This chapter presents the related literature and studies that guided the conduct of the research. It includes local literature and studies, and foreign literature and studies. It also includes the research assumptions, and definition of terms.
Nursing is a practice-based profession. Therefore, clinical education is an essential part of the undergraduate nursing curriculum. Clinical experience in Private and Public Hospitals is different because the rules and regulations in every Hospital are not the same.
According to Robles and Dionisio (Authors of Philippine Nursing Law, Jurisprudence and Ethics 13th Edition) Clinical experience requirements, every college, institute and school of nursing should endeavor to provide an integrated program of instruction and experience and where required courses are to be integrated with other courses, the outline of the integrated course should show where possible, the hospital outpatient department, community agencies, and the family should be used to supplement and coordinate ward experience and classroom instruction.
Clinical experience shall be acquired by the students based on the requirements prescribed under Rule 67 of the rules and regulations of the board.
Effective January, 1971, affiliation are allowed only for experiences in the communicable diseases nursing, orthopedic nursing, mental health and psychiatric nursing, and public health nursing; all other experiences must be provided in the base hospital.
According to (Aquino & Dascil, 2003) in “Philippine Nursing Act of 2002: explained” the CHED Memorandum Order no. 30, Article IV, Sec. 2, states that in order to make a competent and proficient nursing student in their RLE, there are factors that you must consider:
1. The instructor must know the intelligence and capacity of his learner.
2. The size and nature of the learning resources both in the university or institution and the community or society.
3. An equal number and type of patient.
4. A number of qualified nursing and other personnel.
5. A proof of quality nursing care services.
6. The conformity with the required equivalence of fifty-one (51) hours to one (1) R.L.E.
7. The ratio of students to patient depends upon the goal and the capacity of the student.
The ratio of student to clientele is:
Level 1st Sem 2nd Sem
III 1:1 1:2
IV 1:2-3 1:3-5
8. A faculty-student ratio of:
Level 1st Sem 2nd Sem
III 1:8-10 1:8-12
IV 1:12-15 1:12-15
f. The implementation of varied teaching-learning methods/strategies appropriate to the situation
g. Evaluation is an essential part of teaching-learning process and must utilize appropriate feedback mechanism
“Philippine Nursing Act of 2002 Republic Act 9173 Order no. 30, Article IV, Sec. 2, was issued to give emphasis on the clinical exposure of the nursing student during their Related Learning Experiences (RLE). Student nurses perform nursing functions under the direct supervision of the clinical instructor, who is capable of providing continuous learning in such activities where the students engaged.
In the hospital setting student nurses cannot easily initiate and perform nursing service to individual or family, without the clinical instructor or the hospital does not allow students to do so. This interferes with the goal of the student nurse to the patient which is to alleviate their health while refurbishing their own skills.
Universities offering Bachelor of Science in nursing where required having instructional tool as a confirmatory instrument of every nursing care they provide to their patients and to assess the skills they acquired in their hospital exposure. On the other hand, clinical instructors were also evaluated by the students depending on the way they handled there students and how does they impart knowledge during the hospital duty; however it will be done at the end of the second semester.
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Foreign Literature
According to Elliot (2002) and Napthine (1996), the quality of nurse education depends largely on the quality of the clinical experience. Therefore, the learning depends on the hospitals and Professors. Then, how can students experience a method of care if the hospitals and professors don’t allow the students to do it. Strategies like encouraging students to be involved in every aspect of their patients’ care. This means adjusting their role as their scope of practice allows. For example, a student may not be allowed to perform the laying of a skin graft. However, they can be involved in setting up the trolley and environment, positioning and comforting the patient, reviewing the order and policy or opening sterile packets to assist in the process. Added by Elliot, students require effective clinical placements to allow the application of theory to practice.
These experiences are central to the student’s preparation for entering the workforce as a competent and independent practitioner (Penman and White, 2005; Papp et al, 2003). Clinical placement provides the opportunity for students to observe role models, practice, develop their skills and problem-solving abilities, and reflect on what they see, hear and do (Landers, 2000; Thorell-Ekstrand and Bjorvellm, 1995). As they practice in the clinical environment, it is essential that the nursing student integrates theoretical content provided by the educational institutions with the realities of nursing practice (Cope et al, 2000; Dunn and Hansford, 1997).
There are a variety of influences in the clinical learning environment that can significantly limit and hinder the development of the learner (Clarke et al, 2003; Edmond, 2001; Pearcey and Elliot, 2004). Clinical education occurs in an environment that can be unstructured, unpredictable and overwhelming (Papp et al, 2003). This has the potential to generating feelings of vulnerability and anxiety in nursing students (Elliot, 2002). There are many facets that make up the clinical learning environment and it is the interactions of the nursing student with and within these elements that determine both the experience and the quality of their learning outcomes.
Cahill (1996) went as far as to assert that the relationship between the staff and the nursing students is the single most crucial factor in creating a positive learning environment.
Students identify that the skills and attributes of nurse teachers, their attitude towards them (Dunn, 1997; Goopey et al, 2004; Jackson and Mannix, 2001) and access to relevant learning opportunities, is paramount in the achievement of positive learning outcomes (Pearcey and Elliot, 2004; Lofmark and Wilblad, 2001).
Recurrent themes in the literature that have been identified as supporting the learning of nursing students are the adoption by nursing staff of a professional role model and behavior that present a positive attitude and accordingly influence the work culture. The professional orientation of nursing staff significantly influences student learning in the clinical environment. Poor treatment of nursing students is not uncommon in the workplace.
