Influence of Students Perception/Staff Attitude in the Clinical Areas on Student’s Learning in Mathare Teaching and Referral Hospital, Nairobi, Kenya

Clinical learning environment is a very important aspect of nursing teaching. In Europe as well as USA, the principle of nursing education is based on a 50% theoretical class work and 50% practical through clinical experience. In Kenya, the learning is different where 69.5% is class work and 21.5% is the clinical area placement. Kenya government designed a one-year internship for all BScN students before they are entered into nursing council register to give the student enough experience before they enter into the field. Clinical learning is described as the “heart” of professional practice. Practice placement constitutes an important aspect of students` learning through influencing students’ acquisition of skills and knowledge for quality care provision in the right environments. The future of nursing profession is based on capacitating the student nurse with the ability to make critical decision at work. Noteworthy, many aspects affect student learning in clinical placement. Among them is shortage of qualified staff which is the case in the study areaMathare Teaching and Referral Hospital. This study focused on factors that influence students learning in the clinical placement and aimed to determine the effect of student’s perspectives and staff attitude towards learning in placement areas on learning among bachelor of nursing (BScN) students. A self-administered questionnaire was used to collect data that was analyzed by using statistical package of social sciences (SPSS) version 20. Study findings were presented by use of tables, charts and text. The findings revealed that most students (64.8%) were pursuing nursing training out of individual choice and felt that nursing was a calling to them but some (25.9%) would go to another career given a chance. Most (61.1%) students were apprehensive about clinical placement and the work they would be involved in. Reception in the hospital department by supervision staff was generally fairly satisfactory however 5.6% students reported lack of satisfaction. Nursing staff in the clinical area were generally friendly and concerned; and staff supervision in the clinical area was generally helpful and caring but not always available. The clinical placement areas need to enhance nurse-under-placement and receptors relationship to enhance uptake of the real life experience of the nursing profession.


Background Information
Nursing is referred to as a practice-based profession in many parts of the world. This is the case in the United States of America, Australia, New Zealand and European countries, such as the United Kingdom (UK) and Finland where clinical teaching and learning form a significant part of preregistration nursing training and education programmes [1]. In these countries, clinical learning plays an important role in improving the practice of both healthcare professionals and student nurses, which in turn contributes to improve care provision. Clinical learning is described as the "heart" of professional practice [2].
The extent to which newly qualified nurses are adequately prepared for the responsibilities of their first post is a key concern for prospective employers and for the service and education staff charged with responsibility for student nurse education [3]. Students` knowledge and skill acquisition, and theory-practice integration can be enhanced through mentorship activities [4]. In Kenya, one of the major components of student nurse preparation is mentorship; the process by which a student nurse (mentee) during periods of practical experience (placements) is attached to a qualified nurse (mentor) who guides the student's practice, assesses their progress, and judges their competence before being registered in the Nursing Council of Kenya (NCK) [5].
Mentorship has long been regarded as the cornerstone of nurse education and, as such, the experience of both mentor and mentee has been the focus of a considerable volume of research.
Clinical learning is where student nurses are allowed to interact with real patient and real situation in the clinical area and practice what they learnt in class working while being supervised by a qualified nurse. Clinical setting is described as a clinical classroom [6]. One of the most valuable components of a nursing program is the clinical learning environment (CLE). This setting provides students with unique learning opportunities in which classroom theory and skills are put to test with real life situations. CLEs include hospital wards, consultant doctor's clinics in the hospital' theatre, special clinics in the hospital, comprehensive care clinics/patients support clinics, maternal and child welfare clinics and other health care settings utilized for student learning. The CLE differs from the classroom or lab setting in many ways [7].
This study is anchored on social learning theory which can be defined by behavior modeling or observational learning that comprises of motor reproduction, motivation, and retention [8]. Importantly, behavior is subjective to places of learning which in this case is CLE [9]. The CLE is a complex social entity that influences student learning outcomes in the clinical setting. Exploration of this environment gives insight into the educational functioning of the clinical areas and allows nurse teachers to enhance students' opportunities for learning.
The CLE is unpredictable and relatively out of the nursing instructor's control. Staff members, unit environment, equipment and supplies, census, and patients and family members are elements of the CLE that cannot be controlled by instructors [10]. This unpredictable environment can be a major shock for students compounded by difficulty and confusion in the transition from student-learner to studentlearner-worker. Staff members may view students as workers only, especially when patient care demands are high. Nursing students are taught to provide holistic care but at times may be faced with more technical tasks than holistic patient care [11].
WHO recommends provision and maintenance of appropriate clinical learning facilities including workbooks, curriculum, manuals, nursing standard guidelines, reading material, computer, portable video `recorders, pamphlets, equipment and supplies [12]. Nursing procedures should be standardized in order to facilitate nursing care and clinical teaching as well as clinical instructors must be provided with an outline of the clinical education programme [13]. A clinical environment includes everything that surrounds the nursing work, including the clinical settings, the staff and the patients [14].
The attitude of nursing students toward clinical work is a topic of interest for research [15]. The clinical learning environment has been shown to have a direct impact on nursing student's perception of their profession and facilitates professional grounding [12]. Importantly, attitude plays a major role in guiding human behavior toward achieving goals, awareness of its consequences and effective processing of complex information about living environment.
The quality of the clinical learning environment is an essential factor in determining the quality of nursing students' clinical experience and outcome and the qualified professional nurse later in the development of the profession. It is well recognized that clinical setting can be of stress and anxiety hence deterring proficiency [16]. Clinical studies in nursing education are reported to represent the most stressful parts for the students, particularly in the initial stages due to lack of competence and knowledge [17]. The relationship between nursing staff and student nurses is the key component in clinical practice. Collegial relationships with the staff are an important element in student nurses' learning and socialization. [18]. The accompanist for student nurses should develop strategies to build trust and create a caring environment. Such an environment enhances clinical learning for the student nurses. Student nurses should be supported in addressing and overcoming fear and anger, so as to provide quality nursing care. Support should also be given to student nurses to enable them to identify and handle conflict associated with caring for patients [19].

