Nurse Education in Practice 15 (2015) 304e309
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What are the primary concerns of nursing students as they prepare for and contemplate their first clinical placement experience? Tracy Levett-Jones a, *, Victoria Pitt a, 1, Helen Courtney-Pratt a, 2, Gwyneth Harbrow a, 3, Rachel Rossiter a, b, 4 a b
School of Nursing and Midwifery, The University of Newcastle Callaghan NSW 2308 Australia University of Sharjah, UAE
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 25 March 2015
Nursing students' first clinical placement experience can be a critical turning point ereinforcing professional aspirations for some, and for others, a time of emotional turbulence. There is a paucity of research focusing on students’ perceptions and concerns prior to their first placement experience. Thus, the aim of this study was to explore the concerns of first year bachelor of nursing students from one Australian university as they prepared for their first clinical placement. Participants completed an online ‘readiness for practice’ survey consisting of 22 items. This paper focuses on participants' responses to the one open ended question: ‘Please comment on any concerns that you have in relation to being prepared for your first clinical placement’. Summative qualitative content analysis was used for analysis. 144 students (55%) responded to the open ended question. Responses were categorised into six themes including: Not prepared for placement; feeling nervous, anxious and worried; bullying and belonging; practicalities; patient safety and making mistakes; and working outside of my scope of practice. It appears that activities designed to equip students with the capacity to manage the inherent challenges of undertaking a clinical placement may sometimes have a paradoxical effect by increasing students' level of stress and anxiety. An enhanced understanding of students’ concerns may help educators implement appropriate support strategies. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Nursing students Readiness for practice Concerns Clinical placement
Introduction Nursing students' first clinical placement experience can be a critical juncture in their educational and professional journey. It can e into the unfamiliar world of healthcare and signal provide an entre a time of significant change and growth. For some students however, the first placement can be a turbulent and sometimes
* Corresponding author. Tel.: þ61 02 49216559; fax: þ61 02 4921 6301. E-mail addresses: [email protected] (T. Levett-Jones), [email protected] (V. Pitt), [email protected] (H. Courtney-Pratt), [email protected] (G. Harbrow), Rachel. [email protected] (R. Rossiter). 1 Tel.: þ61 02 49216645. 2 Tel.: þ61 02 49217707. 3 Tel.: þ61 02 49215820. 4 Tel.: þ61 02 49217708, þ971 506 34 77 63; fax: þ61 02 4921 6301. http://dx.doi.org/10.1016/j.nepr.2015.03.012 1471-5953/© 2015 Elsevier Ltd. All rights reserved.
distressing experience. Students' preparation for their first placement and, more specifically, students' fears, concerns and issues during this lead up time, have received limited attention in the literature; yet this period of preparation can be pivotal to students' clinical performance, the degree of satisfaction they gain from the placement experience, and their ultimate clinical success (LevettJones and Bourgeois, 2015). The clinical environment provides an authentic context for nursing students to develop the knowledge, skills, attitudes and values of a registered nurse. Students have experiences on clinical placements that cannot realistically be provided in classrooms or simulated settings. However, as academics and clinicians frequently point out, nursing students are not always adequately prepared for clinical placements and concerns related to the development of students' competence and confidence, and their preparedness or “fitness for practice” remain contentious issues
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(Levett-Jones et al., 2006). As part of a larger study addressing first year nursing students' readiness for practice, this paper explored the concerns of students who were preparing for their first clinical placement and makes recommendations for addressing these concerns proactively. Background There is widespread agreement that clinical placements are of central importance to nursing education and specifically designed to facilitate authentic learning opportunities (Levett-Jones and Bourgeois, 2015). From the apprenticeship-style training undertaken decades ago to contemporary university-based education, the integral nature of clinical placements for the attainment of competence remains undisputed (Brown et al., 2011). The first clinical placement experience is critical to nursing students' professional identify formation and socialisation (Trede, 2012). It provides an authentic context that introduces students to the knowledge, skills, behaviours, attitudes and values of registered nurses. The quality of placements, and students' initial clinical learning experiences in particular, generate a range of intense emotional responses and can span a continuum from excitement, exhilaration, joy and pride through to confusion, anxiety, fear, apprehension, and distress (Levett-Jones and Bourgeois, 2015). Importantly, the experiences encountered during the first placement and the way in which students process the resultant feelings are key determinants of students' decisions to withdraw from or remain enrolled in nursing programs (James and Chapman, 2009; Killam and Heerschap, 2013). A number of studies have identified that nursing students frequently experience high levels of stress on their first clinical placement (Moscaritolo, 2009; Sendir and Acaroglu, 2008; Shaban et al., 2012; Sheu et al., 2001), and that this can negatively impact their learning, performance and professional growth (Sun and Sun, 2011; Khater et al., 2014). Students who struggle to adjust to their role during the first placement are also at risk of diminished selfesteem and depression (Wang et al. (2010). There are multiple sources of anxiety, stress and distress when students undertake their first placement. They include intrinsic, extrinsic, personal and professional factors, for example: feeling illprepared for human suffering, death and dying (Parry, 2011); exposure to nudity and the need to provide personal and intimate patient care; and fear of looking ‘stupid’, making mistakes and causing harm to patients (Killam and Heerschap, 2013; Cobo-Cuena et al., 2010). Further areas of student concern during first placement experiences include a lack of clarity about placement expectations; misconceptions about their role and responsibilities (Andrew et al., 2009); a perceived inconsistency between theory and practice; feeling unwelcome and unwanted in the clinical environment (Levett-Jones et al., 2009); and an erosion of confidence when feeling undervalued (Chesser-Smyth and Long, 2013). Students also report difficulties sleeping due to feeling anxious and as a result experience increasing exhaustion throughout the placement period (Killam and Heerschap, 2013). It should be noted however, that the identification and quantification of recurrent stressors and anxiety provoking events related to first placements is sometimes difficult because of the diverse nature of both practice environments and the individuals who enrol in nursing programs. Thus, addressing students' concerns in a proactive manner can be challenging. Nursing students are prepared for their first clinical placements using a range of approaches including clinical skills sessions, simulations (McCaughey and Traynor, 2010; Ricketts, 2011), lectures, tutorials and online modules. Professional behaviours and expectations are highlighted and key workplace health and safety issues
