INTRODUCTION:

Students' learning can be influenced by effective educator–student relationships. Protective characteristics, including caring connections, high standards, and opportunities to participate and contribute, help pupils enhance their academic achievement and skills¹^,².

Children may overcome their inadequacies and environmental difficulties with the support of compassionate teachers who care for their students and serve as confidants, mentors, and role models³^,⁴. Educators can thus positively impact students' academic achievement and behavior and their resilience and long-term success⁵^,⁶.

Interpersonal interaction plays a crucial role in enhancing the quality of learning in clinical settings. In these settings, students learn not only the theoretical aspects of their field but also develop practical skills through hands-on experiences. Interpersonal interaction can facilitate this learning process by providing opportunities for students to engage with patients, colleagues, and instructors. Firstly, interacting with patients can enhance students' clinical skills by providing them with practical experiences that are not available in a classroom setting. Students can learn how to communicate with patients, conduct assessments, and develop treatment plans while also developing empathy and professionalism. Secondly, interpersonal interactions with colleagues and instructors can enhance students' learning by facilitating communication and collaboration. Students can share experiences and knowledge, ask questions, and receive feedback from their peers and instructors, which can help them improve their clinical skills and understanding of the field. Interpersonal interaction provides students with practical experiences, facilitates communication and collaboration, and helps develop their professional skills. Therefore, clinical settings should prioritize opportunities for interpersonal interaction to enhance the learning experiences of their students.

Three factors appear necessary in the educator–student connection: the teaching-learning environment, information sharing, and mentor–peer association³^,⁷. In addition, when Beutel⁸ looked into educators' perceptions of their interactions with students, he discovered five broad categories: delivering information, instructing, facilitating, direct involvement, and mentoring. The educator–student connection is critical in promoting positive and supportive relationships between educators and students⁹. Educators appear to have a critical role in creating an environment that protects pupils from hardship while encouraging the psychological well-being and healthy growth they require to learn¹⁰^,¹¹. Educators who develop caring relationships with students and establish a happy learning environment significantly impact students' learning outcomes¹²^,¹³.

The undergraduate nursing students should spend 3168 hours in clinical placements, while classroom and skill lab hours combined make up 2664 hours, mentioned in BNMC curriculum. Nabolsi et al.¹⁴ mentioned that students usually spent 70% of their training courses on clinical assignments in Jordan. Nursing students usually start the clinical post from 1^st year in Bangladesh and the clinical placement hours gradually increase over the four years.

The process of communicating one person's ideas, emotions, and feelings to another is known as interpersonal communication¹⁵.Treatment communication, on the other hand, was not separated from clinical and interpersonal communication skills¹⁶. Nursing requires regular communication between the nurse, the patient, the patient's family, coworkers, managers, and others (clinical communication)¹⁷. Good communication is crucial in developing trust between nurses, patients, and their families, which is the bedrock of good healthcare⁵^,¹⁷. On the other hand, a communication breakdown has a detrimental impact on patient care, generates stress, and may lead to additional issues. Poor communication, for example, can lead to misunderstandings, dissatisfaction, medical conflicts, errors, and poor patient outcomes, which, in the worst-case situation, could result in death¹⁸. According to recent studies, most medical conflicts are not caused by medical technology or healthcare providers¹⁹. On the other hand, they are frequently caused by misunderstandings between patients and doctors and certain patients' biases against the nursing profession²⁰.

It is commonly acknowledged that a nurse's ability to communicate is a critical component of excellent clinical practice²¹. However, in some countries, communication skills’ training has been neglected. Because of a shortage of adequate education and training programs as well as a scarcity of resources, nurses in these nations have a significant need for communication skills training²². Nursing students are typically solely taught communication methods through lecture-based instruction, with no hands-on experience. Despite their lack of communication training before the practical session, most nursing students will graduate, become full-time nurses, and work in clinical settings¹⁷. As a result, the practical clinical session becomes nursing students' final opportunity to practice communication skills before graduating from school²³. However, clinical learning is unpredictable, and not every student will have the same chances or experiences in learning how to report or transmit the information acquired, when to interact with doctors, when to communicate with patients, etc.,²⁴.

It is necessary to know about interpersonal interaction and hindrances in clinical learning as it can significantly affect the quality of education and learning outcomes. Understanding the level of interaction between students and nurse teachers and identifying related challenges can help improve the clinical learning environment and promote positive experiences for students²⁵. Knowing about interpersonal hindrances such as communication gaps, conflicts, and misbehavior can help institutions and instructors address these issues and create a supportive and effective learning environment. By addressing these challenges, students can have a better learning experience, improve their clinical skills, and become better healthcare professionals in the future.

