CHAPTER ONE

INTRODUCTION

BACKGROUNDOFTHE STUDY

Clinical practice is defined as a model of practice that involves those activities with and on

behalf of clients, especially those activities completed in the client's presence and with the

client's collaboration (Markkanen, 2023). These intervention and change oriented activities

are based on a range of theories with the clinical social worker selecting the one most

appropriate for the client's situation. Clinical placements where students learn clinicalpractice

should allow students to acquire nursing skills and clinical reasoning and develop as

professional nurses. In areas where stimulation learning is limited or not available at all,

learning takes place in the real environment (Markkanen, 2023). Nursing students arestudents

whoarecurrentlyin trainingto studyand belicensed to practiceas nurses, theyneed to be

supported and guided so that they can become responsible, accountable, and independent

professionals who are able to function within the scope of nursing professional practice

(Henderson and Tyler, 2024). Clinical practice provides opportunity for students to apply the

theoretical knowledge into actual health care problem. Clinical placements enable Nursing

students to gain essential skills and provide safe and quality nursing care throughreal life

practice. In the course of clinical practice, students applytheir theoretical knowledge in areal

environment, develop psycho-motor skills, observe and adapt to various professional roles.

The clinical environment should be carefully selected, accepted by Nurse tutors, and

prearranged to be capable of transforming nursing students into competent nursing

practitioners; this is dependent on factors such as curriculum design, cost effectiveness and

relationship with specific health facilities (Jamshidi and Molazem, 2016). Nursing education

isatermusedtodescribetheoverallbodyofknowledgethatappliestonursingprofession.It

encompasses avarietyof knowledge,skills,concepts,andpracticeswhich revolve aroundthe

education consists of acquisition of a body of knowledge that is partly delivered in a classroom

setting which forms the theoretical bases of nursing knowledge and an organized and

supervised clinical training experiences that take place in the clinical settings where the nurse-

patient relationship is experienced directly or indirectly (Shariff and Masoumi, 2015).

Clinical training which is part of nursing education takes place in hospitals, other health care

institutions, communities and homes under the direction and supervision of trained personnel

in nursing profession called clinicians or preceptors. Clinical training as an integral part of

nursing education prepares student nurses with the ability of “doing” as well as “knowing”the

clinical principles in nursing practice. The clinical experience which is a vital part of nursing

education stimulates students to use their critical thinking skills for problem solving.

Itprovidesthestudentsopportunityfortheiractiveself-learning,self-developmentandability to

apply their knowledge from theoretical context situation to emergency and general public

health care.

In line with this therefore, clinical education must be to help the students to acquire the

necessary nursing skills and the ability to perform in order to establish their capacity tohandle

changing realities and situations in nursing practice, (Melone, 2020).

The nursing skills to be acquired consist of series of courses in the nursing curriculum and

manuals. Thesearedesigned to equip students with therequired clinical nursingskills needed

for optimal practice, (Rennie, 2019). These include nurse-patient relationship skill,

interactional Skills, basic physical examination skills, clinical encounter across the life span,

therapeutic communication skills, positive attitudinal skills etc. These courses span

throughouttheyearsofstudies.Studentsmustsuccessfullycompleteallthecomponentsf

the clinical courses to progress as nurses. Examining the development of necessary nursing

skills duringtraining, Indicates that nursing skill acquisition is a continuous learning process.
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This indicates that extensive experiences and supervision from mentors, preceptors,

supervisors, teachers, considerable time on task and involvement of students are necessary to

achieve a considerable nursing skill performance. There is also supporting evidence that the

students’ interest and the practice environment e.g. hospital, exert an influence on the

development of nursing skill (Ericsson 2020).

Clinical practice in the view of the student is a complex and dynamic process in which

students gain experience and convert or transform theoretical knowledge into practice in the

clinical setting to equip nursing students with scientific knowledge of nursing care and to

apply it health care setting through clinical practice.In contemporary nursing education,

duration of practice in a clinical setting is half of the total duration of the undergraduate

nursing education. (Steven and Magnusson, 2018).

At the beginning of the last century, nursing training was based mainly on clinicalexperiences

whereby students do more of clinical experiences in the wards and receive small sums of

payment .However, with increased complexity in today’s nursing care playing a challenge to

the theoretical and clinical training of nursing students, it was realized that theoretical studies

are of great importance in nursing education and practice. This then led to reduction of the

proportion of time spent on clinical experience while the time and courses in relation to

theoretical studies was increased (Harrison, 2020).

Clinical area or setting refers to a specific geographical area of the hospital devoted to the

diagnosis, treatment and care of clients on an in-patient, out-patient or day-care basis. Arange

of health care professionals interact and work together to deliver care using

theirspecialbrandofprofessionalexpertise,makinguseofavailableresourceswhereneeded.

Clinical area otherwise called clinical environment is the arena where students from health care

professions learn about care and what practical care is all about.Clinical area to the student

refers to an area where health students (nurses) acquire clinical practical skills in caring for
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patients and interact with other professional colleagues from different institutionsto gain more

experience from each other. (Preskill and Torres, 2019).

