Research 2

ETHICAL PROBLEMS ENCOUNTERED BY NURSING STUDENTS IN TURKEY Fethiye Erdil and Fatos Korkmaz Nursing students increasingly encounter ethical problems during their clinical practice which sometimes infringe the rights of patients. However, so far there is no study in Turkey on the extent of problems from the perspective of nursing students, as well as how nurses are involved in ethical decision making process. This study is conducted at Hacettepe University Health Science Faculty Nursing Department with the aim of identifying the ethical problems confronted by nursing students. Eighty-four third class and 69 senior nursing students were volunteers to participate in this study. Their age ranged from 19 to 23 years. All participants have taken the course entitled ‘Nursing History and Deontology’ which include 14 hours ethical content. Students were asked to describe moral problems that they observed or encountered during their clinical practice. Ethical problems at clinical practice were reported as physical maltreatment of patients (28%), inappropriate approaches toward patients which cause psychological distress (24%), violation of privacy (21%), providing inadequate information (16%) and discrimination based on the social and economical status (16%). The reasons of these ethical problems were stated by students as the unprofessional conduct of physicians (34%) and nurses (44%), and ineffective hospital management (9%). The most striking finding of this study was that 75% of nurses were not involved in decision making process of resolving these problems. Students suggested that nurses at clinics should be much more informed about the patient rights, ethical problems, and professional conduct. Since nurses are the role models for nursing students at practice, the results of this study demonstrate the importance of an in-service education for nurses on patient rights and ethical issues. We believe that the results of this study will contribute to the enrichment of the ethical content of nursing curriculum. Key Words: nursing students, nursing ethics, patient rights, ethical reasoning Introduction Nursing is a profession that requires alleviating the pain and promoting the health of others. Since the primary aim of nursing is the goodness of others, it is a value laden profession. This specific nature of nursing requires nurses to do what is right during their practice. However, everyday nurses encounter complex situations and conflicts which can not be resolved only through theoretical knowledge and skills. Such situations may involve moral components that require the skills of ethical decision making for nurses. Yet, learning the skills of ethical decision making can not be enough to resolve ethical problems due to many factors including the complex nature of a given problem. Nurse students often come into nurse education without any professional knowledge and consciousness, and socializing into the norms of nursing profession takes time. Furthermore developing an ethical sensitivity toward the moral problems in nursing practice requires additional knowledge on ethics, human and patient rights, and codes of ethics for nurses, and developing the skills of critical thinking. Even equipped with such a knowledge and skills, ethical decision making still requires real life experiences and good role models. For this reason, although ethics has been part of the nursing curriculum in many countries students lack the professional experience and legal authority to make ethical decisions. Therefore it is likely that they can not be able to distinguish the moral component of a problem and be involved in the process of ethical decision making. Under these circumstances, students may experience feelings of helpless and powerlessness and frustration when they encountered ethical problems. In Turkey, since the establishment of the first nursing high school in 1925, there was an effort toward higher education in nursing. In 1955, the first nursing school that offered baccalaureate degree has been opened at university and by 1990 most of the nursing schools integrated ethics into the curriculum. In 2002, a national core nursing curriculum has been prepared which indicates that nursing education should guarantee sufficient knowledge about the nature and ethics of profession as well as general principles governing the provision of health care1. Today, ethics are part of all nursing programs in Turkey even though the backgrounds of teachers, educational resources and teaching methods vary widely across the country. However, students in nursing programs of Turkey are not exceptional from the above mentioned problems. Although most of the nursing students acquire the necessary knowledge and skills on ethics during the theoretical courses, they feel incapable and stressed while observing unresolved ethical problems at their clinical practices. Probably they feel more frustrated than their peers at other countries because they also have to witness the inferior status of nurses among the health care team, especially physicians. Nurses as inappropriate role models at clinical practice who can not be involved in decision making process serve as an important obstacle for students in transferring their theoretical knowledge into the practice. Turkish nurses are disadvantaged in terms of their professional development because nursing in Turkey have to struggle for its autonomy and professionalism. The main reason is that nursing is a women profession in Turkey, and women dominant professions are still regarded as inferior due to the prevail of traditional male dominant cultural values. Therefore the point of view of our students on the ethical problems they confronted at their clinical practice may reflect a cultural component on this issue. So far there is no study on what kind of ethical problems are encountered by nurse students and how they perceive the role of nurses in resolving the problems. This study may have implications both for nurse educators in Turkey and for international nursing education. Method This descriptive study is conducted at Hacettepe University Health Science Faculty Nursing Department with the aim of identifying the ethical problems confronted by nursing students. Eighty-four third class and 69 senior nursing students were volunteered to participate this study. The questionnaire was prepared by researchers according to the literature review. Questionnaire includes the moral problems which student nurses encountered during their clinical practice. At the beginning, students were informed about the aim of the study and asked if they want to take place in the study voluntarily. The students who voluntarily accept to take place in the study were asked to fill the form and given back in the same lesson. It takes minimum 20 minutes to fill the questionnaire. The questionnaire includes 5 open ended questions. This questions are: What are the most frequent ethical / moral problems or situations you have encountered during your clinical practice ( you can write down one to three problems), which of the ethical principles do you think are infringed during this problems, what are the main factors which caused the ethical problems, Do nurses have any contribution to the solution process of these ethical problems and what are the students suggestions about effective participation of nurses into the solution process. The answers were classified according to the content of the problems. Students answers were analyzed by the researchers and then classified into physical maltreatment of patients, inappropriate approaches toward patients which cause psychological distress, violation of privacy, providing inadequate information, discrimination based on the social and economical status and communication problems between nurse-patient, nurse-doctor, doctor-patient, student nurse-ward nurse, student nurse-doctor, student nurse-patient. The results of the study were analzed and the findings were represented with number and percentages. Results All participant students’ age ranged from 19 to 23 years. They have taken 14 hours ethical content in the scope of Nursing History and Deontology course. Ethical problems at clinical practice Ethical problems at clinical practice were reported as physical maltreatment of patients (28%), inappropriate approaches toward patients which cause psychological distress (24%), violation of privacy (21%), providing inadequate information (16%) and discrimination based on

