1. Introduction

Nursing education involves practical training provided to students with the purpose to prepare them for their future duties as nursing care professionals [1]. To apply skills to practice settings, clinical experiences are important for the students [2]. Peyrovi, et al. (2005) mentioned that approximately 50% of any nursing curriculum is dedicated to clinical education [3]. This clinical education is provided to nursing students by experienced college teachers, nursing preceptors and other medical professionals who are qualified in this educational task, use many techniques to organize students’ clinical experiences and supervision [4]. It is very essential for the nursing programs administrations to provide the students with good clinical program by influential clinical instructors because they play a significant role in training the students in practice areas [5].

Many previous researches were done to investigate the students experiences and expectations regarding their clinical training. In one qualitative study done by Esmaeli, et al. (2013) aimed to investigate the expectations of Bachelor of nursing students regarding what creates an effective clinical education, the results revealed three themes: the appropriate communication between instructors and students, integration of theory and practice in clinical education, and having specialized instructors [6]. Moreover, Ohrling and Hallberg (2000) added that three themes appeared as students described their lived experiences in clinical training: directing learning, learning in practical action, and feeling in learning, those themes lead the authors to recommend that the students who received support during their clinical experience will improve their progress in nursing education [7]. Additional study by Brown, et al. (2011) students’ perceptions of ideal clinical education differ from their perceptions of actual clinical education [8]. In the same study students stated three views as being important to clinical training, participation in learning, being familiar with task-orientated roles, being creative and exclusive learning [8]. Kelly (2007); Mete and Sari (2008) mentioned in their studies that students considered having interpersonal skills, giving appropriate feedback and interpretation, and possessing clinical capabilities and proficiency in teaching are the most important characteristics for a clinical instructor [9, 10].

The students' negative experiences of clinical training may leave a major future worries. In one study, it was perceived that negative clinical experiences affect student self-confidence and readiness to practice, also clinical experience has influence either positively or negatively students satisfaction with nursing profession accordingly this will affect nursing retention [11]. It is very essential to enhance students clinical learning opportunities because the quality of student’s clinical experience is a vital contributing factor of the high quality of whole nursing education in the program [12]. The shortage of well prepared, skilled, and supportive faculty members for clinical training is a current issue locally and globally, this may widen the gap between theory and practice which accordingly leads to graduates nurses who are not qualified to be employed in clinical areas. As long as nursing programs in Saudi Arabia are competing to have high quality standards in nursing education in general, it is crucial to have better understanding of the characteristics of good clinical education that is capable to meet the needs and expectations of students in clinical settings. This must be accomplished by recognizing the students’ expectations regarding the clinical training. So the purpose of this qualitative study is to investigate the nursing students expectations regarding the effectiveness of their clinical training, Instructors, and clinical settings in one of the biggest governmental female universities in Saudi Arabia. The result may be enhanced the teaching and training strategies at nursing college.

2. Methodology

2.1. Research Design and Aim

A descriptive interpretive qualitative research design was utilized in this study on a certain setting where the researchers started out with the assumption that entree to reality is only through social constructions such as conversations, and shared meanings. Interpretive studies assume that people create and associate their own subjective and inter-subjective meanings as they interact with the world around them, and the researchers thus do effort to understand phenomena through accessing the meanings participants assign to them [13]. It is worthwhile mentioning that the students in the study went through skill lab, and simulations labs training which allow them to create a picture about the clinical trainers, clinical settings, and environment. Also all nursing students also went through orientation day regarding the clinical training program, in addition, they observe, listen, and discuss the clinical training with their friends from other academic levels. Despite the fact that the students didn’t exposed yet to clinical settings and may be affected by other students' perception, it is still important to consider their expectations. So, in an attempt to create an understanding of the context of the information system, the researchers in this study tried to describe the nursing students' expectations regarding the effectiveness of their clinical training in one of the biggest governmental female universities in Saudi Arabia.

2.2. Ethical Consideration

Institutional Review Board approval was obtained at the institution where the students were recruited. Participants were informed about the purpose of the study at the time of recruitment and they were given all their rights to choose not to participate and right to withdraw without any effect on their performance or scores in the courses they enrolled in especially the interviewer was a faculty member whose not sharing the teaching of the course or any previous or future courses, that to assure that the relationship between the participants and the interviewer will not affect their answers. Students were given the opportunity to ask questions at the time of recruitment and on the day of interview. They were assured of full disclosure of the data, anonymity and confidentiality.