Some clinical experiences that takes place in clinical areas includes :Ward Experience,

Community experience,Psychiatric experience,Obstetrics and gynecology experience,

orthopedic experience, special units etc. Certain traits are expected from the student nurses

during clinical practice as to obtain and maintain good clinical skills: competency, empathy,

sympathy, good communication skills and commitment to patient advocacy, ready to acquire

knowledge, time management etc. Apparently, student nurses have different insights towards

their training environment thus, the facultyand preceptors should be mindful about the actual

experiences and feedback from the students, this helps promote proficiency when working in

different clinical environment (Mellish,and Brink, 2017).

Some factors affects students learning in clinical area namely hospital factors, supervisory

factors, individual (student) factors, social-economic factors. A Study conducted during

clinical posting revealed that nursing students failed to apply theory into practice becausethey

lack adequate supervision in the clinical area which results to low performance in their

clinicalpractices. It has beenreported thatclinicalinstructors’attitudesaffectperformanceof

nursing students in the clinical area. Positive attitudes and supportive environment encourage

students learning environment. Constructivecriticism improves practice in theclinical setting

while negative criticism is an obstacle for effective clinical performance. Limited chance for

hands on practice in training hospitals, shortage of nurse tutors, clinical instructors, and too

many students in the program can negatively affect performance of students in clinical

practice.Thestudents’behaviorsnegativelyaffectstudents’performanceinclinicalpractice as

inability to demonstrate knowledge and skills, attitude problems, unprofessional behavior,

and poor communication skills with patient and clinical instructors, not asking questions,

overconfidence, unmotivated to learn or to work, lack of confidence. Lack of prior clinical

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 experience, unfamiliar areas, difficult patients, fear of making mistakes (Mulenga, and

Amadhila, 2017). Resources needed for effective clinical practice training and non-

availability of qualified and experienced nurses affects performance in clinical practice.

Themajor determinant ofthe effectiveness of aclinical practice are the context in which they

occur, clinical practice in nursing is performed in response to professional, societal and

educational demands using available human intelligent, physical and functional resources as

the context of the curriculum. This informed the researcher’s choice of the topic, “factors

affectingperformance in clinical practice amongnursingstudents in nursinginstitutions” that

promote or hinder their acquisition of necessary nursing skills for adequate nursing practice.

STATEMENTOFTHEPROBLEM

The nursing skills to be acquired consist of series of courses in the nursing curriculum and

manuals.Thesearedesignedtoequipstudents withtherequiredclinicalnursingskillsneeded for

optimal practice, (Rennie, 2019).

The poor standard of education has been a great problem in nursing schools and the countryat

large, some students go through their training and at the end cannot defend what they have

learnt. The challenges confronting in today’s rapidlychanging health care environments have

highlighted the necessity of graduating students that are both competent and prepared for

practice.

Theresearcher observed that nursing students in the course of their practice find it difficult to

perform some basic nursing procedures which could be attributed to poor supervision by the

clinical instructor, poor communication between the instructors and the students, inadequate

hospital equipment, fear of making mistakes and lack of guidance and direction by clinicians

working in the clinical area. Based on the above premise, the researcher wishes to carryout a
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studyon the factors affectingperformance in clinical practice amongstudent nurses in school of

nursing Amachara, Umuahia Abia state.

OBJECTIVE OFTHESTUDY

The main objective of this study is to determine the factors affecting performance in clinical

practice among student nurses in school of nursing Umuahia Abia state.

Specificallythestudyintendsto:

1. Todeterminethehospitalbasedfactorsaffectingperformanceinclinicalpractice among

student nurses in school of nursing Amachara

2. To ascertain the supervisory based factors affecting performance in clinical

practiceamong nursing students in school of nursing Amachara

3. Toelicitthestudentbasedfactorsaffecting performanceinclinicalpracticeamong nursing

students in school of nursing Amachara.

4. Todeterminewaysofimprovingperformanceinclinicalpracticeamongnursing students in

school of nursing Amachara.

RESEARCHQUESTIONS

 What are the hospital based factors affecting performance in clinical practice among

student nurses in school of nursing Amachara?

 Whatarethesupervisorybasedfactorsaffectingperformanceinclinicalpractice among

nursing students in school of nursing Amachara?

 What are the student based factors affecting performance in clinical practice

amongnursing students in school of nursing Amachara?

 Whatarethewaysofimprovingperformanceinclinicalpracticeamongnursing students in

school of nursing Amachara?

The study is significant to Nursing profession, Health care providers, nursing students, and

the society and as a point of reference.

Nursing Profession: Findings from this study will help them plan strategies on how to

improve the training of these students, thus making the nurses more competent in clinical

setting.

Health care providers: findings from this study will help the health care provider to deal

with those factors affecting clinical practice in order to meet the patient’s needs including

emotional, social, physical, cognitive and spiritual, also facilitate patient’s wellness andavoid

medication errors, there by building more competent working staffs. This knowledge will

enable Nurses coach students on clinical posting better.

Nursing Students: findings from this study will help nursing students to deal with

thevariousfactorsaffectingtheirperformanceduringclinicalpostingandadjustproperly.Itwill

also help to increase their confidence in clinical practice and help them identify factors thatwill

affect their performance during clinical postings and avoid them.

Society:findingsfromthisstudywillhelpimprovethequalityofhealthcareamong individuals in the

society.