the social and economical status (16%). Interestingly, students reported communication problems between nurse-patient, nurse-doctor, doctor-patient, student nurse-clinic nurse, student nurse-doctor, student nurse-patient as ethical problems (5%). Frequently infringed ethical principles Frequently overlooked ethical principles were stated as autonomy (26%), privacy (21%), nonmaleficence (18%), beneficence (18%) and justice (17%). Factors causing ethical problems The reasons of these ethical problems were stated by students as the unprofessional conduct of physicians (34%) and nurses (44%) and other personnel (4%), ineffective hospital management (9%), ineffective communication (5%) and unnecessary activities to provide experience for nursing students (4%). Nurses` involvement in ethical decision making process Great amount of student nurses `reports (75%) revealed that nurses were not involved in decision making process. Whereas 25% of responds acknowledged that nurses were involved in this process. Discussion The findings of this study which were classified into more specific topics highlighted that most frequently encountered ethical problems by student nurses were physical maltreatment of patients, inappropriate approaches toward patients which cause psychological distress, violation of privacy, providing inadequate information and discrimination based on the social and economical status. The findings of the study are consistent with some of research results. In one study Berger and friends have found that nurses are confronted ethical problems due to the limited resources which let poor quality nursing care and unprofessional doctors` behavior to patients2. These findings are parallel with other two studies` findings which conducted in Korea and United States of America . In these studies mostly encountered problems were described as; nursing staff`s unprofessional behavior that resulted in poor quality nursing care, humiliation nursing students in front of patients and patients` families and unprofessional physicians behaviours3-4. In the results of study called `An analysis and evaluation of student nurses’ participation in ethical decision making` revealed similar findings such as conflict between nurses and doctors, lieing patients about the helath status, not keeping the confidentiality of patients, letting patients taking decisions without necesarry information, unethical nursing attidue to patients5. In an other study nurses stated most difficult situations as failing treatment procedures to relief excess pain and to make decisions instead of the patients who are in confusion, in demance and communication problems between doctors and nurses6. Student nurses are educated in a very complex health care system that they can observe so many unethical situations. But the extent and the importance of the problem is beyond the results of the studies which have done until today. In one of the study which analysed student nurses` ethical behaviours, it is found that student nurses generally on the fourt level of Kohlberg`s Moral Development Theory that they can make decisions according to the their professional rules but not their personal principles7. Student nurses learn what should do or how should react according to the ward nurses` attitude instead of the theoretical ethical knowledge of them. So they should be educated with real life experiences during their clinical education . In our study most frequently infringed ethical principles were found as autonomy and privacy. This finding can be regarded as a consequence of paternalistic approach of healthcare staff. In paternalistic approach health care professionals especially physicians and sometimes nurses decide on behalf of the patients with the assumption that only they can know right decision and patients can not decide autonomically. This problematic attitude can be seen in every where. For example in an study which was conducted in England 23% of the nurses stated that family members were told the diagnosis instead of the patients, the facts about the health situations of the patients were keep secret because of the patients psychologic and mental health situations8. Also the results of study which conducted in Netherlands showed that doctors maintain the treatment procedure whether patients wants or not (%83)9. The findings of two study also advocate the same approach, health care professionals tend to take decision whether patients are well educated or both menatlly and physical healthy. Nursing students reported in this study that the most striking factors causing ethical problems were unprofessional conduct of nurses and physicians. This finding can be interpreted as although nursing and medicine are professions, the members of these two professions in Turkey sometimes dismiss professional code of ethics and they have problems in transferring ethical knowledge into clinical practice. In the stduy of ethical problems which dutch nurses encountered the most problematic issues were reported also as ethical problems caused by nurses` and doctors` unprofessional attitudes9. When compared with other European countries the nursing profession has not gained the actual power in Turkey although it is an old profession. In Turkey nurses are not aware of their professional power in the healthcare system; their actual power comes from their caregiver role that is why they are expected to act as patient advocates. But on the contrary, our study displayed that nurses are not involved in any of decision making process of ethical problems which patients encounter. This finding is also important because nursing students are generally working with these clinical nurses during their clinical practice and they observe nurses reaction to ethical problems and internalize the same attitude towards ethical problems. The result which can be deducted from the study whether you expand ethical course content or increase credits of the course, when students graduate from the school and start working as nurses in healthcare settings they tend to act as they learned during their clinical practice. Conclusion and Recommendations As today`s student but future`s registered nurses, student nurses revealed too effective clues for nursing curriculum and nursing practice. Since students reported so many ethical problems for which all health professionals accounted, hospital ethical procedure and policy should be reviewed and announced to all staff, ethical violations must be regarded as a performance evaluation criteria besides this kind of violation must be punished. Also, whenever encountered or taken part in an ethical problem, these situations must be recorded and should be analyzed every six month and conclusions must be shared with whole staff. As great amount of student nurses stated most of the nurses were not involved in decision making process, the content of baccalaureate ethical courses must be expanded or another lesson only including ethical issues should be in curriculum, hospital in-service education for nurses should include ethical content and ethical decision making process. Also, nurses must be indispensable members of the hospital ethics committees. In conclusion, further research is needed to identify more real practical cases that contain ethical dilemmas and can be used in educational programmes, and then to evaluate their effect on ethical decision making using the personal experiences of student and clinical nurses.

