Iranian nursing students’ experiences of nursing

Abstract

Background:

The negative attitudes and behaviors of Iranian nursing students impede learning and threaten their progression and retention in nursing programs. The need to understand students’ perception and experiences of nursing provide knowledge about effectiveness of nursing education program as well as their professional identity. The purpose of this study was to discover experiences of nursing students.

Materials and Methods:

In a descriptive, exploratory and qualitative study, twelve senior nursing students of Isfahan University of Medical Sciences (School of Nursing and Midwifery) were participated. Data was collected via unstructured in-depth interview, and thematic analysis method was used for analyzing the data.

Findings:

The findings from this study revealed that the nursing students in Iran experienced altered experiences during their education program as positive and negative. Two major themes were constructed from the thematic analysis of the transcripts: professional dimensions and professional conflicts.

Conclusions:

Regarding the findings, positive experiences of students have leaded them to acceptance and satisfaction of nursing and negative experiences to rejection and hating of nursing and lack of adaptation with their professional roles. Therefore, it is recommended that revision and improvement in nursing education program is essential to facilitate positive experiences and remove negative experiences of nursing student’s educational environment.

INTRODUCTION

Throughout the history of nursing education, conditions of access to course have altered considerably. Overall, the minimum academic qualifications have gradually increased, and since the 70s, educational philosophy has come to regard the nursing student as a person in the process of construction, who is expected to display a critical and constructive attitude towards reality and not be a mere performer of externally defined duties. Entry into higher education is determined in students by the demand for a defined area of activity which accepts professional perspectives based on the accounts of known people or social representations of the chosen area, constructed throughout their life process.

According to Serra that quoted from Coulon, the student’s initial task on entering higher education should be to learn his student work. Introduction to this new context and its respective rituals lead to process whereby the status of pupil is changed to student.[1]

Many authors involved in adult education have pointed out that adult learners are not without any prior background knowledge; they obtain their nursing values through media before entering the profession or through socialization process during their academic years. Therefore, evaluation of early experiences of nurses can promote the perception of profession’s socialization process.[2]

As Warne et al. mentioned in their study that learning in clinical practice provides up to half of the educational experience for students undertaking pre-registration nurse education programs.[3] The clinical experience has been always an integral part of nursing education. It prepares nursing students to be able of “doing” as well as “knowing” the clinical principles in practice. In addition, it stimulates students’ critical thinking skills to solve the problems.[4]

Training and learning are the vital factors of a clinical environment which resulted in knowledge, profession and attitude development. Nursing students would join their theoretical knowledge with practice in such an environment.[5] The value of an ideal clinical education is inevitable in progression of the individual and professional nursing identity and development as well as nursing skills and roles.[5,6]

Nursing, as a role in different cultures, has different meanings. Therefore, the effort to define nursing socially and culturally can help its development. In Iran, nursing is defined as a profession with certain knowledge and practical skills. Nursing performance is accompanied with many challenges in personal, interpersonal and socio-cultural levels; in other words, it is also influenced by particular cultural judgments of the society and would affect the student nurses’ experiences about their profession.[7]

Every profession requires a special level of knowledge, skills, and personal characteristics. Several studies have focused on the professional role and readiness of the nursing students’ graduates to enter into working environment in different time intervals.[8] But, according to Adib- Hajbagheri and Dianati many Iranian nursing students lacked the appropriate personality features for nursing. The results of their study also indicated that most students did not know the requirements of the profession at the time of applying.[9]

According to Nikbakht Nasrabadi et al. nurses have already expressed deep regret for choosing nursing course and advice the students not to enter this course of study. In addition, he concluded that current caring attitude have been changed and it is less in comparison to the past; and nurses involve in a technical and mechanical rather than an individual caring.[7] Pearcey and Draper mentioned that despite new theories of nursing, the tasks will not be focused for a long time; however the routines still determine the style of the nursing profession.[10] Several years’ experience of authors in nursing education showed that many Iranian nursing students are not well motivated, and their negative attitudes and behaviors impede learning and threaten their progression and retention in nursing programs. On the other hand, many of the faculties, instructors and managers in nursing education are interested to know, why students choose nursing and how they define nursing identity in their academic years. The answer to these questions may help to promote students’ motivation and their professional identity, as well as, quality of care and providing knowledge about effectiveness of nursing education program. Then, the main purpose of this study was to discover experiences of nursing students of nursing profession.

