CLINICAL LEARNING EXPERIENCES OF NURSING DEGREE STUDENTS AT THE PUBLIC TRAINING HOSPITALS: KHOMAS REGION, NAMIBIA

CLINICAL LEARNING EXPERIENCES OF NURSING DEGREE STUDENTS AT THE PUBLIC TRAINING HOSPITALS: KHOMAS REGION, NAMIBIA | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article CLINICAL LEARNING EXPERIENCES OF NURSING DEGREE STUDENTS AT THE PUBLIC TRAINING HOSPITALS: KHOMAS REGION, NAMIBIA Joseph Galukeni Kadhila, Louise Pretorius This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2277663/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : Clinical placement provides an opportunity for socialization of students into the health system, and to acquire practice clinical skills in a real life setting while observing the deliverance of care by others. Despite the obvious benefits of clinical placements for students, poor relationships with the supervising nurse, environments that fail to promote belongingness and a lack of supervision hinders learning in the clinical setting. The purpose of the study was to assess the clinical learning experiences of the nursing degree students in general wards at the public training hospitals in Khomas Region. Aims : of the study were to explore and describe the clinical learning experiences by nursing degree students in general wards at the public training hospitals Khomas. The study aimed at answering the following central question: Tell me about your clinical learning experiences during your placement in general nursing wards of the two training hospitals in the Khomas region? Methods : In this study, the researcher selected a qualitative, explorative, descriptive and contextual design and 51 participants from the undergraduate second years, third years and fourth years were recruited. The data collection included 11-individual face to face interviews and the 8 Focus Group Discussions using semi structured interviews. Data was manually coded and analyzed using the Tesch’s method of data analyzes. Results : Four themes emerged from the exploration and description of nursing students clinical learning experiences. These were non-conducive learning environment, negative staff attitude, communication as barrier and shortage of staff. The results show that there were indeed constraints to learning in the clinical setting across all the years of study. Conclusion : Recommendations were made to the School of Nursing, the training hospitals and the Ministry of Health and Social services. Further research is needed on the clinical learning experiences of nursing students in other regions, and the lecturer’s experiences on clinical accompaniments. Hence, this study assessed clinical learning experiences of nursing degree students at the public training hospitals: Khomas region, Namibia. Introduction Nursing has been described as a unique and integrated discipline that includes both sciences e.g. biology, physiology, anatomy) and the arts of humanities (e.g. sociology, physiology, psychology, art, history and language (Mulaudzi, Mokoena & Troskie, 2010 ). It is a professional career that requires extraordinary range of knowledge and skills. Nurses are expected to deliver the highest possible quality of care in a compassionate manner to those in need. Therefore, they must access and evaluate extensive clinical information and incorporate it into their daily clinical decision making as nursing is a clinical practice-based discipline (Kaphagawani et al., 2013). Therefore, it is important that nursing education provides nursing students with the necessary skills to help them offer quality of care for patients with complex health problems, through scientific based clinical learning experiences in clinical practice. It is however in the clinical arena that nursing students learn to practice the art of nursing. For student nurses, clinical placements involve being in direct contact with unwell people, studying and learning how to assess and provide nursing care while integrating knowledge, theories and skills acquired in the academic setting. Achieving clinical competence in these placements also involves understanding how to work in teams and how general nursing is managed and organized in health care settings (Jacobsen, Onshuur, Frisnes &Gonzalez, 2020). Clinical training is regarded as the heart and essence of learning and education in nursing (Kalyani, Jamshidi, Molazem, Torabizadeh & Sharif, 2019 ). Kalyani et al, further stated that a clinical learning environment is a combination of several physical, psychological, emotional and organizational factors affecting the students clinical learning and how they confront the environment. This environment has considerable effects on students positive learning and emotional well-being. Furthermore, students get acquainted with the realities of their profession and functions of nursing in this environment. However, the clinical environment has been referred to as a reason for either quitting or continuing the nursing profession. PURPOSE OF THE STUDY The purpose of the study was to explore and describe the clinical learning experiences of the nursing degree students practicing in general wards at the public training hospitals in Khomas Region. OBJECTIVES OF THE STUDY The objectives of the study were to: Explore the clinical learning experiences by Bachelor of Nursing Science degree students in general wards at the public training hospitals Khomas. Describe the clinical learning experiences by Bachelor of Nursing Science degree students in general wards at the public training hospitals Khomas Region. Research design and methods Research design In this study, the researcher selected a qualitative, explorative, descriptive and contextual design to explore and describe the clinical learning experiences of the students in the Bachelor in Nursing Science degree students, while placed in the general wards at the public training hospitals within Khomas region. This design was found to be most appropriate as the students were given the opportunity to elaborate on their learning during their time of clinical placement in general wards. Study setting The study, to explore and describe participants clinical learning experiences in the general wards of the two training hospitals was conducted while at the School of Nursing and Public Health, University of Namibia. while students were on theoretical block. Study population and sampling strategy The entire population in this study consisted of 312 undergraduate Bachelor of Nursing Science degree students. This number included 101 second years, 94 third years and 107 fourth years registered for the Bachelor of Nursing Science at the University of Namibia’s Main campus, Windhoek, Khomas region Table 1 to 4 . These group of students all rotated through the general wards of the training hospitals as part of their compulsory clinical training. Research instrument The main data collection tool in qualitative study is the researcher, as he formulates meaning through his engagement in the study (Botma et al, 2010 ). The data were collected through interview guides for face-to- face interview and focus group discussions. The interview guide for face-to- face consisted of an open-ended question: Tell me about your clinical learning experiences during your placement in general nursing wards of the two training hospitals in the Khomas region? The interview guide for the focus group discussions consisted of semi-structured questions. Each focus group consisted of seven participants. Data collection procedure Face to face interviews with individuals and focus group discussions from each of the targeted cohorts of students were conducted until data saturation was reached per each cohort. The entire process of data collection was explained in detail by the researcher, including the recording of discussions. The researcher and the prospect participants agreed on a suitable date, time and venue for the individual face to face interviews and focus group discussion. The interviews were conducted in a quiet place to eliminate distractions, support confidentiality and allow quality audio recording; the researcher and the students were seated in a round table form side by side for the focus group discussion see Table 2 to 4 and across the table for the individual face to face interview Table 1 to demonstrate equality and comfort. Data analysis Data analysis is conducted to put data in order and give meaning to the data (Burns & Grove, 2016 ). As the