References

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Görgülü RF, Dinç L. Ethics in turkish nursing education programs. Nurs Ethics 2007; 14(6):741-752. Berger MC, Seversen A, Chvatal R. Ethical issues in nursing. West J Nurs Res 1991; 13: 514–21 ). Park H-A, Cameron ME, Han S-S, Ahn S-H, Oh H-S, Kim K-U. Korean nursing students' ethical problems and ethical decision making. Nurs Ethics 2003; 10(6):638-653.

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Cameron ME, Schaffer M, Park HA. Nursing students' experience of ethical problems and use of ethical decision-making models. Nurs Ethics 2001; 8(5):432-448. Han S-S, Ahn S-H. An analysis and evaluation of student nurses’ participation in ethi cal decision making. Nurs Ethics 2000; 7: 113–23.

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Omery A, Henneman E, Billet B, Luna-Raines M, Brown-Saltzman K. Ethical issues in hospital-based nursing practice. J Cardiovasc Nurs 1995; 9 (3): 43–53.

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Dierckx de Casterlé B, Grypdonck M, Vuylsteke-Wauters M, Janssen PJ. Nursing students’ responses to ethical dilemmas in nursing practice. Nurs Ethics 1997; 4: 12–28.

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Enes SPD, Vries K. A Survey of Ethical Issues Experienced by Nurses Caring for Terminally İll Elderly People. Nursing Ethics 2004; 11, 150.

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Van der Arend AJG, van den Hurk CHM. Moral problems among Dutch nurses: a survey. Nursing Ethics 1999; 6: 468–82.

This research study aims to investigate the learning experiences of the BSN 4 students in their clinical practice from the affiliated hospitals of St. Paul University Philippines. CLINICAL PRACTICE EXPERIENCE BY THE BSN IV STUDENTS IN THE AFFILIATED HOSPITALS OF ST. PAUL UNIVERSITY PHILIPPINES A Research Study Submitted to the Director of Research of St. Paul University Philippines Submitted by: BRYIANE P. MEDINA, RN, MAN SHS FACULTY S.Y. 2008-2009

Chapter 1 THE PROBLEM AND REVIEW OF RELATED LITERATURE Introduction St. Paul University Philippines is the seat of quality education in nursing. In fact, among other nursing schools in the Philippines, the university garnered the highest score in the search for Center of Excellence in Nursing by the Commission on Higher Education last 2008. The University is consistently on the list of the top performing schools nationwide in the Nurse Licensure Examination. The School of Health Sciences College of Nursing continuously upholds the standards as center of excellence in nursing. The school assured that the quality of nursing practice is evidenced not only through academic performance but more so in the related learning experience (RLE) both clinical and community. Clinical experience has been the vital part of nursing education. According to Dunn and Burnette (1995), it is the avenue for the students to utilize the theories that they’ve learned in their discussion. It prepares student nurses to be able of "doing" as well as "knowing" the clinical principles in

practice. The clinical practice stimulates students to use their critical thinking skills for problem solving. It is where the student nurses enhance their knowledge in nursing concepts and principles as well as to develop and improve their skills and attitude towards rendering quality of nursing services. Nursing student's experiences of their clinical practice provide greater insight to develop an effective clinical teaching strategy in nursing education. The main objective of this study was to investigate student nurses' experience about their clinical practice. Nursing is known to be a caring profession. In fact, Florence Nightingale, the founder of nursing, initiated and developed this role utilizing environmental resources. This brilliant founder also instituted specialized roles in health care setting through the years. In the Philippines, nursing course is evidently enrolled most of the college students. And the challenge among nursing schools is to provide this quality education. Evidently, St. Paul University Philippines College of Nursing does not fail its students in this quality education.