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related to placements are generally introduced. While most studies indicate that students consider their clinical placement preparation to be adequate, Chesser Smyth (2005) identified that some aspects require a shift in focus to be more student-centred and aligned with students' actual learning needs and concerns rather than what educators believe is most important. A search of the literature reveals a considerable number of studies focused on nursing students' views and placement experiences; however for each of these studies data were typically collected during or subsequent to students' first clinical placement. There is a paucity of research about the perceptions and concerns of nursing students in the lead up to their first placement. Undoubtedly, this period of time will be daunting for many students; however, without an in-depth understanding of students' specific issues, fears and concerns, strategies designed to support and prepare them may well be inadequate and ill-conceived. For this reason, the study described in this paper is unique in many respects e (a) it was conducted at a time when a group of beginning students were contemplating and preparing for their imminent clinical placements, (b) a large number of students completed and returned the surveys, and (c) the nature of the issues they described were recurring. Analysis of and reflection on these common issues of concern allowed us to suggest recommendations for addressing students’ concerns and better preparing future students for their first placements. Methods Study aim and design This findings profiled in this paper formed one component of a multi-site mixed methods study. The aim of the overall study was to elicit information regarding first year nursing students' perceptions of their readiness for practice and the impact of a one semester long preparation for practice course. Ethical approval for the study was obtained from the university ethics committee prior to contacting potential participants. Recruitment Students were recruited from a first-year cohort of undergraduate bachelor of nursing students from one semi-metropolitan university in Australia. Recruitment was via an email sent to nursing students in the target population and an announcement posted on the electronic learning management system (Blackboard™). Students who expressed an interest in the study were emailed a copy of the participant information statement with a link to the survey. Submission of the survey was taken as implied consent. Data collection Participants were asked to complete the 22 item online ‘Fitness for Practice’ survey distributed in weeks 1 and 6 of a 12 week semester. The results presented in this paper were from the second of these surveys with data collected immediately prior to students' first clinical placement experience. The data analysis presented below addressed participants' responses to the open ended question: ‘Please comment on any concerns that you have in relation to being prepared for your first clinical placement'. Data analysis Hsieh and Shannon's (2005) strategy of summative qualitative content analysis was used for analysis. This approach has a
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quantitative element in that it also looks at proportions or percentages of times that particular issues are referred to by participants. A summative content analysis involves counting and comparisons of keywords and content followed by the interpretation of the underlying meaning (Hsieh and Shannon, 2005). Data analysis began with reading all data repeatedly to achieve immersion and obtain a sense of the whole. Then, data were read word by word to derive themes by first highlighting the exact words from the text that appeared to capture key thoughts or concepts. Occurrences of the identified keywords and concepts were then calculated. If the analysis were to have stopped at this point, the analysis would be considered quantitative (Kondracki and Wellman, 2002). However a summative approach to qualitative content analysis goes beyond word counts to include a detailed interpretation in order to discover underlying meanings of the words or the content (Morse and Field, 1995).
learned when confronted with challenging clinical situations. It also became apparent that the participants were anxious about meeting the expectations of clinical staff and feeling embarrassed if they were not able to do so. The emotive language used by the participants (for example terrified, overwhelmed, stupid) attests to their degree of apprehension and concern: I am feeling overwhelmed at the knowledge I feel I need prior to placement I'm terrified that I will forget everything when I get there and not know how to handle certain situations should they arise I am worried about not having enough knowledge about emergency situations I'm scared about looking stupid because I don't not know enough I am concerned that I won't know enough and I'll feel embarrassed because of needing help all the time
Findings Participant demographics Two hundred and sixty-two students participated in the week 6 survey from a population of 547 giving a response rate of 48%. The majority of participants (233, 89%) were female. Participants' ages ranged from 18 to 59 years with a mean of 27 years. For 227 (87%) English was their first language. Two hundred and thirty-one of the participants (87%) had full or part time work while undertaking their degree and worked an average of 15 h per week. One hundred and nine participants (25%) had experience working as an Enrolled Nurse or Assistant in Nursing prior to commencing their undergraduate nursing program. One hundred and twenty-one (49%) were the first person in their family to attend university and 89 (34%) had a family member who had also studied to become a nurse.
Lack of confidence and the perception of inadequate clinical skills were recurring themes; however some of participants qualified their responses with somewhat optimistic comments and appeared to be more resilient and self-efficacious than their peers: I feel I haven't practiced enough skills for placement - so I don't feel at all confident in my abilities I wish that I felt more confident in the clinical skills we've been learning and that there were more hands-on learning incorporated into the course I'm concerned about my limited skills but I guess that all comes with time My medication calculation skills aren't as good as I would like them to be but I plan on practicing during the semester break before going out on placement I don't feel we have learned many skills yet but I am still excited about my placement
Content analysis One hundred and forty-four participants (55%) responded to the open ended question. Their responses were categorised into six themes (see Table 1) and organised from most frequently to least frequently occurring. Not prepared for placement The most common concern expressed by participants (n ¼ 49, 34%) was in relation to feeling ill-prepared for their first placement. Many described a perceived knowledge deficit and a number were worried that they may not be able to recall and apply what they had
Feeling nervous, anxious and worried Thirty-four (24%) participants expressed feelings of apprehension and anxiety in relation to their placements. Data analysis and clustering of participants' comments revealed a dichotomy between those students whose fears and concerns seemed almost overwhelming and those who were able to normalise their feelings of apprehension somewhat. The differences between these
Table 1 Content analysis and recurring themes. Theme
Number of responses
Percentage
Meaning
Not prepared for placement
49
34%
Feeling nervous, anxious and worried
34
24%
Bullying and belonging
26
18%
Practicalities Patient safety and making mistakes
17 13
12% 9%
5
3%
Concerns related to a perceived lack of knowledge and/or clinical skills; feelings of inadequacy and a lack of confidence. Feelings of apprehension and anxiety moderated somewhat with a sense of anticipation and excitement; fear of the unknown and fear of failure. Concerns about being perceived as a nuisance; not being welcomed or wanted; unreceptive clinical cultures and staff. Concerns about geographical location of placements, family and financial issues. Fear of looking foolish and/or making a mistake that could injure a patient and impact their progress and career. Lack of clarity about role expectations and being pressured to undertake clinical procedures that students do not believe they are prepared for.
