Background: Clinical practicum is an integral part of nursing education because it provides students with opportunities to perform nursing care and practice specific nursing tasks. In Ghana, little is known about the experiences of baccalaureate student nurses with regard to intra-semester clinical practicum. This study therefore, explored perceptions, challenges, and how the intra-semester clinical practicum affects the learning process of student nurses in a private university in Ghana. Methods: Exploratory descriptive phenomenological design was used. Nine in-depth interviews and three focus group discussions were conducted for baccalaureate student nurses in their second, third and fourth years of study. Only those who have attended intra-semester clinical practicum for at least two semesters in the course of their study were recruited. Purposive sampling technique was used to select the participants. The sample size was based on data saturation, however, a total of 33 participants were recruited. Data was analysed using content analysis technique. Results: The findings show that baccalaureate student nurses perceive the intra-semester clinical practicum as beneficial. It affords the opportunity to translate theoretical knowledge into practice concurrently. However, students recounted their stressful experiences during the clinical period which negatively affected their academic work. Additionally, staff nurses assigned the students to do menial jobs instead of appropriate nursing tasks. Conclusions: Areviewof the “block” method in which students will go to clinicals for a stipulated number of consecutive days in a month and then resume lectures, is worth considering. Keywords: Experience, Baccalaureate, Student nurses, Intra-semester, Clinical practicum Background It is well established that student nurses perceive clin- Nursing is a practice-based profession and therefore the ical placement as rewarding  since it has the tendency clinical setting is an essential part of the training [1–3].The to improve their clinical skills, connect theory with preparation of student nurses involves rigorous theoretical practice and support their professional growth [8–12]. and practical instruction . However, effective training is Notwithstanding, the clinical environment presents dependent on appropriate supervision and mentorship numerous challenges to students [3, 13–15]. For in- particularly in the clinical environment [5–7]. stance, in South Africa, nursing students complained of lack of support by staff nurses . Some incidents of bullying of student nurses were documented in other countries [14, 16]. These incidents created anxiety and * Correspondence: firstname.lastname@example.org Department of Community Health Nursing, School of Nursing, College of depression among the students and consequently af- health Sciences, University of Ghana, Accra, Ghana fected the care they offered to their clients. Despite all Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Adjei et al. BMC Nursing (2018) 17:23 Page 2 of 6 these occurrences, the overall positive effect of clinical at Valley View University which was established in 1979 placement of nursing students cannot be underestimated. by the West Africa Union Mission of the Seventh-Day Furthermore, different nursing practical methodologies Adventist Church. The baccalaureate nursing programme are used by various nursing schools all over the world. of the institution commenced in September, 2007. For example, in the United Kingdom (UK), student Currently, it has a student population of 462. nurses are placed in the clinical learning environment for 6 weeks continuously which enables them in gaining Participant’s eligibility self-confidence and improves their communication with Inclusion criteria clients and nursing staff . What is unique about this Participants were included in the study if they were bac- approach is that registered nurses who participate in the calaureate student nurses who have completed at least Nursing and Midwifery Council’s (NMC) approved men- two semesters of their 4 year programme and have torship programme, support the students professionally attended intra-semester clinical practicum at least twice . On the contrary, South African student nurses are in the course of their study and consented to participate. in the clinical environment for only 14 days, a time period which they perceive as too short for acquisition Exclusion criteria of nursing skills . First year baccalaureate student nurses were excluded. In Ghana, a recent curriculum designed by the NMC re- quires each student nurse to obtain clinical contact of Sample and sampling methods 432 h, 624 h, and 576 h during the first, second and third Participants were selected purposively. In all, 33 partici- year of training respectively .This curriculum allows pants took part in the study. The study objectives were nursing schools in the country to adopt either of the ac- shared with the students in class. Those who were inter- ceptable clinical placement schedules; intra-semester and ested to participate and met the inclusion criteria were inter-semester clinical placement . recruited. Nine in-depth interviews made up of three For the past 3 years, Valley View University has imple- students each from year two, three and four were con- mented these two methodologies prescribed by the ducted. In addition, three focus group discussions, which council. During vacation, students are assigned to hospi- consisted of eight students from each of the three levels, tals for clinical attachment for a maximum of 8 weeks were done. (inter-semester practicum). Then when classes are in session, the students attend lectures 3 days in a week Data collection tool and spend the remaining 2 days in the clinical setting to A semi-structured interview guide was used to conduct ensure that they satisfy the NMC’s intra-semester practi- the in-depth interviews and the focus group discussions. cum requirement. This means that teaching and prac- The guide had both open and closed ended questions tical attachment are done concurrently during the such as: “How do you