study is qualitative, data collection and data analysis overlaped and the data were analyzed as it is received (Botma et al, 2010 ). The data was transcribed verbatim, organized, analysed, and interpreted by the researcher by means of eight steps of Techs method of data coding process as proposed by Creswell and Creswell (2018). The data were reduced into themes through the process of coding and condensing those codes and finally presenting the data in form of a discussion see Table 5 . (Creswell 2014). Results and discussions Demographic data of individual and focus group discussions Table 1 Individual face to face interviews Participant Participant code Year of study Age Gender 1. IFFI P1 Second year 20 F 2. IFFI P2 Second year 20 M 3. IFFI P3 Second year 19 F 4. IFFI P4 Third year 21 M 5. IFFI P5 Third year 32 F 6. IFFI P6 Third year 21 F 7 IFFI P7 Third year 22 F 8. IFFI P8 Fourth year 26 F 9. IFFI P9 Fourth year 23 F 10. IFFI P10 Fourth year 24 F 11 IFFI P11 Fourth year 24 M Table 2 Age and gender of the second-year focus group discussion (FGD) FGD − 2nd Year Participant code Age Gender 1 FGD1 P1 20 F 1 FGD1 P2 20 F 1 FGD1 P3 22 F 1 FGD1 P4 26 F 1 FGD1 P5 22 F 1 FGD1 P6 24 M 1 FGD1 P7 21 F 2 FGD2 P8 20 F 2 FGD2 P9 20 F 2 FGD2 P10 22 F 2 FGD2 P11 21 F 2 FGD2 P12 28 F 2 FGD2 P13 20 F 2 FGD2 P14 21 F Table 3 Third year focus group discussions FGD- 3rd Year Participant code Age Gender 3 FGD3 P15 26 M 3 FGD3 P16 21 F 3 FGD3 P17 34 F 3 FGD3 P18 20 F 3 FGD3 P19 21 F 3 FGD3 P20 22 F 3 FGD3 P21 21 F 4 FGD4 P22 22 F 4 FGD4 P23 23 F 4 FGD4 P24 20 M 4 FGD4 P25 21 F 4 FGD4 P26 22 F 4 FGD4 P27 35 F 4 FGD4 P28 22 F 7 FGD7 P43 27 F 7 FGD7 P44 23 M 7 FGD7 P45 24 F 7 FGD7 P46 23 F 7 FGD7 P47 23 F 7 FGD7 P48 23 F 7 FGD7 P49 23 F Table 4 Fourth years focus group discussions FGD 4th Year Participants code Age Gender 5 FGD5 P29 24 F 5 FGD5 P30 21 F 5 FGD5 P31 22 F 5 FGD5 P32 23 F 5 FGD5 P33 21 F 5 FGD5 P34 30 F 5 FGD5 P35 23 F 6 FGD6 P36 23 F 6 FGD6 P37 22 M 6 FGD6 P38 23 F 6 FGD6 P39 23 F 6 FGD6 P40 23 F 6 FGD6 P41 23 F 6 FGD6 P42 23 F 8 FGD8 P50 23 M 8 FGD8 P51 23 F 8 FGD8 P52 24 F 8 FGD8 P53 22 F 8 FGD8 P54 22 F 8 FGD8 P55 24 F The demographic data indicates that sixty-four (64) females and seven (7) male participants participated in this study and their ages ranged between 19 and 35 years of age see Table 1 to 4 . The participants for individual interviews where provided with codes as IFFI P meaning individual face to face interview participant and for the focus groups as FGDP standing for focus group discussion participant, to maintain confidentiality. The female domination in this study was due to the fact that nursing is a female dominated profession, and the School of Nursing and Public Health was no exceptional as it had a low intake of male nursing student throughout the years. Stereotyping and gender bias of men has helped create a less than inclusive, sometimes isolating and challenging experiences for men in nursing, who are frequently treated differently to their female counter parts (Ross, 2017 ). Table 5 Themes and subthemes THEME 1 SUB-THEMES 3.3.1. Non-conducive learning conditions 3.3.1.1 Overcrowding 3.3.1.2 Lack of resources 3.3.1.3 Extended placement 3.3.1.4 Sending students away 3.3.1.5 Unprofessional behaviour 3.3.1.6 Unfamiliar with role of preceptors 3.3.1.7 No orientation or delegation 3.3.1.8 Coerced evaluations 3.3.1.9 Use of cell phones during evaluations 3.3.1.10 No correlation with theory and practice 3.3.1.11 Effects of Covid 19 THEME 2 SUB -THEMES 3.3.2 Negative attitudes 3.3.2.1 Negative attitude towards teaching and demonstration 3.3.2.2 Taking of short cuts 3.3.2.3 Name calling and comparing students from UNAM 3.3.2.4 Harassment by male nurses 3.3.2.5 Favouritism 3.3.2.6 Unapproachable nurse THEME 3 SUB -THEMES 3.3.3 Communicating barrier 3.3.3.1 Use vernacular language 3.3.3.2 Shouting THEME 4 SUBTHEMES 3.3.4 Shortage of staff 3.3.4.1 Compromised time for teaching 3.3.4.2 Overworked students 3.3.4.3 Lack of supervision Theme 1. Non-conducive learning conditions A conducive clinical learning environment can help to reduce some of the anticipated challenges that students meet in the clinical area. Such challenges hinder positive student learning with detrimental in the field of nursing practice (Chiona,2020). Most students felt that their clinical environment was not conducive for learning, and this was evident by the following sub themes that emerged from the study results: overcrowding in the wards, lack of equipment, less placement time, sending of students unnecessary, no orientation, no delegation, role of preceptors not known, using of cellphones during evaluations. Ekstedt, Lindblad & Lofmark, 2019 argues that a good clinical environment for students in clinical placements is depended on engagement and collaboration between preceptors and academic nurse teachers. The same observation was also observed by Rajeswaran ( 2016 ) in a study done in Botswana stating that ward atmosphere directly influences students learning as it determines their perception whether the clinical area is suitable for their learning. Insufficient equipment, theory-practice gap, confusion causes stress, anxiety and may encourage the students to practice short cut method to complete their tasks quickly. Jamshidi et al ( 2016 ) stated that nursing students exposure and preparation to enter the clinical setting are one of the important factors affecting the quality of clinical education. Since an optimal clinical learning environment has a positive impact on the nursing students professional development, a poor learning environment can have adverse effects on their professional development process. Kalyani et al ( 2019 ) also concluded that factors causing problems between students and the department staff include lack of correspondence between education and treatment, rejection of criticism, insufficient equipment provided to students and failure to consider the students list of responsibilities. This theme is contradicting Kolbs theory of 1986 that state that learning is a cognitive process that involves constant adaptation to and engagement with one’s environment. Meaning for learning to take place, the learning environment should be friendly to the nursing students. Sub theme Overcrowding The increase intake of nursing students in nursing colleges led to overcrowding in public academic hospitals, thus negatively compromising availability of clinical learning opportunities and influencing their learning experiences negatively (Motsaanaka, Makhene and Ally, 2020 ). Most participants revealed that there was overcrowding in the wards which led, to missed learning opportunities, scrambling for rare procedures and frustration from both students and nurses. This is illustrated below: “The Universities are a lot the wards are always overcrowded; we have shortage of staff also sometimes getting demonstration is very hard from the staff members as they are always overworked”. (IFFP 2 and IFFI P 7) Kalyani et al ( 2019 ) in a study on how nursing students experience the clinical learning environment reported that nurses found the physical space as inappropriate to the number of students in the department. This results where further supported by Ali & Ali ( 2017 ) who contended that crowded clinical training places by large numbers of students impedes effective clinical learning and learning chances and self-confidence which leads to students not competed to some remedial tasks when completing training hence unable to provide quality care. A study by Motsaanaka et al., ( 2020 ) in Gauteng revealed that nurses had difficulty in managing large number of students in clinical setting- and students were competing for clinical procedures. Ziba, Yakong & Ali, ( 2021 ) states that crowding in clinical setting is a major challenge to clinical teaching and learning. Overcrowding in the wards makes it difficult for nurses and students to engage meaningfully. When students numbers are hig,h than the physical space can accommodate it becomes very difficult for staff to even assist them to learn clinical skills. The UNAM School of Nursing and Public Health places nursing students on a two-week rotational basis in the nursing clinical departments, but due to the fact that there are other nursing training institutions in the clinical settings, overcrowding has become a serious clinical learning burden affecting cohort participants in the study. These findings are in contradiction with Kolbs 1986 fourth stage in his cycle of learning about the active experimentation which advocates for learners to apply newly acquired concepts and ideas in practice. However, if the wards are overcrowded there will be no learning taking place as learning opportunities are limited. 