1. Introduction

One of the most critical experiences for student nurses is their exposure to patients in the clinical. It is where they encounter the human side of nursing. From an educational perspective, the clinical placement is the venue where skills, knowledge and attitudes developed in the theoretical part of the curriculum are applied, developed and integrated (Newton et al. [38] 2010). Learning in clinical practice provides up to half of the educational experience for students taking Bachelor of Science in Nursing. Chan [11] (2009) accounts that among student nurses, the clinical nursing environments is perceived as the most influential context for gaining nursing skills and knowledge. From a clinical perspective, the nurses who preceptor and guide nursing students through weeks of learning experiences see them as potential new recruits to their specialty field of nursing (Happel [21] 2008). From a student perspective, clinical placements are both stressful (Timmins & Kaliszer [56] 2002) and rewarding (Hartigan-Rogers et al. [24] 2007) and also viewed as the most important part of nursing education (Myrick et al. [36] 2006). Regardless of the perspective on clinical placements, a plethora of studies have found that clinical placement experiences may influence positively on nursing students attitudes towards the clinical setting in question (Fagerberg et al. [18] 2000, Abbey et al. [1] 2006, Happel & Platania-Phung [23] 2012 and a recent review by Happel & Gaskin [22] 2013). Graduate nurses contend that they are more likely to apply for work in settings where they had positive experiences during undergraduate clinical placements (Edwards et al. [17] 2004). It is therefore an important task to ensure good learning environments in all clinical settings used in nursing education. Ironically, in most cases, students are not versed as regards standards and measures of clinical work which consequently restricts them in terms of function in a health care setting. What could have these student nurses experienced during their placement in the clinical setting through their training years?

In recent years, nursing education has been focusing on theoretical education and on the deep gap between theoretical and clinical education created. This gap has been frequently mentioned in the research literature with Sandelands [50] (1990) observing that these two ideas were mutually exclusive. Implication wise, students often struggled to see the connection of the holistic grand theorists with the practical world of nursing. Another dimension to this challenge was that theoretical developments informed by research often ran ahead of clinical practice. The theory practice gap created a tension that moved the profession forward over time – new knowledge led to new practices. From the student perspective the theory practice gap has been noted as demanding and sometimes left them confused and uncertain about their roles and practice (Corlett [13], 2000; Ousey & Gallagher [41], 2007, Hatlevik [25], 2012). Also, many nursing researchers reported that nursing students, in spite of good knowledge base, weren’t skillful in clinical settings. As a result, the entrance of these unskillful students to the nursing care system, the quality of such falls day to day.

One of the most valuable components of a nursing program is the clinical learning environment (CLE). This setting provides students with unique learning opportunities in which classroom theory and skills are put to the test with real life situations. Clinical learning environments include hospitals, school clinics, health departments, hospice units, and other health care settings utilized for student learning. The CLE differs from the classroom or lab setting in many ways. Typically, the classroom and labs are controlled by instructors. This includes lectures, labs, tests, dress codes, student conduct, break times, attitudes, and the learning environment atmosphere.

Massarweh [32] (1999) described the clinical setting as a clinical class-room. However, the CLE is unpredictable and relatively out of the nursing instructor’s control. Attitudes, work ethics, staff members, unit environment, equipment and supplies, census, and patients and family members are elements of the CLE that cannot be controlled by instructors. This unpredictable environment is very different from the classroom and can be a major shock for students.

For the application of the theoretical side of nursing in the clinical learning settings, clinical teaching is highly needed.

Clinical teaching is the means by which student nurses learn to apply the theory of nursing and facilitating integration of theoretical knowledge and practical skills in the clinical setting which becomes the art and science of nursing. South African Nursing Council (SANC [55]) (1992) states that the overall objective of clinical practice is to provide student nurses with meaningful learning opportunities in every area of placement according to the level of training to ensure that on completion of the program, the student nurses are able to nurse efficiently. This implies that the group should be able to demonstrate the ability to solve problems effectively. Application of a scientific approach to nursing from the initial assessment to the rehabilitation of the patient or client along with an environment which is conducive to learning and provides the appropriate support from skilled practitioners and educators is a must.