2.3. Sample and Data Collection

The sample was purposive with one hundred (n=100) nursing students from third year who will be enrolled in clinical training course "Adult nursing" for the first time, but they went through skill and simulation labs training experience in previous courses, same students had orientation on clinical training in hospital settings and engaged with other students from higher academic levels in other theoretical courses. Those students were included because they will be exposed to clinical training for the first time in this year. Twenty focus groups were formed included five students in each group. Data were collected using semi-structured face to face interview for answering the questions which developed by the researchers based on a review of related literature. Each focus group discussion took one hour and data were written documented on papers. Data were not audio taped because it’s against the culture of the country. These interview were done in the nursing college setting, in quite, and well organized classrooms during the period of Oct 2016 to November 2016. And the data will be collected by faculty member who teach theory only for first year students and not included in clinical training or in teaching the course that students enrolled in or any future courses. The duration of data collection was two days. 50 students in each day.

The interview questions included:

1) What is your definition of clinical training?

2) What are your expectations from clinical training?

3) How do you expect the effective training will be?

4) What are your expectations from clinical instructors?

5) What are your expectations from clinical settings?

2.4. Data Analysis

The researchers used Braun and Clarke's (2006) thematic analysis which include the following phases: 1) familiarization with the data; 2) generating initial codes; 3) searching for themes, 4) reviewing themes; 5) defining and naming themes; and 6) producing a report [14]. The credibility and trustworthiness of the data analysis were ensured as possible by peer checking through asking colleagues about their experience and thoughts and views during data analysis [15]. Transferability were showed through a highly detailed description of the situation and method, and results in addition, the dependability of the data was ensured by audit trail of the research steps taken from the start of a research project to the development and reporting of findings [16].

3. Results

The findings were based on analysis of students’ responses to the interview questions. So three major themes emerged according to study’s questions: effective training focuses on the answers of questions 1, 2, and 3, effective instructor as an answer for question 4, and effective clinical settings which answering question 5. Several subthemes were explained, exemplified by quotations from the participants.

3.1. Effective Training

According to focus group from students four subthemes themes were formulated:

3.1.1. Application of Theory into Practice at Real Suitable Setting

Majority of the students thought that clinical training is an opportunity to apply theory in real situation and diminishing the gap between theory and practice. Moreover clinical training can be as learning and practice for their experience which assists in developing self-identity and deciding their future career.

One of the participants said: “clinical training is practicing what we previously studied in theory on real patients”.

Another participant reported: “when I experience clinical practice in clinical setting I will decide to leave or stay in this profession”.

3.1.2. Improving Clinical Competencies and Acquiring New Skills

From majority of the focus groups the participants expected that clinical training should improve their clinical competencies including, bedside care, building team work, and applying evidence based practice, all this can be done through organized scheduled training program ensured exposing the students to different cases, units and situations. Many students in this study believed that: “Good clinical training can help in developing our skills and clinical competencies”

On the other hand students emphasized that: “effective clinical training helps us in learning new skills and apply all nursing skills in certain condition if we have organized schedule with clear objectives and guidance”.

3.1.3. Developing Professional Characteristics

Many students highlighted that actual clinical training aiding in breaking the ice between them and the patients, families, nurses and all health team. Furthermore it can serve in rising their professional attributes such as responsibility, accountability, commitment, caring, critical thinking, ethical decision making, and communication and collaboration skills which improving the quality of nursing care. One of the students said: “clinical training is the suitable place to communicate with people and facing situations that may need thinking and ethical decisions”.

Another student reported:

“I expect from my clinical experience to assist me mostly in becoming professional nurse, in my decision making and communicating with patients and their families”.

3.1.4. Training in Positive Motivating Safe Environment

Few students defined clinical training reflecting their negative view or fear from unfamiliar environment including the nurses, medical team, patients, hospital climate and sanitary issues as it will be their first experience in clinical areas. One of the students’ thoughts: “clinical training included difficult situation such as dealing with nurses and others, also communicating with patients so I think we will be in need for continuous guidance and motivation from our college, and instructors”.

Another students said: “clinical training may have a lot of hazards such as unclean environment”.

So many of the students stressed on the point of safe, quite, positive environment as essential for effective training experience, one of them said:” the most important issue for me as characteristic for effective clinical training is to practice in safe encouraging environment which can help me in adaptation with my new experience”.

3.2. Effective Clinical Instructor

The participants in this study expectations for effective clinical instructor were categorized in four subthemes:

3.2.1. Effective Communication Skills

One of the most factors that the students thought is important to have effective clinical experience is to have a good instructor who can communicate easily with the students, able to adapt with their demands and capabilities. Many participants focuses on the fear from clinical experience and their need to have instructor who listen and interact with their concerns, also empathetic and fully respects them.