3.3.1.2 Sub theme- Lack of resources Medical equipment is a necessary tool for nurses to provide quality nursing care. Shortage of medical equipment has a negative impact on nursing care, patients, the hospitals and nursing profession as such it is a barrier to the health system to function (Moyimane, Matlala, & Kekana,2017). Some participants raised their concerns on the lack of resources in the clinical wards that led to unsterile procedures and shortcuts being done in some wards. This situation challenged the students in the application of the principle of asepsis. The participants further mentioned that the nurses in the wards denied students opportunities to practice by hiding resources including gloves and aprons, the findings as indicated below. “The nurses hide gloves in the lockers and tell us there is nothing. Some nurses don’t want us to wear gloves and aprons because we are a lot, and they say we must buy gloves “(FGDP 9 and FGD14). A study by Rajeswaran ( 2016 ) in Botswana also concluded that lack of resources has impacted negatively on students teaching. Kalyani et al ( 2019 ) in his study in Iran on how nursing students experience the clinical learning environment and respond to their experiences, the author argues that lack of facilities and unavailability of the needed equipment led to waste of time and delay in patient care, and that such an educational environment was unpleasant to the students. Kaphagawani and User (2013) also argued that the lack of resources was one of the most important factors which causes students to learn in a difficult way. McMahon, Peters, Ivers & Freeman ( 2020 ) state that the world’s wealthiest countries have been gripped by resources shortage, including shortage of personal protective equipment (PPE) and ventilators during the pandemic, to guarantee these resources for their own nations health workers. Governments around the world are bargaining share in a global strangled supply chain. Although the students raised concerns on the shortage of resources in the clinical setting the Ministry of Health and Social Services has the obligation to ensure that the Hospitals and wards are well stocked with equipment and supplies, to enable safe nursing practice and nursing care. However, that is not the reality on the ground as one will still find shortage of resources in the clinical settings due to the strangled supply chain and delayed orders. Sub- theme: Extended placement Limited educational opportunities were experienced by the participants during their time in clinical. The main reason cited for this problem was the short duration of the clinical education in different wards, large number of students in each clinical education group and lack of diverse cases on wards (Mamaghari,2018). The participants in this study highlighted that they were placed for a short period in the wards and wished for longer placement period. The participants mentioned that the two weeks’ period was not sufficient for learning as the first week they still had to find their way around the ward and the practical registers are extensive to finish in two weeks. The participants expressed their views below: “I don’t understand the time you get mainly you get allocated at a department for just a week, and you are expected to finish procedures there, the first day you are oriented and you do nothing much how do you expect me to finish all activities there in just a week?” (FGD P 31 and P 41). This finding was in line with those of Ali and Ali ( 2017 ) where most students complained from inaptitude of hours and time schedule allocated for clinical learning., The author further stated that among the important effective factors on students clinical learning is unsuitability of the number of hours and time schedule assigned for clinical learning. Gilbert and Brown (2012) emphasized that short placement period can result in a decreased sense of belonging and limited learning opportunities for student nurses due to the time required setting. In a study by Silva et al (2012) done in Sri Lanka, the authors also admitted that majority of the students were unable to finish all their procedures within the allocated time due to short stays in clinical setting. The School of Nursing and Public Health places nursing students on a two weekly clinical rotational basis. The students raised concern on the period of allocation as it was not enough for clinical learning and completion of log books. UNAM through the School of Nursing has received recommendations through the stakeholders on how to mitigate the situation and improve clinical placements. Sub theme: Sending of students Mamaghani et al., ( 2018 ) reported that when health personnel and clinical instructors try to forcibly impose their demands on nursing students and forcing student nurses to perform basic and routine tasks that were deemed by the student as non-important educationally, was a form of bullying. This caused students to believe they were wasting their educational time and negated form them the value of clinical education. Most participants cried foul on the nurses sending them all the time and unnecessarily even for their own private errands and come use it against them if they refuse to be sent being really unprofessional. The participants further stated that the nurses don’t give them time to learn in clinical and work on their practical books. These quotes were captured from the Focus Group Discussions. ‘’The sisters will send you for her personal reasons, but when you refuse and bring your book later they refuse to sign because you did not go where she was sending you before. It is not supposed to be like that because I cannot be sent around every day it is my right to refuse to a sister sending me for her personal things’’. (FGD P8 and P17). The findings from the study are supported by Ali and Ali ( 2017 ) who argued that one of the most unprofessional behaviors of nurses with the students was to ask them to do things which are not particularly defined as their tasks. The findings were also supported by Jamshid et al., (2016) showing that students had missed opportunities for clinical learning when they were sent to perform errands, including going to the laboratory, x-ray, among other things instead of learning. Sub -theme: Unprofessional behavior The professional behavior as an inseparable part of nursing profession is a set of values, norms suitable for profession related behaviors by acquiring knowledge, attitude and skills that results in a commitment towards a specialized field (Mousavisl et al., 2019). Some nurses were upset by the students’ entrance to the clinical wards because they believed that nursing students were the cause of clutter and disorganization in the clinical setting. (Mamaghani,2018). Some of the students felt that some nurses lack professionalism, and they cannot be their role models as they behave in unaccepted manner. This was illustrated by the below quote: “The nurses lack professionalism because we need role models, we need to have someone to look up on to, cause our lecturers are not always around. They don’t do things professional it is just chaotic in the wards you are supposed to have role model and say I want to be like certain sister but at the end of the day you really don’t see who to follow because everybody does the things differently just chaotic there is no professionalism. For example, let me say you are going to do a procedure as a nurse you are supposed to have a trolley packed with your instruments, but for them they don’t take trolley they just their needles in their hands which is not professional they are supposed to have trolley and do everything in order”. (FGD P 40). The nurses in the clinical wards have all gone through nursing training, whereby ethics was a compulsory module to reinforce professional conduct and instill discipline in the work place among the nurses. It is therefore hard to comprehend reports on unprofessional behavior among nurses. Student nurses described professional nurse as being knowledgeable, approachable, skillful, excellent communicator, reflective practitioner and having a positive attitude (De