SciELO - Scientific Electronic Library Online

 
vol.13 issue1Validation of a Brazilian Tool for Mapping Risk Factors and Early Diagnosis of Female Urinary IncontinenceCare Practices Produced by Primary Care Nurses in the Territory: A Study in Boa Vista, Roraima author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Related links

Share


Enfermería: Cuidados Humanizados

Print version ISSN 1688-8375On-line version ISSN 2393-6606

Enfermería (Montevideo) vol.13 no.1 Montevideo  2024  Epub June 01, 2024

https://doi.org/10.22235/ech.v13i1.3665 

Original Articles

Undergraduate Nursing Students’ Experiences of Clinical Supervision at a University in Mozambique

Cristina Simão Nota1 
http://orcid.org/0000-0002-0441-9816

Francisca Márquez-Doren2 
http://orcid.org/0000-0001-8093-4687

Camila Lucchini-Raies3 
http://orcid.org/0000-0001-5704-9778

1 Pontificia Universidad Católica de Chile, Chile

2 Pontificia Universidad Católica de Chile, Chile

3 Pontificia Universidad Católica de Chile, Chile, clucchin@uc.cl


Abstract:

Objective:

To describe the experiences of final year nursing students at the Catholic University of Mozambique regarding the clinical supervision done by nursing technicians.

Method:

A qualitative-phenomenological study carried out with final year nursing students at the Catholic University of Mozambique. The in-depth interview was the technique used to collect data, which was analyzed using Content Analysis.

Results:

The results were divided into four main categories that emerged from the analysis of the interviews and are related to 1) the students' perception of the academic supervisor, highlighted by the presence and absence of teaching staff in the clinical setting; 2) the clinical supervisor made explicit by the nursing technical supervisors, with subcategories on the higher level student as a threat to the technical nurse, tension in the relationship between clinical supervisors and students, disposition and reaction of clinical supervisors; 3) the context, represented by the lack of material and human resources, cultural diversity and the COVID-19 pandemic; and 4) the perception about themselves as students, divided into lack of orientation in the clinical setting, living the clinical practice as a nightmare and hope during the experience. Some proposals for improvement are also presented.

Conclusion:

The results of this study have helped to describe the phenomenon studied, revealing the students’ perception about clinical supervision and the effect of the context that this relationship develops. These results will help to evaluate how to improve clinical supervision by identifying an innovative model to follow. This action is essential for the professional development of nursing students.

Keywords: nursing education; preceptorship; nursing students; nursing

Resumo:

Objetivo:

Descrever as experiências dos estudantes do último ano do Curso de Enfermagem da Universidade Católica de Moçambique sobre a supervisão clínica prestada pelos técnicos de enfermagem.

Método:

Estudo qualitativo-fenomenológico, realizado com estudantes do último ano do Curso de Enfermagem da Universidade Católica de Moçambique. A entrevista em profundidade foi a técnica utilizada para recolha de dados, analisados através da análise de conteúdo.

Resultados:

Os resultados foram divididos em quatro categorias principais que emergiram da análise das entrevistas e dizem respeito 1) à percepção dos alunos sobre o supervisor acadêmico, destacada pela presença e ausência de docentes no ambiente clínico; 2) ao supervisor clínico explicitado pelos supervisores técnicos de enfermagem, com subcategorias sobre o aluno de nível superior como ameaça ao enfermeiro técnico, tensão na relação entre supervisores clínicos e alunos, disposição e reação dos supervisores clínicos; 3) ao contexto, representado pela falta de recursos materiais e humanos, diversidade cultural e pandemia de COVID-19; e 4) à percepção de si mesmos como alunos, dividida em falta de orientação no ambiente clínico, vivência da prática clínica como um pesadelo e esperança durante a experiência. Também são apresentadas algumas propostas de melhorias.

Conclusão:

Os resultados deste estudo permitiram descrever o fenômeno em estudo, revelando a percepção dos estudantes sobre a supervisão clínica e o efeito do contexto em que esta relação se desenvolve. Estes resultados servirão para avaliar a forma de melhorar a supervisão clínica através da identificação de um modelo inovador a seguir. Esta medida é essencial para o desenvolvimento profissional dos estudantes de enfermagem.

Palavras-chave: educação em enfermagem; preceptoria; estudantes de enfermagem; enfermagem

Resumen:

Objetivo:

Describir las experiencias de los estudiantes de último año de enfermería de la Universidad Católica de Mozambique en relación con la supervisión clínica realizada por los técnicos de enfermería.

Método:

Estudio cualitativo-fenomenológico realizado con estudiantes de último año de enfermería de la Universidad Católica de Mozambique. La entrevista en profundidad fue la técnica utilizada para la recolección de datos, que fueron analizados a través del análisis de contenido.

Resultados:

Los resultados se dividieron en cuatro categorías principales que surgieron del análisis de las entrevistas y están relacionadas con 1) la percepción de los estudiantes sobre el supervisor académico, destacada por la presencia y ausencia de personal docente en el entorno clínico; 2) el supervisor clínico explicitado por los supervisores técnicos de enfermería, con subcategorías sobre el estudiante de nivel superior como amenaza para el enfermero técnico, tensión en la relación entre supervisores clínicos y estudiantes, disposición y reacción de los supervisores clínicos; 3) al contexto, representado por la falta de recursos materiales y humanos, la diversidad cultural y la pandemia COVID-19; y 4) a la percepción sobre ellos mismos como estudiantes, dividido en la falta de orientación en el entorno clínico, el vivir las prácticas clínicas como una pesadilla y la esperanza durante la experiencia. También se presentan algunas propuestas de mejora.

Conclusión:

Los resultados de este estudio han permitido describir el fenómeno estudiado, revelando la percepción de los estudiantes sobre la supervisión clínica y el efecto del contexto en el que se desarrolla esta relación. Estos resultados servirán para evaluar cómo mejorar la supervisión clínica, identificando un modelo innovador a seguir. Esta medida es esencial para el desarrollo profesional de los estudiantes de enfermería.