One student reported:” In my opinion, listening to students is the most important characteristics of effective instructor because any of us in our initial training can make mistakes and feel terrible and if we don’t have a supportive instructor who listen to us openly with feel frustrated”.

3.2.2. Competent and Professional Role Model

Majority of the focus groups participants believed that competent and professional instructor can help them a lot in clinical training. Instructor will rise students’ self confidence in the training by helping them in learning nursing principles, new skills appropriately, decrease the theory practice gap. So, they believed that the presence of such instructor can serve a proper model for students. Most of the participants agreed that such a role model can attract their attention and can play a major role in guiding their behaviour and performance in which to improve students’ clinical training skills. One student said:

“I would like to have instructor with competent skills and professional attitude, all of us searching in this age for a role model in the profession and I hope to have one”.

Also many students concentrate on the characteristic for effective instructor that relate most to professionalism which are being organized, and oriented to policies and procedures of college and clinical settings. Since the students knew their weakness especially as new trainers and their disorientation regarding the setting policies and regulations so they thought that clinical instructor more oriented than them and she can orient them and guide them in this point.

“I think the effective instructor can be the one who is the most oriented for clinical setting, policies and procedures, so she will protect us from violating the hospital rules and regulations”.

3.2.3. Provide Appropriate Guidance, Supervision, & Evaluation

Presence of instructor beside the students according to many participant can guide their practice because she will supervise them and teach them step by step through procedures demonstration and in the process of communication and providing the care for patients and families. This presence can serve also the purpose of evaluating the students’ performance in clinical training because the student will be in need all the time to continuous feedback from the instructor in order to improve their practice. In addition, continuous instructors’ presence protected the students from being ignored by the nurse in the units, and wasting their training hours in waiting for skills demonstration.

One of the students who considered this subtheme as the first priority for the effective instructor reported: “the effective instructor can teach me and correct my mistakes directly if she was a good supervisor all the time, because she monitor my demonstration and practice and evaluate me”.

However many students believed that the instructor role will be as evaluator more than teacher in the clinical areas and they expected to be monitored and evaluated in every step they will have in the future clinical training.

3.2.4. Positive Motivator and Supporter

The students agreed that the effectiveness of their clinical instructor shaped by her abilities in motivating the students especially the positive motivation. So according to them the instructor is responsible to identify the students level of competencies, teach, supervise, support, and motivate them to achieve the clinical training intended outcomes.

“I would like to be assigned with instructor that can discover my potentials, collaborate with me, and motivate me to achieve clinical training goals because this can influence my clinical training positively”.

3.3. Effective Clinical Setting

Almost all the students viewed the clinical training to be effective if they have effective clinical setting. Many issues were discussed with the students regarding the training areas and effectiveness of the clinical placements. And their expectations were categorized to the following three subthemes:

3.3.1. Suitable Clinical Setting

The students focused on several points that are considered the importance of clinical setting which included: working in generalized hospital that provide all patients’ services so they can grantee full exposure to different cases, presence of standardized sanitary rules and clean environment, presence of good infrastructure that provide helpful students services such as library, room for praying, and restaurant, presence.

“In my point of view I think the most thing that make me comfortable in the clinical area is the hygienic issue of the environment and students services they offer”.

Being oriented to clear rules and regulation which are flexible and adaptable to students’ need also considered to be a major influence on their clinical training specially many hospital have policy to consider the students as observers only. And also they stressed on the importance of availability of resources, equipment and supplies in the hospital that can lead them to practice in a standardized and ideal way.

“I would like to be assigned in hospital that let the students to participate in clinical procedures not only to observe as I heard from our colleagues”.

3.3.2. Hospital Professional & Ethical Environment

Several students discussed the effectiveness of clinical setting concentrating on its environment specially the professional and ethical characteristics. The participants thought practicing in environment that protect the ethical principle of the patients and workers will help them a lot because they are in stage where their ethical and professional values are developing, and they all want to end up with complete values clarification, solid ethical background and decision making abilities, and professional characteristic in their personality and behaviour.

“I cannot practice in area that not protect the ethical and professional standards which are the most important competencies that should be achieved in clinical training”.

