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Female Saudi Nursing Students’ Experiences of their
Clinical Learning Environment: A mixed methods
study
Submitted by
Ebaa M Felemban
MNurs (RMIT) , BScNurs (KAAU), RN
I.D. 21432546
A thesis submitted for the degree of Doctor of Philosophy at Monash University in
30th September 2016
Faculty of Medicine, Nursing and Health Sciences
School of Nursing and Midwifery
© Ebaa Felemban 2016.
Except as provided in the Copyright Act 1968, this thesis may not be reproduced in any form without the written permission of the author.
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Acknowledgements
In the name of God, Most gracious, Most merciful. I would like to thank God for all the
blessings, health and strength he bestowed on me so that I could make this achievement
possible.
Firstly, I would like to express my sincere gratitude to two outstanding supervisors,
Professor Margaret O’Connor and Professor Lisa McKenna for their continuous support
during my PhD journey, for their patience, motivation, and immense knowledge. Their
guidance helped me throughout the research process and writing of this thesis. I could
not have imagined having better supervisors and mentors for my PhD study. Apart from
my supervisors, I would like to thank the rest of my thesis committee: Associate
Professor Virginia Plummer, Associate Professor Meredith Mclntyre and Dr. Susan Lee,
for their insightful comments and encouragement that helped me to widen my research
from various perspectives. My sincere thanks also goes to the lovely staff in the nursing
and midwifery school, who provided me with much needed support and the opportunity
to join their family.
A special thank you to my family. Words cannot express how grateful I am to my mother
and father for their unconditional and everlasting love and support. They had faith in me
in times when I had none for myself. They made huge sacrifices to allow me to pursue
my dreams and reach this far and for that, and for everything else, I will always be so
grateful. I dedicate this thesis to them and to my three little angels, Fahad, Laryn and
Abdulrahman who spiced up my life and sweetened the PhD journey.
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I wish to acknowledge my friends who stood by me. Thank you for your considerate
support and treasured friendship through my years of study.
Editorial assistant has been provided by Dr. Phillip Thomas in the areas of language and
structure.
Finally, I am thankful to the valuable contributions of the students and to the Nursing
faculties for their participation in this study. Also, I would like to thank my sponsor Taif
University for its valuable sponsorship and support.
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Abstract
The quality of clinical experience in a supportive clinical learning environment is a
significant matter for nursing education. The quality of clinical learning is often a mirror
to the quality of curricula implied in the educational institution. Therefore it is of
importance that a continuous assessment of the clinical setting as learning environment
is applied. The nursing students’ satisfaction is considered to be a critical factor in such
assessment because their feedback will contribute positively in optimising the learning
activities within the clinical setting.
The aim of this research was to explore the quality of clinical education in nursing
education in Saudi Arabia by identifying factors within the clinical learning environment
which affect students’ outcomes, and measuring nursing students’ experiences and
satisfaction with their clinical environment. This study used a mixed methods approach
to gather data from nursing students during their undergraduate courses. Altogether,
112 nursing students were asked to complete the Clinical Learning Environment and
Nurse Teacher scale (CLE+T) developed by Saarikoski, Isoaho, Warne, and Leino-Kilpi
(2008). Furthermore, nine people from the same group participated in semi-structured
interviews.
The initial aim of the research strategy was to seek a detailed understanding from
students of their perceptions of the CLE by using a mixed methods approach. Due to
limited knowledge on the CLE in Saudi Arabia, it was considered to be an appropriate
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strategy for providing a holistic understanding of the topic. A number of topics emerged
from the data including: cultural issues and struggles; need for guidance; and the clinical
learning environment. These issues are important if CLE for nursing students in Saudi
Arabia is to improve.
VII
Table of Contents
Acknowledgements .................................................................................................................. III
Abstract ..................................................................................................................................... V
Table of Contents .................................................................................................................... VII
List of Tables ........................................................................................................................... XIII
List of Figures .......................................................................................................................... XIV
List of Appendices ................................................................................................................... XV
Declaration of Originality ....................................................................................................... XVI
List of Acronyms .................................................................................................................... XVII
Chapter One: Introduction ....................................................................................................... 1
1.1 Introduction .................................................................................................................... 1
1.2 Background ..................................................................................................................... 3
1.2.1 Saudi Arabia ............................................................................................................. 3
1.2.2 Nursing in Saudi Arabia ............................................................................................ 5
1.2.3 Published Paper ....................................................................................................... 9
1.2.4 Nursing Education .................................................................................................. 17
1.3 Aim/ Purpose ................................................................................................................ 20
1.4 Research Questions and Approach .............................................................................. 20
1.5 Significance of the study .............................................................................................. 21
1.6 The Clinical Learning Environment ............................................................................... 21
1.7 Personal Positioning ..................................................................................................... 23
1.8 Organisation of this thesis ............................................................................................ 24
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1.9 Conclusion .................................................................................................................... 26
Chapter Two: Literature Review ............................................................................................ 28
2.1 Introduction .................................................................................................................. 28
2.2 Clinical learning environment in nursing ..................................................................... 30
2.3 Quality of the Clinical Learning environment .............................................................. 32
2.4 Clinical learning environment assessment ................................................................... 35
2.5 Challenges in clinical settings ....................................................................................... 38
2.5.1 Clinical learning opportunities ............................................................................... 40
2.5.2 Interpersonal interactions ..................................................................................... 42
2.5.3 Acceptance and belongingness .............................................................................. 44
2.6 Students’ satisfaction ................................................................................................... 46
2.6.1 Effective Communication ....................................................................................... 48
2.6.2 Collaborative Efforts .............................................................................................. 50
2.7 Clinical Supervision ....................................................................................................... 54
2.7.1 Preceptorship and Mentorship .............................................................................. 57
2.8 Conclusion .................................................................................................................... 64
Chapter Three: Methodology ................................................................................................. 65
3.1 Introduction .................................................................................................................. 65
3.2 Research Objectives ..................................................................................................... 65
3.3 Mixed methods methodology ...................................................................................... 67
3.3.1 Research Philosophy.......................................................................................... 67
3.3.2 Strengths and weaknesses of mixed methods approaches .............................. 69
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3.3.3 Discussion and Rationale for Choice of Approach ............................................ 72
3.4 Recruitment Procedure ................................................................................................ 75
3.4.1 Sampling ............................................................................................................ 75
3.4.2 Research Settings .............................................................................................. 76
3.5 Sample Criteria and Invitation ...................................................................................... 77
3.5.1 Inclusion Criteria ................................................................................................ 77
3.5.2 Exclusion Criteria ............................................................................................... 77
3.6 Data collection .............................................................................................................. 78
3.7 Phase One: Quantitative Survey .................................................................................. 78
3.7.1 Data Collection .................................................................................................. 82
3.7.2 Data Analysis ..................................................................................................... 83
Questionnaire: Parts one and two ................................................................................... 83
Questionnaire: Part three ................................................................................................ 84
3.8 Phase Two: Qualitative Interviews ............................................................................... 86
3.8.1 Data Collection .................................................................................................. 88
3.8.2 Data Analysis ..................................................................................................... 89
3.9 Ethical considerations .................................................................................................. 90
3.9.1 Benefits of the Research Study ......................................................................... 92
3.9.2 The Right to Self-Determination and to Full Disclosure ................................... 93
3.9.3 Trustworthiness of the qualitative data ............................................................ 94
3.10 Summary ....................................................................................................................... 97
X
Chapter Four: Results ............................................................................................................. 98
4.1 Introduction .................................................................................................................. 98
4.2 Results of Phase One (Questionnaire) ......................................................................... 98
4.3 Part one: Description of Variables ............................................................................... 99
4.3.1 Age ..................................................................................................................... 99
4.3.2 Educational Organisation .................................................................................. 99
4.3.3 Year of Study ................................................................................................... 100
4.3.4 Type of hospital at current clinical education ................................................. 100
4.3.5 Area of Clinical Placement ............................................................................... 101
4.3.6 Frequency of Clinical Training ......................................................................... 105
4.3.7 Duration of Clinical Training ............................................................................ 106
4.4 Part Two: Clinical learning environment, supervisor and nurse teacher information108
4.4.1 Clinical Learning Environment and Educational Organisation ........................ 117
4.4.2 Clinical Learning Environment and Year of Study ........................................... 123
4.4.3 Clinical Learning Environment and Type of Hospital ...................................... 129
4.4.4 Relationships between CLE Constructs ........................................................... 139
4.5 Results of Phase One: Part Three (Open-ended Questions) ...................................... 141
4.5.1 Challenges facing students during clinical placement .................................... 142
4.5.2 Most valued in the clinical placement ............................................................ 149
4.5.3 Least valued features of the clinical placement ............................................. 153
4.6 Phase Two: Semi-structured interviews..................................................................... 157
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4.6.1 Introduction ..................................................................................................... 159
4.7 “Beginning to study nursing for real” ......................................................................... 161
4.7.1 “In real life, we do not apply it that way”: The relationship between theory
and practice.. .................................................................................................................. 164
4.7.2 Ability to Practise ............................................................................................. 171
4.8 “All I need is someone to guide me” .......................................................................... 177
4.8.1 Nurse teacher role and the influence of nurses’ supervision ......................... 178
4.8.2 Clinical Learning Environment ......................................................................... 185
4.9 Cultural views and struggles ....................................................................................... 188
4.9.1 ”The broad idea of nursing is marginalised” ................................................... 189
4.9.2 Family influence on students’ studies ............................................................. 191
4.9.3 Multicultural clinical settings .......................................................................... 193
4.9.4 Language Barriers ............................................................................................ 194
4.10 Conclusion .................................................................................................................. 195
Chapter Five: Integrated Discussion .................................................................................... 197
5.1 Introduction ................................................................................................................ 197
5.2 Integration of Data ..................................................................................................... 198
5.3 Consolidation of Issues ............................................................................................... 200
5.4 Cultural issues ............................................................................................................. 202
5.4.1 Cultural views on Nursing ................................................................................ 202
5.4.2 Multicultural clinical learning .......................................................................... 206
5.4.3 Language Barriers ............................................................................................ 211
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5.4.4 Cultural Integration ......................................................................................... 213
5.5 Being a student in the clinical setting ........................................................................ 216
5.5.1 The need for guidance ..................................................................................... 216
5.5.2 Preceptorship and mentorship ....................................................................... 221
5.5.3 Nursing clinical education ............................................................................... 225
5.5.4 Ability to practise............................................................................................. 227
5.5.5 Students’ satisfaction ...................................................................................... 231
5.6 Limitations of this research ........................................................................................ 233
5.7 Conclusion .................................................................................................................. 234
Chapter Six: Recommendations and Conclusion ................................................................. 235
6.1 Introduction ................................................................................................................ 235
6.2 Implementations and Recommendations .................................................................. 236
6.2.1 Culture ............................................................................................................. 236
6.2.2 Students’ experiences ..................................................................................... 238
6.3 Areas for future research ........................................................................................... 239
6.4 Conclusion .................................................................................................................. 240
References ............................................................................................................................. 242
Appendices ............................................................................................................................ 252
XIII
List of Tables
Table 1 Health Services Provided by Health Sectors in KSA (Ministry of Health, 2014) ................... 8
Table 2 Socio-Demographic Details of Participants (N=112) ......................................................... 103
Table 3 Frequency of Clinical Practice ........................................................................................... 105
Table 4 Length of Clinical Practice ................................................................................................. 107
Table 5 Mean values of Clinical Learning Environment (Total) ..................................................... 110
Table 6 Descriptive statistics of the Clinical Learning Environment (Detailed) ............................. 111
Table 7 Clinical Learning Environment and Educational Organization (Group statistics) ............. 118
Table 8 Educational Organisation Effect on CLE perceptions (Independent Samples t-test) ....... 121
Table 9 Clinical Learning Environment and Year of Study (Group statistics) ................................ 124
Table 10 Year of Study effect on CLE perceptions (Independent Sample t-test) .......................... 127
Table 11 Descriptive Statistics CLE constructs by Hospital Type ................................................... 130
Table 12 Test of Homogeneity of variances between CLE and hospital type ............................... 133
Table 13 CLE ANOVA Results by Hospital Type .............................................................................. 134
Table 14 Multiple Comparisons Table ........................................................................................... 136
Table 15 Correlations between CLE constructs (n=112) ................................................................ 140
Table 16 Grouped Themes from the Open-ended Questions ....................................................... 142
Table 17 Question One: Challenges during the clinical placement ............................................... 144
Table 18 Question two: most valued in the clinical placement .................................................... 150
Table 19 Question three: least valued in the clinical placement .................................................. 154
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List of Figures
Figure 1 Political Map of Saudi Arabia (Maps of World, 2016) ......................................................... 4
Figure 2 Convergent parallel design ................................................................................................ 74
Figure 3 Percentage of nursing students in hospitals according to educational organisation ...... 104
Figure 4 Frequency of clinical practice for second and fourth year nursing students .................. 106
Figure 5 Mean and Standard deviation of Clinical Learning Environment .................................... 110
Figure 6 Mean and Standard deviation of Supervisory Relationship (SR) components ............... 114
Figure 7 Mean and Standard deviation of Pedagogical Atmosphere in the ward (PA) components
........................................................................................................................................................ 115
Figure 8 Mean and Standard deviation of Role of the nurse teacher (NT) components .............. 116
Figure 9 Mean and Standard deviation of the Leadership style of the Ward Manager (WM)
components ................................................................................................................................... 116
Figure 10 Mean and Standard deviation of Philosophy of nursing in the ward (PN) components
........................................................................................................................................................ 117
XV
List of Appendices
Appendix A Questionnaire (English and Arabic versions) .............................................................. 252
Appendix B Participant’s Invitation Letter (English and Arabic versions) ...................................... 260
Appendix C Explanatory Statements (English and Arabic versions) .............................................. 262
Appendix D Interview (English and Arabic versions) ..................................................................... 264
Appendix E Consent form (English and Arabic versions) ............................................................... 266
Appendix F Research Approval from Monash University Human Research Committee (MUHREC)
........................................................................................................................................................ 270
Appendix G Research Approval from sponsoring organisation (Taif University) .......................... 271
Appendix H Research Approval from the participating Nursing faculties ..................................... 272
XVI
Declaration of Originality
This thesis contains no material which has been accepted for the award of any other
degree or diploma at any university or equivalent institution and that, to the best of my
knowledge and belief, this thesis contains no material previously published or written by
another person, except where due reference is made in the text of the thesis.
Signature: ……………………
Print Name: ………………….
Date: ………………………….
XVII
List of Acronyms
BSN
CLE
CLE+T
JCI
Bachelor of Science in Nursing
Clinical Learning Environment
Clinical learning environment, supervision and nurse teacher
Joint Commission International
KSA
MN
MOE
MOH
NT
Kingdom of Saudi Arabia
Master of Nursing
Ministry of Education
Ministry of Health
the role of the Nurse Teacher
PA
PhD
PN
SR
Pedagogical Atmosphere on the ward
Doctorate of philosophy
Philosophy of Nursing (in the ward)
Supervisory Relationship
UAE
UK
United Arab Emirates
United Kingdom
USA United Stated of America
WHO The World Health Organisation
WM leadership style of the Ward Manager
XVIII
Publications during enrolment
Thesis including published works declaration I hereby declare that this thesis contains no material which has been accepted for the award of any other degree or diploma at any university or equivalent institution and that, to the best of my knowledge and belief, this thesis contains no material previously published or written by another person, except where due reference is made in the text of the thesis. This thesis includes one original paper published in peer reviewed journals. The core theme of the thesis is Clinical Learning Environment in Saudi Arabia. The ideas, development and writing up of the papers in the thesis were the principal responsibility of myself, the student, working within the School of Nursing and Midwifery under the supervision of Professor Margaret O’Connor and Professor Lisa McKenna. The inclusion of co-authors reflects the fact that the work came from active collaboration between researchers and acknowledges input into team-based research. In the case of Chapter One my contribution to the work involved the following:
Thesis Chapter
Publication Title
Status (published, in press, accepted or returned for revision)
Nature and % of student contribution
Co-author name(s) Nature and % of Co-author’s contribution*
Co-author(s), Monash student Y/N*
1
Cultural View of Nursing in Saudi Arabia
Accepted
80%. Concept and collecting data and writing first draft
1) Margaret O‘Connor, review and input into manuscript 10%
2) Lisa McKenna, review and input into manuscript 10%
No No
I have / have not renumbered sections of submitted or published papers in order to generate a consistent presentation within the thesis.
Student signature: Date: 27/07/2016 The undersigned hereby certify that the above declaration correctly reflects the nature and extent of the student’s and co-authors’ contributions to this work. In instances where I am not the responsible author I have consulted with the responsible author to agree on the respective contributions of the authors. Main Supervisor signature: Date: 19/09/2016
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Chapter One: Introduction
1.1 Introduction
The clinical experiences of nursing students are essential for their learning development,
as well as providing exposure to a range of clinical settings, which may assist in
preferences for future professional practice. Evaluation of the clinical learning
environment (CLE) is a well-discussed subject, and has been frequently mentioned in the
literature in Saudi Arabia, particularly in the fields of medical and radiological education
(AlHaqwi, Van der Molen, Magzoub, & Schmidt, 2010; Binsaleh, Babaeer, Alkhayal, &
Madbouly, 2015; BuAli, Khan, Al-Qahtani, & Aldossary, 2015). However, to date there has
been no published research in the Saudi literature with reference to the nursing
discipline. Due to the lack of availability of evaluative research in the nursing literature to
inform education and practice, it was considered essential to conduct this research to
contribute to the development of, and improvements in, the learning environment in
which nursing students participate during their education.
There are many definitions regarding what comprises a clinical learning environment.
Essentially, the CLE is “an interactive network of forces within the clinical setting that
may influence the student’s clinical learning outcomes” (D'Souza, Karkada, Parahoo, &
Venkatesaperumal, 2015, p. 833). This network of forces may involve everything from
the clinical setting, the equipment, the staff, to the clients and their families. As part of
its role, the nursing faculty seeks to ensure an appropriate CLE is provided that adheres
to both the theoretical and practical aspects of nursing education. A significant
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component of a CLE is related to practical learning and learning outcomes, where clinical
experiences are essential for students’ overall learning development. This includes
promoting nursing skills, preparing for future practice and responsibilities, and
nourishing supportive relationships and communications skills (Hartigan-Rogers, Cobbett,
Amirault, & Muise-Davis, 2007; Skaalvik, Normann, & Henriksen, 2011). The clinical
environment is difficult to control due to the existence of multiple stimuli and factors
such as settings, staff and general atmosphere. It is the nursing faculty and its educators’
responsibilities’ to prepare the nursing students to encounter and manage these stimuli
that the clinical environment offers (Hartigan-Rogers et al., 2007; Papp, Markkanen, &
von Bonsdorff, 2003) in order to ensure effective learning occurs.
Nursing education in Saudi Arabia is delivered at the bachelor degree level. Currently,
clinical education is integrated into all undergraduate nursing courses in Saudi Arabia to
constitute approximately one half of total course content of the curricula. Although
nursing education has developed from hospital-based nursing training schools and
vocational colleges to higher educational institutions, it remains a challenge to achieve
effective learning and teaching from both theoretical and practical perspectives at the
required desired academic level (Johansson et al., 2010).
The aim of this chapter is to provide a contextual and structural outline of the thesis. An
overall rationale for the study is provided, together with an overview of the setting of
the study. In addition, this chapter introduces the theoretical and methodological
underpinnings of the study and finally, it provides a summary of the thesis structure.
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1.2 Background
1.2.1 Saudi Arabia
The Kingdom of Saudi Arabia (KSA) is one of the largest countries in the Middle East
region being geographically the fifth-largest state in Asia and the second largest state in
the Arab world (after Algeria) at 2.24 million km². KSA has one of the largest oil reserves
in the world (Aldossary, While, & Barriball, 2008), and oil wealth has precipitated a rapid
socio-economic transformation in recent decades, the consequences being a marked
impact on the health and lifestyle of its population (Abu-Zinadah, 2006). KSA is bordered
by Jordan and Iraq on the north, Kuwait on the northeast, Qatar, Bahrain, and the United
Arab Emirates on the east, Oman on the southeast, and Yemen on the south and the Red
Sea on the west (Alboliteeh, 2015) (see Table 1). KSA is a relatively young country and its
unification occurred only in 1932 under the Saud ruling dynasty, specifically its founder
King Abdulaziz Al Saud. The latest population figures show that Saudi Arabia now has
30,770,375 people, of which29.5% are under the age of 15 years (Ministry of Health,
2014). Due to high birth rates among Saudis, the United Nations projection has
speculated that Saudi Arabia’s population will reach 40 million by the year 2025
(Alboliteeh, 2015).
4
Figure 1 Political Map of Saudi Arabia (Maps of World, 2016)
Saudi Arabia has a long history and many associated traditions. It is the birthplace of
Islam, and the centre of the holy lands of Islam where both cities, Makkah al Mukarrama
and Al Madina Al Mnoura, are located. Islam is the official religion of Saudi Arabia and its
population is 100% Muslim (Alshmemri, 2014). The constitution of Saudi Arabia is formed
by Shariah law, which is based on the holy Qur'an and the Prophet’s traditions (Sunnah)
(Alboliteeh, 2015). Jurisprudence in Islam is also based on the major elements of
consensus, analogy, innovation and logical thinking. Islamic scholars are in fact able to
make decisions regarding new events or developments for the contemporary society,
culture and technology, in such a way that pronouncements are consistent with Islam
and not mentioned in the Qur'an and Sunah (Almutairi & McCarthy, 2012). Furthermore,
Islam influences virtually every aspect of Saudi society, such as its politics, economics,
banking, business, family, sexuality, hygiene, and social issues (Almutairi & McCarthy,
2012; Alshmemri, 2014).
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Issues around gender in Saudi culture are complex and have been changing in line with
modern lifestyles and technology. Social attitudes considering Saudi men and women are
shaped by religion and the tribal nature of Saudi culture and its traditions (Alboliteeh,
2015). The issue of gender segregation is important to most of the Saudi population, to
the extent that many in Saudi society have found it difficult to accept the concept of
women working outside their homes (Aldossary et al., 2008). In the past, most Saudi
women were housewives performing the essential roles of homemaking and caregiving.
However, Saudi women now play a wider and much more vital role in the Saudi
community; being professionals and working in various sectors, such as hospitals,
schools, universities, the media and banks (Alshmemri, 2014). Traditionally, men have
possessed more rights than women; however, this situation has changed in the past few
years and continues to evolve. For example, in September 2011, Saudi women gained the
right to vote, stand as candidates in municipal elections and become members of the
Shoura Council. However, women are still not allowed to drive motor vehicles. Thus, they
must depend on male family members for their transportation to work and school (Al-
Rasheed, 2010), as well as elsewhere.
1.2.2 Nursing in Saudi Arabia
Although Florence Nightingale is primarily recognised as the founder of modern nursing,
historically nursing goes back to ancient times and was identified as an activity that
focused on caring for sick and wounded people. In the Arabian Peninsula (Saudi Arabia
before Saudi rule began), although little was documented about nursing during the pre-
Islamic period (before 570 AD), it is believed that healers were known to practise nursing
6
and medicine from these times. With the dawn of Islam in the Arabian peninsula, nursing
became more valued when women volunteered in wars to attend the injured and dying,
providing them with care, water, and support (Miller-Rosser, Chapman, & Francis, 2006).
Rufaidah Al-Aslamiyah is regarded as the first Muslim nurse and founder of nursing in the
early Islamic era (570–632 AD). She practised nursing and gained needed skills under the
guidance of her father who was a well-known healer (M. Almalki, G. FitzGerald, & K.
Clark, 2011). Besides serving during war-time, Rufaidah reportedly practised nursing in
peace-time through treating sick people, training other nurses, looking after poor people
and solving social issues (Aldossary et al., 2008).
Since its unification as a Kingdom, the population of Saudi Arabia has rapidly increased
and so have the demands for health care provision by professionals, including nurses
(Miller-Rosser et al., 2006 ). For this reason, the government began to introduce
additional health care programs to attend to its growing population and plan for future
needs. The current and future development of Saudi health care services require a
skilled, competent and well educated multiprofessional workforce (Almutairi, Gardner, &
McCarthy, 2013). During previous years, the Saudi Arabian health system suffered from a
severe shortage of qualified Saudi nurses in clinics and hospitals, in both the private and
public health sectors (Al-Ahmadi, 2002). There are not enough Saudi nationals of both
genders to provide coverage for all the nursing workforce in most hospitals (Almutairi &
McCarthy, 2012). The reasons for this include issues concerning salaries, shift schedules
and social perceptions of nursing not being a suitable profession. These problems have
been exacerbated by the small number of Saudi nurses actually willing to accept difficult
and challenging working conditions (Al-Ahmadi, 2002). Changes in nursing roles are
7
occurring whereby they are becoming more complex and demanding and combined with
the recent economic downturn have significantly influenced the levels of nurses’ job
satisfaction. This has subsequently led to fewer Saudi nationals seeking to enter the field
of nursing (Al-Dossary, Vail, & Macfarlane, 2012).
Currently, the nursing profession in Saudi Arabia is a complicated one due to the recent
rapid changes occurring in the country (Alboliteeh, 2015). The majority of health care
institutions, including hospitals and nursing faculties, consist of expatriates. This
expatriate workforce comes from many different countries including the Philippines,
India, South Africa, Egypt and the United Kingdom, in order to meet the growing health
care needs of the Kingdom (Aboul-Enein, 2002). Due to these high rates of expatriates in
the workforce, health care draws together many different cultural perspectives and
nursing backgrounds. As a result, there are significant cultural dimensions that impact on
nursing practice in Saudi hospitals, such as assessment and communication (Almutairi et
al., 2013). Furthermore, care is primarily delivered in the English language (the accepted
universal language of health care), with a patient population that speaks mostly Arabic.
Consequently the nursing profession in Saudi Arabia faces many unique and complex
challenges (Al-Ahmadi, 2002).
These challenges include a rapidly increasing population, the annual influx of hundreds of
thousands of international pilgrims during the Hajj, financial and workforce planning and
the need for more Saudi nurses to assume roles currently filled by non-Saudis (Almutairi
& McCarthy, 2012). The remit of the country’s Nursing Board is still developing and it is
anticipated that it will gradually widen its focus to include practice guidelines, disciplinary
8
measures and professional conduct. From January 2005, all nurses, Saudi or expatriate,
were required to be registered with the Nursing Board (Miller-Rosser et al., 2006). As
shown in Table 1, the total number of nurses working at hospitals and other health care
facilities in Saudi Arabia in 2014 was 165,324. Of this, Saudi national nurses represented
32.2% of the overall nursing workforce in the country (Ministry of Health, 2014).
Table 1 Health Services Provided by Health Sectors in KSA (Ministry of Health, 2014)
Health Sector No of
hospitals No of Beds Saudi nurses
Expatriate
nurses
Ministry of Health 270 40,300 54,745 (59.6%) 37,109
Other governmental
hospitals 42 12,032 4,470 (14.1 %) 27,232
Private hospitals 141 15,665 2,172 (5.19 ) 39,596
Total 453 67,997 61,387 103,937
Due to high unemployment rates in Saudi Arabia that have characterised the past
decade, the government concluded that the best solution was to push companies to cut
the number of expatriate employees and replace them with locals. This move was
referred to as “Saudisation” (Martin, 2013), the implementation of which was envisaged
to favour Saudi nurses being a majority in the workforce, instead of a minority (Miller-
Rosser et al., 2006). The disparity between the number of Saudi nurses compared to
Western nurses in Saudi hospitals remains very high.
9
Social attitudes are shaped by religion and the tribal nature of Saudi culture and tradition
(Alboliteeh, 2015) and hence, are unique in the Saudi context. The following is a
published paper that describes the effects of cultural views on nursing practice in Saudi
Arabia. It also looks at other aspects that need to be considered by non-Saudi nurses
working in the Kingdom. The paper was written during the development of the
background for the current study.
1.2.3 Published Paper
Felemban, E., O’Connor, M. & McKenna, L. (2014). Cultural view of nursing in Saudi
Arabia. Middle East Journal of Nursing, 8(4), 8-14.
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1.2.4 Nursing Education
Saudi Arabian nursing education was initiated by the World Health Organisation (WHO)
in 1958 in Riyadh, the capital city, with fifteen Saudi males enrolled in a one-year nursing
diploma program (Aldossary et al., 2008 ). The country’s remaining health schools were
upgraded to become intermediate health colleges, and graduates were considered to be
technicians with a nursing diploma (Ministry of Health, 2014). A few years later, similar
programs were offered for women in Riyadh and Jeddah. By 1981, the admission criteria
had risen from fifth and sixth grade to ninth grade entry level as the program curriculum
was changed into a three-year program.
The Bachelor of Science in Nursing (BSN) was introduced to Saudi Arabia in 1976 when
the Ministry of Health (MOH) established two nursing colleges offering the degree for
females at King Saud University in Riyadh and King Abdulaziz University in Jeddah. This
was followed by the establishment of Masters programs in 1987 (Alboliteeh, 2015).
Initially, all the BSN programs on offer were exclusively for females only. The first male
BSN program was implemented in 2004 when 307 students enrolled in a four-year
academic program at King Saud University in Riyadh (El-Sanabary, 1993; Mebrouk, 2008).
These programs were conducted under the supervision of the Ministry of Education
(MOE) [formally known as the Ministry of Higher Education], and according to the
Ministry of Health (2014), the number of Saudi students enrolled in university nursing
programs rose to reach 6,712 students in total by 2014. Furthermore, the MOE possesses
the education facilities, academic experience and financial resources that are crucial to
develop health care education. This was considered a potential way to improve the
18
quality of health education and training for all health disciplines, including nursing
(Alshmemri, 2014).
In 1994, the first nursing Doctor of Philosophy (PhD) program was established at King
Abdulaziz University in Jeddah in cooperation with a British university, offering limited
places to Master’s degree holders (Alboliteeh, 2015). The course aimed to facilitate
career advancement for Saudi women who were unable to study abroad, as well as to
prepare future leaders and nurse teachers through access to overseas study (Abu-
Zinadah, 2006).
The professional nursing qualifications currently available for Saudi men include a three-
year diploma, an Associate Diploma and a Bachelor degree, whereas the Master’s degree
in nursing in Saudi Arabia is exclusively offered to females (King Saud University, 2012).
The rationale for this is that it is more convenient for Saudi women to continue their
education in Saudi Arabia, due to cultural and religious factors, rather than travelling
overseas. According to Abu-Zinadah (2006), the educational programs offered over the
past few years have resulted in Saudi nursing educational levels consisting of the
following proportions of different staffing levels: Diploma holders from health institutes
(67%), and associate degree holders from junior colleges (30%), both are at the technical
level. Graduates with BSN degrees represented 3% and they were considered to be in the
professional and managerial categories. However, this data is quite dated and has likely
changed greatly over the past decade.
19
To facilitate access to qualifications, the MOE has offered a number of scholarships to
support nursing higher education and these are increasing markedly. Overall, the
government’s strategy focuses on aspects that facilitate facing the future challenges and
rapid development in all fields, such as the health care sector (Aldossary et al., 2008).
Although the education system segregates males and females in schools and universities,
women are increasingly able to apply and compete with men for scholarships to study in
other countries, including Australia, the United Kingdom, Canada and the United States
(Alboliteeh, 2015). With the launch of the King Abdullah Overseas Scholarship program in
2007, more than 150,000 Saudi students were sent to 25 different countries to study
different levels of degrees in various fields, including nursing, to cover existing gaps in
the country. This reflected the demand for highly qualified graduates to meet the
population’s needs (Alboliteeh, 2015). However, in 2009, the World Health Organisation
(WHO) provided guidance to transform and scale up the education of health
professionals worldwide (WHO, 2013b). Therefore, the number of Bachelor degree
graduates and postgraduate nurses, as well as other health professionals, may have
increased rapidly as the number of health schools fell from 23 to 4 in 2007. By 2008, the
Director of the Saudi Commission for Health Specialties showed that the total number of
private educational schools in Saudi Arabia was 106 and only 35 institutes were
designated for Saudi females. However, the graduates from these health schools have
different specialties and are considered to be the lowest in the career hierarchy
(Aldossary et al., 2008). The total number of nursing universities attached to the Ministry
of Education rose in 2014 with the addition of 18 new universities to the existing seven
(Ministry of Health, 2014).
20
1.3 Aim/ Purpose
Research into nursing education in Saudi Arabia is currently limited, particularly clinical
education, which takes place in a unique practice context. Yet, with increasing emphasis
on the education of Saudi nationals to assume nursing roles, it was determined that
much research was needed in this area. Hence, the aim of this research was to explore
the quality of clinical education in the curriculum of nursing in Saudi Arabia. This was
done by identifying certain factors within the CLE which affect students’ outcomes, and
measuring nursing students’ experiences and satisfaction with their clinical learning
environment.
1.4 Research Questions and Approach
The study sought to answer a series of research questions, these being:
What is the quality of clinical education in the nursing undergraduate curriculum
in Saudi Arabia?
What are the factors within the CLE that might affect students’ outcomes?
How satisfied are the nursing students with the provided clinical education?
How can the clinical education be improved in the nursing curriculum in Saudi
Arabia?
A sequential mixed methods approach was selected as appropriate for answering the
research questions. The first phase utilised questionnaires with second and fourth year
undergraduate nursing students, while the second involved conducting semi-structured
21
interviews with a smaller group of participants and provided enhanced and rich
understandings of the nature of clinical learning in the Saudi health care system.
1.5 Significance of the study
This research study is significant because it is the first one to explore the quality of
clinical learning environments in nursing in Saudi Arabia. Additionally, the health system
is unique in that it is driven by multicultural and multiethnic forces, which directly impact
on the learning experiences of nursing students. This distinct workforce difference offers
unique perspectives that extend what is currently known about clinical education in
nursing, contributing new knowledge to the available international literature. The results
of this study can serve to inform education providers in Saudi Arabia to develop and
enhance the quality of clinical learning in health care institutions throughout the country.
Furthermore, the findings of this study may have relevance to other Arab countries in
the region.
1.6 The Clinical Learning Environment
The CLE is an interactive network of forces influencing student learning outcomes in the
clinical/practice setting (Dunn & Hansford, 1997). Not only is the CLE important for
clinical skills development; it also offers opportunities to engage with, and learn about
the norms of practice in care delivery. It provides students with opportunities to join
teams of clinicians to learn about professional practice, establish knowledge about how
to effectively integrate into the clinical environment, and achieve a sense of
22
belongingness (Levett-Jones, Lathlean, Higgins, & McMillan, 2009b) in their chosen
profession. These environments are largely created via open communication channels
within the clinical team and direct interactions with students during their placements
(Henderson, Cooke, Creedy, & Walker, 2012). Therefore, the experiences in the clinical
setting that nursing students are exposed to play a fundamental role in enhancing their
education, professional development and career decisions as future nurses (Brodie et al.,
2005). Saarisko et al. (2002) suggest that these experiences are very important in
determining a student’s choice concerning a graduate workplace in the future.
According to Weiss, Bagian, and Nasca (2013), the field of clinical learning has undergone
evolved considerably over the years. The manner in which nursing students perceive
their clinical learning experiences has also changed as a consequence of a transformation
in the chief learning perspectives in nursing. Warne et al. (2010) assert that these
learning perspectives include the concepts of self-regulation, attitudes towards the
nursing profession and direction of the self within nursing. These, in turn, will enhance
the critical thinking and problem-solving ability of nursing students, promote a strong
sense of belonging, enhance confidence, and inspire nursing professionalism and identity
(Ha, 2015). D'Souza et al. (2015) state that the evolution of clinical learning experiences
for nursing students has also been evidenced to be contingent on the level to which
students are allowed to take part in critical events in the hospitals where they learn. In
addition, Rahmani et al. (2011) claim that during placements many nursing students
learn to integrate diverse functions, preparing to become specialised nursing experts and
campaigners for patients’ rights.
23
According to Zilembo and Monterosso (2008), the relationships that a nursing student
forms with different relevant people such as nurses, physicians and patients, affect their
clinical learning processes, reflecting a very significant shift that has occurred as per
reviews in nursing studies (Burch, Guthrie, Kidd, Lewis, & Smiler, 2010). These
relationships can affect the levels of nursing students’ self-esteem, stress and anxiety,
depression and general wellbeing, motivation and capacity to learn (Levett-Jones &
Lathlean, 2009). Unlike previous hospital-based training, Brodie et al. (2005) contend
that modern facilitators and educators in nursing education are more sensitive about the
needs of nursing students. This is reflected in the learning methods that are employed to
assist nursing students in the integration of theory and practical aspects of their studies
(Rahmani et al., 2011). Further information on CLE will be discussed later in Chapter Two.