Palabras clave: educación en enfermería; preceptoría; estudiantes de enfermería; enfermería.

Introduction

Several countries around the world have taken an interest in the subject of clinical supervision in nursing, which is professional support for students. Its aim is to help trainees develop professional skills and confidence, integrate them in the clinical setting and therefore foster the transfer of theoretical knowledge into practice, thus ensuring better patient care. 1,2 After all, “for trainees to be properly prepared, they need to be guided and supervised”. (3 Nurses play an important role in this process for the development of nursing students’ competence, acting as a source of support in the context of clinical practice to fortify nursing students’ professionalism. 2,3

Most research on clinical supervision in nursing has focused on the experiences of students and clinical supervisors, with positive experiences being found as a result, for example, the support given to students by supervisors. There are also negative experiences, which serve as barriers to students’ education and learning. These include an inadequate clinical setting; abuse of power (experiences related to abusive behaviour); supervisors’ incompetence; supervisors’ lack of continuous training in formative skills; lack of implementation of strategic tools to facilitate clinical supervision (innovative models of clinical supervision); clinical supervisors’ absence (lack of availability of supervisors who do not yet support learning); short formative evaluation procedures; and lack of formal recognition of supervisors’ roles. The need to implement innovative models of clinical supervision that allow for a structured and formal process is a concern in several countries around the world. 1,2,3,4,5,6,7,8,9

Innovative models of clinical supervision for nursing students and midwives are being developed worldwide, consisting of collaboration between the institutions involved in this process (university and clinical field) and the participation of the triad academic supervisor, clinical supervisor and student, with the aim of promoting successful learning in students, an effective and rewarding clinical environment for the triad and improving public health. 1,10,11,12,13,14,15,16 Among these, the Partnership Participation Model (PEM, acronym in Portuguese) is the most tried and used in several countries around the world and it consists of each member of the partnership, the triad (academic supervisor, clinical supervisor and student), being responsible for the quality and effectiveness of the clinical learning activities, with a continuous commitment from planning to evaluation. 15,16 Studies conducted show that the use of such models improves the clinical learning setting and the supervisor’s competence. 11,14,15,16

Several African countries, including Ghana, Kenya, Malawi, Uganda, and South Africa, have shown concern regarding clinical supervision in nursing. Studies conducted in these countries have explored the experiences of nursing students and clinical supervisors in terms of clinical supervision, revealing both positive and negative influences on the process. Negative experiences reported in African countries often align with those observed globally. However, there are issues that, in some African countries, continue to be factors that negatively influence clinical supervision, such as lack of human resources and supervisors’ lack of remuneration. In view of this, it is necessary to look for strategies to improve clinical supervision and support for students. Additionally, nurse educators need to receive continuous training, plan clinical supervision and support effectively in order to promote competent nursing students.2,3,17,18,19,20 There is evidence that clinical supervision is a complex and dynamic educational perspective that can have both positive and negative aspects. 1,3,21) Therefore, the student’s experience in the clinical field is very important, as it can have a significant impact on their learning.

Mozambique is a country in Eastern and Southern Africa that became independent in 1975, and was then devastated by a civil war that ended in 1992. 22 After these long periods of war, most of the main health technicians left the country, resulting in a serious shortage of personnel to meet the needs in this field. The Mozambican government set out new strategies to train nurses at elementary and basic levels. This training lasted for many years. In 1980, the need arose to promote complementary and specialisation courses in different areas of nursing. At the same time, technical-professional health careers were established, divided into four levels: elementary, basic, middle-level and specialised middle-level. 23 In 2003, Maputo approved the creation of Instituto Superior de Ciências de Saúde (ISCISA), the first higher institute of health sciences, with higher education in various areas of health, including nursing. 23 Currently, the country has three levels of nursing training: middle-level, specialised middle-level and Bachelor’s Degree. For the general nursing technician (middle-level), the duration is 2 years and for the specialised technician (specialised middle level) it is 1 year and 6 months, both with competency-based training (CBT) “knowing how to do”. It focuses on the specific knowledge, attitudes and skills needed to carry out the procedure or activity. And as for the Bachelor’s Degree in Nursing, “nurse A”, the training lasts 4 years and emphasises competence in the student’s human development for humanised care and the future professional’s critical thinking and ability to intervene promptly with scientific knowledge.24 In 2008, Universidade Católica de Moçambique (Catholic University of Mozambique), UCM in short, began offering Bachelor’s Degree in Nursing. The course lasts four years and uses the PBL (Problem-Based Learning) teaching method.24 Clinical supervision, however, is an informal process, in which the university contacts a middle-level or middle-skilled nursing technician, depending on the area of practice, with no ongoing training in supervision and assigns them to supervise a group of students. 24 The lecturers and management of the Faculty of Health Sciences (FCS, acronym in Portuguese) at UCM act as mentors to control the process (24). Furthermore, in Mozambique there is a shortage of human resources. Existing health professionals cannot cover the large number of students entering the clinical field. Currently, there is one nurse for every 2,000 inhabitants, 22 and the majority are technicians.

As mentioned in the previous paragraph, at this embryonic stage, university students are supervised by nursing technicians. 24 According to Patricia Benner’s “from novice to expert” theory, clinical supervision is necessary for each stage in nurse training, and it is recommended that students be mentored by competent but not expert nurses, and guided by formal supervision programmes, to improve student and patient satisfaction, as well as organisational quality.(25, 26) No previous studies related to this topic were found in Mozambique. Therefore, a study exploring nursing students’ experiences of clinical supervision in the local context is relevant. The study aims to understand the experiences of final-year nursing students at UCM regarding clinical supervision provided by nursing technicians, in order to improve nursing education and learning (clinical supervision).