Working outside of my scope of practice
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emotional reactions may hold the key to the development of appropriate preparatory activities and support strategies:
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I am quite worried about finances during placement as I won't be able to work - I live paycheque to paycheque and only get a very small amount from Centrelink
I am concerned about almost everything to do with clinical placement. The long hours and stress and the full on experience … it all worries me … I don't know how I will cope
I am concerned about being placed in a rural setting … finding accommodation and financial support
Fear of failure. Fear of the unknown. Fear of letting patients and myself down
I'm nervous about balancing my family and work life for the duration of the placement
I'm just nervous. I'm sure this is normal and I'm confident that this will improve during my time on placement
I am concerned that my personal health issues could affect my ability to complete activities on my placement; or if I do experience issues, that I won't feel comfortable acknowledging them to nursing staff
Just the normal anxiety of meeting new people for the first time which should go away with time I am slightly nervous and anxious about what I will face on my clinical placement, but other than that I am excited to learn more things and expand my nursing knowledge
Bullying and belonging Twenty-six (18%) participants commented on the culture of nursing and apprehensions about potential bullying; their perspectives were illuminative and of significant concern. Whether through conversations with other students, friends, family members or academic staff it seemed that many students had been ‘forewarned’ about inhospitable clinical learning environments and unsupportive nursing staff. This well intentioned advice, coupled with the pervasive fears and concerns held by participants, appears to have resulted in a very bleak outlook for many. Concerns about being perceived as a nuisance, not being welcomed or wanted, and unreceptive clinical cultures and staff were a recurring theme in a number of the participants' responses: All I can think about is how every RN I encounter is going to hate me simply because I am a student
Patient safety and making mistakes Although only 9% (n ¼ 13) of the participants’ comments related to patient safety and making mistakes it was evident from the words used (terrified, harm, kill) that this was a significant concern for some students. With patient safety a key focus area in undergraduate education it is important to understand how this topic may exacerbate the fears and concerns of beginning students. It is also essential that educators appreciate the apprehension students feel when contemplating the possibility of making an error while on placement: I am concerned that I don't know enough and that I might make a mistake that could affect my nursing career or that I could harm a patient I am terrified about making a mistake. I don't want to be responsible for someone being hurt or even just upset I'm concerned that I still don't know enough … that I will make too many mistakes that could harm or even kill a patient I feel as though I will make a mistake. I have the information I need but I feel it will be a lot harder to apply in a clinical setting
Placement at this stage is very daunting as all we seem to hear about is the terrible 'culture' of nursing I am worried that I won't be accepted or made feel welcome at my placement I think it's mainly the nurses' perceptions and attitudes towards student nurses that concern me. I don't want to feel like a nuisance or for the RNs to think “what a stupid question .... you shouldn't be a nurse if you don't know that!” Because I am inexperienced I hope the RNs don't get frustrated and feel as if I am a burden to them
Practicalities Participants' concerns about the day-to-day issues related to their placement experiences were not surprising but did highlight the types of stressors that some students have to contend with. Seventeen participants (12%) described how pragmatic issues such as location of placements and associated costs were a source of worry for them. Given the mean age of the participants (27 years) and that 87% worked either full or part time, the financial, physical and logistical impact of a full time placement, particularly when allocated to a hospital a distance from home, is significant. My concerns mainly relate to the geographical location of the allocated placement as travel will impact on my finances
Working outside of my scope of practice For a small number of participants (n ¼ 5, 3%) being asked or expected to work outside of their scope of practice was their primary concern. Interestingly the participants' comments did not refer to the relationship between patient safety and scope of practice but instead the emphasis was on the impact their refusal may have on their relationship with clinical staff. Although educators reiterate the importance of students knowing and working within their scope of practice (as they should), understanding the potential or perceived dilemma this may create for students needs to be appreciated: I am concerned about being left alone and expected to complete tasks outside of my scope of practice I feel it might be hard to say “no” or “it is outside my scope of practice” if I am asked to do something I am unable to do I'm nervous that my mentor will not understand that I have to work within my scope of practice.
Discussion and recommendations The concerns raised by the participants in this study in relation to their imminent clinical placement are consistent with previous research detailing how students’ describe their actual clinical
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placement experiences (Sheu et al., 2001; Shaban et al., 2012; Sun and Sun, 2011; Watson et al., 2009). Although curricula are planned with the intention of adequately preparing students for their clinical placements these findings suggest that, for some participants, their perceptions and experiences are markedly at odds with the desired outcome. The predominant finding relates to a sense of being underprepared for the first clinical placement. While some students expressed concern at a perceived knowledge deficit, others focused more on what could be described as ‘performance anxiety’ using words denoting embarrassment or fear of being exposed as ‘stupid’ or ‘incompetent’. Negative emotions such as anxiety serve to alert the person to perceived threat (Parrott, 2014). However, high levels of anxiety can divert a person's attention away from the task at hand to focus more on the perceived threats with the result that there is less attention available to undertake the required tasks effectively (Nieuwenhuys and Oudejans, 2012). Fear of negative evaluation has been associated with significant increases in anxiety and a marked decrease in performance (Mesagno et al., 2012). Students who express limited confidence in their ability to manage the challenges of clinical placement, who are fearful of poor performance and negative evaluation, and overwhelmed by anxiety, are more likely to have difficulties meeting expectations while on placement. Preparation for clinical placement includes a focus on professional behaviours and expectations of students in the clinical setting. Activities designed to equip students with the capacity to manage potentially challenging interpersonal interactions with clinical staff appear to have had a paradoxical effect. In seeking to prepare students for the realities of practice such as interactions with staff who may be unsupportive or even bullying, it appears that rather than feeling equipped to manage such situations, students' anxiety and fear has been exacerbated. Some participants' responses suggested a degree of resilience and self-efficacy consistent with an ability to identify negative stimuli in order to problem solve and negotiate these challenges successfully (Sassenberg et al., 2014). In contrast, others displayed an emotional response to potential threats that perhaps diminished their capacity to imagine themselves overcoming these threats (Sonnentag and Sparr, 2008) and may have resulted in a hypervigilance that is focused on detecting and avoiding perceived threats. A small proportion of students highlighted practical issues related to placement requirements. These concerns provide insights into the hurdles confronting contemporary nursing students, particularly those who, like the majority of participants in this study, are working either full or part time while studying and for whom placements can result in a loss of income from missed work. For all students transport and accommodation costs may be substantial where the placement requires temporary relocation. This financial burden associated with clinical placements may impact upon students' physical and emotional wellbeing (Wray and McCall, 2007). A strong focus on patient safety remains an imperative in undergraduate nurse education (Robson, 2014). Again, the emphasis given to this essential area of clinical practice in the first year curriculum appears to have had an unintended impact upon almost 10% of the participants in this study. The participants' language indicates an excessive level of fear; ‘I will make too many mistakes that could harm or even kill a patient’. The expressions of concern also reveal limited awareness of the activities expected of a student on an initial clinical placement and a sense of being without support or a safety net to prevent such an alarming outcome. These fears link closely to concerns expressed in relation to feeling unprepared, nervous and anxious when contemplating the upcoming clinical placement.
