Experiences of Student Nurses and Midwives at Selected Hospitals in the Volta Region of Ghana

Introduction: Nursing and midwifery are practice-based professions and require that student nurses and midwives learn how to become professional nurses and midwives in the clinical environment. Evidence obtained from research studies demonstrate that student nurses and midwives have various experiences during clinical placements. Though there are eighteen hospitals in the Volta Regions of Ghana that serve as clinical training environments for six nursing and midwifery schools, a search of literature identified no study on the experiences of student nurses and midwives in these clinical settings. Aim: This study sought to explore the experiences of student nurses and midwives in clinical placement in selected hospitals in the Volta Region of Ghana. Materials and Methods: This study was conducted using exploratory qualitative design. Data was analysed using qualitative content analysis. Thirty student nurses and midwives who the Volta Regional Hospital, Municipal Hospital and Keta Municipal were interviewed using a semi-structured interview guide. Recorded interviews were transcribed, reviewed several times by researcher, and analysed using content analysis. Findings: Four main thematic categories were identified; 1. Nursing and midwifery practice is honourable but a sacrifice. 2. Missed objectives and expectations during clinical placements; 3. Experiences of fears and anxieties before and during clinical placement; 4. Poor interpersonal relations between students and staff during clinical placement. Conclusion: A supportive clinical learning environment is a pre-requisite to acquisition of skills in the clinical setting by nursing and midwifery students. Provision of supportive clinical learning environment for student nurses and midwives is the responsibilities of both nursing schools and health facilities. Ghanaian nursing schools may also explore the subject of simulation in skills laboratory in areas where students do not benefit during clinical placements.


INTRODUCTION
Clinical placement is an essential component of the education of nursing and midwifery students [1]. Clinical placement allows student nurses and midwifes the opportunity to correlate theoretical knowledge with clinical practice [2,3]. Students' experiences in clinical placement can affect the quality of their learning [4]. Students require effective clinical placements to allow application of theory to practice [5]. Evidence obtained from research demonstrate that student nurses and midwives have negative as well as positive experiences throughout their clinical placements [1,2]. A qualitative study by Mabuda et al. [2] in South Africa identified lack of teaching and learning support, lack of opportunities for learning, poor theory-practice integration, and poor interpersonal relationships between students, college tutors and ward staff as challenges nursing and midwifery students experienced in clinical placement. In a similar study by Helgesen et al. [6] some students highlighted information failure and a lack of communication of objectives as reasons for not understanding what to do during clinical placements. Clinical practice education generally does not work as planned in accordance with the learning goals set by teachers [7]. Factors responsible for unmet objectives by students include considerations for patients' comfort and safety, increased attention to patients' rights, and shortage of field training personnel [7]. In the area of obstetric nursing practice, there is more difficulty than in other fields in obtaining clinical practice onsite [7]. This is because of concerns for the safety of the mother and fetus and for mother's privacy [7]. It is usually difficult for midwifery students to observe and perform the practice of midwifery [7]. Problems in maternity nursing are complex because they involve the entire process leading to pregnancy, delivery, and the period after delivery [7]. Problems can spontaneously arise at any point throughout this time and can include a variety of problems involving the whole family [8]. In some countries, simulations with multimedia technology and anatomical models are used more frequently for teaching nursing and midwifery students as a result of problems with onsite nursing and midwifery training [9].
On the other hand, research findings in a study by Salamonson et al. [4] identified that students were positive about the opportunities to make a difference and be involved in nursing and midwifery during clinical placements. Positive experiences in clinical placement occurred in stimulating, permissible atmospheres where there were visible preceptors [10]. There is need to explore student nurses and midwives experiences to make informed decisions on clinical nursing and midwifery education in Ghana. There are eighteen hospitals in the Volta Regions of Ghana [11] which serve as clinical training environments for six nursing and midwifery schools [12]. Apart from intra-semester clinical placements, students come from other parts of the country for clinical placements during their vacation periods. However experiences of student nurses in health facilities in the Volta Region of Ghana have not been researched. This study aimed at identifying both positive and negative nursing and midwifery students' experiences during clinical placement in the Volta Region of Ghana and recommend ways of improving nursing students' learning in the clinical setting during placements.

Research Questions
The following research questions guided the study: 1. What is the perception of nursing and midwifery by student nurses and midwives in clinical placement? 2. What is the level of achievement of clinical objectives by student nurses and midwives during clinical placement? 3. Are there any anxieties and fears by student nurses and midwives during clinical placement? 4. What kinds of relationship exist between students, staff nurses and staff midwives during clinical placement?

Research Design
This study was conducted with a qualitative explorative design. Data analysis was carried out by qualitative content analysis.

Research Setting
The study was carried out in three public hospitals in the Volta Region of Ghana; Keta Municipal Hospital (KMH), Volta Regional Hospital (VRH) and Ho Municipal Hospital (HMH).