Methodology

Type of study

This study used the constructivist-qualitative paradigm, 27 according to which each participant has a subjective perception and discourse about the phenomenon. The research design used phenomenology, which is a philosophical method developed by Edmund Husserl (1859-1938),28 it is concerned with how things or phenomena are experienced from a first-person perspective and describes common meaning, with the purpose of explaining the structure or essence of the lived experience of a phenomenon from the perspective of the unity of meaning, which is the identification of the essence of a phenomenon and its precise description through everyday lived experience.27,29 This is descriptive phenomenology, which consists of directly exploring, analysing and describing particular phenomena as freely as possible. The three steps of descriptive phenomenology were followed: (1) intuit; (2) analyse; and (3) describe. When in the first stage, intuiting, one became totally immersed in the phenomenon under study, one began to get to know the phenomenon described by the participants. Any criticism, evaluation or opinion was avoided and rigorous attention was paid to the phenomenon under study as it was described; the second stage consists of phenomenological analysis, which consisted of identifying the essence of the phenomenon under study from the data obtained and the way it was presented, as the descriptions were listened to, common themes or essences began to emerge; the third stage is phenomenological description, in which the written and verbal descriptions of the phenomenon were collected, classified and grouped.29 This methodological approach was instrumental in addressing the research question: What are the experiences of final-year nursing students at Universidade Católica de Moçambique regarding the clinical supervision provided by nursing technicians? Additionally, it facilitated the achievement of the research aim.

Sample

The research participants were students in the 4th year of the bachelor’s degree in Nursing, as they begin clinical practice in the 2nd semester of the 1st year, in the Medicine sectors (Fundamentals of Nursing) at Hospital Central da Beira (Beira Central Hospital), HCB in short, to put basic nursing skills into practice. In the 2nd year, students have internships throughout the year. First semester, medical surgical internship at HCB; second semester, obstetrics internship at the health centres of Macurungo, Manga Mascarenha and Munhava (Beira-Sofala-Mozambique), which means that the internship hours are more extensive. In the 3rd year, the first semester is a paediatrics, emergency and psychiatry internship at HCB; and in the second semester, a community health internship with vulnerable families (which takes place in a suburban neighbourhood); and in the 4th year, the internship time is longer in a pre-professional system, that is, 8 hours a day and with night shifts, as well as a supervision internship where the 4th year students accompany the 1st year students in the fundamentals of nursing internship. Therefore, 4th year students have more experience of clinical supervision by nursing technicians. Seventy-five percent (75 %) of the practicals are carried out at HCB, which is the second largest hospital in the country and is also located in the country’s second largest population centre. 24 The participants were selected by purposive or convenience sampling, since the aim was to choose people who had experienced the phenomenon under study. Since the principal investigator was not in Mozambique, but had contact with some of the students at some point, the mobilisation was carried out by a research assistant, a doctor who is UCM alumnus and was not part of the faculty’s nursing department and had no contact with the final-year students. The role of the research assistant consisted only of applying informed knowledge and was not competent to understand the training context of the future nursing professional, as he was a general practitioner. There were 104 students, of whom 36 were male and the rest female. In this way, they were guaranteed voluntary participation and freedom to take part in the project.

The principal investigator prepared a video presentation detailing the purpose of the study and the conditions of completely voluntary participation, including information about the assistant and the researcher in charge, and sent it to the assistant who then forwarded it to the class WhatsApp group. This was followed by the recruitment phase, which culminated in 14 signed Informed Consents (ICs), applied in person by the assistant. The study had the following inclusion criteria: being a final-year nursing student at UCM-FCS; having completed their final internship (full internship) and expressing their willingness to take part in the study, formalised by signing the informed consent form. The exclusion criterion was not having completed the final internship (full internship). The exclusion criterion was not considered because of the COVID-19 pandemic, there was a delay in the programme, the entire group was still in the full internship, 2nd semester of the 4th year, and their participation was voluntary. Ten interviews were obtained with information saturation. 27

Data was collected through in-depth interviews, between October 2021 and February 2022, with a single question: 27 What has been your experience of the clinical supervision provided by nursing technicians during your professional training? The interview was conducted in Portuguese language and online by the principal investigator via the Zoom platform. The students were connected to the platform at UCM-FCS establishments, where there was a tablet with Internet access. The assistant connected the participant to the platform and left them in the room. Since it was not the principal investigator who applied the ICs, at the beginning of the interviews each participant was asked to review the terms of the signed IC form for clarification in case of doubts. The duration of the interviews varied from approximately 40 minutes to 3 hours.

Data análisis

The ten interviews were analysed using the five steps described by Colaizzi, namely: 1) to become familiar with the information, the transcripts were read and the recordings were listened to, repeatedly, in order to gain a deep understanding of the experience; 2) the original transcripts were returned, and the significant statements were extracted; 3) the meaning of each significant statement was interpreted; 4) meanings were organised into sets of categories and subcategories; and 5) a comprehensive description was written. Bracketing was done, which according to Husserl means suspending or bracketing all judgment of the real (the researcher’s experience) in order to focus on the experience described by the participant, to get to the essence of the phenomenon. 27 In addition, the software Dedoose version 9.0.46 was used for this analysis to ensure the efficient and rigorous use of all the information obtained in this study. (29

Data reliability

As this is a qualitative study, four rigor criteria were ensured: credibility, reliability, confirmability and transferability. 29 In this research, the credibility of the study results was ensured in the following way: after completing the discourse analysis and results, the principal investigator prepared a presentation, shared it with the assistant and then he forwarded it to nine participants, and they felt identified with the social dynamics exposed. 27,29 In terms of reliability, the interviews were audio and video recorded and transcribed immediately afterwards. The categories and subcategories emerged from the content analysis, thus confirming that the results of the study were determined by the interviewees’ experiences and not the researchers. To this end, field notes were also taken when necessary, throughout the data collection process. Finally, whether the results are appropriate or transferable depends on whether the results are applicable to another context. Therefore, in order to let other authors know whether the results are applicable to their context, this research provides detailed descriptions of the participants and the data collection and analysis process. 29

Ethical aspects

The research is a response to a real situation that currently affects the training of nursing students at UCM-FCS, hence its scientific and social value. The research project was approved by Ethical-Scientific Committee of Pontificia Universidad Católica de Chile, ID: 210715007, 2021. Permission was sought and granted from the Rector of UCM, the Director of FCS and the Coordinator of the Nursing Department, from which the participants come. The students gave their consent to voluntarily participate in the audio and video recording of the interviews. During the interviews, the participants’ well-being was carefully monitored and followed up. No one except the researcher and her supervisors had access to the data, to ensure confidentiality. Each interviewee was identified by the letter “P” (participant) and a number.