1.7 Personal Positioning
My journey started when I unknowingly enrolled in the nursing undergraduate program
at King Abdulaziz University, Kingdom of Saudi Arabia, in 2002. The program was titled
“Applied Medical Sciences” and it was only after the first lecture that I learned that it was
a nursing program. I was not aware that such a discipline was available to Saudi students,
believing that it was something limited to expatriates from other countries.
Being a female Saudi nursing student, I have had many different experiences throughout
my years of study. I was torn between being accepted and rejected by the society and my
family, especially my mother. My mother had concerns around my future as a nurse and
all the difficulties I may face if I got married and started a family. The work regimen of a
24
nurse was viewed as incompatible with the Saudi family and its demands. She pointed
out that with a twelve-hour shift, I would struggle to maintain my role as a wife and a
mother. Furthermore, during my hospital placements, I was able to experience firsthand
the different reactions that Saudi society had towards nursing in general, and female
Saudi nurses in particular. In addition, many learning issues arose during these
placements. These included lack of support and opportunities, lack of time needed to
complete the course requirements and demands, and dealing with the hospital as a new
learning environment. With my father’s support, I was able to overcome these obstacles
and managed to get both my Bachelor and Master’s degrees.
It was when I first started my work as a lecturer at Taif University in 2011 that I realised
that nothing had changed. Nursing students still encountered the same dilemmas and
difficulties that I had experienced nine years previously. I started to ask questions: Why is
no-one acknowledging these issues if they are reoccurring? Have there been any changes
in the curricula to better suit the students and minimise those issues? What causes these
issues and how are students are coping? What can be done to resolve this? I needed to
know. I wondered if this applied to other nursing faculties in other countries and I
started reading. It came as a surprise to find that clinical learning issues were not unique
to the Saudi nursing curricula and its students. It is this aspect of CLE that is explored in
this thesis.
1.8 Organisation of this thesis
This study comprises five chapters. Chapter One has introduced the study, providing an
overview of the research background, and descriptions of the current practice in clinical
25
learning and practical education in nursing institutions in Saudi Arabia. It defines the
study’s aims, describes briefly the significance of the study and the research methods
used, as well as a personal account of how the study question arose.
Chapter Two provides a review of the literature, particularly the implementation of
clinical learning in nursing institutions. The focus of the review is on the history and
development of clinical learning frameworks, with an analysis of the factors affecting the
quality of clinical learning environments. Finally, it provides recommendations emerging
from the literature, to improve the status of clinical education in nursing institutions. The
chapter is divided into four sections. Section one explores the history of nursing in Saudi
Arabia, the evolution of nursing education and the cultural views on the profession.
Section two explores the concept of clinical learning and its contribution to nursing
studies. This includes an overview of the clinical learning environment, as well as its
importance and benefits. It also demonstrates the importance of clinical guidance by
exploring the staff nurses and nurse teachers’ roles required to support students in
practice. Next, the literature review focuses on nursing students’ experiences and
satisfaction with clinical learning, including a discussion of the tools previously used to
measure experiences and satisfaction of clinical learning environments in the literature,
and explores factors involved. The last section provides recommendations drawn from
the literature to improve the quality of clinical learning environments.
Chapter Three discusses the research design and the significance of adopting a mixed
methodology to address the research questions, including the use of a convergent
parallel research design. In doing so, this chapter describes the use and development of
the questionnaire and semi-structured interviews, forming the quantitative and
26
qualitative research components. This is followed by an outline of the ethical
considerations underpinning the study, along with the methods used to collect the data
and methods by which data analysis was undertaken.
Chapter Four consists of two parts. Part One presents the findings of the questionnaire
conducted in the first phase of the study, including open-ended questions included in the
questionnaire. It highlights important information that arose from the analysis as
follows: firstly, socio-demographic information; secondly, participants’ opinions with
reference to their clinical learning environment; and thirdly, participants’ free comments
sought through six open-ended questions. Part Two presents the findings from the
second phase of the study, which is the semi-structured interviews, in the form of
categories and themes.
In Chapter Five, the data generated by this study are analysed and discussed. Data from
phases one and two are integrated and compared and connected to the existing and
current international literature, serving to position the current study into what is already
known. The limitations of the current study are also discussed. Finally, Chapter Six
summarises the research, including the key findings and provides recommendations and
implications for future research, practice and education in relation to clinical education
and clinical learning environments.
1.9 Conclusion
This chapter has introduced the research study. It has explored the context of nursing
education and undergraduate clinical learning in nursing institutions in Saudi Arabia. It
27
has provided an overview of the study approach and its significance, as well as an
overview of the thesis structure. The detailed literature review is presented in the
following chapter and examines available literature on clinical learning in nursing, as well
as giving consideration to education in nursing and Saudi Arabia, providing a context for
the current study.
28
Chapter Two: Literature Review
2.1 Introduction
Clinical placement is a core component in the undergraduate nursing curriculum, since it
gives nursing students opportunities to become competent in practice by linking
theoretical information and scientific facts with the practice environment, and refining
clinical skills. In addition, by being present at a patient’s bedside, clinical education allows
students to gradually gain experience in the nursing profession. The standards of nursing
education and nursing care, in part, depend on the attributes of the clinical learning
environment. In the event that learning does not take place, the nursing student may not
acquire adequate knowledge and refine their skills sufficiently, to effectively manage
patients following graduation.
Factors such as the clinical setting, equipment, staff, and clients, can either improve or
hinder the quality of clinical learning, and have been identified as having a significant
impact on nursing students’ learning (D'Souza et al., 2015). The need for nurse teachers
and clinical nurses to work collaboratively is fundamentally important in nursing clinical
education (Haigh & Johnson, 2007). Their role is to ensure that nursing students do not
only acquire the needed skills and knowledge, but also have positive attitudes towards
nursing so that quality becomes the area of their clinical focus (Ha, 2015). This chapter
examines the existing international literature on clinical learning in nursing. Although this
area of study to date has been rare in Saudi Arabia, clinical learning is being more widely
29
explored in the nursing literature worldwide; it is this literature from where most existing
research is drawn.
This chapter begins by exploring the concept of the clinical learning environment (CLE)
and its contribution to nursing studies. This includes an overview of clinical learning
environments, and its importance and benefits. The importance of clinical guidance is
highlighted by exploring staff nurses’ and nurse teachers’ roles. Next, the literature
review focuses on nursing students’ experiences and satisfaction with clinical learning,
including discussing tools previously used to measure experiences of, and satisfaction
with, the CLE described in the literature and factors involved. Lastly, recommendations
emerging from the literature to improve the quality of clinical learning environments are
explored.
This review provides evidence from current international literature around the CLE in
nursing. The review highlights factors affecting the quality of clinical learning in health
care facilities and the influence on nursing students’ practical progress and satisfaction.
While this review explores a global perspective, it takes a closer look at the practice
within Saudi Arabia’s unique culture and environment. Data related were extracted from
published literature obtained by reviewing prior studies and other existing analyses on
this topic. A background and literature search was conducted using several databases
including CINAHL, ProQuest, PubMed, and Ovid MEDLINE. In addition, the Monash
University library catalogue, Saudi health databases, Saudi health journals, government
reports and relevant texts and search engines such as Google Scholar were used. Precise
key words were used in order to systematically manage the number of search results
30
obtained in the study. While viewing the literature, the search was restricted to the title
and abstract, and in the case that the title search was not easily accessible, an advanced
search was undertaken. Key words included phrases such as: ‘nursing clinical education’,
‘clinical learning environment’, ‘students’ perspectives’, ‘undergraduate nursing
students’, ‘nursing education’, ‘Middle East’, ‘Saudi Arabia’, ‘nursing assessment’ and
‘clinical practice’. Materials ranged from articles to peer-reviewed journals and books.
Despite a date restriction of ten years being applied, a few older resources that were
nonetheless relevant to the topic were actually included due to the lack of more recent
materials.
2.2 Clinical learning environment in nursing
A majority of nursing students perceive the clinical environment as a place where they
acquire practical knowledge and skills. It also provides a chance to become involved in
learning tasks that enable them to become competent, develop positive attitudes
towards the nursing profession, and upon qualification, to provide quality care to
patients without any difficulties (Connell, Yates, & Barrett, 2011). In the clinical learning
environment, nursing students can practise on their own, reflect on what they have done
so that they can improve once another opportunity is available or mimic the behaviour
of other nurses (Barnett, Cross, Shahwan-Akl, & Jacob, 2010) and to observe their
interactions in a professional socialisation setting (Levett-Jones, Lathlean, Higgins, &
McMillan, 2009a). Students should observe and participate in up-to-date care
approaches designed for patients. To do so, students require knowledge of care
pathways, multidisciplinary teamwork and inter-professional learning in the clinical
31
setting Therefore all health care providers, including nurses, need to be role models so
that nursing students can adopt the best behaviours, because the literature asserts the
socialisation of nursing students into nursing practice occurs in the clinical environment
(Henderson, Briggs, Schoonbeek, & Paterson, 2011).
Clinical placement is a time of transition and nursing students are expected to be
competent in practice, attitudes, and professional ethics and conduct (Mousa, Adam, &
Hassan, 2012). It is also highly significant to students due to the opportunity given to
apply theory into practice, an experience that Seeleman, Suurmond, and Stronks (2009)
claim that determines how the competence of the health care student will be upon
completing their education. Additionally, a positive learning environment has an effect
on the recruitment, as well as retention, of the student once employed as a qualified
practitioner. This is due to the fact that during the clinical placement, the nursing student
does not only acquire the required knowledge and skills but also develops attitudes
towards the nursing profession (Moridi, Khaledi, & Valiee, 2014 ). For instance, if a
nursing student perceives the CLE to be a place where nurses are always in conflict with
other health care providers, or a setting associated with stress and an excessive
workload, the student may never want to be associated with these issues. This situation
could discourage the student from wanting to be associated with nursing upon
completion of training (Omer, Suliman, Thomas, & Joseph, 2013).
Poor clinical experience can also ultimately result in student disillusionment about
nursing and losing the ability to integrate and learn (Mamchur & Myrick, 2003). However,
it has been shown that a huge difference exists between the ideal and actual clinical
32
learning environment (Saarikoski et al., 2013). An ideal CLE is considered to be present
where nurse teachers and clinical nurses, especially those selected to guide students,
have effective teaching skills and give nursing students opportunities to be active
participants in the care of patients. This motivates the students to learn because they
will not only feel that they have control over learning but can also be independent with
regard to being involved in decisions concerning the welfare of the patient (Levett-Jones
et al., 2009b). Quality of clinical learning, assessment of the clinical environment, and
challenges that may face students during their clinical learning are explored in the next
sections of this chapter.
2.3 Quality of the Clinical Learning environment
A clinical setting is said to be ‘the best’ when all the health care providers are committed
to quality services and continuous improvement (AlHaqwi, Van der Molen, Schmidt, &
Magzoub, 2010), and depending on the level of commitment, the learning environment
can be measured for quality. Bradbury-Jones, Sambrook, and Irvine (2011) stated that
the best clinical practice could be made possible via continuous training of clinical nurses
and application of scientific evidence into nursing care. This will ensure that when the
nursing students are in the clinical setting, they learn the ideal nursing care and are
updated on the current issues regarding the nursing management of the patient. The
best clinical practice involves competent clinical nurses who can act as role models for
nursing students and ensure that they develop positive attitudes towards the nursing
profession (Walker, Cooke, Henderson, & Creedy, 2011).
33
The quality of clinical learning in nursing faculties usually mirrors the quality of the
curriculum used. Continuous assessment of the clinical settings as learning environments
is of importance in the nursing education. In their study to investigate the quality of
clinical learning in Cypriot universities, Papastavrou, Dimitriadou, Tsangari, and Andreou
(2016) found that nursing students’ satisfaction was considered an important factor in
curriculum assessment and their feedback would positively contribute to any potential
reforms in order to optimise the learning activities and achievements within clinical
settings. In a clinical learning environment where a nursing student’s voice can be heard,
the quality of care is often high because such a nursing student does not suffer from
stress or emotional irritability (Chuan & Barnett, 2012; Daly, Perkins, Kumar, Roberts, &
Moore, 2013; Henderson & Tyler, 2011).
A quality CLE will not only benefit patients but also nursing staff (Henderson et al.,
2011). Patients will be advantaged by receiving quality nursing care because nursing
students have acquired the necessary skills and knowledge needed for effective
management of patients. Staff nurses will benefit because they will be relieved from
much of the daily workload of patient care. Generally, a positive correlation exists
between the quality of CLE and standard of care that the patients receive (Courtney-
Pratt, FitzGerald, Ford, Marsden, & Marlow, 2012). A properly functioning CLE means
that the health care providers and nursing students are working collaboratively with the
one aim to ensure there is continuity of high quality patient care (Levett-Jones et al.,
2009b).
34
The quality of the CLE can be further rated depending on education/training qualification
and experience of clinical nurses. A clinical nurse with a higher level of training is likely to
work collaboratively with nursing students and supervise them so that students
accomplish the set clinical objectives (Walker et al., 2011). M Tomietto et al. (2012) add
that a trained clinical nurse will not only focus on practical skills of nursing students but
also the social, psychological and emotional aspects of learning. As a result, the nursing
student will adapt easily to the CLE since there will be no obstruction to the learning
process. Warne, Johansson, Papastavrou, Tichelaar, et al. (2010) asserted that nurse
managers should ensure that the CLE is of high quality by either sending clinical nurses
for nursing updates or allowing the nurses to advance academically through higher
education to achieve an undergraduate or postgraduate qualification.
A number of studies have attempted to explore the factors affecting the learning
experiences of nursing students. From the literature it is clear that several aspects of
undergraduate placements are critical in providing a high quality experience and they
include the following: dealing with clinical placement challenges, such as creating
learning opportunities and gaining independence (Newton, Billett, & Ockerby, 2009),
facing a variety of socio-cultural interpersonal differences (Van der Zwet, Zwietering,
Teunissen, van der Vleuten, & Scherpbier, 2011), sense of acceptance and belongingness
(Levett-Jones et al., 2009a) and interacting with personnel in the clinical setting. These
interactions include staff nurses, nurse teachers, patients and other hospital workers
(Warne, Johansson, Papastavrou, Tichelaar, et al., 2010).
35
2.4 Clinical learning environment assessment
The assessment and analysis of the CLE has been an area of interest for many
researchers. Van der Zwet et al. (2011) claim that researchers have been concerned
about clinical learning environments, especially the quality and the need for nursing
students to acquire knowledge and skills as they practise. The concept of clinical learning
is highly emphasised and it is a key aspect in many studies. For instance, Henderson et al.
(2011) reported that clinical learning is influenced by the physical layout of the health
care facility, the health care providers, the culture of the facility and the interpersonal
relationships between nursing students and other personnel. De Witte, Labeau, and De
Keyzer (2011) add that mutual respect among nurse teachers, nursing students and
clinical nurses is fundamental in facilitating learning in the clinical setting.
Although Hossein, Fatemeh, Fatemeh, Katri, and Tahereh (2010) assert that a nurse
manager plays a significant role in ensuring that the CLE is favourable for nursing
students, the students have reportedly had different opinions. Nursing students believe
that the best CLE is that which gives them an opportunity to learn and they can approach
any health care provider with ease, regardless of whether one is at the managerial level
or not (Henderson et al., 2012). According to Baglin and Rugg (2010), nursing students do
not only prefer a CLE where there is friendly staff, but also one where they are supported
emotionally, physically, and socially. Levett-Jones et al. (2009b) reported that work
relationships and assessments in clinical placements could be a source of either stress or
satisfaction to the nursing students depending on their perceptions. It is the role of the
36
nurse teachers and clinical nurses to ensure that nursing students develop a positive
attitude to their clinical learning environment.
With regard to professional development of clinical nurses, Henderson, Creedy,
Boorman, and Walker (2010) attempted to measure the existence and prevalence of
staff attitudes within clinical contexts. They concluded there is a positive correlation
between quality learning in the clinical environment and knowledge and skills acquisition
by nursing students. Bradbury-Jones et al. (2011) affirmed that in the event where
clinical nurses had the necessary training, most nursing students reported that learning
took place because they: firstly, were actively involved in patient care; and secondly, they
worked independently and consulted where necessary. In order to facilitate learning in
the clinical setting, it is vital for nurse teachers, staff nurses and the education sector to
collaborate (Carlisle, Calman, & Ibbotson, 2009 ). This is because the ability of nursing
students to acquire the necessary skills and knowledge in the clinical environment is not
only influenced by the level of knowledge of the clinical nurses, but also the mentorship
of the nurse teacher.
Studies since the 1990s have employed both quantitative and qualitative techniques to
measure the quality of clinical learning environments using numerous methods (Dunn &
Hansford, 1997; Papp et al., 2003; M Saarikoski, H. Leino-Kilpi, & T. Warne, 2002). Issues
in the clinical learning have been reported to be similar in different countries. These
included linking theory to practice, poor acquisition of skills, and problems in the
supervision of clinical practice (Chuan & Barnett, 2012; D’Souza, Karkada, Parahoo, &
Venkatesaperumal, 2015; E. Papastavrou, E. Lambrinou, H. Tsangari, M. Saarikoski, & H.
37
Leino-Kilpi, 2010; E. Papastavrou, E. Lambrinou, H. Tsangari, M. Saarikoski, & H. Leino-
Kilpi, 2010; Sundler et al., 2014). In one country, Cyprus, regarding nursing education it
emerged that there were weaknesses in the level of support offered by nurse teachers
and clinical teachers to nursing students (E. Papastavrou et al., 2010).
Dunn and Burnett (1995) developed the clinical learning environment (CLE) scale in an
attempt to identify the factors that were most predictive of desirable student learning
outcomes and those which may have a negative impact on such outcomes. The CLE scale
is a 23-item instrument with five subscales including: staff–student relationships, nurse
manager commitment, patient relationships, interpersonal relationships, and student
satisfaction. Their study concluded that the scale provided a valid and reliable instrument
to evaluate the factors within the clinical learning environment effectively (Dunn &
Burnett, 1995).
Later, the Clinical Learning Environment Inventory was developed in Hong Kong by Chan
(2002) and validated in (2003) study. It uses the concept of classroom learning
environment studies to test nursing students’ perceptions of the CLE through an analysis
of six variables: individualisation, innovation, satisfaction, involvement, personalisation,
and task orientation. Chan (2002) concluded that this inventory was most suitable for
assessing undergraduate nursing students’ perceptions of clinical settings. However, in a
later paper reporting testing of the clinical learning environment inventory, Newton,
Jolly, Ockerby, and Cross (2010) concluded that there may be other latent dimensions,
and items that could be designed that would improve the utility of the inventory.
38
Saarikoski et al. (2008) developed an additional sub-scale to the Clinical Learning
Environment Scale for measuring the quality of nurse teachers’ involvement with nursing
students in the clinical setting in Finland. A validated evaluation tool was produced to be
used as a part of the total quality assessment of nurse education perceived by student
nurses in Finland. Their resulting tool was called the Clinical Learning Environment and
Nurse Teacher Scale (CLE+T). There are a number of studies that have adopted this scale,
including this study, and they are explored later in the methodology chapter.
Further tools were developed after the collection of data for this study. In India,
Choudhary, Kumar, and Kumari (2014) developed the Clinical Learning Environment and
Supervision Evaluation Scale for nursing students of M.M. University Mullana, Ambala.
The scale comprises 53 items which were tested to be positively correlated, proving that
it is a valid and reliable scale to evaluate the clinical learning environment and
supervision for nursing students. Similarly, AlHaqwi, Kuntze, and Van der Molen (2014)
developed an instrument that measures the effectiveness of the clinical learning
environment and to determine its factor structure. Their instrument, known as the
Clinical Learning Evaluation Questionnaire, provides a multidimensional and reliable
instrument that evaluates clinical teaching activities, both by educators as well as
students.
2.5 Challenges in clinical settings
Clinical experiences can be fraught with difficulties that may challenge the students’
success and therefore, are hard to control (Mamchur & Myrick, 2003). O'Flanagan and
39
Dajee (2002) identify some of these difficulties as follows: the limitation of opportunities
to develop practical skills, the presence of a student-friendly clinical environment, and
the availability of support and resources. Further, while investigating how undergraduate
health-related students viewed their CLE, compared to their preferred clinical
learning, Brown et al. (2011) referred to six factors that described a positive clinical
learning environment. These were: autonomy and recognition, role clarity, job
satisfaction, quality of supervision, peer support, and opportunity for learning. In other
work, Löfmark and Wikblad (2001) assert that earlier studies on experiences in clinical
practice have indicated other factors that are important to the development of
educational and professional outcomes. These include the possibilities of varieties of
experiences, the workplace’s culture, and communication between the educational
institution and health care facilities. However, less is known about the opportunities
which students are given in order to practice the skills that they will be expected to do as
new graduate nurses.
The quality and characteristics of the clinical setting may have an effect on the involved
personnel including students (Marks-Maran et al., 2013). This includes attitudes,
friendliness, and cooperation of all staff and their interactions and relationships with
students. In fact, the ward’s atmosphere has been determined to have a huge impact on
students’ perceptions of the CLE (Chuan & Barnett, 2012).
40
2.5.1 Clinical learning opportunities
The core goal of clinical learning is to bridge the gap between theory and practice (Ten
Cate & Scheele, 2007). Van der Zwet et al. (2011) report that most nursing students
believe that a quality clinical setting is that which gives them an opportunity to apply
classroom work to clinical care. A variety of learning opportunities means that nursing
students are given opportunities to not only provide nursing care, but to be involved in
other activities such as specimen collection, management of the hospital unit and
attending educative meetings. Adequate preparation of nursing students for the clinical
environment calls for collaborative efforts from the nurse teacher and clinical nurses in
ensuring that students have learning programs and are well prepared to work and be
evaluated (Moore, Green, & Gallis, 2009 2009). Therefore, the positivity of the learning
environment is an indicator of quality. Nursing students reportedly prefer a CLE where
they are involved in patients’ management (Chuan & Barnett, 2012). Levett-Jones and
Lathlean (2009) suggest that a positive correlation exists between the involvement of the
nursing student in clinical learning and their evaluation results. Students’ involvement
can be displayed by completing clinical learning tasks that may include caring for
patients, submitting clinical assignments and attending clinical training (Chuan & Barnett,
2012; Daly et al., 2013; Henderson & Tyler, 2011).
Walker, Cooke, Henderson, and Creedy (2013) asserted that a supportive CLE is a core
aspect of nursing students’ development and there is a need for education about clinical
placements. Edgecombe and Bowden (2009) concur with Walker et al. (2013), stating
that a supportive CLE is one where the ability of the nursing student to become
41
independent is facilitated and nursing students are allowed to consult each other,
experienced nurses, and other health care providers, especially when students
encounter an issue that they cannot handle. Student involvement in patient care is
important because it gives them an opportunity to learn practical skills, educate their
colleagues, become competent, develop interest in clinical work and engage in reflective
thinking and practices (Baeten, Kyndt, Struyven, & Dochy, 2010). Further, Bradbury-Jones
et al. (2011) reported that nursing students in the United Kingdom who were being
valued as team members were more empowered to achieve their clinical learning
objectives. Cummins (2009) concurs with Bradbury-Jones et al. (2011) by claiming that
nursing students felt more comfortable in the clinical setting when clinical nurses took
students’ levels of education into consideration when executing procedures. Therefore,
in a positive CLE there must be clear description of roles (D’Souza et al., 2015) and
responsibilities, job satisfaction, effective management and peer support (Courtney-Pratt
et al., 2012 Marsden, & Marlow, 2012).
The issue of adequate resources in enhancing learning in the clinical environment is
controversial. Newton, Billett, and Ockerby (2009), Warne, Johansson, Papastavrou,
Tichelaar, et al. (2010) and E. Papastavrou et al. (2010) claim that psychological and
social support are more important than the availability of practical materials and
equipment since the nursing students cannot learn when they are unhealthy. Conversely,
Mattila, Pitkäjärvi, and Eriksson (2010); Newton, Billett, Jolly, and Ockerby (2009) suggest
that in the absence of necessary materials and supplies in the clinical learning
environment, nursing students will not be in a position to learn what ideal care is. In
order for learning to take place, the necessary learning materials and adequate
42
supervision by health care providers is needed (Henderson et al., 2011). In the event of
staff shortages, existing health care providers may not have sufficient opportunity to
teach nursing students and as a result, learning will not take place. Henderson and Tyler
(2011) asserted that effective channels of command are necessary in the clinical setting
so that the resources that facilitate learning can be procured and distributed effectively.
In order to facilitate learning in the clinical setting, resources are highly significant.
Henderson et al. (2010) stated that such resources including adequate supply of
materials and equipment that are needed to provide ideal nursing care to patients. Daly
et al. (2013) add that personal supplies for students such as the teaching resources and
learning aids are paramount in an effective learning environment. This is because the
nursing students will require them in group discussions to do simulation and role-play
learning. Human resources are imperative because nursing students may require
psychological, emotional, or physical support owing to the fact that the CLE could be a
source of stress and fatigue to some nursing students (Mattila et al. (2010). A CLE where
resources are available and well utilised can be scored more highly with regard to quality,
than one with either insufficient resources or poor utilisation of the available materials
and supplies.
2.5.2 Interpersonal interactions
The effectiveness of the CLE depends on the characteristics and behaviours of the
nursing students, the qualified nurses, other health care providers, and the health care
facility itself. Most aspects of the clinical setting, for example social relationships with the
43
health care providers, influence the ability of the nursing student to acquire knowledge
and skills. Hope, Garside, and Prescott (2011); Newton, Billett, and Ockerby (2009)
suggested that incorporation of clinical learning into the nursing curriculum through
simulations and role-play can create a significant difference when nursing students are
released into the clinical setting. Hossein et al. (2010) added that when the CLE is of good
to high standard, patients will receive the best care. Nonetheless, while engaged in
clinical learning, Moridi et al. (2014) asserted that clinical learning may be stressful for
some nursing students, as they could face unpleasant experiences and feelings and have
ineffective interpersonal relationships with surrounding people. Consequently, it
becomes difficult for them to assume the different roles, while at the same time apply
theory into practice, which results in ineffective clinical learning experience.
Van der Zwet et al. (2011) attempted to capture the socio-cultural context in clinical
learning for medical students in the Netherlands. They found that students needed
developmental space so that they could learn and develop professionally. This space
results from the workplace context, personal and professional interactions and
individuals’ emotions such as self-confidence and feelings of respect. These forces
enhanced students’ clinical experiences. The culture of the clinical setting influences the
ability of nursing students to learn and develop positive attitudes towards the nursing
profession. Walker et al. (2013) contended that a positive culture in the CLE that
promotes quality depends on interpersonal relationships, an emphasis on learning, and
standard services. According to Hylin, Lonka, and Ponzer (2011), nursing students believe
that interpersonal relationships in the clinical setting are highly significant and that there
is need for emotional, social and psychological support as the students provide care. In
44
the absence of the aforementioned support, the quality of nursing care will decline,
nursing students will not learn effectively, and stress and fatigue will increase among
students (Moridi et al., 2014 ). Hence, it is evident that nursing students believe in a
welcoming clinical setting as a mark of quality.
D’Souza et al. (2015) assessed the effectiveness of the clinical learning environment
among nursing students in Oman and reported the positive association a supportive
relationship in the CLE has with the improvement of learning outcomes for nursing
students. In order for nursing students to work collaboratively with all health care
providers in the clinical learning environment, supportive relationships are vital because
negative or poor interpersonal relationships limit the students’ ability to provide routine
care only. Saarikoski et al. (2013) add that a culture of a supportive CLE gives nursing
students an opportunity to clarify any issue regarding the patients’ care, enhances
psychological functioning of students through alleviation of stress, and encourages self-
awareness through reflective practice. As a result, nursing students find fulfilment and
satisfaction in the CLE as it becomes easier for them to apply theory into practice (Chan,
2003).
2.5.3 Acceptance and belongingness
The level of acceptance and friendliness of staff can wield an impact on student learning
and perceptions. Familiarity of the surrounding environment is crucial in such cases. As
implied by Chuan and Barnett (2012), students and nurse teachers perceived the CLE to
be less learner friendly than staff nurses at the hospital. This could be due to staff nurses’
45
familiarity with their ward compared to students’ lack of familiarity due to constant
clinical rotation. In their exploration of the relationship between belongingness and
placement experiences of nursing students in Australia, Levett-Jones et al. (2009b)
suggested that the relationship between the staff nurse and the students can affect their
learning outcomes dramatically. They pointed to the importance of belongingness
because it has a direct influence on one’s cognitive functions, health and well-being,
emotional pattern and behavioural responses. In their narrative review to establish the
characteristics of leadership that influence clinical learning, Walker et al. (2011) reported
that the level of nursing student satisfaction with their clinical environment was poor
due to the poor interaction with staff nurses. They reported that only a few staff
members were willing to help students to learn while the rest were unapproachable and
hostile.
Intimidating behaviours and aggression in the CLE are among the most common
unethical practices that affect nursing students since most students may not know their
rights in the clinical setting (Bradbury-Jones et al., 2011). In the clinical learning
environment, nursing students can be left feeling powerless, thus susceptible to
unethical practices such as intimidation that prevent the acquisition of practical
knowledge and skills (Anthony, Yastik, MacDonald, & Marshall, 2014). In their study to
determine stress-inducing factors for nursing students during clinical training in Iran,
Moridi et al. (2014) concluded that the most tension-inducing factors included the
following: unkind emotions and feelings, the clinical environment, experiences in the
clinical setting, and interpersonal relationships.
46
2.6 Students’ satisfaction
Students’ satisfaction has been consistently considered to be an essential factor of a
“good” CLE (Moscaritolo, 2009), but it is a complex and multifactorial issue (Papastavrou
et al., 2016). Relevant studies have revealed positive links between students’ satisfaction
and the quality of nursing care, the ward’s pedagogical atmosphere and leadership style,
the sense of belonging, the peer support and the motivation level.
In their study conducted in Australia that describes the characteristics of effective clinical
educators, Lee, Cholowski, and Williams (2002) concluded that good role modelling,
supportive interaction with students and other demographics such as age and previous
experience, had a positive impact on their satisfaction levels. Another Australian study
aimed to explore nursing students’ experiences of clinical settings and found that
acceptance, learning and reciprocity, and accountability were three major elements in a
successful learning environment for nursing students (Ranse & Grealish, 2007). Further,
in their study to assess the satisfaction with and effectiveness of the clinical learning
environment among nursing students in Oman, D’Souza et al. (2015) concluded that
students’ satisfaction was highly significant and had a positive relationship with the
clinical learning environment sub-dimensions. These included the role of the nurse
teacher, the premises of nursing care on the ward, leadership style of the ward manager,
supervisory relationship, the premises of learning on the ward, ward atmosphere,
student satisfaction, staff-student relationship, staff nurse commitment, patient
relationship and hierarchy/ ritual. Finally and more recently, Papastavrou et al. (2016)
attempted to investigate nursing students’ satisfaction of the clinical settings as learning
47
environments and came to similar conclusions as D’Souza et al. (2015). They asserted
that a positive CLE reflected positively on students’ satisfaction and stressed that
students’ supervision and the relationships among the nursing students and nursing staff
or nursing nurse teachers were considered the most noteworthy elements for the
effectiveness of the CLE (Papastavrou et al., 2016).
The CLE is viewed as a vital component of nursing education and therefore, it has to be
well suited to both students’ perceptions and expectations (McDonald, Wiczorek, &
Walker, 2004). Most of the time, nursing students have reportedly felt vulnerable when
they are in the clinical setting (E. Papastavrou et al., 2010), and this could be either due
to the fact that students are learning how to apply theory to practice, or are concerned
about the attitudes of qualified nurses towards the care being provided. Hylin et al.
(2011) assert that nursing students find it difficult to distinguish between their
responsibilities as learners and as nurse workers. According to Hope et al. (2011), nursing
students in the United Kingdom (UK) are placed temporarily in a particular hospital unit
where they belong to a nursing team for a short duration, and usually students have
different expectations and goals from those of the clinical nurses. The nursing students
were found to experience difficulties adjusting to the clinical environment because they
were continually rotating from one unit to another, each with different expectations
concerning patient care. Therefore, nurse teachers and staff nurses should ensure that
the CLE is one that facilitates learning. This is possible through effective communication
between nursing students, staff nurses, and the nurse teachers, as well as availability of
the necessary resources (Cummins, 2009). Nursing students reportedly prefer a CLE
where they can interact freely with staff nurses who guide them in the clinical setting as
48
they grasp the concepts of providing quality care to patients through the application of
theory to practice (Newton, Billett, & Ockerby, 2009). While the National Association of
School Nurses (2015) support the significant importance of school nurse to student ratio
and its involvement in health, safety, and abilities to learn, there is no one-size-fits-all
workload to fill the increasingly complex needs of students and schools communities.
2.6.1 Effective Communication
Baglin and Rugg (2010) affirmed that effective communication among students, nurse
teachers and other health care providers was a predecessor to a quality CLE, because the
preparation of the CLE is the most difficult duty for the nurse teacher. As a part of a CLE
assessment, nursing students are often asked to provide their perceptions about the
clinical placements at the end of the learning experience. Carlisle et al. (2009) reported
that nursing students are usually stressed in the CLE when clinical nurses are not
informed about their arrival in advance, the students’ roles and responsibilities are not
outlined, and the expected outcome during the placement is unknown. According to
Levett-Jones et al. (2009b), health care providers are usually concerned when there is
ineffective communication amongst the nurse teachers, the nursing students and
themselves. When ineffective communication is evident, the CLE cannot be of sufficient
quality because it becomes hard to contact the nurse teachers, the nursing students
cannot be oriented to the clinical setting in the appropriate or effective manner, and the
students may not be in a position to know their clinical learning objectives.
49
For this reason, Van der Zwet et al. (2011) suggested there is a need for effective
communication in the CLE especially about the expectations of the nursing students, so
that clinical nurses will be in a position to assist them to achieve their objectives.
Effective communication processes between nursing students, clinical nurses and nurse
teachers is the hallmark of quality in the CLE and can be used to measure quality.
Baghcheghi, Koohestani, and Rezaei (2011) stated that in order for learning to take place,
students should interact with other health care providers and exchange relevant
information regarding how patients are cared for. Effective communication will ensure
that learning and teaching processes improve because the nursing students can clarify
their roles and responsibilities while at the same time the clinical nurse can give them
feedback about their performance (Barnett et al., 2010). Therefore, an effective
communication process between nursing students and other health care providers is an
indicator of quality clinical learning environments.
The CLE in nursing is an element that is presented as multidimensional and intricate
within a social context (Warne, Johansson, Papastavrou, Tichelaar, et al., 2010). Several
researchers have conducted studies about classroom learning and clinical learning and
this is discussed thoroughly in the literature. Nonetheless, learning in the clinical setting
is considered challenging for most nursing students when compared to classroom
teaching and learning (Mattila et al., 2010). In their study to explore students’
perceptions of clinical learning at one medical college in Saudi Arabia, A. AlHaqwi et al.
(2010) confirmed that the clinical learning experience can arouse feelings of anxiety and
students can be stressed, particularly in their interaction with patients. Killam and Carter
(2010) stated that the nurse teacher should be aware that anxiety and stress, which can
50
lead to burnout and fatigue among nursing students, are issues of particular concern in
the clinical learning environment.
Experiencing high levels of anxiety and stress during clinical education might ultimately
undermine students’ learning and success (Moridi et al., 2014). It is the role of the clinical
mentor to ensure that nursing students do not suffer from stress or anxiety by
addressing any causative factors through problem-solving processes (Ness, Duffy,
McCallum, & Price, 2010). Additionally, the nurse manager must assess the learning
environment and alleviate any negative factor such as poor communication processes
(Hylin et al., 2011). M Tomietto et al. (2012) argued that in order to provide a conducive
clinical learning environment, the nurse teacher, hospital staff nurses, students, and
patients should work collaboratively and respect each other’s autonomy and dignity. This
means that having good communication and collaboration between the personnel
involved in the clinical environment will ultimately result in providing an effective clinical
learning experience for students (Baghcheghi et al., 2011).
