The attitudes of student nurses toward clinical work

Clinical work in nursing education is an important component of the nursing curriculum aimed at actively engaging student nurses with the necessary skills needed for the nursing profession. The attitude of nursing students toward clinical work is becoming a topic of interest for nursing researchers. The objectives of the study were to determine the perspective of practicing nurses on students’ attitude toward clinical work. Structured and semi-structured questionnaires were administered to determine the attitude of nursing students towards clinical work from the perspective of 100 practicing nurses from Agogo Presbyterian Hospital. The results indicated that 63% of the respondents said nursing students reported late to work, 60% reported that students were absent from clinical work without seeking permission, and 64% reported they used mobile phones during clinical working hours. In addition, 41% of the respondents stated that the nursing students did not show commitment to clinical work. Also, the attitude portrayed by students had an influence on the way the medical and nursing staffs related to them. It is recommended that students should receive in-service training before going to the clinical area, so that they are aware of what is expected of them during clinical placement. Also, systems should be put in place to ensure that nursing students do not use mobile phones in the clinical environment. There should be preceptors in the ward to monitor and mentor student nurses. The nursing schools should periodically follow-up with practicing nurses, to assess the behaviors and attitudes of the nursing students.


INTRODUCTION
According to Potera (2009), "the U.S. will require 1.2 million new registered nurses by 2014 to meet the nursing needs of the country, 500,000 to replace those leaving the practice and an additional 700,000 new registered nurses to meet growing demands for nursing services."Talley (2006) also projected a shortfall in the number of nurses that Ghana as well as other African countries need.According to Ghana Health Service (2007), the nurse to patient ratio for Ghana is 15,724 nurses available to provide care to a population of 22,808,193 in 2007.With recent advances in technology, people now live longer than before, therefore, increasing the aging population who require medical and nursing care.
More students are graduating from nursing programs, yet the nurses may not be sufficient enough to provide care to the aging population (Potera, 2009).Because of the nursing shortage, nursing education is being challenged with actively engaging a safe qualified workforce while preventing or reducing student attrition (Hathorn, 2006).As part of the academic preparation for the nursing profession, students are required to take part in clinical rotation work in various local health care settings, under the supervision of staff at the facilities and faculty of the department of nursing.The purposes of clinical work is for the students to learn how to perform physical and psychosocial assessments, interact with clients, families and staff, administer medications and perform other needed skills, develop critical thinking skills, and develop plans of nursing care (Presbyterian University College, 2007).
Clinical work in nursing education is an important component of the nursing curriculum aimed at actively engaging student nurses with the necessary skills needed for the nursing profession.Also, nursing is essentially a practice discipline, informed by a theoretical base.It is crucial that students have a rigorous preparation in both theoretical and practical elements during their programme.Thus, clinical work provides the necessary practical skills that the students need (Dunn and Hansford, 1997), and it is also an environment where students among others socialize, into the profession.A clinical environment includes everything that surrounds the nursing work, including the clinical settings, the staff and the patients (Papp et al., 2003;Hathorn, 2006).The clinical learning environment has been shown to have a direct impact on nursing student's perception of their profession and facilitates professional grounding (McKenna et al., 2010).However, 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.Little research has been done on the perception of practicing nurses on the attitude and behaviors of nursing students toward clinical placement, which was the focus of the study.The objectives of the study therefore, were to determine the perspective of practicing nurses on student's attitudes toward clinical work.Also, to determine the factors influencing the attitude of nursing students towards clinical work.

METHODOLOGY Study design and area
Considering the goal of the study, the mode of inquiry used was the case study approach, which is perceived in this research to be most the useful as compared to other strategies.As described by Yin (2003), a case study approach investigates a contemporary phenomenon within its real context, especially when the boundaries between phenomenon and context are not clearly defined.Since students' attitude can be deduced from how they behave at clinical placement, this implies that there is no definitive line between students' attitude and their behavior at clinical work.Hence, a case study approach allowed both variables to be studied together.A single case study approach was used in this study, because conclusions from single-cases are considered to be appropriate if the research is carried out well.
This research was conducted in Agogo Presbyterian Hospital which was established on 21st March, 1931 , 2007).