Interpersonal interaction research can enhance the quality of a future nurse by providing insights into effective communication and collaboration in clinical settings. By understanding the importance of interpersonal interaction and identifying related challenges, future nurses can develop better communication skills, empathy, and professionalism. They can learn to work effectively with patients, colleagues, and instructors and navigate complex situations that may arise in clinical settings. Moreover, by addressing the challenges associated with interpersonal interaction, institutions and instructors can create a supportive and effective learning environment that can help future nurses acquire the necessary knowledge and skills to provide high-quality care.

Many studies have been shown on nursing education²⁶, clinical environment²⁷, challenges in the clinical setting²⁸, and student-educator relationships in different countries²⁹. But, the status of interpersonal communication among nursing students, senior nurses, and teachers in Bangladesh has not been focused. So, it is necessary to understand the level of interpersonal communication among related stakeholders and challenges in the clinical environment for ensuring quality education and skills. Therefore, this study addresses a research question: What are the levels of the interpersonal interaction between students and nurse teachers during clinical learning and challenges? So, this study aims to assess the level of interaction between students and nurse teachers during clinical learning and identify related challenges.

MATERIALS AND METHODS:

Study design:

The research design was qualitative, exploratory, and phenomenological. Qualitative research is regarded as a good strategy for developing insight³⁰ and interpretation in nursing education³¹ because it promotes trust, transparency, reliability, and adaptability.

Place of study and sampling:

The research was carried out at Bangabandhu Sheikh Mujib Medical University's Department of Graduate Nursing in Bangladesh (BSMMU). The population of this study was undergraduate nursing students (third and fourth-year Bachelor nursing students). Respondents had to be in their third or fourth year of bachelor's degree in nursing and willingly accept to be interviewed. The sample was chosen using a non-probability purposive sampling technique. Data was gathered until fresh information became available.

Data collection:

Data collection techniques included in-depth interviews, Focus Group Discussions (FGD), and observation. Guidelines for Semi-structured In-depth Interviews (IDIs), guidelines for Semi-structured FGD, and checklists for Observation were all followed. The information was gathered using a combination of approaches, including 14 in-depth interviews, 4 focus group discussions, and clinical observations of third- and fourth-year bachelor of nursing students. Each FGD included between 10 and 12 respondents. In order to get more detailed information, data were gathered using a mixed methodology that included FGDs, IDIs, and observations of the students during their clinical assignments. All IDIs and FGDs were first conducted, and audio recordings and notes were made. Following the conclusion of all the audio recording sessions, they were transcribed. The research was carried out between 18 July 2019 and 25 March 2020.

Ethical issues:

The Institutional Review Board (IRB) of Bangabandhu Sheikh Mujib Medical University has authorized the Research Project to initiate the study. Prior to data collection, informed consent was obtained from participants after explaining the study's objective and providing assurances that their information would be kept anonymous and confidential. Participants also provided prior consent for voice recording. Additionally, the Dean of the Nursing Faculty at the same university approved the data collection. The data will be used for the study without disclosing the identities of the participants.

Data analysis:

The data were analyzed using qualitative content analysis to understand better the students' perceptions of their clinical learning experiences. Debriefing meetings with the observer were held immediately after each IDI and FGD to take debriefing notes. Comments about the IDIs and FGDs processes, nonverbal communication, gestures, and participant behavior are included in the debriefing notes³². Data were coded, categorized, and eventually sorted under the headings according to objectives after listening to the tape and transcribing its content³³.

RESULTS AND DISCUSSION:

The following findings were taken from the transcribed data after the in-depth interviews, focus groups, and clinical observations used to gather the data were finished, and they were arranged under the headings in accordance with the study's goals.

Interaction between teachers and student nurses:

Providing objectives about wards and labs:

In FGDs, 5 respondents, and in-depth interviews, 5 interviewees noted that the nurse teachers gave them objectives regarding different wards and activities.

“At first our teachers taught us in the skill labs and when we went to the clinical practices, she/he then taught us there too” phrased an interviewee. In in-depth interviews, 7 out of 14 interviewees agreed with the statement above. 10 out of 14 interviewees and 5 out of 24 respondents stated that when they had their first day of duty, the teachers went with them and introduced the student nurses to the ward in-charge, senior nurses, and other doctors. Again, the other five members of FGDs noted that the teacher requested other senior nurses to assist the student nurses.

Teaching during clinical practice:

“During our clinical practice, the teachers paid regular visits. When he/she went to visit, they taught us by first hand. We learned a lot of things from them during his/her round” articulated by an interviewee. 12 out of 14 interviewees noted that the student nurses learned many things from the teacher during the clinical practices. 4 respondents of FGDs supported these findings.