Concerns related to being left alone emerge again for the small number of participants fearful of working outside of their scope of practice. Consistent with concerns related to potential bullying and interpersonal difficulties, these participants identified limited confidence in their ability to negotiate the interactions that could arise if asked to work outside their scope. The participants' candour in describing their concerns has provided information that can be utilised to enhance students' preclinical preparation. Under each theme, participants describe emotional responses that range along a continuum from manageable anxiety to overwhelming anxiety and fear. Complete eradication of anxiety is neither possible nor desirable; however, enhancing student's capacity for emotion regulation has the potential to improve student performance and emotional well-being. Nursing students are entering a profession that is both fulfilling and emotionally demanding. High levels of stress combined with low levels of self-care contribute to emotional exhaustion and burnout in the nursing workforce. It follows that the initiation of practices such as mindfulness that build emotion regulation, enhance resilience and self-care as a student will also be protective for graduate nurses (Foureur et al., 2013). Mindfulness as a stress-reduction intervention in clinical populations has demonstrated significant benefits in research spanning more than 30 years (Day and Horton-Deutsch, 2004; Kabat-Zinn, 1982; Praissman, 2008). Mindfulness-based stress reduction has likewise demonstrated promising results in healthy individuals (Sharma and Rush, 2014). A growing literature also describes the beneficial impact of mindfulness practice on student well-being (Chen et al., 2013; van der Riet et al., 2015). White (2014) promotes the concept of mindfulness as underutilised in nursing and argues both the potential benefit for nursing students' well-being and an enhanced capacity for sustaining therapeutic engagement in clinical practice. Incorporating basic teaching of mindfulness activities into preparation for practice sessions for first year students could help develop a skill that will serve them well throughout their education and clinical practice. The frequency of concerns related to adequacy of preparation for clinical practice requires focused attention from academic staff. The constraints of staffing budgets, resources and time may preclude increased formal clinical laboratory sessions. However, creative solutions must be sought and additional self-directed practice session for students to engage in prior to clinical placement may be helpful. Likewise videoed simulated clinical placement activities may serve to lessen the ‘fear of the unknown’ by enabling students to envision themselves undertaking clinical activities (Gantt, 2013). Countering the paradoxical impact of attempting to enable students to manage a wide-range of potentially threatening situations such as bullying necessitates a change in emphasis. The average age of participants in this study was 27 years. A strengthbased approach that enables students to identify the interpersonal skills and strengths that they have already developed is vital. Academic staff and clinical educators can empower students to negotiate difficult situations by displaying confidence in their ability to call upon their previous experiences and existing interpersonal skills. Additionally, opportunities for cognitive rehearsal may enhance students' confidence and capacity to manage challenging interactions if encountered in clinical practice (Griffin, 2004). Conclusion The ultimate goal of clinical placements is the development of efficacious, confident, competent nurses who have a healthy selfconcept and a commitment to person-centred care and selfdirected learning. The realisation of this goal is dependent upon
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the extent to which students are adequately supported and prepared for placements. To date there has been a paucity of research focusing on students' perceptions and concerns prior to their first placement experience, and in particular the issues that are of most concern and why. This paper shed light on many of the challenges experienced by nursing students who are preparing for their first clinical placement and provides recommendations for educators who teach and support first year nursing students both in and before their clinical placement experiences. While clinical skills and knowledge are essential for safe clinical practice this study has identified that focused attention to the enhancement of students' emotional wellbeing, resilience and self-care is also imperative. Acknowledgement This study was funded by a Australia Government Department of Education Higher Education Participation and Partnerships Program (HEPPP) grant. References Andrew, N., McGuinness, C., Reid, G., Corcoran, T., 2009. Greater than the sum of its parts: transition into the first year of undergraduate nursing. Nurse Educ. Pract. 9 (1), 13e21. Brown, T., Williams, B., McKenna, L., et al., 2011. Practice education learning environments: the mismatch between perceived and preferred expectations of undergraduate health science students. Nurse Educ. Today 31 (8), e22ee28. Chesser-Smyth, P., 2005. The lived experiences of general student nurses on their first clinical placement: a phenomenological study. Nurse Educ. Pract. 5 (6), 320e327. Chesser-Smyth, P., Long, T., 2013. Understanding the influences on self-confidence among first-year undergraduate nursing students in Ireland. J. Adv. Nurs. 69 (1), 145e157. CoboeCuena, A., Sanchez-Donaire, A., Vivo-Ortega, I., Castellanos-Ranero, R., Rodrigues-Aguilera, C., Gomez de Zamora, R., 2010. Nursing students' stressors and anxiety in their first clinical practice. Nurse Investig. 49, 1e13. Day, P., Horton-Deutsch, S., 2004. Using mindfulness-based therapeutic interventions in psychiatric nursing practice-Part I: description and Empirical support for mindfulness-based interventions. Arch. Psychiatr. Nurs. 18 (5), 164e169. Foureur, M., Besley, K., Burton, G., Yu, N., Crisp, J., 2013. Enhancing the resilience of nurses and midwives: Pilot of a mindfulness-based program for increased health, sense of coherence and decreased depression, anxiety and stress. Contemp. nurse: a J. Aust. Nurs. Prof. 45 (1), 114e125. http://dx.doi.org/10.5172/ conu.2013.45.1.114. Gantt, L.T., 2013. Featured article: the effect of preparation on anxiety and performance in summative simulations. Clin. Simul. Nurs. 9, e25ee33. http:// dx.doi.org/10.1016/j.ecns.2011.07.004. Griffin, M., 2004. Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. J. Contin. Educ. Nurs. 35 (6), 257e264. Hsieh, H.F., Shannon, S., 2005. Three approaches to qualitative content analysis. Qual. Health Res. 15, 1277e1288. http://dx.doi.org/10.1177/1049732305276687. James, A., Chapman, Y., 2009. Preceptors and patients e the power of two: nursing student experiences on their first acute clinical placement. Contemp. Nurse: A J. Aust. Nurs. Prof. 34 (1), 34e47. Kabat-Zinn, J., 1982. An outpatient program in behavioural medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. General Hosp. Psychiatry 4, 33e37. Khater, W., Akhu-Zaheya, L., Shaban, I., 2014. Sources of stress and coping behaviours in clinical practice among Baccalaureate nursing Students. Int. J. Humanit. Soc. Sci. 4 (6), 194e202. Killam, L., Heerschap, C., 2013. Challenges to student learning in the clinical setting: a qualitative descriptive study. Nurse Educ. Today 33 (6), 684e691. Kondracki, N., Wellman, N., 2002. Content analysis: review of methods and their applications in nutrition education. J. Nutr. Educ. Behav. 34, 224e230.