perceive intra-semester clinical course of the semester. This study therefore was aimed practicum?”; “Did the clinical practicum have any effect at documenting the perception and challenges that (positive or negative) on your learning?”; “Did you face students face during intra-semester clinical placement any challenges with intra-semester clinical practicum?” since the limited literature in Ghana focuses primarily The guide was designed based on literature and experts’ on student’s attitude toward clinical work . contributions (refer to Additional file 1). Methods Data procedure Study design Data collection started between June and August, 2016 This study used exploratory descriptive phenomeno- following ethical clearance and permission from Univer- logical design. Considering the fact that intra-semester sity authorities. On the day of the scheduled interview/ clinical practicum is a new practical methodology used discussion, the researchers met the participants at the by the University, this design was best suited to explore agreed venues which included classrooms and confer- the experiences of the students. ence rooms in the school. The study aims were ex- plained to the participants and their written consents Study setting were obtained. In addition, their consent to audio record The study was conducted in the Greater Accra region of the interviews/discussions were sought. The in-depth in- Ghana. The region is the capital town of the country and terviews lasted between 45 min and 1 h. However, the shares borders with the Eastern region to the north, focus group discussions lasted between 60 min and Central region to the west, Volta region to the east and 90 min. None of the participants experienced any psy- the Gulf of Guinea to the south . About 4,010,050 chological disturbances in the course of narrating their people reside in the region .The study was conducted experience. Adjei et al. BMC Nursing (2018) 17:23 Page 3 of 6 Data analysis they are taught in the classroom, particularly courses Data were analysed using content analysis technique. that are practically oriented. Some shared their The recorded interviews were played and listened to thoughts: by the researchers. Each researcher coded the data, which was followed by a series of group discussions “Intra-semester clinical is very helpful because aside by the research team. Finally, major themes and the lectures and the skills lab, you need a real patient sub-themes were generated and presented as findings to try your hands on. It is only on the ward that you of the study. get such cases and time to practice.” [Kofi − 300] Methodological rigour “Intra-semester clinical is important. For example, you Rigour refers to trustworthiness. Rigour in qualitative can only appreciate a course like community health study must satisfy the following criteria: credibility, nursing when you see it being practiced and not that transferability, dependability, and confirmability . you learn and wait till a certain period of time before In this study, credibility was achieved by piloting the you go and practice.”[Akua − 300] interview guide using baccalaureate student nurses who shared similar characteristics but were not part Notwithstanding, some students indicated that they of the study participants. Transferability was ensured only derived the full benefit of the clinical practicum by the use of direct quotes from participants and a when they were assigned to wards that offered care to thick description of the study setting. An audit trail patients with conditions that were in line with the topics with the voice records, transcripts, field notes and being discussed in class. diaries was kept to ensure dependability and confirmability. “When you are placed on a ward that is related to what you are studying in class, it helps you better Ethic approval understand the theoretical aspects of the nursing The study was ethically approved by the Dodowa Health course” [Afia − 400] Research Center of the Ghana Health Service (protocol Number-DHRCIRB/07/06/16). Permission was also sought from the Head of the Nursing Department of the Stress University. In addition, participants’ written consents Almost all the participants during the interview were obtained after the rationale of the study was expressed their concerns about the stressful nature of explained. Pseudonyms are used to ensure anonymity of the intra-semester clinical practicum. According to the the participants. participants, long distance to the hospitals and the fact that they must attend lecture the next day compounds Results the situation. Socio-demographic characteristics They lamented: The study involved thirty three (33) baccalaureate student nurses in their second, third and final year “Going for the clinical is stressful, I mean very of the nursing programme. They ranged in age from stressful. The long distance from the school to the 19 to 24 years. Each participant had attended hospital makes it very stressful.” [Adwoa-300] intra-semester clinical practicum at least twice in the course of their study. In all, three themes and seven “Going for afternoon shift especially is very tiring. We sub-themes emerged from the data and are pre- come back from clinical very late in the evening sented below. meanwhile, we have lectures early in the morning on the next day. So I think it’s too stressful.” [Akosua-400] Perception about intra-semester clinical practicum This theme describes how the students perceived intra-semester clinical practicum. A number of the par- Effects on academic performance ticipants indicated that the practicum was very benefi- Some participants echoed the effect of the intra-semester cial. However, some added that it was associated with clinical on their academic performance. According to stress, which consequently affected their academic work. them, they were unable to prepare adequately for class the next day especially when they returned to Benefits of intra-semester clinical practicum campus very late. The carry over effect of the stress The study revealed how clinical practicum presents also influenced most students to sleep in class