Review of Related Literature Nursing students need sufficient practical experience to qualify with the full range of skills required for effective practice. The study considers the variety of support to the criteria in determining the accuracy of the analysis. Ensuring that nursing students receive sufficient practical experience to develop the full range of skills they need for effective practice has become a focus in nurse education (DOH, 1999). The clinical placement experience is a significant learning component within the nursing curriculum. It provides nursing students with an opportunity to use the theory and skills they have learned in the classroom and laboratory settings (Barney). The rapid changed in the health care environment have many implications for nursing education and nursing practice. The rapidity of knowledge changes have resulted in knowledge become obsolete. Thus, nurses need to keep learning in response to the rapidly changing healthcare environmenr so they can keep abreast of expectations of patient and the health care system (Studdy, Nicol & ox-Hiley, 1994). Clinical education is a vital component in the curricula of pre-registration nursing courses and provides student nurses

with the opportunity to combine cognitive, psychomotor, and affective domains. Various studies have suggested that not all practice settings are able to provide nursing students with a positive learning environment. In order to maximize nursing students' clinical learning outcomes, there is a need to examine the clinical learning environment. (Chan,) However, the literature suggests that there is a gap between theory and practice. It has been identified by Allmark and Tolly (1994). The development of practice theory, theory which is developed from practice, for practice, is one way of reducing the theory-practice gap. Rolfe (1995) suggests that by reconsidering the relationship between theory and practice the gap can be closed. He suggests facilitating reflection on the realities of clinical life by nursing theorists will reduce the theorypractice gap. The theory- practice gap is felt most acutely by student nurses. They find themselves torn between the demands of their tutor and practicing nurses in real clinical situations. They were faced with different real clinical situations and are unable to generalize from what they learnt in theory. Theoretical Framework Dr. Patricia Benner is well known in the nursing community for her work over the past 21 years with the Dreyfus model of skill acquisition. Recently she has written about her studies in nursing using the Dreyfus model, in an article entitled “Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education” (Benner, 2004). The Dreyfus model is developmental and is based on experiential learning. Benner writes that nursing requires both techné and phronesis. Techné is defined as explicit knowledge that can be captured from procedural or scientific knowledge. For techné, Benner gives the example of providing clear parameters and guidelines to students for determining fluid balance. At this stage the learner cannot rely on previous experience, so the student must be given safe, clear directions on how to proceed. For adequately teaching techné the nursing program must provide for specific situated learning in the clinical situation, though students would benefit from previous simulated experiences. Phronesis, on the other hand, is more complex; it is a reasoned practice employed by expert clinicians through experiential learning, where the nurse is continually improving her or his practice. According to Benner, the integrated, rapid response is the hallmark of phronesis (Benner, 2004, p. 196). Benner (2004, p. 197) gives a complex example of phronesis where the nurse made some rapid decisions when the patient developed a carotid hemorrhage. Phronesis is learned in the authentic situation with patients and feedback from experts.

Dr. Benner’s stages of skill acquisition include the “novice,” or the period in the nursing program when students have no experiential background on which to base their approach or their understanding of the clinical situation; “advanced beginner” or new graduate; “competent” or one to two years in practice; “proficiency,” a transitional stage on the way to expertise; and “expertise,” which involves practical wisdom or phronesis. For the purpose of this position statement, the focus is on the stages of the novice and advanced beginner. In the novice stage the nursing instructor carefully selects patients that are stable and predictable. As with the earlier discussion of techné, Benner (2004) suggests that the novice operates from the perspective of inflexible, rule-governed behavior. Benner (2004, p. 191) states, “Skills that are performed easily on a mannequin in a skills lab require adaptation and communication and reassurance skills when performed on a range of patients who may be calm or highly anxious.” Qualified faculty provides coaching, feedback and reflection throughout the nursing education program. As graduation approaches, students are expected to function at the “advanced beginner” stage of skill acquisition. Newly licensed graduates, who function as advanced beginners, have a heightened awareness of feedback and they frequently experience anxiety and excessive fatigue (Benner, 2004).