MATERIALS AND METHODS

This descriptive, exploratory, qualitative study used in-depth unstructured interviews as the method of data generation. The researchers used descriptive qualitative approach which emphasized on depth of the experiences to achieve the in-depth data. The exploratory research design is a commonly used and well recognized approach to qualitative studies when little is known about aparticular phenomenon.[11,12]

The data were generated and thematically analyzed concurrently in order to give direction to further interview questions. The findings are presented as two major themes that describe the lived experience of Iranian senior undergraduate nursing students, who were studying in Faculty of Nursing and Midwifery of Isfahan University of Medical Sciences, Iran.

The participants included 12 Iranian senior undergraduate nursing students, who had finished theoretical courses in nursing school and were in Isfahan University Medical Education Centers for their clinical courses and practicum, selected by using purposive sampling. The inclusion criteria were: enrolled in a fourth year bachelor of nursing program, willingness and the provision of written consent to participate in the study and to be able to provide rich and adequate qualitative data of being as a nurse student. Nine participants were female and three were male, with a mean age of 22.5 years.

In-depth and face to face unstructured interviews were used for data gathering. Each interview began with, “Could you please tell me about your experiences about nursing”, “How do you think about nursing?” and “How do you feel about nursing and becoming a nurse student?” The interview questions were asked in an open ended manner. The questions that followed were based on the individual participant’s response in the first instance, by using probing questions, such as ‘could you say something more about that?’, ‘what did you think then?’ and ‘could you please give an example?’

The interviews were scheduled at times that were convenient for the students and when there was no conflict with the scheduled clinical education program. All participants interviewed in the first author’s private office in Nursing and Midwifery Faculty. The duration of the interviews ranged between 45 to 60 minutes. The concurrent data collection and analysis were undertaken until the identified themes were saturated.

All interviews were recorded and then transcribed verbatim and were treated confidentially. Thematic analysis was conducted to identify themes, with sub-themes. According to Braun and Clarke thematic analysis is a method for identifying, analyzing, and reporting patterns (themes) within data. It goes through six phases of analysis.[13] The process of analysis in this study started when we begin to familiarize with data, notice, and look for patterns of meaning and issues of potential interest in the data. This phase fallowed by generating initial codes and searching, reviewing, defining and naming themes. The endpoint was the reporting of the content and meaning of patterns (themes) in the data. Analysis involved a constant moving back and forward between the entire data set, the coded extracts of data that we were analyzing and the analysis of the data that we were producing.

Peer debriefing and member checks, which are common methods of establishing authenticity, were used. Researcher reviewed all the transcribed texts, encoded and classified the important concepts several times to ensure validity and reliability for each identified codes and concepts.[14] Each transcription was checked for accuracy by the other co-researchers. To ensure reliability of coding, an independent qualitative researcher also analyzed and coded the transcribed data and this coding was compared with the original. No major differences in coding were identified. Minor differences were discussed and resolved between the researchers. Credibility was enhanced by continuous and prolonged engagement with the participants.

The Isfahan University of Medical Sciences Research Ethics Committee approved the study. Permission was sought from head of nursing education department and clinical settings. The participants received an explanatory statement about the aims of the study and the proposed methods of data generation and measures to ensure the participants’ confidentiality and anonymity. The participants provided written informed consent prior to interviewing. The students were informed that they would not receive compensation for participating in the study.

FINDINGS

The themes that emerged from the data of this study are all related to the nursing experiences of Iranian undergraduate nursing students who were studying in their last academic year. After analyzing, sorting and organizing number and different codes into subthemes, two major themes were constructed. These included: professional dimensions, and professional conflicts.

Professional dimensions

The theme of professional dimensions included four subthemes: “professional roles and tasks (as major and minor)”, “professional characteristics”, “professional achieved capabilities” and “tendency towards the profession”.

The findings showed that students have to deal with nursing roles and tasks during their education; and they have experienced educational, caring and corresponding roles in various situations. Regarding the students’ attention and the time they spent to play these roles, they were divided into two major and minor categories. The following routines were mentioned as one of the major roles of a nurse. For example, a participant stated his experience of nursing role as follows:

“…in the mornings, when we come to the hospital we would wait till the matron distributes the daily tasks, then with the bedside nurse, we go to the units greeting the patients and then we would provide treatment and medications schedules…”.

Achieved scientific abilities and clinical skills during the education and before entering the work place leads students in providing suitable and favorable cares independently which is necessary for the clients in the clinical environment. Most of the participants believed that more independency gradually would be gained at last semesters; and they also used nursing skills to offer services to their families and relatives. A participant said:

“Nursing profession has increased my self-confidence, patience, tolerance, devotion, tidiness and sensitiveness in doing the tasks; generally, moral values have grown more inside me….”