Results

Characteristics of the participants

The research participants were ten final-year nursing students aged between 22 and 25, all without children. Seven were male, nine were single, and also seven were from the central region of the country and mastered the most widely spoken local languages in the territory, which are Sena and Ndau, 30 and the other three were from the north of Mozambique. Nine of them did not work before entering university, and more than half were not employed. Finally, nine were not academically delayed.

The analysis of the interviews unveiled four main categories, along with their respective subcategories and proposals for improvement concerning the students’ perception of clinical supervision, as detailed in Table 1.

Table 1: Categories, subcategories, and proposed improvements 

Students’ perception of the academic supervisor

The academic supervisor in this study refers to the teacher employed at the teaching institution (university), chosen to supervise and facilitate the trainees’ learning in clinical practice. Most of the participants reported good experiences of being accompanied by academic supervisors in the first two years of their training. The presence of academic supervisors was seen as positive because the supervisors and students were of the same level, the professionals respected the students and theoretical knowledge was integrated into practice. As one of the participants mentioned:

Thanks God we had supervision in the first and second year (...), regardless of whether they were UCM students or professionals, but it helped a lot because we spoke the same language with the same people (P5).

However, some participants noted a decline in academic supervision from the 3rd year onwards, with supervisors being absent or merely present as mentors. This absence was attributed to the limited number of lecturers unable to accommodate the increasing student population. Consequently, during internships, students felt unsupported, lacking guidance on their tasks, thus hindering their achievement of internship objectives and undermining the quality of their training. One of the participants said that:

From the 2nd or 3rd year onwards (...) supervision by lecturers has been a bit scarce, it’s normal for a week only twice (...) and it hasn’t been full time (...) just to check attendance, ask the heads or nurses who are our supervisors about how the internship is going (P9).

Students’ perception of the clinical supervisor

The nursing technician (NT) clinical supervisor in this study is a professional nursing technician employed in the hospital institution (clinical field), with a training duration of 2 years for the middle-level and 1 year and 6 months for the specialised middle-level, who supervises the university nursing student in a clinical setting. However, it should be noted that most of the interviewees said that because the clinical supervisors are NT, they showed some difficulties in supervising university students, such as the lack of clarification of doubts, and they felt threatened because the students were from higher education. One of the participants said:

This made it a bit difficult, because it's well known that a technician supervising a higher education student has limitations, no matter how much experience the person has in practice, but a higher education student has have a certain theory that they haven't seen it (...) and they also think that you don't know anything, now that we're supervising you, how basic will you be afterwards (...) they'll come here to be our bosses and with the highest salary (...) so I don't have that tendency to be able to supervise you (P5).

This created tension in the relationship between clinical supervisors and students.

The participants also reported that the clinical supervisors, in retaliation for the threat, contradicted the theoretical knowledge that the students brought from university to apply in the clinical field. In addition, the lack of remuneration for clinical supervisors made them unmotivated to accompany the students. The interviewees also noted that the poor guidance provided by some of the clinical supervisors was due to a lack of ongoing training in student supervision. As one of the participants pointed out:

I was inserting a venous catheter, I failed (...), but my supervisor didn't have the cooperation, the patience to say (...), look how I'm going to get the catheter and how I'm going to insert it so that next time you can do the same (...) he got angry with me and said that these students don't know anything, that they come here for a walk (P1).

The interviewees also pointed out that, in response to the threat and lack of pay, the clinical supervisors showed a bad disposition and reaction in the practice environment, i.e., aggressive and abusive behaviour, such as a lack of respect, exclusion from the work team and resistance to the students' initiatives because they were from university. As one of the participants mentioned:

You spend a month in a sector, obviously (...) you're treated dangerously badly, because they talk to each other (the clinical supervisors), so when they don't like you, they talk to other colleagues (P6).

The students' perception of the context

The context in this study refers to the clinical setting where students can learn and develop clinical nursing skills in a real-life situation, under the guidance of an experienced professional (31). When reporting on their experience, some participants mentioned the lack of materials as one of the reasons for poor patient care. They also noted with displeasure that health professionals no longer followed the rules of asepsis. One of the interviewees revealed:

In some sectors, due to lack of material, mothers had to buy (...), and sometimes they shared syringes, and due to lack of conditions, catheters lasted more than 2 or 3 weeks, this can cause infection in the child (...), and the COVID-19 pandemic affected (...), there was a time when we stopped for more than 5 months, year 2020, when we came back in the 3rd, 4th year everything was rushed, even internships. Maybe we could have had lecturers supervising us, but they couldn't (...) some modules we did in a week (P10).

In addition, some interviewees mentioned the lack of human resources. There are fewer nurses with bachelor’s degree and NT in the internship field, who end up overloaded and, therefore, giving 3rd- and 4th-year students a lot of work on the grounds that they should already be experienced in some procedures. One of the participants said:

There are too few nursing professionals to supply all the students coming in (...), and they end up putting a lot of pressure on us, giving us the full load (...), like we have to do all the activities (P2).