Swardt, 2019 ). Theme 2: Challenging conditions to learning Unsupportive learning environment combined with unwelcoming clinical staff, clinical instructors lack of expertise, and a lack of sense of belonginess among nursing students are a few key challenging factors with negative impact on students learning in the clinical learning environment. Understanding these factors is essential to take appropriate action to overcome the challenges (Panda et., al 2021). Sub theme: Unfamiliar role of preceptors The role of a preceptor extends beyond the technical aspects required of a supervisor in the clinical environment to also involving the social aspects of caring for preceptees wellbeing (Quek and Shorey,2018). The education of the future generation in nursing is dependent on the availability of qualified preceptors and appropriate clinical sites. Students need extensive real-life patient care experiences with knowledgeable, dedicated preceptors to achieve competency for practice (Tenfelde & Fantasia, 2018 ). Asif et al., (2021) state that students also have a variety of concerns about precepted clinical experiences. Perceived barriers reported by students have included concern about competition at clinical sites and the inability to find preceptors in specialty practice. Some participants questioned the role of the preceptors as the preceptors only came to take attendance and do examination evaluations in the wards. The participants mentioned that the preceptors needed to be visible in the wards all the time to guide and observe if the students are carrying out their skills correctly, and assist students in all clinical procedures. And not just come take register and assess them on clinical procedures; this quote is supported below. “The only time we see our preceptors and lecturers was time for osce or evaluations or when we go to the University for class, I feel like we missed out on information that could be important due to Covid 19”. (FGD P 35 and P36) the findings of a study conducted by Rajeswaran ( 2016 ) emerged that clinical tutors were only seen in the clinical area when they came to evaluate students. The same evidence was found by Eksdetd, Lindblad & Lofmark (2019) in Sweden stating that student’s dissatisfaction with clinical learning was not only associated with having limited preceptors, but also with the preceptor’s attitude and approaches; College instructors and preceptors should design a programe for accompaniment and avail themselves in clinical settings on continuous basis to guide student nurses. Ekstedt, Lindblad and Lofmark (2019) further indicated that a supervision model for students based on peer learning in students dedicated rooms with many preceptors can be more satisfying than a model with traditional supervision where each student is depended on a single preceptor. These findings were also supported by Kaphagawani (2016) acknowledging that in the absence of nurse educator in the clinical area, students were not able to integrate theory and practice. Kolbs, (1984) through his learning cycle argued that a student needs reflective observation. The student nurse makes sense of what they have observed and reflect on the clinical encounter. In the absence of clinical preceptors and lecturers in the wards, the students are denied reflective observation in clinical learning and are missing out on important clinical learning experiences as nobody is guiding them in the clinical settings. The lecturers as academicians are responsible for the organization, planning, coordination, implementation and evaluation of learning and teaching aspects of the studies. Therefore, lecturers are responsible to ensure efficient and effective implementation of the curriculum and ascertain that students have achieved the set learning objectives, through theoretical and practical teaching and evaluation of students. Additionally, preceptors are complementary/supporting staff responsible for accompaniment of students during clinical practice to mentor and guide student’s nurses towards professionalism and provide clinical bed side teaching and simulations to ensure clinical competencies for students. Sub theme: No orientation and delegation To optimize teamwork, there is need to have a shared mental model in performing basic nursing care tasks, mutual support for workload management, better delegation practices, enhanced interpersonal relationships and better team orientation (Goh, Ser, Cooper, Cheng & Liaw,2020). Some participants expressed that they did not receive any orientation until on their fourth day of work or no orientation at all and they were working without delegation which led them to work, get lost in the wards and found it difficult to find certain equipment in the ward. The participants felt that if orientation and delegation was done it could have made their clinical placement worthwhile for learning. “My clinical learning experience was terrible we were not oriented therefore got lost in the wards and in there is shortage of staff meaning that the staff members did not have time to teach’’. (IFFI P1, IFFI P9) Hubbard, (2016) states that delegation promotes efficiency and flexibility, it allows for work to be implemented by different people in different ways thereby ensuring a high level of success and achievement of objectives. This also results in balance workload and promote effective communication. Therefore, This finding is in analogous with Kalyani et al., ( 2019 ) stating that there was no clear description of tasks for nurse and students, which was why they were irresponsible, for instance, caused a negative attitude towards nursing and confusion about nursing. Lortan and Maistray, (2019) concludes that the main reason for orientation are to enhance skills and knowledge in the new graduate, to facilitate the integration of theory and practice and to ease the new graduates’ transition from university life to the clinical setting. Sub theme: Coerced evaluations Some participants raised concern on how preceptors treat them unfairly, stating that lecturer’s and preceptors do not care if you are ready for evaluation or not. What they care most was their marks, this experience made the students uncomfortable”. This is illustrated by the students below. “I was evaluated on a certain procedure I was not even given enough time to adjust to the wards because what they only think is for their procedure to be done as long as they obtain their marks you know for their CA they not putting in consideration that okay this student are they ready for evaluations”. (FGD p38) This finding is coincident with the study by Kaphagani and User (2013) arguing that clinical nurse educator’s role is to enhance learning through provision of opportunities for learning supporting, guiding and conducting timely and fair evaluations. However, in this study, students felt that this role was not filled as lecturers, clinical instructors and preceptors took more time in evaluating then teaching. Tiwaken et al., ( 2015 ) added that students were concern about the manner in which faculty staff interact with them, believing themselves to be worthy of respectful treatment. The lecturers and preceptors are supposed to prepare students well in advance for their clinical evaluations. Clinical evaluations are a delegate task for nursing students as the practical component contributes 50% to the passing marks. Student nurses are adult learners who have the different learning styles and learn differently as alluded in Kolbs learning cycle. Coerced evaluations contradict Kolbs learning style. Sub theme: Use of cellphones during evaluations The use of the mobile phone by nurses for personal purposes is unequivocally considered unprofessional and often risky behavior. If not used with discretion, smart phones can have serious consequences both on patient safety and on healthcare professionals’ approach with the risk of dehumanization care (Osorio-Molina et al,2021). The participants expressed their frustration on the fact that some lecturers, clinical instructors and preceptors use their cellphones during evaluations. The participant alluded that, that behavior lead to preceptors having divided attention and ending up failing students: the participant’s quotes are captured below. “As much as we are not allowed to use phones at work, there are some preceptors who use their phones, they are receiving calls during clinical evaluation. Imagine how distractive that is for