2.6.2 Collaborative Efforts
Baghcheghi et al. (2011) claim that a positive CLE is enhanced by collaboration amongst
students, clinical nurses and nurse teachers and in the presence of good collaboration,
the learning outcomes are better. Collaboration between the clinical setting and the
nurse education institution is essential in promoting quality in the CLE because each
party will be able to identify its scope as well as involvement in the clinical setting
(Warne, Johansson, Papastavrou, Tichelaar, et al., 2010). Saarikoski et al. (2013) add that
51
collaboration between the nurse teacher and clinical nurses is highly significant in
ensuring that the clinical mentors can obtain support regarding the management of
nursing students from the nurse teacher when the need arises. For instance, Newton,
Billett, and Ockerby (2009) reported that the nurse teacher could allocate the nursing
students to a clinical mentor who is expected to supervise them while they provide care
to the patients. In so doing, the nurse teacher is assured that the nursing students will be
able to meet their objectives in the clinical setting, since a qualified and experienced
nurse is guiding them. Furthermore, the nurse teacher may not need to be always
present in the clinical setting to supervise the nursing students. According to Moridi et al.
(2014), the aforementioned process of allocating a group of students to a clinical nurse
helps in reducing anxiety and stress in the working environment. This is because the
clinical nurse will not only induct the students into the clinical placement but also cater
for their physical, social and emotional needs.
According to Saarisko et al. (2002), the environment in which a nursing student does
his/her clinical learning needs to be both academically and mentally supportive of the
learning process. It is inevitable that a nursing student will at one time or the other,
during their clinical procedures and rounds, find themselves in a patients ward. This
requires the health practitioners in charge of the clinical setting to come up with
effective instructional methodologies that will enhance the nursing students’ learning
processes. Bezuidenhout, Koch, and Netshandama (1999) stated that the ward
administrators are responsible for ensuring that they are aware of every patient’s needs
and requirements. According to Newton and Smith (1998), after satisfactorily
ascertaining the needs of each patient, the ward manager then assigns different nursing
52
students to various placements according to how proficient they are. Some nursing
students can also spend some time with other health care personnel doing activities that
are beyond the scope of nursing practice, and by so doing, the nursing students will not
become competent in nursing issues once they qualify (Newton, Billett, & Ockerby,
2009).
As a result, it is through the effective leadership methodologies, as well as qualities of
the ward manager, that the nursing students will be able to achieve their academic
objectives in clinical learning (Papp et al., 2003). A. Henderson, J. Briggs, S. Schoonbeek,
and K. Paterson (2011) state that a successful learning environment is established
through effective management, proper leadership, and developing positive relations
with partners. In a clinical culture, such as the hospital, where practice is task oriented,
leadership is required to ensure that patient care is being delivered successfully. It also
encourages new methods of practice and establishes new learning opportunities.
Nursing leaders play an essential role in enabling staff members to build a learning
environment. To do this they need to develop the desired role-modelled behaviour that
influences the norms at their units in a positive way. This includes understanding
characteristics of quality learning environments and reflecting necessary behaviour for
staff to teach and learn (Davidson, Elliott, & Daly, 2006).
Walker et al. (2011) have commented that leadership exerts a huge influence on the
quality of clinical learning for undergraduate nursing students. Factors around leadership
have emerged to affect the process of clinical learning. These include the role of the
nurse manager, collaborations and relationships, role modelling, and transformative
53
standards. It is the management team’s responsibility to support successful interactions
and behaviours of staff who deliver direct patient care, to ensure bedside learning. Staff
need to be supported adequately within the clinical setting to help them achieve
productive interactions with others. Once they are prepared, staff are engaged in guiding
other students and novices (A. Henderson et al., 2011). Saarisko et al. (2002) state that
the ward manager should ensure there is a good working relationship between the
nursing students and themselves. This is fundamental since it will allow for the processes
of productive criticism and motivation which are very important if the nursing students
are to achieve their educational goals (Zilembo & Monterosso, 2008).
The students should be assisted in the process of amalgamating the theory learnt in class
with the practical skills required in the ward as well as other units in a medical
institution. Saarikoski et al. (2005) assert that the leadership style of the ward manager is
also very significant for the effective conduct of clinical learning. Nursing students
perceive the ward administrator as a very important resource person in their learning
activities. They can consult with the ward manager anytime that they encounter
unfamiliar issues in the ward. As a consequence, it is important that in their choice of
leadership styles, the ward managers make sure they are very approachable and
acknowledge and appreciate the efforts of the nursing students as well as any other
workers in the ward (Allan, Smith, & Lorenzon, 2008).
According to Dunn and Hansford (1997), the issue of decision-making in clinical wards is a
very important one for both practising nurses as well as nursing students. When they
encounter situations of which they are unsure and there is pressure on them to make
54
immediate decisions, the judgments of a nurse are usually determined by the socio-
cultural, financial, historical and the philosophical orientation of the clinical settings of
which they are part. It is therefore important, as stated by Vallant and Neville (2006), in
the processes of clinical learning, that nursing students are equipped with adequate
information about the application of the concept referred to as reflection in practice. In
addition to this, the philosophy of nursing in many health care institutions demands that
the nurses be able to effectively manage issues that affect the patients in the ward.
These include, for example, the administration of medication and assessment of whether
or not the patients are recovering from their varied medical conditions.
2.7 Clinical Supervision
In the clinical learning environment, learning opportunities can be provided by
simulation and role play (Hope et al., 2011). Such opportunities will help nursing students
reflect on the procedures that they have performed in the clinical setting. In addition,
the nurse teacher can combine face-to-face instructions with online mentoring so that
nursing students can access learning materials without any difficulties and consult the
nurse teacher at any time (McHugh & Lake, 2010). In spite of learning opportunities in
the clinical setting being beneficial to nursing students, supervision is required so that
the student can develop professionally and become competent in nursing practice
(Newton, Billett, Jolly, et al., 2009). Through supervision, the nurse teacher or the clinical
nurse can identify the areas where students are performing well and encourage them,
while at the same time correcting their mistakes. A clinical setting that values learning is
one that ensures that the learning environment is favourable for nursing students to
55
acquire knowledge and skills as they provide care to patients through application of
theory to practice. In such a clinical learning environment, there is a positive
interpersonal relationship between nursing students, health care providers and patients
(Baglin & Rugg, 2010), and it can be rated as being of high quality. The staff nurse and/or
nurse teacher ensure that nursing students are active participants in managing patients
and achieve the established goals and objectives (Barnett et al., 2010). In addition, the
nurse teacher is allowed to supervise the nursing students and evaluate their
performance while at the same time demonstrate the delivery of nursing care (Courtney-
Pratt et al., 2012).
Effective clinical supervision is essential in the CLE in order to ensure that patients
receive quality care, while at the same time assisting nursing students to develop
professionally (Moore et al., 2009). This calls for the formative, restorative and
managerial functions of a nurse supervisor, which McHugh and Lake (2010) affirm is
difficult to achieve, especially in the presence of a nursing shortage and high demands of
patients. In spite of the aforementioned challenges, Levett-Jones et al. (2009b) contend
that clinical supervision is imperative in promoting quality in the CLE since it ensures that
nursing students become competent upon completion of their clinical placement. A
number of authors, such as Henderson et al. (2010); Hope et al. (2011); Killam,
Montgomery, Luhanga, Adamic, and Carter (2010) have asserted that nursing students
from different countries including Canada, the UK and Australia report that clinical
supervision increases their satisfaction in the clinical setting. The reason is suggested that
because they are able to learn correctly and in the event of a mistake, they are corrected
accordingly. Edgecombe and Bowden (2009) posit that the supervisory relationship
56
between the staff nurse and the nursing students is associated with efficiency and
positive learning in the clinical setting. It means that the students are able to acquire the
needed skills and knowledge, while at the same time developing positive attitudes
towards the nursing profession.
Moore et al. (2009) state that supervision in the clinical environment is imperative
because it assists in identification and correction of any negative factors in the learning
environment and as a result, nursing students will provide care in a safe and supportive
environment. A positive CLE reportedly is one which does not predispose the nursing
students to stress, has a variety of learning opportunities, and students are ready to
learn because they are well prepared (Seeleman et al., 2009 ). In their study to explore
and compare nursing students’, staff nurses’ and nurse teachers’ perceptions of the
clinical learning environment in Malaysia, Chuan and Barnett (2012) concluded that all
groups valued the supervisory role. However, to minimise delays, staff nurses preferred
students to work “the hospital way” and therefore were less favourable to the
supervision role.
McHugh and Lake (2010) contend that a nurse teacher in a clinical placement does not
only supervise the nursing students, but also attends to patients and the needs of clinical
nurses. Furthermore, supervision in the CLE is highly recommended for the students
because if left unattended, they will engage in patient activities that will not assist them
to meet the clinical placement objectives (Mousa et al., 2012). Some nursing students
can also spend time with other health care personnel doing activities that are beyond the
scope of nursing practice, and by so doing, they will not become competent in nursing
57
activities once they qualify (Newton, Billett, Jolly, et al., 2009). Effective supervision in
the CLE helps nursing students to learn from the challenges they experience, because
they receive support from the staff nurse via discussion and feedback (De Witte et al.,
2011). Through supervision, a nursing student can ask for assistance in performing
difficult nursing procedures and as a result, the student will learn the needed skills.
Therefore, effective clinical supervision requires the development of a good
interpersonal relationship between the individual nursing student and their clinical
supervisor. Courtney-Pratt et al. (2012) reported that the development of effective
supervision depends on the attributes of both the staff nurse as well as the nursing
student. An effective supervisor should be competent in clinical practice, be organised,
have effective communication skills and be able to relate well with nursing students. On
the other hand, clinical supervision can only be effective if nursing students are
enthusiastic about learning, have positive attitudes towards nursing and can relate well
to the clinical supervisors (Courtney-Pratt et al., 2012).
2.7.1 Preceptorship and Mentorship
Students in the health care professions, such as nursing, traditionally gain practical
experience within clinical settings. There are expectations that students identify their
own needs and are self-directed in seeking skills relevant to their practices (Lewin, 2007).
Although ward-based hospital learning environments are fundamental to nursing
education and have multidimensional to characteristics, it has been argued that not all
practical settings can be positive clinical learning environments (Chan, 2002). This can be
due difficulties and struggles that may challenge the students during their clinical
58
learning (Mamchur & Myrick, 2003) and the possible unpleasant experiences they may
encounter (Moridi et al., 2014).
Although the primary responsibility of the staff nurse is the delivery of the highest
standards of nursing care to patients, as professionals, it is also their responsibility to
support the learning of other nurses (Courtney-Pratt et al., 2012). The term “mentor”
originates in Greek mythology where it referred to a wise older man who taught and
guided the young novice. Early research on mentorship, however, was focused on
business organisations in North America and in management contexts. Literature shows
that mentorship in nursing and midwifery has its origin in North America in the 1980s
and 1990s where it became a part of the educational language (Kilcullen, 2007).
However, E. Papastavrou et al. (2010) argued that after the application of the mentor
role in clinical setting in Cyprus as learning support, mentorship was considered
inadequate. Mentors were staff nurses who received a one-day preparation from the
nursing faculty to assist students during their clinical learning. However, due to the
ambiguous nature of their role, challenges in effectively fulfilling their roles as a
consequence of workloads, insufficient time, inadequate staff levels, primary patient
care responsibility, and lack of coherent training and support, mentorship did not meet
students’ expectations or outcomes. Levett-Jones et al. (2009b) added that this role
might have an adverse effect on the nurses themselves as the nursing climate is facing
the challenge of staff shortages, which is generally leading to increasing workloads and
stress on nurses. Therefore, supervising nursing students and providing support in their
clinical learning might be perceived as a burden and can cause reluctance from the
nurses’ side.
59
Preceptorship, on the other hand, has come to represent the process of “pairing new
graduates with an experienced nurse to facilitate role transition to that of a staff nurse”
(McCarty & Higgins, 2003, p. 91). In their paper to evaluate a preceptorship program and
determine its impact and sustainability, Marks-Maran et al. (2013), added that
preceptors in the UK provided individual attention to a novice’s learning needs by
enabling them to experience independent decision-making, time management and
setting priorities. Preceptors also maintain communication, when possible, with the
faculty regarding their students’ progress (Yonge, Billay, Myrick, & Luhanga, 2007).
Though the preceptorship is a short term relationship, it tends to focus primarily on the
development of students’ clinical competencies and involves some sort of judgment or
evaluation of their overall clinical performance (Sword, Byrne, Drummond-Young,
Harmer, & Rush, 2002). Therefore, preceptors hold a superior role to mentors in
teaching, advising, supervising and evaluating role with their preceptees. In this context,
it should be noted that nursing education in Saudi Arabia relies mostly on preceptorship
for facilitating students’ clinical learning. Saudi students in the clinical setting are assisted
by both staff nurses and nurse teachers (Omer et al., 2013).
The term Nurse Teacher (NT) describes the role of a qualified nursing teacher employed
by a nursing educational facility. A nurse teacher’s role is to assure integration between
theory and practice in cooperation with clinical placement (Johansson et al., 2010). The
theory-practice gap is the mismatch between what students have been taught and what
is being practised. This gap can be a common source of stress, confusion, and anxiety for
students. Students and new graduates reportedly find difficulties determining whether
to practise what they have learnt in class or what is practised in the ward (Chuan &
60
Barnett, 2012). Ness et al. (2010) discuss the many roles that nurse teachers have in the
clinical area. One of the most important in facilitating skills development in students is
that of a “role model”. Ness et al. (2010, p. 41) suggested that “being a role model
provides an observable image of imitation, demonstrating skills and qualities to
emulate”. Questioning skills, thinking aloud, debriefing, reflection, action planning and
problem-based learning are some of the techniques the nurse teacher can use to
highlight these skills to students (Ness et al., 2010).
According to Warne et al. (2010), another very important aspect of clinical learning is the
role of the nurse teacher. The functions of nurse teachers can be effectively grouped into
two broad categories: instruction and assessment. These two functions can be very
challenging roles to fulfil in an area of study such as nursing which involves the very
sensitive issue of preparing individuals to safeguard the lives of others. In addition, as a
part of the clinical faculty, it is critical to foster a supportive learning environment
conducive to students’ learning (Moscaritolo, 2009). To make students’ learning
experiences successful, collaboration between academics, the clinical setting, nurse
teachers and preceptors should be recognised by individuals involved (Papp et al., 2003).
The involvement of nursing students in clinical courses through teaching and learning
strategies such as mentorship seminars and peer review are also reported to give
students confidence to practice in the clinical environment (Walker et al., 2013).
Therefore, the nurse teacher needs to maintain a balance between practical assignments
and clinical work for students, because as Henderson et al. (2012) contend, it reduces the
levels of stress that are usually experienced by most nursing students while they are in
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the clinical learning environment. Clinical assignments should be in line with the learning
needs of the nursing students so that effective acquisition of knowledge and skills can
take place depending on the level of training of the student at that particular clinical
placement. Cummins (2009) claimed that in order to facilitate effective learning in the
clinical environment, the nurse teacher and preceptor should appreciate the fact that
each nursing student has a unique personality, which determines their ability to provide
care to patients, and the student should be treated as an individual. For instance, the
ability of a student to be either reactive or proactive in the management of patients
varies from one nursing student to another, meaning that some nursing students should
be closely monitored while others can work on their own with little supervision (De Witte
et al., 2011 ).
During the clinical learning process, nursing students are allocated to a staff nurse who
will guide students during the hospital placement. Tarrant, Sinfield, Agarwal, and Baker
(2008) defined the staff nurse as a clinical nursing expert with a specific role, working
together with patients and supporting them to be involved in, and if appropriate, make
their own treatment decisions. Literature implies the necessity of the staff nurse during
clinical placement due to their effective role on students’ development (Suise & Kane,
2010). The everyday routine where staff and students interact with each other is when
learning occurs in clinical settings. Students learn through observation and practice with
good role models, interacting with staff, who are willing to share knowledge and
productive feedback (A. Henderson et al., 2011). From her research to elicit nursing
students’ perceptions of the impact of mentorship on clinical learning in Ireland, Kilcullen
(2007) identified a range of roles of a mentor including socialisation, support in learning,
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being a role model, assessor, challenger, and being an expert in problem-solving. The
staff nurse also bridges the gap between theory and practice in patient health care (Suise
& Kane, 2010).
The availability of adequate resources in the CLE is imperative in ensuring that learning
takes place. Connell et al. (2011) asserted that the role of the nurse teacher is to ensure
that nursing students have all the needed materials and equipment that will help them
achieve their clinical objectives. The nurse teacher should not only explain to students
what is expected of them in the clinical setting but also put them in groups where they
can engage in reflection activities at the end of each work shift (Baeten et al., 2010).
Reflection helps nursing students to learn from each other and improve nursing care for
patients. Edgecombe and Bowden (2009) argued that reflection bridges the gap between
theory and practice because students are able to reflect on what they have learned in
the classroom, compared with the actual care in the clinical setting, and make
appropriate adjustments.
Nursing students can gain a placement learning opportunity when guided by a staff
nurse. These may include gaining knowledge and understanding of the nurse specialist’s
role, being part of multi-professional working setting, participating in the patient care
process, developing interpersonal and therapeutic communication skills, and developing
assessment and decision-making skills (Suise & Kane, 2010; Warne, Johansson,
Papastavrou, & Tichelaar, 2010). According to Lyth (2000), the preceptor is expected to
distribute duties and responsibilities to the students concerning the care of patients.
Moreover, the preceptor conducts procedures in the presence of students so as to guide
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and offer them constructive responses to any doubts they may have. In addition to
facilitating and evaluating their students’ clinical learning, preceptors also act as
counsellors and allies to their students, especially when the students have personal
transition or adjustment issues that they need an experienced person’s opinion to work
through (Dunn & Hansford, 1997).
Preceptor skills and the emotional support provided to the students have a significant
impact on students’ initial post-baccalaureate performance. However, by nature, the
preceptor relationship between nurses and students is ripe for conflicts and students
may face difficulties and interpersonal issues with their preceptors during the clinical
learning. “Conflict within a supervisory relationship can take many forms ranging from
mild tension to very extreme forms” (Mamchur & Myrick, 2003, p. 189). This can be due
to different reasons such as differences in personality or style, different expectations,
knowledge, experiences or world-view, work load and lack of preparations. Mamchur
and Myrick (2003) inferred that such a multidimensional relationship is hard to predict as
it may be present in different degrees, and can have different outcomes, sometimes
positive and sometimes negative. Conflict may result in positive personal growth for
both preceptor and student, achieved by productive acknowledgement and problem-
solving approach. Nonetheless, unresolved issues can result in disaster for both parties
leading to frustration and feeling disheartening (Mamchur & Myrick, 2003). Kalischuk,
Vandenberg, and Awosoga (2013) further state that without a positive relationship of
respect and mutual trust, it will be difficult for the preceptors to assist their students in
clinical learning. Since poor clinical experience can ultimately result in student
disillusionment about nursing and loss of the ability to integrate and learn, preceptors
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who experience conflict and have poor experience usually refuse to accept further
students (Mamchur & Myrick, 2003). Therefore, according to A. Henderson et al. (2011),
preparation of nurses to act as mentors is essential and is usually achieved though
workshops that are followed by opportunities to accommodate one another in both
personal and professional capacity while providing care to patients.
2.8 Conclusion
Clinical placement is a significant requirement in the nursing curriculum because it
facilitates nursing students to apply classroom theory into practice. This chapter has
examined literature around the nature of the CLE and support for students within that
context. In order to facilitate learning in the clinical setting, clinical nurses need to
promote a culture of quality so that nursing students can develop positive attitudes
towards the nursing profession. In addition, maximisation of involvement of nursing
students in the management of patients in the clinical setting is fundamental in ensuring
that appropriate learning takes place. Therefore, nurse teachers and clinical nurses
should ensure that nursing students are actively involved in the proper management of
patients in the clinical learning environment. The review has highlighted a lack of studies
around clinical learning in nursing conducted in Saudi Arabia, which is the context for this
analysis. The next chapter describes the methodology underpinning the current study.
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Chapter Three: Methodology
3.1 Introduction
The previous chapter examined the available literature on the clinical learning
environment associated with nursing education. Despite very different clinical practice
settings, little research has been conducted in Middle Eastern contexts, and specifically
in Saudi Arabia. Hence, the current study sought to rectify that dearth of research, and
provide evidence to inform nursing education in that country.
The overview of literature around the proposed topic, and the emergent distinct gap in
what is known about nursing students in clinical settings, provided a significant impetus
for shaping the study, to compare and contrast with other settings from other disciplines
or other countries. This chapter presents the methodology developed for the current
study. A mixed methods research design was selected to explore the CLE from the
perspective of Saudi Arabian nursing students. The use of mixed methods research
utilised in this study, and its qualitative and quantitative approaches are discussed, as
well as the research settings, ethical considerations, participant recruitment and general
description of the sample.
3.2 Research Objectives
The purpose of this current study was to explore the quality of clinical education and
clinical learning environments experienced by nursing students in Saudi Arabia. It also
sought to identify factors affecting students’ learning outcomes, how they viewed their
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learning experiences and their satisfaction with their clinical learning environments. It is
anticipated that outcomes from this study will result in recommendations associated
with the improvement of nursing clinical education in Saudi Arabia. Additionally,
reflection on Saudi nursing students’ needs and demands to achieve more satisfactory
clinical learning experiences and outcomes will guide recommendations.
In order to explore the nature of clinical learning for Saudi nursing students, the study
sought to answer a series of research questions, these being:
What is the quality of clinical education in the nursing undergraduate curriculum
in Saudi Arabia?
What are the factors within the CLE that might affect students’ outcomes?
How satisfied are nursing students with the provided clinical education?
How can clinical education be improved in the nursing curriculum in Saudi Arabia?
These questions were aimed at examining the theory or assumption that factors within
the CLE can affect students’ clinical learning outcomes. A comprehensive reading on, and
critique of, study philosophies was used to determine the appropriate research
approach.
There are many types of research approaches. Simmons (2010, p. 29) pointed out that
the type of research to a large degree determines the methods that can be employed to
answer the research questions. An analysis of different types of research such as
descriptive versus analytical, applied versus fundamental, quantitative versus qualitative,
and conceptual versus empirical, among other types, shows that there are three main
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research approaches: quantitative, qualitative (Polit & Beck, 2008) and mixed methods
(Creswell & Clark, 2011). These approaches influence the choice of research design, data
collection methods, data analysis, and data interpretation. Quantitative research
methods involve generating data in numerical or statistical form, and performing analysis
using specific quantitative data analysis techniques (Osborne, 2008). On the other hand,
qualitative approaches involve the subjective evaluation of attitudes, behaviours and
opinions, so as to give the researcher pertinent insights and impressions into the topic
under investigation (Ritchie, Lewis, Nicholls, & Ormston, 2013). A mixed methods design
was considered to be an appropriate approach which by utilising both qualitative and
quantitative methods, provides an holistic understanding of the topic, as well as enabling
robust results to provide rigour. This last point has been emphasised by Creswell (2013).
3.3 Mixed methods methodology
3.3.1 Research Philosophy
Over the last decade, mixed methods research has become an increasingly recognised
approach, especially in nursing research (Sandelowski, 2014). Mixed methods is a
research methodology with a unique philosophical assumption and technical methods of
inquiry (Creswell, 2013). In mixed methods, multiple approaches that may be qualitative,
quantitative or a combination are utilised together in a single study or series of related
studies (Bisholt, Ohlsson, Engström, Johansson, & Gustafsson, 2014). Some researchers
may focus solely on the technical challenges of mixed methods research. This leads to a
view of quantitative methods as simply for collecting and analysing numerical data and
qualitative methods as simply techniques for collecting and analysing non-numerical or
68
textual data (Bisholt et al., 2014). However, according to Creswell and Clark (2011), the
fundamental principle of mixed methods research states that it is beneficial to collect
multiple sets of data using different research approaches. Yet, mixed methods research
is argued to be understood less as a new mode of inquiry than as a discursive re-
packaging of the combinations of already existing theoretical methodologies
(Sandelowski, 2014). Focusing exclusively on the technical approach of the research
design will foster uncritical and un-reflexive practices, resulting in poor quality research
that undermines the potential of mixed methods (Bisholt et al., 2014). Proper integration
of both methods provides more insight, validity and understanding to a study that might
be missed when using a single method (Polit & Beck, 2008).
Qualitative researchers attempt to interpret phenomena, using different approaches to
considering the meaning people attest to them (Creswell & Clark, 2011). Qualitative
research examines issues, events or phenomena based on the thoughts, feelings, and
experiences of people (Denzin & Lincoln, 2012). Since reality is socially constructed, each
individual may assign different meanings to events based on their own personal
understandings (Simmons, 2010, p. 93). Given this framework, the meanings people
attribute to events become stories and may have real effects on people’s lives; in fact
they shape their experiences (Denzin & Lincoln, 2012). Consequently, it was identified as
being beneficial for this study to add a qualitative component because it focuses on
processes and meanings that were unquantifiable.
On the other hand, quantitative research encompasses the use of logical positivism in
investigational methods and quantitative measures to investigate hypothetical
69
generalisations (Leedy & Ormrod, 2010). It measures and examines information based on
measurements such as quantities, frequencies and intensities. It stresses causal
relationships between different variables (Patten, 2012). In such a model, the focus is on
specifics and causes of behaviour and the information is in the outline of numbers that
can be quantified and summarised. By and large, quantitative research views the world
as being comprised of discernible, measurable facts (Creswell & Clark, 2011). Due to its
unique objectives, adding a quantitative component to this research was important.
While Creswell and Clark (2011) contended that only mixed methods research can
address diversity and complexity in behavioural, health, and social sciences, Sandelowski
(2014) argued that using mixed methods research does not necessarily result in
improved research outcomes, because multiple and diverse methods do not
automatically equal good science.
3.3.2 Strengths and weaknesses of mixed methods approaches
The philosophical issues around mixed methods research arise from the fact that
quantitative and qualitative approaches have different philosophies (Bisholt et al., 2014).
While qualitative approaches are conventionally linked with constructionist or
interpretive epistemologies, quantitative approaches are conventionally linked with
positivist or more recently post-positivist epistemologies (Creswell, 2013; Mengshoel,
2013). While interpretivists seek to gain an understanding of human behaviour and the
world, a positivist explains the situation (Denzin & Lincoln, 2012; Mengshoel, 2013).
70
Firstly, interpretive epistemology suggests that only through the subjective
understanding of, and intervening in, reality is the only way the reality can be
understood. The study of the problem in its environment is important to the
interpretivist, together with the agreement that researchers cannot avoid changing and
affecting the problem they study (Welman, Kruger, & Mitchell, 2006). Subjectivity and
bias is key to interpretivists; furthermore, people within the study population are an
important element in an analysis and are constantly changing. So studying the
environment alone without the individuals is not applicable (Walsham, 2006). Overall, it
was believed that an interpretivist approach was crucial to the study questions given its
inductive nature; deductions and conclusions were to be made after collection and
critical analysis of in-depth data (Ritchie et al., 2013).
Positivists, on the other hand, claim that reality is constant and can be seen and
highlighted from an objective view without changing or interfering with the study or the
problem being analysed (Walsham, 2006). Positivists argue that the problem should not
be interfered with and that the observation can be repeated. This deals with changing
realities, with variations in a single variable that is independent, in order to identify how
it is affected and to create relationships between other variables (Osborne, 2008).
A study philosophy underpins how data relevant to the study is collected, sorted,
analysed and implemented. Considering the objectives of the study, a mixed methods
approach was used in collecting data. While the researcher was aware of the possibility
of fragmentation that such an approach could bring, this research was constructed
within a context that, while agreeing that there may not be one single variable affecting
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the issue being studied, assumptions are made within the broad categories. Further,
while pragmatism can be interpreted as simply choosing the appropriate method to
achieve research aims at a practical level, it can provide further perspective at a
philosophical level. It can view qualitative and quantitative methods as distinct and yet
commensurate since both are means of knowledge production that derived their value
from the research (Yardley & Bishop, 2015). From this context, to avoid issues of
application, the researcher in this study was equipped about this method to make
decisions on proper integration between the qualitative and quantitative components of
the mixed methods research (Yardley & Bishop, 2015).
So far, the descriptions of reliability and validity in quantitative research disclose that in
regard to reliability, the results should be replicable, and in regard to validity, the means
of measurement should be accurate and actually measure what they are intended to
measure (Morse & Niehaus, 2009). However, it is important to note that these are
viewed differently by qualitative researchers, who strongly consider descriptions in
quantitative terms as inadequate (Leech & Onwuegbuzie, 2009). In other words, these
requisites as defined in quantitative terms may not be applicable to qualitative research.
The issue of reliability in the results is of no concern to them, but precision, credibility,
and transferability provide the framework for evaluating the results of qualitative
research. In this perspective the two research approaches are for all intents and
purposes completely different paradigms (Polit & Beck, 2008).
There is a misconception that strengths and weaknesses of both qualitative and
quantitative research approaches would offset each other in mixed methods research.
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Rather, it is the researcher who will decide on the necessity of combining approaches
appropriate to meet their research objectives and further judge on its strengths and
weaknesses (Sandelowski, 2014). An appreciation of the deeper differences between
qualitative and quantitative methodologies can help avoid such pitfalls and better
maximise the potential of qualitative and quantitative components and their
combination (Yardley & Bishop, 2015). In the next section, the different types of mixed
methods are outlined and rationales for the choice of approach are discussed.
3.3.3 Discussion and Rationale for Choice of Approach
This research study was mainly aimed at analysing and assessing the quality of clinical
learning in the Saudi Arabian nursing curricula, by measuring and understanding
students’ experiences and satisfaction with their clinical setting. It also sought to provide
an improved understanding of factors within the clinical settings that affected nursing
students’ outcomes, and understand the plausible relationships among the components
of the research. This research also aimed to allow comparisons to be made with previous
research undertaken in other contexts around the quality of nursing curricula. The
research aimed to acquire an insight into the problem and propose further
recommendations for future research.
According to Johnson and Christensen (2004), the fundamental principle of mixed
methods research is its benefit in collecting multiple sets of data using more than one
approach, to produce results with corresponding strengths and with minimal errors. In
73
their book, Creswell and Clark (2011) introduced four designs for mixed methods
research exploratory, explanatory, triangulation, and embedded designs. Timing and
emphasis are major key differences between these designs. With reference to timing,
Yardley and Bishop (2015) explained that exploratory and explanatory designs are
sequential where the first research component is completed before the second begins.
Triangulation and embedded designs are concurrent in that qualitative and quantitative
components are typically undertaken simultaneously. For the design’s emphasis,
Creswell and Clark (2011) stated that exploratory designs devote greater resources and
weight to the qualitative component, while explanatory designs emphasise more on the
quantitative component. Further, triangulation designs tend to weight components
equally, while embedded designs emphasize either the qualitative or the quantitative
component. Creswell (2013) further explored the types of mixed methods approach to
include the following: explanatory sequential design, exploratory sequential design,
embedded design, and convergent parallel mixed methods design. Explanatory
sequential design uses a qualitative approach to explain quantitative findings, whereas
exploratory sequential design does the opposite to generalise qualitative findings to a
larger sample. Further, embedded design uses different types of data by embedding one
approach into the other to answer different questions. Lastly, convergent parallel mixed
methods design, is the one chosen for this research (Creswell, 2013).
Convergent parallel mixed methods design is appropriate when using different methods
to confirm that the obtained results are of greater applicability for a diverse population.
In the convergent parallel mixed methods design, different methods are used to
74
complement each other using both quantitative and qualitative data collection and
analysis related to the same dimensions occurring simultaneously (Andrew & Halcomb,
2009). As shown in Figure 2 below, data are collected concurrently, analysed
independently, and then the results are merged for a general interpretation (Creswell &
Clark, 2011). The results of both are usually compared and confirmed, resulting in either
convergences or divergences in the results.
Once the convergent parallel mixed methods design framework was chosen for this
study, the next step was choosing methods of data collection. In this study, data
collection was divided into two phases; both parts of the study were of equal weight and
data collection and analysis of both phases were undertaken during the same time
period. Phase one involved distributing and analysis of the questionnaire using previously
validated tools; and phase two involved conducting semi-structured interviews with
selected participants from the same sample as phase one to further understand the
phenomenon under investigation, that is, students’ perspectives of their CLE. Later,
Quantitative data
collection and analysis
Qualitative data
collection and analysis
Compare or
relate (Point of
Interface)
Interpretation
Figure 2 Convergent parallel design
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interpretations of results from phases one and two were undertaken, and finally these
were integrated to achieve overall understandings. In the following section, sampling,
recruitment of participants and the ethical considerations are discussed.
3.4 Recruitment Procedure
3.4.1 Sampling
Sampling is a procedure of selecting an adequate number of elements from the whole
population that has been selected for research, so the study and understanding of the
features of the sample will enable the researcher to simplify such features or description
to the population elements (Kumar, 2011). It is worth emphasising that a study’s
research objectives and characteristics of the study population, such as size and diversity,
determine which and how many people to select (Mack, Woodsong, MacQueen, Guest,
& Namey, 2011). In the upcoming sections, sampling, the process of recruiting
participants for this study and research settings are discussed. The inclusion and
exclusion criteria applied in the recruitment process will also be examined.
In phase one of this study, which was the quantitative component, a convenience
sampling technique served to determine the participant group who were undergraduate
Saudi Arabian nursing students. Sampling involved a collection of subjects who were
accessible and willing to complete the questionnaire. Convenience sampling technique
was chosen because it increases effectiveness and efficiency as there is homogeneity
across the whole study population (Creswell, 2013). The method was also chosen to
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increase accuracy by reducing most causes of estimation bias. To make an accurate
inference, sampling errors were avoided. Sampling errors are basically understood as the
degree by which a single sample varies from all the other samples in the target
population (Leech & Onwuegbuzie, 2009).
In phase two of this study, which constituted the qualitative component, purposive
sampling was used, where participants were chosen according to preselected criteria
that will be listed in the upcoming sections of the chapter. In this type of sampling,
sample sizes may or may not be fixed prior to data collection and depend on the
resources and time available (Mack et al., 2011). Recruitment processes are covered in
more detail within detailed descriptions of each phase of the study.
3.4.2 Research Settings
For the purpose of having a range of variety of data, a cross-sectional sample of second
and fourth year nursing students from three nursing faculties at two cities in Saudi
Arabia were included. These nursing faculties ranged between governmental and private
facilities. They had a range of access to governmental, university and private hospitals for
clinical learning. An invitation letter was sent to the target nursing faculties to acquire
approval to invite nursing students to participate in this study. Due to cultural
restrictions, this study included female nursing students only.
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3.5 Sample Criteria and Invitation
3.5.1 Inclusion Criteria
For the purposes of this study the participants were required to meet these criteria:
Female Saudi undergraduate nursing student.
A second or fourth year student in nursing.
Had clinical experiences in a hospital clinical setting.
Had a clinical experience in a minimum of one clinical placement of the following
wards: medical, surgical, maternity, paediatrics, and oncology.
The justification for the student year level was that in the Saudi nursing curricula, second
year students experience nursing clinical practice in hospital settings for the first time
(King Abdulaziz University, 2015). Furthermore, fourth year students were chosen in
order to measure the change of perspectives and views towards clinical learning
compared to their experiences from previous years of study.
3.5.2 Exclusion Criteria
Participants were excluded from this study if they met any of the following criteria:
Non-Saudi students.
Male undergraduate nursing student.
A first or third year student in nursing.
Undergraduate students from disciplines other than nursing.
Nursing students with no clinical experiences in a hospital clinical setting.
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Nursing students with no clinical experience were excluded because they were
considered unlikely to be able to adequately reflect on the quality of the CLE at their
faculties or hospitals. Faculty and hospital staff were not involved directly in this
research.
3.6 Data collection
Data collection for this study had two phases which were applied in the same time
period using two different approaches.
3.7 Phase One: Quantitative Survey
A quantitative component measures how respondents act and think in a specific way and
how many do so. Structured questionnaires are usually used including closed questions
that already have set responses (Welman et al., 2006). A researcher relies on numerical
data to gain insights into relationships emerging from the data. The researcher used
post-positivist theories for developing information, such as hypotheses and specific
questions, cause and effect thinking, use of measurement and observation, reduction to
specific variables, and the testing of theories. This study used questionnaires in phase
one to gain numerical data to analyse the problem, and specifically to address the first
three research questions, that is:
What is the quality of clinical education in the nursing undergraduate curriculum
in Saudi Arabia?