The participants stated that some factors like positive attitude toward the profession and job satisfaction have resulted in accepting the professional dimensions and the adjustment with career conditions. These cases were involved in accepting concept. As an example, a participant declared:

“Feeling of being useful would help to decrease patient’s anxiety and working independently made me feel very interested in nursing…”

Professional conflicts

The theme of professional conflicts included two subthemes: “internal conflicts” and “external conflicts”. The unpleasant feelings and escaping or aversion from a profession were considered as the internal conflicts. While, social factors including organizational and cultural structures, professional relationship and educational conflicts (theoretical and clinical) were considered as the external examples. In this regard, one of the participants said:

“When I want to tell someone I’m a nurse, at first I hesitate for a moment and then I tell doubtfully.”

Conflicted internal feelings sometimes appear in the form of some factors which resulted in the increase of individual’s tendency to quit the job. The most obvious case is the attempt of some students to give up or change their course in primary semesters. As one of the participants expressed:

“In dormitory, we always argued with the midwifery students about our courses; they said their field is better and requires a better rank. But when the practice started, I completely hated nursing and even tried to give up or change my field of study.”

The individuals’ attitudes and beliefs in a society can strongly influence the professional development and individual’s tendency towards the profession. Cultural beliefs about nursing in our country have created some conflicts in the students to accept the profession. One of the participants reported:

“The society’s view has reduced my interest in nursing and even has affected my future, for instance some of my suitors gave up when they realized I’m a nurse.”

Another participant mentioned:

“The people do not have a good opinion about this course and they have sometimes asked me if nursing requires academic education?!”

According to participants in this study one of the important factors to achieve the nursing goals and adequate professional performance was having a good relationship with other medical team; however, students believed they rarely have good experiences in this case which resulted in conflicts in the student to accept the profession. One of the students declared:

“Liver biopsy was going to be done in the ward; the professor said 2 or 3 students come and take a look. When we went there, the physician said, “Are you medical students? We said “no, we are nursing students”. He called the supervisor nurse and wanted us to leave the section immediately”

Finally, results showed educational insufficiencies in two practical and theoretical dimensions have created some conflicts among the Iranian nursing students. Affaires such as the gap between theoretical and practical education, focusing on routine actions in internship programs, poor relationship with the patients, vain nursing rounds, having no position in medical team and low self-confidence of the professors were experienced by the studied participants. They believed having good and adequate relationship especially with the patients and the medical team is very essential; however, for some reasons, these roles are not played well. The students mentioned that they did not play this role adequately because of a lot of work load in the ward and no chance to communicate with the patients. And they were worried about this matter. Most of the students mentioned lack of knowledge and capabilities or skills of patient care during the internship program as well as not using graduated students in practical settings as the educational problems. One of the participants in this regard stated:

“Some of the professors have very low self-confidence and transfer it to the students. They work very cautiously. I haven’t seen such a professor who discuss with physicians. Most of the times, they are not eager to take part in the rounds.”

DISCUSSION

This qualitative study of the experiences of the Iranian undergraduate nurse students produced a deeper understanding of their perception of nursing profession. The finding showed that students have to deal with nursing roles and tasks during their education. Obeying the routines was mentioned as one of the major roles of a nurse. Pearcey and Draper also reported the same results in their study. They mentioned that despite the new theories of nursing, the tasks will not be focused for a long time but the routines still determine the style of the nursing profession.[10]

Sharif and Masoumi have also pointed to the counseling role of nurses in association with patients that had a positive effect on them to feel the sense of being useful. In fact, professional role involves acquired skills, knowledge and behavior during the professional socialization.[4]

Some pleasant experiences have resulted in creating the sense of accepting the profession in the students. Wong and Lee found that the appropriate relationship with patients, helping the individuals and patients’ care were kind of the motivations to keep nurse at nursing job.[2] Pearcey and Elliott also found that positive experiences have an increasing effect on the individuals’ attitude toward nursing; and in spite of existing many negative experiences, a positive clinical experience can affect positively on nursing students’ feelings.[15]

In addition to learning, positive patterns have affected on the individuals’ motivation to continue the nursing field. Many studies have also shown that nursing students learn how to care and clinical skills from nursing staff and instructors as the role models. Therefore, an appropriate model can be effective on professional socialization. The students considered the existence of supervisors, staff and instructors very significant in the clinical supervision and emphasized on their important role in increasing self-confidence, socialization, professional independence and finally acquiring the clinical skills.[4,8,16]

One of the strongest reasons to choose nursing is the sense of generosity and philanthropy. This view is a combination of the internal and external motivations that create the sense of commitment and responsibility in the individual to care about others.[2,17] In the present study, the entrance of the students to the field had been unawareness and during the education, humanitarianism feelings have been created in some of them. These findings were in accordance with the study of Haussler, Reiskin and Fagermone’s which mentioned that nursing is a loving and affectionate profession and a way to approach God; and feelings of generosity and humanitarianism are moral aspects of this profession. Having humanitarianism is one of the basic values of this profession.[17] The attraction of this feeling is so strong that individuals tend to continue nursing profession under hard working conditions.