me personally when I was evaluated a particular person that was evaluating me received 3 phone calls and later on when we had to go through after evaluation she is telling me you did not do that and that I was like I did how do you expect to get everything if you are on your phone. “(FGD P38) This finding is supported by Ping-Huang et al., (2012) stating that student learning is hindered by teachers unclear and non-useful feedback or teaching without a respectful attitude. The findings where further supported by Fiorinelli et al.,2021 concluding that although mobile technology can improve nurse’s performance and the quality of care provided, however, the application of regulations and policies by health facilities is desirable to avoid inappropriate use of this devices by nurses. A circular 85 dated 05 September 2016 released by the Executive Director in the Ministry of Health and Social Services of Namibia states that usage of cellphones during official working hours is prohibited for all staff of the hospitals, health centers, clinics and outreach (MOHSS, 2016), However it is observed that this circular does not prevent staff from using their phones. Sub theme: No correlation with theory and practice. Transferring theory into practice in a structural manner requires professional support in the workplace, trust and the opportunity for direct experience, using valid and up to date knowledge by clinical staff and bridging the simulated situations with real life scenarios (Hashemiparast, Negarandeh & Theofanidis, 2019). Some participants felt that they were having difficulties adjusting in the wards, as what they were taught in class differs from what they were taught in practice. The participants further raised their concerns as there was a difference in the way things were done in the two training hospitals and they had to keep on adjusting to new skills or different skills from either hospital. “When you are taught theoretically compared to how it is done practically it is always a challenge, because in the theory you are expected to see in that sense that you understand it theoretically, it is a challenge because you imagine it like when you are taught theory, but when you have to do it is so different and also the way they do procedures from hospital to hospital is a challenge one has to keep on adjusting even the soaping differs and one has to be adjusting with clinical rotation”. (IFFI P 4). In a study by Saleh ( 2018 ) in the USA it is indicated that the primary purpose of theory in nursing is to improve practice by positively influence the health and quality of life of patients. The relationship between theory and practice is reciprocal. Practice is the basis for the development of nursing theory whereas nursing theory must be validated in practice. Saifan et al., ( 2015 ) argues that the nursing profession is composed of two parts, the theoretical part which reflects knowledge which is conveyed in the classroom and the practical part which focuses on improving skills in the clinical area and prepares student nurses to be able of doing as well as knowing. Motsaanaka et al., ( 2020 ) also support the findings that placing large number of students in the clinical setting led to overcrowding creating challenges for students to integrate theory into practice. Kaphagawani & User (2013) also argue that students become anxious and confused if they practice something different from what they learn in classroom. The participant’s experiences indicated that there was a theory practice gap as what was taught in class was not what was practiced in the wards., indeed this gap was already pointed out by the relevant stakeholders during consultations with UNAM School of Nursing and Public Health. The University of Namibia embarked on a curriculum transformation after consultation with relevant stakeholders to come up with strategies to strengthen the closure of the theory practice gap in the School of Nursing in order to produce ready to work nurses for the market. Sub theme: Effects of Covid 19 The highly contagious and fatal nature of the Covid 19 continues to place immense pressure on hospitals and psychological wellbeing of healthcare workers. This pandemic has also affected clinical education for nursing students whose programme is already known to be highly stressful even without additional challenges presented by Covid − 19. The corona virus disease has led to fears and increased stress levels among nursing students who strive to acquire the requisite skills and competencies necessary for patient care (Baluwa et al 2021 ). Globally, Corona virus disease 2019 has had negative consequences for higher education such as universities closing in response to lockdown measures. The School of Nursing and Public Health at the University of Namibia was no exception. Some student stated that their clinical learning was negatively affected by Covid 19 for the past year and a half as they were withdrawn from the clinical practice and the lecturers and preceptors were also absent from clinical due to the fear of contracting Covid 19; the negative encounter was that the students missed out on clinical learning opportunities. The participants had this to say: ‘’My clinical learning was also affected by Covid − 19 so since Covid − 19 came we were withdrawn from clinical and we were unable to go to work for almost half a year and so on and we were also not allowed to work in other departments since they were either turned in Covid wards or something like that this affected our teaching and experiences’’ (FGD P 53, P 51). This finding coincides with Triemsta et al., (2021) stating that the Covid 19 pandemic has forced learners and educators to rapidly adapt within their altered clinical learning environments personal separation, social distancing, organizational changes and the shift from physical to virtual learning environments have significantly disrupted the status quo. Hoofman & Secord, ( 2021 ) stated that the Covid 19 pandemic has affected and will continue to affect the delivery of knowledge at all levels of education including nursing. Agu, Stewart, Stewart & Rae, (2021) stated that the impact of Covid 19 on developing countries may be greater than in developed countries due to disparities. Online learning has become the solution to complete the curriculum, however it does not address the clinical component. Ulenaers, Grosemans, Schrooten & Bergs, ( 2021 ) state that the students indicated that clinical placement during the pandemic was more demanding than usual, using various objectives such as: busy, insecure, hectic, difficult, rare, overwhelming, heavy, stressful, weird, unsafe and psychologically stressful The Republic of Namibia reported their first case of Covid 19 on 13 March 2020 and on the 14 of March the President of the country declared a state of emergency for the country leading to a lock down of borders and educational institution. In the same vein the UNAM School of Nursing and Public Health also withdrew their nursing students from the clinical settings. This decision affected the students clinical learning negatively as the students missed on clinical learning experiences because clinical cannot be done on line as the theoretical part. NEGATIVE ATTITUDES Nursing staff negative attitude towards students and clinical instructors was one of the major factors that caused inappropriate interactions and it included poor communication skills and short duration of clinical experience (Mamaghani, 2018). Most of the students across all years of study in the clinical learning experienced negative attitude from the clinical staff and clinical supervisors during their clinical placement. This was also shown by emerged sub themes from the study Nurses refusing to teach, name calling, comparing of students from different universities, male nurses harassing students, shouting at students and favoritism. This finding was analogous to a study by Rajewaran (2016) in Botswana arguing that lack of harmony, communication, and interpersonal relationship between the educator and the student negatively affect the clinical learning. The attitude, approach, interpersonal relationship and neutrality of the lecturers create trust among the studentsThis finding is similar to research done by Kalyani et al., ( 2019 ) stating that the interpersonal relationship between the instructors and clinical nurses and the students plays an important role in the development of