Study Population and Sampling
The target population for this study consisted of student nurses and student midwives placed in VRH, HMH and KMH. A sample size of 30, large enough for data saturation was used. Selection of participants was based on purposive sampling technique. Only diploma student nurses and midwives were selected to participate in study.

Ethical Considerations
The research proposal was submitted to and approved by the University of Cape Coast Institutional Review Board (UCCIRB). Additionally, study received approval from the Ghana health Service (GHS) and each hospital where research was conducted. Adherence to all principles of research ethics was strictly observed. Researchers briefed participants about study aim and procedures before obtaining written informed consents from them. Participants were informed about their rights to refuse participation in study at any time without giving any reason. Also, participants were informed that their refusal to participate in the study would not be used against them in any form. Confidentiality of participants was enforced, and they were assured that data obtained would be used for research purposes only. The study process did not entail any harmful effects on participants.

INSTRUMENTATION
Data for this study was collected using a semistructured interview guide. Interview guide was reviewed by two nursing education experts. Interview guide was constructed in two parts. The first part was constructed to collect demographic data and the second part was constructed to collect data that answered research questions. Instrument was pretested in Cape Coast Teaching Hospital (CCTH) and Cape Coast Municipal Hospital (CCMH). Three questions were reviewed and modified by two nursing education experts.

Data Collection Procedure
Participants in this study were selected through a purposive sampling technique. Only diploma nursing and midwifery students were selected. Data was collected from second and third year students. Second and third year students presented richer experiences in clinical placements because they had more placements than first years. Data were collected in January 2016 when students were on their vacation clinical placements. An introductory letter from the University of Cape Coast was submitted to the hospitals of study. A list of all students on clinical placements was requested from Nurse Managers of the Volta Regional Hospital (VRH), Ho Municipal Hospital (HMH) and Keta Municipal Hospital (KMH). Inclusion criteria were students who were in their second and third years and were offering diploma in nursing and midwifery programmes. The eligible sample size was estimated to be 30 participants, large enough for data saturation. Saturation was reached after interviewing 30 participants, when new data confirmed previous data without adding new insights [13]. Mobile phone numbers of selected participants were requested. Participants were called on phone to arrange convenient time and place for interviews. Due to an absence of validated interview guide relevant to the topic of interest, themes of interview and the questions were developed by the research group, based on previous scientific literature. One semi-structured interview was conducted with each participant. Interviews were audio-recorded and recordings were transcribed verbatim. Participants told their stories with minimal interruption. The interviews ranged from 30 to 60 minutes. Transcribed interviews were stored in electronic folders that were created and labeled appropriately for easy identification. These folders were kept on a pen drive solely meant for the purpose of the study and kept under lock and key.

Data Analysis
Transcribed data were analyzed using conventional qualitative content analysis. Each transcribed interview was read several times and the primary codes were extracted. The related codes were put in groups. Categories were developed based on similarity and content of codes. To ensure trustworthiness of data, continuous investigation of the data, peer check and member check were performed. Moreover, the objectivity of the data was determined through continuous, accurate, and proper treatment of all stages of the research study and clarity of the research method. Using a team approach in data analysis ensured reliability of results.

Limitations of Study
This study utilised qualitative approaches and thus sample size was small. Though data saturation and triangulation was employed to improve trustworthiness and reliability of study, researcher recommends further quantitative study into experiences of students in clinical placement to make results more generalisable.

RESULTS
In this study, 27 participant were within the ages of 20 to 24. Sixteen participants were in their third year whilst fourteen were in their second year at the Nursing Training Colleges (NTCs) and Midwifery Training Colleges (MTCs). Fifteen students were in their 4th clinical placement. Nine students were in their 5th clinical placement. Only six students were in their second clinical placement. Twenty-three participants were females whilst seven were males. Four thematic categories were extracted after data analysis; 1. Nursing and midwifery practice is honourable but a sacrifice; 2. Missed objectives and expectations during placements; 3. Fears and anxieties before and during placement; 4. Poor interpersonal relations between students and staff during clinical placement.
Nursing and midwifery practice is honourable but a sacrifice: Almost all student nurses and midwives interviewed considered nursing and midwifery practice as noble but a sacrifice. Many students indicated that though nursing and midwifery is exciting, it is plagued with challenges of accommodation, feeding and transport. One participant indicated this in the following statement: Nursing and midwifery are noble professions which involves self-denial to save lives. I feel blessed to be a student in this profession but it needs much more dedication. Sometimes  I expected to be welcomed nicely by nurses when we started but it did not happen. I also thought the experienced nurses will always take their time to teach us but that too did not happen as often as I wanted.
Another student stated: When I was coming, I thought there will be clinical lecturers and tutors in the wards to demonstrate and teach us but there was none. I have to force myself to learn. Nursing and midwifery can be improved when students are given the standard training they require and also motivated so they will find the profession enjoyable [participant 7].
A participant also said: I was expecting a warm welcome from staff of the hospital that will be ready to teach and answer questions from students and correct students when they make mistakes. My expectations were not met because the nurses are always busy. They make us do more errands and less learning [participant [19].
Experience of fears and anxieties before and during clinical placement: Majority of student nurses and midwives interviewed indicated that they faced anxieties and fears before and during clinical placements. A participant stated:

Poor interpersonal relations between students and staff during clinical placement:
Many student midwives and nurses said the relationship between them and practicing nurses was poor. This was explained in the following statements by a participant: I devote myself to hard work in the ward but just because I do not force myself on any staff and in-charges to be their friend, at the end of the day they behave as if they did not see me on their ward [participant 8].
Another student said:

Most of the time, senior nurses shout at me when I am going wrong in performing a procedure. Their choice of words towards us at work is very bad [participant 25].
A participant also described the poor relationship between staff and students in the following words:

Senior nurses make us feel we are worse ever human beings on earth when we make mistakes. Nurses usually look at your mistake to judge your competence [participant 14].
Another student confirmed the poor relationship between students and staff in the clinical setting in the following sentences:

DISCUSSION
The findings of this study clearly show the phenomenon of clinical experiences by student nurses and midwives in clinical placement. The study participants stated their experiences in clinical placement through four thematic categories which were: 1) nursing and midwifery practice is honourable but a sacrifice, 2) missed objectives and expectations during clinical placements, 3) experiences of fears and anxieties before and during clinical placement, and 4) poor interpersonal relations between students and staff during clinical placement.
The perception of nursing and midwifery professions is an important factor in attracting student nurses and midwives to the study of nursing and midwifery. [14] Almost all students who took part in this study indicated that they view nursing and midwifery practice as honourable but a sacrifice. A study in Bahrain by Sanad and Awadhalla [14] concluded that newly enrolled nursing students have positive images of the nursing profession as a future career because they thought nursing was an honourable profession. Student nurses and midwives in this study indicated that it was an honour to make clients recover from their diseases. They usually felt happy and proud to be part of the healing process in the clinical setting. However student nurses and midwives in Ghana face challenges in nursing schools and clinical environments during training [15]. This is consistent with a study by Opare and Mill [16] who found that education for nurses and midwives in Ghana following independence is fraught with problems for tutors and students alike. Clinical skills laboratories and wards are poorly supplied with equipment and equipment available are usually very old [17]. Disposable nursing supplies are inadequate or simply not available for teaching [13]. For instance, bed for patients to sleep on at times becomes an issue and the few available ones are sometimes not in good conditions [15]. Nurses and midwives as well as students in many hospitals in Ghana are forced to improvise in performing many procedures. These situations of inadequate resources make it difficult for students to connect what they learn in the classroom to what is learnt or practiced in the clinical setting. Practicing nurses and midwives in Ghana also face problems of poor conditions of service [17]. Though work of nurses and midwives is important in saving lives of client, it is sometimes done at the expense of personal comfort. This is consistent with empirical evidence which shows that there is close association between nursing/midwifery and powerlessness [18], poor pay and poor conditions of service [19]. Many career seekers perceive nursing and midwifery as a poor career choice for reasons of too little financial compensation and its subservient image [20]. Despite the many references to the importance of effective student learning and socialisation during clinical practice, many researchers repeatedly report negative experiences of student nurses and midwives in the clinical setting. The negative experiences of students may be largely attributed to the many challenges that confront staff nurses and midwives in practice. Staff nurses and midwives face challenges of poor remuneration and poor working conditions, heavy workload [17] and these may influence the kind of attention they pay to students. Poor conditions of service and heavy workloads influence perceptions of students about the nursing and midwifery profession where they perceive nursing and midwifery as a sacrifice. Some nurses and midwives were asked in a study whether they will encourage relatives to pursue nursing and midwifery as courses [17]. Some indicated that they will not encourage relatives to pursue nursing and midwifery professions because they were demanding professions with less motivations [17]. More efforts are needed by key stake-holders such as nursing and midwifery leaders, policy makers, health training institutions, Ministry of Health (MOH), Ghana Health Service (GHS), and non-governmental organisations (NGOs) to remove bottlenecks in the nursing and midwifery professions to make it rewarding as well as honourable. Students should be provided conducive and supportive environments in order to have a positive perception about the nursing and midwifery professions and learn clinical care as well [2]. Health facilities in the Volta region could provide busses that will pick workers and students to and from work. Accommodations could also be provided for students' nurses and midwives during placements. Issues of feeding could be resolved by the provision of canteens where parents of student could be made to pay money to the hospitals before students start their placement experiences.