Problem Statement
Since training of nurses started in the 1950s, there has been progressive increase in number of institutions training nurses and nurses being trained under the same management [20]. As of 2012, NCK reported 82 accredited nurse training institutions, of whom 10 were opened between year 2010 and 2012. Together these institutions offered 19 BSc. N programmes across Kenya with about 8.3% students having gone through BSc. N in the Kenya by 2012 [7].
On the contrary, clinical placement areas and resources have not increased at a similar rate. In the late 1980s the nursing schools were given autonomy. Nursing schools have to get a memorandum of understanding (MOU) with the hospital for students' placement at some fee. The MOU increased chances of clinical placement of students from private institutions compared with their counter parts in public nursing institutions [20]. The unmatched increase in number of nursing-students clinical placement areas has caused over-stretch of the clinical resources therefore adversely affecting student's learning. Influx of students reduced effectiveness of follow up of students in the placement areas. Additionally, shortage of nurses in the health facilities negatively impacts on supervisory roles, student learning time, and consequently patient care [10]. The basis of the principles of nursing education worldwide are 50% class work and 50% clinical experience which is not the case in Kenya [21]. This study aimed to assess how student's perspectives and staff attitude may have influenced clinical learning of the students.

Clinical Practice
Clinical placement in many part of the world is the base of training for BScN. In the Norwegian for example, the bachelor of nursing, students are assigned to clinical placements for 42% of the total education time. These placements are defined as supervised practice in which case students are preceptored by a registered nurse [22]. In Kenya, the BSCN students have more time in class (69.9% class work) and slightly less time in clinical practice (29.1%) clinical practice. Students learn more of clinical practice and undertake nursing council licensing examination during one year of internship after graduation from college. This is presumed to contribute to the presence of unregistered nurses in the Kenyan market [7].

Student Perception
There has been a rise in the negative attitude displayed by nursing students as well as nurses toward the nursing profession due to unpleasant hard work in the hospital, working on holidays, lack of respect for work, and low salary [23]. Loss of nurses' interest in what they do, not only negatively affects the quality of work, but also demoralize the profession [1].

Attitude of Staff
Qualified staff should treat student nurses with kindness and understanding, and should try to show interest in them as people. They should be approachable, helpful, provide student nurses with necessary support, and try to foster student nurses' self-esteem. Qualified staffs need to be sensitive to the study needs of the student nurses [22]. Caring as an important element for maintaining positive relationships by both the student nurses and faculty, and was perceived as an important aspect of the student nurses' learning experiences [18].
The triad model of the ideal teaching relationship, where the teacher plays a supportive role and provides learning opportunities for student nurses, as a facilitator of learning [24]. This relationship is vital if student nurses' clinical learning experiences are to be maximized. Such a teacher must be willing to be less of an advice-giver and rescuer than one who facilitates the student nurses' exploration of nursing practice [25]. Lack of separation of roles results in the development of an inappropriately balanced relationship, wherein the teacher fosters student nurses' dependence, which adversely affects the student nurses' learning experience. Another negative aspect in this model is where the teacher consistently and inappropriately takes over the responsibility for client care from the student nurses, and by so doing, depriving the student nurses of the opportunity of practice and clinical decision-making [24].
There is a health care crisis resulting from a shortage of nurses in the workforce and the shortage impacts upon nurses' workloads by creating increased responsibilities [26]. The increased responsibility of nursing students may add to the already existing stress in the work setting. As nursing educators recognize the need to prepare a competent, dedicated nursing workforce for the future, it is imperative that nursing schools retain students and facilitate a positive effective learning environment within the clinical practice setting.
Nursing students encounter a wide range of support from being treated very badly to very good depending on the staffing and attitudes of the nurses [27]. Often the students feel that when there are staffing shortages, they are being exploited, as just a pair of hands to get the work done and their learning objective is not important.