Conceptual Framework Ensuring that nursing students receive sufficient practical experience to develop the full range of skills they need for effective practice has become a focus in nurse education (DOH, 1999). The hospital related learning experience is an important learning factoring nursing education. In the research paradigm, nursing students have given the opportunity to utilize the theory and skills they have learned in the classroom discussion and skills laboratory. The related learning experience (RLE) duties in the hospital will serve as a tool to enhance more the knowledge, develop the skills, and improve the attitude of the nursing students. Research Paradigm Input Theories and Skills learned in the discussion And in the Simulation Laboratory Process Output Clinical Practice/ RLE Duties Effective performance: -Enhanced Knowledge -Developed Skills -Improved Attitude Figure 1. A paradigm showing the relationships of the input, process and output of the study.

Statement of the Problem This research study aims to investigate the learning experiences of the BSN 4 students in their clinical practice from the affiliated hospitals of St. Paul University Philippines. Specifically, it answers the following questions: 1. What are the expectations of the BSN 4 students in the affiliated hospitals of St. Paul University Philippines? 2. How extent from which these expectations have been met? 3. What is the rate of the students on the managerial/leadership aspects of their Clinical Instructors? 4. How do the students rate the importance of the clinical activities in the area? 5. How do the students rate their clinical performance as to their: a. Knowledge b. Skills c. Attitude 6. What are the problems encountered by the students during their clinical practice? 7. What are the suggestions of the students to improve the program of the school in the clinical practice? Significance of the Study

This study will benefit the following groups of people: Administrators of the University where the researchers as faculty members are working could use the findings as inputs for enhancing their administrative and supervisory skills for the improvement Experience. Faculty members who will follow up the students in the of the nursing program on Related Learning clinical area to improve their managerial/leadership aspects as clinical instructors. Students who will enroll and currently enrolled in nursing, to motivate them to focus on their studies for them to apply the theories and skills effectively in the clinical practice. Researcher of the study who is also one of the clinical instructors of the students to know whether the activities in the area are performed by the students as well as to know what to improve on in terms of managerial/leadership aspects in the clinical practice. Scope and Delimitation The study had focused on the BSN 4 students of the School of Health Sciences and it is limited only to the second batch of RLE.

The study had utilized survey questionnaire to investigate the learning experiences of the students. Definition of Terms Affective Domain. Refers to the area on attitude, feelings and/or emotion of an individual. Affiliated Hospital. Refers to the clinical placement of nursing students or any health-related course with an opportunity to use the theory and skills they have learned in the classroom and laboratory settings. Cognitive Domain. Refer to the area of knowledge. Clinical Instructor. Refers to the person who supervises, guides and teaches students during the clinical practice in the hospital. Clinical Practice. Refers to the related learning experience of the students in the hospital. Nursing. Is a profession that utilizes a body of knowledge integrating physiological and biopsychosocial sciences. It is a practice discipline using a holistic, caring approach across the Health – Illness continuum. Nursing education. Is a systematic, dynamic process through which the learner acquires knowledge of the science and art of nursing. This process is accomplished through the transfer of theory to practice through meaningful clinical experiences in a variety of settings. The nursing curriculum. Is built upon and uniquely integrated with the humanities, arts and sciences. Psychomotor. Refers to an area of skills, talent or abilities of a person.

Chapter 2 RESEARCH METHODOLOGY AND PROCEDURES This chapter presents the methods and procedures used in the study. It includes the research design, locale of the study, respondents and sampling procedure, data gathering procedure, and statistical treatment of data. Research Design The study had made use of Descriptive Method utilizing both Quantitative and Qualitative methods to investigate the learning experiences of the BSN 4 students in the clinical practice. Locale of the Study The study was conducted at the School of Health Sciences of St. Paul University Philippines. Respondents of the Study The respondents of the study were the BSN 4 students Batch 2 of RLE on the 2nd semester of the S.Y. 2008-2009.

Research Instrument A Survey Questionnaire as devised by the researcher was being used in the study. Data collection The researcher floated the questionnaire during the scheduled plenary sessions. Before the start of the session, the researcher distributed the questionnaire and then collected them after the session. Statistical Treatment of Data The researchers will use the more efficient and effective methods of analyzing The use data of in connection with the research instrument objectives. appropriate statistical provided a systematic structure for the organization, analysis and interpretation of research data. For problem number 1, the frequency distribution and percentage was used. For problem numbers 2-5, weighted mean was used and interpreted by using the Likert scale.