As a point of reference: Thestudywillserveasapointofreferencetoupcomingresearchers and

also help to build up the body of knowledge around student nurses in clinical practice.

SCOPEOFTHESTUDY.

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 The study is delimited to factors affecting performance in clinical practice among nursing

students in School of Nursing Amachara Abia state. It is also delimited to nursing students in

school of nursing Amachara Abia state

OPERATIONALDEFINITIONOFTERMS

Clinicalpractice:thisistheactormeansbywhichstudentslearntoapplythetheoretical knowledge

into practical skills in clinical setting.

Performance:Thisistheprocessofcarryingoutanactionoramanneroffunctioningor operating

Nursing: This is the care given to all ages, families, groups and communities sick or well in

all settings

School:Thisisaneducationalinstitutionprovidingprimary,secondaryand tertiaryeducation in a

learning environment.

Nursing Student: It can be refer as a person undergoing a training in a nursing institution to

acquire a certificate in nursing.

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 CHAPTER TWO

LITERATUREREVIEW

This chapter discussed the related literature on the topic, Factors affecting performance in

clinical practice among student nurses

TheTopicwas discussedunderthesub-headings

CONCEPTUALREVIEW

Introduction / Definition of clinical practice

Types of clinical

practice/ExperienceFactorsthataffectsstudent

’sclinicalpractice Introduction/ Definition of

Clinical Practice

Clinicalnursingistheprocessthroughwhichstudentnursesareexposedtoreallifesituations in order

to acquire the skill inherent in nursing profession for effective nursing practice (Rekiku,

2016). It provides the students with the necessaryopportunityto acquire knowledge and skill

that help critical thinking and performance of needed clients/patients care.

According to (Albino, 2016), Clinical practice is the means by which nursing students learnto

apply the theoretical knowledge in to practical skills in clinical setting. Clinical practice plays

an important role in teaching learning process. It provides nursing students the development

and acquisition of skills, self-clinical skills, and the ability to apply the knowledge gained

from the theoretical context to any emergency situation or in generalpublic health care.

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Clinical practice is a term referring to the agreed upon and customary means of delivering

health care by Doctors , Nurses and other health professionals, (Melone, 2018). It is only in

clinical practice that nursing care becomes a reality and the students nurses can observe the

responseofpatientstothecaregiven.Theoverridingpurposeofclinicalpracticeistoprepare nurses to

meet the health care needs of the public, therefore clinical practice must be well aligned. It has

been widely recognized by those engaged in Nurse education that clinical practice is a

significant and essential part of student Nurses education. (Wong & Wong, 2016). Good

clinical practice based on sound, Nursing education is the only option to equip nurses with the

current trend in Nursing practice. The ultimate goal of clinical practice is to prepare the

students to think critically, communicate accurately and perform indicated therapeutic nursing

interventions in patient care situations and exhibit the caring behaviors inherent in nursing

actions. They are also to apply ethical perspectives in clinical decisions making and function

effectively as a team member within organizational structures surrounding the delivery of

patients care. (Sharrif, 2019).

Typesof ClinicalPractice

Clinicalpractice/experiencecan beclassified into different types in orderto produceversatile,

competent professional Nurse.

Ward posting

Communityexperience

Psychiatric experience

Obstetricsandgynecologyexperience

Orthopedic experience

Specialunitexperience
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 WardPosting

This is a form of clinical practice in which students are posted to diverse wards ranging from

male to female wards, surgical wards, orthopedic ward, and gynecology and pediatric wards.

The duration varies from about 2weeks to 2months. It involves students of all levels of

training and occurs at every level. In the late 90’s students practical promotional exams were

conducted in the various wards. The aim of the diverse posting is to facilitate a greater

understanding and application of the various theoretical aspect of the clients care and

management into practice on life patients, also to know what obtains in each ward in form of

thecaseshandled,howpatientsaremanaged andtheoverallcaregiventothem.Duringward posting,

students also get the chance to interact well with students from other institutions far and near.

(Alex, 2022) and establish contacts that could be beneficial to their studies.

CommunityExperience

In community experience, students are posted to nearby rural communities usually under

different health centers. It is an experience that lasts for about 2 months, usually done in the

second year of training and it is usually organized by the school in collaboration with thelocal

government health sector. Experience gotten during the community experience include

treatment of some minor ailments, immunizations, Antenatal care, deliveries (Home

deliveries), circumcision, post-natal, family planning methods, health education, guidanceand

counselling, team collaboration, community assessment, advocacy skills, public health

understanding etc. It prepares the students in the utilization of primary health care

strategiestomanagethehealthcareofindividuals,familiesandcommunitiesinhealthandillness.Mos

t times after the experience the students are given certain seminar topics to present in their

schoolinrelationtothehappeningsinthecommunitiestheywerepostedto.(Alex,2022).In

other cases, post community ward conference are held in the school where students sharetheir

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experiences and gain more knowledge from the contributions of the teaching staff and fellow

students.