Student nurses are found to be on the verge of developing the sense of responsibility for the health and well-being of others as having been introduced to the threshold of clinical practice at early adulthood. Leaving the safe and supportive teaching environments of their school, they are placed into clinical environments that are perceived as unfamiliar and complex and that require dealings with diverse human relations. Despite the difficulties brought primarily by the environment, the group’s clinical practice provides deeper insight to develop an effective clinical teaching strategy in nursing education.

On a personal note, expressing whether excitement, happiness, fulfilment, concerns, or dissatisfaction with clinical learning experiences generated an interest to formally investigate the experiences of student nurses during placement in clinical learning environments that include hospital wards and units, the community and health clinics. These experiences could only be accessed through the people- the student nurses who lived them. It is in such light that the barest essentials of exploring through the lived experiences of student nurses is underscored. Through this endeavour, the group may be assisted in achieving their educational goals during clinical practice while investing on having to develop an effective clinical teaching strategy in nursing education.

The research findings and recommendations may assist nurse educators and unit managers in shaping effective clinical learning environments for student nurses, consequently enabling the group to distinguish, anchored on their perspective attributes which positively or negatively influence clinical learning. This knowledge contributes to the improvement of nursing education for the production of more efficient nurses. Also, it may cast some light on the problems encountered by student nurses today. As to nurse educators and unit mangers, the material may serve as basis for them to be able to assist and offer necessary support to the student nurses while in practice placement. These go in consonance with Quinn [45] (2000) who states that qualified nurses are the key factor in influencing the learning environment of student nurses. It is then with this study’s aim to explore the experiences of student nurses during clinical practice and to recommend guidelines for improvement or enhancement of learning during the experience.

2. Background

Early studies in the 1990s examined multiple facets of student learning on clinical placement and demonstrated the complexity and demanding nature of the clinical environment, indicating that this area of learning is unpredictable and far beyond the control of faculty members (Twinn and Davies [57], 1996). Other studies questioned the effectiveness of clinical settings, claiming that they fail to provide students with positive examples of behavior (Greenwood [20], 1993) and even recognized it as a source of stress, creating feelings of fear and anxiety which in turn affect the students’ responses to learning (Chesser-Smyth [12], 2005).

Studies similarly described other influences on student nurse perceptions of CLE (clinical learning environments) experiences. Distinctly, Dunn and Hansford [16] (1997) suggested good collaboration among nurse educators, clinical sites, and other participants providing clinical education among student nurses promoting the creation of a positive CLE and the development of well-educated, competent nurses.

In support, Papp, Markkanen, and von Bonsdorff [42] (2003), in a study conducted among 16 student nurses showed three major factors: the appreciation and support received by students; the quality of mentoring and patient care; and, students’ self-directedness. Notably, students felt clinical practice and available opportunities provided a reflection of the process of becoming a professional nurse.

Contrastingly, Lipinge and Venter [29] (2003) reveal negative experiences reported by student nurses in a clinical setting, these cover: (a) expectations of the student nurses not being met as the staff members are sometimes not aware of student nurses’ learning objectives; (b) frustrations experienced during daily practice due to poor integration of theory and practice; and, (c) lack of tutorial support and guidance by lecturers.

As regards supervision, leadership style of the ward manager remains an important element of learning (Saarikoski and Leino-Kilpi [48], 2002); similarly, cultural and organizational factors in the ward often influence students’ learning experience (Pearcey and Elliott [43], 2004). Later empirical studies concentrated on the supervisory relationships and supervision that takes place with an individual supervisor or in a group (Saarikoski and Leino-Kilpi [48], 2002).