Likert scale interpretation: POINT SCALE 5 4 3 2 1 MEAN RANGE 4.20-5.00 3.40-4.19 2.60-3.39 1.80-2.59 1.00-1.79 QUALITATIVE INTERPRETATION Excellent Very Satisfactory Satisfactory Fair Poor

Chapter 3 PRESENTATION, INTERPRETATION AND ANALYSIS OF DATA 1. What are your expectations from the affiliated hospitals of the School of Health Sciences-College of Nursing regarding your clinical practice? Please check all that applied. Table 1: Frequency Count and Percentage of Respondents with their expectations from the affiliated hospitals EXPECTATIONS a. Provides opportunities to render health services and practice nursing in the hospital b. Provides therapeutic climate for learning experience c. Opens communication between the school and the hospital to ensure the safety of the students d. Allows students to manipulate facilities or equipment available in the area e. Nursing staff assumes Role Models as to practices of punctuality, honesty and integrity f. Medical and Nursing Staff share theories and experiences in their practice g. Involves students as members of the health team h. Keeping communication lines open i. Securing the student the enhancement of knowledge, improvement of skills, and development of good attitude in the area j. Screening competent and knowledgeable Clinical instructors or preceptors to qualify in guiding and FREQUENCY 101 PERCENTAGE 100% 101 101 101 101 100% 100% 100% 100% 101 101 101 101 100% 100% 100% 100% 101 100%

supervising the students Based from the data at the previous page, 100% of the respondents had checked all the given possible expectations from the affiliated hospitals. 2. How will you rate the extent to which these expectations have been met? Table 2: Extent to which the respondents’ expectations have been met EXPECTATIONS a. Provides opportunities to render health services and practice nursing in the hospital b. Provides therapeutic climate for learning experience c. Opens communication between the school and the hospital to ensure the safety of the students d. Allows students to manipulate facilities or equipment available in the area e. Nursing staff assumes Role Models as to practices of punctuality, honesty and integrity HOSP SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH WEIGHTED MEAN 4.29 4.10 4.46 4.48 4.13 4.29 4.35 4.16 4.17 4.42 4.31 4.37 4.70 3.85 4.18 INTERPRETATION Excellent Very Satisfactory Excellent Excellent Very Satisfactory Excellent Excellent Very Satisfactory Very Satisfactory Excellent Excellent Excellent Excellent Very Satisfactory Very Satisfactory

f. Medical and Nursing Staff share theories and experiences in their practice g. Involves students as members of the health team h. Keeping communication lines open i. Securing the student the enhancement of knowledge, improvement of skills, and development of good attitude in the area j. Screening competent and knowledgeable Clinical instructors or preceptors to qualify in guiding and supervising the students SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH 4.16 4.41 4.31 4.63 4.48 4.48 4.52 4.14 4.82 4.62 4.27 4.50 4.35 4.71 4.33 Very Satisfactory Excellent Excellent Excellent Excellent Excellent Excellent Very Satisfactory Excellent Excellent Excellent Excellent Excellent Excellent Excellent 3. How do you rate the importance of RLE activities? Have you experience them? Table 3.1: Frequency Count and Percentage of the respondents who experienced RLE activities RLE ACTIVITIES a. Attending the general endorsement b. Orientation before going to patients c. Participating in the Nursing rounds d. Utilizing the nursing care plan as tool in patient care YES FREQUENCY PERCENT 101 101 101 101 100% 100% 100% 100% NO FREQUENCY PERCENT

e. Performing nursing activities s/a - Vital signs taking - turning.positioning - bronchial tapping - suctioning - NGT feeding - Medication administration - Health Teachings - others: please specify 101 100% Based from the table above, all of the respondents or 100% of the population experienced the RLE activities in the area. Table 3.2: Respondents’ rate of importance on the RLE activities RLE ACTIVITIES a. Attending the general endorsement b. Orientation before going to patients c. Participating in the Nursing rounds d. Utilizing the nursing care plan as tool in patient care e. Performing nursing activities s/a - Vital signs taking - turning.positioning - bronchial tapping - suctioning NGT feeding - Medication administration - Health Teachings - others: please specify WEIGHTED MEAN 3.88 3.11 3.92 3.95 4.00 INTEPRETATION Very much important Much Important Very much important Very much important Very much important

4. How would you rate the managerial/leadership aspects of the Clinical Instructors? MANAGERIAL/LEADERSHIP ASPECTS a. Creative and innovative in organizing clinical activities b. Secures team work and cooperation among students c. Demonstrates competence in the area d. Lets all students involved in goal setting/planning for patient care e. Secures that the responsibilities in the ares are all shared equally f. Gives the SNs a free access to the facilities to enrich their clinical experience g. Recognizes students as vital members of the health team h. Alerts in identifying student’s needs i. Keeps students satisfied in the assigned tasks j. Treats students fairly and as a team WEIGHTED INTERPRETATION MEAN 3.78 Very satisfactory 3.72 Very satisfactory 3.17 Satisfactory 3.12 Satisfactory 3.11 3.77 3.76 3.13 3.16 3.52 Satisfactory Very satisfactory Very satisfactory Satisfactory Satisfactory Very Satisfactory 5. How would you rate your clinical performance? CLINICAL PERFORMANCE ATTITUDE a. Reports for duty on time, neat and properly groomed b. Reports for duty with complete paraphernalia c. Shows respect to CI, staff and other students d. Collaborates well with others for patient care e. Shows willingness to learn f. Uses self therapeutically g. Opens to corrections and suggestion h. Possesses caring behavior i. Shows concern, privacy and comfort to the patient WEIGHTED MEAN 4.74 4.70 5.00 4.86 4.88 4.69 5.00 4.94 4.93 INTERPRETATION Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent

j. Accepts negative feedback as learning strategy KNOWLEDGE a. Assesses the needs of the patient b. Identifies well the problem based on the needs of the patient c. Plans with patient and other members appropriate nursing action d. explains the rationale behind each intervention e. evaluates the patient accurately and effectively SKILLS a. utilizes NCP effectively for patient care b. Performs with accuracy the nursing procedures c. Records and reports accurately the patient’s status/improvement d. Manipulates instruments safely e. Guides and motivates groupmates in doing responsibility task 5.00 4.97 Excellent Excellent Excellent 4.96 Excellent 4.91 Excellent 4.73 Excellent 4.88 Excellent 4.67 Excellent 4.61 Excellent 4.71 4.70 4.50 Excellent Excellent 6. What are the problems encountered by the students during their clinical practice? Several students stated that one of their problems during their clinical practice is their clinical instructor. “There are some clinical instructors who embarrass their students in front of the patient” “Some approachable” “There are Clinical Instructors who does not treat of the Clinical Instructors are not their students fairly” “Some of the Clinical Instructors are toxic, which eventually makes me anxious”

There problems (SOs). are also some who stated and that one of their others was that their patients significant “There are patients who do not want the students to stay with them inside the room” “Some of the patients and SOs always ask questions that sometimes I’m unprepared to answer.” “Some of the SOs scold the students and even to the CI.” The sudden shifting of the schedule was also their problems during the clinical practice. “The five-day continuous duty made me so stressed and always tired that eventually affected my performance in the area.” They also had encountered staff nurses who are not approachable and annoying. “There are staff nurses particularly at Notre Dame de Chartres Hospital Baguio City are demanding, not approachable and always angry with us.” “Some staff nurses are moody and not approachable.” 7. What are the suggestions of the students to improve the program of the school in the clinical practice?

Most of the respondents suggested bringing back the previous schedule which is three days RLE duty every week to prevent the toxicity. ”They should change our schedule back to original.” “The schedule was very toxic. In fact, when the third day comes, I am already exhausted. Therefore, for the 4th and 5th day, I can no longer function well.” Clinical instructors also have to treat the students fairly and become role models to them. “The Clinical Instructors should treat the students in a fair manner to avoid biases.” “The Clinical Instructors should assume role model to their students most especially when coming in for duty, they should not be late.” “The Clinical Instructor should always be available at all times and be approachable.” “The hospital administration should allow the students utilize all the resources and operate the equipment available in the area.” “The hospital should have enough facilities to have better opportunity for good clinical practice.” Chapter 4 SUMMARY

Summary This study was aimed to investigate the clinical practice experience of the BSN IV students in the affiliated hospitals of St. Paul University Philippines. The researcher had designed a survey questionnaire for the investigation. questions It involves for seven questions. study and The the last rest two are serve qualitative quantitative study. After collecting the survey questionnaire, the researcher collated the data and tabulated them. After the process of tabulation, the researcher used statistical tool which is the frequency count and percentage as well as utilizing likert scale for evaluation. From this study, it was found out that the BSN IV students excellently performed in their clinical practice from the different affiliated hospitals of the school. It problems was found out by from this study also that there were encountered these students during their clinical practice which include their clinical instructor, sudden change of schedule, the staff and the patient and significant others. REFERENCES

A. Books: Benner, P. (2004). Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. Bulletin of Science, Technology & Society, 24, 188-199. Rolfe G. (1994). Listening to students: Course evaluation as action research. Nurse Education Today, 14(3):223-227 Studdy, S.J., Nicol, M., $ Fox-Hiley, A. (1994). Teaching and Learning clinical skills (Part 2: Development of teaching model and schedule of skills development. Nurse Education Today, 14. 186-193. B. Journals: Allmark P. (1995). Classical view of the theory-practice gap in nursing. Journal of Advanced Nursing, 22(1):18-23 Dunn SV., Burnette P. (1995). The Development of a Learning Environment Scale. Journal of Advanced 22: 1166-1173. Clinical Nursing, Tolley K (1995). Theory from practice for practice: Is this a reality? Journal of Advanced Nursing, 21(1):184-190 C. Internet: Barney, Amanda. (). Nurses from Across the State Learn the Importance of Providing A Welcoming Environment. http://www.hari.org/press/06profdevelop.pdf) April 2, 2009.5:15PM. Chan, D. (). Nursing Student’s Perceptions of Hospital Learning Environments: An Australian Perspective. http://www.bepress.com/ijnes/vol1/iss1/art4. April 2, 2009.5:10 PM. APPENDIX A