PsychiatricExperience

This experience takes place at the school of psychiatry for a duration of two months which is

divided into theoretical sections and practical sections. The experience is usually for students

in their 2ndyear of training. During this experience, students are taught how to apply the

health-illness concept in the assessment and management of mental ill clients by the

utilization of the Nursing process and interpersonal relationship concept in understanding

dynamics of behaviors and providing compassionate and effective care to individuals and

groups, assessing the clients personality structure and characteristics and the patterns of

adjustments. The student Nurses after the clinical practice should be able to recognize

common psychiatric conditions and demonstrate the ability to manage psychiatric

emergenciessuchasde-escalationtechniquesandmanagingacute behavioraldisturbancesfor

careers. This experience prepares the students psychiatric Nursing or other mental health

specialties and society at large.

ObstetricsandGynecologyExperience

This experience aids nursing students gain basic knowledge in child birth, care of the mother

with respect to the diseases in females especiallythose of child bearing age. It is usuallydone

during the first year of training for a duration of 8weeks. This experience is organized and

done at the school of midwifery. The eight weeks comprises of intensive block study and

clinical postinginto obstetricand gynecological wards/units such as prenatal care, laborward,

antenatal clinic, family planning unit, neonatal or nursery unit, maternity theatre,post-partum

care,gynecologicalcare,surgicalprocedures,emergencyandobstetriccare.These

knowledge will help them provide comprehensive care to women throughout their reproductive

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lives (from adolescence through menopause) and equip them with skills in related health care

settings.

OrthopedicExperience

This experience is organized by the school of orthopedic nursing usually for a duration of

about 3weeks divided into two weeks of intensive block study and 1week of practical. The

experience is mostly done at the 3rdyear of training. The students are posted to gain skills in

various assessment, post-operative care: mobility and rehabilitation, orthopedic procedures,

patient education, pain management, assertive devices and emergency orthopedic care.

Wards/units in the orthopedics hospital like the burns unit, trauma unit, the spinal unit, the

septicunitetc.whereskillsonbonemanagementandplasticcasesarederived. It preparesthe nurseto

have adetailed knowledge about the Musculo-skeletal system and theaccompanying disease

conditions. (Alex, 2022). Also managing those clients in acute care settings, rehabilitation

centers, orthopedic clinics, or outpatient facilities.

SpecialUnitExperiences

These are experiences gotten from units other than the general wards that specializes on a

particular condition or function in the clinical area. The postings vary in duration and it is

mostly done in a rotational form in order to cover a lot units within the time assigned for the

experience. The units includes: the main theatre, maxillofacial units, ENT (Ear, Nose and

throat) units, ophthalmology unit, dialysis units, general outpatient department, accident and

emergency, intensive care unit (ICU), cardiac care unit (CCU), Neonates intensive care unit

(NICU),PICU,Operating room, Burn unit, Oncologyunit, rehabilitation unit, psychiatric unit.

This experience prepares the students to have an idea of nursing activities carried out in

variousunitsofthehospitals.(Alex,2022).Eachofthesespecialunitsprovidesunique

learning opportunities for nursing students to develop specialized clinical skills, critical

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thinking abilities and empathy in caring for patients with specific health needs.

FactorsAffectingClinicalNursing Practice

The major determinants of the effectiveness of clinical training are the context in which they

occur. According to Smedley and Penney (2019), clinical training in nursing is performed in

response to the professional, societal and educational demands using available human

intelligence, physical and financial resources as the context of the curriculum. The factors

affecting nursing student’s clinical practice are as follows:

LackofQualifiedandExperiencedClinicians

For efficient and effective clinical training aimed at ensuring quality care, theoretical nursing

taught in the classroom must be repeated and in-congruence with what the students practicein

the clinical areas (Oermann and Gaberson, 2019). To maintain this fact, there must be

competent personnel in the schools and the wards to supervise and handle the clinical aspect

of nursing

Effectively. Thereshould be qualified and experienced clinicians and teacher- lecturers in the

schools and hospitals or other places where the students go for their clinical practice. These

nurses must be conversant with the new innovations in nursing research, education and

practice, so that they may be able to help the students under their care. These humanresources

employed in clinical training of students help the students to enhance the practical learning

process and ensure production of qualitative, critical thinking and benevolent nurses who will

engage in decision making and evidence based nursing care based on research findings.

InadequateEquipmentintheSchoolsandClinicalSettings

Items or equipment used in the schools and clinical areas are regarded as the life wire of any

nursing school and for there to be a meaningful nursing education, (Melone, 2018). There

must be that conscious effort to direct sufficient resources to such areas that will ensure
14
 drawing maximum benefit from the equipment and infrastructure available. For standard

nursing education, lack of equipment sets back student performance and creates a lot of

tension and anxietyon the students because of poor performance. Cannon (2017) emphasized

strongly the unavoidable needs for adequate equipment, noting that, “at all stages of skill

acquisition, good

Demonstration with adequate equipment is important and often a vital part of teaching in

acquiring a skill we learn by imitation”. Accordingly, Tonne (2019) observed that the most

effectivedevice fortheteachingofskillisteacherdemonstrationwithappropriateequipment. For

example a clinician teaching a nursing student how to check a patient’s temperature must

teach using a well-functioning thermometer.

Inadequate Funding: Funding goes along wayto help in clinical training ofnurses. Lack of

fund affects everyother aspect in the training such as adequate staffing, students’ motivation,

provision of equipment etc. Therefore, lack of fund for the provision of the materials

necessary for clinical training will jeopardize the training.