Ranse and Grealish [46] (2007) explored nursing students’ experience of learning in the clinical setting of a dedicated education unit using communities of practice framework. To quote, open forums should be held for clinicians to discuss their concerns regarding facilitating student learning and to collaboratively develop strategies to support student learning in practice.

3. Methods

3.1. Research Design

Qualitative, exploratory, descriptive and contextual designs were used employing the phenomenological method to explore the lived experiences of student nurses during clinical practice.

3.2. Population

Bonafide Benguet State University-College of Nursing fourth year student nurses formed the target population. This is so, understanding that the group has been exposed to different clinical settings as hospitals, clinics, and the community. Also, at this level, the students have covered almost all study disciplines for the four-year program (SANC [55] 1985). They would therefore be able to reflect on their various experiences during clinical practice. Willingness to participate topped the criteria.

3.3. Sampling

Purposive sampling method was utilized in this research. The participants were voluntarily selected by the researcher for the purpose of sharing their knowledge and experiences with the researcher as to which it was explained to them.

The inclusion criteria were: being a final (fourth) year student in the basic nursing programme; willingness to participate in the study; and having been exposed to the clinical learning environment in the hospitals, clinics and community.

A total of nine participants were interviewed, and at that stage, data saturation appeared to have been reached by means of repeating themes. Those interviewed were two males and seven females, with the age range of 19-21 years. Participants were requested to give written consent for the interviews to be audio-taped. All participants conformed to the sampling criteria.

3.4. Data Collection

To explore the lived experiences of the student nurses during placement in the clinical setting, semi-structured interviews were facilitated. Bernard [6] (1988) and Banfield [3] (2004) describes that semi-structured interviewing is best used when the researcher won't get more than one chance to interview someone and when he will be sending several interviewers out into the field to collect data. Semi-structured interviews are often preceded by observation, informal and unstructured interviewing in order to allow the researcher to develop a keen understanding of the topic of interest necessary for developing relevant and meaningful semi-structured questions. Participants were interviewed until data saturation appeared to have been reached by means of repeating themes.

One (1) focus group discussion and nine (9) interviews were facilitated. Interviews lasted with an average of 30 minutes and ranged between 15 minutes and 1 hour. The interviews were tape recorded, taken down in notes and verbatim transcriptions were made. No adverse events occurred. Participants did not receive any form of compensation at the conclusion of the interviews. Interviews typically began with a question about what they felt during their first placement in the clinical setting.

3.5. Data Analysis

“Researchers in the phenomenological mode attempt to understand the meaning of events and interactions to ordinary people in particular situations”, Bogdan & Biklen [7], (2009). The researcher captured personal experiences and drew rich descriptions and deep meanings from those shared. Transcripts were subjected to Colaizzi’s phenomenological method of data analysis as it offers personal insights into how to present an auditable decision trail in a phenomenological research study and explores issues of rigor and trustworthiness. It provides practical examples of how to illustrate the processes that can be employed to interpret and make sense of the research material when writing a thesis or research report.

The aim of this analysis stage is to understand more of the experiences reported by the participants (Knudson, B. & Coyle, A [27], 2002) by the following methods: reading and rereading descriptions, extracting significant statements, formulating meanings, and categorizing into clusters of themes and validating to identify experiences common to all informants with original text.

3.6. Ethical Considerations

The participants were asked of their consent and were assured of the confidentiality of the information to be shared. Especially on having to audiotape the interviews, they were requested to sign a consent form. Emphatically, their right on having to withdraw at any stage of the study has been defined.

4. Results and Discussion

Two broad domains: Cognitive Academic Proficiency and Practice, and Affect in Clinical Placements emerged from the group discussion and interviews done. Themes under the broad domain, Cognitive Academic Proficiency and Practice are Clinical Practice, Clinical Supervision and Interplay between Theory and Practice while under the other broad domain, Affect in Clinical Placements are Affective Barriers: Anxiety over Confidence, and Timeless Radiating Aura: Enjoyment and Appreciation.

