Impact of clinical practicals on the mental health status of university nursing students

INTRODUCTION

Mental health is equally as essential as any other aspect of health. It impairs the productivity and functionality of an individual thus it is vital and it is addressed as such. Students are faced with challenges from all angles of life and their academic life, such as time, finances, fitting in with peers and good academic performance. The aim of the study was to explore the impact of clinical practicals on the mental health status of 4^th year nursing degree students at the University of Namibia main campus. The objective of the study was to explore the impact of clinical practicals on the mental status and describe the general attitude of 4^th year nursing degree students at the University of Namibia main campus towards clinical practicals.

The synchrony of the academic and social aspects in a healthy way so that there is a balance between them, enables students to thrive in both. Mental illnesses are thought to impair learning hence the academic and clinical performance of nursing students.¹

Clinical practice provides student nurses with necessary knowledge, skills and attitudes required for their future nursing functions. Good health is hence deemed vital in ensuring thus. During clinical practice students are being equipped with the necessary skills, knowledge, and attitudes in order to render quality health services to their patients in the future. It is the responsibility of nursing staff, other health professionals and clinical instructors to guide students through this process and ensure their competence and confidence.²

Acquiring knowledge in a clinical practice is a vital component in nursing education considering nursing is a practice-based profession. Therefore, it is important to ensure that the clinical learning environment is conducive, and experiences contribute favourably towards clinical competence of students. Good health is hence deemed vital in ensuring thus.³

A study on the “experiences of Jordanian nursing students in their clinical practice”, a theory-practice gap is present in nursing education. The findings identified challenges to nursing educators in supporting students’ clinical practice and facilitating narrowing the theory-practice gap. It is challenging for the clinical instructors to ensure adequate learning experience for all the students, students need to take the initiative in their learning experience to ensure they are equipped with the needed skills for the future roles.²

Clinical practice ability in nursing is the skill to manage complex nursing diagnosis efficiently and promptly and to cater according to high quality health services. In order to provide quality healthcare, students need to be in optimum health. Dealing with different people from different cultures, backgrounds, beliefs, attitudes on a daily basis requires special skills and abilities hence students need enough emotional, psychological, physical and social support to deal with patients.⁴

Furthermore, how it effects how they think, feel, act relate to others, handle stress and make choices. As in the other aspects of health, mental health problems can be a result of multiple factors or events such as the biological make up of an individual which makes one more susceptible to trivial triggers to life experiences such as trauma and abuse.

In a study on “a review of the literature regarding stress among nursing students during their clinical education”, recommends that hospital administration promote policies to promote a training environment where students are supported and inspired. A conducive environment would ensure that students acquire adequate information, knowledge and skills needed, whereas an unconducive environment would lead to less than optimum health. This is inclusive of all aspects of health, but little is done to improve the mental health status of students.⁵ At last, herein the main purpose was to establish what impact clinical practical’s have on the mental health status of 4^th year nursing degree students at the University of Namibia main campus. As helping students cope with clinical practice related stress may enable students to perform better in clinical practicals. A healthy individual in terms of all health aspects, be it a student or any other normal individual will be able to function at their best and yield the absolute results.⁶

METHODS

Study design

A cross-sectional, explanatory research study with a qualitative approach was employed. The participants were among 104, fourth year 2021 nursing degree students at the University of Namibia main campus. Interviews were conducted until saturation point was reached at sixteen interviews. The analysis of any unstructured data including responses to open ended survey questions, literature reviews and audio recordings was done through deductive and inductive reasoning.

Study place

The interview was conducted from the comfort of the participant’s home and that of the researcher as it was a virtual interview. Prior telephonic arrangements were made with the willing participants regarding the date and times most convenient to them so the interviews would be conducted.

Study period

Research study was conducted from January 2021 to October 2021.

Study population

A population is the entire group of persons or objects that are of interest to the researcher, and which meet the criteria they are interested in studying. All 4^th year nursing degree students at the University of Namibia main campus made up the study population 104 nursing students: five males and ninety-nine females. The target population was limited to 4^th year nursing degree students registered at the University of Namibia main campus for the academic year of 2021. It was done on the students who were willing to participate and whom were within a reachable distance saving cost and money. Selection was based on the willingness of participants to participate and whom were within a reachable distance saving cost and money.⁷

Study size

Research design was qualitative hence interviews were conducted until a saturation point was reached at sixteen interviews.

Procedure during the interview

The researcher introduced themselves, explained the purpose and objectives of the study and obtained verbal consent secondary to the written permission of the participants to be part of the research study. Demographic data was first obtained, interview then commenced, it was conducted in English and consisted of open-ended questions.

Data collection instrument

The data was collected with or using an interview guide. The interview guide had semi-structured four (4) main questions with probing or supporting questions as outlined in the interview guide see attached annexure of the interview guide. Microsoft Teams was used to conduct the virtual interviews with a screen recorder to provide proof of the interviews.