Inadequate Length of Time for Clinical Practice: The time allocated for clinical practice

goes a longwayin promotingpractical learningskills. Thelength of time forclinical practice

helps to determine how well they may learn the skills. Inadequate length of time does nothelp

the students to learn much before leaving the clinical area.

Lack of available Patients or Client to learn with: Nursing profession is a practice dominated

service profession. Therefore, it requires that the student nurses need to do a lot of practice

under guidance to enable them to learn the art of nursing. Lack of patients who will easily

make themselves available does not provide opportunities for real life practice.

Inadequate Supervision: This is as a sequence of lack of enough supervisors and clinicians

who are supposed to guide, teach, supervise and assess the students in their clinical areas.

15
Inadequate supervision leads to lack of students’ assessment and evaluation to elicit

theextentofknowledgeand practice gainedbythestudents. Inadequatesupervisioncanbeinthe

context of working with a clinician who is not interested in helping the student gain an

effective experience which can be due to incompetency.

Limited Procedures for Nurses: Nurses have limited procedures to practice with in the

clinical arena compare to the procedures they learnt in the classroom, for example, giving an

intravenous line medication. This does not give room for them to practice all the procedures

learnt in the classroom thereby leading to poor performance in those aspects of nursing

practice, e.g. some training hospitals do not allow nurses to carry out procedures like

intravenous medications etc.

Lack Of Incentive To Teachers And preceptors: Lack of XA incentives to the teacher,

supervisorsandnursesintheclinicalareasaffectclinicaltrainingofstudentsandposealotof

constraints to clinical training. These incentives include opportunities for attending

workshops, conferences and seminars etc.especially in research and new technological

approaches in nursing which are widely in use today.

According to Waldock (2020) registered nurses (RNs) working with student nurses in the

clinical area have a major influence on student performance as they are more with

thestudentsthantheirothersupervisors.Theyhavetheabilitytopromoteandfacilitatestudent

learning or cripple the students' ability to apply knowledge and skills and accommodate new

learning in clinical practice.

Some of the hospital factors affecting clinical practice have great impact in the knowledge

acquisition of the students and also aids the clinicians to teach the students. Some of this

factors are as follows:

Lack of modern equipment/facilities: it has been observed that most of the training

16
 hospitals don’t have modern equipment to enable students practice what they have learnt in

the theoretical study. The use of modern facilities help build up the competency of the

students. Waldock (2020)

Lack of cooperation among health workers: Discrepancies among doctors and nurses inthe

clinical setting are contributing hospital factors that impairs students clinical performance as

there is no interpersonal relationship with the Doctors causing the students to be hostile, to go

to the doctors for assistant in areas that are not clear to them, this happens because there is no

cooperation between the health workers.Waldock (2020)

Poor Clinician – student relationship: This factor has an important influence on students’

experiences in clinical practice. When there is a good interpersonal relationship between the

clinician and the student nurses it builds more chances for learning as the students feels freeto

ask questions of their choiceto gain clarityon specific areas. When there is no relationship

between them it brings about incompetency of the student nurses as full knowledge is not

gained in clinical experience.Waldock (2020)

Adequate supervision of the students during their clinical practice goes a long way

inbuildingupcompetentnursesinthesociety.Someofthesupervisoryfactorsaffectingclinical

practice are as follows

Lack of interest by clinicians: the interest rate of the clinicians towards the clinical practice

learningof students affects the waytheysupervise the students during clinical practice. Some

things that are meant to be corrected by the clinicians won’t be corrected because of this

factor and this will affect the clinical learning of the students as they are being left to do

whatever they want to do.Waldock (2020)

Incompetency of clinicians: this is a very crucial supervisoryfactor affecting clinical practice

among student nurses. When a clinician is incompetent in his/her field of study it will be

17
 difficult to pass adequate knowledge and supervise the students because of their knowledge

deficit Waldock (2020)

Lack of certain skills in supervision: the way in which the clinician oversees the students

helps to either enhance their learning process or delays it.Waldock (2020)

THEORETICALREVIEW

DREYFUSMODELOFSKILLACQUISITION

Theoryunderlyingfactorsthataffect clinicaltrainingofnursingstudentsin nursingschoolsis the

Dreyfus model of skill acquisition as developed by Benner (2024). This model contains a

systematically planned process for teaching students to acquire the required clinical skills for

nursing practices.v

The Dreyfus model of skill acquisition is a model of how students acquire nursing skills

through formal instruction and practical experiences. It has originally five steps such as novice

stage, advanced beginner, competent stage, proficiency stage and expert stage.

(1) Novice’s stage: This being the first step, orientations and instructions on the subject

matter are given to the students. Rigid adherence to taught rules, plans of actions, procedures

of doing things are advocated by the trainer. The students have no sense of responsibility

beyond following the rules and Procedures exactly. In this stage, good orientation and

practical demonstrations of nursing skills by a professional is advocated.

(2) Advanced beginners: With the teacher’s drilling of instructions, demonstrating and

students practicingprocedures with adequate equipment and adequate supervision ofstudents,

students leave the former stage. Here individual students develop organizing principles to

quickly access the particular rules or procedures that are relevant to the specific task at hand.

18
 Students also have limited situational perception and treat all aspect of work separately with

equal importance. Students’ participation in practicing the things they have been taught help

them to understand the nursing skills involved well.