Cognitive Academic Proficiency and Practice

In this domain, the participants put premium on the areas in their clinical experience’ whether or not they be desirable, that helped them improve their knowledge and enhance their skills in the field.

Clinical Practice. The student nurses considered the clinical practice as a vital component of their learning process as it plays an important role in enriching clinical competencies of the students. F states, “Clinical experiences are the stepping stones as one goes to the path of being a nurse. Without these great experiences, I won’t be able to perform interventions to the best of my abilities. These clinical experiences are the best learning experiences one can gain. Experiences are truly the best teachers.” In support, N accounts, “My experiences in the clinical practice have been a rollercoaster of feelings. It depends on the wards I have been assigned and on my personal preferences. My competence has been enhanced with the help of the clinical instructors, staff nurses and doctors.” Finally, G says, “My abilities have improved due to these experiences in the hospitals and I think I will be ready to be a staff nurse after graduating.”

Clinical practice is the field for student nurses to study, experience and develop nursing competence in relation to different diseases and in different patient situations in cooperation with experienced professionals. It provides an anticipatory knowledge of the organizational contexts in which nursing care is delivered (Boyer [8], 1990). The following transcribed responses go in consonance with the account: “It made me more flexible as early as being a student nurse. I learned how to adapt with the different situations that may occur any time. Now, I can somehow manage my time as taught by my clinical experiences.”; and, “During my first exposure to the clinical area specifically in the pediatric ward, I was so nervous. I was unsure with the procedures I am to perform to my patient. I can still remember the days I was so obsessed and compelled in checking my patient’s intravenous fluid not just once but every minute during the entire shift. But, as the days passed, my level of anxiety was lowered and my continuous exposure to the hospital made me feel more at ease. Before I even realize how proficient I can be, I was able to adapt myself to the different situations that may happen.”

Being knowledgeable of the different nursing concepts and having been updated with the existing technologies as to status quo lead the student nurses to delivering the care deserved by the patients. J expresses, “No letters from A to Z would describe the clinical learning experiences I had during my exposure in the clinical environment. It prepared me in becoming a competent registered nurse someday that I will be forever thankful. It taught me how to operate equipment that are new to me that are of great help for the patients.” Chapman [10] et. al. (2002) found that the students considered clinical practice as an essential component of their learning process. Their participants also considered that clinical practice allowed them to develop interpersonal relationships with others and what is more, to become aware of the political aspects of health care.

Sharif [53] (2010) defines the clinical practice as an area that allows students to have direct experience with the real world of nursing, to practice the clinical skills required for the job, to learn about general nursing routines and to learn about the responsibility of the nurse that will hone and improve their skills in preparation to becoming a registered nurse. Some of the student nurses approved stating, “I am more at ease right now when I am on duty because of the previous exposures we had for the past years as compared to my first clinical exposure which was nerve-racking. I always make sure that I am prepared and I have read my notes before going for duty and to check if there are any updates in the nursing field.”; and, “I would like to describe my clinical learning experiences as challenging, educative, extravagant, expect the unexpected and stressful. Despite all of these, the best is that it felt rewarding every after duty.”

Clinical Supervision. Lambert V & Glacken M [28] (2005) argues effective supervision by clinical teachers in clinical environment is vital for students learning; the student nurse-clinical instructor relationship is crucial (Chan. D. [11], 2009). Working closely with clinical teachers can foster students’ confidence and help them find meaning in their practice learning experience (Bradbury-Jones, C. Irvine, F., & Sambrook, S. [9], 2010).