The stress resulted from entering into hospital and starting anxious internship program were experienced by the majority of the students. Some of them stated that they have gradually become hard-hearted. In Wong and Lee’s research some events such as unsuccessful resuscitation, unexpected death as well as death in very early age resulted in sense of disability to control the emotions, disappointment and uselessness in inexperienced and novel nurses who knew themselves as a key role in patient care.[2] The difference in findings might be related to the fact that nurses who stay in one ward would increase emotional attachment to the patients; while nursing students’ task in one ward would be short and the emotional dependence on the patients will not be created in them.

In a study carried out by Admi, the students mentioned that the most stressful experiences included having insufficient knowledge, facing with offensive and opposite beliefs, precise supervision of the instructors, and insufficient hospital resources as well as patients’ pain and suffering.[18] In other studies, some factors such as the sense of being unprepared to enter the working environment and forgetting all learned subjects were seen.[8]

In the present study, the participants mentioned that some factors such as incompatibility with the course, low self-confidence, negative role models in the wards and humiliating by the nursing personnel were very important experiences that led them to quit the profession. Many nursing students especially freshmen tried to change or give up after being informed about the professional conditions of nursing.

Wong and Lee also concluded that crowded wards and the situations of the patients cause students to think about giving up the nursing field.[2] Self-confidence is an important part of nursing clinical performance;[19] therefore, its promotion should be facilitated in nursing educational process. Nursing instructors have an important role to increase students’ self-confidence, promote their social role and encourage them to be independent to create clinical values in students.[19,20]

Dissatisfaction of nursing staff, lack of professional independence and having no nursing position in medical team were experienced by the studied participants. It seems that some educational deficiencies resulted in the decrease of the students’ abilities and scientific skills; so they act according to physicians’ idea rather than their theoretical knowledge to make a decision about the patients’ status. This matter is an obstacle to professional independence.[21] As Malmsten stated, many nurses accept the physicians’ orders unquestionably and it may have made them physician-oriented people rather than care- oriented nurse.[22]

The studies have shown that Iranian nurses are not satisfied from their job because of lack of an appropriate reward and encouragement from the system. Fletcher, Seago and Faudett believed that nurses’ job satisfaction would be influenced by some factors such as working environments, management method as well as job stresses.[23,24] However, in Colling’s study it has been shown that people selected nursing not for money but to help others and this issue was the best motivation and more important than the external motivations like high salary or society prestige.[25] Since students have the most interactions with the nurses, they naturally confront with these unsatisfactory statements.

Nursing as a model has various concepts in different cultures. The society perception of nursing profession will be influenced by socio-cultural conditions. Nursing performance is accompanied with serious challenges in the personal, interpersonal and social levels; and on the other hand it will be influenced by special cultural judgments of the society. The participants faced with some challenges like being socially disagreeable, unprofessional opinions about the nurses and having an unacceptable profession especially from the family’s view point. To confirm the present results, Nikbakht Nasrabadi et al. in the interview with the nurses realized that every day, a majority of the nurses have faced with an unsatisfactory and disillusioned sense for having lower social position and improper cultural opinions about their profession in Iran. Most of the people even today believe that the nurse is a simple assistant of physician. On the other hand, some traditional beliefs about working at night in an environment with the opposite gender co-worker have created a negative attitude in Iranian families.[7]

These results are in accordance with a study done in Japan in 1994 in which nursing was described with some expressions like hard, dirty, dangerous, low income, little holidays, little chance to marry and bad image in Japanese culture contrary to western countries that consider nursing as an acceptable/valuable profession.[26] French et al. in their study also found the same results in Pakistani culture that they disrespect the girl’s decision to enter nursing, because it will result in their communications with unfamiliar males.[27] Other studies also mentioned the society’s disrespect to the nursing profession.[28,29]

It seems that cultural beliefs of a society play an important role to value and respect to a profession. In eastern families because of having traditional attitudes, nursing profession is faced with problems while western countries valued the job very much. On the other hand, the belief of being physicians’ assistant may be derived from the existence of nursing ranking in Iran that all of them are nurses in the people’s view though they do unprofessional affairs. As Chitty and Black declared that this factor is one of the obstacles to achieve the professional nursing.[30]

