 minutes were audio and video-recorded, notes were taken and verbatim transcriptions were made. Participants were not compensated for the interviews. Interviews typically began with introduction on the topic and went on to asking them to narrate any memorable experiences in the course of their education followed by other question. The objective was to explore the lived experiences of student nurses by eliciting their memorable experience and the changes they noticed in them at the end of their student period.

Data analysis: The transcripts were transcribed verbatim. The analysis involved listening and observing to audio and video tapes, transcribing the con- versations verbatim, reading and rereading the descriptions, extracting significant statements, formulating meanings and categorising them into cluster of theme and the revalidating them to identify commonalities of the informants with the original texts.

Ethical consideration: Willingness to participate was taken through a consent form. They were informed of their right to withdraw or keep silent at any stage of the study. The confidentiality of the study was explained to them. They were informed that a copy of the written research will be shown to them before publishing it.

Results and Discussion

The broader themes emerged from the study were:

(1) beginning negative memories (2) slowly developing academic and clinical proficiency and self-growth

(3) fruitful positive experiences (4) general and specific changes that occurred in the students.

Beginning Negative Memories

Difficulties with basic care: First experience with en- ema to a semi-conscious patient: In the first year students were taught basic procedures like bed making, hair care, mouth care, back care, bed bath etc. Students expressed that their first contact with human body was frightening. Till then they had no such close contact with naked human body parts. They said that proximity made them unnerved. Though the teachers were there with them throughout they felt this was not something they were happy doing.

Error of giving a wrong drug: Some of them had negative memories of medication errors. When they realised their mistakes they felt guilty about harm- ing the patients. One student said, “My hands were shaking while loading my first injection in the sy- ringe. Because of my nervousness I had accidentally expelled the injection. I was very scared. But my teacher was relaxed; she reassured me and made me repeat it slowly and this time I didn’t expel it.” One student said, “I did not have any idea of the three way regulator that was connected to the patient’s IV cannula. I had no idea which way to regulate it out of fear. Even here the teacher guided me with a calm approach.”

First OT posting, seeing so much blood: Incidentally all the students remembered their first OT posting as a frightening experience. Too much of blood, new doctors and nurses had frightened them. One student said “I was made to assist an ophthalmologist for a simple surgery. But the surgeon was in great hurry and restless. He wanted an experienced nurse to assist him. I became blank. I had to unwash. My teacher spoke to an ENT Surgeon and made me as- sist him for a tracheostomy procedure. This doctor was very cool and he spoke to me and told me to be relaxed. I assisted him so well, he appreciated me.”

Long standing work, very tiring: Students reported that “When we had to learn for 8 hours in clinicals we were very tired. Our legs ached. We felt like leaving nursing.”

Shouting nurses and angry teachers: Students stated that “Some nurses in the clinicals were always rude and kept telling us not to do this and that. At times our teachers got irritated and shouted at us in front of the patient or team members. We felt very hurt about it. We asked the teachers to correct us in private, and then never again they corrected us in front of others.”

Slowly Developing Academic and Clinical Profi- ciency and Self-growth

Seeing private body parts of the patients for the ini- tial days frightened the novice student nurses. They were not mentally ready to comprehend that this stranger is a helpless consumer hospitalised because of his / her illness and needs assistance for basic care. Slowly the attitude of compassion along with comprehension of the patients’ problems developed, and they took care of patients with ease.

Positive Experiences in Clinical Area

  • Independent actions and its rewards
  • Identifying complication alone in ICU and preventing it by informing and assisting in care.
  • Learning to ask why for any action and thoughts; looking for rationale.
  • Acting promptly at the sight of accident and transporting victim and psychologically supporting family of victim on vacation.
  • Preventing drug error by a pharmacist by counter checking.
  • Making a crying oncology patient eat and relatives touching the feet of the student in gratitude for mak- ing the patient eat.
  • Being blessed by a lonely old man for being an “An-gel of Mercy”, and better than any person in his fam- ily to attend to him despite initial negative reactions.
  • Giving insulin to the student’s grandfather regularly and witnessing her family being proud to see her giving the injection.
  • Friends calling them first for all their health issues for help and support.
  • Guiding and educating my grandmother regarding her hypertension drug and its management.
  • Doctors asking me whether I am a doctor, and “I replied proudly that I am a BSc nurse.”
  • Helping drug addicts and alcoholics with empathy and without any bias.
  • Experiencing the wonder of labour and being a part of the labour process with the mother.
  • Being fast and efficient to work as a team to manage a code blue call for a drug allergy.
  • Explaining to my relatives about their disease condition, signs and symptoms and its management.
  • Earning the respect of my mother and my family after being ridiculed as good for nothing in the be- ginning.
  • Being an all-rounder, multi tasker and a confident communicator.
  • Being able to teach juniors confidently and moti- vating and boosting their morale in clinical areas.