during an opportunity for student nurses to appreciate what lecture periods. Adjei et al. BMC Nursing (2018) 17:23 Page 4 of 6 “...when you go for afternoon shift and come around “…because the practicum is not continuous, there is 9pm, you will be tired, and learning your books before absence of that kind of close relationship and cordial the next lectures becomes very difficult. You are relationship with the nurses.” [Akweley-300] unable to revise your lecture notes and so you get confused when you’re taught new things in class” Furthermore, some participants expressed that the [Kwaku-400] poor relationship had a negative impact on their skill ac- quisition on the ward. A student said: “We mostly sleep in class because of the tiredness we experience. Also, we don’t have time to read on our “Becausewe gotwice aweek, we’re always new on previous lessons” [Akua − 300] the ward so the ward in-charges do not have confi- denceinustolet us do much of theprocedures. They think we still don’tknow…,we’re still novice Learning environment on the ward because they don’t see us every day.” The study revealed that there is a huge gap between [Kwabena − 400] what students learn in class and what is being practiced in the hospitals. In addition, some participants reported One participant was afraid that continuing with just that they were not supported by the staff nurses. the 2 day contacts in a week at the hospital will not give him the chance to practice advanced nursing procedures Theory and practice gap but only the checking of vital signs. The majority of the participants indicated that a gap existed between theory and practice. According to “When we continue to go twice a week, we’ll always check them, the nurses in the hospitals did not follow vital signs only till we finish the school.” [Kofi-200] standard protocols in providing nursing care. This contradicts the systematic way in which they are taught in the school’s skill laboratory. Some shared Challenges of intra-semester clinical practicum their frustrations: This theme describes the challenges that confronted the students during the intra-semester clinical practicum. “The procedures that they use at the wards mostly Some participants indicated that they were only used for don’t follow protocol like how we’re taught in the menial jobs in the hospitals. Others also mentioned that school’s skills laboratory. The way they (nurses) do the twice a week contact at the hospital did not afford things on the ward is different. They (the nurses) want them opportunity to know the outcome of their patients’ to be able to serve everybody quickly and therefore do conditions. not follow the exact protocol that we’ve been taught” [Nii-200] Break in continuity of care The study revealed that most participants were unable One participant argued why it may be better to learn to follow their patient’s progress to the end and there- the practical component of nursing from the literature fore were not able to measure their success. rather than going to the hospital. He said: “When we go twice a week and we care for patients, it “Sometimes I think it seems better reading the literature takes another week before we meet them again. and getting things right about practical aspect of Sometimes, it is very difficult to follow up… you have nursing than going to the ward where improvisation is to pick a new patient again.” [Kwesi-300] the theme of the day. You can imagine if you pick the wrong things there by doing them, it’ll be very difficult to conform to standards” [Kojo-400] “when you’re on the ward and you nurse a patient for a particular week, by the time you go for the following week you’ll realize that the patient has been discharged Student-nurse relationship and you can’t get access to the folder so it seems you’ve Some participants mentioned that the learning envir- done nothing for the patient.” [Adwoa-400] onment was not friendly due to a lack of bonding be- tween the students and the staff nurses. This was attributed to the fact that students were placed in the Messenger role hospital twiceaweekand thereforewereunableto A number of the participants expressed how the staff acquaint themselves very well with the staff nurses. nurses used them for menial jobs on the ward instead of Adjei et al. BMC Nursing (2018) 17:23 Page 5 of 6 allowing them to spend productive hours with their speculate that some nurses are not confident enough to patients. demonstrate nursing procedures to students. Clinical su- Yaw had this to say: pervisors need to be guided by clinical objectives before assigning students to the hospital wards. In addition, “They (nurses) kept on sending me everywhere, I went preceptors must be trained and assigned to students for to the orthopedic unit, and many places. Anytime I supervision and assessment. This will bridge the exten- return they will say that I have the long legs so I have sively reported gap between theory and practice. to be transporting patients to other units. Sometimes, The study also found that the learning environment I don’t even get time with the patients. I sometimes was unsupportive and this was evidenced by the poor re- spent a maximum of five minutes with my patients lationship that existed between students and staff nurses. the whole day.” [Yaw-200] This corroborated a study by Mabuda, Potgieter& Alberts  which found that nurses failed to support students during clinical attachment. Perhaps the behav- Discussion iour of students, including lateness to work, the use of This study explored the experiences of baccalaureate mobile phones on duty, lack of commitment to clinical student nurses regarding intra-semester clinical work and absenteeism without permission as docu- practicum. The findings showed that students per- mented in a similar study in Ghana , might have in- ceived intra-semester clinical practicum as beneficial fluenced the reaction of the staff nurses toward the since it afforded the opportunity to translate theory students. It is therefore important to orient students on into practice concurrently as previously reported in their clinical objectives before commencing their