In the case of professional relationships, the students experienced some events like being rejected by the physician team, blamed continuously by the nurses and discouraged by the nurses from continuing in the field. The results of the study by Dehghani et al. showed that 40% of the students pointed out the inadequate behavior of the medical team.[6] The existence of unsuitable relationships and conflicts are critical events in the working environment.[2] The results of other studies also showed that physicians consider nurses as the assistants not as the professional care giver. In a study in Japan, Primomo mentioned that though nurses are educated people, they are after physician in the hierarchal rank.[31]

Appropriate cultural and organizational structures can form appropriate professional relationship. Because people enter this field with some cultural backgrounds and organization can develop or suppress these attitudes. It seems that the organizational structures are also influenced by the culture and will be resulted in having inappropriate relationship in medical team.

Educational insufficiencies in two practical and theoretical dimensions cause some conflicts in the students. And students were worried about this matter. The results were in accordance with the Pearcey and Draper’s study in which the students were anxious about this matter.[10] Wong quoted from Cook’s findings that the main concern of the students before clinical experiences was the sense of being ineffectual to implement the clinical skills properly; and after having clinical experience the difficulty to have interpersonal relations will occur.[2]

The gap between theoretical and practical education and having no plan during internship period led to confusion of the students. The results of two studies in Iran which examined the various aspects of clinical education showed that the quality of the clinical education is not favorable and there are some shortages such as problems to use theoretical principles in practice, stressful factors in clinical environment, being forced to do staffs’ tasks and not being evaluated properly by the instructor.[32,33] Other studies also mentioned some problematic factors in clinical education like lack of scientific knowledge in the ward, obeying the incorrect habits of the environment, wandering and confusion during instructors’ absence and having no skill to care about patients.[6]

The findings of this study showed that graduated nursing students are in an unfavorable situation regarding the theoretical knowledge to patients care or make appropriate decisions; therefore, after arrival to the ward, they would worry about the commitment to care for a very ill patient. Corresponding to the results of the present study, other studies like Abedi et al. also have reported some experiences of nursing students such as necessity of more study, poor performance in some skills such as administering prescribed medication and change dressings, insufficient skills to find vein and serum therapy.[21] The results of studies which were conducted after project of 2000 and followed the revolution of the British educational system were almost different from the pervious and the present study. As the nurses lived up to expectations regarding to the clinical and technical skills and they were in favorable status in some fields such as analytical decision making and interpersonal skills contrary to the graduated students of the traditional system.[34,35]

As in the present study the students declared that doing the nursing procedures based on standards followed by inappropriate behavior of the nursing staff. Hathorn et al. also believed that the greatest effort of students is to fulfill staff’s expectations by doing the routines, because in some cases doing the procedures principally would be accompanied by the inappropriate reaction of the nursing staff.[16] Therefore, the gap between theoretical knowledge and practice remains unsolved and the students will be ignored to adjust with these two approaches. As Admi stated that if students are developed with sufficient knowledge and information in professional education they would have fewer problems in work place.[10]

Another experience of the Iranian nurse students was their instructors’ low self-confidence and unwillingness to attend the medical rounds. Elcigil and Yildirim study in Turkey also revealed that nurse students have similar experiences during their internship program.[35] Jefferys stated that students need instructors’ supports. Then instructors should develop their educational role model for the nurse students.[36] They must accept the responsibility of providing a learning climate and create an effective interaction with students.[8]

Regarding the finding in this study, positive experiences of students have leaded them to acceptance and satisfaction of nursing profession and negative experiences to rejection, runaway, and hating of nursing career and lack of adaptation with their professional roles. Also this study revealed that it is obvious that issues of educational system in Iran especially clinical educational settings and inappropriate interaction between students and medical, educational and caring team lead to incompetency and inefficiency of the students and poor professional socialization. These issues finally cause inability of nursing education system to retain students in nursing program and clinical setting.

In this study the students were allowed to mention their options for a professional purpose and to explore the obstacles prevalent in all the professional jobs. However, the objective of the study was intended to explore and improve teaching methods; it was also helpful for the participants to understand their goals as well. Noteworthy is the impressive list of students’ references explored similar conditions in the nursing educational system worldwide.

So it is recommended that revision and improvement in nursing education system in Iran is essential. Also, the modifications of the clinical education system should be in line with real requirements of the nursing students in clinical environment to facilitate positive experiences and remove negative ones of nursing students’ educational environment.