(Survey questionnaire) St. Paul University Philippines SCHOOL OF HEALTH SCIENCES Tuguegarao City, Cagayan North March 18, 2009 Dear respondent, Warm Paulinian Greetings! I am currently THE BSN conducting IV STUDENTS my IN study THE entitled: DIFFERENT “CLINICAL AFFILIATED PRACTICE OF HOSPITALS OF ST. PAUL UNIVERSITY PHILIPPINES.” In this connection, may I ask your genuine participation by answering the enclosed questionnaire needed for this research study. Your active participation is highly appreciated. Thank you and more power! Respectfully, BRYIANE P. MEDINA,MAN SHS Faculty

Name (optional): __________________________________________________________ Age: __________________ Sex: _________________ Please answer the following questions correctly and honestly. 1. What are your expectations from the affiliated hospitals of the School of Health Sciences-College of Nursing regarding your clinical practice? Please check all that applied. EXPECTATIONS a. Provides opportunities to render health services and practice nursing in the hospital b. Provides therapeutic climate for learning experience c. Opens communication between the school and the hospital to ensure the safety of the students d. Allows students to manipulate facilities or equipment available in the area e. Nursing staff assumes Role Models as to practices of punctuality, honesty and integrity f. Medical and Nursing Staff share theories and experiences in their practice g. Involves students as members of the health team h. Keeping communication lines open i. Securing the student the enhancement of knowledge, improvement of skills, and development of good attitude in the area j. Screening competent and knowledgeable Clinical instructors or preceptors to qualify in guiding and supervising the students 2. How will you rate the extent to which these expectations have been met? Use the following scale: 5 – Very much 4 – Much 3 – Moderate 2 – Little 1 – Not at all EXPECTATIONS HOSP 5 4 3 2 1

a. Provides opportunities to render health services and practice nursing in the hospital b. Provides therapeutic climate for learning experience c. Opens communication between the school and the hospital to ensure the safety of the students d. Allows students to manipulate facilities or equipment available in the area e. Nursing staff assumes Role Models as to practices of punctuality, honesty and integrity f. Medical and Nursing Staff share theories and experiences in their practice g. Involves students as members of the health team h. Keeping communication lines open i. Securing the student the enhancement of knowledge, improvement of skills, and development of good attitude in the area j. Screening competent and knowledgeable Clinical instructors or preceptors to qualify in guiding and supervising the students SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH SPH CVMC NDH 3. How do you rate the importance of RLE activities? Have you experience them? Use the following scale:

4 3 2 1 – – – – very much much little unimportant YES NO 4 3 2 1 RLE ACTIVITIES a. Attending the general endorsement b. Orientation before going to patients c. Participating in the Nursing rounds d. Utilizing the nursing care plan as tool in patient care e. Performing nursing activities s/a - Vital signs taking - turning.positioning - bronchial tapping - suctioning - NGT feeding - Medication administration - Health Teachings - others: please specify 4. How would you rate the managerial/leadership aspects of the Clinical Instructors? Use 5 – 4 – 3 – 2 – 1 – the following scale: Excellent Very Satisfactory Satisfactory Good Poor 5 4 3 2 1 MANAGERIAL/LEADERSHIP ASPECTS a. Creative and innovative in organizing clinical activities b. Secures team work and cooperation among students c. Demonstrates competence in the area d. Lets all students involved in goal setting/planning for patient care e. Secures that the responsibilities in the ares are all shared equally f. Gives the SNs a free access to the facilities to enrich their clinical

experience g. Recognizes students as vital members of the health team h. Alerts in identifying student’s needs i. Keeps students satisfied in the assigned tasks j. Treats students fairly and as a team 5. How Use 5 – 4 – 3 – 2 – 1 – would you rate your clinical performance? the following scale: Excellent Very Satisfactory Satisfactory Good Poor CLINICAL PERFORMANCE ATTITUDE a. Reports for duty on time, neat and properly groomed b. Reports for duty with complete paraphernalia c. Shows respect to CI, staff and other students d. Collaborates well with others for patient care e. Shows willingness to learn f. Uses self therapeutically g. Opens to corrections and suggestion h. Possesses caring behavior i. Shows concern, privacy and comfort to the patient j. Accepts negative feedback as learning strategy KNOWLEDGE a. Assesses the needs of the patient b. Identifies well the problem based on the needs of the patient c. Plans with patient and other members appropriate nursing action d. explains the rationale behind each intervention e. evaluates the patient accurately and effectively SKILLS a. utilizes NCP effectively for patient 5 4 3 2 1

care b. Performs with accuracy the nursing procedures c. Records and reports accurately the patient’s status/improvement d. Manipulates instruments safely e. Guides and motivates groupmates in doing responsibility task 6. What are the problems evolved during the Clinical