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Levett-Jones, T., Bourgeois, S., 2015. The Clinical Placement: an Essential Guide for Nursing Students, third ed. Churchill Livingstone, Marrickville. Levett-Jones, T., Lathlean, J., McMillan, M., Higgins, I., 2009. Staff-student relationships and their impact on nursing students' belongingness and learning. J. Adv. Nurs. 65 (2), 316e324. Levett-Jones, T., Fahy, K., Parsons, K., Mitchell, A., 2006. Enhancing nursing students' clinical placement experiences: a quality improvement project. Contemp. Nurse 23 (1), 58e71. McCaughey, C., Traynor, M., 2010. The role of simulation in nurse education. Nurse Educ. Today 30 (8), 827e832. Mesagno, C., Harvey, J., Janelle, C., 2012. Choking under pressure: the role of fear of negative evaluation. Psychol. Sport & Exerc. 13, 60e68. http://dx.doi.org/ 10.1016/j.psychsport.2011.07.007. Morse, J., Field, P., 1995. Qualitative Research Methods for Health Professionals, second ed. Sage, Thousand Oaks, California. Moscaritolo, L., 2009. Interventional strategies to decrease nursing student anxiety in the clinical learning environment. J. Nurs. Educ. 48 (1), 17e23. Nieuwenhuys, A., Oudejans, R., 2012. Anxiety and perceptual-motor performance: toward an integrated model of concepts, mechanisms, and processes. Psychol. Res. 76 (6), 747e759. http://dx.doi.org/10.1007/s00426-011-0384-x. Parrott, W., 2014. The Positive Side of Negative Emotions. Guildford Publications. Parry, M., 2011. Student nurses' experience of their first death in clinical practice. Int. J. Palliat. Nurs. 17 (9), 448e453. Praissman, S., 2008. Mindfulness-based stress reduction: a literature review and clinician's guide. J. Am. Acad. Nurse Pract. 20 (4), 212e216. Ricketts, B., 2011. The role of simulation for learning within pre-registration nursing education e a literature review. Nurse Educ. Today 31 (7), 650e654. Robson, W., 2014. Eliminating avoidable harm: time for patient safety to play a bigger part in professional education and practice. Nurse Educ. Today 34 (5), e1ee2. http://dx.doi.org/10.1016/j.nedt.2012.06.002. Sassenberg, K., Sassenrath, C., Fetterman, A.K., 2014. Threat s prevention, challenge s promotion: the impact of threat, challenge and regulatory focus on attention to negative stimuli. Cognit. Emot. 1e8. http://dx.doi.org/10.1080/ 02699931.2014.898612. Sendir, M., Acaroglu, R., 2008. Reliability and validity of Turkish version of clinical stress questionnaire. Nurse Educ. Today 28 (6), 737e743. Shaban, I., Khater, W., Akhu-Zaheya, L., 2012. Undergraduate nursing students' stress sources and coping behaviours during their initial period of clinical training: a Jordanian perspective. Nurse Educ. Pract. 12 (4), 204e209. Sharma, M., Rush, S.E., 2014. Mindfulness-based stress reduction as a stress management intervention for healthy individuals a systematic review. J. Evid. Based Complement. Altern. Med. 33 (10), 1166e1172. Sheu, S., Lin, H., Hwang, S., 2001. The relationships among stress, physio-psychosocial status, coping behaviors and personality traits of nursing students during first time clinical practice. J. Nurs. Res. 9 (3), 233e246. Sonnentag, S., Sparr, J., 2008. Feedback and self-regulatory focus: predicting affective reactions and performance in a field study. In: Academy of Management Annual Meeting Proceedings, pp. 1e6. http://dx.doi.org/10.5465/ AMBPP.2008.33643503. Sun, J., Sun, H., 2011. Facing, accepting, growing and expecting: the practical experience of nursing students during their first clinical practice. J. Nurs. 58 (2), 49e56. Trede, F., 2012. Role of work-integrated learning in developing professionalism and professional identity. Asia-Pacific J. Coop. Educ. 13 (3), 159e167. van der Riet, P., Rossiter, R., Kirby, D., Dluzewska, T., Harmon, C., 2015. Piloting a stress management and mindfulness program for undergraduate nursing students: student feedback and lessons learned. Nurse Educ. Today 35 (1), 44e49. http://dx.doi.org/10.1016/j.nedt.2014.05.003. Wang, C., Lee, H., Lu, K., 2010. Nursing student depression and associated factors during students' first clinical practice. J. Nurs. Healthc. Res. 6 (1), 65e75. Watson, R., Gardiner, E., Hogston, R., Gibson, H., Stimpson, A., Wrate, R., Deary, I., 2009. A longitudinal study of stress and psychological distress in nurses and nursing students. J. Clin. Nurs. 18 (2), 270e278. http://dx.doi.org/10.1111/j.13652702.2008.02555.x. White, L., 2014. Mindfulness in nursing: an evolutionary concept analysis. J. Adv. Nurs. 70 (2), 282e294. Wray, N., McCall, L., 2007. Money matters: students' perceptions of the costs associated with placements. Med. Educ. 41 (10), 975e981. http://dx.doi.org/ 10.1111/j.1365-2923.2007.02840.x.
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
What are the primary concerns of nursing students as they prepare for and contemplate their first clinical placement experience? Tracy Levett-Jones a, *, Victoria Pitt a, 1, Helen Courtney-Pratt a, 2, Gwyneth Harbrow a, 3, Rachel Rossiter a, b, 4 a b
School of Nursing and Midwifery, The University of Newcastle Callaghan NSW 2308 Australia University of Sharjah, UAE
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 25 March 2015
Nursing students' first clinical placement experience can be a critical turning point ereinforcing professional aspirations for some, and for others, a time of emotional turbulence. There is a paucity of research focusing on students’ perceptions and concerns prior to their first placement experience. Thus, the aim of this study was to explore the concerns of first year bachelor of nursing students from one Australian university as they prepared for their first clinical placement. Participants completed an online ‘readiness for practice’ survey consisting of 22 items. This paper focuses on participants' responses to the one open ended question: ‘Please comment on any concerns that you have in relation to being prepared for your first clinical placement’. Summative qualitative content analysis was used for analysis. 144 students (55%) responded to the open ended question. Responses were categorised into six themes including: Not prepared for placement; feeling nervous, anxious and worried; bullying and belonging; practicalities; patient safety and making mistakes; and working outside of my scope of practice. It appears that activities designed to equip students with the capacity to manage the inherent challenges of undertaking a clinical placement may sometimes have a paradoxical effect by increasing students' level of stress and anxiety. An enhanced understanding of students’ concerns may help educators implement appropriate support strategies. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Nursing students Readiness for practice Concerns Clinical placement
Introduction Nursing students' first clinical placement experience can be a critical juncture in their educational and professional journey. It can e into the unfamiliar world of healthcare and signal provide an entre a time of significant change and growth. For some students however, the first placement can be a turbulent and sometimes
* Corresponding author. Tel.: þ61 02 49216559; fax: þ61 02 4921 6301. E-mail addresses: [email protected] (T. Levett-Jones), [email protected] (V. Pitt), [email protected] (H. Courtney-Pratt), [email protected] (G. Harbrow), Rachel. [email protected] (R. Rossiter). 1 Tel.: þ61 02 49216645. 2 Tel.: þ61 02 49217707. 3 Tel.: þ61 02 49215820. 4 Tel.: þ61 02 49217708, þ971 506 34 77 63; fax: þ61 02 4921 6301. http://dx.doi.org/10.1016/j.nepr.2015.03.012 1471-5953/© 2015 Elsevier Ltd. All rights reserved.