Study population, instrument, and procedure
Purposive sampling was adopted for the study where the researcher selects respondents based on personal judgment about which one will be most representative or informative (Polit and Beck, 2004) and was willing to take part in the study.Since it was the practicing nurses who worked with the student nurses, the practicing nurses were therefore the focus of the study.Out of the 138 nurses of the hospital, 100 of them took part in the study.The hundred nurses have previously worked with nursing students during their clinical rotation, while the remaining 38 nurses have never interacted with student nurses.Thus, 100% of the population (those who worked with the students) took part in the study.
Structured and semi-structured questionnaires was used to gather data about reporting time for clinical work, absenteeism, use of mobile phones while at work, participation in general ward rounds, showing respect to patients, commitment to work, attitude of nursing students toward other medical staff, anxiety, how the student's attitude affected the way nurses related to them, and the influence of the program of study on the attitude displayed, from the practicing nurses.
Since the nurses could read and write, the questionnaires were given to the nurses to fill at their own conveniences and later submitted to the researcher.It took the respondents an average of one month to respond to the questionnaires.The data was analyzed using Statistical Package for Social Sciences (SPSS) software.
The research received a Human Subjects Protections Committee Review from the hospital administration, and was approved prior to the conduct of the research.Also, consent was obtained from the respondents/nurses before administration of the questionnaires.

Demography of the respondents
The respondents in the study had various certificates in nursing as shown in Table 1: 3% had certificate in nursing, 68% had diploma and 29% had bachelors of science degree in nursing.Departmentally, 25% worked in the surgical, 16% in the accident and emergency, 10% in the pediatric, 4% in the intensive care unit, 14% in the internal medicine department, 7% in the ophthalmic, 14% from maternal health department and 5% from the outpatient.Five of the respondents did not indicate their departments.Majority of the respondents, 61%, reported working in the institution between 1 to 5 years, 20% between 6 to 10 years, 7% worked for less than one year, and the remaining 12% reported working for more than 10 years.

Reporting time and absenteeism
When the respondents were asked the time student nurses' report for duty, 19% reported that the student nurses reported 30 minutes before the start of shift, 26% responded that students reported at the exact start of the shift, 41% maintained that students reported 30 minutes late, and 14% responded that students reported more than one hour late.The findings indicate that majority, 55%, of the nursing students reported late to clinical work.If students cultivate the habit of reporting late to clinical work, they are also likely to report late to work when they start practicing.According to the study by Cohen and Galan (2007), it predicted absenteeism and turnover intentions by prior absenteeism have direct relationship with later absenteeism.Also, when nursing students report late to clinical work, it is likely that they will miss out on the opportunity to observe some of the procedures carried out on the patients and will not have the opportunity to observe or perform those procedures.With reference to absenteeism, 34% of the respondents stated that nursing students were absent with permission during clinical work, while 66% of the respondents stated that the students were absent from clinical work without seeking permission.In the clinical setting, learning depends on the patient's condition and the ability of the student to put into practice what has been taught.When this opportunity is missed as a result of absenteeism, it is likely that one cannot achieve this notion.The findings are in line with a study conducted by Baker and Jansen (2000) that maintains students who are absent have lower achievement and are penalized on test scores.