Methodology
This was a cross sectional descriptive research study that utilized quantitative approach. Study site was Mathare Teaching and Referral Hospital. Study population was 63 BScN students in clinical areas and in placement at the time of data collection. A sample of 54 students was selected using stratified sampling technique. Five different learning institutions formed strata. Data was collected using selfdirected structured questionnaires. Quality control measures were employed including pre-test, validity and reliability checks.
Approval to conduct research was obtained from Regina Pacis University, Kenyatta National Hospital Ethical Review Committee; and clearance from Mathare Teaching and Referral Hospital. Respondents consented to participate with confirmation of confidentiality. Collected data was crosschecked for completeness and any missing entries corrected upon completion of each interview.
Data coding, entry and analysis was done using SPSS version 20 software. Descriptive data analysis included frequencies and percentages. Findings were presented as text, graphs and tables.

Social Demographic Data
The study sample comprised majorly of females who were in 3 rd and 4 th year of studies, Table 1.

Perception of Clinical Placement on Learning
The greatest proportion (64.8%) students did nursing training as an individual choice and felt that nursing was a calling. A group of 18.5% students followed the interest of their parents. Section of 25.9% and 9.3% would go to another career given a chance and were not sure about the interest in nursing respectively. Similar findings were made in a study among newly admitted students to campuses in Kenya where they observed that majority (46.3%) of the students were not influenced to pursue nursing career; while 22.7% were influenced by qualified nurses, 16.3% influenced by parents [23]. Contrary findings were among Chinese students whose decisions to choose nursing was usually made by their parents or influenced by other people with some of the students studying nursing as a major due to being transferred from other majors [28]. The parents, the school teachers, friends, past experiences with career activities and working in hospital were some of the influences that made the students in Hong Kong to have the intent to study nursing [29]. Most 33 (61.1%) students were apprehensive about clinical placement and the work they would be involved in, 11 (20.4%) didn't know what they expected while 8 (14.8%) were anxious and 2 (3.7%) feared the staffs they would meet. Majority 24 (44.4%) students thought of the staff working in the hospital before their placement to be friendly. On the contrary, 21 (38.9%) students thought the staff in hospital would not care or help in learning, 8 (14.8%) thought they would be hostile and 1 (1.9%) thought that they wouldn't help in learning. Similar findings were expressed by psychiatric student in one of the hospital in Kenya where they felt psychiatric nursing is associated with stigma and luck of motivation [30]. Similar findings were made among Norwegian students which reviewed that the students expressed their anticipations about how they expected to be received by the Bangladeshi nurses and how they expected to achieve their learning objectives during their clinical placement. Initially these mentioned apprehensions about, on the one hand, being excluded from performing 'hands on' clinical practice and on the other hand, being expected to perform 'hands on' clinical practice without relevant preparation and guidance [31]. Similar findings were also made among Australian students where the study demonstrated students' negative emotions or feelings towards clinical placement in a high-acuity setting but the student confidence to perform individual clinical skills increased over the semester; however their feelings of preparedness for high-acuity clinical placement decreased over the same time period [32]. Majority 26 (48.10%) students were placed in males wards, 24 (44.4%) in female wards, 9 (16.7%) in OPD, 7 (13.0%) in special clinics, 4 (7.4%) in rehab and 1 (1.9%) dressing /injection rooms and occupational therapy. The overall rating of the clinical areas was 63% which implied that the students considered the clinical area to be good. Majority 18 (33.3%) students reported that the clinical areas were good, 16 (29.6%) reported they were fairly good and 10 (18.5%) reported that they were fair and very good each.
Similar findings were made among nursing students on placement at teaching and referral hospitals in Kenya in which it was found out that they were able to take initiative in their training and meet clinical objectives but were dissatisfied with unavailability of procedure manuals for reference at clinical sites [33]. Similar findings observed that most nursing students in placement were more satisfied than dissatisfied with the learning environment in the nursing homes [19].  An assessment of the perception on various issues evaluated on a percentage of the average established that nursing staff were fair (50.5%); other medical staff were fair (51.4%); other professionals were fair (53.7%); administration was fair (49.1 nursing care of patients was fair (60.6%); handling of health workers was fair (57.1%) and handling of the students was fairly good (64.8%).
Contrary findings were made among students in placement in rural hospitals in South Africa where it was found out that the nursing students experienced lack of support, inadequate mentoring and guidance, isolation from clinical activities, an inhumane attitude by clinical staff, a poor clinical environment and many other aspects as hindering students' learning [34]. Similarly, students expressed most satisfaction with peer collaboration, the placement's contribution to awareness of future nursing role and described the learning arena as exciting and interesting [19].