distressing experience. Students' preparation for their first placement and, more specifically, students' fears, concerns and issues during this lead up time, have received limited attention in the literature; yet this period of preparation can be pivotal to students' clinical performance, the degree of satisfaction they gain from the placement experience, and their ultimate clinical success (LevettJones and Bourgeois, 2015). The clinical environment provides an authentic context for nursing students to develop the knowledge, skills, attitudes and values of a registered nurse. Students have experiences on clinical placements that cannot realistically be provided in classrooms or simulated settings. However, as academics and clinicians frequently point out, nursing students are not always adequately prepared for clinical placements and concerns related to the development of students' competence and confidence, and their preparedness or “fitness for practice” remain contentious issues
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(Levett-Jones et al., 2006). As part of a larger study addressing first year nursing students' readiness for practice, this paper explored the concerns of students who were preparing for their first clinical placement and makes recommendations for addressing these concerns proactively. Background There is widespread agreement that clinical placements are of central importance to nursing education and specifically designed to facilitate authentic learning opportunities (Levett-Jones and Bourgeois, 2015). From the apprenticeship-style training undertaken decades ago to contemporary university-based education, the integral nature of clinical placements for the attainment of competence remains undisputed (Brown et al., 2011). The first clinical placement experience is critical to nursing students' professional identify formation and socialisation (Trede, 2012). It provides an authentic context that introduces students to the knowledge, skills, behaviours, attitudes and values of registered nurses. The quality of placements, and students' initial clinical learning experiences in particular, generate a range of intense emotional responses and can span a continuum from excitement, exhilaration, joy and pride through to confusion, anxiety, fear, apprehension, and distress (Levett-Jones and Bourgeois, 2015). Importantly, the experiences encountered during the first placement and the way in which students process the resultant feelings are key determinants of students' decisions to withdraw from or remain enrolled in nursing programs (James and Chapman, 2009; Killam and Heerschap, 2013). A number of studies have identified that nursing students frequently experience high levels of stress on their first clinical placement (Moscaritolo, 2009; Sendir and Acaroglu, 2008; Shaban et al., 2012; Sheu et al., 2001), and that this can negatively impact their learning, performance and professional growth (Sun and Sun, 2011; Khater et al., 2014). Students who struggle to adjust to their role during the first placement are also at risk of diminished selfesteem and depression (Wang et al. (2010). There are multiple sources of anxiety, stress and distress when students undertake their first placement. They include intrinsic, extrinsic, personal and professional factors, for example: feeling illprepared for human suffering, death and dying (Parry, 2011); exposure to nudity and the need to provide personal and intimate patient care; and fear of looking ‘stupid’, making mistakes and causing harm to patients (Killam and Heerschap, 2013; Cobo-Cuena et al., 2010). Further areas of student concern during first placement experiences include a lack of clarity about placement expectations; misconceptions about their role and responsibilities (Andrew et al., 2009); a perceived inconsistency between theory and practice; feeling unwelcome and unwanted in the clinical environment (Levett-Jones et al., 2009); and an erosion of confidence when feeling undervalued (Chesser-Smyth and Long, 2013). Students also report difficulties sleeping due to feeling anxious and as a result experience increasing exhaustion throughout the placement period (Killam and Heerschap, 2013). It should be noted however, that the identification and quantification of recurrent stressors and anxiety provoking events related to first placements is sometimes difficult because of the diverse nature of both practice environments and the individuals who enrol in nursing programs. Thus, addressing students' concerns in a proactive manner can be challenging. Nursing students are prepared for their first clinical placements using a range of approaches including clinical skills sessions, simulations (McCaughey and Traynor, 2010; Ricketts, 2011), lectures, tutorials and online modules. Professional behaviours and expectations are highlighted and key workplace health and safety issues
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related to placements are generally introduced. While most studies indicate that students consider their clinical placement preparation to be adequate, Chesser Smyth (2005) identified that some aspects require a shift in focus to be more student-centred and aligned with students' actual learning needs and concerns rather than what educators believe is most important. A search of the literature reveals a considerable number of studies focused on nursing students' views and placement experiences; however for each of these studies data were typically collected during or subsequent to students' first clinical placement. There is a paucity of research about the perceptions and concerns of nursing students in the lead up to their first placement. Undoubtedly, this period of time will be daunting for many students; however, without an in-depth understanding of students' specific issues, fears and concerns, strategies designed to support and prepare them may well be inadequate and ill-conceived. For this reason, the study described in this paper is unique in many respects e (a) it was conducted at a time when a group of beginning students were contemplating and preparing for their imminent clinical placements, (b) a large number of students completed and returned the surveys, and (c) the nature of the issues they described were recurring. Analysis of and reflection on these common issues of concern allowed us to suggest recommendations for addressing students’ concerns and better preparing future students for their first placements. Methods Study aim and design This findings profiled in this paper formed one component of a multi-site mixed methods study. The aim of the overall study was to elicit information regarding first year nursing students' perceptions of their readiness for practice and the impact of a one semester long preparation for practice course. Ethical approval for the study was obtained from the university ethics committee prior to contacting potential participants. Recruitment Students were recruited from a first-year cohort of undergraduate bachelor of nursing students from one semi-metropolitan university in Australia. Recruitment was via an email sent to nursing students in the target population and an announcement posted on the electronic learning management system (Blackboard™). Students who expressed an interest in the study were emailed a copy of the participant information statement with a link to the survey. Submission of the survey was taken as implied consent. Data collection Participants were asked to complete the 22 item online ‘Fitness for Practice’ survey distributed in weeks 1 and 6 of a 12 week semester. The results presented in this paper were from the second of these surveys with data collected immediately prior to students' first clinical placement experience. The data analysis presented below addressed participants' responses to the open ended question: ‘Please comment on any concerns that you have in relation to being prepared for your first clinical placement'. Data analysis Hsieh and Shannon's (2005) strategy of summative qualitative content analysis was used for analysis. This approach has a
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quantitative element in that it also looks at proportions or percentages of times that particular issues are referred to by participants. A summative content analysis involves counting and comparisons of keywords and content followed by the interpretation of the underlying meaning (Hsieh and Shannon, 2005). Data analysis began with reading all data repeatedly to achieve immersion and obtain a sense of the whole. Then, data were read word by word to derive themes by first highlighting the exact words from the text that appeared to capture key thoughts or concepts. Occurrences of the identified keywords and concepts were then calculated. If the analysis were to have stopped at this point, the analysis would be considered quantitative (Kondracki and Wellman, 2002). However a summative approach to qualitative content analysis goes beyond word counts to include a detailed interpretation in order to discover underlying meanings of the words or the content (Morse and Field, 1995).