The use of mobile phone and participation of general ward rounds
When asked if nursing students use mobile phones while on duty, 84% of the respondents reported in affirmative, while 16% responded in negative.The use of mobile phone has a lot of adverse implications to both the user and the patient on the ward.The patients will not receive the needed attention especially when the student nurse is on the phone for a very long time and also is a way of transferring their bacteria from the workplace to home on the part of the student nurse (Shahaby et al., 2012).
Eighty-eight percent of the respondents confirmed that nursing students partook in general ward rounds and 12% said that they did not.However, when asked whether the nursing students asked questions during the general ward, 73% responded 'no' and the remaining 27% responded 'yes'.Thus, although nursing students took part in general ward rounds, they did not ask questions.However, the importance of asking questions during the general ward round cannot be overemphasized.For example, it is during general ward rounds that nursing students interact with the medical staff and this interaction is most effective when students ask questions.Learner readiness forms part of the factors that promote good attitude towards clinical work.This facilitates the learner to make sense of their observations and reflect on practice situations (Henderson et al., 2006).The fact that the students failed to ask questions could mean they were not ready to learn.Also, general ward rounds is seen as a platform for learning more indepth knowledge from the medical team and it is through asking questions where learning is optimized.Nursing students who do not partake in rounds as well as those who do not ask questions during rounds could miss important learning opportunities.

Showing respect to patients
When the respondents were asked whether nursing students showed respect to the patients, 95% responded 'yes' and the remaining 5% responded 'no'.Although majority of the students respected the patients, it is important that all should show respect toward patients, because one skill of a good nurse is the ability to show respect to patients, and it is mandatory.For example, Nursing and Midwifery Council of London ( 2002) confirms this by stating in the Code of Professional Conduct that, "As a nurse or midwife, you are personally accountable for your practice".In caring for patients and clients as a student nurse, it is mandatory to respect them as individuals.

Nursing student's commitment to work
When respondents were asked whether nursing students were committed to their clinical work, 41% reported that students were not committed, while the majority, 59%, said the students were committed.Nurses who are committed to their patients are likely to provide the best of quality of care.The findings are in line with a study done by Salancik (1977) which defined commitment as a state of being in which an individual becomes bound by their actions and it is these actions that sustain their activities and involvement.

Attitude of nursing students towards other medical staff in ensuring team work
Regarding readiness of nursing students to interact with medical staff, 64% said 'yes', 32% said 'no' and the remaining 4% did not answer the question.Majority of the respondents maintained that nursing students were ready to interact with the medical staff.Unreadiness of nursing students to work with others poses a serious threat to the nursing profession as nurses do not work in isolation but as a team to enhance patients' wellbeing (Duchscher, 2001).

Academic level of nursing student's class influencing attitude towards clinical work
Many of the respondents (85%) perceived that the academic level of the student nurses contributed to their attitude toward clinical work, while the remaining 15% responded that the academic level has no influence on the clinical work.When further asked what the pattern was, 70% said it deteriorated as the student moved from a lower level to a higher level of the academic ladder, 10% said it improved as the students moved from a lower level to a higher level, and the remaining 20% did not answer the question.This observation could be attributed to the fact as freshman/fresh woman, students are excited over the idea of going to the clinical setting where they see patients and have the opportunity to work with the medical staff, but the excitement and the enthusiasm decreases as they move to higher academic level.This confirms the findings made by Brillhart et al. (1990) that a nursing student's attitude deteriorated over their course of study.Consequently, first year students have good attitude towards care as compared to their final year counterparts.Final year students are faced with the challenges of sitting for the licensing examinations and also working sooner or later, hence they do not take clinical work very serious.

Anxiety contributing to poor attitude of nursing students
On the issue of anxiety as a contributing factor to the poor attitude of nursing students towards their clinical work, 20% of the respondents said 'no' and the remaining 80% of the respondents said 'yes'.Anxiety is a major obstacle to learning in the clinical setting (Becker and Neuwirth, 2002) that may result in students being unable  to perform procedures on patients (Schmeiser and Yehle, 2001) and impairs cognition (Meisenhelder, 1987).While a moderate level of anxiety is needed for learning to occur, a high level of anxiety results in decreased learning (Audet, 1995).Greenberg (2004) added that anxiety contributes to a student's performance in the clinical setting, because it activates the flight-or-fight response resulting in a positive or negative outcome.Students perform best with a moderate level of anxiety; however, when anxiety levels are too high or too low, performance is decreased (Yerkes and Dodson, 1908).Therefore, it is essential that student nurses anxiety levels are reduced so that the clinical learning environment can be optimized.