Nursing Staff Attitude Towards Supervision and Learning of BScN Students
Reception in department by supervision staff was generally fairly satisfactory however 3 (5.6%) students reported lack of satisfaction. Nursing staff in the clinical area were generally friendly and concerned however 11 (20.4%) and 7 (13.0%) students reported staff as indifferent and unfriendly.
Similar findings were made in mental health facilities in Kenya in which it was observed that most (90.8%) students commended the nursing staff for being responsive to their requests for assistance and 89.1% enjoyed their placement [30]. Contrary findings indicated that students often perceive mentors to be too busy to provide the required level of support in United Kingdom [35]. This can lead to increased levels of anxiety for students as they may feel unsupported. Mentors are one of the critical factors affecting students' ability to learn and cope on their placements. Similarly, students expressed less satisfaction with supervision from preceptor and how the practice site was prepared for and organized students' placements [19].
Staff supervision in the clinical area was generally helpful and caring but only available a few times however 4 (7.4%) students reported that the staff didn't care about learning respectively. Clinical staffs were generally availability for help in learning when needed and helpful in the process of learning. However 4 (7.4%) and 5 (9.3%) students reported that the staff were not available at all and were not helpful in the process of learning respectively. Similar findings were made among nursing students on placement in a mental health facilities in Kenya in which it was observed that there was shortage of staff of whom majority were not trained in mental health and tended to concentrate on giving service rather than assisting students thus interfering with mentorship [30]. Contrary findings were made among Norwegian nursing students where it was found out that students highly valued teachers' and preceptors' supervision, although teachers' supervision was rated somewhat more highly. Fulfillment of learning outcomes for clinical practice was also rated highly, and the teachers' supervision was estimated, to some extent, more highly than the preceptors' supervision in this respect [36]. Similar, students in nursing homes found it less easy to approach the staff as compared to students in hospital placements which was attributed to the fact that nursing homes in Norway are often lower staffed than hospitals, perhaps resulting in nursing students feeling that they were a disturbance when and if approaching nurses [37].  A proportion of 35 (64.8%) students felt that the trained nurses positively influenced their learning in the clinical area by guidance, 16 (30.2%) practical / adequate examples 7 (13.2%); positive attitude 6 (11.3%); motivation 5 (9.4%); encouragement 4 (7.5%); supportive 4 (7.5%); availability 3 (5.7%); helpful 1 (1.9%); caring 1 (1.9%) and patient mobilization 1 (1.9%). However 1 (1.9%) reported negative influence as a result of staff not being helpful.

Conclusion
Most students pursued nursing training as an individual choice with the feeling of a calling to them. Some of the students give an indication of being in the 'wrong' career with high chances of exiting nursing. Most students were apprehensive about clinical placement and the work they would be involved. Staff working in the hospital before student placement were mostly presumed to be friendly. In this study, the reception by supervision staff was fairly satisfactory. Nursing staff in the clinical area were generally friendly and concerned. Staff supervision in the clinical area was generally helpful and caring. Availability of staff supervision in the clinical area poses as a challenge to the student nurses.

Recommendation
All clinical learning stakeholders need to collaborate to ensure that all needed equipment and staff are available.
There is need for proper sensitization of would-be nurse trainees on career choices as it has been shown that some of the nurses, although few, were pursuing the nursing profession following the interest of their parents and even some of them were considering changing profession if granted a chance to do so. This implies that these students had negative attitude towards nursing which is considered a 'calling' profession.
There is also need for proper preparation of students prior to placement to alley their apprehension during this practice.
The clinical placement areas need to enhance nurse-underplacement and receptors relationship as this will enhance uptake of the real life experience of the nursing profession since some students' perceived supportive but rarely available supervision especially in the clinical area.

Ethics Approval and Consent to Participate
The study was performed under protocol approved by Regina Pacis University, Kenyatta National Hospital Ethical Review Committee; and clearance from Mathare Teaching and Referral Hospital.

Consent for Publication
Not applicable.