Participants reported both positive and negative experiences of cultural diversity in the practice environment. Some said that clinical supervisors in some sectors kept their cultures in reserve, being neutral, while others used their mother tongue to criticise students. For polyglot students, it was a good experience. For others, it wasn't easy to do an internship in a hospital with professionals from different cultures who interacted better and paid more attention to students from the same ethnic group. Some interviewees said:

My culture helped and helps me a lot (...), because I understand Ndau and Sena, there are professionals who talk to me, I answer them and then, if the conversation isn't relevant, it's not prolonged, they realise that I understand (P6).

Supervisors take a greater interest in and become much closer to those students who are from the same ethnic group, for example I speak Guitonga to a patient, a supervisor who is from Inhambane realises that he is from Inhambane, he becomes closer, they become friends and they give him more attention compared to colleagues who are from a different ethnic group (P9).

Finally, some participants reported that the COVID-19 pandemic was a positive impact on their internship because the clinical supervisors were closer and more attentive to the students. On the other hand, some reported negative experiences because they had little time in clinical practice. Some of the interviewees said:

The COVID-19 pandemic has had a positive impact, because we have to pay a lot of attention when carrying out any activity (...) and the supervising professionals have become a little more attentive and closer to the students, (...) clarifying doubts, thinking that perhaps the inspection could come and the trainees could carry out procedures without their presence (P9).

Some participants also said that the way HIV-positive patients are treated is very different from others and that there is a lot of stigmatisation, procedures are done badly to these patients, they are mistreated and this can even lead to death. On the other hand, depending on their social status, low-status patients are less respected and mistreated, as the interviewees reported:

I saw a lady who was 33 and had been HIV-positive for 5 years and was already on ART (antiretroviral treatment), (...) and she had a hysterectomy (...), the suture itself is regrettable, and the other health professionals ended up commenting (...), poorly done suture, they opened the abdomen too much, it went from the pubic symphysis to the hypogastric region, which is the xiphoid process, they opened the whole abdomen (...). This shows that an HIV-positive patient (...) is treated very differently (P5).

I also remember the visiting part, (...) when someone comes in wearing pants and a coat (upper class), they can come in until 10 o'clock to visit their sick relative, but when it's anyone else they can't come in (P7).

Students’ perception of themselves

The students in this study refer to those attending bachelor’s degree in Nursing at UCM-FCS in the clinical field. The participants reported that they felt very disoriented during the clinical practices, due to the lack of follow-up from the academic supervisors, which contributed to the internship's objectives not being met. For the interviewees, this calls into question the quality of the training of future UCM’s nursing students, as well as from other institutions. As some of the participants pointed out:

Sometimes the hospital supervisors give us tasks that have nothing to do with nursing, while we would be learning techniques that they know and could teach us, but (...) when there's no agent on duty, students go to clean floors, carry water, bins, where we do all this they can spend two hours (P10).

We've heard that next year they're going to introduce the classic method, it's going to be the worst (...) for UCM, even with PBL now they're not managing to control the students, the quality isn't what it was before, even half of us, we're leaving with a bit of that quality, due to the supervision we have, but from the 3rd year downwards nothing (P6).

In addition, the students considered the moments of clinical practice as a nightmare, due to the treatment given by the clinical supervisors, which demotivated them and did not make them enjoy learning as much as they should. As one of the participants put it:

Every situation in the internship setting is sad, you just want hours to leave this sector (...), because you arrive, the nurses understand, they insult you (P6).

The participants said that even though they are demotivated and experience clinical practice as an unpleasant time, they hope to complete the course one day, so they dedicate themselves a lot to the internship and, as a result, gain more experience and skills in practice. One of the interviewees revealed:

We’ve endured a lot since the first year, it's not today that we're already at the end, although they say that the baggage weighs a lot at the end, to unload it is difficult, there are no easy things, so sometimes we hold our hearts, we go to the locker room, we cry and it passes (...) it's to be reckoned with in the future (P6).

Proposals for improvement

Some proposals for improvement emerged from the participants with a view to quality clinical supervision and the successful learning of nursing students. Participants suggested that there should be academic supervisors in the internship setting because they teach theory and know how to accompany each student. One of the participants said:

For me, we should have supervision from the 1st to the 4th year, the lecturers who give us theoretical lessons should be the same even in our practical field, (...) they already know us from the classroom that this student needs a lot of attention (P8).

The participants also proposed implementing some strategies to improve the clinical supervision process, such as a training programme for NT clinical supervisors. In addition, health professionals and students should find out about the culture of the community in which they will be working, in order to have fundamental information. Some of the interviewees attested to this:

They say that those who educate should set an example to motivate the student (P7).

Supervisors should have ongoing training in terms of supervision, because not everyone knows how to supervise. They could learn to be more patient with this process (...) and try to know exactly what language is spoken there. At least to know the basics, this can help in the relationship with patients (P8).

Finally, the interviews allowed the participants to vent about their day-to-day experiences of supervision during clinical practice, as one of the interviewees revealed:

After this conversation I feel a bit more relieved because no one now comes up to ask, (...) how was the internship? From the beginning to now, there's a lot we need to get out of the way (...) and you've just done that (...) by listening to me (P9).

Discussion

A Clinical supervision is very important in a nursing career. 1,2 There have been a number of international studies looking at the experiences of students and clinical supervisors at university level. 1,3,5,7,8,32 In this study, we sought to do something different by exploring the experiences of undergraduate students regarding the clinical supervision provided by NT.