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What are the factors within the CLE that might affect students’ outcomes?
How satisfied are the nursing students with the provided clinical education?
Questionnaires are the most common and relatively inexpensive tools for collecting data
and are easy to administer. A well-designed questionnaire is a valuable tool in the
collection of information from unlimited respondents. The questionnaire is understood
as a multi-stage process that begins with defining the questions under study, and ends
with the interpretation of results (Simmons, 2010). Thus, in the design of the research
instrument, the objectives, sample, appropriate questions, and desired findings were
taken into account. Basically, closed questionnaires are used in collecting data for
quantitative analysis aimed at determining underlying patterns and trends (Churchill &
Lacobicci, 2010). Closed questions eliminate uncertainty and ambiguity, while enhancing
reliability and validity of the data collection process. In this study, a previously validated
tool was adopted and was directly implemented in the research.
In this phase, the questionnaire used was divided into three parts (Appendix G). Part one
included the participants’ socio-demographic details. This information included the
following: age, year level, types of organisations involved, and students’ previous clinical
experience details. Part two included questions to measure the quality of CLE
experienced by participants. The Clinical Learning Environment and Supervision
Evaluation (CLE+T) was used. This scale was adapted from Saarikoski et al. (2008) who
previously reported a Cronbach's alpha value of 0.95. A Cronbach's alpha value of .947
was calculated by the researcher. For the purpose of this study and to avoid
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misinterpretation and misunderstanding, a professional translation office in Melbourne,
Australia was used to translate and provide an Arabic version of the questionnaire.
A number of studies have utilised the CLE+T tool. Johansson et al. (2010) suggest that the
CLE+T evaluation scale had been used in several universities across Europe, including
theirs in Sweden, as part of quality assessment and evaluation of nursing education. In
their study, nursing students from three university colleges were involved. The
researchers concluded that the scale was deemed sufficient and had the satisfactory
psychometric properties useful to measure the quality of nursing education.
Furthermore, in the neighbouring country of Norway, Skaalvik et al. (2011) measured
nursing students’ experiences and satisfaction with their clinical learning environments.
Their interest lay in comparing the results between clinical practice in nursing homes and
hospital wards. They concluded that working with older people was the least preferred
area of practice. However, Johansson et al. (2010) suggested that further investigation
was required to further develop and evaluate the questionnaire.
M. Tomietto et al. (2012, p. B1) described the CLE+T evaluation tool as “the gold
standard to assess a good clinical learning environment”. Their study involved Bachelor
degree students in nursing in three universities in Italy and the subsequent results
enabled an international debate concerning the theoretical structure of CLES+T. It has
proven to be a reliable and valid tool for the comparison of supervisory models in guiding
nursing students' clinical learning with a Cronbach’s alpha of .95. Furthermore, a wider
scale study aimed to merge students’ perceptions at different organisational levels.
Tomietto, Comparcini, Saarikoski, Simonetti, and Cicolini (2014) conducted a cross-
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sectional multilevel design involving three Italian universities, six hospitals and seventy-
three individual wards with highlighting a Cronbach’s alpha coefficient of 0.95. They
concluded that the clinical learning environment was indeed a multilevel phenomenon
and had multidimensional aspects that if further investigated could enhance research
development in this field of studies. Lastly and most recently, Papastavrou et al. (2016)
investigated nursing students’ satisfaction of the clinical settings as learning
environments using the same tool with undergraduate nursing students from the three
universities in Cyprus. Participants in their study were found to be highly satisfied with
their clinical settings. All constructs related to clinical learning environment in the tool
with scales’ Cronbach’s alpha values ranging between 0.82 and 0.96.
The CLE+T questionnaire has 34 items that target five factors in the clinical environment
(Saarikoiski, Isoaho, Leino-Kilpi, & Warne, 2005). These include the following: supervisory
relationship (SR), pedagogical atmosphere on the ward (PA), the role of the nurse
teacher (NT), leadership style of the ward manager (WM), and the philosophy of nursing
in the ward. Each question had its own purpose and specific meaning. The questions
were made to be quick and easy for respondents to complete. The responses to the
questionnaire are classified using a five-point Likert scale where 1 indicates strong
agreement to 5 indicating strong disagreement (see Appendix A).
Part three of the questionnaire incorporated structured questions developed and added
by the researchers to elicit further information. Six open-ended questions were used to
give the respondents the chance to present information that they may have missed in
the closed-ended questions but that they wished to express. These questions permitted
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participants to give their thoughts and suggestions regarding clinical learning. Questions
included students’ values and experiences of their clinical learning, as well as
recommended remarks to enhance their clinical practice experiences (see Appendix A).
3.7.1 Data Collection
After approval to conduct the study was provided by the university human research
ethics committee and each of the heads of the three nursing faculties involved,
participants who met the research criteria stated earlier could be recruited into the
study. This invitation was initially made by placing information posters on notice boards
in all of the selected nursing faculties (Appendix B).
Following discussion with the nursing faculties’ heads of department, an arranged time
and place within the faculty was provided to give a brief presentation to second and
fourth year nursing students who might be interested in participating. The aim of the
presentation was to inform the students of the study’s objectives and to recruit
participants. A written Explanatory Statement was provided that outlined the study and
what participation entailed (see ). Interested students were then invited to complete the
questionnaire. Time was provided by the nursing faculties to meet their students in one
of their classrooms without their lecturer being present. A total of one hundred and
twelve questionnaires were disseminated by the researcher herself to undergraduate
nursing students from the three different universities. All of these were completed and
returned on the spot.
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3.7.2 Data Analysis
Questionnaire: Parts one and two
The questionnaire data collected in this study were entered and analysed using SPSS
version 23.0 (IBM Corp., 2015). Quality control was completed at this stage of data
reduction, which involved coding the responses of the questionnaire items, choosing the
procedure to be taken regarding missing data and entering completed data to the
programme for analysis. There was a low number of missing values in the completed
questionnaire, and to avoid errors in statistical analysis, missing data was statistically
excluded by pairwise exclusion (Pallant, 2011).
In phase one, the questionnaires were used to determine, evaluate and identify the
quality of CLE for nursing students in Saudi Arabian hospitals and nursing faculties. The
data analysis conducted included descriptive analysis and inferential technique.
Descriptive analysis, in the form of frequencies, percentages and means, was used to
describe the demographic data and explore the levels of students’ satisfaction with their
clinical learning environment. Quantitative continuous data were compared using t-tests
for comparisons between two groups and analysis of variance (ANOVA) for comparisons
between more than two groups by analysing comparisons of variance estimated. ANOVA
tests were used to identify and explore the factors that influence students’ satisfaction
and examine mean group differences in the study.
The reliability of the final questionnaire was estimated with a Cronbach’s alpha of 0.947.
Taking into account the data deviation from normality, non-parametric inferential
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statistics were selected. Inferential statistical analyses were conducted to examine
demographic or independent variables of the study. It also helped making a sophisticated
assumption from the data obtained to figure out what the population might think. Thus,
inferential statistical analysis can be used to make general inferences from the data,
whereas descriptive statistics describe what is happening in the data (Trochim &
Donnelly, 2008). The correlation analyses between the students’ satisfaction and the five
constructs of the CLE were conducted with Pearson bivariate correlation coefficient.
Questionnaire: Part three
General open-ended questions offer a number of benefits as they can assist the
researcher to include all associated issues, especially when added to surveys. It is
suggested that by doing so, it will provide statements or quotes to illustrate interesting
and pertinent ideas that make a purely statistical statement more interesting (Chambers
& Chiang, 2012). For data from this study’s open-ended questions, analyses were
undertaken using a content analysis technique to identify relevant responses and
commonality in responses between the different answers to the open-ended questions
(White & Marsh, 2006). Munhall (2007) observed that content analysis may be a
standard method for studying responses to open-ended questions. Content analysis
refers to a number of different strategies used to systemically and impartially analyse
text (Vaismoradi, Turunen, & Bondas, 2013). Content analysis is defined as “a process of
identifying, coding, and categorizing the primary patterns in the data” (Chambers &
Chiang, 2012, p. 1115). Additionally, in content analysis, large amounts of textual
information are condensed into smaller categories using specific rules of coding
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procedure to determine trends and patterns of words used, their relationships, their
frequency and the structures and discourses of communication (Chambers & Chiang,
2012; Vaismoradi et al., 2013). In this respect, information indicated in the open-ended
questions part of the questionnaires in this study were analysed on the basis of their
contents. Information with similar themes or ideas was grouped together for easier
identification. Neuendorf (2011) identified six major variables that should be decided
prior to conducting content analysis. These include: theory used in analysis, scope of the
data collection, past research and measurement, population, involvement and coding.
According to Hsieh and Shannon (2005), there are three major approaches to content
analysis including conventional, direct and summative content analysis. This study used a
summative approach to qualitative content analysis. The process started with identifying
and quantifying words based on the frequency of participants’ answers to a question in
order of majority (see Table 16). The purpose is to provide basic insights into how words
are actually used and later classify them into themes. According to Hart, Smith, Swars,
and Smith (2009) quantifying data includes transforming original qualitative data into
numerical counts that can be statistically analysed. However, quantification is an attempt
not to infer meaning but rather, to explore usage (Vaismoradi et al., 2013). After
quantifying the content of the text, latent content analysis is applied. Hsieh and Shannon
(2005) referred to latent content analysis as the process of interpretation of content
where the focus is on discovering underlying meanings of the words or the content.
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3.8 Phase Two: Qualitative Interviews
During the interviews process the researcher seeks to understand how respondents feel
regarding a particular situation, issue or experience (Denzin & Lincoln, 2012). Individual
or group interviews are two common types of data collection. Through this means of
data collection, the researcher makes intuitions based on the constructivist (Walsham,
2006) or participatory (Munhall, 2007) perspectives. In a qualitative study, data is
acquired from those immersed in the everyday life of the setting in which there is a
research interest. This study used face–to-face interviews from those involved, that is,
nursing students in Saudi Arabia. Since reality is socially constructed, each individual may
assign different meanings to events based on their own personal understanding
(Simmons, 2010). Offering a richly described narrative will provide a more concise, vivid
understanding of the research topic. In addition, qualitative research would be the best
method to employ when there is a focus required on the socially constructed nature of
reality. This mode of inquiry seeks to find what an experience is like for a particular
person and to get inside the meanings they draw from that experience based on their
reality. The researcher was able to capture the essence of the participants’ social
environment through the language they used as well as their points of view (Denzin &
Lincoln, 2012).
In this study, open-ended semi-structured interviews were used (Appendix H). These
sought specifically to address the second to fourth key research questions, that is:
What are factors within the CLE that might affect students’ outcomes?
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How satisfied are nursing students with the provided clinical education?
How can clinical education be improved in the nursing curriculum in Saudi Arabia?
These were considered a useful tool for ensuring that the research reflected the current
situation of the Saudi nursing students and their CLE. Interviews enabled the students’
experiences in the topic to be captured in their own words, and in this way provide rich
data and obtain detailed understandings. Data from the interviews were later integrated
with data from the questionnaire and open-ended questions to provide clear
understandings of the issues and hence, provide evidence to enhance the overall
reliability of the findings. Interviews included asking students general questions about
their clinical learning experiences. They also explored topics of specific incidents and
reactions related to students’ study progress, along with participants’ preferences and
backgrounds that might affect them as nursing students and their choice of study. It also
looked at their encounters in the hospital during clinical placements with other staff,
colleagues and peers from other disciplines. Participants were encouraged to express
them freely as they were assured of complete confidentiality prior to starting the
interview (see Appendix H).
Semi-structured interviews were selected because they provide a few key questions but
allow flexibility in the interview process. Also, the involvement of the researcher with the
participant, provided further information that could be gathered by looking at non-
verbal communication like body language, facial expressions, and gestures (Kothari,
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2004). Interviews enabled the interviewer to get more information by probing further,
thus acquiring more accurate and relevant information through learning from the facial
expression and other non-verbal gestures of the respondents (Kumar, 2011).
3.8.1 Data Collection
The same sample from phase one were invited to participate in an audio-recorded
interview with the researcher. Those who were willing to take part were asked to leave
their contact details in a separate document to the questionnaire. Nine students
indicated interest in participating. Later, arrangements were made to meet and interview
them at a time and place of their convenience. Prior to conducting the audio-recorded
interview, each participant was asked to sign a consent form (Appendix E) which
indicated their voluntary participation. Each interview lasted up to one hour and was
conducted in Arabic language. Data saturation was reached after the ninth interview;
where no new data emerged and the information gathered was sufficient to explain
initial results from phase one.
Interviews may be appropriate but they are also costly and time-consuming (Bechhofer &
Paterson, 2010). One major obstacle encountered by the researcher during this phase
was the geographic limitations. Given that the participants for this study came from
three different locations in two different cities, extensive travel was needed to meet with
participants. In Saudi Arabia this can be particularly difficult for females. Hence the study
locations were limited to three universities.
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3.8.2 Data Analysis
While transcribing the recordings in the Arabic language, the researcher carefully
reviewed each interview to ensure that the transcription was accurate. All transcripts
were then translated into the English language by a professional translation office in
Melbourne, Australia. The researcher then carefully revised and compared the
translations with the original interview transcriptions to ensure that the translations
were correct and that meaning had not been lost or altered in the translation.
Thematic analysis was used for the purpose of supporting the questionnaire results.
Thematic analysis is the method of encoding qualitative information and is used to
identify what and how frequently perceptions occur in text (Guest, MacQueen, & Namey,
2011). Common textual words and phrases were gathered to identify the main themes
for each question. According to Minichiello, Aroni, and Hays (2008), thematic analysis
procedures are suitable for analysing qualitative data and to identify themes emerging
from analysis of interview transcripts. Declarations made by participants, which are
essential to the participants’ perceptions and experiences and are considered relevant
for the study, were tracked and compared through a process of coding and analysis
(Creswell & Plano Clark, 2011). There were nine formal questions and one open question
for participants to add further points. The responses were analysed individually to
identify common words and phrases. The questions required respondents to comment
on their experiences of the current clinical learning in the hospitals involved in the study.
The respondents were then given the opportunity to add other comments (Appendix D).
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Common statements were used to generate themes that represented the perceptions of
the participants. The statements were clustered into categories. These categories are
presented as part of the findings. To support theme generation and an in-depth
understanding of the experiences and perceptions of the participants, textual data in the
form of literal examples from the interview discussions are included in the report to
highlight the key common themes. Finally, conclusions of the analysis were provided by a
comprehensive review and interpretation of the data in the form of principal themes
(Minichiello et al., 2008).
3.9 Ethical considerations
The research study and all its aspects were based on ethically sound foundations and
complied with the Australian National Statement on Ethical Conduct in Research
Involving Humans (National Health and Medical Research Council, 2007). Approval for
undertaking the research project including the methodology used for data collecting, was
obtained from the Monash University Standing Committee of Ethics Research in Humans
in 2012, reference number: CF12/0196–2012000061 (Appendix F), from the sponsoring
organisation (Appendix G) and from targeted nursing faculties (Appendix H).
The researcher recognised the importance of confidentiality, anonymity, protection from
discomfort and the human rights of the participants. As such, participants (nursing
students) received an explanatory letter outlining the aims of the study and explaining
that the project involved filling in questionnaires and participating in an interview.
Further, informed consent was provided by participants prior to taking part in the
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interviews to conclude participation was voluntary and that they could refuse to take
part in the research without penalty. No gifts or payments were made to the students in
exchange for their participation.
Ethical concerns always take priority when conducting research, especially where the
research deals with human experience, such as that of the nursing students in this study.
Therefore, an evaluation of the risks and benefits of this was initiated before applying for
approval to commence the research. Walsham (2006) points out that it is imperative to
the integrity of the study, that all material collected for the research project is kept
confidential. To ensure confidentiality, data including consent forms, completed
questionnaires, notes, data analysis notes, transcribed documents, and the researcher’s
journals were kept in a locked filing cabinet in the School of Nursing and Midwifery at
Monash University. Only the researcher and the researcher’s supervisors had access to
the data. All demographic information, such as names and telephone numbers, were
kept separately from the all other data. Since the researcher used email, all
computerised files were only viewed by the researcher on a password-protected
computer. Files were saved to be viewed only by the researchers; and back-up files were
placed on a flash drive and the Monash University drive, which was kept in a locked file.
According to Monash University regulations, data are stored securely for five years, after
which time it will be discarded (Monash University, 2016).
In addition, to ensure anonymity, no names or any identifying information were available
on the questionnaire. The type of questions asked did not identify the participants and
what was reported did not link to the participants or their location or organisation and
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other relevant information. Interviews were conducted in three nursing faculties and the
participants’ names were coded to ensure anonymity. As the researcher is a lecturer and
previously a qualified nurse with skills in counselling, any minor distress would have been
managed within the context of the interview. However, none occurred during the
interviews. Furthermore, in reporting statements or quotes from the interview phase,
pseudonyms have been employed.
Respondents’ privacy was not invaded. Relevant information was not withheld from
participants and freedom from coercion of any type was ensured (National Health and
Medical Health Council, 2007). To safeguard study participants’ confidentiality the
researcher did not reveal any details about them or link participants to their data (Polit &
Beck, 2008). Participants were not forced to take part in this study. In addition, there was
no relationship between researchers and participants that may have affected
participants’ involvement in this thesis.
3.9.1 Benefits of the Research Study
Beneficence is considered to be one of the ethical principles in research whereby the
researcher seeks to maximise benefits and minimise harm. This means that human
research should be aimed towards producing benefits for both the individual and society
(Polit & Beck, 2008). One of the major concerns in any research is the protection of
participants’ rights; therefore, the main focus was participants’ rights by protecting them
from harm and discomfort. Their participation was essential to achieve scientific and
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socially important aims that could not be otherwise achieved and realised (Grove, Gray,
& Burns, 2015).
In research, consideration of harm and discomfort can take many forms such as physical,
emotional, social, psychological or financial (Grove et al., 2015). The researcher
acknowledged that the participants in interviews might experience some discomfort in
discussing experiences of their clinical learning. However, the participants were fully
aware of the interview topics through the explanatory statement and before giving
consent to participate. Nonetheless, the questionnaire was not likely to cause distress or
minor inconvenience during the time that participants were involved in completing the
questionnaire. If it was noticed by the researcher that participants started to feel
stressed, it was planned to advise them to withdraw. However, none of the participants
decided to do so. In any research the participants have the right to be protected from
exploitation. Polit and Beck (2008) suggest that participants should not be placed at a
disadvantage or be exposed to situations for which they have not been prepared. The
researcher needs to assure that each participant’s information will not be used against
them by maintaining their confidentiality.
3.9.2 The Right to Self-Determination and to Full Disclosure
In this study, the questionnaire and interview invitation included an explanatory
statement that introduced the research and assured participants of anonymity (Appendix
C). The statement ensured the principle of self-determination by stressing that the
respondents had the right to decide voluntarily to participate or not and they had the
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right to withdraw at any time without the risk of incurring consequences. Moreover, they
had the right to ask questions or clarifications of any point. Self-determination also
includes freedom from coercion of any type. Coercion involves explicit or implicit threats
of penalties for not participating in the study or excessive rewards for agreeing to
participate in the research study (Grove et al., 2015). In regard to these issues, the
researcher did not have any influence over the participants as they had volunteered to
participate and no money or rewards were offered for their participation. Moreover, if
they felt unhappy about anything they could withdraw prior to collation of data, and
their data would be discarded immediately.
The researcher was responsible for ensuring respect for human dignity which includes
the participant’s right to make informed and full disclosure. Full disclosure means that
the researcher has fully described the nature of the study and has avoided any biases in
the research. These biases are firstly, biases resulting from inaccurate data and secondly,
biases resulting from sample recruitment problems (Polit & Beck, 2008). In this research,
explanatory statements and invitation letters encompassed fully all important details for
the participants by describing the nature of the study, the criteria for participation in the
interview and for answering the questionnaire.
3.9.3 Trustworthiness of the qualitative data
For a research study to be considered as accurate it is vital to establish trustworthiness
(Mack et al., 2011). A study is said to be trustworthy if it is reliable and the findings are
deemed to be accurate. Thomas and Magilvy (2011) explored four principles to ensure
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rigor in qualitative studies. These principles are credibility, transferability, dependability,
and confirmability.
Credibility is obtained by ensuring that the content of the interviews are sufficient
enough to elicit all of the information needed for the study. Thomas and Magilvy (2011,
p. 152) stated that “a qualitative study is considered credible when it presents an
accurate description or interpretation of human experience that people who also share
the same experience would immediately recognize”. There are many techniques to attain
credibility, such as prolonged engagement, persistent observation, triangulation, peer
debriefing, negative case analysis, referential adequacy, and member checks (Morse,
2015). In this study, the researcher asked the participants to check the interpretations of
analysed data to ensure that the researcher correctly understood the information
presented to her during the interview, and represented it in an accurate way.
The next issue of concern is transferability which refers to the ability to transfer research
findings from one group to another, or extending findings of a particular inquiry and
apply them in other contexts or with other participants (Thomas & Magilvy, 2011). It is
also referred to as external validity or generalisability (Morse, 2015). Therefore, it was
important that each participant met the criteria to be involved in this research study.
Providing relevant rich, thick descriptions of the issue being studied, which in this case
was clinical learning and clinical environment in the Saudi nursing undergraduate
curricula, will allow this study’s findings to be applied to other situations or groups.
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Although there may be similarities between participants’ responses, repeating the study
methods with different groups in a different geographical location might yield different
results.
Further, dependability, sometimes referred to as reliability, is attained if other
researchers can follow the decision trail of this study, and elicit similar findings (Thomas
& Magilvy, 2011). Dependability is attainable through credibility, the use of overlapping
methods, splitting data and duplicating the analysis, and the use of an audit trail (Morse,
2015). In this study, some research findings are repeated from other studies that applied
similar methodologies but not consistent due to population and geographic location
differences (Johansson et al., 2010; Papastavrou et al., 2016; Saarikoski et al., 2005;
Skaalvik et al., 2011; Tomietto et al., 2014; M. Tomietto et al., 2012). This study has
reported the research process in detail to enable other researchers to: firstly, understand
the methods and their effectiveness; and secondly, repeat the inquiry to possibly achieve
similar results.
Finally, confirmability, sometimes referred to as objectivity, occurs when credibility,
transferability, and dependability have been established (Thomas & Magilvy, 2011).
Confirmability seeks to find out how data collected is reinforced by the research findings
and to establish whether bias exists in the study. The researcher was objective and
maintained neutrality throughout the research project. This was accomplished through
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reflexivity; by maintaining and viewing all data, notes, and activities relating to the
research study “audit trail” (Morse, 2015, p. 1213).
3.10 Summary
This chapter has explained how a mixed methods research design was selected to
explore the CLE from the perspectives of Saudi Arabian nursing students. The data
collection process for this study consisted of two phases which were applied at the same
time using both quantitative and qualitative approaches. Phase one represented the
quantitative component where the CLE+T evaluation tool was used to evaluate the
quality of clinical learning in the Saudi nursing curricula by measuring students’
experiences and satisfaction with their practical setting. A qualitative component was
added by conducting semi-structured interviews. The discussion included methods used
in the research, research settings, ethical considerations, recruitment and sample. In the
next chapter the findings of the two phases of data collection are presented.
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Chapter Four: Results
4.1 Introduction
The previous chapter outlined the methodology employed for this study. In this chapter
the findings are reported in line with the two phases conducted to answer the research
questions. The first section reports on the data generated from the questionnaires
conducted in phase one. The second part reports the data from the open-ended part of
the questionnaire. Lastly, the third part of the chapter reports data from phase two
generated by the semi-structured interviews.
The findings from phase one are reported in three parts: firstly, socio-demographic data;
secondly, respondents’ views and experiences on their clinical learning environment; and
thirdly and finally, the responses of respondents to the open-ended questions. The
findings of phase two from the semi-structured interviews are presented under the
emerging themes. In this section the participants’ statements are used to support
conclusions drawn.
4.2 Results of Phase One (Questionnaire)
As described in the previous chapter, a cross-sectional sample of second and fourth year
undergraduate nursing students from three nursing faculties in Saudi Arabia was invited
to complete a questionnaire. The respondents were all female Saudi students who had
been exposed to the clinical environment in their studies. The same individuals were
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given the opportunity to participate in an interview. A total of one hundred and twelve
female Saudi nursing students completed and returned the questionnaire on the spot,
giving a response rate of 100%. Questionnaire items were designed to provide the
essential social and demographic information about undergraduate nursing students in
Saudi Arabian universities. Information included: age, gender, types of organisations
involved, and details of students’ previous clinical experiences.
4.3 Part one: Description of Variables
Descriptive statistics including frequencies, means and standard deviations were
calculated from the demographic data.
4.3.1 Age
Age was classified into five categories: 18-20 years, 21-23 years, 24-26 years, 27-30 years,
and 31 years and over. The number of students in the age group 18-20 years and 21-23
years was 38 and 60 respectively and the total respondents in these two groups
represented around 87.5% of the total sample (see Table 2). Generally therefore the
sample reflected students who had entered the course as school leavers.
4.3.2 Educational Organisation
The undergraduate nursing programmes in Saudi Arabia are offered in both private and
government faculties. These two served as the options in the questionnaire. Three
universities were involved in the study, two were governmental, and the third was
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private. The majority of students attended governmental nursing faculties representing
60.7% of the total sample. On the other hand, 39.3% of the total respondents attended a
private nursing faculty (see Table 2).
4.3.3 Year of Study
Year of study referred to the year level that the student was in during her nursing course
at the time of the study. For the purposes of this research, the years of study were either
second or fourth years, since the sample population was drawn from these two years of
study. The questionnaire was almost equally distributed among second and fourth year
students to represent 45.5% and 54.5% respectively of the total respondents (see Table
2).
4.3.4 Type of hospital at current clinical education
In relation to type of hospital, there were three types to choose from, these being
government, private and university hospitals (see Table 2). Governmental nursing
faculties had access to both governmental and university hospitals. On the other hand,
private faculties only had access to private sector hospitals. It is worth mentioning here
that university hospitals are also classified as governmental in concept. The main
difference is that these particular faculties have a more direct and easier link and access
to them for clinical training. In this study four governmental, two private, and two
university hospitals were involved.
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Table 2 and Figure 3 show the percentage of nursing students in hospitals according to
educational organisation. A majority of students (n=68) attended two government
nursing faculties which represented 60.7% of the total sample. These organisations had
access to governmental and university hospitals for training with 40 and 27 students
representing 35.7% and 24.1%, respectively. On the other hand, private faculties only
had access to private hospitals, with 44 students accounting for 39.3% of the total
respondents.
4.3.5 Area of Clinical Placement
The area of clinical placement referred to the hospital section/ward that a student was
assigned to during the course of their studies. Students could choose from six areas of
clinical focus listed as response options to the question in the questionnaire. Five of
these were specific areas of clinical placement and included medical, surgical, maternity,
oncology and paediatric.
The respondents’ clinical placements are illustrated in Table 2. It shows that the majority
of students had their clinical training in medical and surgical wards with 35 and 33
students, respectively, representing 31.3% and 29.5% of the total sample. Twenty
students were distributed among other units, including the emergency room, day care
and intensive care unit, forming 17.9% of the total sample. The results in this section
could be attributable to a number of factors. For instance, one could infer that the
medical and surgical wards are normally the busiest in the hospitals involved in this
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study, thus warranting the assignment of more nursing students to them. It is also
possible to infer that surgical and medical wards have the most frequent and longest
practical sessions for students. Another possible explanation for these results is that the
medical and surgical wards in these hospitals can accommodate more students at a time
while simultaneously providing adequate practical experience than would the rest of the
clinical areas of practice.
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Table 2 Socio-Demographic Details of Participants (N=112)
Socio-Demographic Items Frequency Percentage
Age 18 – 20
21 – 23
24 – 26
27 – 30
31 and more
38
60
11
2
1
33.9
53.6
9.8
1.8
.9
Educational organisation Governmental
Private
68
44
60.7
39.3
Year of study Second year
Fourth year
51
61
45.5
54.5
Clinical training at current hospitals Governmental
Private
University hospital
40
44
27
35.7
39.3
24.1
Clinical placement Medical
Surgical
Maternity
Oncology
Paediatric
Other
35
33
4
1
9
20
31.3
29.5
3.6
.9
8
17.9
Duration of clinical training Four hours
Five hours
Six hours
36
13
34
32.1
11.6
30.4
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Seven hours
Eight hours
Other
11
7
11
9.8
6.3
9.8
Table 2 summarises the essential demographic features of the participants and other
clinical learning-related information. The questionnaire was almost equally distributed
among second and fourth year students to represent 45.5% and 54.5%, respectively, of
the total respondents. Twenty-two per cent (n=11) and 73% (n=37) of second year
students fell into the 18-20 years and 21-23 years age groups. In the meantime 16%
(n=10) and 80% (n=49) of fourth year students were between the ages of 21-23 years
and 24-26 years.
Figure 3 Percentage of nursing students in hospitals according to educational organisation
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4.3.6 Frequency of Clinical Training
Frequency of clinical training referred to how often students attended clinical practice
sessions at hospital settings. Respondents could choose from five categories in this
respect. These were “once weekly”, “twice weekly”, “three days weekly”, “four days
weekly” and “five days weekly”. The categories were listed based on the understanding
that most nursing faculties’ policies in Saudi Arabia require a minimum of once per week
exposure to the clinical setting and a maximum of five days per week. It is noteworthy
that the frequency of clinical training may be subject to the year of study, the area of
clinical practice and nursing faculty and hospital regulations. It can be assumed that
different years of study and areas of clinical practice are either more or less demanding
than others. Results show that medical and surgical clinical settings had the most
respondents. It is plausible that these areas are more demanding, featuring numerous
practical cases frequently compared to others such as oncology.
Table 3 Frequency of Clinical Practice
Frequency of Clinical Practice 2nd Year 4th Year
Once weekly 1 (2%) 26 (44%)
Twice weekly 50 (98%) 17 (29%)
Three days weekly 0 (0%) 14 (24%)
Four days weekly 0 (0%) 2 (3%)
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Table 3 and Figure 4 illustrate the frequency of how often nursing students attended
clinical practice at the hospital per week. Fifty students (98%) in second year reported
that they had clinical placements at the hospital twice per week, while 26 students in
fourth year, representing 44% of the fourth year students, indicated they went once
weekly to the hospital for clinical placements. Another 29% (n=17) and 24% (n=14),
respectively, indicated they went twice and three times per week for clinical practice.
4.3.7 Duration of Clinical Training
The duration of clinical training was synonymous with the length of practical sessions
that students were required to attend per day. For the purposes of this research,
students could choose from six options of hours per session. The first five of these
Figure 4 Frequency of clinical practice for second and fourth year nursing students
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options were specific and included durations ranging from four to eight hours. On the
other hand, the last option was classified as “other, specify”, and this allowed
respondents to specify any other duration apart from the five listed in the questionnaire.
Table 4 Length of Clinical Practice
Length of Clinical Practice 2nd Year 4th Year
Four hours 14 (27%) 22 (36%)
Five hours 3 (6%) 10 (16%)
Six hours 18 (35%) 16 (26%)
Seven hours 4 (8%) 7 (11%)
Eight hours 1 (2%) 6 (10%)
Other 11 (22%) 0 (0%)
The amount of time spent during clinical placements in the hospital by nursing students
is shown in Table 4. Between 14 and 18 second year students indicated that they spent
between four and six hours, respectively, in clinical placement per day. This constitutes
27% and 35% of the total number of second year students. Another 11 students of the
same sample chose the “other” category and specified that they had spent only three
hours in clinical training at the hospital, and this represented 22% of the sample. Fourth
year students, on the other hand, stated that 22 and 16 students had spent four and six
hours in the hospital forming 36% and 26%, respectively, of their total number. Another
10, seven and six fourth year students claimed they spent five, seven, and eight hours,
respectively, in the hospital. The inconsistency in students’ answers indicates different
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practices either from between faculties or the students themselves. Further, it is worth
noting that students are not required to attend a full shift that staff nurses work, which is
twelve hours in the wards and eight hours in the clinics.
4.4 Part Two: Clinical learning environment, supervisor and nurse teacher information
In part two of the questionnaire, 34 items were ranked and analysed to measure the
quality of the CLE from the participants’ perspectives. The results have been divided into
categories and summarised in Table 6. The instrument used was a five-point Likert scale
as designed in the original tool, where 1= Strongly Disagree, 2= Disagree, 3= Neutral, 4=
Agree and 5= Strongly Agree.
The reliability of the data was estimated with Cronbach’s alpha of 0.95. Taking into
account the data deviation from normality, non-parametric inferential statistics were
selected. The correlation analyses between the students’ satisfaction and the five
constructs of the CLE were performed with Pearson bivariate correlation coefficient. Chi-
square tests were also used to examine the relationship between the nominal scales of
students’ satisfaction and their demographic data as well as regarding students’
relationship with their mentors. However, Chi-square tests were also undertaken for
additional insight into the relationships.
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Table 5 Mean values of Clinical Learning Environment (Total) and Figure 5show the mean
values and rankings of categories for nursing students who responded to the
questionnaire. Results indicate that the overall mean scores of the CLE elements were as
follows: the supervisory relationship mean was 2.7 (SD=.09), pedagogical atmosphere on
the ward’s mean was 2.6 (SD=0.75), role of the nurse teacher mean was 3.01 (SD=1.12),
leadership style of the ward manager mean was 2.8 (SD=1.0), and the philosophy of the
nursing in the ward mean was 2.9 (SD=1.02). Overall, the results in Part 2 reveal that
responses tended to fall between the “disagree” and “neutral” categories. However, with
a high standard deviation value, it can be interpreted that the respondents’ answers
were spread out over a large range of values. Overall, it is evident that participants found
the CLE they were exposed to was still not fully satisfactory in meeting their practical
learning needs. However, it is noteworthy that the missing values in the responses may
have affected the mean representation for the entire sample. In other words, perhaps
the means may have varied had all respondents responded to all of the questions. This is
only speculative though, since there is no evidence from the findings upon which to base
this premise.
110
Table 5 Mean values of Clinical Learning Environment (Total)
Clinical learning environment N Mean Std. Dev.
Supervisory relationship 112 2.7 .09
Pedagogical atmosphere on the ward 95 2.6 0.75
Role of nurse teacher 108 3.01 1.12
Leadership style of the ward manager 98 2.8 1.0
Philosophy of nursing in the ward 108 2.9 1.02
Figure 5 Mean and Standard deviation of Clinical Learning Environment
Table 6 below displays a detailed descriptive analysis of the clinical environment
evaluation for the whole sample. Overall, the participants gave negative responses to
these questions. Significant data are reported under sub-headings following the table.
SR PA NT WM PN0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
CLE content
111
Table 6 Descriptive statistics of the Clinical Learning Environment (Detailed)
Clinical learning environment N Mean Std.
Dev.
SUPERVISORY RELATIONSHIP
I felt comfortable going to the ward at the start of my shift.
112
2.69
1.29
There was a positive atmosphere on the ward. 110 2.72 1.3
My preceptor showed a positive attitude towards supervision. 108 2.66 1.37
I felt that I received individual supervision. 112 2.4 1.26
I continuously receive feedback from my preceptor. 109 2.66 1.33
Overall I’m satisfied with the supervision I received. 111 2.53 1.31
The supervision was based on a relationship of equality and
promoted my learning.
108 2.69 1.38
There was a mutual interaction in the supervisory relationship. 111 2.64 1.26
Mutual respect and approval prevailed in the supervisory
relationship.
111 2.97 1.34
The supervisory relationship was characterised by a sense of
trust.
110 2.64 1.39
PEDAGOGICAL ATMOSPHERE ON THE WARD
The staff are easy to approach.
112
2.54
1.3
During staff meetings (e.g. before shifts) I felt comfortable taking
part in the discussion.
106 2.26 1.3
Patients received individual nursing care. 109 2.91 1.31
There were no problems in the information flow related to 108 2.78 1.37
112
patients’ care.
Documentations of nursing (e.g. nursing plan, daily recording of
nursing procedures, etc.) was clear.
109 2.8 1.34
The staff are generally interested in student supervision. 112 2.2 1.17
The staff learned to know the students by their personal names. 111 1.96 1.08
There were sufficient meaningful learning situations in the ward. 111 2.5 1.37
The learning situations were multidimensional in term of
content.
