General characteristics of participants
Three-quarters of the participants were within the age group between 20-25 years old. The proportion of females was slightly higher than males (54% compared to 46%). More than three-quarters of the participants were nurse-midwife technician students pursuing a college diploma in Nursing and Midwifery. Most participants (57%) were in the third year of study (see Table 1).
The scores among the participants ranged from 97 to 164 (Mean [M] 131, standard deviation [SD] = 13.28). Satisfaction subscale had the highest mean score (M = 26.93, SD = 4.82), followed by personalisation (M= 23.27, SD=4.02) while individualisation had the lowest mean score (M = 18.01, SD =3.50) (see Table 2). There was no significant difference between the total score of each subscale and age, gender, students study program and students’ training institution.
We used satisfaction subscale as the outcome measure, with the other subscales as explanatory variables. Students’ satisfaction with the clinical learning environment was positively correlated with all the other subscales. Pearson correlation coefficient ranged from 0.20 (Individualisation subscale, p = < 0.05) to 0.54 (Personalisation subscale, p = < 0.001) (see Table 3).
Authors of research in the clinical learning environment using Fraser’s social-psychological conceptual framework  have found a relationship between satisfaction subscale scale and other CLEI subscales [32-34]. We, therefore, conducted multiple linear regression analysis to assess the association between satisfaction with clinical learning as a dependent variable and other psychosocial characteristics of CLEI (subscales) as independent variables. The findings of the multivariate analysis showed statistically significant association between satisfaction with clinical learning environment and personalization (β = 0.50, p = < 0.001) and task orientation (β =0.16 p= < 0.05). The two variables retained in the model explain 31% of the variability of the student satisfaction with their clinical learning environment (See Table 4).
Three focus groups, each per training institution, were conducted. Each focus group had ten participants conveniently drawn from those who responded to the survey questionnaire. Three main themes emerged from the data, and these are 1) Clinical teaching and supervision; 2) Working support and relationship, and 3) Barriers to clinical learning and teaching.
Clinical teaching and supervision
Participants shared their thoughts regarding clinical teaching and supervision. The discussions mainly focused on the following areas 1) clinical assessment and feedback related challenges, 2) lack of student accompaniment in the clinical area, and 3) students expected functional learning
Clinical assessment and feedback related challenges
Students complained that clinical assessments were not done in time and that feedback was not always given to students. Some students further narrated how their clinical assessments for a particular departmental allocation were not undertaken throughout the clinical placement. For such students, an arrangement was made to defer and undertake the clinical assessments at a different hospital and at a convenient time to assessors. However, students complained that this strategy caused them to be assessed in different areas from what they had learnt in their original clinical placement. Others complained that deferring clinical assessments worked to students’ disadvantage because assessments piled up and caused stress as they were required to do multiple assessments within a short period. Below are the quotes from the students:
“You find that most of the clinical assessments that were supposed to be done in the first year are carried forward to the third year, which puts pressure on us as we would have to do so many clinical assessments within a short period” (Participant Focus group discussion [fdg] 2)
“You will basically be at a new hospital that is totally different from the previous one, and they only come after the allocation to do assessments. You discover that what you have been learning is different from what you are being assessed on. You don’t even know they are coming for this carried forward assessment. I feel they should be assessing us on what we have been learning in that hospital allocation” (Participant fdg 1)
Poor communication skills of the qualified nurses was another salient area discussed by participants. Students understood the benefits of being corrected by qualified nurses or lecturers during their practical placements; however, lack of privacy and confidentiality and criticism when correcting students robed them the dignity and confidence to try new skills. Others mentioned that they disliked being shouted at in front of peers. Examples of such narrations are as follows:
“It happens that you are doing a procedure in the ward, and as a student, you are not as skilful and may fail to carry out the procedure competently. You find that staff members criticise you right there. This flattens my morale, and I don’t feel comfortable to do procedures with them [staff members]. I would love to be criticised in private when there is a problem and not in the presence of all patients because they lose trust in you” (Participant fdg 1)
“When a student is wrong, the qualified nurse would shout at you in the presence of patients and everyone” (Participant fdg 3)
Lack of student accompaniment in the clinical area
Student discussed the unavailability of lecturers in the clinical area. The sporadic presence of lecturers at the clinical placement was attributed to many reasons, including the shortage of mentors. They further indicated that a lack of an adequate number of qualified staff in the clinical area also affected their clinical learning and experience. Many students reported that the wards had a shortage of staff, which resulted in inadequate supervision of students. This is narrated in the following quotes:
“Previously, the clinical instructor used to accompany us to the hospitals. But these days, you find that you are allocated somewhere and you are left alone. They used to come with us; maybe it’s because of the transportation issues and the like” (Participant fdg 3)
“We have a shortage of human resource….we are failing to achieve our goals because of lack of mentors in the clinical area” (Participant fdg 1)
Students expected functional learning
Students had expectations in the ward, which was not always the reality. Regarding assessments and availability of clinical instructors, students unanimously across the three focus groups reported that they wished their lecturers accompanied them to the clinical area. They valued the presence of clinical instructors in the first days of their allocation to assist with the familiarisation to the new environment. They further wished for the presence of qualified nurses, who were often busy to supervise, mentor and evaluate their daily clinical engagements as narrated below:
“I think lecturers must be here [clinical area] at least for a week at the beginning of our allocation to orient us. Our current supervisory guidelines indicate that we should have at least not less than two visits from our supervisors. Let’s say we are doing labour and delivery for 4 weeks, coming twice within this allocation would be better than none” (Participant fdg 1)
“The qualified nurses should be able to supervise some of the procedures….so that when am doing something wrong at least they should tell me so that next time I should not do the same mistake” (Participant fdg 3)
Students generally preferred lecturers because it was easier to approach them when confronted with a clinical problem and they were uncertain of the reactions of the health workers to students in the unfamiliar new allocations. Unlike when working under the supervision of nurses, students highlighted their comfort to ask questions and learn different skills if the clinical instructor or lecturer were present, which facilitated learning.