There is little research into the experiences of auxiliary nurses, known in Mozambique as nursing technicians, in clinical supervision, given that they play some role in the process. In Australia, the role of the auxiliary nurse is pertinent when the clinical supervisor appointed by the university/clinical field is not part of the ward or when patients are assigned to trainees. 33 Both are continuously trained. Even so, the auxiliary nurse is considered an informal clinical educator. 33 They are asked for formative feedback on the students' performance throughout their shift, but do not take part in their formal evaluation.33 Unlike Australia, in Mozambique the nursing technicians play an important role in the students' clinical practices, accompanying them during the process, but they do not have continuous training for this, which makes the accompaniment unsatisfactory for the students. In Uganda, nurses with no bachelor’s degree also participate in the clinical supervision of undergraduate students. A study carried out in a regional hospital in Uganda on the perceptions of practicing nurses (NT) about their preparedness for the clinical supervision of undergraduate nursing students shows that NT feel prepared for the clinical supervision of undergraduate nursing students, but that they need support to perform the role of clinical supervisor of undergraduate nursing students. 34

Regarding the clinical supervision provided by nurses who attended a bachelor’s degree, a reference was found describing the support provided by clinical supervisors to students as a positive experience, helping them to alleviate the fear of having to deal with patients for the first time.1 Another reference was identified which described job insecurity as the reason for inadequate clinical supervision, in other words, clinical supervisors felt threatened by being at the same level as students and resented the lack of remuneration.3 However, in this research, the threat was the fact that the students were university students.

One study found tension in the relationship between clinical supervisors and students (educational confusion), in which clinical supervisors forced students to comply with their demands and, due to a lack of clarity in the students' duties, did not clarify doubts about the clinical practices to be carried out, completely ignoring their concerns.7 It is important to note that in this study, identical answers were also obtained, but for different reasons: lack of remuneration and limitations in the supervision of university students. Furthermore, there were no ongoing training programmes for clinical supervision.

A study conducted in South Africa with the aim of “exploring the experiences of undergraduate nursing students in the context of clinical supervision” also found negative experiences, such as abusive behaviour, i.e., “abuse of power” in the clinical field.1 Furthermore, a study carried out in Iran with the aim of “explaining the experiences of Iranian nursing students in relation to their clinical learning setting” also referred to difficulties during the clinical internship, such as the exclusion of students from the work team, 7 as well as resistance to student initiatives, which was an obstacle to student empowerment in clinical practice.

Studies have also been found that reveal inadequate communication and coordination between universities and practice institutions, 6 as well as the absence of academic supervisors in the clinical setting due to inadequate numbers of lecturers’ staff. 32 The reports presented in this study showed that these aspects hindered the students' learning process.

Material resources are important for nursing education and learning because they help students to become competent. The lack of these materials can make students feel lost, without help. (32 A study on the clinical setting revealed that in the absence of material resources, students felt helpless, without support. 18 In addition, clinical supervisors performed asepsis techniques inadequately. Some international studies also show that there is a shortage of human resources in the clinical setting, 3,32 however, there are a greater number of trainees, which can lead to less comprehensive monitoring and thus affect student learning. 32,35,36

In the same vein, an Australian study on “factors affecting the clinical learning of students from different cultural and linguistic backgrounds” 37 revealed that supervisors discriminated against students. Supervisors talked to each other in their mother tongue while supervising students, which ended up being negative learning experiences for the students. 37 This study revealed that there were good relations between clinical supervisors and students from the same ethnic group, which meant that trainees from other ethnic groups were excluded.

The COVID-19 pandemic has had a remarkable impact worldwide, especially in the health sector. Since this is a new topic, there are not many studies on it. A study from Belgium revealed that the majority of participants felt supported by academic and clinical supervisors due to the pandemic. 38 However, in this study, the focus is on NT clinical supervisors in relation to students. On the other hand, students complained about the short clinical practice time caused by the pandemic, which also contributed negatively to their learning. It should be noted, however, that a discussion article was found that addresses the relevance of collaboration between both institutions (clinical and educational) for better clinical supervision of students during the COVID-19 pandemic. 39

The lack of supervision from academic supervisors during the internship can lead to students learning procedures inappropriately and losing interest in the profession. 3 A study conducted in Malawi revealed that some students were forced to carry out routine activities unrelated to nursing during their internship, which hindered their learning process. 32 In the present study, such behaviours mean that students do not achieve the desired goals. They also lead us to believe that the quality of training for undergraduate nursing students is declining. The present study also brought new results: students found clinical practice a torment due to the unsuitable clinical setting. Nevertheless, they hoped to complete the course one day, so they focused on the internship and gaining more skills. Furthermore, with this study, the interviewees were hopeful about changes for future students. They thought this study was extremely important for nursing teaching and learning in Mozambique and suggested that academic supervisors accompany students during their internships and that NT clinical supervisors be trained in clinical supervision.

A limitation of this research was the lack of opinions from clinical supervisors, as the principal investigator was not in Mozambique. It is therefore hoped that future research will explore the views of academic and clinical supervisors. Also in this study, interviewees reported that there was discrimination against HIV-positive patients based on social class in the clinical setting. Lower-class patients were less respected and poorly cared for. Future research on this topic in the hospital setting is therefore also suggested.

Conclusion

The aim of this research was to describe the experiences of final-year nursing students at UCM on the clinical supervision provided by nursing technicians. The results revealed that although the students had a positive experience with the presence of academic supervisors in the first two (2) years of their training and with the support of clinical supervisors during their internship, they experienced many challenges in the clinical field, which at some point negatively affected their learning, such as the absence of academic supervisors during the last two (2) years of training, the poor relationship with clinical supervisors, the lack of human and material resources, the cultural diversity in the practice setting and the COVID-19 pandemic. This shows that many aspects of the clinical learning setting need to be improved. The Faculty of Health Sciences of UCM, especially the Department of Nursing, needs to have an innovative model of clinical supervision of students, which implies more participation of academic supervisors in the clinical practice setting and continuous training of clinical supervisors in student supervision, despite their enormous experience in the field.