108 2.69 1.38
The ward can be regarded as a good learning environment. 112 2.81 1.43
ROLE OF THE NURSE TEACHER
In my opinion, the NT was capable of integrating theoretical
knowledge and everyday practice of nursing.
112
3.19
1.36
The NT was capable of operationalising the learning goals of this
clinical placement.
111 3.15 1.35
The NT helped me reduce the theory-practice gap. 112 2.94 1.31
The common meetings between my mentor, NT and I were
comfortable experiences.
112 2.8 1.31
Climate of the meetings was congenial. 109 3 1.42
Focus on the meeting was my learning needs. 111 2.85 1.36
LEADERSHIP STYLE OF THE WARD MANAGER
The WM regarded his/ her staff as key resources.
105
3.03
1.44
The WM was a team member. 109 2.7 1.33
Feedback from the WM could easily be considered as learning 105 2.51 1.39
113
situation.
The effort of individual employees was appreciated. 106 2.62 1.42
PHILOSOPHY OF NURSING IN THE WARD
The ward’s nursing philosophy was clearly defined.
110
2.71
1.33
The NT was like a member of the nursing team. 110 3.14 1.27
The NT was capable of giving her/ his pedagogical expertise to
the clinical team.
110 2.87 1.31
The NT and the clinical team worked together supporting my
learning.
110 2.81 1.35
114
Supervisory relationship
As concluded from Table 6 and Figure 6, most data in the supervisory relationship was
found to fall under the “neutral” and “disagree” categories, with most participants not
giving agree or strongly agree responses. However, the most significant results recorded
were the responses to the statement: “I felt that I received individual supervision” with a
mean of 2.4 (SD=1.26) and the statement: “Overall I’m satisfied with the supervision I
received” with a mean of 2.56 (SD=1.31). These numbers indicate that students were
mostly unsatisfied with their supervisors and their clinical learning directions.
Figure 6 Mean and Standard deviation of Supervisory Relationship (SR) components
Pedagogical atmosphere in the ward
As shown in Table 6 and Figure 7, concerning the atmosphere of the ward category,
noteworthy results were recorded in response to the statements: “The staff learned to
know the students by their personal names” and “The staff are generally interested in
student supervision” with means of 1.96 (SD=1.08) and 1.22 (SD=1.17), respectively.
1
2
3
4
5
1 2 3 4 5 6 7 8 9 10
SR Components
115
These numbers indicate that students felt that were not wanted by the staff in the
clinical setting.
Figure 7 Mean and Standard deviation of Pedagogical Atmosphere in the ward (PA)
components
Role of the nurse teacher
From Table 6 and Figure 8, regarding the role of the nurse teacher category, almost all
responses fell under the ‘neutral’ category; hence students neither agreed nor disagreed
with the statements. The ambivalence of these results will be further explored in the
discussion chapter, in combination with associated qualitative data.
1
1.5
2
2.5
3
3.5
4
4.5
5
1 2 3 4 5 6 7 8 9 10
PA Components
116
Figure 8 Mean and Standard deviation of Role of the nurse teacher (NT) components
The leadership style of the ward manager
As shown in Table 6 and Figure 9, referring to the leadership style of the ward manager,
while items had mean values ranging between 2.51 and 3.03, almost all responses fell
under the ‘neutral category’, hence students neither agreed nor disagreed. Again the
results will be further explained in the discussion chapter with relevant qualitative data.
Figure 9 Mean and Standard deviation of the Leadership style of the Ward Manager (WM)
components
1
1.5
2
2.5
3
3.5
4
4.5
5
1 2 3 4 5 6
NT Components
1
1.5
2
2.5
3
3.5
4
4.5
5
1 2 3 4
WM Components
117
Philosophy of nursing in the ward
From Table 6 and Figure 10, for the philosophy of nursing in the ward category, almost all
responses fell under the ‘neutral’ category, again indicating ambivalence in students’
opinions. Results will be further explained in the discussion chapter.
Figure 10 Mean and Standard deviation of Philosophy of nursing in the ward (PN)
components
4.4.1 Clinical Learning Environment and Educational Organisation
The researcher investigated the effect of differences in the participants’ educational
organisations on perceived Supervisor Relationship, Pedagogical Atmosphere, Role of the
Nurse Teacher, Leadership of Ward Manager, and Nursing Philosophy in the ward. Prior
to running the tests, the means of the different questionnaire items were computed into
new variables for ease of aggregate analyses. An independent sample t-test was
conducted to evaluate the intergroup variations with respect to the remaining variables.
1
1.5
2
2.5
3
3.5
4
4.5
5
1 2 3 4
PN Components
118
Educational organisation was set as the grouping variable whereas the other CLE
constructs were used as the test variables. The results appear in Table 7 and Table 8,
which display the group statistics and the t-test results, respectively.
Table 7 Clinical Learning Environment and Educational Organization (Group statistics)
ORGANISATION N Mean Std. Dev
Supervisory Relationship (SR)
Mean
Governmental 68 2.98 .90
Private 44 2.26 .92
Pedagogical Atmosphere (PA)
Mean
Governmental 68 2.83 .71
Private 44 2.22 .66
Role of Nurse Teacher (NT)
Mean
Governmental 68 2.97 1.00
Private 44 3.07 1.29
Leadership Style of Ward
Manager (WM) Mean
Governmental 68 3.06 .87
Private 43 2.51 1.11
Philosophy of Nursing in the
ward (PN) Mean
Governmental 68 2.97 1.00
Private 43 2.88 1.05
The above table summarises the descriptive statistics according to the organisation type,
either governmental or private. These results show that there were differences in the
means of all the constructs including the perceived quality of CLE depending on the
organisations the respondents were from. However, these results are not strong enough
to infer significance of variation in the means. Therefore, reference is made to Table 8,
which contains the results of the independent samples test.
119
For the factor SR, the mean is higher for government organisations than private ones
with means at 2.98 and 2.26 and SD at .90 and .92, respectively. It is safe to infer that
nursing students in governmental organisations perceived their supervisory relationships
more positively compared to those students placed in private organisations. Whether
this implies that the quality of supervision in governmental organisations was of better
quality than in private organisations is subject to further research and will be explored in
more detail in the discussion chapter. Altogether, none of the category means on the
supervisory role reached the “agree” Likert score of four (4). This means that overall
most of the nursing students in both governmental and private institutions had neutral
to negative perceptions of their supervisory relationships.
For the factor PA, the mean is higher for government organisations than private
organisations with means at 2.83 and 2.22 and SD at .71 and .66, respectively. This is
evidence that nursing students in governmental organisations were more positive in
terms of their perceptions of the pedagogical atmosphere than their counterparts in
private organisations. Additionally, the results could possibly indicate that governmental
organisations had a more positive pedagogical atmosphere than private organisations
involved in this study. However, both the governmental and private organisations’ means
were below three, which means that most of the nursing students in both types of
organisations did not agree with most of the statements concerning a positive
pedagogical atmosphere.
120
For the factor NT, the mean is higher for private organisations than government
organisations with means of 2.97 and 3.07 and SD at 1.00 and 1.29, respectively. Results
indicate that participants from both organisations had neutral perceptions of the role of
the nurse teacher. Overall, none of the category means on the supervisory role reached
the “agree” Likert score of four (4).
For the factor WM, the mean is higher for government organisations than private
organisations with means of 3.06 and 2.51 and SD of .86 and 1.11, respectively. Results
show that participants from governmental organisations had increasingly positive
perceptions of the leadership styles of their ward managers in comparison to the
participants from private organisations. Three inferences are made from these results.
Firstly, nursing students in governmental organisations were more positive about the
leadership styles of their ward managers in comparison to those in private organisations.
The second point is that it is possible that the leadership style in nursing governmental
organisations is superior in some way to that of ward managers in private organisations.
Finally, it is likely that most nursing students in governmental organisations either agreed
to, or were neutral to, the questionnaire items on this construct since the mean for this
group was in excess of the neutral point denoted by the neutral Likert scale of 3.
Finally, for the factor PN, the mean is higher for government organisations than private
organisations with means at 2.97and 2.88 and SD at 1.0 and 1.05, respectively. These
results mean that nursing students in governmental organisations had fewer negative
121
perceptions regarding the philosophy of nursing in the ward compared to their
counterparts in private organisations. However, none of the categories of participants
entirely agreed about holding positive perceptions concerning the philosophy of nursing
in the wards. This is reflected in their mean scores being below the neutral point of three
(3) based on the Likert scale scores.
Table 8 Educational Organisation Effect on CLE perceptions (Independent Samples t-test)
Levene's Test for Equality
of Variances t-test for Equality of Means
Sig. (p-value)
Sig. (2-
tailed)
95% Confidence
Interval
SR
Mean
Equal variances
assumed 0.703 0 0.363 -- 1.066
Equal variances not
assumed 0 0.361 -- 1.068
PA
Mean
Equal variances
assumed 0.236 0 0.340 -- 0.873
Equal variances not
assumed 0 0.343 -- 0.869
NT
Mean
Equal variances
assumed 0.002 0.651 -0.531 -- 0.333
Equal variances not
assumed 0.669 -0.557 -- 0.359
WM
Mean
Equal variances
assumed 0.01 0.005 0.173 -- 0.927
Equal variances not
assumed 0.008 0.15 -- 0.95
PN
Mean
Equal variances
assumed 0.625 0.644 -0.303 -- 0.487
Equal variances not
assumed 0.648 -0.308 -- 0.492
122
Based on Table 8 above, the results of the Levene’s Test for Equality of Variances show
the significance values of the test are greater than .05 based on 95% as the confidence
interval for SR Mean, PA Mean and PN Mean. Consequently, this means that the equality
of variances was assumed for these constructs and interpretations will be made on first
row t-test. However, the NT mean (p= .002) and the WM mean (p= .01) had significance
values below .05 and thus, the null hypothesis of equal variances is rejected. It is
therefore concluded there is a difference between the variances in the population. For
this reason interpretations will be made on second row t-test.
The t-test showed that the SR and PA means were significantly different between the
values (p= .000) for both. Also, t-test for WM indicated that results were significantly
different (p=.008). Thus, it can concluded that the differences between SR, PA and WM
means are not likely due to change and are probably due to the educational organisation
type.
The mean differences in the two organisational categories with respect to NT and PN did
not reveal statistical significance with p=.669 and p=.644, respectively. These inform the
inference that the organisation type does not have an effect on these two perception
constructs. Secondly, one could allude to the possible similarity in the role of the nursing
teacher and perceived nursing philosophy in the ward in governmental and private
institutions. Possible explanations for these results could be that the roles of the nursing
teachers and the defined nursing philosophies in the ward are standardised for both
123
governmental and private organisations in Saudi Arabia. Subsequently, this warrants the
conclusion that nursing students’ perceptions in either organisation type are similar.
To summarise Table 8, the results substantiate the inference that it is possible that the
supervisory relationship, pedagogical atmosphere and the leadership of the ward
manager strike the perceptions of nursing students as relatively dissimilar depending on
whether they are in private or governmental organisations. A possible explanation for
these findings and inferences is that there are no role standardisations in Saudi Arabia
concerning the supervisory relationship, pedagogical atmosphere, leadership of the ward
manager and quality of the clinical environment. Therefore, it is likely that governmental
organisations have different standards of the constructs and their execution than private
organisations.
4.4.2 Clinical Learning Environment and Year of Study
An independent samples t-test was conducted to determine whether the perceptions of
the participants were different and whether their year of study could account for the
differences. The results of the group variables appear in Table 9, while Table 10 displays
the t-test results.
124
Table 9 Clinical Learning Environment and Year of Study (Group statistics)
Clinical Learning Environment (CLE)
Construct Year of Study N Mean Std. Dev
Supervisory Relationship
(SR) Mean
Second year 51 3.11 .86
Fourth year 61 2.35 .93
Pedagogical Atmosphere
(PA) Mean
Second year 51 2.66 .72
Fourth year 61 2.53 .77
Role of Nurse Teacher
(NT) Mean
Second year 51 3.65 .92
Fourth year 61 2.48 .99
Leadership Style of Ward Manager
(WM) Mean
Second year 51 2.94 .91
Fourth year 60 2.77 1.08
Philosophy of Nursing in the Ward (PN)
Mean
Second year 50 3.16 .81
Fourth year 61 2.75 1.13
The results in Table 9 above give the descriptive statistics according to the year of study,
either second or fourth year. These results show that there are differences in the means
of all the constructs including the perceived quality of CLE depending on the year of
study the respondents were in. With reference to the results in Table 9, participants in
second year had more positive perceptions of SR (mean= 3.11) than their fourth year
counterparts (mean= 2.35). These results inform the inference that, the higher the
students’ study level, the more their relationships with their supervisors tended to
deteriorate. It can be speculated that the more advanced the student is in their study,
the less it is that they are required to be closely supervised.
125
As for the PA component, the results show the portrayed slight differences in the means
between second year (mean= 2.66) and fourth year students (mean=2.53). This implies
that the perceptions of the nursing students concerning the pedagogical atmosphere
remain relatively the same despite the year of study. However, it is important to point
out that the means for both categories of participants were below the neutral value of 3
on the questionnaire’s Likert scales. This revelation supports the inference that most
nursing students perceived the pedagogical atmosphere in the clinical environment to be
more negative than positive. Further, it is evident from the group statistics that second
year participants had more positive perceptions of the NT (mean= 3.65) than their
colleagues in fourth year (mean= 2.48). This implies that nursing students tended to be
more satisfied with the role of the nurse teacher during their clinical learning in their
earlier years of study. Similar to the SR construct, this may infer that the more advanced
the student is in their study, the less likely they will be closely monitored.
The results in Table 9 showed that the means were relatively close with second year
participants registering a higher mean (mean=2.94) than those in their fourth year
(mean= 2.77) in relation to the WM construct. These results support two inferences. The
first one is that the year of study did not affect the perceptions of the WM for the
nursing students in this study. The second inference is that most of the nursing students
held more negative perceptions about the leadership styles of their respective ward
managers since all scored below the neutral value of 3 on the Likert scale.
126
Finally, the results of the PN construct as shown in Table 9 indicate that second year
students had a higher mean score (mean=3.16) than that of the fourth year participants
(mean=2.75). This demonstrates that the fourth year nursing students disagreed that the
CLE in terms of philosophy of nursing was positive, since their mean score on the
construct was less than the neutral value of 3 on the Likert scale. Thus, one could
conclude that the longer nursing students stayed in the course, the more their
perceptions about the philosophy of nursing in the ward tended to be negative.
Nonetheless, these results are inadequate to substantiate the making of any conclusive
inference statistically. Therefore the results displayed in Table 10 below inform the
making of inferences.
127
Table 10 Year of Study effect on CLE perceptions (Independent Sample t-test)
Levene's Test for Equality of Variances
t-test for Equality of Means
Sig. (p-value)
Sig. (2-tailed)
95% Confidence Interval
SR Mean
Equal variances assumed
.553 .000 .425 -- 1.104
Equal variances not assumed
.000 .427 -- 1.101
PA Mean
Equal variances assumed
.429 .384 -.158 -- .408
Equal variances not assumed
.381 -.156 -- .406
NT Mean
Equal variances assumed
.385 .000 .807 -- 1.530
Equal variances not assumed
.000 .809 -- 1.528
WM Mean
Equal variances assumed
.055 .377 -.21 -- .551
Equal variances not assumed
.370 -.204 -- .546
PN Mean
Equal variances assumed
.002 .065 .028 -- .788
Equal variances not assumed
.060 .04 -- .776
The results of the Levene’s test for the assumption of homogeneity show the variables of
SR, PA, NT, and WM Means have significant values greater than .05 at the 95%
confidence interval. This means that equal variances could be assumed for the mean
differences in these constructs. Interpretations, therefore, will be made on first row t-
test. On the other hand, equal variances could not be assumed for the PN Mean
construct since it registered a significance value of less than .05 (p= .002) for the Levene’s
test for equality of variances. Thus, the null hypothesis of equal variances is rejected and
128
it is concluded that there is a difference between the variances in the population.
Therefore, interpretations were made on second row t-test.
Concerning the independent samples test results, there were significant differences in
the perceptions of respondents to SR and NT for second year and fourth year students
(p= .000). Thus, it can be concluded that the differences between SR and NT means are
not likely due to change and are probably affected due to students’ year of study.
On the other hand, the mean differences in the two levels of study categories with
respect to PA, WM and PN did not reveal any statistical significance with p=.384, p=.377
and p=.06, respectively. These make it possible to infer that the year of study did not
influence these perception constructs. Secondly, one could infer the possible similarity in
the perception of pedagogical atmosphere, the leadership style of ward managers and
perceived nursing philosophy in the ward of both second and fourth year students.
Possible explanations for these results could be that the perception of pedagogical
atmosphere, the leadership style of ward managers and the defined nursing philosophies
in the ward are standardised in all clinical settings in Saudi Arabia. Subsequently, this
suggests that nursing students in both levels of study had similar perceptions.
To summarise Table 10, the results substantiate the inference that it is possible the
supervisory relationship and role of the nurse teacher, affected the perceptions of
nursing students as relatively dissimilar; this depended on whether they were in second
129
of fourth year of their study. A probable explanation for these findings and inferences is
that there are no role standardisations in Saudi Arabia concerning the supervisory
relationship, the nurse teacher role and quality of the clinical environment. In addition,
views on students’ needs for supervision and monitoring can differ from one level of
study to another. Therefore, it is likely that supervision and clinical teaching are different
from one individual to another, whether they are staff nurses who provide supervision or
faculty staff who accompany students into the clinical setting as nurse teachers.
4.4.3 Clinical Learning Environment and Type of Hospital
The researcher investigated the possible differences in perceived CLE quality depending
on hospital type. Independent samples t-test was not applied since previous variables
such as hospital type in this study consisted of more than two groups. Instead, one-way
Analysis of Variance (ANOVA) and post hoc tests were conducted to determine
underlying mean variances and homogeneity of variance. The descriptive statistics
results as shown in Table 11 indicate that the means of all the CLE constructs vary
depending on the various hospitals type categories, which include government hospital,
private hospital and university hospital.
130
Table 11 Descriptive Statistics CLE constructs by Hospital Type
Hospital Type N Mean Std. Deviation
Supervisory
Relationship (SR)
Mean
Governmental Hospital 40 2.77 .87
Private Hospital 44 2.26 .92
University Hospital 27 3.28 .9
Pedagogical
Atmosphere (PA)
Mean
Governmental Hospital 40 2.6 .71
Private Hospital 44 2.22 .66
University Hospital 27 3.21 .53
Role of Nurse
Teacher (NT) Mean
Governmental Hospital 40 2.79 1.04
Private Hospital 44 3.07 1.29
University Hospital 27 3.24 .91
Leadership Style of
Ward Manager
(WM) Mean
Governmental Hospital 40 2.8 .90
Private Hospital 43 2.51 1.11
University Hospital 27 3.45 .69
Philosophy of
Nursing in the ward
(PN) Mean
Governmental Hospital 40 2.58 .96
Private Hospital 43 2.88 1.05
University Hospital 27 3.6 .72
For the SR category the results show that participants who had their clinical placements
at a university hospital had a higher mean (mean= 3.28) than others in governmental and
private hospitals with means of 2.77 and 2.26, respectively. It is safe to infer that nursing
students in university hospitals had more positive perceptions of their supervisory
relationships compared to those students placed in governmental and private hospitals.
Whether this implies that the supervision quality in university hospitals was of better
131
quality compared to governmental and private organisations is subject to further
discussion later on.
Similarly, the mean in the perceived pedagogical atmosphere by participants from
university hospitals was 3.21, where the means obtained from scores of participants
drawn from governmental and private hospitals were 2.6 and 2.22, respectively. This is
evidence that nursing students in university hospitals were more positive in terms of
their perceptions of the pedagogical atmosphere than their counterparts in government
and private hospitals. However, a total mean of 2.6 indicates that most of the nursing
students in hospital clinical placements did not agree with most of the statements
concerning a positive pedagogical atmosphere.
Results also showed that participants from university hospitals had increasingly positive
perceptions of their nurse teacher (mean = 3.24) in comparison to the participants from
governmental and private hospitals (means = 2.79 and 3.07, respectively). Similarly, the
mean of students’ perception of the leadership style of the ward manager in university
hospitals was 3.45, whereas the means obtained from scores of participants drawn from
governmental and private hospitals were 2.8 and 2.51, respectively. This is evidence that
nursing students in university hospitals had more positive perceptions concerning the
ward managers and their leadership abilities than their counterparts in government and
private hospitals.
132
Lastly, For the PN category, the results show that participants who had their clinical
placements at a university hospital had a higher mean (mean= 3.6) than others in
governmental and private hospitals (means= 2.58 and 2.88, respectively). This infers that
students in university hospitals perceived that the nursing philosophy in the ward more
positively than students placed in governmental and private hospitals.
Overall, university hospital-based students tended to have more positive experiences
compared to their peers in other government and private hospitals. Nonetheless, none
of the categories reached the “agree” Likert score of four (4). This means that most of
the nursing students had overall negative perceptions of their experiences in the clinical
placements at the hospital. A possible explanation for these results could be that
university hospitals function to serve the students’ interests as a part of their mission,
while the others do not.
133
Table 12 Test of Homogeneity of variances between CLE and hospital type
Levene Statistic (Sig.)
Supervisory Relationship (SR) Mean .729
Pedagogical Atmosphere (PA) Mean .327
Role of Nurse Teacher (NT) Mean .006
Leadership Style of Ward Manager (WM) Mean .002
Philosophy of Nursing in the Ward (PN) Mean .031
The results for the test of homogeneity of variances as presented in Table 12 showed
that equal variances of means could be assumed for SR Mean and PA Mean since their
significance values were more than .05 (.72 and .32, respectively). On the other hand,
equal variances of means could not be assumed for NT Mean (p= .006), WM Mean
(p= .002) and PN Mean (p= .031). ANOVA test is conducted for the significance of mean
variances for these constructs which are presented in Table 14. The underlying
intergroup variances are also exhibited in the post hoc analysis in Table 14 presented
later.
134
Table 13 CLE ANOVA Results by Hospital Type
Clinical Learning Environment
(CLE) Construct Sig. (p-value)
Supervisory Relationship
(SR) Mean
Between Groups .000
Within Groups
Pedagogical Atmosphere
(PA) Mean
Between Groups .000
Within Groups
Role of Nurse Teacher
(NT) Mean
Between Groups .250
Within Groups
Leadership Style of Ward Manager
(WM) Mean
Between Groups .000
Within Groups
Philosophy of Nursing in the Ward
(PN) Mean
Between Groups .000
Within Groups
From the table above, the means of SR, PA, PN and WM (p= .000) varied significantly
across the different hospital types. However, there were no significant differences in the
means of NT after registering a significance value in excess of .05 (p= .250). This indicated
that nursing students in this analysis did not display statistically significant variances in
their perceptions of the nursing teacher’s role in different hospital type notwithstanding.
Subsequently, running post hoc tests was not warranted and therefore not carried out.
To establish where the actual variances in the means lay, the researcher referred to the
multiple comparisons table under post hoc analyses. As per results in Table 12, while
equal variances of means could be assumed for SR Mean and PA Mean, equal variance of
135
means could not be assumed for NT, WM and PN. With respect to the results of the
Homogeneity of variances, the variances for SR and PA Mean warranted reference to
Tukey HSD results since their equality of variances of means was assumed (see Table 12).
Conversely, the interpretations of the underlying differences for NT, WM and PN Mean
depending on hospital type were read from the Games-Howell test results. The results
appear in Table 14.
136
Table 14 Multiple Comparisons Table
Dependent Variable (I) HospitalType (J) HospitalType Sig. 95% Confidence
Interval
SR
Mean
Equal variance
assumed (Tukey
HSD)
Governmental
Hospital
Private Hospital .031 .0365 -- .973
University
Hospital .060 -1.05 -- .0176
Private Hospital
Governmental
Hospital .031 -.973 -- -.036
University
Hospital .000 -1.545 -- -.497
University
Hospital
Governmental
Hospital .060 -.017 -- 1.050
Private Hospital .000 .497 -- 1.545
PA
Mean
Equal variance
assumed (Tukey
HSD)
Governmental
Hospital
Private Hospital .028 .032 -- .712
University
Hospital .001 -.998 -- -.223
Private Hospital
Governmental
Hospital .028 -.712 -- -.032
University
Hospital .000 -1.364 -- -.603
University
Hospital
Governmental
Hospital .001 .223 -- .998
Private Hospital .000 .603 – 1.364
WM
Mean
Equal variance
not assumed
(Games-Howell)
Governmental
Hospital
Private Hospital .407 -.245 -- .818
University
Hospital
.004 -1.125 -- -.187
Private Hospital Governmental
Hospital
.407 -.818 -- .245
137
University
Hospital
.000 -1.461 -- -.424
University
Hospital
Governmental
Hospital
.004 .187 – 1.125
Private Hospital .000 .424 – 1.461
PN
Mean
Equal variance
not assumed
(Games-Howell)
Governmental
Hospital
Private Hospital .359 -.833 -- .224
University
Hospital
.000 -1.518 -- -.523
Private Hospital
Governmental
Hospital
.359 -.224 -- .833
University
Hospital
.004 -1.226 -- -.206
University
Hospital
Governmental
Hospital
.000 .523 -- 1.518
Private Hospital .004 .206 -- 1.226
The results in the multiple comparisons table above show that there were statistically
significant differences in the SR Mean between governmental and university hospitals
and private hospitals (p< .05). This means that female nursing students in private
hospitals perceived the supervisory relationships differently from their counterparts in
both governmental and university hospitals. However, the mean differences in
perceptions concerning SR for female nursing students in governmental hospital types
were not significantly different from those of students in university hospitals (p=.060).
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Concerning the perceptions of the female nursing students with respect to PA Mean
results, it is evident there were statistically significant variations in the means of
participants drawn from any of the hospital types (p< .05). This suggests there is a
relationship between students’ perceptions on PA constructs of the CLE and the type of
hospital where the clinical learning takes place.
Concerning the ward manager’s leadership style, there were underlying variances in WM
means between governmental and university hospitals (p= .004). Variances in means also
exhibited perception means of private hospital and university hospitals (p= .000).
However, there were no underlying mean variances between the perceptions of female
nursing students in governmental hospitals and those in private hospitals (p= .407) in
terms of leadership styles of ward managers.
The results assist in inferring that Saudi female nursing students in governmental
hospitals perceived the PN differently from their colleagues in university hospitals types
(p=.000). Additionally, the results support the argument that the perceptions of Saudi
female nursing students in private hospitals differed significantly from their counterparts
in university hospitals (p=.004). In summary, these results confirm that the perceptions
of Saudi female nursing students in university hospitals are incomparable to those of
students in any other institutional type. However, the perceptions of Saudi female
nursing students in governmental hospital types and those in private hospitals are not
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significantly distinct with respect to the philosophy of nursing in their respective wards
(p=.359).
To conclude these results, the researcher substantiates the inference that it is possible
the perceptions of nursing students are relatively dissimilar, depending on the hospital
type in which the clinical learning takes place. Results contend that Saudi female nursing
students in governmental hospitals perceived the SR, PA, WM and PN constructs of the
CLE differently to those in university and private hospitals.
4.4.4 Relationships between CLE Constructs
The researcher conducted Pearson bivariate correlation tests to determine whether the
CLE constructs exerted any influence on each other with respect to perceived clinical
learning environment. The results of the tests appear in Table 15 below. Results should
value between -1 and +1.
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Table 15 Correlations between CLE constructs (n=112)
SR Mean PA Mean NT Mean WM Mean PN Mean
SR Mean Corr. Coefficient (r-value) 1 .499** .650** .466** .511**
Sig. (p-value) .000 .000 .000 .000
PA Mean Corr. Coefficient (r-value) .499** 1 .286** .327** .391**
Sig. (p-value) .000 .002 .000 .000
NT Mean Corr. Coefficient (r-value) .650** .286** 1 .435** .644**
Sig. (p-value) .000 .002 .000 .002
WM
Mean
Corr. Coefficient (r-value) .466** .327** .435** 1 .580**
Sig. (p-value) .000 .000 .000 .000
PN Mean Corr. Coefficient (r-value) .511** .391** .644** .580** 1
Sig. (p-value) .000 .000 .002 .000
**. Correlation is significant at the p= 0.01 level.
Overall, it is evident from the results shown in Table 15 that all the constructs used to
define the Saudi female nursing students’ perceptions of the clinical environment
exhibited positive correlations. The implication is that these participants’ perceptions
concerning one construct significantly affected the other in the same direction. For
instance, if students’ opinions of the supervisory relationship in their respective
institutions were positive, then it was likely that they would also perceive the rest of the
constructs as positive and vice versa. This means that there is a need to ensure that the
perception of students overall lean toward the positive in all constructs to reach a
positive CLE. Focusing on the improvement of one CLE construct at the expense of the
other constructs would result in negative perceptions of all the other constructs.
Therefore, it is not enough for nursing administrators, hospital managers, personnel and
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university staff to focus on only some aspects of the CLE. Instead, focus should be on
upgrading all the relevant CLE areas to create positive perceptions of CLE in general.
4.4.5 Summary of Quantitative Questionnaire Data
Results for the questionnaire data showed that, overall, responses tended to fall
between the “disagree” and “neutral” categories with means ranging between 2.69 and
3.14. However, with a standard deviation valued above zero, it can be interpreted that
the respondents’ answers are spread out over a large range of values. It is largely evident
that participants found that the CLE they were exposed to was not fully satisfactory in
meeting their practical learning needs.
4.5 Results of Phase One: Part Three (Open-ended Questions)
In part four of the questionnaire, participants were invited to answer questions freely in
their own words. This allowed for exploring the answers through content analysis to
identify emerging major themes in the responses. Content analysis was applied to
analyse the frequency of the themes arising. Data were identified, classified, and
quantified in the form of numbered responses for each question. Common themes were
developed from the responses to questions one to five. Subsequently, a quantitative
process was undertaken to generate five headings representing these responses (see
Table 16). These were the challenges facing nursing students during clinical placement,
most valued experiences during clinical placement, least valued experiences during
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clinical placement, students’ evaluation of their clinical placement and recommendations
proposed to improve clinical placement.
Table 16 Grouped Themes from the Open-ended Questions
No. Theme N Example
1 Challenges during
clinical
placement
71 Lack of cooperation between staff and students, lack of
time and equipment for training and theory-practical gap,
Paper requirements and work load that prevents training,
Inadequate supervision by ‘nurse teacher’.
Insufficient time at clinical placement, language barrier,
lack of cooperation between hospital and
hospital/ignoring of students’ needs by the college.
2 Most valued
during clinical
placement
90 Availability of learning resources and opportunity to apply
theory into practice and to experience the profession with
staff and patients, interactions with patients.
3 Least valued
during clinical
placement
78 Unproductivity, lack of cooperation and support from the
staff and lack of opportunities to practice, improper policy
and procedures leading to disconnect between theory and
practice, workload and paperwork.
4 Evaluation of
clinical
placement
94 The majority ranged between acceptable to very bad.
5 Recommendation
to improve
clinical
placement
87 Increasing practical opportunities and resolve hospital-
related issues, enhance cooperation between universities
and hospitals, improve university-related issues to do with
teachers.
4.5.1 Challenges facing students during clinical placement
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When respondents were asked about the challenges they encountered during their
clinical placement, several answers emerged. Six key themes emerged including the gap
between theory and practice, student-related factors, hospital-related issues, clinical
time and workload, university-related issues, and patient-related issues. Table 17
illustrates the number of responses in which the theme was highlighted to provide
holistic information.
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Table 17 Question One: Challenges during the clinical placement
Theme N
(n=71)
% Example
Gap between theory
and practice
5 4.46% Equipment is outdated and there is no
proper application of policy and procedure in
the hospital.
Student-related
factors
19 16.96% Fear and sense of insecurity, having
difficulties with medical terminologies and
practicing skills on patients and lack of
autonomy in practice.
Hospital related issues 48 42.85% Difficulties in dealing with nurses and other
staff, the environment is not fit for clinical
training, lack of supervision and language
barriers.
Clinical time and
Workload
12 10.71% Too little time spent on clinical training and
too much workload ‘check lists, documents
and lectures after hospital placement’
University related
issues
13 11.6% Lack of teaching supervision during clinical
placement and lack of cooperation between
the university and the hospital.
Patient-related issues 11 9.82% Patients’ attitudes towards nursing and
nursing students and issues dealing with their
families
Six main themes were identified according to the respondents’ answers and are
illustrated in the order of majority responses. The majority of participants expressed
their challenges faced as being related directly to the clinical setting/ hospital. These
difficulties arose from issues such as ineffective communication with hospital staff and
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lacking of proper clinical environment to practice. Each of the themes is outlined with
supporting statements.
1- Hospital-related challenges
Forty-eight students indicated that dealing with hospital-related issues was considered to
be their main challenge during clinical practice. One key issue was dealing with the
nursing staff: ‘the nurses were uncooperative (pt. 11, 4y; pt. 19, 2y)’, ‘the nurses were
unwilling to give students a chance to practice (pt. 3, 4y)’ and ‘the staff nurses do not
care, especially those with non-Arabic nationalities (pt. 99, 2y)’. According to the
respondents, some of the nursing staff were acting unprofessionally towards them ‘.. the
bad treatment from the nurses (pt. 78, 4y)’, ‘there was discrimination in treatment
against students from the nursing staff (pt. 70, 4y)’, ‘they always treat us as if we were
naïve (pt. 75, 4y)’ and ‘constant disapproval from the staff nurses (pt. 73, 4y)’. Further,
students found it challenging dealing with other hospital employees and medical staff,
for example: ‘being targeted by some of the physicians (pt. 8, 4y)’, ‘none of the hospital
staff accepted me (pt. 36, 4y)’, ‘uncivil attitude from the employees (pt. 75, 4y)’, ‘rejection
and bad viewing from the medical staff (pt. 78, 4y)’ and ‘language barrier (pt. 58, 2y)’.
Finally, the hospital’s environment and lack of equipment and tools to practise were
considered barriers to the respondents: ‘the environment is uncomfortable to work in (pt.
9, 4y)’, lack of equipment at some hospitals (pt. 46, 4y)’, ‘few cases were available and
minimum access (pt. 48, 4y)’, ‘the hospital environment as a clinical setting was
challenging (pt. 111, 2y)’ and ‘cannot find a proper learning environment (pt. 51, 4y)’.
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1. Students’ own issues
Another factor that emerged from 19 students’ answers was the effect of the student’s
own issues that altered their clinical experience. Fear was one of the most common
obstacles to face students: ‘fear of failure (pt. 3, 4y) (pt. 4, 2y) or performing the
procedure in the wrong way (pt. 3, 4y) (pt. 49, 2y)’ ‘.. fear of harming the patients’ (pt. 4,
2y), ‘…sense of insecurity’ (pt. 75, 4y) and ‘…the hospital interior was scary for us’ (pt. 47,
4y). Also, lack of knowledge and communication skills in dealing with staff and patients
included: ‘I had difficulties with medical terminologies’ (pt. 26, 4y) (pt. 27, 4y) (pt. 64, 2y),
and ‘…understanding the pathology of some diseases’ (pt. 3, 4y) (pt. 64, 2y) and ‘being
merged with the working environment’ (pt. 31, 2y). Other issues such as empathy and
level of autonomy affected respondents’ clinical experience, for example: ‘... constant
observation from the nurses limited my movement’ (pt. 6, 2y) and ‘the patient’s status
was so critical it touched me deeply that I’m considering changing my career’ (pt. 52, 4y).
2. University-related issues
University-related factors ranked third-highest amongst the emergent issues that
influenced how the participants perceived their clinical practice. Lack of teaching
supervision in the course of clinical placement and lack of cooperation between the
university and the hospital stood out as the most dominant problems in this respect.
Some of the participants felt that their supervisors ‘did not care whether we really learnt
or not’ (pt. 43, 4y). Participant 66 (2y) expressed her disappointment by stating, ‘…no
need to call if supervision, it is simple routine and allocation of duty’. Furthermore ‘my
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supervisor takes breaks during clinical practice hours and does not care what we do,
really’. It was also stated that: ‘Supervisor unfriendliness scared me off’ (pt. 84, 2y) and
‘we did not know what we were doing most of the times’ (pt. 9, 4y). The absence of
cooperation between the university and the hospital meant that the latter ‘…did not
know what area of placement corresponded with what I had covered in theory’ (pt. 71,
4y) and ‘the hospital always put me in one clinical area for close to a year…’ (pt. 18, 2y).