3.3.3. Competent Human Resources

The clinical setting and all human resources working there including health care professional and administrative staff are most significant in the development of nursing knowledge and skills. Most students emphasized that presence of competent, supportive, and collaborative team can help them a lot to achieve clinical training goals. Especially, the availability of good preceptor ship program that handled by competent nurse who can find the best opportunity for the students to practice since it is well known that the number of students training in hospital units are large and exceeding the capacity of the unit sometimes. So the strong competent preceptor collaborating with motivated instructor can provide the students with best hand on clinical training experience.

“I think if the hospital have strong preceptor ship program and provides us with competent preceptor, this may influence my clinical training effectively”.

4. Discussion

The main aim of this study was to explore the nursing students expectations regarding the effectiveness of their clinical training. Clinical training is considered to be the exceptional experience for nursing students to practice patients' care where they can transfer what they learn in classrooms to real clinical situations. The first expectation of effective training that mentioned by students in this study was application of theory into practice at real suitable setting was supported by many previous studies, Esmaeili, et al. (2013) mentioned in their study that the expectations of Bachelor of Science nursing students regarding what constitutes an effective clinical education is to incorporation of both theory and practice in clinical education [6]. Similarly, the participants in Aktas and Karabulut (2016) study wanted to integrate theory and practice [17]. However, theory practice gap has well known to be a problem in nursing students' clinical training as indicated by many studies [18]. In Elcigil and Sarı (2007) study, students experienced difficulty in integrating theory learned in the classroom with clinical practice [19]. Since it is well common that the students will confronted by real situations they should be prepared for that by efficient program with teaching, learning and evaluation tools that decrease the gap between theory and practice [20]. Yet, the students in this study expected what have been always predicted from clinical training which is to improve clinical competencies and acquiring new skills. The experience of developing professional attributes is essential for successful nursing role of patient care, this is also stated. Papp et al. (2003) pointed out that one of the main objectives of nursing clinical education is to develop the students' professional skills to create self-confidence, and to guarantee that, the nurse must able to make her clinical decisions and be independent [21]. Benner et al. (2010) also describe professional formation as central to the development of the professionals and to achieve the desired goal from clinical training the students viewed effective training to be positive motivating safe environment [22]. Motivation is the key factor to improve the students interest in learning, and the motivation better to be intrinsic because the most important thing that causes a person to perform a work or action is intrinsic motivation [23]. Some students hesitated to enter a nursing programs due to the negative view of the nursing staffs stand in the front position of patient care, so there is a high possibility that they may come across infectious contaminating diseases and injure their physical safety, this considered nursing a high-risk job as mentioned in Tseng, et al. (2012) study [24].

Clinical instructors have major impact on the students clinical training outcomes. Nabolsi, et al. (2012) study results showed that most students emphasized the clinical instructor responsibility for shaping the learning environment to provide opportunities for students to achieve their learning objectives [25]. Based on this study participants’ responses, instructors’ professional skills is a major subject of the effective training. One of the most important factor for students’ success in clinical training is the presence of professionally motivated, experienced instructors [26]. Moreover, the results of a study by Kelly (2007) indicated that the knowledge of the clinical instructor is an important factor in creating an effective educational environment. The students also stressed on the most important factor that make the instructor effective from their point of view, which is being good communicator [9], and according to Mete and Sari (2008) qualitative study which aimed to determine what nursing students expectations from tutors, the communication skills of clinical education instructors are of highest importance [10]. Likewise, Stevenson et al. (2006) mentioned many characteristics of clinical instructors that play a role in enhancing student learning process which are communication, organization, motivation, consistency, and support [27].

All those characteristics were covered according to many participants in this study as being role model. Nabolsi, et al. (2012) study participants discuss the issue of what makes the instructor a good role model, and they were: being a good communicator, caring person through supporting the students, guiding them, being non-judgmental, fair evaluator, and respect them [25]. Nursing students learn everything from the instructor such as caring for the patients, skills, knowledge application, personal and professional behaviors by observation, so it is very central that the instructor have role model characteristics. Rush & Cook (2006); Tingle (2007) studies discussed the same issue that the students began the way idealistically, keen to care for patients and in some situations they were not happy with the attitude of nurses being uncaring preoccupied with getting through the work [28, 29].