Program of study as a contributing factor to poor attitude
The program of study (whether degree or diploma) was suspected to be a major factor that could contribute to the attitude of student nurses toward their clinical work.However, 56% of the respondents reported that the program of study had no effect on the student's attitude toward clinical work, while 38% felt that it was a contributing factor.The remaining 6% did not respond to the question at all.To have a better understanding to this concept, those who maintained that it was a contributing factor were asked reason(s) for their response and they indicated that degree nurses tend to have this notion that they are better than the diploma nurses.Specifically, one of the respondents stated "the degree nursing students are very nonchalant and they have this perception when they come to the ward that they know it all".Another, respondent claimed "the young nurses of today are very materialistic and only think about the money they will receive after school, and that is why they portray this bad attitude during clinical placement."It should, however, be noted that since nursing is a hand on profession, theory without practice does not make one a good nurse.The findings make it clear that the program of study, whether diploma or degree, does not contribute to the attitude of the nursing student towards clinical work.

Response of the nurses to the attitude of nursing students
The attitude of student nurses affects how nurses interact with them.About 83% of the respondents stated that the poor attitude of the student nurses influenced the way practicing nurses interacted with them, while 7% reported that it had no influence.The findings imply that if the student's attitude is bad, then the nurse in the ward will not interact in a positive manner with the student nurse and vice versa.In this way, the clinical environment will not achieve its purpose and learning will not take place.If nursing students are not portraying a positive attitude, it means learning will not take place which will in the long run affect the care that will be given to patients since nurse's production will not be efficient.

Conclusion
Results indicated that majority of the nursing students reported late to work.In addition, majority of the students were absent from their clinical work without permission.Also, respondents reported that students use mobile phones during clinical working hours.However, majority of the students were committed to clinical work.The attitudes of the students largely determine how the practicing nurses relate to them.Nursing students who are absent during clinical working hours or report late to clinical work are likely to miss out on important learning opportunities.Even though, the nursing students attended general rounds, they did not embark on the opportunity to interact and learn from the medical staff by asking questions.Some of the students were nervous during clinical, but anxiety in the clinical negatively impedes students' learning.Some of the students did not show respect for the patients.
Nursing students should receive orientation about clinical work and what is expected before being placed on the ward.Also, nursing students should be informed that using mobile phones during clinical placement is prohibited.Nursing students should have a clinical instructor from the educational institution at all times to monitor their behavior and attitude whilst on clinical rotation.Furthermore, the nurses should be trained on how to mentor students in order to reduce anxiety in nursing students.Lastly, nurses should periodically receive in service training concerning how to relate with nursing students.Lastly, registered nurses also need to be given guidance on how to effectively and positively mentor nursing students Conclusively, clinical work is an important integral part of nursing education.The clinical practice is equally important as the theory learned.In addition, the clinical environment provides the necessary practical skills that the students need to help them in their future endeavors as competent and efficient nurses.Therefore, educational institutions, practicing nurses, and student nurses must ensure that clinical learning is optimized.

LIMITATIONS
A multiple case study approach should have been used, because conclusions from multiple-cases are considered to be more compelling and robust (Herriott and Firestone, 1983).The views of the students should have been assessed as well for the purpose of triangulation.There is a need for a follow up research to assess the views of student nurses toward clinical placement.
as the first missionary hospital in Ghana.It is the second largest hospital in the Ashanti Region (after Komfo Anokye Teaching Hospital), but also a leading hospital in Ghana for ophthalmic surgery.It is situated at Agogo, in the Asante Akyem North district of the Ashanti region of Ghana and

Table 1 .
Educational background of the respondents.