Clinical supervision by clinical instructors is another theme that emerged under the domain. A great percentage of the participants agreed that clinical instructors are always there to supervise them and that they are helpful. They are there to guide the students, to make sure that they are doing the right interventions and to improve their skills and knowledge in preparation to becoming a full-fledge nurse. Beyond the acknowledged roles, ideas reveal that some instructors are rather distracting in some observed means. N reveals, “Clinical instructors are of great help during clinical practice and they teach us on almost everything we need to know to prepare us for our future. I sometimes find them distracting when I’m doing nursing interventions because they will tell you what to do even though you already know.” A statement by V reads, “Helpful! Sadly sometimes, the closer the clinical instructor while I am doing some procedures, the more I am making mistakes but all in all they are helpful and supportive. Clinical instructors should be aware that they have huge influence on students’ learning passion, professional identity, and future career engagement.”

Anchored on direct observation, the following were noted: “We often notice that during clinical duties, most of the male clinical instructors make themselves busy playing games in their mobile phones. Clinical supervision must be a building block for students in developing and improving their skills that is why it must always be comprehensive in nature. Clinical instructors must have the heart to listen and able to communicate effectively with their students. They should not get angry without listening to the students’ explanations.” Some of the participants appeal that they feel more anxious with their clinical instructors than having duty in the hospital. G adds, “They are always there to help and teach student nurses. Some of them give appropriate evaluation to students but for some, they just can’t get away from their personal issues with students that will affect the grades of the students. Clinical instructors often get angry when student nurses do something wrong without exactly hearing some explanations.”

Chapman [10] (2002) emphasizes in her study that personal characteristics of the clinical teacher and agency staff such as, being supportive, encouraging, resourceful, confident, approachable, friendly, available, helpful, understanding, welcoming, and having the students’ interests at heart, were all important aspects which the students perceived as enhancing their clinical performance.

Based on the above responses, the participants suggest that clinical instructors be aware of having a huge influence on students’ learning passion, professional identity, and future career engagement. The participants viewed clinical supervision as a field for great support and guidance and where clinical instructors conduct timely and fair evaluations; contrastingly, as evidenced by the following statements, their views start to diminish over time:

“I’m so scared with my clinical instructors. They should be aware that they influence us with their actions and will affect our performance during clinical practice”; and,

“Some clinical instructors are helpful if they encourage you but they are not when they always get angry. Clinical instructors should reflect on their teaching whether they are in students’ shoes to understand students’ learning needs and feelings.”

Ping-Huang [44] et. al. (2012) stated that students’ learning is hindered by teachers’ unclear and non-useful feedback or teaching without a respectful attitude. Poor student clinical teacher relationships could push students to lose interest in learning and to lose a supportive resource in the clinical setting. Proper feedback can offer insight into students’ clinical learning, thus improving their learning and performance and helping them fit into the setting.

Nabolsi et. al. [37] (2012) says in her study that students need the continuous support of their instructors or preceptors. Students were concerned about the manner in which faculty staff interacted with them, believing themselves to be worthy of respectful treatment.

The findings of Henderson, Cooke , Creedy and Walker [26] (2012) states that individualized supervision facilitates learning on the premise that one to one relationship with the mentor or preceptor allows students to express about their learning experiences and feelings in the practice thus leading to self-confidence, promote role socialization, professional development and independence thereby attain clinical competency.

Interplay between Theory and Practice. It has been a common observation that theories taught do not equate the type of environment designed for practice; a participant remarks, “A lot of things they teach us at the college just don’t happen when you're out there. It is a course you get taught about what's right and what's wrong, but when you're out there you sort of get taught what you should do.” Students feel that what they had been taught in the classroom was too ideological and not functional in the real world V states, “Theories in the classroom being taught differ when you are already in the hospital setting. It’s like bookish ideas are not always applicable given the situation of our country. Also, some procedures taught in the classroom differ on the different hospitals we go for duty like providing newborn care which makes us confused.” In support, Chapman [10] (2002) emphasizes that what students observed were taught in theory did not always connect in practice. Initially, this led to conflict until the students were able to accept the differences. Accepting the differences required the students to be versatile in how they performed on clinical practice.