Procedure for data collection

A computer based interviewing system was used to conduct an electronic interview via Microsoft Teams and Zoom camcorder (provides both audio and video camera) and/audio recorder (sound recorded on disc, film etc.) as a backup interviewing system. The interview was conducted from the comfort of the participant’s home and that of the researcher as it was a virtual interview. The researcher used an in- depth interview schedule which is particularly useful for qualitative studies. Semi-structured (open ended) questions (4) were asked by the researcher which were followed by probing questions depending on the response from the participant. The interview was conducted on the 4^th year nursing degree students at the University of Namibia main campus. Interviews were conducted until saturation point was reached. A total of 16 participants were interviewed for 15-20 minutes.

Pilot study

Pilot study is a small-scale study conducted prior to the main study on a limited number of participants, a test run of the actual study.⁷

An interview guide was finally pilot tested in an appropriate population of four student respondents in the 4^th year nursing degree class at the University of Namibia main campus, Windhoek. The four participants of the pilot study were not part of the actual participants. Interviews lasted between 15-20 minutes on average. The pilot study was done in order to determine whether the required data could be obtained to identify and correct the inadequacies in the interview guide and note the time of completion.

In conclusion there were no further discrepancies and the responses from the participants were positive leading to go ahead with the main research data collection. The interviews were recorded.

Data analysis

Thermatic/grounded theory was used to establish themes from the context. The process started with managing and organizing qualitative data. This first step allows the researcher to become immersed in the data. During this study, the researcher was completely involved in the data analysis process and made reflective and marginal remarks to understand what is happening before and after the interview. The next step is finding patterns and producing explanations using both inductive and deductive reasoning to categories data in segments. The researcher used different types of codes to categories data, namely descriptive and interpretive codes which will involve looking for deeper meaning in what the participant stated. ⁸

The researcher also started unravelling the possible meanings, and these codes develop and change as the researcher gains more insight about the data’s meaning. The researcher did manual analysis and thoroughly review recorded information obtained during course of data collection. Data was analysed into themes and sub themes and presented as such. Piecing of connected data that have a similar meaning are coded in a few cycles, then clustered in similar theme categories. Themes emerged from the clusters, who were interpreted to answer research questions. It concludes that the researcher interpreted the data as it is read and re-read, categorise and code data and inductive develop a thermatic analysis.

Trustworthiness

The trustworthiness of the study was addressed by ensuring credibility (through prolonged engagement with the students, as we work together and the situation allows for persistent observation), dependability and conformability (having an external audit such as a research supervision). Trustworthiness is the validity and reliability of the findings which involves accuracy, credibility, dependability, conformability, and transferability of the qualitative study. Research ethics namely principle of respect for persons, informed consent, principle of confidentiality and autonomy principle of beneficence and principle of justice were addressed.⁸

RESULTS

Demographic information

The researcher had a total of six-teen participants. All the participants were females with age ranges between 21-23 years. All were 4^th year nursing degree students at the University of Namibia main campus.

The researcher used manual analysis which involves a thorough review of all the recorded information. After the data has been collected, it was then transcribed and proofed read against the recorded interviews. The researcher compared the data collected from one participant with another participant to come up with themes and sub-themes discussed above. During this process, reflective and marginal remarks was made to understand the phenomenon.⁸

According to the response of nine out of sixteen participants was evident that clinical practicals do have an impact on 4^th year nursing degree students at the University of Namibia main campus.

Discussion of themes and sub themes

Theme 1: overwhelmed/stressed

According to the participants, they were overwhelmed. Clinical practice has a lot of clinical requirements, clinical hours and clinical evaluations in all the practical modules.

Participant number 3: “I’m exhausted; I don’t feel good at all”.

Participant number 5: “Clinical practice has a certain effect on an individual, it can be draining”.

Participant number 6: “There is a lot to be done in little time, it can be quite frustrating”.

Participant number 9: “Clinical practice can be overwhelming”.

Sub-theme 1.1: enormous number of clinical requirements and limited clinical hours

Although students get two weeks of clinical practical’s and two weeks of theory it is not adequate to complete the needed requirements. Hence the students have to dedicate their free time, recesses and holidays to ensure they meet the requirements. This academic year they have three practical modules each with their clinical requirement (clinical logbook), clinical hours and clinical evaluations.

Participant number 1: “We have to work during weekends and public holidays to fulfil clinical requirements”.

Participant number 6: “We have no holiday’s, we sacrifice to complete clinical procedures, last year I didn’t see my family at all”.

Participant number 7: “We don’t get enough exposure, the little time we get, we aim to finish our logbooks”.

Participant number 8: “There is no balance between clinical practice and theory, practicals are more, especially the workload. It’s so stressful”.

Participant number 10: “We have no recess, basically, we use that time to complete logbooks”.