(3) Competentstage:Withmuchexposureandpractice,trainingbecomesmoreconcrete.

Students now are engaged in active decision making in choosing a course of action, e.g.

coping with crowded activities, accumulation of information, some perception of actions in

relation to goals, deliberate planningexecution ofaction undersupervision and can formulate

and carry out routines.

(4) Proficient stage: With active participation in clinical experiences, students have learnt

some nursing skills. Also with much clinical nursing practice, individual student nurse

develops intuition to guide his/her decisions and develops the ability to formulate nursing

plansaccordingtotheprofession.Candidatenowhasholisticviewofsituations,can

prioritize important aspects of activities, perceives deviations from the normal pattern and

employs maxims for guidance with meanings that adapt to the situation at hand.

(5) Expert stage: Candidates here transcend reliance on rules, guidelines and maxims. They

have intuitive grasp of situations based on deep, tacit understanding. They have vision ofwhat

is possible and use analytical approaches in new situations or in cases of problems.

APPLICATIONOFDREYFUS’SSKILLACQUISITIONMODEL PATRICIA

BENNER NOVICE TO EXPERT MODEL

The Dreyfus skill acquisition model as propounded by Benner (2024) can be utilized to

explain clinical training of students in nursing profession. This training theory views each

student and their stages of performance uniquelyand helps the teachers/ supervisors to attend

19
to theirneeds individuallyand appropriately. It aims at upgrading thestudents from noviceto

expert nurses by identifying the training needs at each stage and drilling the students to

acquire those needed skills before stepping forward to the next stage.

In the model of study, the dependent variables are the stages of skill acquisition which are

novice stage, advanced beginner, competent stage, proficient and expert stage. The

intervening variables are the study variables which include factors of adequate

teachers/supervisors, equipment, techniques/measures used for training and students attitude

towards training. The intervening variables are the factors that may affect clinical training of

nursing students either positivelyor negatively depending on the adequacy of the intervening

variables. The independent variable is the clinical training offered to nursing students which

involves skill acquisition that manifests in the quality of nursing care rendered by students.

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The model shows that adequacy and competency of the intervening variables using the five

stages approach of the model will affect clinical training of nursing students. This is because

at each stage, the students will be drilled properly on the skills to be learnt before moving up

to the next stage. In other words, it is hypothesized that with experienced teachers and

supervisors using appropriate equipment with right training techniques and students being

interested in clinical experiences, students will acquire adequate and appropriate nursingskills

necessary for practice. Also, lack or inappropriateness in any of the intervening

variablesorlack ofproperutilization ofthestages ofthemodel will result to pooracquisition of

the necessary nursing skills thereby leading to poor clinical nursing practice. The model also

showed that acquisition ofnursingskill is acontinuous process that neverends but needs

regular updating in order to remain relevant and proficient in nursing profession.

EMPIRICALREVIEW

According to Wuthiphong and Suthineum (2019), on ‘factors influencing clinical practice

behavior of nursingstudents’ inIgando School of nursingAlimosho local government lagos.

The study was a descriptive research design and focused group discussion was used. Simple

random sampling technique was applied to select study subject of 100 students among 345

students in the school. Data was collected using a group administered questionnaire to gather

information on the factors influencing student nurses clinical practice behaviors. Descriptive

analysis were employed to understand the background information of the sample.The result

indicated that inadequate number of experienced educators/clinical supervisors (35%) in the

teaching hospital were a negatively influencing factor to the clinical learning behavior of

student nurses.

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Another study done by Agu Grace in 2014 on ’’factors that affect clinical training of nursing

students in School of Nursing Afikpo in Ebonyi State and Department of Nursing Sciences,

University of Nigeria, Enugu Campus in Enugu State’’. The research design used was

descriptive cross-sectional survey method. The population of both schools had over 5000

students each and simple random sampling technique was used. A face and content validated

questionnaire with 34 items was used for the collection of data. Data derived from the

questionnaire were analyzed descriptively. Based on the findings, it was recommended that

adequate experienced and qualified nurse educators and clinical instructors should be

employed and maintained by the competent authorities. Majority of their supervisors were

staff nurses in the wards while few were specialist nurses, 73% of the students had schedule

supervision sessions with their supervisors without their nurse teachers. Also, 75% of the

students recorded satisfaction with the successful mentorship experiences they observed inthe

wards which enhanced skill acquisition .Proper supervision of students by experienced

teachers, nurses and clinicians should be advocated.

An exploratory study carried out by Sumari-Ayo (2015) at Rusangu University, Monze

campuson’’theclinical practical experiences ofstudentnursesallocatedto theclinicalarea’’.

Study population included the Eight (8) Clinical teachers involved in the clinical supervision

of students. Purposive sampling method was used to select the study sample and data were

collected using in-depth interviews. Participants were interviewed until data saturation

appeared to have been reached by means of repeating themes. Data was analyzed using

themes. The interviews were tape recorded, taken down in notes and verbatim transcriptions

were made. The study revealed that an effective supervision between the student and the

Clinicians affects clinical practice and indicated that the school skill laboratory and the

hospital wards lacked equipment and other necessary supplies, which do not help students to

practice and concretize what they learnt in the classroom..