A participant confessed, “What we get taught at university is too ideological, not the real world, once we get working out there, we should know how things go in a certain hospital and we go with the flow which leaves us to ask ourselves, “What should I follow, what my instructor taught me or what the hospital is practicing?” They find themselves torn between the demands of their clinical instructor and practicing nurses in real clinical situations.

Participants are also faced with diverse real clinical situations which leave them unable to generalize what they learned in theory. One of them proves, “In the wards they have their own way of doing things quite different from the books and procedures as taught by the instructors at the college.”

These findings concur with that of Davhana-Maselesele [15] (2000), who found that student nurses were having difficulty in applying theory to practice, mainly because the theoretical content of the curriculum is too idealistic and academic, and bears little relationship to the real needs of clinical practice.

Some of the participants argue that due to the scarcity of materials in the hospital, concepts in the books can’t be applied, to quote, “Ideally, the theories taught in school should also be the same with the procedures done in the hospital and I think some are being done in the hospital just like what is being done inside the school. The only difference is the completeness of the materials and strict compliance with the maintenance of sterility. J approves stating, “Most of the theories that we learn from school is not the same as that of the actual procedures and there are instances where in due to the scarcity of resources/equipment, improvised materials are used. Performing the actual procedure is definitely horrible than that of the return demonstrations done in the college.”

Rolfe [47] (1994) suggests that by reconsidering the relationship between theory and practice, and facilitating reflection on the realities of clinical life by nursing theorists, the theory-practice gap will be reduced, if not closed.

Sari and Elcigil [51] (2008) in Turkey and Safadi et al. [49] (2012) in Jordan, students reported disparities between what was learnt in class and simulation laboratory and the actual practice in clinical practice.

Affect in Clinical Placements

These accounts on what the participants mostly felt during their clinical experiences. These involve details on why they felt that certain emotion and its influence in their practice.

Affective Barriers: Anxiety over Confidence. The participants describe their clinical placements as stressful, nerve-raking and typified by a fear of making mistakes or saying something foolish. Members were confronted with feelings of anxiety and apprehension as they traversed different clinical placements. They confess that in all their clinical rotations, anxiety has always been there and will always be present. The participants found the following as reasons for such: patients having watchers that are a member of the health care team, being supervised by clinical instructors they are not in good terms with, and being unfamiliar or lacking of experiences and knowledge in procedures and unaccustomed wards.

Patients having watchers who belong to the healthcare profession are nerve-racking as to what the participants said. D states “Having knowledgeable watchers of my patients was the scariest moment I had. They asked questions they already knew to make sure that I am that knowledgeable and competent.” F adds, “I was always nervous when I am in the hospital. I can’t forget the time I was assigned to a patient who has a watcher that is a registered nurse and it really didn’t help me. The watcher always checked what I was doing to the patient and she asked unending questions maybe just to test my knowledge.” Although N hasn’t been through the scenario, she holds, “All of the clinical rotations I have been were anxiety- producing but I would be more anxious if the watcher of my patient will be a nurse or doctor. It would be great if they are cooperative and you learn from each other but if they’re not, it will leave me questioning myself if I did the correct interventions even though I know in myself that I did it right.”

One of the factors that make the participants anxious during clinical practice is being supervised by clinical instructors they are not in good terms with. Of the numerous clinical rotations handled by few clinical instructors, assessment as regards behaviour and relations towards the latter has long been structured. Here are some of the student nurses comments:

“I also feel anxious when I am being handled by clinical instructors I am not in tune with. I have been handled by all of the clinical instructors in our college so I know who I am not that in good terms. Being handled by these clinical instructors affects my performance which in turn makes me anxious also with what my grade will be?”; and,

“Clinical instructors that I feel hate me makes me nervous. They will always be checking you and try to look for loopholes in the interventions you have done just right.”