This is often the result of: Staff shortages; increased workload; Lack of teaching skills; Staff feeling threatened by nursing students (Davey, 2003).
If students do not feel supported in their environment – for example if they are treated with hostility and disrespect or even ignored completely (Davey, 2003) – they are unable to participate in the necessary communication to further their learning activities (Papp et al, 2003) and overall learning goals (Marson, 1982).
The amount of interest the nurse shows in the learning needs of the student and the key role she or he plays in their achievement are vital to the student’s development (Jackson and Mannix, 2001; Marson, 1982).
Chapman and Orb (2000) discuss the characteristics of ‘good’ clinical teachers as identified in their study The Nursing Students Lived Experience of Clinical Practice. They described these characteristics as: Supportive; Encouraging; Resourceful; Confident; Approachable; Friendly; Available; Helpful; Understanding; Welcoming; Having the student’s interests at heart.
The competence of a future nurse is evaluated by evidence-based documents, instructors, mentors assignment and examination results and is based on a continuum of regular assessments. The learning experience of a student nurse remarkably influences own practice in clinical areas, as well as the performance level of the student in academic matters.
First timers in clinical rotation engage themselves in the initial stage of familiarizing and accustoming one’s self to the practice becomes crucial. This is the point when printed theories in books and hand outs are recalled and reshuffled in the mind in order to carry out the best intervention suited for a particular situation. It was never easy for the a novice student nurse to be assigned in the OB ward or in the emergency room without sufficient knowledge about postpartum care or familiarity with the basic instrument used in minor surgeries. Also, inadequate and ineffective education influences the manner that one gains necessary principles and skills needed in actual and assisted delivery cases. This has affected the coping strategies of the trainees to different problems arising in the clinical settings. In reality, some just performed as assistants instead of handling actual deliveries, this is also dependent to the hospital protocols, and some were just given free cases.
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Nursing is an art, an art of caring. Nurses are much involved in lots of health teachings and interventions; and are expected to portray a variety of roles. Be it as an educator, communicator, caregiver, counselor, advocate or as a leader, a nurse should possess a well- defined body of knowledge and expertise in the field especially on actual scenarios (Kozier et.al.,2008). Student nurses may be perceived as trainees, yet it is far apart from that thought. It is incorporating oneself to and embracing the vocation of helping and providing care in order forastery and dedication to be more likely.
Nursing students at this point of time should be cautious whether they have delivered or could deliver appropriate care. They have to be very vigilant because they deal with a lot of toxic things every single day (Tacdol, 2008). It is not anymore in a classroom setting, it is more of real life situations. When at the area, there is no room for mistakes. Then, many hospitals like private hospitals don’t allow students to perform methods like giving medication. The professors are also afraid of losing their registered nurse ID. In Manila Central University, in our experience, nursing students are not allowed of giving medications.
The performance of students in the clinical area is greatly affected by difficulties they encounter especially in their first clinical duty. Factors include relationship with clinical instructors, misunderstandings arising from group works, hospital policies and requirements, alterations in contingencies when handling patients and so on. As new members of the healthcare team, adjustment to different stressors seems to be crucial.
Many have agreed that the student nurses are very effective in delivering their duties and responsibilities in the clinical areas, there should still be improvement in the learning scheme of the education provider because there is no room for mistakes in the medical profession because it deals with a very fragile thing-life- and a single mistake may cause an enormous damage which is death. Students must be test before going in their duties so that it is surely sure that methods are properly given to the clients.
Hospital policies and protocols may at times become annoying and confusing. Different shifts and location of clinical duties tend to be the second in the list. Personal moods and anxieties affect functioning of the whole personality which may result to unproductive planning and ineffective nursing interventions (Abaravar et.al. 2006). As nursing students open their minds and eyes to these wonderful chances, a good experience they had gained when they were still first timers would be a pertinent tool and inspiration in attuning upcoming difficulties and developing passion in the career. These would let them not to desist from this world of struggles.
Theoretical framework:
Good characteristics manifested by clinical teachers:
Understanding
Approachable
Encouraging
Helpful
Confident
Supportive
Resourceful
Available
Welcoming
Friendly
Productive and effective clinical performance
Exposure to hospital cases
Student’s background knowledge
Good clinical experience
Figure 1: This shows the three factors that greatly contribute an effective learning environment. Good clinical teachers such as those who are supportive, understanding and approachable motivate the student nurse to develop initiative in performing clinical procedures. Hospital cases provide room for knowledge and learning especially cases that appear new to the student nurse. The student’s background knowledge is the supportive foundation that increases his efficiency in understanding how methods of care are performed. With these three factors the student nurse gains productive and effective clinical performance which results to good clinical experience.
Conceptual Framework
The challenge in conducting this study is to understand the aspects and factors that contribute to the perception of nursing students regarding clinical experience in both private and public hospitals.
Strict observation of private hospital protocols regarding in handling patients’ cases
Restriction on performing certain methods of care
Failure for the student nurse to gain enough clinical experience
Nursing student perceives clinical experience in private hospitals a hindrance to learning and acquiring skills
Figure 2: This figure is based on the experience of some student nurses in performing in private hospitals. In private hospitals, hospital rules and regulations are strictly observed as handling a patient’s case may affect the process of recovery especially under the hands of a health worker with less experience. To avoid complications student nurses are being oriented by the protocol and must obey it. The student being aware of the rule restricts himself into performing procedures, resulting into gaining the essential clinical experience. Therefore, this experience becomes a disadvantage according to the student’s perception as he was hindered from learning.
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