students personal and professional identities. The author further added that hopelessness was another psychological reaction created under the influence of nurses attitudes. The theme is in contradiction with Kolbs 1986 cycle of learning theory, the Concrete experience which may be attained through the process of apprehension, that is the learner sense what he or she feels in the environment. If it is negative energy the student nurse will not learn anything. This theme is evidence by participants experiences of negative attitude towards teaching and demonstrations by nurses, taking shortcuts, name calling and comparing students from UNAM and harassment by male nurses. Negative attitude towards teaching and demonstrations The concept academic incivility does not seem to be completely established yet, but is characterized by a violation of the norms of mutual respect in interpersonal interactions among faculty members, administrators and students. Academic incivility hinders teaching -learning activities between faculty members and students which puts the purpose of higher education institution at risk (Park & Kang,2021). Most participants raised concern on nurses that refuse to teach them and sign their log books in the clinical, saying that it was not part of their duties. The negative attitude affected the students learning negatively as the students found it hard to learn on their own without demonstrations. The findings are stated below. “Sometimes, some of the nurses are just rude, keeping information to themselves and don’t like helping giving demonstrations teaching students, and they don’t like signing also. Sometimes you work with them but at the end of the day when you have to give feedback they will say, I never saw you where did you work such things and it is- not really good someone answering you like that”. (IFFI P 7, P 8 and P 9, FGD P17). Shadadi, Sheyback, Balouchi & Shoorvazi, ( 2018 ) state that the most important obstacle against clinical education is associated with nurses include inadequate knowledge and skills and uncooperativeness of the personnel. In a study by Webster, Browno, Maich & Patterson, (2016) argues that nursing behavior, attitude and willingness to teach have an important influence. If students do not feel wanted, trusted, respected or supported, or feel bullied, intimidated or treated unprofessionally the work place culture causes them to lose confidence. This hinders growth, resulting in inadequate preparation for professional nursing practice. Ziba, Yakong & Ali, ( 2021 ) states that in Ghana it was regarded the responsibility of every registered nurse or midwife to provide teaching or guidance for students who work with them on their shift. The registered nurses supervise students and do not receive payment by any of the institutions for this service. Taking shortcuts Workers in health care organizations thus develop workaround behavior in response to four factors they perceived: prevent or weaken the care they provide to their patients, are not in the best interest of their patients, make the realization of their job difficult or longer or potentially threaten professional relationships. Work arounds are created under the pressure to respect rules or meet other work demands, they can also have negative consequence such as medical errors which can subsequently lead to injuries (Mansour and Tremblay 2019 ). Safe and timely patient care also requires optimal coordination of staff, resources, equipment, schedules and tasks. However, health care workers encounter barriers when implementing these standards and engage in workarounds to overcome these barriers (Mula, Human and Middleton, 2019). Some students from the study felt that some nurses were taking short cuts and were not willing to demonstrate the actual procedures. This was quoted below. “Some nurses do short cuts, so you will end up doing shortcuts as you see them doing. They don’t want to demonstrate because they don’t want us to know the shortcuts”. (FGD P13) Student nurses described challenges they experienced when observing risks to patient safety. Registered nurses request students to engage or conspire in unsafe practices, leading them to experience discomfort and remain silent. Student acknowledge they frequently remain silent due to the fear of negative consequences (Fagan, Lea and Parker, 2020). Moreover, this finding contradicts KELT 1984 second stage of learning reflective observation that state that a student learns by reflecting, if procedures are done the wrong way, the students will end up not learning. Name calling and comparing students from UNAM Nurse eat their young is an unfortunate idiom understood and used by nurses internationally. Dishearteningly, the idiom has been in use for over 30 years. Nurses eating their young does not literally refer to being cannibalistic with other nurses but refer to bullying behaviors experienced by nurses (Gillespie, Grubb, Brown, Boesch and Ulrich, 2017 ). Most participants experienced name calling and ill treatment during their clinical placement by the nurses, the negative experience made the student nurses feel hopeless and demoralized leading to poor learning outcomes and a feeling to quit. This experience was mostly encountered by the second- and third-year group, as fourth year participants were most likely to be respected as they were seniors. The participants further felt downgraded and demotivated by belittling from nurses in the wards as they always compare them to other institutions training nurses. Discriminatory behaviors and an unsupportive atmosphere in clinical environments as well as the negative attitude towards nursing students in clinical departments and the society, caused an inferiority complex, a sense of humiliation or deficiency in self-confidence in students this was quoted as follow. “The nurses blame you for things that they did when you were not there you come in the morning then you are blamed for something that you don’t know, that causes a very uncomfortable situation for us they will either call you stupid or incompetent but what they don’t understand is if you want your student to know something teach them on the first and second day but they don’t do that, they rather ridicule us, make fun of us, say the meanest things to us and they demoralize us. So, when they want you to do something we are not even comfortable because you know if you do something in a wrong way they will judge you saying what do they teach you in UNAM you guys are just useless”. (FGD P5, P7, P 8 and P36) ‘ Kaphagawani (2016) agreed with the findings that some staff would talk down on students in the presence of patients, calling them names. As a result, patients sometimes refused for procedures to be done on them by students. In addition, student in most cases receive destructive feedback. Students were reprimanded in the presence of patients, other staff and students, and if make mistakes they were humiliated, insulted and laughed at in presence of guardians, who made students seek for withdrawal from clinical learning site. Such type of feedback instilled fear and caused students to refrain from performing any procedures in case they made mistakes causing them to lose opportunities for clinical learning. Harassment by male nurses Some female students articulated their distress at being harassed by male nurses if they refused- to play along with their advances. The students felt that they had to learn to deal with the harassment which resulted in them focusing less on learning as illustrated by the following quotations. “The male staff members when they feel like they like you, you also see in the way they treat you, that is also were favoritism starts from. You will be doing the least but they will still sign and they will let you get away with anything, but the moment they ask for your number or visitation outside clinical environment and you turn it down you become a problem, you will no longer get signed it goes beyond critic even things you do no longer get signed for. You become a problem child all because you don’t want to entertain their advances” (FGD P 38). Kahsay, Negarandeh & Nayeri et al., ( 2020 ) indicated that the female nurses were harassed verbally as in unwanted mail-blackmail or telephone calls for sexual relations, asked their private matters, asked for a sexual relationship unwillingly and asked to do something sexual in exchange with for favors. Bullying is a