The clinical observer observed the same things. She observed that the students were more interested when their teacher came. They asked questions, and she answered them and made them understand. When the teacher went away, she asked how they feel when their teachers visit them. They said, “we learned a lot when our teachers visited us during our clinical practice.”

Asking questions and note takings:

During interviews, the teachers asked questions in front of a patient if he/she found any similarities what he /she taught in the classrooms. The 7 interviewees mentioned this.

“When teachers visited different wards, they encouraged us to take notes what we could not understand or what was new to us. They said, keep notes and ask us when we will be available.” Said by a participant of a FGD. During FGDs, 4 respondents mentioned that teachers encouraged the nursing students to take notes about what they do not know.

Seven out of 14 interviewees remarked that the teachers would discuss the difficulties they faced during their clinical practice and made them understand.

Taking feedback from patients:

When the teacher arrived, the observer noticed that she went to every bed and asked how their students served them. During in-depth interviews, 10 out of 14 interviewees and in FGDs, 5 out of 24 respondents noted that the teacher would take feedback from the patients about how much services their student nurses could provide during their clinical practice. Another 5 interviewees mentioned that the teacher asked them to evaluate their clinical practices. 4 out of 24 respondents said their teacher would teach about the different diseases by showing them practical patients. They told them about different symptoms in front of the patients, and thus students learned very fast. Again, during in-depth interviews 5 out of 14 interviewees mentioned that they were taught and gave them a lot of new information about new diseases.

Providing home-work and checking:

2 interviewees noted that the teacher would give them homework about different diseases and later he/she would check it.

“During clinical practice, the teachers would carefully listen to the patients. Then he/she would tell what can be done for this issue and in which his/her condition will be better.” said an interviewee. 5 interviewees said that their teacher would give advice this way.

5 interviewees mentioned that their teacher introduced and taught them how to use newly invented instruments. “Generally, we documented what we did in the wards. Then our teacher checked our daily activities and gave his/her feedback regarding my works,” said a participant. During FGDs 10 out of 24 agreed that their teachers regularly checked their daily documented activities.

Feeling comfortable with teachers:

During interviews, 3 interviewees mentioned that teachers were very co-operative and friendly. They also added that they feel comfortable with their teachers. “Our teachers called us by our names and we felt important and joy that he/she knows me personally. It increases our self-esteem too,” commented an interviewee.

An interviewee said, “There are some special wards and these wards have some special works. Before going clinical practices, our teacher taught us about these wards, symptoms, treatment methods and other works.” 4 interviewees mentioned that before going to some special wards their teacher gave them proper knowledge about it.

Appreciating in the hospital setting and, in the classrooms:

During the FGDs and interviews, the nurse teacher praised their students and senior nurses in front of the class. A respondent mentioned, “When our teacher praised us in front of our senior nurses we felt good and encouraged. Our attempts for providing services would increase by their recognition of our work.”

During interviews, 5 interviewees and 4 participants in FGDs noted that their teacher regularly checked their dress code and carefully noticed whether they joined clinical practice on time or late.

Learning from doctors:

During FGDs, 5 and in-depth interviews, 7 mentioned that doctors were very co-operative with them. When they asked them something, the doctors answered them in detail so that they could understand and learn. Other 4 respondents said, “When the doctors went on round (routine visit) they taught every student from first to last in details and with care.” During interview an interviewee said, “The doctors taught in the same way as they taught their medical intern students.” 3 interviewees mentioned that they got a lot of help from foreign doctors.

Interaction among nurses:

Senior nurses as clinical instructor:

During FGDs, 20 out of 24 respondents stated that their senior nurses learned what they learned during clinical practice. The in-depth interviews endorsed it. 13 out of 14 interviewees agreed that senior nurses taught them from very simple to complex things. One interviewee pronounced as, “During our clinical practice, most of the time we have to depend on senior nurses for learning.”

The clinical observer also noticed that senior nurses helped the student nurses communicate, relax the patients, administer the injection properly, etc.

Senior nurses as confidence booster:

“Our senior apu and viyara (senior nurses) keeps us along with them during their work. Then they show us how to do this, that, that way…if you do this that way patient will feel less pain…more comfortable. All these increased our confidence level, and we could perform better” uttered by an interviewee. 9 out of 14 interviewees reported that their seniors helped them in such way they would learn something and increase their confidence level. 5 respondents out of 24 said in the same line. Moreover, when the research assistant conducted her clinical observations, she also found that nursing students worked very confidently with the senior nurses.