3. Clinical time and Workload
From the sample, 12 participants indicated that clinical time and workload was another
factor that constituted the challenges students encountered during their clinical
placements. Spending too little time on actual clinical training while handling too many
‘check lists, documents and lectures after hospital placement…’ (pt. 59, 2y) stood out as
the main issues. Participants claimed that ‘most of the time we felt like nursing clerks’ (pt.
33, 4y) and ‘…at times we would go for a week and do nothing but documents and lists…’
(pt. 77, 4y). Some students could ‘…not understand why most of the time clinical training
took the least time…’ (pt. 90, 2y), or why ‘…clinical training was never the main
thing…instead it was documents, documents, documents…’ (pt. 53, 4y). Participants also
expressed the view that ‘…lectures organized after training at hospital were a waste…’
(pt. 21, 4y) and ‘…we are usually overworked for no good cause…’ (pt. 61, 2y).
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4. Patient-related issues
Patient-related issues were cited by 11 participants. Issues to do with the attitudes of
patients to nursing as a profession and nursing students dominated this theme. The main
concerns involved ‘…patients feel like nurses are not qualified enough to cater for them
medically’ (pt. 109, 2y) and ‘…some patients will not even let nurses come close to them…’
On the other hand, negative patient attitudes towards nursing students were a common
occurrence. Ptarticipant 16 (4y) claimed, ‘patients think the worst of nursing students and
want nothing to do with them…’ ‘Patient hostility towards nursing students’ (Pt. 111, 2y)
and ‘refusing assistance from nursing students’ (pt. 16, 4y) ‘unless the doctor or some
senior nurse insists on supporting the student’ (pt. 91, 2y) were the other challenges
posed by patients. Participants also expressed concerns over challenges involving dealing
with the families of patients. ‘Some will specifically ask that no nursing student comes
near their patient…’ (pt. 107, 2y) while some families ‘will blame it on you should their
patient die or deteriorate…’ (pt. 70, 4y).
5. Gap between theory and practice
The gap between theory and practice was remarked on by only five students. Two major
issues in this respect were to do with: firstly, equipment being obsolete; and secondly,
the proper implementation of policy and procedure in the hospital: ‘…some of the
equipment seriously need upgrading…they are too old’ (pt. 88, 4y) and ‘the hospital uses
equipment that curriculum has made obsolete…’ (pt. 31, 2y); and ‘…such equipment
creates disconnects what classwork work says and what to practice…’ (pt. 44, 2y).
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Concerning the implementation of policy and procedure, students felt that ‘…most
policies were just theoretical…I never saw some of them applied once…’ (pt. 83, 4y) and
‘…pathology is a mess in terms of policy application here’ (pt. 44, 2y).
4.5.2 Most valued in the clinical placement
When respondents were asked about what it was that they most valued in their clinical
placement, several answers emerged. Table 18 illustrates the numbers of responses in
which the theme was highlighted to give holistic information.
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Table 18 Question two: most valued in the clinical placement
Theme N
(n=90) % Example
Application of
theory into practice
and gaining nursing
skills
26 23.21% Applying what was learned in classes and
lectures into practice, students were able to
experience applying procedures like
administering medications and taking vital signs
of patients, Gaining confidence at nursing skills
and becoming familiar with the profession.
Dealing with
patients
12 10.71% Encouragement, supporting statements, and
being a rewarding experience.
The hospital is a
proper environment
for clinical learning
24 21.42% Availability of a variety of cases to study and
practice, with access to different wards in the
hospital and being in a realistic clinical
environment.
Cooperation from
both university and
hospital staff
12 10.71% Nurses were cooperative and active in the
learning process, teachers were available for
students and care was provided by the hospital
staff.
Nothing to value 21 18.75% Students were not able to get a learning
experience due to lack of autonomy and
equipment and the environment’s quality led to
poor practice.
Five main themes were identified according to the respondents’ answers and are
presented according to their importance. These were application of theory into practice
and gaining nursing skills, dealing with patients, the hospital is a proper environment for
clinical learning, cooperation from both university and hospital staff, and clinical learning
being of no value.
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1. Application of theory into practice and gaining nursing skills
Twenty-six out of 90 students asserted that application of theory into practice and
acquisition of nursing skills were their most valued aspects of clinical placement.
Opinions included the following: ‘the most important is applying what I learn in class to
the practical environment’ (pt. 69, 4y), and ‘…nursing is all about practice’ (pt. 46, 4y).
Others argued in favour of ‘being able to apply theory in a hospital setting is top of the
list’ (pt. 100, 2y), and ‘…you know you are learning as a nurse when you have the practical
feel of it’ (pt. 87, 4y). As a sub-section of this theme, participants also indicated that
‘practical sessions give [me] the opportunity to familiarise with procedures’ (pt. 99, 2y)
and ‘…you learn to read signs that patients show when practicing’ (pt. 75, 4y). There were
those who felt that practising what they learn in class ‘…boosts my confidence as a nurse’
(pt. 61, 2y) and ‘…shows me the side of the profession not shown in theory’ (pt. 24, 4y).
2. The hospital is a proper environment for clinical learning
The perception of the hospital as a proper environment in clinical learning was
highlighted by 24 participants, making it the second most valued aspect of clinical
learning. The responses given indicated that the ‘diversity of cases available in hospitals
sharpen various nursing skills’ (pt. 102, 2y). Students also commented that ‘access to
various wards with different nursing cases is very good’ (pt. 30, 2y) and ‘increased my
familiarity with areas of weakness’ (pt. 14, 4y). There were also indications that the
hospital environment ‘…made nursing look and feel real’ (pt. 89, 2y). Hospitals also
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provided students with ‘unusual clinical learning opportunities’ (pt. 27, 4y), thereby
‘increasing exposure to complex and simple clinical scenarios to learn from’ (pt. 11, 4y).
3. Nothing of value in clinical learning
Of particular concern, 21 participants did not associate being in a hospital environment
as having any value to their clinical learning. The major issues noted in this respect
included ‘not getting anything clinical to learn from’ (pt. 65, 2y), ‘inadequate hospital
equipment’ (pt. 53, 4y), or the ‘equipment that was too old for the present nursing
curriculum’ (pt. 101, 2y). Furthermore problems emerged regarding of the lack of
‘independence to practise freely’ (pt. 38, 4y) and the hospital environment being
‘…substandard to ensure proper nursing practice’ (pt. 13, 4y). Evidently, issues arose
concerning the attitude towards the current hospital placement as evidenced by pt. 45
(2y), who claimed that ‘I just do not like it here...’
4. Dealing with patients
Among the participants, 12 students stated the opinion that dealing with patients was on
their list of most valued aspects in the clinical placement. Issues in this instance included
‘getting encouragement from dealing with patients’ (pt. 40, 2y). Some patients also
‘support you even if only by word of mouth’ (pt. 96, 2y), which ‘…sort of keeps you going’
(pt. 110, 4y). Dealing with patients in the clinical placement was to some participants ‘…a
rewarding experience’ (pt. 93, 4y).
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5. Cooperation from both university and hospital staff
The same number of participants as those discussed in the previous section (12
students), also ranked cooperation from both university and hospital staff among the
most valued aspects of clinical placement. Finding ‘cooperative nurses who actively
participated in my learning process’ (pt. 23, 2y) and ‘…nurses who assist me to learn
more’ (pt. 17, 4y) were among the comments mentioned. The availability of ‘teachers
who also cared to guide me’ (pt. 100, 2y) and ‘hospital staff that were caring and
supportive of my role as a student’ (pt. 74, 4y) also featured in the comments made by
the participants concerning this theme.
4.5.3 Least valued features of the clinical placement
Responding to the question of what participants least valued about their clinical
placement, several answers emerged. Table 19 summarises the number of responses in
which each theme was highlighted and holistic information is provided.
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Table 19 Question three: least valued in the clinical placement
Theme N
(n=78) % Example
No cooperation from
hospital staff
20 25.64% Staff did not explain how things were
supposed to be done; hospital staff
discouraged students asking questions.
No proper policy and
procedure application
4 5.12% There was no connection between theory
and practice; policies taught in class were
contravened at the hospital.
Lack of practical
training
22 28.2% We were not guided on how to undertake
some procedures; patients were not
available and/or we were not allowed to
practice with them
Workload on students 5 6.41% After hospital placement lectures, there
was too much paperwork.
Unproductive clinical
placement
19 24.35% Clinical placement was a waste of time; I
never learnt anything worthwhile through
clinical placement.
Unavailable or
uncooperative nurse
teacher
5 6.41% The nurse teacher was always too busy to
attend to students; the nurse teacher took
breaks during clinical placement hours.
Other comments 4 4.12% Lack of equipment, disrespect shown by
patients
1. Lack of practical training
Twenty-two out of 78 students valued least the lack of practical training during their
clinical placements. Participants’ major concerns related to the lack of guidance they
received concerning procedures. For instance, participants expressed the disregard
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shown to them about ‘no one telling how [them] how to execute procedures’ (pt. 20, 2y)
and the expectations that ‘enough procedure was covered in class and no practical
orientation was necessary’ (pt. 78, 4y). The unavailability of patients and being denied
permission to practice with those available was another major issue. ‘Although I do not
wish that people get sick, I fear some of the things we learn in theory I will never practice’,
stated pt. 36 (4y). Participant 22 (2y) gave an example of how they never got to ‘practice
procedures like IV cannula insertion on patients’, and ‘we are not allowed to do this with
patients…it is sort of procedure here’ (pt. 57, 4y).
2. No cooperation from staff
Another 20 participants criticised the lack of cooperation from hospital staff. They did
not specifically value the occurrences when ‘staff did not care to explain how we are
expected to do things’ (pt. 92, 2y) or ‘expect students to do things the right way when we
are here to learn’ (pt. 28, 4y). Participants in this respect also raised issues concerning
staff members who were ‘unwilling to answer questions from us [students]’ (pt. 88, 4y) or
staff members who ‘joked about questions students asked’ (pt. 72, 2y). There were also
issues to do with ‘staff leaving out students on conversations like important patient
history’ (pt. 10, 4y) or ‘staff putting down professional conversation between students’
(pt. 15, 2y).
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3. Unproductive clinical placement
A considerable number of participants, representing 19 students, indicated that the
clinical placement was unproductive. Among the most prevalent comments to emerge
were the following: ‘it was a complete waste of time’ (pt. 49, 2y); ‘clinical placement was
just routine all along’ (pt. 54, 4y); ‘it made no sense to my nursing course’ (pt. 108, 4y);
and ‘it was more beneficial to the hospital...I did the oddest of jobs’ (pt. 55, 2y). There
were also issues raised concerning lack of worthwhile learning opportunities by students
in the course of their placement. Students mentioned the ‘lack of any worthy lessons
from placement’ (pt. 68, 2y) and ‘learn? Nothing worthy of the time and pressure’ (pt. 34,
4y).
4. Workload on students
Five students indicated that workload for nursing students was one of the aspects they
valued the least in their clinical learning placements. Their concerns were mainly in two
areas. The first one concerned lectures being organised after hospital placement, which
‘were just for the lecturers to fulfil timetable plans’ (pt. 34, 4y) and ‘only add to my
fatigue than knowledge’ (pt. 106, 2y). The second one was that clinical placement
involved ‘too much paperwork’ (pt. 76, 2y’ that made students ‘feel like hospital clerks’
(pt. 33, 4y).
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5. Unavailable or uncooperative nurse teacher
Another five respondents indicated that nurse teachers’ unavailability and lack of
cooperation with students were the two of the major issues. For instance, nurse teachers
were away most of the time because ‘their busy schedules left them little time for us
[students]’ (pt. 6, 2y) and ‘finding extra time with them is nearly impossible’ (pt. 98, 4y).
Sometimes the nurse teachers would ‘leave when students need them most…’ (pt. 20,
2y).
6. No proper policy and procedure application
Lack of proper application of policy and procedure in hospitals was represented by four
students as one of the aspects of clinical placement that they valued the least. This was
especially due to the perceived ‘disconnect between what theory says and what is
actually practiced here’ (pt. 71, 4y). Contravention of policies taught in class at the
hospital or ‘teaching water and practicing wine’ as it was put by participant 42 (2y).
4.6 Phase Two: Semi-structured interviews
The previous section presented findings from the questionnaire that sought to examine
students’ perceptions of their clinical learning environment. Overall it found that
participants believed their CLE did not fully meet their practical learning needs.
Subsequently, this section presents findings from the qualitative component of the study
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the semi-structured interviews to further advance our understanding of the nature of
clinical learning for Saudi Arabian nursing students.
An analysis of the students’ transcripts revealed a number of common themes. In
particular, three key themes were drawn out through reading and re-reading of the
transcripts. Each theme emerged strongly from the interviews and was then divided into
further sub-themes. The first theme covered the situation in which students felt that
clinical learning was the “beginning to study nursing for real”. Students found their
clinical learning to be “important” and “essential” for their nursing studies and without
clinical training, their studies were considered “meaningless”. However, participants
argued about the controversial reality of theory application into practice and how “in
real life, [students] do not apply [theory] the same way” as being taught in nursing
faculties. Difficulties were identified, such as limited ability to practise and the existence
of a gap between classroom theory and their clinical practice. The second theme
explored the students’ “need for someone to guide [them]” through the clinical learning
process. Students’ supervision, physical structure of the clinical settings and peer support
were considered important elements that directly affected students’ clinical learning.
The final theme to emerge from the interviews was the influence of culture on students’
clinical learning experiences. In this theme students discussed some matters arising with
reference to the marginalisation of nursing in Saudi Arabia, the impact of having a
multicultural staff in the workplace and hospital settings, with the existence of language
problems where, as noted, English is the second most commonly spoken language
159
spoken in the country. However, not all staff were proficient in this language through
which most clinical care is delivered.
4.6.1 Introduction
Clinical learning was reported by participants to have taken place from the second year
of the undergraduate course in two settings, nursing laboratories at the faculty and in
hospitals. After learning the underpinning theory of skills in classes, Sara (2y) suggested
that the teacher would “play a recorded video, then [she] starts to explain the procedure,
and finally [they would] practise it in the nursing laboratories”. Participants pointed out
that not all procedures were applicable in the nursing laboratories because they relied
on the availability of necessary equipment, such as dolls and mannequins. If that was the
case, students were asked to visualise the procedure scenario.
We get our initial training at the nursing lab [laboratory] within the
university but not all procedures are practised. This depends on the
availability of equipment. There are times when we are asked to
visualise a situation and react to it. (Fayza, 4y)
The amount of time spent in these clinical settings progressed accordingly to students’
needs and learning demands. One student reported:
It started in the second year of our study, where we are placed in the
hospital for clinical practice for four hours a week. After that, the clinical
hours in the hospital increased. (Fatmah, 4y)
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So by their fourth year, students had spent more time in the hospital setting than in the
faculty’s classrooms and nursing laboratories. At the hospital, participants explained how
they were divided into groups and then distributed around the hospital wards where
they would rotate between wards periodically. Students spoke about being able to
directly apply theoretical learning to their choice of patients:
We are divided into groups and each group will visit a certain ward in
the hospital for a period of time and then switch into another. For
instant, we were in the surgical ward for about three weeks before
shifting to the medical ward (Nora, 2y)
We’re being placed into wards in the hospital, where we have the right
to choose our cases/ patients. If the medical case was compatible with
our learning needs, the instructor would guide us through the history,
signs and symptoms, laboratory results and treatment to match up with
what we’ve learned (Abeer, 4y)
It was pointed out that the decision to choose the wards in the hospital for clinical
learning at some faculties was up to the students themselves. If a student arrived at the
hospital early, she would have priority to choose a ward of her liking. Juri (4y) suggested
this led to confusion among students due to high demands on some wards there.
Furthermore there was no opportunity to rotate between wards, which resulted in
unequal clinical learning opportunities:
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The students pick their wards. This led to major confusion by the end of
the semester due to high demands on some wards. It really depends on
who arrives first. (Juri, 4y)
4.7 “Beginning to study nursing for real”
The first theme to emerge, beginning to study nursing for real, reflects participants’
views that clinical placements exposed them to the reality of nursing, not experienced
in the university. They expressed some understanding of the complexity of the nursing
role, the multidisciplinary nature of learning and how responsible they needed to be.
They talked about how clinical practice “summarises everything learnt in theory and
gives a precise instruction of what should be done” (Fatmah, 4y) was and was thus
considered “important” (Abeer, 4y; Juri, 4y). Specifically, participants highlighted the
fact their clinical experience really helped them see how different aspects of the nursing
role fitted together:
The moment we started practising at the hospital, I felt that we are just
beginning to study nursing for real… When I’m at a clinical setting, it’s
equal to practising nursing as a profession. You learn a lot in terms of
procedures, dealing with other medical staff, learn about
documentation needed and all the responsibilities expected of me as a
nurse. (Lama, 2y)
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The nursing students valued the applied connection between theoretical learning and
clinical practice, as clinical practice gave meaning to the theory learned. One participant
stated that:
It is only by training that we may grow and mature in our studies.
Without training and applying what we’ve learned practically, our
studies are meaningless. (Sara, 2y)
Exposure to the CLE was seen to help students relate to the expectations of their future
profession as nurses. Learning clinical skills was an important aspect of clinical
education, but equally having the opportunity to interact in the clinical environment
with both other members of the health care team as well as patients, was considered
important:
It increases the opportunity to earn practical skills and learn new
procedures. Observe the interaction between staff and students and
learn skill of dealing with patients from the staff. (Fayza, 4y)
During their first encounters with the clinical environment at the hospital, most
students recalled being “terrified”, “confused” and shared feelings of “insecurity” and
lack of “confidence” meeting the patients and executing procedures. This is reflected in
the words of the following two second year participants:
When we first came to the hospital, we were terrified and confused.
When we first saw the patient’s file, it was scary... we were still too shy
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to enter to a patient and have no confidence in practising procedures.
(Hayfa, 2y)
It was my first clinical experience outside the faculty and I lacked
necessary knowledge, not knowledge but practical experience and
confidence. (Sara, 2y)
However, by their fourth year, students had been more exposed to the clinical
environment and hence expressed being more at ease in handling tasks required of
them. They could articulate how different they felt, from second to fourth year
especially in terms of confidence, as evidenced by Fatmah’s comment:
When I was in my second year, I knew nothing. I used to be afraid to get
in contact with patients, afraid of handling procedures like giving
medications. I used to be too afraid my hand won’t stop shivering. But
now I have more confidence. (Fatmah, 4y)
Reflecting her insecurity, Amal (2y) suggested that “practice and clinical placements are
and should be mandatory from the beginning” regarding this aspect of her course as so
integral to her developing professional self. Fatmah (4y) further confirmed the
importance of the clinical learning as a part of her nursing studies by saying:
I think it’s impossible for me to study nursing without any clinical
learning. Because clinical learning summarises everything we learnt in
theory and give us precise instructions of what we should be doing.
(Fatmah, 4y)
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4.7.1 “In real life, we do not apply it that way”: The relationship between
theory and practice
This sub-theme reflected how participants were clear about their clinical learning
demands and expectations. However, in their interviews they revealed a number of
issues within the clinical environment that hindered the process of having positive
clinical learning experiences. Although as already discussed, participants valued the
clinical education in their course, they anticipated problems with the application of
theory into practice. They identified gaps between theory and practice and bad timing of
synchronising theory into practice as major blocks in their clinical experience. Students
asserted that they were taught the ideal scenario of nursing procedures such as
medication administration, dressings and physical assessment, in in terms of theory.
Students were being provided with specific steps and instructions in the classroom to
follow while executing these procedures in a practical setting. However, these guidelines
seemed to be in stark contrast to what they saw in practice as: “When we went to the
hospital, especially the first time, it didn’t resemble anything we’ve learnt in theory”.
(Hayfa, 2y). Lama added that:
During the theory classes, we learn procedures with detailed steps and
high accuracy. However, in real life, it’s not necessarily applied.
Procedures can be done, carelessly, or not as we expect them to be.
(Lama, 2y)
This was not a unique situation to second year students. Fayza, a fourth year
student, had similar observations of a discrepancy between theory and practice
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and remarked: “In the practical classes, we were asked to perform procedures
according to the check list in the same order, but in real life, we don’t apply it
that way” (Fayza, 4y)
Some students complained that the gaps between learned theory and clinical
practice mean that their clinical learning progress experienced delays:
In terms of experience, I’m still at the same level as I was in the 4th level
[2nd year]. (Juri, 4y)
Surprisingly, in some situations it was seen to be staff nurses who encouraged this gap in
theory to practice application by being ineffective and inconsistent role models, as noted
by Lama:
Procedures can be done, carelessly, or not as we expect them to be. It
can be over the simplest things, such as gloves, they don’t wear them.
The only reason to wear gloves is when the patient is known to be a high
risk of transmitting disease. Other than that, we are advised by [the
nurses] to not wear gloves because it can be a barrier to working freely.
(Lama, 2y)
Another student had also noted observing poor practices being performed by other
health care providers throughout the hospital. Abeer (4y) noted that patient care was
not as good as it should be and due to the clinical preparation she received, she was able
to identify the existence of a divide between theory and practice:
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I saw a dressing done by a physician and I was shocked that he used the
same gloves in removing the old dressing to apply a new one. This is
wrong, and I know that because we’ve studied it… The phlebotomist
back then, he was not wearing gloves, cleaned the skin with alcohol
swaps, touched the skin again to feel the vein, and then inserted the
needle. I knew that was wrong and it was not the proper way in doing it
because of the clinical training we got in the university. (Abeer, 4y)
Additionally, it was perceived that qualified health professionals would ignore any advice
or feedback about their performance when provided by students:
Prior going to the hospital, our teacher told us that the nursing staff in
the hospital will most likely refuse any advice coming from you “as
students” because they are in the middle of their job or they may feel
that they’re more aware or knowledgeable about their profession than a
student. So, we were asked to not interfere and just observe. Even
though we did complain about the misuse or not using the gloves,
nothing actually happened and remained the same. (Lama, 2y)
Another student discussed reporting a similar incident back to the nursing faculty where
they advised the students to ignore and not interfere with staff practices, unless a more
friendly relationship was established. It was thus made clear to students that they were
expected to observe and not say anything:
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We went directly to our teacher and told her what the nurse said, she
replied, it’s none of our business! Unless I have a good and friendly
relationship with the nurse, I cannot advise her about the procedure.
Otherwise, we are here only to train and observe. (Hayfa, 2y)
Further, interviewees suggested that theory lectures did not always align with what
students would be experiencing in their clinical practice. Such a mismatch between the
actual learning of the theory and its application into clinical practice led students to a
state of “confusion”:
There are things we have been asked about in the hospital before we
had the chance to learn about them, e.g. the ventilator, we did not study
about it until we were in fourth year. Nonetheless, during second year at
the hospital, we were expected to be knowledgeable about it. This led us
to become confused… we should learn about a procedure first in the
lecture and then apply it or observe it in the hospital, and not the other
way around. (Fatmah, 4y)
Conversely, students were not always properly introduced, or prepared to perform some
of the clinical procedures required in their clinical placements during theoretical and
laboratory classes. This reflected on the quality of provided skills learning. As a result,
students described lacking confidence when asked about some of these procedures in
the hospital. Amal, a second year student, stated:
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Some procedures, for example, oxygen therapy, were not taught nor
practised well in the faculty. Therefore, we had a really tough time
practising them in the hospital. (Amal, 2y)
Fourth year students reported encountering similar experiences where it was described
that they did not have the opportunity to apply theory into practice in the faculty
laboratory environment before clinical placements. This resulted in poor performance
during hospital placement because, again like their more junior colleagues, the students
reported lacking sufficient skills and confidence to turn theory into practice. Clinical
nurses’ high expectations of students resulted in one student bearing the brunt of anger
from one staff nurse:
I really don’t like being asked about a procedure that I haven’t even
studied. For example, there’s one lecturer who asked me to perform
several procedures using the NGT on a patient. Keep in mind that we’ve
just taken the lecture, saw it once in the lab [laboratory] and didn’t
practise it properly on a doll, not to mention on a patient. She asked me
to do the flushing and aspiration, but I was not confident enough of the
technique. So, I replied saying “I don’t know”. She got angry at me
saying “why would you not know! You’re supposed to have taken the
lecture and therefore you should know how to apply it in practice”. I
apologised saying that I didn’t have the chance to practice and I cannot
apply it on the patient. (Fatmah, 4y)
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Furthermore, teaching aids, specifically dolls and mannequins, were not perceived by
participants as ideal ways to practice certain procedures in nursing laboratories, being
unable to fully understand the real situation. That subsequently reflected on the quality
of clinical learning students received:
With the CV [Cardiovascular] devices, we were asked to visualise a
patient been connected to the device. There was a doll attached to the
device, but these things cannot be taught unless a real patient is
available for observation and monitoring. (Fayza, 4y)
In some situations, participants explained how availability and low quality of equipment
in the nursing laboratory further compromised the clinical learning of students:
In the nursing lab [laboratory], we have a major shortage in supplies;
even most of the gloves have already expired. I had an allergic reaction
from the latex material in these gloves. (Sara, 2y)
A student who transferred to a nursing faculty from the medical faculty commented on
her appreciation for the faculty staff, who were dedicated to the nursing profession.
However, the disorganisation of the nursing laboratories was reported to have caused
her disappointment and regret:
I tried to love the discipline and the faculty staff has a lovely way in
doing so, but when I’m faced with such difficulties, I get disappointed
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and frustrated and sometimes think “why did I even enter this
profession?” (Sara, 2y)
Another issue that students reported as problematic was the timing of applying theory to
clinical practice. Participants suggested that there was often a long wait between theory
classes and their clinical placements. One fourth year student talked about her
experience with one clinical procedure in the hospital and how the nurse teacher refused
to review the lecture on the basis that it had already been taught the previous year. The
student felt pressure to perform but had been taught the theory so long previously, she
reported simply forgetting:
Some [nurse teachers] for example will say something like “you already
took this procedure during the previous year, and I’m not obligated to
re- teach it to you” but I simply forgot. (Fayza, 4y)
While students acknowledged the nurse teacher’s premise that it was their responsibility
to review a previous lecture, it was argued that often an instant response was needed
during the clinical practice to emphasise the clinical learning experience. Interacting
positively with students about their clinical practice was seen to encourage a more
positive clinical experience, rather than punishing them for what they did not know, as
described by Abeer:
Sometimes we need an instant answer, on the spot, to help us with the
case! I personally, don’t appreciate this method because I lose interest in
discussion if not at the time of the question, though I would obviously go
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and read later. But if she had answered my question on the spot that
may inspire another question and open the chance for discussion, which
is a good thing in learning. (Abeer, 4y)
4.7.2 Ability to Practise
The second sub-theme, ability to practise, emerged through students’ repeated
descriptions of aspects that affected their ability to practise in a timely way. It did in fact
contribute in a major way to the perceived gap between theory and practice. Interviews
revealed a number of reasons as to why the students had limited ability to practise in the
hospitals. Perceived limitation in hospitals’ resources included “unavailability of
equipment”, “lack in medical cases” presented or accepted by the hospital, and the
individual hospital’s policy and limitations on students’ eligibility to practise. Time and
workload that students had to meet during clinical placement from both faculty and
hospital were also key aspects influencing their ability to practise. These aspects made it
difficult to fulfil clinical requirements.
Participants argued that hospital resources, including equipment, determined their
availability of clinical practice. Lama (2y) said that “the tools in the hospital, if available,
are out-dated” and therefore cannot be used. Further, Sara (2y) stated that some
sections on her clinical checklist were left blank due to limited access to a stethoscope
available on the ward. Fourth year students continued to report similar issues. One
pointed out that that: “We’re provided with a checklist to follow and complete...
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Sometimes, however, that depends on the availability of equipment in the hospital itself”.
(Fayza, 4y)
Similarly, Fayza (4y) remarked that due to the absence of the nurse manager in the ward,
she had no access to some of the clinical documentation forms required to complete the
course assignments. Ultimately, such situations had negative effects on the students’
evaluation outcomes and their perceptions of their placements:
The management course, on the other hand, was completely horrible.
We have a single day to practise for this course and I was supposed to
get the forms and sheets needed from the nursing managers themselves
but they were not available. (Fayza, 4y)
Participants pointed out that there were differences between private and governmental
hospitals in regard to the variety of medical cases available and this influenced clinical
learning. Private hospitals seemed to have tighter criteria on medical cases accepted and
limited student access to some cases. This meant that time was often wasted while the
student waited for an appropriate case where they were allowed to practise:
The hospital I’m at now is not open for all cases and does not receive
any patients like the other governmental hospitals. Therefore, they have
a lack in medical case variety, and if there were rare cases, it is difficult
for us as students to look it up and observe. When the situation is like
this, we lose time waiting for a traumatic case to be admitted and
therefore cannot learn a thing by then. (Abeer, 4y)
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This limitation on students’ activity was not exclusive to private hospitals. In
fact, interviews suggested that most hospitals limited students’ activities to
observation only in some cases, regardless of their knowledge of the procedures
being seen. This was believed to be due to the fear of possible litigation in case
complications occurred with patients:
Even though we have taken the theory on IV cannula insertion and
practised it, [the nurse] refused that we would administer it to any of
her patients. Because it was going to be her who will sign on its insertion
and she is the one who will be at risk if any complication occurs. (Nora,
2y)
This matter extended to fourth year students as well, who were only allowed to
perform simple tasks such as checking vital signs. This resulted in frustration
because they felt hindered in the process of clinical learning and limited in the
quantity, breadth and experience of nursing skills gained:
The very thing we are allowed to do is taking vital signs, and we should
be thankful too. Regardless of whether the student is eager or not to
learn, the hospital just won’t help. (Juri 4y)
Furthermore, participants expressed their disappointment in not being able to achieve
their learning goals due to these impositions on their ability to practise. One second year
student made the following remark:
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The problem is that the nurses have no confidence in our practical ability
and deny the fact that we have been taught to do these things. We are
always being shut down because we are at our second year of study and
according to them, we don’t have these skills yet. (Nora, 2y)
Regardless of their expertise, fourth year students faced similar restrictions on their
ability to practice in the hospital:
I do feel that we don’t gain enough skills during the clinical practice
because they don’t allow us to practise, only observation or practice of
those simple and easy procedures. (Fatmah, 4y)
Students’ inability to practise was reported by participants to have ultimately affected
their grades, and their overall clinical learning experiences. They expressed frustration at
being assessed by nurses who had not actually witnessed them performing procedures:
What made things worse for us was the nurses’ evaluation of the
students...How did nurses evaluate our performance when they are the
ones who don’t allow us to do anything?...Now, I struggle mentally
when I realise that I have to go to the hospital because I know I won’t be
doing anything. (Juri, 4y)
Another difficulty that participants faced was the time provided for the actual clinical
learning to take place. Time allowed for students in the clinical placement was
considered insufficient to cover their learning goals. Hayfa (2y) stated that five hours per
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day were provided for clinical learning in the hospital. However, situations such as the
patient being asleep or the patient’s file being used by someone else, reduced the actual
time for practising by students:
We barely have five hours in the clinical placement and the actual
training hours are merely two! There are some circumstances when we
cannot train. For example, when the file is with the nurse and therefore
we can’t have it, or if the patient was asleep. I think the appropriate
thing to do is to go early morning, before 8 am. Usually the ward is too
busy and we cannot do anything before 10 am, that’s why I feel we are
losing a lot of time. (Hayfa, 2y)
Fayza (4y) explained that clinical learning time could also be wasted due to weather
conditions and faculty holidays, where the university would be closed and there would
be no access to the hospital and hence, would cancel the opportunity to practise at the
hospital. She also added that university transportation could be time-consuming,
especially when students needed to gather at the university and then take the bus to get
to the hospitals. In Saudi Arabia, students are unable to take their own transport to and
from clinical placements and the university transport them. Further, faculty examinations
would detract from clinical training time since students had to consider their
examinations during their clinical placements or if an examination would take place at
that same time:
The next day [of clinical training] was cancelled due to weather
conditions and the week after was a mid-semester vacation. Tomorrow
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will be our second encounter at that ward [in a month]… Time [is
limited], we don’t have enough hours to train in the hospital. Also, the
hospitals assigned are far from the university and takes time to be
reached. The pressure of exams also affects our training. (Fayza, 4y)
Many participants complained about work overload and how they found it difficult to
manage between faculty demands and hospital placement requirements:
For us second year students, our schedule is busy and we have many
subjects to cover. It’s hard to differentiate between what is important
and what is less important. (Amal, 2y)
The same issue was reported to have been experienced by fourth year students.
Fatmah (4y) talked of a massive workload that students were expected to
complete, during the limited clinical practice time. Students’ evaluations were
based on completing both compulsory paperwork and clinical tasks. However,
students found it challenging and confusing to meet both requirements. This
ultimately caused her to feel repelled by clinical learning:
Pressure! I don’t like to carry a lot of workload in a single area. I cannot
do many things at the same time, should I practise, observe procedures,
study, complete the paperwork, or do my homework? These loads of
paperwork did not assure me that I could do the practical part of my
learning, neither complete the reports asked of me. This confusion is
what repelled me from the clinical training… Sadly, we are evaluated by
these reports, so whether you’re a good student practically, if you didn’t
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do your paperwork properly, marks are deducted. After all, we are
nurses not writers. (Fatmah, 4y)
Another student added that good time management was needed to sort through the
many requirements:
I’m already overwhelmed with workload and the paper tasks. We have
to submit the graduation research and other papers for other subjects.
We also have continuous quizzes for various subjects, not to mention the
presentations that we have to present. The main issue is with time
management. (Fayza, 4y)
4.8 “All I need is someone to guide me”
The second theme to emerge from the interviews involved participants’ need to seek
support and guidance in managing their clinical experiences in an often unfamiliar
environment. Their discussions around this included nurses, nurse teachers and the
actual learning environment. During their clinical experiences in the hospital setting,
students required a certain level of guidance to support their learning. Most hospitals
would host students from different disciplines and they might not be the best guiding
choice for their peers or other students. Amal stated:
You feel lost and have no one to turn to since the entire hospital is
hosting students. It’s useless going up to another student for an answer
because they usually do not know. (Amal, 2y)
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4.8.1 Nurse teacher role and the influence of nurses’ supervision
This sub-theme emerged as students described being mostly guided during their clinical
placements by nurse teachers, usually academic staff from the nursing faculty, with a
role to teach and guide. Participants talked about the important enabling role of nurse
teachers in preparing and supporting students for their clinical learning, such as that
described by Abeer:
They [nurse teachers] are the most helpful source during our training
and they’re available and ready to answer no matter how many
questions we have...Most are supportive and follow up with us
continuously, encouraging us to learn, observe and perform procedures.
They go sometimes to the extent of asking around for procedures due
that day and informing us to be a part of them. (Abeer, 4y)
However, some participants complained about the attendance of their nurse teachers.
They were seen to have busy workplace roles and were in and out the ward many times.
Consequently they were not always available to assist students as much as needed. As
explained by some students, due to the large numbers of students in the clinical settings
and the shortage of faculty staff, the nurse teacher had to rotate frequently between a
number of wards, and therefore, was not easily accessible at times during the day:
Nurse teachers do help you and answer your questions but they are not
available all the time. I only see them at the beginning when they assign
you with nurses, disappear, and come back again by the end of the day.
(Amal, 2y)
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…our nurse teacher guides us always as much as she can and because
our group is large, she comes and goes a lot during the shift. (Fayza, 4y)
Another difficulty facing students was understanding the teaching approach used by the
individual nurse teacher. Fatmah (4y) claimed that her nurse teacher was “strict” and
“demanding” of students in the clinical setting, seeking perfection in their performance
from day one. She also added that her teaching method was disciplinary-based:
Some [teachers] remain by your side in a restrictive manner that it’s
almost difficult to breathe and we’ve been criticised over the smallest
things, e.g. if we wanted to sit down to rest our legs, we get scolded
“why are you sitting and doing nothing?”…I really don’t like this
approach…I won’t be able to work. This is the difficult part in dealing
with the instructors. (Fatmah, 4y)
Fatmah (4y) subsequently added that students were continuously criticised and scolded
over their appearance and performance during their hospital placements. The
participants reported not appreciating this type of approach. The consequence was a real
hindrance on performance and the overall experience of clinical learning:
Some of them just scold you all the time “you don’t study! You don’t
work! When we were at your age we used to study 24 hours a day!”. I
don’t like this style. I’m ok with her correcting my mistakes but not
saying things like “You never study! You’re useless! How will you ever be
nurses!” It’s a big “No” for this approach. (Fatmah, 4y)
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This perception was reinforced by Fayza:
Criticism! That’s what we get most of the time…They focus more on the
attendance and the dress code more than the actual training and
knowledge. (Fayza, 4y)
Fayza then added that some nurse teachers lacked proper communication skills when it
came to conversing with students. In fact, they tended to handle matters on a very
personal basis. Fayza said:
She refuses to discuss matters with students. For her, to discuss or argue
means you’re being impolite. She has no skills in dealing with students.