These findings are consistent with that of Nolan [40] (1998) who found that student nurses experienced fear and anxiety during clinical placement, which in turn affected the student nurses’ responses to their clinical learning environment.

Unfamiliarity to wards and procedures is another factor that makes the student nurses tremble. F shares, “If there is one area that I feel anxious about, that would be the medicine ward especially the stroke unit and renal unit. I am not that familiar with these units aside from the fact that the smell makes my stomach turn like a mixer. Administering medicines to patients whether what route they should be, it needs proper guidance and conscience before administering.” Patient safety is their greatest concern as G elaborates, “Having duties in unfamiliar wards would make me anxious for I will need great assistance to be knowledgeable in that ward and I will not be sure in the procedures I will perform. For me, it will be better to ask and let them know that you don’t have that enough knowledge rather than being pretentious. The patient’s safety is the greatest concern.” It is better to admit not being knowledgeable in some aspects in order to provide safety to both the patient and the student nurse.

V further explains, “Doing procedures without knowing how to will be anxiety-producing. Those “what ifs” will come out from your mind and it will be better to ask first. ” Melincavage [33] (2008) reveals anxiety has an effect on how participants interact with each other in the health care setting and how they provide patient care.

The participants generally account that all the clinical rotations and experiences make them anxious but they don’t let the anxiety and uneasiness interfere with their concentration in doing interventions to provide the best care to the patients. It coincides with the findings of Mlek [34] (2011) which states that despite the anxiety and stress experienced by the student nurses, most of them were able to perform clinical skills and for the most part of the anxiety did not affect their performance negatively.

Addressing anxiety- creating incidents for student nurses, Sellek [52] (1982) reveals that the ward is the best place to learn but very few of the learner's needs are met in this setting. Incidents such as evaluation by others on initial clinical experience and total patient care, as well as interpersonal relations with staff, quality of care and procedures are anxiety producing.

Student nurses should be supported in addressing and overcoming fear and anger, so as to provide quality nursing care. Support should be given to student nurses to enable them to identify and handle conflict associated with caring for patients (Naude and Mokoena [38], 1998). The accompanist for student nurses should develop strategies to build trust and create a caring environment for student nurses (Naude and Mokoena [38] (1998). Bayoumi et. al. [5] (2012) states lack of clinical experience, unfamiliar areas, difficult patients, fear of making mistakes and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience.

Timeless Radiating Aura: Enjoyment and Appreciation. Although most of the participants’ feedback regarding their experiences during the clinical practice focused on how anxious they were, they still managed and found grounds for enjoyment and appreciation. K approves saying, “Ever since, I always enjoy having duty for I can be able to share stories with my patients and their watchers as well about their lives and there are always things that I can relate to. Some patients also speak the same dialect as me so establishing rapport is easy.” The following support the above:

“I was still able enjoy my clinical experiences despite being nervous at first. Particularly, the things I enjoy much are administering injections, responding to emergency cases for I can be able to show how flexible I am, assisting in deliveries and performing newborn care for they are so cute.”;

“I enjoy having duty especially in providing newborn care.”;

“From the start of being in the clinical settings, I appreciate all the things I am learning and I never thought it was enjoyable. Nurse-patient interaction and performing nursing procedures has always been my favorite.”; and,

“I enjoyed all my clinical experiences which eventually helped me to be a better person.”

The findings coincide with Chapman [10] R. (2002) in which participants expressed they 'loved' being on clinical practice.

Henderson et al. [26] highlights that an environment that positively influences learning have been reported as where staff are happy, friendly with good morale and attitude, cooperative and willing to teach and guide students provide quality patient care Students feel confident and motivated to learn in an environment where they are respected, recognized, supported and regarded as part of the team.

5. Conclusions and Recommendations

Despite a wealth of research on clinical education learning in clinical practice is still a problem (Croxon and Maginnis [14] 2008). Nevertheless, findings from the studies provided insight into the experiences of nursing students learning in the clinical practice on what impacts effective clinical learning.