22
Anotherstudyconducted byAlbino Kalolo (2019) which was aimed at identifyingthefactors

influencing performance in clinical practice among diploma nursing students in northern

Tanzania, 4 research questions guided the study. This study relied on a Descriptive cross

sectional research design from nursing schools in northern Tanzania in which 208 (125

nursing students and 85 nurse tutors) participants were recruited in the study. Simple random

sampling technique was used and Data was gathered using a questionnaire which collected

information based on hospital factors and clinicians opinions assessed .descriptive analysis

was used and the topic laid emphasis on how availability of facilities and medical equipment

affects clinical learning. Majority of the nursing students (84.4%) agreed that clinical

placement offers student adequate opportunity for clinical learning was reported by 70.1% of

the participants and the barriers include student factors such as lack of self-confidence,

absenteeism. Moremale students (62.1%)significantlyreported unsupportive environment as a

barrier and anxiety was more common in female nursing students (48.9%).

Another study conducted by RekikuFikre, (2016) on assessment of factors affecting clinical

practice competency of undergraduate nursing science students in Hawassa University, south

Ethiopia.Cross-sectional method was used from April to May 2016 by using structured

questionnaire and focus group discussion. Simple random sampling was applied to select 100

study subject among 345 students. Data were entered using Epi Info version 3.5.1 was

exported and analyzed bySPSS version 20. Thestudyrevealedthat Improvingsupervision of

clinical instructors, appropriate selection of clinical site and design appropriate clinical

practice protocol is important to enhance clinical practice competency of nursing students

A descriptive cross-sectional study by Juliana Lawal (2015) on “factors affecting in the

clinical area among students at a school of nursing in jamaica” with stratified random

sampling of 149 Year 2 and Year 3 students enrolled in a three-year baccalaureate nursing

programmewasconducted.Datawerecollectedusinga30-itemself-administered

23
questionnaire and analysed using SPSS version 17 R for Windows R. Results: All selected

participantsinYear3and70.3%ofYear2recruits,participatedinthestudy;meanagewas

23.9 ± 4.52 years (range 19-42 years) and 98.4% were females. The majority of the students,

identified preceptor-ship (89.6%), support from the clinical staff (78.4%), ratio of preceptorto

students (74.8%) and the qualityof pre-clinical conferences (63.8%) as having the greatest

impact on learning. Over 70% of students indicated that the type of interpersonalrelationships

they had with the clinical staff and preceptors affected their learning experiences. Most

(75.8%) of the participants were of the opinion that there were reasons to be anxious in the

clinical area. Conclusions: Positive interpersonal relationships and the useof demonstration

and return demonstration were identified as being influential to learning in the clinical area.

These factors should inform the teaching of nursing students through preceptor-ship in the

clinical area.

A descriptive study done by Williams & West (2021) titled, “Approaches to nursing skills

training in three countries” showed that the central role of the clinical instructors is clinical

training of students, the relative freedom given to nursing students to participate in their own

learning needs 68 helped their self-confidence, interest and it increased learning. Also the

academic qualification and educational methodologies that were required for clinical

instructors helped them in drilling and concertizing nursing skills taught to the nursing

students duringclinical training. It showed that the large number of patients theytook care of

during their clinical experience helped them to acquire nursing skill. In all the studied

countries, the clinical supervisors were large in number in the wards to ensure adequate

control teaching of students.

24
SUMMARYOFTHELITERATUREREVIEW

Conceptual review of nursing education shows that nursing education consist of acquisitionof

a bodyof knowledge which is partlydelivered in a classroom setting and an organized and

supervised clinical training done in different areas where student nurses do their clinical

experiences. While clinical training as part of nursing education consist of acquisition of

knowledge, skills and competences useful for rendering quality nursing care.From the

empirical review it was said that good and experienced clinical teachers and preceptors,

conducive environment and adequate equipment are needed in the schools and clinical areas

to help thestudents integrateknowledgeinto clinical practical skills. Thetheoryon which the

study was based is the Dreyfus model of skill acquisition .The theory captured the valuables

of Nursing, teaching and learning as well as its application to nursing several empirical

studies were compared and contrasted with the present study.

Common findings: Across various studies, it it consistentlyfound that nurses, like learners in

other fields, progress through stages of skill acquisition (Novice, Advanced ,Beginner,

Competent, proficient expert) as they gain experience and practice this progression is often

influenced by the complexity of the tasks they encounter, the quality of mentor-ship and

learning environment.

25
 CHAPTER THREE

RESEARCHMETHODOLOGY

This chapter describes the research design and method that was used in this study, it was

discussed under the following headings: Research design, Area of Study, Target population,

Sample and Sampling technique, Instrument for data collection, Validation of the instrument,

Method of data collection, Method of data analysis, Ethical consideration.

RESEARCHDESIGN

Descriptive design was used for the study. This design was considered adequate because it

has the abilityto describe the existingpractice and reveals areas that need change. It involves a

systematic collection, analysis, interpretation and reporting of important facts about the

existingevent.This design seeks tostudythefactorsaffectingclinicalpracticeamongstudent

nurses in school of nursing Amachara.

AREAOFSTUDY

The area of the study is the School of Nursing Amachara, located inside Amachara specialist

hospital in Umuahia South local Government Area Abia state. It is boarded at the east by

Abia Tower and tower garden, north by okpurudara square, west by Amachara community

hall centre and south by mbaise road. The School comprises of the administrative block,

demonstration room, classrooms, Male and Female hostels, refectory and the common room.