REFERENCES

1. Donough, G, Van der Heever, M. Undergraduate nursing students’ experience of clinical supervision. Curationis. 2018;41(1): a1833. doi: 10.4102/curationis.v41i1.1833 [ Links ]

2. Alhassan, A, Duke, M, Phillips, NM. Nursing students’ satisfaction with the quality of clinical placement and their perceptions of preceptors competence: A prospective longitudinal study. Nurse Educ Today. 2024;133:106081. doi: 10.1016/j.nedt.2023.106081 [ Links ]

3. Kaphagawani, NC, Useh, U. Clinical supervision and support: Exploring pre-registration nursing students’ clinical practice in Malawi. Ann Glob Health. 2018;84(1):100-109. doi: 10.29024/aogh.16 [ Links ]

4. Pitkänen, S, Kääriäinen, M, Oikarainen, A, Tuomikoski, AM, Elo, S, Ruotsalainen, H, et al. Healthcare students’ evaluation of the clinical learning environment and supervision - a cross-sectional study. Nurse Educ Today. 2018;62:143-149. doi: 10.1016/j.nedt.2018.01.005 [ Links ]

5. Kalyani, MN, Jamshidi, N, Molazem, Z, Torabizadeh, C, Sharif, F. How do nursing students experience the clinical learning environment and respond to their experiences? A qualitative study. BMJ Open. 2019;9:e028052. doi: 10.1136/bmjopen-2018-028052 [ Links ]

6. Celma-Vicente, M, López-Morale,s M, Cano Caballero-Gálvez, MD. Analysis of clinical practices in the Nursing Degree: Vision of tutors and students. Enfermería Clínica (English Edition). 2019;29(5):271-279. doi: 10.1016/j.enfcle.2018.04.006 [ Links ]

7. Aliafsari Mamaghani, E, Rahmani, A, Hassankhani, H, Zamanzadeh, V, Campbell, S, Fast, O, et al. Experiences of Iranian Nursing Students Regarding Their Clinical Learning Environment. Asian Nurs Res (Korean Soc Nurs Sci). 2018;12(3):216-222. doi: 10.1016/j.anr.2018.08.005 [ Links ]

8. Mathisen, C, Bjørk, IT, Heyn, LG, Jacobsen, TI, Hansen, EH. Practice education facilitators perceptions and experiences of their role in the clinical learning environment for nursing students: a qualitative study. BMC Nurs. 2023;22:165. doi:10.1186/s12912-023-01328-3 [ Links ]

9. Donough, G. Nursing students’ experiences of clinical assessment at a university in South Africa. Health SA. 2023;28:2161. doi: 10.4102/hsag.v28i0.2161. [ Links ]

10. DeMeester, DA, Hendricks, S, Stephenson, E, Welch, JL. Student, preceptor, and faculty perceptions of three clinical learning models. Journal of Nursing Education. 2017;56(5):281-286. doi: 10.3928/01484834-20170421-05 [ Links ]

11. Grealish, L, van de Mortel, T, Brown, C, Frommolt, V, Grafton, E, Havell, M, et al. Redesigning clinical education for nursing students and newly qualified nurses: A quality improvement study. Nurse Educ Pract. 2018;33:84-89. doi: 10.1016/j.nepr.2018.09.005 [ Links ]

12. McLeod, C, Jokwiro, Y, Gong, Y, Irvine, S, Edvardsson, K. Undergraduate nursing student and preceptors’ experiences of clinical placement through an innovative clinical school supervision model. Nurse Educ Pract . 2021;51:102986. doi: 10.1016/j.nepr.2021.102986 [ Links ]

13. Nursing & Midwifery Council. Standards for education and training (Internet). Londres: Nursing & Midwifery Council; 2018. Disponível em: https://www.nmc.org.uk/standards-for-education-and-training/Links ]

14. Rusch, L, Beiermann, T, Schoening, AM, Slone, C, Flott, B, Manz, J, et al. Defining Roles and Expectations for Faculty, Nurses, and Students in a Dedicated Education Unit. Nurse Educ. 2018;43(1):14-17. doi: 10.1097/NNE.0000000000000397 [ Links ]

15. Schaffer, MA, Schoon, PM, Brueshoff, BL. Creating and sustaining an academic-practice Partnership Engagement Model. Public Health Nurs. 2017;34(6):576-584. doi: 10.1111/phn.12355 [ Links ]

16. Tang, FWK, Chan, AWK. Learning experience of nursing students in a clinical partnership model: An exploratory qualitative analysis. Nurse Educ Today. 2019;75:6-12. doi: 10.1016/j.nedt.2019.01.003 [ Links ]

17. Aryere, MT. Assessment of factors influencing the quality of clinical supervision of nursing and midwifery students at the 37 military hospital (Internet). Afribary; 2018. Disponível em: https://afribary.com/works/assessment-of-factors-influencing-the-quality-of-clinical-supervision-of-nursing-and-midwifery-students-at-the-37-military-hospitalLinks ]

18. Hester, CdS. The clinical environment: A facilitator of professional socialisation. Health SA . 2019;24:a1188. doi: 10.4102/hsag.v24i0.1188. [ Links ]

19. Kavili, JN. The impact of clinical nurse instructor’s practices on clinical performance among bachelor of science in nursing students in Kenya (Tese de graduação ). Kenya; 2020. Disponível em: https://repository.kemu.ac.ke/bitstream/handle/123456789/917/JULIAN%20NTHULE%20KAVILI%20THESIS.Pdf?Sequence=1&isallowed=yLinks ]

20. Mubeezi, MP, Gidman, J. Mentoring student nurses in Uganda: A phenomenological study of mentors’ perceptions of their own knowledge and skills. Nurse Educ Pract. 2017;26:96-101. doi: 10.1016/j.nepr.2017.07.010 [ Links ]

21. Rojo, J, Ramjan, LM, Hunt, L, Salamonson, Y. Nursing students′ clinical performance issues and the facilitator’s perspective: A scoping review. Nurse Educ ation in Practice. 2020;48:102890. doi: 10.1016/j.nepr.2020.102890 [ Links ]

22. Ivo Garrido, P. WIDER Working Paper 2020/131-Saúde, desenvolvimento e factores institucionais: o caso de Moçambique. 2020. Disponível em: https://www.wider.unu.edu/sites/default/files/Publications/Working-paper/PDF/wp2020-131-PT.pdfLinks ]