Others will evaluate you depending on their likes, if the teacher likes
you, you could have good grades, but if not, then you marks will be low.
I’m not the only one saying that, many students have the same
observation. (Fayza, 4y)
Aside from their role to deliver the highest standards of nursing care to patients, as
professionals it was also the staff nurses’ responsibility to support the learning of other
nurses, including students. Fayza (4y) believed that nurses in the hospital were
considered to be role models to students as they could observe the interactions between
the staff themselves and the execution of patients’ health care needs:
It increases the opportunity to learn practical skills and learn new
procedures. Observe the interaction between staff and students and
learn skill of dealing with patients from the staff. (Fayza, 4y)
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Nurses played a significant part in the process of students’ clinical learning, either as
important positive influences or a source of negative experiences:
The nurse I was assigned with today was completely cooperative, she
taught me a lot and if I had any question, she would answer me. I was
highly satisfied with her and completely comfortable dealing and
working with her (Fatmah, 4y)
However, nurses from different hospital departments were seen to have different
attitudes toward students. Outpatient nurses were observed to be less supportive of
students compared to other departments where students went for their placements:
At the outpatients department, the majority of nurses were horrible and
not supportive. However, at the ward, the nurses were somewhat
helpful, especially during the first day. They would take you around,
teach you basic information, and will guide you to other nurses if busy or
do not know an answer (Amal, 2y)
Due to the ambiguous nature of their role, challenges in effectively fulfilling their roles as
a consequence of workloads, insufficient time, inadequate staff levels, primary patient
care responsibility, and lack of coherent training and support, just another aspect of their
busy day, staff nurses’ support to students were viewed by participants as satisfactory.
Overall, students concluded that nurses could do more to support their clinical learning:
Around 10% of the nurses would actually explain what they do as they
are doing it, and if you have a question they would give you a
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satisfactory answer. The others, on the other hand, if provided an
answer, it would be a short one. They would ignore you and do not
involve you in the practice... The attitude you get is ‘hurry up and leave
me to do my job. (Lama, 2y)
Due to their heavy workloads and other responsibilities, many nurses felt that having
students to supervise was perceived by them as an extra “burden”:
I feel that I am a burden on them. They are all competent, but the main
issue is they have a huge workload and on pressure, that’s why they are
too busy to teach, instruct, or even answer my questions. (Fatmah, 4y)
Additionally, past experiences with other students were seen to have possibly influenced
nurses’ attitudes and interactions, as suggested by Lama:
It might be possible that they had a bad experience with previous
students before, or they really have no time to explain things during the
shift (Lama, 2y)
Furthermore, one student stated that even with the support of the nursing faculty and
the efforts made to motivate the nursing staff to assist students during their clinical
learning, nurses remained unhelpful or supportive to students. Jury (4y) said:
[the faculty] will motivate nurses by increasing their salary in exchange
for the time spent teaching and guiding students. The head of the
faculty (the same person who owns the hospitals where students train)
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gathered all the students and advised that it was done. So we waited!
The situation remained the same. Nothing changed (Jury, 4y)
Students pointed out how staff nurses’ attitudes strongly impacted on their clinical
learning experiences and performance, as evident in the following statements:
There has been an issue lately regarding a nurse refusing to have a
student around her. (Nora, 2y)
The nurses are not supportive at all, they patronise you as if you’re
nothing... and when I ask her about something in the file she would
answer in an unwilling manner. How am I supposed to learn in these
circumstances? (Juri, 4y)
Notably, it was the local Saudi female nurses who were observed as having the worst
attitudes in their treatment of students. In contrast, Saudi male nurses were seen to be
more cooperative and helpful in the clinical learning process, as highlighted by Fayza and
Amal:
There is a hospital where the entire surgical ward’s nursing staff was
Saudi, it was the worst. It’s different with the male Saudi nurses though.
They tend to help us and teach us about procedures, unlike the Saudi
female nurses, who took our belongings out from the staff nurse and
threw them at the nursing station. (Fayza, 4y)
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I also feel that male nurses are more willing to help than females. (Amal,
2y)
In Saudi Arabia, most hospital staff nurses hold diplomas in nursing. It was suggested by
participants that students who were undertaking undergraduate degree studies, were
viewed as rivals to the nurses’ positions in the future. This further impacted on the level
of support they received during placements:
Most staff carry a diploma certificate, perhaps they find us as
competitors. Some of them refuse to teach and guide us whether they
were Saudis or non-Saudis. (Fayza, 4y)
I think nurses don’t want to be involved in my learning process because
they are worried we might take their places one day. (Juri, 4y)
After choosing their ward of interest, students were appointed to a hospital staff
member, usually a nurse, to act as a preceptor to monitor and guide them through their
clinical placement:
At first, our teacher would introduce us to one of the nurses and advise
her of our presence during her shift. (Lama, 2y)
However, the idea of continuity in support was not always possible in practice. One
student suggested that:
Every day we are assigned to a different nurse to supervise us during our
clinical placement in the ward. (Nora, 2y)
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Others claimed they were allocated to the nurse manager. The nurse manager’s role was
to provide students with a list of patients explaining their diagnosis from which they
could choose, as well as a number of tasks for them to complete during their clinical
placement. That role, however, did not include direct guidance and support of actual
practice:
We are not assigned to nurses, we get in touch with the nursing
manager who in his/ her turn provide us with tasks to complete during
our stay at the hospital, in addition, we are provided by the complete list
of patients rooms with their diagnosis for us to choose a case. (Fayza,
4y)
4.8.2 Clinical Learning Environment
The second sub-theme to emerge under the need for guidance related to the CLE itself.
Participants explained that the clinical learning setting had an impact on their learning
experiences. The hospital’s physical appearance influenced students’ perceptions as it
reflected the quality of the hospital itself. Sara (2y) was disturbed to see wild animals,
such as cats, roaming casually in the hospital with the acknowledgment of the hospital
staff. Additionally, she argued that hospital rooms were unfit to accommodate patients:
I myself was puzzled as to how can a governmental hospital, and a
training hospital for that matter, be like this… there are wild cats
running around and when we reported this to the nurses, thinking that
they have no clue about the situation, we were shocked by their
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response. They said “yes we know, they usually stay around at the
outpatient clinics and every now and then we leave food for them”…it
was chaos. Another thing, is the patients’ room structure including beds,
I feel if was not fit to properly hospitalise a person. (Sara, 2y)
Lama (2y) reinforced these perceptions by stressing the generally unclean state of the
clinical environment, especially how it negatively affected her clinical experience:
The general cleanliness of the environment is almost zero and that
includes the floors and the rooms. I even suspect the staff too, since
none want to wear gloves. I get the sensation that I’m walking into an
industrial factory, all the equipment are out in the corridors. Not to
mention the density of the place; the space is too small and too
crowded. I think it’s becoming uncomfortable even for the patients
themselves. (Lama, 2y)
Sometimes the general atmosphere and hospital harmony was reported to have an
effect on students and their clinical performance. Lama (2y) explained how an argument
between one of the physicians and his patient made its impression on her. The patient’s
yelling caused tension around the hospital ward, which only encouraged her to avoid this
particular person and others with the same attitude:
Sometimes, the attitude of others including patients, visitors, nurses,
other medical staff, can have a huge influence on me. If I had a bad
experience with a patient, it would affect my performance…The other
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day I was walking on the ward, when a patient was complaining about
her physician. She [the patient] was yelling so hard that her voice
resonated all around. I went there to calm her down but she kept on
yelling. Other staff thought she was yelling at me, too. Ever since, I‘ve
been avoiding her room and only went into her room once or twice.
(Lama, 2y)
Abeer (4y) also suggested that arguments between staff themselves would have
a negative effect on students. She talked about how nurses’ behaviours and
moods would reflect on them:
Sometimes it gets really stressful in the ward, for example, sometimes a
fight happens between two physicians and I lose focus. Another incident
is when the nursing manager is “angry” at the staff for breaching the
rules, as an example. In return, the nurses’ behaviours would reflect
negatively us students. (Abeer, 4y)
Another way that students may have perceived the hospital as an inhospitable
environment for learning was the treatment they received from staff nurses. Fayza (4y)
suggested that nurses did not welcome their presence at the ward and were unhappy
with students using the staff room to store their personal belongings:
As students, we don’t have the space to place our personal belongings
during training. Once, at the last hospital we were at, we entered the
staff nurses’ room to have our lunch break. The next morning, it was
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locked and we were prohibited from entering it. At that hospital,
students are mistreated by the staff. (Fayza, 4y)
At the nursing faculty, students complained of security issues where a number of
students had their personal belongings and clinical equipment stolen from their lockers.
Nora stated:
There have been some incidences of theft. One has lost SR [Saudi Riyal]
500, and most students who leave their stethoscopes in the college
lockers, had theirs stolen. Sphygmomanometers, lab [laboratory] coats,
and my friend had her jacket stolen too. (Nora, 2y)
Having such equipment and personal effects stolen could have deeply compromised
their ability to practise as well as their perceptions of their clinical learning environment.
4.9 Cultural views and struggles
The third theme to emerge from participant interviews involved cultural issues and how
these impacted on clinical learning. This theme contained three sub-themes: the broad
idea of nursing is marginalised, family influences on students’ studies, and multicultural
workplace. These are described in more detail below.
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4.9.1 ”The broad idea of nursing is marginalised”
Marginalisation of nursing as a profession emerged as an important factor influencing
students’ clinical learning experiences. Nursing is not yet considered to be a valued
profession, particularly for females, according to local perspectives in Saudi Arabia. This
was raised as having an influence on participants’ experiences during their clinical
placements:
The broad idea of nursing is marginalised and it makes no difference
whether you were Saudi or not, in the end you are a mere nurse. I know
it takes time for the community to accept us completely...There’s a
major lack of support from the community to the Saudi female nurses in
particular. (Lama, 2y)
While “nurses were respected and appreciated by all” (Fatmah, 4y) in some hospitals,
others were perceived by students to look down on the profession and see it as an unfit
occupation for Saudis in general, and for Saudi females in particular. Locals including
patients, patients’ relatives or visitors would attempt to persuade nursing students to
quit the discipline and seek a more socially acceptable profession such as management.
Participants reported that some Saudi patients would refuse to be cared for by Saudi
female nurses:
With the patients, I observed that most female patients refuse to be
handled by students. (Fayza, 4y)
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Sometimes, I have an issue with visitors and patients’ relatives. They
would approach you and talk badly about you. They would say “you’re a
Saudi female; you should not be working as a nurse, find another
position for yourself ‘a supervisor or a manager’, and let the other
foreigners do this job. However, on the other hand, there are some who
are completely supportive and consistently thanking you for what you
are doing; ‘we are proud of you, being a Saudi who helps us’ and other
encouraging statements. (Lama, 2y)
Similarly, other health care workers, for example physicians and medical students, were
also reported to be unappreciative of nursing and this affected the clinical experience of
nursing students:
Some of the other students, especially medical students, will harass you
with looks that patronise our profession. (Amal, 2y)
The physicians themselves can be bothered by our presence. Sometimes
during the rounds, we are faced with comments like ‘not them again,
what are they doing here’. Therefore, to avoid such harassment, we
leave. (Juri, 4y)
However, in other hospitals, students reported experiencing different reactions from the
medical staff. According to Fatmah (4y), physicians did support students’ clinical learning
and were willing to communicate and interact with nursing students:
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There are physicians who are willing to be involved in our learning
process, for example, explaining procedures. It sometimes goes as far as
calling us to join rounds to learn. I sometimes feel that we don’t keep
enough contact and I think we should cooperate with them. (Fatmah,
4y)
Additionally, students pointed out that the nursing status differed from one city to
another. Nursing faculties have existed in some cities for a long time and therefore
nursing was more accepted there, and provided a higher quality education compared to
that in the other cities:
I hear from other colleagues at different cities, that the nursing
education, especially the practical part, is much better than what we are
having here. Also, another friend of mine who studies at a medical
college told me that the nursing status at that city is really something. I
don’t know why it’s not the same here, maybe because those have been
around longer! (Hayfa, 2y)
4.9.2 Family influence on students’ studies
Families play an important role in supporting nursing students through their studies.
General views of nursing in Saudi Arabia extended to students’ families and it, in return,
had a direct effect on students. In Lama’s instance, her family was supportive of her
study choices. She felt that:
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Family has a big influence on you. Thank God I was blessed with
understanding parents who encourage me to follow my destiny. (Lama,
2y)
However, Amal had a very different experience given that her family was initially
opposed to her desire to enter the nursing discipline. However, due to her proficiency in
providing patient care compared to her medical student sibling, family approval was
granted:
None of my family [approved of my study], everybody was against it.
But now it’s different...[now] my mother approves of me as a nursing
student…My sister is in her fourth year in medicine and I have much
wider knowledge than she does. There are some skills that I’m aware of
and she isn’t, such as taking the vital signs. In a way, I’m more advanced
than she is. This is the main cause that my mother approves of me as a
nursing student. (Amal, 2y)
Given that nurses work shifts often lasting twelve hours, this also had an effect on
students’ perceptions and their future expectations of their profession. It challenged
their family-oriented cultural traditions in limiting their availability to fulfill certain roles
within their family structure. Fatmah suggested that twelve-hour shifts were not
considered ideal for family life as it is lived in Saudi culture. She expressed her interest in
working as a staff nurse if an eight-hour shift was introduced:
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I do wish they would introduce the eight-hour shifts to our system. This
way I can feel I’m a regular person rather than the 12-hour shifts. If I
think about my future and had a family, I cannot stay 12 hours outside
the house working. (Fatmah, 4y)
4.9.3 Multicultural clinical settings
In Saudi Arabia the nursing workforce is predominantly foreign and comprises nurses
from many countries such as the Philippines, India, South Africa, Egypt and the United
Kingdom. This draws together many different cultural perspectives and nursing
backgrounds. As a result, there are significant dimensions of culture that impact on
nursing practice in Saudi hospitals.
Cultural variations in the CLE were seen to present unique challenges for nursing
students in this study. Juri (4y) explained how she found staff members had a wide range
of attitudes and methods of dealing with students. In one incident, a staff member was
perceived as rude and abusive towards one of the students. Juri contended that her
behaviour was due to her non-Saudi background. However, the incident was not
reported to the nurse teacher due to insufficient information:
One of the obstetricians grabbed one of the girls by her clothes and
yelled at her “What are you doing here? Who said you can be here?”
and kicked her out. My friend was too shocked, she kept silent and didn’t
respond. Of course news travels fast and we learned about this incident
and encouraged her to tell our teacher about it. The girl didn’t know the
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name of the obstetrician, other than she was non-Saudi (Egyptian). (Juri,
4y)
4.9.4 Language Barriers
Language barriers present extensive challenges for nursing students in Saudi Arabia. In
nursing faculties, courses and materials available to students are provided in the English
language. Given that English is a secondary language in Saudi Arabia, and not students’
first language, this creates unique challenges for students communicating with non-
Arabic speaking teachers at university. This factor was reported to have affected the
entire process of clinical learning, for example, by Lama:
Our nurse teacher is leaving soon and my deepest hope is that we get a
Saudi, or at least an Arabic-speaking replacement. Language barrier is
not going to help our learning process and we need to gain as much as
we can in the theory to practise properly later. (Lama, 2y)
Within the multicultural workplace, few nurses speak in Arabic and care is primarily
managed in English, and complicated by different accents. Here too, language barriers
hindered students’ communication given the predominance of non-Arabic speaking
hospital staff, including nurses. This factor was reported to have further prevented
students from taking full advantage of the clinical learning experiences available:
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There are nurses who are willing and fit for supervision, but the
language stands as a barrier ‘accent/dialect’ and we cannot
communicate effectively. (Nora, 2y)
Perhaps due to language barrier, a nurse might think that it’s a waste of
time to try and communicate with students when they might not
understand her. (Lama, 2y)
Some hospital staff acknowledged the issue of miscommunication, not only with
students but also with patients, their relatives and other non-English speaking personnel.
To manage this matter, Arabic language courses had been introduced for them:
The nurse managers were completely supportive and participate in our
learning process effectively. They even learned how to speak the Arabic
language which made it much easier for us to communicate. (Nora, 2y)
4.10 Conclusion
This chapter provided findings from both phases of the study. The first section presented
findings from the questionnaire. Questionnaire results showed overall responses
between “disagree” and “neutral”, which constitutes evidence that participants found
the CLE they experienced was not fully satisfactory in meeting their practical learning
needs. The second section presented findings from the semi-structured interviews with
second and fourth year nursing students, and their comments further enhanced our
understanding of how Saudi Arabian nursing students perceived their clinical learning
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experiences. Three key themes emerged from the interviews: firstly, beginning to study
nursing for real; secondly, all I need is someone to guide me; and thirdly, cultural views
and struggles. The findings suggest that there are particular clinical learning experiences
that are unique to Saudi nursing students. The next chapter presents a discussion of the
quantitative and qualitative findings in the wider context of existing knowledge and
literature.
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Chapter Five: Integrated Discussion
5.1 Introduction
This study explored the quality of clinical education in the nursing undergraduate
curriculum in Saudi Arabia by looking at the factors within the CLE that might affect
students’ outcomes. The study also measured the nursing students’ satisfaction with
their clinical education. By doing so, this study provides recommendations to improve
the nursing curriculum in Saudi Arabia. It sought to answer the following research
questions:
What is the quality of clinical education in the nursing undergraduate curriculum
in Saudi Arabia?
What are the factors within the CLE that might affect students’ outcomes?
How satisfied are nursing students with the provided clinical education?
How can clinical education be improved in the nursing curriculum in Saudi Arabia?
A detailed analysis of the data collected during phases one and two in this study was
presented in Chapter Four. This included interpretation of the quantitative and
qualitative findings which identified current factors impacting on the preparation of the
future Saudi nurses involved, and creating a professional environment for clinical
learning.
This chapter discusses the key findings arising from the data to contextualise them in the
broader scope of what is already known and previously reported in the existing
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literature. It demonstrates this study’s uniqueness and provides new perspectives on
understanding the intricacies of clinical learning, thus contributing new knowledge to
what is already known. The socio-demographic data were designed to obtain essential
information about nursing students from three different nursing faculties in the western
region of Saudi Arabia. The questionnaire included questions that sort to elicit specific
meanings and purpose. In the interviews, open-ended semi-structured questions were
employed to explore topics of specific incidents and reactions related to students’ study
progress. These included participants’ preferences, backgrounds, and encounters in the
hospital during clinical placements with other staff, colleagues and peers from other
disciplines. The need for this information is explained by the dearth of research and
statistical information on the Saudi population generally, and the quality of the CLE
provided for nursing students in particular.
5.2 Integration of Data
As described in Chapter Three, the mixed methods research design “captures the best of
both methods” (Creswell & Clark, 2007, p. 560). However, Creswell and Clark also state
that “the researcher does not have to converge or integrate two different forms of data”
(Creswell & Clark, 2007, p. 560). There are many ways in which qualitative and
quantitative methods can be combined during sampling, data collection, and data
analysis (Yardley & Bishop, 2015). Morse and Niehaus (2009) defined the point at which
qualitative and quantitative data are related to each other in a mixed methods research
study as the “point of interface”. While in an ‘analytic’ point of interface, qualitative and
quantitative data are analysed together, a ‘results’ point of interface analyses qualitative
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and quantitative data separately, followed later by the results being integrated (Creswell,
2013; Yardley & Bishop, 2015). In this study, scores derived from quantitative findings
could be examined further in qualitative interviews, each complementing the other.
In the previous chapter, the results of quantitative and qualitative data were reported
separately; however, integration is the key to fully understanding the perspectives of
students, who showed enthusiasm and interest in the study. It was clear that the
objectives of the research related to issues they faced during their clinical education, and
to them, this study was a way for their voices to be heard, as evidenced by the 100%
response rate achieved with the questionnaire. The students were open for discussion
and wanted to speak about their thoughts and share their opinions through both the
questionnaire and interviews.
Firstly, results of the quantitative data showed that overall, responses tended to fall
between the “disagree” and “neutral” categories on most items in the questionnaire
with means ranging between 2.69 and 3.14. However, with standard deviations above
zero, it can be interpreted that the respondents’ answers were spread over a large range
of values. Largely, it is evident that participants found the clinical learning environment
(CLE) to which they were exposed, did not satisfy their practical needs. Data from open-
ended survey questions further supported this. Secondly, qualitative findings from the
semi-structured interviews provided enhanced understandings of the perceptions of
Saudi Arabian nursing students on their clinical learning experiences. From the
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interviews, three key themes emerged: ‘beginning to study nursing for real’, ‘all I need is
someone to guide me’, and ‘cultural views and struggles’. The overall findings suggest
that there are particular experiences that may be unique to Saudi nursing students. The
integration and interpretation of these results within the context of existing knowledge is
now reported in this chapter. Discussing the data in an integrated way allows for
interpretation that bridges data sources.
5.3 Consolidation of Issues
As previously described, the aim of this research was to explore the quality of clinical
education in the nursing curriculum in Saudi Arabia by identifying factors within the
clinical environment which affected students’ learning outcomes. It also sought to
measure students’ experiences and satisfaction with their clinical learning environment.
From the nursing students’ perspectives, the study found that the environment provided
for clinical learning in undergraduate nursing was only somewhat satisfactory and
required improvements. The importance of this is that nursing students considered their
learning needs were not met and they faced challenges that hindered their clinical
experiences and subsequently their confidence in clinical settings. This was
demonstrated by the perceived lack of learning support and clinical facilities in both
nursing faculties and hospitals, resulting in low quality clinical learning.
This research has clearly shown that providing a quality learning environment,
encompassing both school and hospitals, is vital for students. A recent study that aimed
to measure the quality of clinical learning and nursing students’ satisfaction in Greece,
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found that only by having positive CLE constructs were students highly satisfied with
their clinical learning (Papastavrou et al., 2016). These are the same constructs of this
study’s questionnaire which included: the pedagogical atmosphere, the ward manager’s
leadership style, the premises of nursing in the ward, the supervisory relationship and
the role of the nurse teacher.
The interview component of the study demonstrated that there were positive student
attitudes to the value of clinical learning and its importance in their nursing studies.
Participants expressed the important role clinical learning played in their nursing studies
and how hospitals were considered the best clinical settings for students to apply their
learned theory into practice. This was, however, in contrast to the results from the
questionnaire which indicated a lack of clinical learning support in nursing faculties, as
well as hospitals, where students had been placed. Issues identified from the
questionnaires and open-ended comments were combined to form major aspects.
A number of topics emerging from the data were major issues which have the potential
to impact on the quality of the nursing workforce in Saudi Arabia, unless corrected.
These issues will continue to hinder efforts to improve CLE for nursing students in Saudi
Arabia unless addressed by hospital and nursing faculty managers. Two key recurring
aspects emerged: one was the existence of issues involving cultural views on nursing
within Saudi society; and by extension, the impact of the multicultural nature of the
clinical environment. The second major aspect that arose was the difficulties students
faced during their clinical learning. This involved the need for guidance, the need to
address the gap between theory and its application to practice in clinical placements,
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and the level of mentorship and preceptorship provided for students. Other difficulties
described were the quality of the present clinical learning environment, the amount of
motivation, encouragement and resources provided to students.
5.4 Cultural issues
5.4.1 Cultural views on Nursing
It was apparent from the interviews conducted that the uniqueness of Saudi culture
wielded a major influence on students’ perceptions of nursing and their performance
during clinical placements. Participants contended that their families’ attitudes had a
significant influence on their study choice, because most family members were against
them studying nursing. Elamin and Omair (2010) indicate that Saudi Arabia, in particular,
is a distinctly tribal and conservative country where Arab cultural values are strictly
followed. Miller-Rosser et al. (2006) further explained that Saudi society is largely
patriarchal, with firm codes of conduct exerted on Saudi females. As shown from the
results of this study, participants observed different attitudes that the society had
toward female Saudi nurses and nursing students. It was clear from the students’
descriptions that there was still a lack of societal acceptance of Saudi females being
nurses, through actions such as refusing their contribution to their provision of health
care. This matter would extend to verbal abuse in some cases. In their paper,
Hutchinson, Jackson, Haigh, and Hayter (2013) looked at studies about workplace
violence in nursing and health care internationally and outlined that one of the problems
facing nurses were acts of violence, bullying and aggression from patients, their families
and other staff. Other countries neighbouring Saudi Arabia, such as the United Arab of
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Emirates (UAE), have demonstrated similar practices where foreign female labour was
needed, since female nationals were discouraged from entering the workforce,
specifically in nursing (El-Jardali, Jamal, Jaafar, & Rahal, 2008). This study is the first to
demonstrate that not only qualified nurses, but female nursing students, also experience
resistance to females working in these roles in Saudi Arabia. This potentially leads to
reinforcement of workforce issues and may impact on moves towards Saudisation in the
context of nursing.
Some of the current study’s students’ experiences can be further explained by work
described by other researchers, both locally and internationally. Almutairi and McCarthy
(2012) showed how major concepts, such as honour and shame, may distinguish Saudi
culture from others. These concepts have been around for many years and are inter-
connected. Honour is what an individual upholds from personal reputation, respect, and
values. If one’s honour is tarnished the individual and family will both be shamed. As
nursing is not yet considered a socially accepted career among Saudis, especially women,
choosing this profession may be viewed as bringing shame to the individual and by
extension, their family (Almutairi & McCarthy, 2012). This is shown clearly from this
study’s data, where some students were not allowed to be involved in the health care
process by the patients themselves, and/or experienced family issues related to resisting
their choice to become a nurse. Historically, nurses have been considered an oppressed
group due to extended power imbalances causing violent behaviours to occur (Milesky,
Baptiste, Foronda, Dupler, & Belcher, 2015). Further, due to a poor social image, it is not
only that enrolment rates in nursing programs worldwide are critically low (El-Jardali et
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al., 2008), but also a considerable number of newly graduate nurses are leaving the
workforce (Milesky et al., 2015). In Saudi Arabia, this has reportedly been partly caused
by not enough local people of both genders entering the nursing workforce in most
hospitals (Almutairi & McCarthy, 2012). All these factors can lead to decreased
confidence, emotional hardship, and low job satisfaction rates in nurses (Hutchinson et
al., 2013), and by extension to nursing students. Participants in this study expressed a
range of difficulties they faced due to societal views. Some participants reported being
verbally harassed about being nursing students by their families, patients and their
relatives, as well as students from other disciplines.
Almutairi, McCarthy, and Gardner (2015, p. 21) defined the word ‘ethnocentrism’ as “the
way that people interpret the world around them and attach meaning to things
according to their own cultural conditioning”. In the Saudi health care system, registered
nurses work twelve hour shifts which has the potential to interfere with their family
responsibilities (Ministry of Health, 2011). Some female Saudi nurses are unable to
balance their work as nurses and their roles in the family. This is not unique, however, as
Pocock (2001) described a similar complexity of the relationship between working hours
and family life in Australia, with longer working hours creating negative consequences for
families. This is similar to other parts of the world, where taking on long-shift jobs has
reportedly affected women, especially those with partners and dependent children. This
may increase the risk of workers developing mental and physical health disorders,
difficulty in balancing work and family life, with possible adverse effects on children’s
emotional and intellectual development (Weston, Gray, Qu, & Stanton, 2003).
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In this context, ethnocentrism could also explain the attitudes that many male patients,
visitors and family consciously or unconsciously exhibited toward Saudi female students
in the study, where they were questioned regarding their study choices. In Saudi culture,
men and women do not usually mix or interact with each other, unless necessary. As a
result, they may be pushed to divert to a different speciality that is more family-friendly
and does not require such long hours, such as management or teaching. However, this
situation may be in the process of change. In their study undertaken to explore males’
attitudes to working females in Saudi Arabia, Elamin and Omair (2010) concluded that
single, unemployed, young and educated Saudi males had less traditional attitudes
towards working females in comparison to the married, employed, older, and less
educated men. Hence, in time it may become more acceptable for Saudi females to work
in nursing.
Aside from the cultural characteristics that distinguish Saudi society from others, culture,
views and norms also differ from one family to another. Students in this study pointed
out that nursing status differed from one city to another. They indicated that cities with
older nursing faculties were more accepting of female nursing roles and provided a
higher quality education and clinical learning opportunity compared to other cities with a
recently established faculty. This further suggests that attitudes towards females working
as nurses may be changing. Hence, the experiences of students in the current study may
not necessarily be the experiences of nursing students in the future. This situation
warrants further exploration.
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Social views towards females working as nurses extended to some participants’ families
and, in return, had a direct effect on the students themselves. According to Almutairi and
McCarthy (2012), elders in Saudi society exert a significant level of decision-making
authority in family matters and career choices. In this thesis, while some participants’
families were supportive and understanding of their daughters’ study choices, others
were against entry to the nursing discipline and endeavoured to force other more
socially-accepted choices onto them, such as medicine.
Some participants displayed strength and control over their current and future life
decisions, such as study choices and marriage regardless of their conservative
surroundings. Cusack and Pusey (2012) argued as to whether culture is a legitimate
justification for violations of women’s human rights; in this case, their right for education
and work, and that the debate could be part of human rights discourse on universalism
and cultural relativism. Where Arab women have different representations of their
working lives, Elamin and Omair (2010) asserted that women’s status in the Arab region
is changing and they can no longer be described as scared, inferior, or domestic women
who hardly leave their houses.
5.4.2 Multicultural clinical learning
As noted previously, for many years the Saudi Arabian health system has suffered from a
severe shortage of qualified local nurses in clinics and hospitals, in both the private and
public health sectors. The nursing profession in general has been unable to attract
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adequate numbers of Saudi men and women, due to a range of difficulties including
salaries, shift schedules and social perceptions of nursing not being a suitable profession
(Al-Ahmadi, 2002). Furthermore, lack of recognition and appreciation seem to have
generated disappointment, frustration and regret, which adversely generates low work
satisfaction environments for nurses in Saudi Arabia and other Arab countries (Lamadah
& Sayed, 2014). Others from Western countries such as Canada and the United Kingdom,
have explained that nurses not being able to find safe, accessible and affordable child-
care facilities for their young children adds more pressure on working mothers (Lamadah
& Sayed, 2014). All of these factors can lead to low admission rates into nursing.
Consequently, the health workforce in Saudi Arabian hospitals and faculties relies heavily
on expatriates recruited from a range of countries, such as the Philippines, India, South
Africa, Egypt and the United Kingdom, in order to meet the healthcare needs of the
Kingdom (Aboul-Enein, 2002). This draws together many different cultural perspectives
and nursing backgrounds. Nurses, in turn, are also faced with new and complex
challenges because of the increasingly diverse cultural population (Flood &
Commendador, 2016). As a result, there are significant dimensions of culture that impact
on nursing practice in Saudi hospitals (Almutairi et al., 2013) and hence students’ clinical
experiences. These recruited expatriates from different countries have their own values
and beliefs, which are quite different to those in Saudi culture. They may lack sufficient
knowledge about the local culture, so their practice may neglect sensitivity to the beliefs
and values for others (Almalki, Fitzgerald, & Clark, 2011), such as Saudi patients and
students. Coming from countries with very different histories and contexts, they have
also studied nursing in a variety of different health care and educational models.
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Students in the current study discussed in the interviews, how they had experienced
difficulties working with nurses from particular cultural backgrounds, including their own,
and this added to the complexities and issues faced during their clinical learning. This
could be, in part, due to very different educational systems. Certainly, this indicates a
need for additional research around the area.
Almost all Gulf region countries have reported having similar struggles with their health
systems. The United Arab Emirates (UAE) is one of the world's richest oil nations located
in the Gulf Cooperation Council (GCC) region and has become the destination for
employment opportunities for temporary labour migrants, offering higher standards of
living than their countries of origin. In 2013, 7.8 million migrants were reported in the
UAE making it the fifth largest international migrant stock in the world (Malit Jr. & Al
Youha, 2013). Approximately 82% of health workers in the UAE are expatriates, while
nationals only comprise around 18% of all health workers (El-Jardali et al., 2008) with 3%
of the total employed nationals being nurses (Almalki et al., 2011). In their case study
analysis of the patterns of Emirates and Lebanese health professionals’ status, El-Jardali
et al. (2008) explained how other Arab countries such as Lebanon shared the same
struggles as the UAE where foreign health care professionals filled the gaps in the
medical and nursing workforces. Potentially, nursing students in those countries may also
have similar issues to the students in the current study, however, little research has been
done on this. Consequently more is warranted in order to better understand how
widespread this situation is.
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While the UAE relies heavily on expatriates, the low- and semi-skilled sectors are mostly
dominated by immigrants from Asia, the Middle East and North Africa. Workers from the
United Kingdom, United States, Australia, Canada, and various Western European
countries have concentrated the UAE's key high-skilled sectors, including the oil and gas
industry as well as banking and finance (Malit Jr. & Al Youha, 2013). El-Jardali et al.
(2008) suggested that American and European health workers were given higher
positions such as administrators and head nurses, while middle status registered nurse
positions were usually occupied by Filipinos and Egyptians. Sri Lankan and Pakistani
workers, however, usually occupied unskilled orderly and janitorial positions in health
care facilities (El-Jardali et al., 2008). Similarly, the international nursing workforce in
both nursing faculties and hospitals in Saudi Arabia is multilingual, multi-cultural and has
a wide range of educational preparation. Further discussion on how this impacts
students’ clinical education is presented later in the chapter.
Countries with low numbers of national health workers tend to provide employment
opportunities in the public sector. This phenomenon is common among the Arab Gulf
countries where nationals represent a small proportion of the labour force. In these
states, nationals compete with expatriates for many positions and by employing national
workers in the public sector, the government can minimise the competition and ensure
their national workers are employed (El-Jardali et al., 2008). Part of the explanation for
staff members’ negative attitudes to Saudi students could be, according to this study’s
findings, perceptions of job threat and subsequent unsettledness.
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One reason for negative staff attitudes towards Saudi students was seen to be the
influence of the global standards for initial education of professional nurses and
midwives as prescribed by the World Health Organisation in 2009. The goal of these
standards was to regulate criteria for evidence and competence-based nursing education
programs. The implementation of these regulations aimed to: firstly, promote the
professional nature of nursing and midwifery education; and secondly, ensure the
employment of practitioners who are competent and promote positive health outcomes
in their environment by providing high-quality care (WHO, 2013a).
In response to this world-wide guidance, nursing education in Saudi Arabia moved to
Bachelor degree preparation in 2009. It was suggested by participants in the current
study that students who undertook undergraduate degree studies, were viewed as
future rivals to the nurses’ positions who were mostly diploma holders. This further
impacted on the level of support they received during placements, where staff felt they
were competing with these students and therefore, were not motivated to assist with
their learning process.
During the past decade, Saudi Arabia has been experiencing high unemployment rates
that led the government to push companies to cut the number of expatriate employees
and replace them with locals. This move was referred to as “Saudisation” (Martin, 2013).
In future years, Saudisation will cause the Saudi nursing workforce to lean more
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favourably towards local nurses being a majority, instead of a minority in their own
country (Miller-Rosser et al., 2006).
Such a policy is not exclusive to Saudi Arabia. El-Jardali et al. (2008) spoke of a new trend
that emerged to deal with the rising levels of national unemployment in the UAE,
referred to as “Emiratisation”. However, despite the implementation of “Emiratisation,”
the flow of foreign health workers to the UAE has not changed and the recruitment of
foreign health workers in different medical fields continued. The country is placing
significant pressure on recruitment of both nationals and expatriates to aid its healthcare
workforce shortage, in particular, nursing (El-Jardali et al., 2008). The application of such
movements could create a culture of egos, as Milesky et al. (2015) described; such a
culture of egos arising from years of experience and rank had created a competitive
environment that might contribute to shortages of new nursing graduates. This may
explain why participants in this study found themselves in compromised positions, where
some staff nurses viewed them as a threat to their current positions and this flowed onto
creating problems in their interpersonal relationships with those nurses.