Theclasssectionismadeupofstudentsinthree(3)differentlevels(firstyear,secondyear

26
and third year) and the refresher students. It shares the same compound with Amachara

specialist hospital and chapel of faith renewal. Along umuahia-mbaise;

From the hospitals gate straight down to school of Nursing administrative and classroom

block is directly opposite Gregory university medical student classrooms with the school

extends down to male and female..

TARGETPOPULATION

The study population will comprise of Male and Female Nursing Students in School of

NursingAmachara.Thepopulationsoftheschoolaremadeupofmaleandfemaleasstated

inthetablebelow:

Years Population

2023Aset. 75

2023Bset 75

2022A set 75

2022Bset 75

2021Bset 100

Total 400

Source:(ClassroomRegisterfromSchoolofnursing,Umuahia,Administrativeblock,2022)

27
SAMPLEANDSAMPLINGTECHNIQUE

𝑛=
𝑁

1+N(e)²
Thesamplesizeis determinedusingTaro Yamaneformula.

WhereN is population, n is thesamplesizeand (e) is marginof error=0.05, 1 is (constant)

𝑛= 400
1+
400(0.05)²

𝑛= 400
1+
400(0.0025)

𝑛= 400
1+ 1

𝑛= 400
2

𝑛=200

Approximatedto 200as thesamplesize.

Thesamplingtechnique that was used for thisstudyis a multi stagesamplingtechnique.

In the first stage, cluster sampling technique was used because of the distinct and differences

in the classes. The clusters used are as follows: 2021B, 2022A, 2022B, 2023A, 2023B sets.

In the second stage simple random sampling technique without replacement was used toselect

40 respondents from each of the above clusters.

In the third stage convenient sampling was used to select the appropriated amount of

respondentsfromeachoftheclustersuntiltherequirednumberforeachclusterismetgivena total of
28
the calculated sample to be 200.

29
INSTRUMENTFORDATACOLLECTION

Data was collected using a self-structured closed ended questionnaire entitled “Factors

affecting performance in clinical practice among student nurses (FAPCPSNQ). The

questionnaire comprises of four sections A to E with 21 items. Section A which consist offive

(5) questions seek to determine the personal characteristics of the respondents with respect to

their demographic data, section B has five (5) statements which would elicit responses on

Hospital-based factors affecting clinical practice. Section C has five(5) statements and was

geared towards determining the supervisory factors affecting clinical practice. Section D has

five (5) statement identifying student-based factors affecting performance in clinical practice.

Section E has five (5) items which determined the ways of improving clinical practice. The

instrument was designed on a likert with: Strongly agree (SA=4), Agree (A=3), Disagree

(D=2), Strongly Disagree (SD=1).

VALIDITYOFTHEINSTRUMENT

Thefacevalidityofthequestionnairewas donebytheresearch supervisors, sheexamined the

specific section in the items of the instrument to justify if the contents of the questionnaire is

within the study objective. She made suggestions and modifications where necessary so as to

improve the quality of the instrument and the corrections were affected.

RELIABILITYOFTHE INSTRUMENT

Theinternalconsistencyofthequestionnairewas resolvedusing20%ofthetargetpopulation

thatweresent toSchoolofNursingAmacharaUmuahia,AbiaState.Researchquestionswere used

and the result was analyzed to reveal that the internal consistency was accurate.

30
METHODOFDATACOLLECTION

The researcher with the help of research assistance who was given an orientation on the

questions and how to answer them through direct deliverymethod distributed 200 copies of a

self-structured questionnaire to the respondents in their various class rooms in School of

Nursing Amachara. This gave researcher the opportunity to explain any word that might not

be understood bythe respondents.Thereafter respondents were addressed on how to complete

the questionnaire item. After each exercise, 180 copies of the questionnaires was realized

from them. A total number of 180 questionnaires were returned.

METHODOFDATAANALYSIS

After collection of the questionnaires. Descriptive statistical method was used in analyzing

the data collected and the data was represented in tables only

ETHICAL CONSIDERATION

The respondents were adequately informed about the study and they voluntarily consented to

participate in the study. Personal information was not needed for the confidentiality and

anonymity of the study.

31
SUMMARY

This study assessed the factors affecting performance in clinical practice among nursing

students in school of nursing Amachara. The study was limited to only students in school of

nursing Amachara.

The objectives were to assess the hospital and supervisory factors affecting performance in

clinical practice together with the ways of improving performance in clinical practice.

Research questions were formulated from the objectives and were in accordance with the

purpose of the study. Literature were reviewed based on the research questions including the

theoretical review using the Dreyfus skill acquisition Model Theory.

A sample of 200 students were used and the instrument for data collection was a structured

close-endedquestionnairewhich was analyzedusingtables.Thefindingsofthestudyshowed that

majorityof the students accepted Lack of interest byclinicians in students practice as the

supervisoryfactoraffectingclinicalpracticeand Lack ofqualifiedandexperiencedClinicians as

the hospital factor affecting clinical practice. Based on the findings the researcher made

recommendations, suggestions for further studies in relation to the studyand the implications

of the study to nursing.

32
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