Senior nurses as information provider:

During interviews, 2 out of 14 interviewees reported that the senior nurses taught the nursing student what they could not learn during their own clinical practice time. Another 3-interviewees said that the senior nurses did not answer their questions in front of the patient or patient party if they asked any questions. But she/he made them understand later.

Senior nurses create opportunities for nursing students:

During FGDs, 7 out of 24 respondents reported that sometimes patient or their families did not allow nursing students to serve them. Then senior nurses convinced the patient or patient party so that nursing student may work smoothly. One respondent said, “senior nurses create an environment, convince the patient’s families and then we work with the patient.”

Hindrances for effective clinical learning:

Communication gaps:

From the interviews, it has been obtained that 3 out 14 interviewees face difficulties with English language. One interviewee mentioned, “I studied in Bangla version up to 12th grade. But I had to study in English, which created a problem for me during the first six months of the nursing course.”

7 out of 24 respondents in FGDs expressed that communication gaps among doctor-nurse, nurse-patient, and patient’s family create a problem for better patient services. A respondent uttered, “Doctors never talk about patients with us.”

On the other hand, among the 24 participants of FGDs, 6 agreed that there is a communication gap among the nurses and the patient or patient’s family. They also found out two major reasons for those communication gaps. The first one is by a respondent who said, “When a doctor finishes his/her prescription then I must describe and give direction to patients about what to do or what not or time for medications. But everything is done by ward boys and then I have nothing to do with the patient. Thus, create a gap.”

Respondent expresses the second one: "We can’t communicate or build up a relationship with patients because senior nurses do that job more than us.”

Conflict between Diploma and BSc nursing course:

When nursing students go for their clinical practice and try to build rapport with other senior nurses they have to overcome the conflict between those who completed BSc nursing and the diploma nursing course. During an interview, an interviewee said, “When we try to build up a relationship with them, firstly we have to overcome the conflict between BSc and Diploma nursing courses.” Another respondent in a FGD stated, "Those who completed Diploma nursing courses said, we have learned those in our first semester but you did not even know how to insert the cannula in third year.”

Absence of clinical instructor:

During FGD, 6 out of 24 participants noted that there was a clinical instructor in the first year but now they have none. 4 interviewees have also confirmed it out of 14, who mentioned that their clinical practice is being hampered in the absence of a clinical instructor.

Moreover, during an interview, an interviewee said,

“The guide-teacher has a lot of work inwards, so he is not always available to us.”

During FGDs, a respondent noted that doctors did not stay in the hospital in the evening shifts. They also added that the doctors generally paid a visit and then left the wards. The clinical observer found the same thing. She did not find a doctor when their (Doctor) assistance was badly needed at the ward at 4.45pm.

Noncompliance between doctors-nurses-patients:

From the 14 interviews, it has been obtained that doctor did not cooperate with the intern doctors. 5 out of 14 interviewees agreed on it. Similar findings have been drawn from the FGDs. 5 respondents noted that doctors did not help them properly. A respondent said, “Doctor asked me what we male nurse would do knowing about gyne department”. Another respondent added that, “If we asked about something, they behaved with us in such a way that we need not know about them.” This kind of behavior affects us negatively.

Another 4 interviewees noted that when professors or senior doctors go on the routine visit (round), they only teach the intern doctors and do not care about student nurses. The two respondents also confirmed it from FGD. One interviewee said, “When professors went for a routine visit (round), they only taught and talked with intern doctors. I stood behind of them. Even I couldn’t hear properly what they were talking about.”

Misbehavior with student nurses and feeling discouraged:

“The patient’s condition was critical, so I went and called the doctor. He saw the patient and shouted at me. Angrily he asked me why did I call him,” said an interviewee. During interviews 6 interviewees out of 14 reported that doctors shouted at nursing students. Again, during FGDs, 4 out of 24 stated that patients or patient families misbehaved with them. The finding was also validated through the findings of 9 interviewees. “Nowadays, ward boys shout at senior staff nurses. The ward boys make nurses silent. They run the wards. Even they sign on behalf of the senior nurses without their permission,” said by a participant in FGD. During the FGDs, 7 out of 24 respondents noted that ward boys or M.L.S.S or mistress misbehaved with them.

Less time for clinical practice:

During FGDs, 4 out of 24 and in in-depth interviews, 6 out of 14 interviewees stated that they got very short time for clinical practice. A participant said, “We were six members in a group. We observed the instruments and learnt their names serially. When one of us did something like cannula, blood drawing and rest of us eagerly observed it. We didn’t get enough time for clinical practice.” Another interviewee expressed as, “We had 5 to 7 days placement in each ward. It was very difficult for us to learn something new in NICU, ICU, CCU, OT wards within that short period. We only learnt about different instrument’s names not their uses.”