23. Monjane, LJ, Barduchi Ohl, RI, Barbieri, M. A formação de enfermeiros licenciados em Moçambique. Rev. Iberoam. Educ. Investi. Enferm. 2013;3(4):20-28. Disponível em: https://www.enfermeria21.com/revistas/aladefe/articulo/87Links ]

24. Casapía, GZ, Vieira, MMS. Formação em Enfermagem com Aprendizagem Baseada em Problemas (PBL). O caso da Universidade Católica de Moçambique (Tese de graduação). Porto: Universidade Católica Portuguesa; 2016. Disponível em: https://repositorio.ucp.pt/bitstream/10400.14/24195/1/Tese-GZC-Final%2001.pdf Links ]

25. Benner, P. From Novice to Expert. The American Journal of Nursing. 1982; 82(3):402-407. Disponível em: https://journals.lww.com/ajnonline/citation/1982/82030/from_novice_to_expert.4.aspx#ContentAccessOptionsLinks ]

26. Howard, ED. Fostering Excellence in Professional Practice with Mentorship. Journal of Perinatal and Neonatal Nursing. 2020;34(2):104-105. doi: 10.1097/JPN.0000000000000477 [ Links ]

27. Creswell, JW. 3ª ed. Qualitative Inquiry & Research Design. Thousand Oaks: SAGE; 2013. [ Links ]

28. Sanguino, NC. Fenomenología como método de investigación cualitativa: preguntas desde la practica investigativa. Revista Latinoamericana de Metodología de la Investigación Social. 2021;20(10):7-18. Disponível em: http://www.relmis.com.ar/ojs/index.php/relmis/article/view/fenomenologia_como_metodo Links ]

29. Rinaldi Carpenter, D. Phenomenology as a Method. En Streubert, HJ, Rinaldi Carpenter, D, editors. 5ª ed. Qualitative Research in Nursing. Hong Kong: Lippincott Williams & Wilkins; 2011, p. 72-94. [ Links ]

30. Instituto Nacional de Estatística. Estatísticas da Cultura 2018 (Internet). 2018. https://acortar.link/kpXwl3 [ Links ]

31. Muthathi, IS, Thurling, CH, Armstrong, SJ. Through the eyes of the student: Best practices in clinical facilitation. Curationis . 2017;40(1):e1-e8. doi: 10.4102/curationis.v40i1.1787. [ Links ]

32. Mbakaya, BC, Kalembo, FW, Zgambo, M, Konyani, A, Lungu, F, Tveit, B, et al. Nursing and midwifery students’ experiences and perception of their clinical learning environment in Malawi: a mixed-method study. BMC Nurs . 2020;19:87. doi: 10.1186/s12912-020-00480-4 [ Links ]

33. Rebeiro, G, Evans, A, Edward, K leigh, Chapman, R. Registered nurse buddies: Educators by proxy? Nurse Educ ation Today. 2017;55:1-4. doi: 10.1016/j.nedt.2017.04.019 [ Links ]

34. Drasiku, A, Gross, JL, Jones, C, Nyoni, CN. Clinical teaching of university-degree nursing students: are the nurses in practice in Uganda ready? BMC Nurs . 2021;20:4. doi: 10.1186/s12912-020-00528-5 [ Links ]

35. Abuosi, AA, Kwadan, AN, Anaba, EA, Daniels, AA, Dzansi, G. Number of students in clinical placement and the quality of the clinical learning environment: A cross-sectional study of nursing and midwifery students. Nurse Educ Today . 2022;108: 105168. doi: 10.1016/j.nedt.2021.105168 [ Links ]

36. Arkan, B, Ordin, Y, Yılmaz, D. Undergraduate nursing students’ experience related to their clinical learning environment and factors affecting to their clinical learning process. Nurse Educ Pract . 2018;29:127-132. doi: 10.1016/j.nepr.2017.12.005 [ Links ]

37. Hari, R, Geraghty, S, Kumar, K. Clinical supervisors’ perspectives of factors influencing clinical learning experience of nursing students from culturally and linguistically diverse backgrounds during placement: A qualitative study. Nurse Educ Today. 2021;102:104934. doi: 10.1016/j.nedt.2021.104934 [ Links ]

38. Ulenaers, D, Grosemans, J, Schrooten, W, Bergs, J. Clinical placement experience of nursing students during the COVID-19 pandemic: A cross-sectional study. Nurse Educ Today. 2021;99: 104746. doi: 10.1016/j.nedt.2021.104746 [ Links ]

39. O’Donnell, C, Markey, K, Murphy, L, Turner, J, Doody, O. Cultivating support during COVID-19 through clinical supervision: A discussion article. Nurs Open. 2023;10(8):5008-5016. doi: 10.1002/nop2.1800 [ Links ]

Data availability: The data set supporting the results of this study is available upon request from the corresponding author

How to cite: Nota CS, Márquez-Doren F, Lucchini-Raies C. Undergraduate Nursing Students’ Experiences of Clinical Supervision at a University in Mozambique. Enfermería: Cuidados Humanizados. 2024;13(1):e3665. doi: 10.22235/ech.v13i1.3665

Authors’ contribution (CRediT Taxonomy): 1. Conceptualization; 2. Data curation; 3. Formal Analysis; 4. Funding acquisition; 5. Investigation; 6. Methodology; 7. Project administration; 8. Resources; 9. Software; 10. Supervision; 11. Validation; 12. Visualization; 13. Writing: original draft; 14. Writing: review & editing. C. S. N. has contributed in 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14; F. M. D. in 1, 6, 7, 10, 11, 12, 13, 14; C. L. R. in 1, 6, 10, 11, 12, 13, 14.

Scientific editor in charge: Dr. Natalie Figueredo

Received: September 06, 2023; Accepted: March 16, 2024

Creative Commons License Este é um artigo publicado em acesso aberto sob uma licença Creative Commons