The point of instructor being supporter and motivator also highlighted by students in this study, all students would like to be appreciated and their work to be valued and they need someone to support them in all situations and motivate them positively so this will improve their self-confidence and enhance their learning journey. This is reasonable and many literature discussed that, Delaram (2006) asserted that one of the important factors for students’ achievement during their clinical practice is the presence of professionally motivated instructors. The presence of supervision, guidance and evaluation by clinical instructor plays an important role in improving the learning and satisfaction of students in the clinical environment [30]. This is similar to this study results and supported by many other studies. For instance, Sharif and Masoumi (2005) study results showed that clinical supervision was one of the main themes in their study. And according to participant, instructor role in assisting student nurses to reach professional excellence is very important. In the same study, the majority of participants had the perception that their instructors have a more evaluative role than a teaching role, so being evaluator is also important as well as teaching [20].

The clinical setting and learning climate are most influential in the students clinical training. Students require effective clinical placements to allow the application of theory to practice [31]. And according to Koontz et al. (2010) this settings can influence the development of nursing skills, knowledge, and professional socialization [32]. Several issues were discussed related to the clinical setting such as the sanitary and safety issues, using high technology and equipment, competency of human resources and health care team, and the professional and ethical climate. Students expressed most satisfaction with effective clinical settings that will contribute to their awareness of future nursing role and will help them to view the learning field as stimulating and interesting. It is worth wise to mention that many studies have shown that most of the learning environments, despite having many benefits for nursing students, do not provide a positive learning situation for nursing students [33, 34]. Clinical experiences for students can deeply influences students’ overall perception and ability to have meaningful clinical practice. So clinical setting, instructors, and the clinical training program have major impact on the students intended learning outcomes.

Unfortunately in Saudi Arabia, there were no attempt previously to explore nursing students expectations regarding effective clinical training despite the fact that in this country the female students have special needs and expectations as the culture put them in a place that they will be under great observation and monitoring. But there is a qualitative study done by AlHaqwi, et al. (2010) on a medical students to explore the perceptions of students of the College of Medicine at King Abdul-Aziz Bin Saud University for Health Sciences about the determinants of effective clinical training. And the results showed that students identified five main themes of factors perceived to affect their clinical learning: the provision of authentic clinical learning experiences, good organization of the clinical sessions, issues related to clinical cases, good supervision and students' own learning skills [35]. In addition, the main themes divided to subthemes that were similar to this study results despite the differences in the students major specialty but they still train in the same field. So according Al Haqawi (2010) graduating clinically competent students is probably the principal objective of curricula and clinical teachers. There is another study done by Mutair (2015) discussing the barriers and challenges confronting nursing clinical teaching in Saudi Arabia and mentioned that clinical teaching lacks effectiveness which indicates a need for more active clinical setting to be able to make the theoretical components come alive in the practice and enthuse students [36]. In addition, he argued that there is a lack of preparing nursing clinical preceptors thus may affect negatively on the teaching process. And potential challenges related to the clinical educator and nursing students might act as obstacle toward achieving a good environment for clinical teaching. Those findings is in agreement with and support our study finding because it shows that the students share the same concerns and the situation needs more attention from nursing program administrators. In regards to being female nursing students and its correlation with the study results, the participants showed no concern regarding gender difference because Saudi Arabia nowadays in an approach for supporting and empowering women in all fields specially in medical field. In a study done by (Alwazzan & Rees, 2016) explored female medical educators' views and experiences of gender, career progression and leadership in academic medicine in Saudi Arabia and the results showed positive views and experiences of Saudi women in career progression, leadership and gendered workplace cultures [37]. So women currently do not present any special fear regarding clinical settings or workplaces except being save which is actually a major demand for both gender.

5. Study Limitations & Recommendations

One of the major limitations of this study is that the participants were female nursing students from just nursing department in one university in Saudi Arabia, so the findings may not be generalizable to other settings. Consideration in future studies can be given to use mixed method of quantitative and qualitative, in addition to a larger sample size and different demographical areas. As recommendations future researchers can address many related issues such as, the impact of clinical setting or instructors on nursing students' clinical competencies, academic motivation, and clinical decision making. It also would be thought-provoking to follow up this study with a longitudinal study to determine whether students' expectations was met or not and their experience in different years till graduation.

6. Conclusions

Nursing is a practice-based profession. Therefore clinical training is an crucial part of the undergraduate nursing programs. This study aimed to investigate the students’ expectations regarding effective clinical training and three major themes reflected the effectiveness of clinical education including effective training, instructor and clinical setting. Different subthemes were discussed and necessitated that measures to improve the clinical training should be developed and implemented as a result of a joint effort between a university college and clinical settings to facilitate the students achievements of intended learning outcomes. Academic, professional preparation for instructors should be considered and establishing good collaboration between college administration, clinical instructor and clinical setting administration, preceptors, and staff in developing clinical education in of major importance to any nursing program.