“I expect that the lecturers should be visiting us frequently…. we are used to our lecturers and we feel free to ask them questions. In the ward, you are unsure of how the qualified staff will react to your question because you are new and unfamiliar” (Participant fdg 2)
“My expectation is that the lecturers should be visiting us frequently. If there is a condition in the ward, you are more open to asking the lecturers questions” (Participant fdg 2)
Working support and relationship
Discussions under this theme revolved around the positive support from staff and peers’ experiences, and the negative experiences.
Positive support from staff and peers’ experiences
Positive support was anything done to students that was perceived as helpful to their learning experience. Such positive support included a thorough hospital orientation by friendly management, ward orientation, peer education and support, and supportive staff. Positive feelings enhanced learning.
“ if it is your first day at a specific ward, the qualified personnel or the head of a department welcomes you in a friendly manner and orients you around. You get comfortable because you now know the place” (Participant fdg 3).
“We are students from different schools; we meet in the clinical area, we learn through sharing what we learn in classrooms in our different colleges. So we try to assist one another” (Participant fdg 3)
Some students reported top managers such as the District Health Officers (DHOs) and the District Medical Officers (DMOs) taught better about how to manage patients of different conditions. Notably, teaching support from senior managers was described as inspiring. Similarly, the presence of lecturers in the ward enhanced learning by encouraging students to provide comprehensive nursing care to patients. Below are the quotes from the students:
“People like the DMO and DHO do have a heart for students and know what we need. They are knowledgeable about the practical management of conditions, and they can explain to you…sometimes they give us assignments to complete” (Participant fdg 1)
“When a lecturer is there, you do comprehensive procedures, like history taking will sort of be thorough and you learn through that” (Participant fdg 2)
Several students reported that their clinical experiences were negatively impacted by the poor relationship with some clinical staff. Students recalled some experiences when qualified clinical staff shouted at them in the presence of patients and fellow students. One student reported:
“The qualified nurse shouted at me in the presence of patients and everyone. It spoiled my day, and I did not meet my objective that day because I was stressed up and annoyed….that wasn’t okay” (Participant fdg 1)
Barriers to clinical learning and teaching
Under this theme, barriers to acquiring skills and achieving their clinical objectives were discussed. Their discussion focused on the lack of resources and failure to follow standards and guidelines.
Lack of resources
Apart from human resources, students also mentioned a lack of resources to help them attain their clinical competencies, such as clinical equipment and protective gear. Lack of resources did not only fall below the students’ expectations but also facilitated poor quality of their clinical learning and the provision of substandard nursing practice through improvision of resources. Below are the quotes from the students:
“When it comes to real practice, you find that most of the equipment or accessories that you learned in class are not available in the ward” (Participant fdg 2)
“Sometimes it is difficult because what you learn is from Western Countries and here in Malawi we do not have those resources, so we end up improvising, which is a challenge” (Participant fdg 1)
Lack of patients was another reported resource-related barrier, and this happened as a result of an increased number of students in the ward from different institutions. Although a good relationship between students from these training institutions was generally reported, students were uncomfortable with having high numbers of counterparts from various institutions in the same ward. Having large numbers resulted in fighting over patients, as one student explained:
“In the ward, you can have students from three nursing training institutions. All of you would want to identify case studies for assessments. We end up fighting over patients instead of assisting them” (Participant fdg 3)
Failure to follow standards and guidelines
Students narrated that during the first weeks of their clinical placement, they tried to do what they learnt in class but over time, they also joined the qualified nurses in not following guidelines to perform procedures. The students reported that huge workload was the reason behind qualified nurses’ use of ‘shortcuts’ during procedures in the clinical area. Cutting corners was difficult for students to integrate theory into practice in the clinical area.
“…..when you are with qualified nurses….. maybe it is due to high workloads, they cut corners and you learn nothing.” (Participant fdg 1)
“It becomes a problem to integrate what we learnt in class and what we meet in the ward. During classes, we learn the best way to conduct procedures, but when we go to the clinical areas, we sort of cut corners unless the clinical supervisor is around” (Participant fdg 1)
While some students reported having support from the qualified nurses, others experienced an unwelcoming and unattractive learning environment, where ward staff expected them to do the work of a qualified nurse in the ward.
“The qualified staff in the ward, most of the time think that if students are in the second, third or fourth year, they know everything, forgetting that we are not there to do their work but to learn….they just leave us to work unsupervised.” (Participant fdg 3)