Sub-theme 1.2: other teaching universities

There are roughly five higher institutions of nursing in Windhoek, such as the University of Namibia, International University of Management, ICare teaching institute and Welwitchia. Each University allocates their students at teaching hospitals, it appears as if there is no communication or allocation agreements between the institutions. Hence the students can become crowded at healthcare facilities, with the same or similar requirements to complete leading to tense and stressful workplace situations.

Sub-theme 1.3: high workload

Due to the enormous clinical requirements students have to do what they need to and what they want to. They have to spend extra time and do extra work in order to get the logbooks done.

Participant number 1: “Students are doing the most work at hospitals”.

Participant number 2: “I spent so much time there; we literally do everything”.

Participant number 7: “Too much workload, I don’t get enough time to spend with my friends and family”.

Sub-theme 1.4: clinical evaluations

Clinical evaluation is defined as an integrated form of evaluation seeking to combine knowledge, understanding, problem solving, technical skills, attitudes, and ethics in evaluation of the students, Herein, clinical instructors test if the student were able to grasp necessary and crucial skills and abilities.

Participant number 3: “Clinical practice has a lot of requirements and to add, we also get evaluations which require study time, so they be a bit more demanding”.

DISCUSSION

The findings suggest that students spend most of their academic year at clinical practicals to complete the enormous amounts of clinical requirements and clinical hours whereas facing other life obstacles such as competition with other students from their university or institutions and social issues. Hence indicating that most stressors that hinder the mental health status of students to be arising from the clinical aspect of their academic life.

The study on the “investigating the relationship between workload- resources and exhaustion of nurses and police officers in Namibia”. The results revealed that exhaustion had a relationship with the workload, resources, and organisational support. The study was focused on civil workers and not the students but the study at hand is suggesting students working in the same or similar environments might be exposed to the same pressures.⁹

The study focussing on the “improving general health and reducing burnout in nurses in Namibia”, the result pointed out that the healthcare sector needs to invest in health education and stress management programmes for nurses on how to take care of their own health and emotional wellbeing. Nurses are again the focus but considering the fact that nursing students are exposed to the same working environment and probably similar or more constraints than the nurses suggested the importance of catering for the wellbeing of all healthcare workers in order to care for others.¹⁰

A qualitative study on “challenges of nursing students in clinical environment”, it revealed that these students are faced with many challenges that affected the students learning in clinical setting. In the proposed research, an in-depth analysis of how and what impact clinical practice has on the mental health status of 4^th year nursing degree students at the University of Namibia main campus. The findings suggested that the clinical requirements, clinical hours, competition for procedures, clinical evaluations and high workload at clinicals are some of the factors that facilitate the impact of clinical practicals on the 4^th year nursing degree students at the University of Namibia main campus.¹¹

Park and Lee, findings of a research report stated that the development of a stress coping and ego resilience in nursing students is important for college adaption hence further research in improving ego resilience and stress coping is warranted. In order to breed quality and efficient healthcare practitioners in thus situations nurses it is vital to equip students with skills, tools and the ability to withstand or at least conquer this environment.¹²

CONCLUSION

The study concludes there is no balance either between the clinical or theoretical aspect or the social and academic life of the students. Most students did not seek mental health treatment as they did not deem it necessary, or they did not get to the point where mental health treatment would be crucial but admit to being emotionally distraught.

Although three out of sixteen students received mental health treatment due to the clinical practical constraints.

Recommendations

Educational recommendations

The Ministry of Health and Social Services should create awareness and facilitate the health of healthcare workers. Healthcare practitioners tend to forget to take care of themselves hence they should establish or encourage organizations such as “helping the helpers”. Healthcare professionals should receive regular training on organizational skills and time management which enable better healthcare services and healthcare workers.

Different teaching universities/institutions should coordinate or at least work together to organize student allocations, planning the number of students to be allocated at a certain unit in order to facilitate learning and completion of requirements. Student intake per year should be lowered to at least hundred students per academic year to reduce the high level of student competition at healthcare facilities hence ensuring students fulfilling requirements.

The University of Namibia should encourage clinical preceptors to visit students more often in clinical practice especially at night shift allocations.

The time allocation should be extended from two weeks block system to at least four weeks block system to facilitate completion of clinical requirements and acquisition of clinical competence. Mini surveys or suggestion boxes should always be available so students can voice their opinions and suggestions.

Since there is already a clinic at the University of Namibia it would be great to implement or integrate mental health into the clinic.

Governmental recommendations

Students should be remunerated for their work; as students lessen the workload for healthcare workers. They should at least be provided with a basic from a lot of people.

ACKNOWLEDGEMENTS

I would like to thank my lecturers for research methodology; the co-ordination role and my project supervisor. The University of Namibia for permission granted to carry out the research and the 4^th year nursing degree students for taking part in study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the School of Nursing Ethical Committee in accordance with the University of Namibia’s Research Ethics Policy and Guidelines. Ethical Clearance Reference Number: SoNEC 092/2021

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