systemic, pervasive problem that begins well before nursing school and continues throughout nurses career. A significant number of nurses leave their first job due to the negative behaviors of co-workers and bullying is likely to exacerbate the growing nurse shortage. Edmonson & Zelonka, ( 2019 ). The clinical learning setting must be a conducive environment to promote teaching and learning, and not be bullying ground where students feel hostile. Bullying in nursing is unacceptable and the profession should not tolerate any bullying of an individual. Sub theme - Favoritism Uncivil clinical environment behavior can have a detrimental effect on the nursing students’ morale, aversively affecting their motivation and ability to learn (El Hachi, 2019). The participants experienced a feeling of victimization and discrimination in the wards by the nurses, as some nurses were having their favorite students or were favoring some students from other institutions. The nurses were choosing who to work with, who to teach and who to sign for without doing the actual procedures. The following quotes evidence the above: “In some ward,s there are some nurses who only want to work with specific students from a specific University “(FGD P10). This finding is supported by Farzi, Shahriari & Farzi, ( 2018 ) stating that in the clinical environment, the doctors and nurses show more attention to medical students than other students of health science including nursing students and this led to negative attitude of other students. This can have negative effects in creation learning opportunities and also can reduce learning motivation. Similarly, Hagrass et al., (20202) reveals that students experienced favoritism between college and university students during their clinical placement as more attention was given to college students. These results are further in agreement with the results from a study done by Mwai ( 2014 ) that showed that the majority of student nurses did not feel welcomed from the nursing team and even many of them did not feel accepted. Unapproachable nurses Incivility in nursing education is a persistent global problem that threatens the psychological and physiological health of faculty and students. Incivility in nursing education is defined as a range of disruptive behaviors or failing to take actions when action is warranted. These behaviors and inactions may result in psychological or physiological distress for people involved- and if left unaddressed, may progress into threatening situations (Urban, Smith, Wilson & Cipher,2021). Most students experienced unapproachable nurses in the clinical setting, where nurses are always angry and answering students inappropriately. This experience made students feel unwanted and afraid of asking questions to learn clinically. Sometimes you will be in a ward and they won’t even listen to what you have to say they will really downgrade you, really so demotivate you that you won’t even want to come to that certain ward the next day (FGD P 31). This result coincides with results from a study by Siew Yen ( 2012 ) where results shows that student nurses described uncaring behaviors of instructors as a lack of interest in student nurses being unapproachable, refusing to give clarification on student nurses questions openly criticizing students nurses in front of others and being rigid, this uncaring behavior left the student nurses feeling powerless, intimidated, angry and it interfered with their learning. This finding was supported by Chapman (2002) as cited by Tiwaken et al ( 2015 ) emphasizing that personal characteristics of a nurse and clinical instructor such as being supportive, encouraging, resourceful, confident, approachable, friendly, available, helpful. Understanding, welcoming and having students interest at heart were all important aspects which the students perceived as enhancing their clinical performance. The findings are also constant with the results from Kalyani et al ( 2019 ) participants expressed feeling of missing out on many training opportunities because of the authoritarian and intimidating instructors who were unapproachable, difficult to communicate with and sarcastic. Theme 4: Communication barrier Communication is important in order to provide quality nursing care to the patient. Some participants reported that language barrier impeded their learning in the clinical setting. As much as English is the official language some nurses where teaching and reporting in their native languages felt that they were discriminated as some staff members where giving report and teaching in their native languages. A lack of common language between the clinical mentors and students made the clinical practice rather frustrating at times. Opportunity to observe and learn clinical procedures were most of the time missed because the students were busy trying to understand the language rather than clinical procedures, Mwai ( 2014 ). This theme is supported by sub-themes of Use of vernacular language and shouting at student nurse Subtheme: Use of vernacular language Nursing students with a native language other than that of the majority of their peers, might face an additional challenge when it comes to communication skills. Language competence is described as a prerequisite for good communication skills. Internationally, good communication skills are described as an important part of nurses core competencies, crucial for nursing practice and patients- centered care (Furness, Kvaal & Hoye,2018). Students acknowledged seeing disadvantages and limitations in their learning possibilities because of their different cultural background. The author further states that it was a serious challenge because language competence and good communication skills are crucial in enabling successful outcomes that lead to positive experiences in the clinical learning environment (Mikkonen et al., 2020). Some participants felt that they faced discrimination, racism, neglect and isolation in the wards by the nurse in the wards. This feeling lead to lost learning opportunities as some students did not understand what the nurses where reporting or teaching fellow students doing it in a non-official vernacular language rather than in English. The students had this to narrate. “Language usage in certain wards where we go I will say certain sisters, and will just blame one tribe, most of the wards where we go the sisters think all students know how to speak local even when they are handing over they do it in a local language and some of us don’t understand and that makes us feel left out so it is better if they start using English as it is the official language for everyone, for all to be accommodated”. (FGD P7). Weyman, (2018) argues that language barrier and culture differences can become detrimental stumbling blocks barring the way to clinical learning success. El Shamsi, Almutairi Al mashrafi & Kalbani, (2020) state that language barrier can make the delivery of high-quality healthcare very challenging, it has a negative impact on the quality of healthcare, patient safety and the satisfaction of medical professionals and patients In another studies Mwai ( 2014 ) and Baraz, Memarian and Vanaki, (2015) a student stated that documentation, giving and receiving report clinical staff was challenging because even if they knew what they wanted to say, they couldn’t express it completely in Finnish language. Students with good command of Finnish language seemed to settle in their clinical environments easier. It was also pointed out that useful professional communication of the instructors and nursing personnel with the students is important to facilitate learning and socialization of nursing students. Sub-theme: Shouting Nursing students mentioned shouting, isolation, humiliation and being assigned work below their competency level as their commonly experienced bullying behaviors. The majority of the students shared that they have experienced shouting and described it as a bad experience that should be stopped (Amoo, Menlah, Garti and Appiah, 2021 ). Some participants felt that some nurses are rude as they don’t know how to approach and reprimand students they just shout in front of other students making look useless and making them feel hopeless. “The general nursing lecturers and nurses don’t have that heart on speaking to students without freaking them out and show them some love. They will come to you in a way that no-one? wants want to be