learned when confronted with challenging clinical situations. It also became apparent that the participants were anxious about meeting the expectations of clinical staff and feeling embarrassed if they were not able to do so. The emotive language used by the participants (for example terrified, overwhelmed, stupid) attests to their degree of apprehension and concern: I am feeling overwhelmed at the knowledge I feel I need prior to placement I'm terrified that I will forget everything when I get there and not know how to handle certain situations should they arise I am worried about not having enough knowledge about emergency situations I'm scared about looking stupid because I don't not know enough I am concerned that I won't know enough and I'll feel embarrassed because of needing help all the time
Findings Participant demographics Two hundred and sixty-two students participated in the week 6 survey from a population of 547 giving a response rate of 48%. The majority of participants (233, 89%) were female. Participants' ages ranged from 18 to 59 years with a mean of 27 years. For 227 (87%) English was their first language. Two hundred and thirty-one of the participants (87%) had full or part time work while undertaking their degree and worked an average of 15 h per week. One hundred and nine participants (25%) had experience working as an Enrolled Nurse or Assistant in Nursing prior to commencing their undergraduate nursing program. One hundred and twenty-one (49%) were the first person in their family to attend university and 89 (34%) had a family member who had also studied to become a nurse.
Lack of confidence and the perception of inadequate clinical skills were recurring themes; however some of participants qualified their responses with somewhat optimistic comments and appeared to be more resilient and self-efficacious than their peers: I feel I haven't practiced enough skills for placement - so I don't feel at all confident in my abilities I wish that I felt more confident in the clinical skills we've been learning and that there were more hands-on learning incorporated into the course I'm concerned about my limited skills but I guess that all comes with time My medication calculation skills aren't as good as I would like them to be but I plan on practicing during the semester break before going out on placement I don't feel we have learned many skills yet but I am still excited about my placement
Content analysis One hundred and forty-four participants (55%) responded to the open ended question. Their responses were categorised into six themes (see Table 1) and organised from most frequently to least frequently occurring. Not prepared for placement The most common concern expressed by participants (n ¼ 49, 34%) was in relation to feeling ill-prepared for their first placement. Many described a perceived knowledge deficit and a number were worried that they may not be able to recall and apply what they had
Feeling nervous, anxious and worried Thirty-four (24%) participants expressed feelings of apprehension and anxiety in relation to their placements. Data analysis and clustering of participants' comments revealed a dichotomy between those students whose fears and concerns seemed almost overwhelming and those who were able to normalise their feelings of apprehension somewhat. The differences between these
Table 1 Content analysis and recurring themes. Theme
Number of responses
Percentage
Meaning
Not prepared for placement
49
34%
Feeling nervous, anxious and worried
34
24%
Bullying and belonging
26
18%
Practicalities Patient safety and making mistakes
17 13
12% 9%
5
3%
Concerns related to a perceived lack of knowledge and/or clinical skills; feelings of inadequacy and a lack of confidence. Feelings of apprehension and anxiety moderated somewhat with a sense of anticipation and excitement; fear of the unknown and fear of failure. Concerns about being perceived as a nuisance; not being welcomed or wanted; unreceptive clinical cultures and staff. Concerns about geographical location of placements, family and financial issues. Fear of looking foolish and/or making a mistake that could injure a patient and impact their progress and career. Lack of clarity about role expectations and being pressured to undertake clinical procedures that students do not believe they are prepared for.
Working outside of my scope of practice
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emotional reactions may hold the key to the development of appropriate preparatory activities and support strategies:
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I am quite worried about finances during placement as I won't be able to work - I live paycheque to paycheque and only get a very small amount from Centrelink
I am concerned about almost everything to do with clinical placement. The long hours and stress and the full on experience … it all worries me … I don't know how I will cope
I am concerned about being placed in a rural setting … finding accommodation and financial support
Fear of failure. Fear of the unknown. Fear of letting patients and myself down
I'm nervous about balancing my family and work life for the duration of the placement
I'm just nervous. I'm sure this is normal and I'm confident that this will improve during my time on placement
I am concerned that my personal health issues could affect my ability to complete activities on my placement; or if I do experience issues, that I won't feel comfortable acknowledging them to nursing staff
Just the normal anxiety of meeting new people for the first time which should go away with time I am slightly nervous and anxious about what I will face on my clinical placement, but other than that I am excited to learn more things and expand my nursing knowledge
Bullying and belonging Twenty-six (18%) participants commented on the culture of nursing and apprehensions about potential bullying; their perspectives were illuminative and of significant concern. Whether through conversations with other students, friends, family members or academic staff it seemed that many students had been ‘forewarned’ about inhospitable clinical learning environments and unsupportive nursing staff. This well intentioned advice, coupled with the pervasive fears and concerns held by participants, appears to have resulted in a very bleak outlook for many. Concerns about being perceived as a nuisance, not being welcomed or wanted, and unreceptive clinical cultures and staff were a recurring theme in a number of the participants' responses: All I can think about is how every RN I encounter is going to hate me simply because I am a student
Patient safety and making mistakes Although only 9% (n ¼ 13) of the participants’ comments related to patient safety and making mistakes it was evident from the words used (terrified, harm, kill) that this was a significant concern for some students. With patient safety a key focus area in undergraduate education it is important to understand how this topic may exacerbate the fears and concerns of beginning students. It is also essential that educators appreciate the apprehension students feel when contemplating the possibility of making an error while on placement: I am concerned that I don't know enough and that I might make a mistake that could affect my nursing career or that I could harm a patient I am terrified about making a mistake. I don't want to be responsible for someone being hurt or even just upset I'm concerned that I still don't know enough … that I will make too many mistakes that could harm or even kill a patient I feel as though I will make a mistake. I have the information I need but I feel it will be a lot harder to apply in a clinical setting
Placement at this stage is very daunting as all we seem to hear about is the terrible 'culture' of nursing I am worried that I won't be accepted or made feel welcome at my placement I think it's mainly the nurses' perceptions and attitudes towards student nurses that concern me. I don't want to feel like a nuisance or for the RNs to think “what a stupid question .... you shouldn't be a nurse if you don't know that!” Because I am inexperienced I hope the RNs don't get frustrated and feel as if I am a burden to them
Practicalities Participants' concerns about the day-to-day issues related to their placement experiences were not surprising but did highlight the types of stressors that some students have to contend with. Seventeen participants (12%) described how pragmatic issues such as location of placements and associated costs were a source of worry for them. Given the mean age of the participants (27 years) and that 87% worked either full or part time, the financial, physical and logistical impact of a full time placement, particularly when allocated to a hospital a distance from home, is significant. My concerns mainly relate to the geographical location of the allocated placement as travel will impact on my finances
Working outside of my scope of practice For a small number of participants (n ¼ 5, 3%) being asked or expected to work outside of their scope of practice was their primary concern. Interestingly the participants' comments did not refer to the relationship between patient safety and scope of practice but instead the emphasis was on the impact their refusal may have on their relationship with clinical staff. Although educators reiterate the importance of students knowing and working within their scope of practice (as they should), understanding the potential or perceived dilemma this may create for students needs to be appreciated: I am concerned about being left alone and expected to complete tasks outside of my scope of practice I feel it might be hard to say “no” or “it is outside my scope of practice” if I am asked to do something I am unable to do I'm nervous that my mentor will not understand that I have to work within my scope of practice.