During FGDs, 2 respondents and 2 in-depth interviewees complained that they had to practice in traditional methods. They also added that even they were not introduced to this updated knowledge. During a FGD, one participant said, “Now-a-days nursing profession is developing throughout the world. Every day, a lot of research has been conducted, and many new service providing techniques have been added. But we are not getting introduced with them. Even updated knowledge is not included in our curriculum. We did not practice these upgraded methods as well. So ultimately, we have to practice the hundred years back conventional rules.”

Refusal of receiving services from Student nurses:

During in-depth interviews, 9 respondents and in FGDs, 14 respondents reported that patient’s families refused to take services from the student nurses. One respondent during FGD expressed as, “They refused to take services from us. They would tell us, you are junior. You will not be able do this. Go and call the senior nurse.” Even in an OT, when a student nurse was assisting the doctor; the doctor said, “You will not be able to inject a cannula to the patient. The patient is a relative of our senior professor. Let him (ward-boy) do it.”

During FGDs, 7 respondents reported that patient families or patient attendants create barriers and difficulties for novice nurses in providing services. Those findings were validated by 12 out of 14 interviewees too. One interviewee stated, “When we were doing something with the patients, the patient attendants began advising me like: do it in this way, no it will be like that, do slowly etc. Then I became confused and nervous and could not perform my work.” Too many instructions at a time made us confused.

Insufficient nurses and lack of documentation:

“It is challenging to properly deal with every single patient with an insufficient number of nurses. So, the senior nurses provide generalized treatment to every patient. They could not pay special attention to those who need special care” said a participant of FGDs. During FGDs, 9 out of 24 participants and one in interviews agreed that the number of nurses in the hospital setting was insufficient.

During FGDs, 8 participants out of 24 reported that they faced difficulties due to lack of documents. They also added that the nurses are not interested in documenting what services they provide to the patients, and thus, it creates a problem for the next service provider nurse.

“I was working in the septic ward. I was checking patients’ documents and providing medicines. I gave a baby an antibiotic, and the baby’s condition became so critical after some time. I called the doctor. When he came and checked the baby, he said that it was due to the overdoses of medicines. Later, I knew that the nurse who worked before she gave the medicine but she didn’t write it on the chart”, said a respondent in a FGD.

Insufficient nursing teacher and less supervision hour:

During FGDs, one respondent stated, "We have very few teachers with lots of subjects. So, a single teacher has to take many classes on different subjects. Moreover, they have other duties like taking classes, setting questions, conducting examinations, checking the examination answer scripts, helping students in skill labs and clinical practice, and having family responsibilities too. Because of all these reasons they have very little time for personal study. As he has less time for their study, they are not updated with current knowledge, and thus we are deprived of updated knowledge due to a shortage of teachers.”

During FGDs, 3 respondents noted that their nursing teacher did have training on teaching methods. One respondent expressed, “One of our senior nursing students became a teacher a few days ago. They have no training on teaching methods. Though they were bright students, we are not satisfied with their teaching style.”

CONCLUSION:

To create a healthy learning environment that fosters resilience and effective learning, a strong interpersonal connection is necessary in clinical contexts. Despite its importance, previous research has only briefly touched on this topic. Therefore, this study aims to determine the extent of contact between nursing students and their teachers during clinical learning, as well as to identify any obstacles that may arise. To investigate the relationship between teachers and students, we examined factors such as the quality of lecture delivery, teaching during clinical practice, asking questions and taking notes, feedback, and assignments.

Our findings indicate that most students are satisfied with the information provided during their introduction to clinical practice, as well as with their ability to learn through asking questions, completing assignments, and receiving feedback. Additionally, students reported learning more in-depth information about clinical practice from physicians during their hospital visits. We also assessed the communication and teaching abilities of senior nurses as clinical instructors, finding that they are excellent instructors who provide confidence and relevant information, and facilitate learning in clinical settings. We identified several challenges that respondents face, including communication gaps between doctors, nurses, patients, and students, conflicts between graduate and diploma nursing courses, lack of clinical instruction, noncompliance, misbehavior by doctors and ward boys, poor timing, reluctance to accept services from students, conflicts between theory and practice, and malpractice.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

We greatly appreciate the research grant received from Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag, Dhaka, Bangladesh.

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Received on 18.01.2023 Modified on 09.04.2023

Asian J. Nursing Education and Research. 2023; 13(3):171-178.

DOI: 10.52711/2349-2996.2023.00037