5.4.3 Language Barriers
According to Almutairi and McCarthy (2012), Arabic is the official language of Saudi
Arabia, while English is a mandatory second language in schools. Nevertheless, not all
Saudi nationals speak English, especially those with no tertiary education. This can create
language barriers in health care facilities between non-Arabic speaking staff and Saudi
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locals, as patients or students. Additionally, although most healthcare staff, including
nurses communicate in English, many nurses in Saudi Arabia do not speak English as their
first language and neither are they skilled in Arabic (Aldossary et al., 2008). Participants
in the current study referred to delays in students’ learning processes because English
was not their first language, or they considered they were not properly taught English. In
their study to evaluate baccalaureate students’ perspectives on their acquired cultural
competency throughout the curriculum in the USA, Flood and Commendador (2016)
pointed out that during their clinical learning, nursing students cared for patients who
did not communicate in the same language as their own. With lack of access to medical
interpreters and poor access to written materials in other languages, the language gap
between teaching materials and their application in clinical practice was created. The
nursing curricula in most Saudi Arabian colleges are delivered entirely in English. A report
from the Saad College of Nursing and Allied Health Sciences (2016) argued that by doing
so, the curriculum would be specifically designed to maximise theoretical knowledge,
practical and clinical skills necessary to become registered staff nurses. This study
suggests that language issues for Saudi nursing students do exist, particularly in the
clinical setting, and can be problematic.
Alhetheli (2012) explained that Saudi nurses, and by extension nursing students, need to
deal with language issues relating to reading professional nursing texts not written in
their native language and working closely with nurses from a variety of cultures who
speak numerous languages. In this study language barriers caused miscommunication
between students and non-Arabic speaking nurses. Translating materials from other
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languages into Arabic created an extra burden required of students and consumed time
that could have been better spent in developing students’ clinical skills. That, in turn,
caused students to feel frustrated. Flood and Commendador (2016) explained how such
situations could result in unpleasant experiences for some students and impact badly on
them. Additionally, not only did this issue create a gap in communication, but could also
affect the quality of health care delivery and adversely influence patient satisfaction.
While some Saudi governmental hospitals provide translation services to overcome
communication problems between non-Arabic speaking health care providers and
patients (Almutairi & McCarthy, 2012), others may use family members as interpreters
(Flood & Commendador, 2016).
5.4.4 Cultural Integration
Findings derived from this study highlight some clear turbulence in the clinical learning
process for participants. From the findings discussed, program evaluation focussing on
cultural competence seems to be a vital part of nursing education. In their study, Reyes,
Hadley, and Davenport (2013) described the importance of cultural competency in the
nursing curricula. It is required for accreditation in many countries but not in Saudi
Arabia currently (Fielden, 2012). It is argued that curriculum evaluation should be an
ongoing process, whereby the program is closely monitored in order to evaluate its
effectiveness and quality and contribute to improvements, including changes to the
curriculum such as the integration of culture into curricula (Flood & Commendador,
2016). It is envisaged that this will ensure best healthcare education for nursing students.
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A number of researchers have evaluated the effectiveness of cultural integration in the
nursing curriculum as an educational intervention. Kardong-Edgren and Campinha-
Bacote (2008) used four different approaches to measure the effectiveness of cultural
competency in four undergraduate groups from four different geographic regions. The
findings showed that regardless of the program students attended, they only show
positive significance in the cultural awareness range with no significance to the other
ranges including desire, knowledge, skill and encounter. Kardong-Edgren et al. (2010)
used Campinha-Bacote's Inventory for Assessing the Process of Cultural Competency
among Healthcare Professionals-R on six different undergraduate programs in the USA.
They found, on average, that students were more culturally aware after undertaking the
program. These results suggest that no particular approach is proving to be more
effective than another in achieving essential cultural competency.
Another study assessed the nursing curriculum of one of the United States’ public
universities to measure the cultural education content by comparing students’ self-
perceptions of cultural competency before and after the course. Students from that
study perceived that they had become culturally competent during their nursing
education. However, it also highlighted the need for continuous education relating to
this concept throughout the entire nursing curriculum (Reyes et al., 2013). Lipson and
DeSantis (2007) presented a variety of methods used to integrate cultural competency in
the nursing curriculum of different nursing programs in the United States. The study
discussed the use of course models, specialty focus, distance learning and simulation.
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Although cultural content was incorporated into the nursing curricula, several issues
were identified in all levels of the nursing program. This included lack of standards on
what should be taught, limited and inconsistent formal evaluation of effectiveness, the
focus on the basic level of nurse-patient interactions, and the need for support and
preparation of the faculty (Lipson & DeSantis, 2007). Strategies to properly address
integration of culturally appropriate health care strategies in the undergraduate nursing
programs curriculum were discussed by Eshleman and Davidhizar (2006). They included
storytelling, articles, learning from childhood, cultural analysis, a cultural dinner, guest
speakers, international health exercise, and limericks.
Only by considering diversity considered from a multidimensional approach throughout
the educational process, will cultural competency occur throughout the health care
system. It is important that nursing faculty use intentional teaching strategies in
undergraduate nursing programs. Nursing students need to learn the necessary skills to
care for and accommodate the culturally diverse population and to work within a
multicultural health care workplace. The nursing faculty should have a clear
understanding of how strategies can be placed in curriculum to achieve best program
outcomes. When faculty utilise creative and innovative strategies to develop cultural
competency, care for patients from culturally diverse backgrounds can be improved
(Eshleman & Davidhizar, 2006).
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5.5 Being a student in the clinical setting
5.5.1 The need for guidance
In their study to evaluate the palliative care programs in Australia, Connell et al. (2011)
found a majority of nursing professionals perceived the clinical environment as a place
where they acquired practical knowledge and skills. In the clinical learning environment,
nursing students can practise on their own under supervision, reflect on what they have
done, so that they can improve once another opportunity is available, or mimic the
behaviour of other nurses (Barnett et al., 2010). All health care providers need to be role
models so that nursing students can adopt the best behaviours because the literature
affirms that socialisation of nursing students into nursing practice occurs in the clinical
environment (Yonge et al., 2007). Alongside these health care workers, nurse teachers
play a further important role in supervising and setting positive examples for students to
meet their clinical needs (McHugh & Lake, 2010).
Throughout their education, students in this study encountered a range of people with
different backgrounds and roles, including nursing staff and nurse teachers who were
important role model figures for them. Due to this diversity it became difficult for
students to assume a role of their own in the clinical setting, while at the same time
apply theory into practice. This multicultural environment leads to the need for
emotional, social and psychological support to function adequately (Hylin et al., 2011).
Belongingness is a basic human need, is universal and pervasive in order to achieve the
best health care (Levett-Jones & Lathlean, 2009). Staff-student relationships are an
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important influence on students’ experiences of their clinical learning, which in this study
was significantly influenced by the many staff in supervisory roles who came from other
cultures; diversity in management and supervision styles, as well as different professional
approaches were evident in participants’ descriptions. These relationships can affect
nursing students’ levels of self-esteem, stress and anxiety, depression and general
wellbeing, motivation and capacity to learn (Levett-Jones et al., 2009b).
Although most students in the current study recalled some positive experiences in their
clinical environment, many examples of perceived indifference, unfriendliness,
resentment and hostility were raised, such as facing unpleasant experiences and feelings
and ineffective interpersonal relationships. In turn, these experiences affected their
clinical outcomes. In their study seeking to explore Iranian nursing students’ viewpoints
on stress-inducing factors within the clinical setting, Moridi et al. (2014) explained how
interpersonal issues could affect anxiety, sense of wellbeing, and capacity and motivation
to learn. As a consequence, students in this study were left feeling uneasy,
uncomfortable and alienated, ultimately losing the anticipation and excitement they
expected from their clinical learning environments. Exploring incivility in nursing
education and practice in the USA, Milesky et al. (2015) explained how novice nurses
entering the profession were often faced with less welcoming environments where there
had been reports of bullying, belittlement and abuse. These reports caused a lack of
teamwork, communication, organisational disruption and ultimately poor patient
healthcare outcomes. In the current study, students perceived that some staff found the
responsibility of supporting students in practice difficult and burdensome. They were
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seen to disregard students’ feelings, making little effort to hide their impatience and
frustration. Similar findings were presented by Levett‐Jones, Lathlean, Higgins, and
McMillan (2009) while exploring the relationship between belongingness and placement
experiences of Australian nursing students; which ultimately led to students in their
study ultimately feeling unwanted. This experience extended across both nursing
faculties and hospital settings. It is possible that the different backgrounds of staff had a
further contribution to play in this, although it was not directly found (Levett-Jones et al.,
2009b).
Nonetheless, learning in the clinical environment can be challenging for most nursing
students, when compared to classroom teaching and learning (Mattila et al., 2010). A.
AlHaqwi et al. (2010) found that most Saudi nursing students in their study reported
clinical learning environments aroused feelings of anxiety, and students were usually
stressed, as they interacted with clinical nurses while providing care to patients. Killam
and Carter (2010) stated that the faculty staff should be aware that anxiety and stress,
which can lead to burnout and fatigue among nursing students, are serious issues in the
clinical learning environment. In order to provide a good clinical learning environment,
the faculty members, clinical nurses, students, and patients should work collaboratively
with each person respecting the autonomy and dignity of each other (M Tomietto et al.
(2012). This means that the personnel involved in the clinical environment must develop
good communication and collaboration skills, because doing so will ultimately contribute
to a productive clinical learning experience for students. Omer et al. (2013) described the
positive outcomes from a good clinical learning and student-preceptor relationship in
Saudi nursing programs.
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When preceptors engage actively and positively with students, the clinical learning
experiences will be enhanced. Conversely, as students from this study stated, when
faced with negative relationships and some of their preceptors’ behaviours, their clinical
learning is disrupted. In their narrative study of twenty-six international papers to
identify characteristics of leadership that influence clinical learning, Walker et al. (2011)
reported similar observations where the level of nursing student interaction with
mentors in the clinical environment was poor. This was because the students reported
that merely a third of the mentors were willing to help them learn, while the rest were
unapproachable and hostile. This appears therefore to be a universal issue, not just one
unique to the Saudi Arabian context.
Similar remarks can be applied to the relationships between nurses and nurse teachers.
Questionnaire data in this study showed strong correlation between the role of the nurse
teacher and the supervisory relationship. This may indicate that students are mostly
satisfied with their clinical learning when, and if, tasks and priorities between the needs
of healthcare and the goals of the universities’ staff are unified. Some students in this
study reported being instructed by their nurse teachers to keep their remarks about the
hospital’s staff practices to themselves. Mohamed, Newton, and McKenna (2014)
suggested that supressing knowledge about other nurses’ behaviours was due to nurse
domination and the desire to maintain acceptance and control within the hospital
environment. Students and faculty often feel as though they are not protected against
uncivil behaviour and if they speak up, they will be negatively stigmatised and perhaps
their clinical experiential progress will be blocked. Such behaviour may imply the lack of
communication between the school and the hospital, as well as highlight the differences
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between both approaches. In the USA, a study concurred that while both staff nurses
and nurse teachers should be collaborating in order to create a proper learning
environment, due to the multicultural nature of the nursing professions, they might be
found in adversarial positions (Milesky et al., 2015).
Most of the time, nursing students reportedly feel vulnerable in the clinical setting and
this could be either due to students’ desire to learn how to apply theory to practice, or
having concerns about the attitudes of qualified nurses to the care being provided (E.
Papastavrou et al., 2010). According to Hope et al. (2011), nursing students are placed
temporarily in a particular hospital unit where they belong to a nursing team for a short
time, and usually students have different expectations and goals from those of other
clinical nurses. Findings from the current study suggest that the experience of Saudi
nursing students is similar to that reported elsewhere; however, it is further complicated
by the dominant multicultural, expatriate nature of the workforce. In this study, students
reported experiencing difficulties adjusting to their clinical environment because they
kept rotating from one unit to another, with each staff group having different
expectations and approaches concerning the patient care. Therefore, nurse teachers and
staff nurses need to ensure that the CLE is one that facilitates learning. This is possible
through effective communication between nursing students, hospital staff, and the
nursing nurse teachers, as well as the availability of the necessary resources (Cummins,
2009).
The findings of this study may imply the absence of the government role in regulating
clinical placements. Saudi Arabia lacks the presence of a peak professional body, a
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“council” that regulates the profession by developing and enacting standards and laws.
In fact, the organisation that approves licencing of health professionals in Saudi Arabia,
the Saudi Commission for Health Specialties, is yet to finalise standards for nursing
practice (Fielden (2012). However, the established hospitals in the major cities of Riyadh
and Jeddah are accredited by the Joint Commission International (JCI). JCI is part of a
global enterprise of dynamic, non-profit organisations that address all dimensions of
accreditation, quality care, and patient safety. Founded in 1994 by The Joint Commission,
it is the oldest and largest standards-setting and accrediting body in health care in the
United States. JCI has touched more than 90 countries where it identifies, measures, and
shares best practices in quality and patient safety with the world (Joint Commission
International, 2016). A part of the Commission’s role is that hospitals accredited by the
JCI reflect their expectations around graduate nurse practice. Nonetheless, other
hospitals, including those involved in this study, are not accredited by any such
organisation, and regulating nursing students’ practice remained the result of a
coordinated agreement between the nursing faculty of each university and the relevant
hospital.
5.5.2 Preceptorship and mentorship
Although preceptorship in nursing is a short-term relationship, it tends to focus primarily
on the development of students’ required clinical competencies and involves some sort
of judgment or evaluation of their overall clinical performance (Sword et al., 2002).
According to Omer et al. (2013), nursing education in Saudi Arabia relies mostly on
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preceptorship for supporting students’ clinical learning. In this study, the supervisory role
in the clinical placements was reportedly divided among the nurse teachers from the
school and staff nurses from the hospital as preceptors. Although the primary
responsibility of the registered nurse is to deliver the highest standards of nursing care to
patients, as professionals, it is also their responsibility to support the learning of other
nurses (Courtney-Pratt et al., 2012) and by extension, nursing students. Preceptorship
represents the process of “pairing new graduates with an experienced nurse to facilitate
role transition to that of a staff nurse” (McCarty & Higgins, 2003, p. 91). In their paper,
Marks-Maran et al. (2013), added that preceptors in the United Kingdom held a unique
role around mentorship in aspect of teaching, advising, supervising and evaluating with
their preceptees. Preceptors are also expected to maintain communication, when
possible, with faculty staff regarding their students’ progress (Yonge et al., 2007).
According to Omer et al. (2013), applying preceptorship models in clinical learning can
result in more effective practice in the clinical environment. Preceptor teaching is a
continuous process involving open communication and trusting relations between the
preceptor and the students which would influence students’ abilities to acquire
knowledge and skills (Hope et al., 2011). Marks-Maran et al. (2013) found that regular
meetings with the preceptor in the clinical setting can reduce students’ stress. However,
there are a number of factors that may inhibit developing a successful relationship
between the preceptor and the preceptee. These factors include employing efficient
nurses for the preceptor role, lack of time, lack of interest and commitment and
comprehensive training of preceptors. Nonetheless, it is worth mentioning here that a
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successful preceptorship relationship may depend on students’ preparedness, readiness
and eagerness to learn (Papastavrou et al., 2016). The findings of this study confirmed
that the majority of nursing students were dissatisfied with the supervision they had
received during their clinical practice, which included the quality of preceptorship
provided by the nursing staff and/ or with the nurse teachers. They reported having
unpleasant encounters with some nursing staff in the clinical setting at the hospital and/
or their nursing nurse teachers. Consequently, regardless of students’ willingness to
learn, not all experiences had a positive impact on these students.
It was stated from the findings of this study that some students faced rejection and
experienced a lack of care during their clinical practice. Milesky et al. (2015) examined
studies monitoring academic incivility among nurses and nursing students and found
disrespectful acts were reported by these students from the faculty nurses in the clinical
settings and their peers. Robertson (2012, p. 21) identified some of the problematic
behaviours in the academic nursing community. These included behaviours of disrespect
that can be manifested in the form of spoken words, gestures, or actions. Clark (2008)
reported that nursing students in 41 states in the USA frequently endured negative
faculty behaviours. These included tardiness of the nursing teachers in class, holding
distracting conversations, refusal to answer questions, making condescending remarks
and exerting rank or superiority. Some of this study’s participants reported similar
experiences, including the occurrence of continuous criticism and scolding over their
appearance and performance in their hospital placements by their nurse teacher or staff
nurse. This approach in dealing with students was not appreciated as it negatively
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influenced their performance and the overall experience of clinical learning. Students
who face such experiences in their clinical setting suffer from poor performance and high
anxiety levels. Further, they may have a higher tendency to be acculturated into being
uncivil nurses or leave the nursing program altogether, seeking other professions
(Milesky et al., 2015). Hence, some students from this study expressed regretting their
choice in entering the nursing profession due to such surrounding behaviours and the
environment. This has the potential to further compound future workforce shortages if
not managed properly.
To develop standards for an effective clinical practical setting for nurse students in Egypt,
Mousa et al. (2012) found that effective supervision in the CLE was highly recommended
for the nursing students because if left unattended, they may engage in patient activities
that would not assist them to meet their clinical placement objectives. Furthermore,
some nursing students can also spend time with other health care personnel doing
activities that are beyond the scope of nursing practice, and by so doing, they will not
become competent in nursing activities, in preparation for becoming practicing nurses
(Newton, Billett, Jolly, et al., 2009). In this study, some students argued that overloaded
clinical tasks and school assignments enforced by the nurse teachers had a major effect
on their direct involvement with patient care. Therefore, it was suggested that the nurse
teacher needed to maintain a balance between practical assignments and clinical work
for students, because as Henderson et al. (2012) contend, this can reduce the levels of
stress usually experienced by most nursing students while they are in the clinical learning
environment.
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5.5.3 Nursing clinical education
As discussed earlier in this chapter, the international nursing workforce in both nursing
faculties and hospitals in Saudi Arabia is multilingual, multi-cultural and has a wide range
of educational preparation. This might have both positive and negative impacts on the
nursing care provided to the largely Saudi population (Al Hosis, Plummer, & O'Connor,
2012). Students in this study implied that the differences in both the nursing faculty staff
members and hospital nursing staff impacted on their behaviours towards treating
students and their teaching approaches. Where some were supportive and considered
an essential element of students’ learning process, others were viewed to be outdated in
their approaches and seen to behave in an unacceptable manner.
In their attempt to explore students’ perceptions of preceptorship, Omer et al. (2013)
looked at two different preceptorship models implemented in the nursing curriculum at
King Saud University, Saudi Arabia. One model required intensive mentorship while the
other required increasing students’ independence and self-directed learning. Their study
concluded that nursing students were more satisfied with intensive monitoring. As
discussed earlier in the chapter, students in this study expressed their dissatisfaction
with the unwillingness and lack of support they faced from some of the nursing staff.
Nonetheless, some students rationalised these negative behaviours to nurses’ multiple
responsibilities, previous negative encounters with students, and lack of time and
preparation. A study exploring Canadian staff nurses’ perceptions on preceptorship
concurred with the findings of this study. It reported that preceptors had large
workloads, no educational preparation, and lack of time for assessing and assisting
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students. The unprepared preceptor is not confident in the role and this could result in
the preceptee making a poor transition to staff member (Kalischuk et al., 2013).
A recent study to evaluate the effects of preceptorship classes on nurses’ behaviours as
preceptors in the USA concluded with three themes associated with good
preceptorships; a caring relationship, mutual respect, and a deep sense of responsibility
(Sanford & Tipton, 2016). Due to the general negative perception of the supervisory
relationship students had in this study, it was safe to imply that the nursing staff were
not prepared to handle the preceptor role. However, it was contended by Kalischuk et al.
(2013) that preceptors who viewed the positivity of benefits and rewards associated with
preceptorship demonstrated the most commitment. Nonetheless, this was not the case
with some of the students who participated in this research. Even though preceptors
were provided with financial rewards in exchange for mentoring nursing students,
preceptor nurses were reported not to be committed nor motivated to be involved in
students’ clinical learning.
Kalischuk et al. (2013) explained how variables such as nurses’ experience, gender, and
educational preparation can have an impact on preceptors' perceptions of the rewards
and/or commitment to the role. As such, it was of most importance for nursing
education to prepare nurses as preceptors for the role. Doing so will thereby increase
satisfaction and improve the preceptee's experience and ultimately increase students’
satisfaction with their clinical learning experiences (Sanford & Tipton, 2016). Though
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governmental hospital-based students were the most satisfied with their clinical
supervision, this did not mean that these nurses had adequate preceptorship
preparation. Lamadah and Sayed (2014) concluded that on-the-job services, including
developmental classes, seemed to vary considerably across the different hospitals and
sectors. Compared to their counterparts at other hospitals, nurses working in
government hospitals sounded more frustrated and disappointed for having fewer
opportunities to attend such services.
5.5.4 Ability to practise
Clinical placement is a time of transition where nursing students are expected to be
competent in practice, attitudes, and professional ethics and conduct (Mousa et al.,
2012). Data from the questionnaire suggested a weak correlation between the
pedagogical atmosphere and premises of nursing care, indicating that students had not
been actively involved in patient care. As supported from this study’s interviews,
participants expressed their frustrations from having a restricted ability to practise and
excessive monitoring during their clinical practice by the hospital staff mostly and the
nurse teachers in certain situations. This suggests that participants fell into a traditional
approach of nursing education. Historically, nurse training required students to attend to
a workload environment with a list of tasks, while allocated to a different staff nurse, and
this was performed in a ritualistic fashion (Henderson et al., 2012).
Nonetheless, literature suggests that nursing students prefer a more contemporary CLE
where students seek to become members of the clinical team during their clinical
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practical placement (Henderson et al., 2012). Furthermore, students prefer to interact
freely with their mentors as they grasp the concepts of providing quality care to patients
through application of theory to practice (Newton, Billett, & Ockerby, 2009). Levett-Jones
and Lathlean (2009) suggest that a positive correlation exists between the involvement
of the nursing student in clinical learning and their evaluation results. Students’
involvement can be displayed by completing clinical learning tasks that may include
caring for patients, submitting clinical assignments and attending clinical training (Chuan
& Barnett, 2012; Daly et al., 2013; Henderson & Tyler, 2011). Consequently, students will
become competent, develop positive attitudes towards the nursing profession, and upon
qualification, be able to provide quality care to patients without any difficulty (Cummins,
2009).
Clinical learning environments are highly dependent on the characteristics and
behaviours of the nursing students, faculty, qualified nurses, other health care providers,
and the health care facility itself. Students in the current study were confused due to the
gap between theory and practice, as well as the existence of a gap between their
expectations and reality of the clinical environment. Van der Zwet et al. (2011)
attempted to capture the socio-cultural context of clinical learning for medical students
in the Netherlands by exploring their perspectives on their clinical settings. They found
that students needed developmental space to be able to learn and develop
professionally. This space resulted from the workplace context, personal and
professional interactions and individuals’ emotions such as self-confidence and feelings
of respect. These forces enhanced students’ clinical experiences. Nonetheless, a huge
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discrepancy exists between what students perceive to be the ideal and the actual CLE
(Saarikoski et al., 2013).
An ideal CLE is present where nurse teachers and clinical nurses, especially those
selected as preceptors, have effective teaching skills and give nursing students
opportunities to be active participants in the care of patients (Levett-Jones et al., 2009b).
Cummins (2009) added that the nurse teacher too, should appreciate the fact that each
nursing student can be either reactive or proactive in the management of patients, and
this varies from one nursing student to another, meaning that some nursing students
should be closely monitored while others can work on their own with little supervision
(De Witte et al., 2011). This motivates students to learn because they will not only feel
that they have control over their learning but can also be independent with regard to
being involved in decisions concerning the welfare of the patient (Levett-Jones et al.,
2009b). This contradicts this study’s findings where students had restricted access to
clinical practice opportunities. Participants were relatively restrained completely from
being involved with direct physical patient care, had strict roles in the clinical setting
from both hospital and school staff, or were not given the opportunity to practise
autonomy. Ultimately, these students were confused about their exact role in the clinical
environment. Hylin et al. (2011) added that nursing students mostly find it difficult to
distinguish between their responsibilities as learners and as nurse workers. Therefore, to
achieve positive clinical learning environments, studies suggest having clear descriptions
of roles and responsibilities for persons involved, effective management and peer
support (Courtney-Pratt et al., 2012).
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As Saudi women are not permitted to drive and with no safe and reliable public
transportation services available (Lamadah & Sayed, 2014), transportation to and from
hospitals and schools was reported as problematic for students in this study. Participants
believed that most students depended on their schools’ transportation to get to their
clinical placement. Students additionally expressed frustration, that much time was
wasted organising and waiting for students to gather, and this was time deducted from
the clinical placement period in the hospital. The availability of adequate resources in the
CLE is imperative in ensuring that learning takes place. This aspect has not been
previously described and would appear contextually bound in Saudi Arabia.
Connell et al. (2011) asserted that the nurse teacher’s role is to ensure that nursing
students have all the necessary materials and equipment that will help them achieve
their clinical objectives. The nurse teacher should not only explain to students what is
expected of them in the clinical setting, but also put them into groups where they can
engage in reflection activities at the end of the work shift (Baeten et al., 2010). In this
study, university hospital-based students tended to have more positive experiences
altogether compared to their peers who were in other government and private hospitals.
It is possible that most students preferred governmental faculties due to the perceived
wide range of access to different clinical settings, such as different wards, operating
rooms, emergency departments and clinics.
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Reflection helps nursing students to learn from each other and improve nursing care for
patients. Edgecombe and Bowden (2009) argued that reflection bridges the gap between
theory and practice because students are able to reflect on what they have learned in
the classroom, compared with the actual care provided in the clinical setting, and make
appropriate adjustments. This issue is an international occurrence. Bjørk, Berntsen,
Brynildsen, and Hestetun (2014) highlighted that staff nurses and nurse teachers in
Norway failed to encourage students’ reflection on their experiences of care, showing
how nursing learning was only practical problem-solving and theoretical perspective-
based.
5.5.5 Students’ satisfaction
There is considerable evidence in the literature to support the benefits of the CLE in
nursing. The CLE is where theory is integrated with the practical, it stimulates and
enhances students’ decision-making and critical thinking, and it introduces students to
various socio-cultural, biological and psychological aspects of patient care (Papastavrou
et al., 2016). Nonetheless, the CLE is considered “one of the most anxiety-provoking
components of nursing education” (Moscaritolo, 2009, p. 22) due to all the challenges a
student may face, as discussed earlier in the chapter. As a result, not all clinical settings
are conductive to students’ needs and clinical outcomes or contribute to their
developmental competencies (Moscaritolo, 2009). This study’s data showed that
participants were not fully satisfied with the quality of their clinical education. Second
year students tended to have more positive attitudes towards the CLE than their peers in
the fourth year. In their study seeking to measure nursing students’ satisfaction with
232
their clinical learning in Greece, Papastavrou et al. (2016) reported similar observations.
Junior year students reported having the highest satisfaction compared to later years. A
probable explanation for that finding might be the constant mentoring available to help
novice students to deal with the physical and mental stress they undergo due to their
limited clinical skills. Further, students in this study implied having high, enthusiasm, and
willingness to learn and apply theory into practice and hence perceived the CLE more
positively.
Based on this study’s data, it can be implied that university hospital-based students
tended to have more positive experiences, compared to their peers in other government
and private hospitals. As explained by students in this study, private nursing faculty
students go to exclusive private hospitals that run under the same management as the
school. Governmental nursing faculties’ students, on the other hand, go to either
governmental or educational hospitals with no access to private facilities. A possible
explanation for these findings is that governmental institutions have different standards
of constructs and execution of practice compared to private organisations. Additionally,
the difference between hospital types is in the regulation of students’ access to practice
and patients, with governmental hospital-based-students enjoying better access to
clinical learning materials. More research is needed to further understand the
differences in students’ experiences in different hospital types.
233
5.6 Limitations of this research
It is noteworthy that the researcher had access to only three universities which were
included from one location in Saudi Arabia, Jeddah. This is because they were the ones to
provide consent to undertake research in the timeframe allowed. As a result, data may
not represent the experiences of students in other areas. In addition, only second and
fourth year students were included and students in other year levels may have had
different perspectives and experiences. Finally, only students with particular issues on
clinical placement may have volunteered to participate in the interviews and their views
may not reflect all students’ views. Caution needs to be exercised in the adoption of the
discussions in this study, as these are only possible explanations for nursing students
elsewhere.
Other limitations should be noted when drawing firm inferences from the findings of this
study, specifically, the relatively short periods of time spent in specific ward
environments, from two to three days per week during a period of seven to eight weeks
as “short clinical rotations”. These may not provide sufficient time to build mutual
understanding and familiarity within the specific CLE. Finally, only one side of the CLE
was explored, that is from the students’ perspectives. The voices of others who are
involved in the provision of CLE are important in clinical education and have not been
represented.
234
5.7 Conclusion
This chapter integrated this study’s findings and contextualised them in a broader scope
of what is already known and previously reported in the existing literature. Study findings
suggest that the unique cultural views on nursing within Saudi society are what
distinguish this study among others from different countries. Saudi culture has been
recognised to have crucial and dynamic effects on the nursing profession, and by
extension, the nursing education in Saudi Arabia. However, a number of similar
difficulties facing nursing students during their clinical learning were raised in this
chapter. They involved the need for guidance, the need to address the gap between
theory and its application to practice in clinical placements, the level of mentorship and
preceptorship, and the amount of motivation, encouragement and resources provided
for students. The next chapter presents conclusions for this study, including
recommendations that seek to contribute to future improvements for nursing students’
experiences in clinical environments.
235
Chapter Six: Recommendations and Conclusion
6.1 Introduction
Nursing students represent the future nursing workforce; thus nursing education is an
important investment in exposing students to the quality of clinical care provided in
health care systems. During a pre-registration program aimed at enabling their clinical
learning, students are systematically prepared to reach the minimum standards of
‘competencies’ of knowledge, skills and attitudes, in order to be certified for their
professional capability.
This study set out to explore the quality of clinical education in the nursing curriculum in
Saudi Arabia by identifying factors within the clinical environment which affected
students’ learning outcomes. It also sought to measure students’ experiences and
satisfaction with their clinical learning environment. In doing so, it found that the
environment provided for clinical learning in the Saudi undergraduate nursing programs
was only somewhat satisfactory. Further, major issues have been identified to potentially
impact on the quality of the nursing workforce in Saudi Arabia, unless corrected. These
issues will continue to undermine efforts to improve the clinical learning environment
(CLE) for nursing students in Saudi Arabia unless they are addressed by government,
hospital and nursing faculty managers and making the required improvements.
236
6.2 Implementations and Recommendations
The aim of this study was not to draw negative attention to clinical practices in the
nursing education system in Saudi Arabia, rather to draw attention to the issues, in order
to contribute to improvements. Two main issues are covered - culture and students’
experiences. Accordingly, recommendations arising from the study involve suggestions
for education, the community and practice, then for future research. These
recommendations are elucidated in more detail below.
6.2.1 Culture
Based on the findings of this study, the recommendations to resolve cultural matters are
as follows:
Saudi society is complex, yet a lot can be done within the wider community on raising
the profile of nursing as an essential profession and worthwhile career. Public
education is important in order for nursing to be taken seriously as a legitimate
profession for Saudis, not just women. How this is achieved within Saudi society will
require significant cooperation and strategising among many who share a goal of
creating a positive image of nursing. Representing nursing as a legitimate career and
an essential service needs to be addressed by government, health care services and
education providers.
237
The Saudi nursing board should instigate public awareness-raising activities such as
introducing a national nurses’ day and to consider other culturally appropriate ways
to promote positive images of nursing, especially for Saudi women.
A collaboration between the nursing authorities and hospitals should be established
to provide child care facilities to facilitate a more suitable family friendly
environment for the Saudi community. This move would assist in enticing more locals
into the profession and enabling their full participation in study and the workforce.
Given the characteristics of a diverse, multi-cultural expatriate workforce, prior to
employing expatriates in Saudi health care facilities, these facilities should provide
sessions to familiarise recruited staff with the Saudi community and its culture. These
sessions if executed correctly will minimise the inter-professional differences and
boost the cultural competency in health care practices.
While expatriate nursing staff are required to undertake some cultural training about
Saudi society, this research raises questions about the quality, consistency and
effectiveness of such training in the experience of the participants. Thus there
appears to be an opportunity to examine the content and delivery of such training
and to formally evaluate the learning outcomes.
Promoting the development of educational processes in culturally-appropriate
conflict resolution as well as uniform enforcement of policy about nursing education
238
and CLE is important in providing comprehensive and positive experiences for
students. This may form part of the cultural training described above.
To minimise language-related issues, it is recommended that health care faculties
make it compulsory for students to undertake a recognised English language test as
part of their curricula, such as IELTS or TOEFL.
To further minimise language-related problems, it is recommended that health care
facilities, including hospitals and clinics, employ professional interpreter services to
best enhance communications between staff, patients and families, and students.
6.2.2 Students’ experiences
Based on the findings of this study, the recommendations to enhance students’ clinical
experiences are as follows:
Hospitals and nursing faculties should collaborate to ensure expert supervision for
students in the clinical setting by applying the following recommendations:
1. Standards for selecting staff suitable for supervising students should be set by both
the hospital and the faculty.
2. Apply preceptorship training to those pre-selected staff to establish a clinical learning
culture best suited for students.
3. From the experiences described by the research participants, it may be opportune for
hospitals to take a different approach to engaging their staff in supervising students.
Instead of expecting all nursing staff to take on student supervision and besides the
239
various training opportunities described above, a tangible reward like a special title,
promotion or monetary reward, may benefit those who do value the supervisory
role, as well as it being a more attractive option for those wishing to undertake this
role.
Clear expectations about the CLE, as well as constructing an agreed and quality
syllabus, are two ways to minimise students’ anxiety about placements. Further,
ethical standards need to be met by both students and faculty, and to policies
employed to enforce these standards.
The Saudi Nursing Board should set policies, standards and define roles that are very
relevant to staff, nurse teachers and students in hospitals. In particular these
requirements must contribute to a more positive culture of nursing in clinical
settings.
These recommendations are aimed at strengthening the Saudi nursing policy in relation
to the multicultural workforce as well as staff and students’ experiences, and it is
important to address them, since these students are the future workforce.
6.3 Areas for future research
Nursing research is considered the main avenue for nursing development in Saudi Arabia
as it involves sharing information on an international basis. From this research, it has
been clearly shown that the nursing profession, especially for Saudi females, carries a
240
stigma that needs to be changed and further investigated. Overall, results have shown
that continuous research is necessary to assess factors impacting on Saudi nursing clinical
education. There is a need for a national study of Saudi nurses in terms of gender
balance, level of education, and the practices and challenges facing the nursing
profession. What is also required are further studies with reference to the supervision
and mentorship of students in clinical settings.
Research exploring the perspectives of nursing staff and nurse teachers on clinical
learning is recommended. Findings of this research have uncovered a range of
improvements required of the Saudi nursing educational system and practice; this has
implications for government policy in relation to governance and education of the whole
nursing profession.
While this research revealed the perspectives of nursing students, further research is
also required to gain insight into the perspectives of the registered nurse supervisors,
patients, and educators in relation to CLE. Doing so will provide a fuller picture of this
complex area of nursing.
6.4 Conclusion
The findings from this study have uncovered some of the current realities and practices
facing female Saudi students in hospital-based clinical settings, and have revealed the
breadth and depth of their experiences. It is evident that a clear distinction exists
between Saudi Arabia and other countries in terms of clinical learning practices. Overall,
241
the cultural context, the poor social image of nursing, the low levels of education,
training and preparation contribute to the quality of clinical learning environments in
Saudi Arabia. This study has revealed important issues about studying and practicing
nursing in Saudi Arabia and highlighted a range of challenges encountered by female
Saudi nursing students. This analysis might inspire other researchers to undertake
further investigations that extend this study further. It is this researcher’s sincere hope
that these findings influence changes in the Saudi nursing education and contribute to a
more positive future for the nursing profession.
242
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Appendices
Appendix A Questionnaire (English and Arabic versions)
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Appendix B Participant’s Invitation Letter (English and Arabic versions)
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Appendix C Explanatory Statements (English and Arabic versions)
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Appendix D Interview (English and Arabic versions)
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Appendix E Consent form (English and Arabic versions)
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Appendix F Research Approval from Monash University Human Research Committee (MUHREC)
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Appendix G Research Approval from sponsoring organisation (Taif University)
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Appendix H Research Approval from the participating Nursing faculties
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