Discussion and recommendations The concerns raised by the participants in this study in relation to their imminent clinical placement are consistent with previous research detailing how students’ describe their actual clinical
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placement experiences (Sheu et al., 2001; Shaban et al., 2012; Sun and Sun, 2011; Watson et al., 2009). Although curricula are planned with the intention of adequately preparing students for their clinical placements these findings suggest that, for some participants, their perceptions and experiences are markedly at odds with the desired outcome. The predominant finding relates to a sense of being underprepared for the first clinical placement. While some students expressed concern at a perceived knowledge deficit, others focused more on what could be described as ‘performance anxiety’ using words denoting embarrassment or fear of being exposed as ‘stupid’ or ‘incompetent’. Negative emotions such as anxiety serve to alert the person to perceived threat (Parrott, 2014). However, high levels of anxiety can divert a person's attention away from the task at hand to focus more on the perceived threats with the result that there is less attention available to undertake the required tasks effectively (Nieuwenhuys and Oudejans, 2012). Fear of negative evaluation has been associated with significant increases in anxiety and a marked decrease in performance (Mesagno et al., 2012). Students who express limited confidence in their ability to manage the challenges of clinical placement, who are fearful of poor performance and negative evaluation, and overwhelmed by anxiety, are more likely to have difficulties meeting expectations while on placement. Preparation for clinical placement includes a focus on professional behaviours and expectations of students in the clinical setting. Activities designed to equip students with the capacity to manage potentially challenging interpersonal interactions with clinical staff appear to have had a paradoxical effect. In seeking to prepare students for the realities of practice such as interactions with staff who may be unsupportive or even bullying, it appears that rather than feeling equipped to manage such situations, students' anxiety and fear has been exacerbated. Some participants' responses suggested a degree of resilience and self-efficacy consistent with an ability to identify negative stimuli in order to problem solve and negotiate these challenges successfully (Sassenberg et al., 2014). In contrast, others displayed an emotional response to potential threats that perhaps diminished their capacity to imagine themselves overcoming these threats (Sonnentag and Sparr, 2008) and may have resulted in a hypervigilance that is focused on detecting and avoiding perceived threats. A small proportion of students highlighted practical issues related to placement requirements. These concerns provide insights into the hurdles confronting contemporary nursing students, particularly those who, like the majority of participants in this study, are working either full or part time while studying and for whom placements can result in a loss of income from missed work. For all students transport and accommodation costs may be substantial where the placement requires temporary relocation. This financial burden associated with clinical placements may impact upon students' physical and emotional wellbeing (Wray and McCall, 2007). A strong focus on patient safety remains an imperative in undergraduate nurse education (Robson, 2014). Again, the emphasis given to this essential area of clinical practice in the first year curriculum appears to have had an unintended impact upon almost 10% of the participants in this study. The participants' language indicates an excessive level of fear; ‘I will make too many mistakes that could harm or even kill a patient’. The expressions of concern also reveal limited awareness of the activities expected of a student on an initial clinical placement and a sense of being without support or a safety net to prevent such an alarming outcome. These fears link closely to concerns expressed in relation to feeling unprepared, nervous and anxious when contemplating the upcoming clinical placement.
Concerns related to being left alone emerge again for the small number of participants fearful of working outside of their scope of practice. Consistent with concerns related to potential bullying and interpersonal difficulties, these participants identified limited confidence in their ability to negotiate the interactions that could arise if asked to work outside their scope. The participants' candour in describing their concerns has provided information that can be utilised to enhance students' preclinical preparation. Under each theme, participants describe emotional responses that range along a continuum from manageable anxiety to overwhelming anxiety and fear. Complete eradication of anxiety is neither possible nor desirable; however, enhancing student's capacity for emotion regulation has the potential to improve student performance and emotional well-being. Nursing students are entering a profession that is both fulfilling and emotionally demanding. High levels of stress combined with low levels of self-care contribute to emotional exhaustion and burnout in the nursing workforce. It follows that the initiation of practices such as mindfulness that build emotion regulation, enhance resilience and self-care as a student will also be protective for graduate nurses (Foureur et al., 2013). Mindfulness as a stress-reduction intervention in clinical populations has demonstrated significant benefits in research spanning more than 30 years (Day and Horton-Deutsch, 2004; Kabat-Zinn, 1982; Praissman, 2008). Mindfulness-based stress reduction has likewise demonstrated promising results in healthy individuals (Sharma and Rush, 2014). A growing literature also describes the beneficial impact of mindfulness practice on student well-being (Chen et al., 2013; van der Riet et al., 2015). White (2014) promotes the concept of mindfulness as underutilised in nursing and argues both the potential benefit for nursing students' well-being and an enhanced capacity for sustaining therapeutic engagement in clinical practice. Incorporating basic teaching of mindfulness activities into preparation for practice sessions for first year students could help develop a skill that will serve them well throughout their education and clinical practice. The frequency of concerns related to adequacy of preparation for clinical practice requires focused attention from academic staff. The constraints of staffing budgets, resources and time may preclude increased formal clinical laboratory sessions. However, creative solutions must be sought and additional self-directed practice session for students to engage in prior to clinical placement may be helpful. Likewise videoed simulated clinical placement activities may serve to lessen the ‘fear of the unknown’ by enabling students to envision themselves undertaking clinical activities (Gantt, 2013). Countering the paradoxical impact of attempting to enable students to manage a wide-range of potentially threatening situations such as bullying necessitates a change in emphasis. The average age of participants in this study was 27 years. A strengthbased approach that enables students to identify the interpersonal skills and strengths that they have already developed is vital. Academic staff and clinical educators can empower students to negotiate difficult situations by displaying confidence in their ability to call upon their previous experiences and existing interpersonal skills. Additionally, opportunities for cognitive rehearsal may enhance students' confidence and capacity to manage challenging interactions if encountered in clinical practice (Griffin, 2004). Conclusion The ultimate goal of clinical placements is the development of efficacious, confident, competent nurses who have a healthy selfconcept and a commitment to person-centred care and selfdirected learning. The realisation of this goal is dependent upon
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