Student nurses and midwives indicated that majority of their objectives and expectations were not met during clinical placement. Many student nurses and midwives expected to be welcomed in the clinical setting, taken through pre-clinical and post clinical conferences and taught patiently by nurses and midwives in the clinical setting. A number of students expressed dissatisfaction with the modes of teaching during placement. Students stated that they had to force themselves to learn. Only few staff nurses and midwives were ready to take time off their schedules to teach students. This is consistent with a study conducted in South Africa by Edwards et al. [21] who concluded that nursing and midwifery education institutions faced the challenge of producing nurses who are clinically competent. Mabuda, Potgitere and Alberts [2] also found in a study that student nurses and midwives in South Africa were usually left on their own to be taught by ward sisters. Similarly, clinical nursing and midwifery education in Ghana is currently facing challenges of poor working relations between hospitals and health training institutions [1]. Challenges of clinical nursing and midwifery education in Ghana include inadequate preceptor preparations and inadequate faculty supervisions [1]. Since the first regional trainings in preceptorship organised by the NMC of Ghana in 1992, there has not been a standardised continuous training of preceptors [1]. Faculty and tutor promotions in Ghana are mainly based on scholarship of research and teaching and usually not associated with clinical teaching [1]. Clinical teaching of students in placement is usually left to ward sisters. Ward sisters are often not ready to teach students because either they do not have enough time or feel they are not being paid to teach students [2]. Some wards sisters also feel they are not adequately prepared to teach students [2]. Studies by several investigators reported positive findings of collaborative preceptorship models between schools of nursing/midwifery and health service agencies where nursing and midwifery students had a positive experience, expanded their knowledge, increased their confidence, and integrated their skills with real-life situations [22][23][24]. For preceptorship to become an effective clinical component of nursing education in Ghana, there must be a strong collaboration between nursing/ midwifery schools and health service, where preceptors and faculty members are regularly participating in collaborative preceptorship (CP) or clinical teaching partnership (CTP) programmes [1].
Student nurses and midwives experienced many fears and anxieties before and during clinical placements. Students were mostly anxious about where they were sent for clinical practice, how staff nurses and midwives will receive them, and patients dying during their shift hours. Several research finding indicate that nursing/midwifery professionals and students are often confronted with situations which lead to anxiety [25]. The findings in this study agrees with a research by Bole and Bregar [25] who found that student nurses and midwives experienced more fears and anxieties in the clinical setting than practicing nurses and midwives. Fears of criticism and disapproval were some of the situations that caused anxieties in student nurses and midwives [26]. Melincavage [26] found that anxiety experienced by student nurses and midwives interfere with the acquisition of knowledge and skills during clinical practice. Counseling services could be provided by managers of health facilities to reduce stress, depression or anxieties in student nurses and midwives during clinical practice so that stress, anxieties and depressions do not derail students learning experiences [25]. Staff nurses and hospital managers could make students feel welcomed in their health facilities to reduce anxieties and fears that occur with clinical placements. Health facilities should provide a conducive and supportive environment for students in clinical placement.
Poor interpersonal relations between students and staff during clinical placement was experienced by student nurses and midwives. Students stated that some staff nurses and midwives had their favourite students and if a student was not a favourite of any staff, he or she was not taught by any nurse or midwife. Many nurses and midwives also embarrassed students when they made mistakes in the wards. Some students stated that they were made to feel as if they were the worse ever human beings on earth. This is consistent with a study in South Africa by Mabuda, E Potgieter, and Alberts [2], who found that student nurses and midwives were called names, harassed, and were in most instances used as scapegoats for any wrongdoings in wards. Many students in this study were scolded in front of patient which they found embarrassing and frustrating. Mabuda, Potgieter, and Alberts [2] concluded in their study that situations of name calling and using students as scapegoats compromised open and honest interactions between students and staff and this impacted negatively on students' learning. A clinical environment with the necessary support for students is crucial to students' acquisition of knowledge. Clinical facilities with rich learning opportunities must also provide a conducive environment for students learning because evidence available shows that clinical environment with less learning opportunities but more clinical learning support and conducive environment was more favourable for students learning than clinical settings with rich learning opportunities without clinical learning support [2]. Establishing caring relationships with students is key to creating caring learning environments [27]. Workshops on customer care in health facilities should include treating students in our facilities as customers as well.

CONCLUSION
A supportive clinical learning environment is a pre-requisite to acquisition of skills in the clinical setting by nursing and midwifery students.
Provision of supportive clinical learning environment for student nurses and midwives is the responsibilities of both nursing/midwifery schools and health facilities. Nursing/midwifery schools should institute systems where lecturers or tutors will find it rewarding to supervise students in the clinical setting. Student nurses and midwives should also be regarded as clients in health facilities and shown the necessary care and concern. Clinical nursing education in Ghana can be more effective with a formally institutionalised yearly training of nursing teachers and staff nurses on clinical nursing education models.