The findings and the literature that supported each indicate the need to rethink about the clinical skills training in the field of nursing. It is clear that all themes mentioned by the students play an important role in student learning and nursing education in general. Evidences as based on literature revealed that students’ experiences in the clinical practice can either positively or negatively impact their learning. As noted, there were some similarities between the results of this study with other reported studies and confirmed that some of the factors are universal in nursing education. It can be said that the integration of both theory and practice with good clinical supervision could enable student nurses to feel confident with their abilities and competent to take care of the patients.

Participants in this study recognized that there was conflict between what is taught in the classroom and what happens in the real world. The results should be considered by nursing education and nursing practice professionals. Approaches in order to decrease the gap that exists between the academic and the clinical component of nursing education should be explored. It would also help the clinical instructors to design strategies and new innovative ways for more effective clinical teaching and there is a need to be concerned about solving student problems in education and clinical practice. There are also opportunities for both educators and students to work within a more creative environment that will promote and add to the professional knowledge base (Barton [4], 1998).

Further the study reflects that clinical teachers make a valuable contribution to the students learning process. Clinical instructors may enhance students learning by creating a positive learning environment and participating as role models so students’ anxiety will be lowered and their passion towards caring will increase. However, this research has shown that the participants in this study considered clinical practice to be an essential component of their learning process. From this perspective, nurse education must commit itself to a high level of clinical practice for students of nursing. Skaalvik, Normann and Henriksen [54] (2009) states that in order to recruit graduated nurses to work in hospitals, it is necessary that nursing students experience positive clinical learning environments characterised by a pedagogic atmosphere conducive to teaching and learning with a clear nursing philosophy and systematic individual supervision in a one-to-one relationship.

A supportive clinical training environment is most influential in the development of nursing skills, knowledge, and professional socialization. The clinical educational environment and the characteristics of the clinical instructors play a major role in empowering students’ learning, bridging the theory-practice gap, enhances their sense of responsibility, and provides them with opportunities to demonstrate nursing competence.

It is recommended that further interviews on how to close the gap between the academic and the clinical component of nursing education be done- investing on rather personal inputs. Similarly, those responses as regards strengthening student-instructor relations should be elicited. Wall, Andrus and Morrison [58] (2014) states that simulation will be especially useful in preparing student nurses for clinical work.

Furthermore, college instructors should design a programme for accompaniment, and avail themselves in clinical settings on a continuous basis to guide student nurses. They should regularly update their knowledge and skills on the latest trends in clinical practice, to enable them to teach procedures which are relevant to the current practices and technological developments in the clinical setting.

Clinical supervision by the members of the health care team such as those of staff nurses and doctors should also be explored in order to distinguish whether their teachings impact the performances of the student nurses. The authors further recommend future authors to dig deeper into the positive feelings and experiences of student nurses in the clinical area when replication of the study is intended. More on the part of registered nurses, they must be encouraged to view clinical teaching and supervision of student nurses as part of their teaching function and quality improvement strategy in the wards. Nurse managers should ensure that there is sufficient equipment and personnel within the clinical facilities to enable clinical teaching and learning to take place. College instructors and registered nurses working in the hospital wards and clinics should realize the importance of acting as role models and mentors for students to facilitate professional attitudes and behavior.

Future research be conducted anchored is needed to build on the findings presented here. In-depth research on each of the five themes made be done with anticipated responses by curriculum planners in-charge of the degree program.

Lastly, further studies to explore the experience of clinical instructors are recommended to identify the perception of educators regarding clinical nursing education.

ACKNOWLEDGMENTS

The authors are thankful to all students who willingly participated in the study, without their wholehearted input this study could not have been possible. No manuscript is ever a reality without the dedication and perseverance of editorial staff who were our colleagues. This was a non-funded study and there is no conflict of interest.