Taking full care of an injured and fainted teenager in a train till recovery. How teachers and team members helped them build their morale: by posi- tive comments, support and acknowledgement. Support from senior team members acknowledging that it is okay to be nervous in the clinicals, and helping us to cope with it by just being there.

 

General and Specific Changes that have Occurred in Students

General knowledge: Earlier students stated that they had no inkling on Nursing. Now they clearly know about professional nursing. They state they have the theoretical background on health needs, preventive aspects and care of diseases and disorders affecting human beings from birth to death.

Communication: They are able to understand the com- plexity of communication and communicate effec- tively. Earlier, their communication was limited to their friends and family, now they feel that they are able to hold a conversation on any topic with any- body. They state instead of reacting to situations they act upon it effectively through thoughtfulness.

Confidence: Earlier, students stated they could nottravel alone, and were scared to ask information from strangers. Now they feel they are confident in mov- ing out, seeking employment in a new set up and adapt positively.

Life skills: They stated to have learnt to work effec- tively and efficiently. No donkey works for us, we can work smartly. They stated that they have clarity about personal and professional boundaries and could ward off any unwanted harassment at work; they are more emotionally balanced and matured now. One student stated “Earlier, on admission my mother would say that I cannot do anything, I won’t succeed in my stud- ies. Now my mother is happy with me. She takes my opinion on my younger sibling’s education. In my third year, my father met with an accident and became bedridden; I managed to help him, run our home as well as my studies. Now, they know that I can stand on my own and help myself as well as them.”

Specific learning: They stated to have understanding of health, ill health and preventive aspects of all diseases and disorders. We know and check about drugs before administration. We are confident to perform all basic and advanced nursing procedures. We can communicate effectively. We have become confident and independent.

One student stated, “I came from a city, which is roughly about 700 km away from the institute. In hostel there would be somebody continuously talking. I learnt to sleep with noise. I learned to adjust. Regarding the subjects, I like anatomy, physiology, psychology & psychiatric nursing and pharmacology. All these subjects made me understand about human beings, their body, mind and actions. I learnt to be punctual, responsible and communicative. I learnt how to respond to all people. I learnt to teach, make effective AV Aids, I learnt so much… I am a different person now. But these changes are highly appreciated by me and by my family and friends.”

Another student stated, “My father forced me to take up nursing. In the beginning I had a negative attitude towards nursing. First year, I was often sick. My roommates, friends, seniors and teachers sup- ported me. I could complete my studies in first year because of the teachers. Gradually I started mixing with others. I came out of my loneliness and help- lessness. I learnt to share. Now all the negative feel- ings are gone. I know now I am confident and happy because of nursing.” Another student stated: “I learnt in nursing, how appearance is important. When you look clean, tidy and happy, patients and relatives feel happy to talk to you. I realised even though you have no less knowledge, appearance is important, slowly keeping clean became a habit. Then you start expecting cleanliness in your patients and hospital environment. So you start working on both. I combed my patients’ hair, cut their nails, kept the unit clean. My teacher really appreciated it. I realised that clean- liness and confidence are interrelated.”

Student X: “In my school days, I was interested in sports. As I joined nursing I thought I won’t be able to participate in sports. So in the 1st year, I took no interest in the sports period. But in 2nd year I joined the volley ball team, I was selected by the University to represent local level colleges. Gradually in 3rd and 4th year I was sent to state level sports by institute and University. I participated in sports and all the extra-curricular activities. These activities helped me to express myself. It helped in movement and fitness of both body and mind.”

The analysis of the memories and the changes they perceived in themselves highlight their anxi- ety turning into confidence, clarity, confidence, commitment and caring needed to stay and practice the nursing profession.

Conclusion

Participants in this study were happy and optimistic to face the real world. There seems to be no gap that exists between the academic and the clinical component of nursing education. There were adequate opportunities for students to work within a more creative environment that promoted and added to the professional knowledge base. Further, teachers made a valuable contribution to the students learning pro- cess. In the parent hospital the students experienced a positive clinical  learning  environment characterised by a pedagogic atmosphere conducive to a one-to-one relationship.

Supportive clinical training environment was most influential in the development of nursing skills, knowledge, and professional socialisation. The existing Baccalaureate syllabus prescribed by Indian Nursing council is effective and well-placed, taking into the consideration students’ growing maturity. The authors further recommend future authors to go deeper into the positive feelings and experiences of graduating nurses about their experiences with the prescribed curriculum.

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Source: Nursing Journal of India

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