clinical other studies [8, 10, 22]. For instance, in Saudi Ara- schedules. It is also important to have the students bia, about 75.6% (n = 205) of nursing students were followed by experienced clinical instructors to ensure satisfied with their clinical practicum . The simi- the best learning results . Faculty support in the clin- larities may have resulted from the fact that student ical environment has significant impact, particurlarly in nurses recognised nursing as both an art and science facilitating, evaluating and monitoring the students dur- and therefore understood the importance of the prac- ing the clinical period , and therefore it is worth tical component. strengthening. Moreover, staff nurses need to recognise The study also found that clinical placement was themselves as mentors and important stakeholders in associated with stress. The long distance (35.5 km) to the the training of student nurses. hospitals and early morning class schedules for the next The findings further showed that some staff nurses day, compounded the participants’ stressful experiences. treated the students as messengers instead of learners. It Previous studies have also documented stress as one chal- was widely reported that student nurses were used for er- lenge that negatively affected the learning processes and rands and were further tasked to do menial jobs instead of the general health of nursing students [12, 23, 24].Accord- providing nursing care. This finding is not peculiar to ing to Jamshidi et al. ,student nurses in Iran were Ghana but is also present in other countries [3, 18]. This stressedbythe newexperienceof being in thehos- obviously has an implication for nursing skill acquisition pital and also by the complexities of devices they ob- since the students are not encouraged to take on challen- served on patients. Other related studies supported the ging tasks to develop their professional skills. It is import- experiences of stress in the clinical environment for ant to assign students to specific tasks as soon as they students [24, 25].It is worth considering repackaging the report to the hospital and these tasks should be evaluated clinical placement schedule such that students spend at the end of the shift by a preceptor or clinical instructor. sometime in the classsroom and subsequently halt for practicum during the course of the semester. Conclusions Many studies have reported on the existence of a gap The findings of this study provide insight to nursing stu- between theory and practice in relation to nursing edu- dents’ experiences in the clinical environment. It reveals cation [8, 18]. Some participants in this study mentioned that student nurses perceive intra-semester clinical prac- that the systematic way of carrying out nursing proce- ticum as a good approach for acquisition of skills. How- dures was missing in the hospitals. Students were there- ever, there are some challenges that require an fore in a state of dilemma as to whether or not they immediate review of the methodology so as to help stu- should copy the practices of staff nurses, which were not dents derive the full benefit of the intra-semester clinical evidence supported. The non-compliance to standard practicum. One suggestion may be an adoption of the procedures by the staff nurses is not surprising since it “block” method where students will go for clinical at- appears there is an imbalance in the nurse-to-patient ra- tachment for a stipulated number of consecutive days in tio which increases the workload of nurses. Also, we can a month and then resume lectures. Adjei et al. BMC Nursing (2018) 17:23 Page 6 of 6 Additional file 11. Wang H, Li X, Chen H. Perceptions of nursing profession and learning experiences of male students in baccalaureate nursing program in Changsha, Chian. Nurse Educ Today. 2010;31(1):36–42. Additional file 1: Interview guide (DOCX 14 kb) 12. Sharif F, Masoumi SA. Qualitative study of nursing student experiences of clinical practice. BMC Nurs. 2005;4(1):1–7. 13. Killam LA, Carter IM. Challenges to the student nurse on clinical placement Abbreviation in the rural setting: a review of the literature. Rural Remote Health. 2010; NMC: Nursing and Midwifery Council of Ghana 10(3) https://www.rrh.org.au/journal/article/1523. Accessed 7 Oct 2017 14. Mabrouk A, Rahman R. Perception of student nurses’ bullying behaviors and Acknowledgements coping strategies used in clinical settings [paper presented at the sigma The authors acknowledge the contribution of the students who participated Theta tau international, nursing education research conference, in the study. Indianapolis]. 2014. http://www.nursinglibrary.org/vhl/handle/10755/316820. Accessed October 2017. 15. Mabuda BT, Potgieter E, Alberts UU. Student nurses’ experiences during Availability of data and materials clinical practice in the Limpopo province. Curationis. 2008;31(1):19–27. All data are with the authors and available for sharing. 16. Budden LM, Birks M, Cant R, Bagley T, Park T. Australian nursing students’ experience of bullying and/or harassment during clinical placement. 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Ghana Statistical Service. 2010 Population and Housing Census Regional Official permission was obtained from the head of department of Nursing. analytical report-Greater Accra Region. 2013. http://www.statsghana.gov.gh/ Additionally, informed consent (written) was sought and obtained from docfiles/2010phc/2010_PHC_Regional_Analytical_Reports_Greater_Accra_ participants after explaining the purpose and objectives of the study to them. Region.pdf. Accessed 12 Aug 2016. 21. Lincoln Y, Guba E. Naturalistic Inquiry. Beverly Hills: Sage publication inc; 1985. p. 290. Competing interests 22. Cameron-jones M, Hara PO. Practicum as part of higher education. Kluwer The authors declare that they have no competing interests. Academic Publisher. 2015;19(3):341–9. 23. Jamshidi N, Molazem Z, Sharif F, Torabizadeh C, Kalyani MN. The challenges of nursing students in the clinical learning environment: a qualitative study. 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Published: May 29, 2018