approached, you cannot come to a student shouting in front of the other students. The other preceptor shouted at a student saying you cannot dress like that you look like an ambulance driver”. (FGD P40 FGD P 35) This finding relates to a report from Rahman (2013) that students reported being yelled at or shouted at or were behaved toward in an inappropriate, nasty, rude or hostile way, or were belittled or humiliated. Ali & Ali ( 2017 ) agree with findings from this study where students complained about poor communication between students and clinical staff and the cooperation was barely with each other and which inevitably lead to frustration and demotivation thus, negatively affecting students learning in acquisition of knowledge and skills. The authors further state that proper communication between key stakeholders can support and simplify the clinical learning community and help to illustrate the roles of both students and clinical nurses. Discussion and Conclusion Objective One: Explore the clinical learning experiences by Bachelor of Nursing Science degree students in general wards at the public training hospitals Khomas. Clinical learning experiences in the Bachelors of Nursing Science degree in general wards at the public training hospitals, Khomas region was explored by conducting focus group discussions and face to face interviews with the concerned group of students. It can be concluded that there are limited learning opportunities for nursing students in the clinical setting in all the levels of year studies. The study revealed that students encountered several constraints during their clinical placement that negatively affected their clinical learning during their placement. Some of the negative experiences included overcrowding in the wards, resulting in to reduced learning opportunities and frustrations in the clinical setting. The participants also mentioned that there was a shortage of equipment and manpower in the clinical setting that affected their learning as the procedures were not executed up to the expected standard and there was no body to monitor when procedures where performed clinically. It was further revealed that students fell victim in the clinical setting by the nurses as they were called names, were bullied and compared to other training institutions. They also encountered favoritism and faced a language barrier. As a result of the use of local languages instead of English, declared as national language in the country. The participants from the study also mentioned that they missed out on important learning opportunities due to Covid − 19 pandemic as they were withdrawn from the clinical setting by the University in concern to their health safety in the clinical setting, or they were either confined to a few wards as other wards did accommodate Covid − 19 patients and there was no learning taking place. Objective two: Describe the clinical learning experiences by Bachelor of Nursing Science degree students in general wards at the public training hospitals Khomas Region. It was noted that across all the years of study, that all participants from the IFFI Table 1 and FGD Table 2 to 4 experienced an unconducive clinical learning environment, due to the fact that there was overcrowding, less placement time, no orientation on placement and delegation in the clinical environment these led to students competing for procedures among themselves to learn and complete their log books. The participants also felt that they were getting lost in the wards as they had nothing to do because there was no orientation and delegation. The participants further mentioned that there were discrepancies on what is taught in class and what is practiced in the clinical settings because of the lack of equipment in the clinical area. This finding also provided evidence that the preceptors were forcing students to do practical exams without prior preparation. This finding made students very uncomfortable as they were working under pressure and did not feel they are learning. The participants also agreed that Staff shortage affected nursing students negatively as all participants mentioned that they were not taught, or demonstrated to and were working unsupervised. They also feel they are overworked. The participants agreed that this experience made them work under fear of making mistakes and risking their own education as they had minimal skills to practice. The participant also felt that the shortage of staff led to them students to become fatigued and less functional, leading to poor concentration, poor learning and being less productive to carry out nursing care. As much as the students were concerned about clinical learning the attitude of the nurses in the clinical, preceptors and lecturers were not welcoming towards students. This was noted by all year levels revealing that the nurse was calling them names, comparing them to students from other Universities, shouting at them and refusing to teach them, that experience made them feel useless, demoralized and some mentioned that they felt like quitting. The female participants also expressed their uncomfortable clinical learning experiences whereby some male nurses are proposing to them in the clinical area which leads to hostility, favoritism and nurses refusing to sign if advances are rejected or disapproved. Some participants agreed that there was indeed a language barrier in the clinical area were some nurses refused to communicate in the official language and only communicate in their native language. In the same vein the students also showed their dismay on the fact that some nurses don’t know how to communicate at all and only shout and scream in the clinical area which affect their clinical learning in negative way as they missed out on important morning reports and teaching opportunities that were done in a non-official language. The experience made them feel isolated, discriminated, demoralized and unwanted in the clinical setting. Study limitations The following were identified as limitations during the study: The sample of the study was expected to include 312 nursing student’s participants but saturation was reached at 61participants from 9 individual face to face interviews and 8 focus group discussions consisting of 7 participants each (Sunders et al., 2018). Therefore, generalization to other campuses cannot be done. The exclusion of first year bachelor’s nursing students from the study due to their limited clinical exposure. The study was further limited to the two training hospitals Khomas Region, Windhoek Central Hospital and the Katutura Intermediate Hospital and findings cannot be generalized to other hospitals. Notwithstanding its limitations this study has provided important information regarding the clinical learning experiences of nursing degree students at the public training hospitals Windhoek: Khomas region, Namibia. Declarations Declarations Ethics approval and consent to participate Ethical considerations Declarations Consent to Publish Not applicable Declarations Competing interest The authors declared no conflict of interest. Funding No funding was received for this study Authors contribution * Joseph Galukeni Kadhila was the principle investigator, conceptualized the study, responsible for literature review and data collection and manuscript preparation University of Namibia 2. Louise Pretorius was responsible for supervisory role and the guaranteed the integrity of the study. Acknowledgement Special thanks go to the students nurse who participated in the study, as well as the university for granting me permission for their facilities to be accessed for completion of the study. References Abd E, Rahman RM. (2014). Perception of student nurses' bullying behaviours and coping strategies used in clinical settings. Agu CF, Stewart J, McFarlane-Stewart N, Rae T. COVID‐19 pandemic effects on nursing education: looking through the lens of a developing country. Int Nurs Rev. 2021;68(2):153–8. Al Shamsi H, Almutairi AG, Mashrafi A, S., & Kalbani A, T. 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Challenges for men in a female dominated environment. Links to Health and Social Care. 2017;2(1):4–20. Saifan A, AbuRuz ME, Masa'deh R. (2015). Theory practice gaps in nursing education: A qualitative perspective. Journal of Social Sciences/Sosyal Bilimler Dergisi, 11 (1). Saleh US. Theory guided practice in nursing. J Nurs Res Pract. 2018;2(1):18. Shadadi H, Sheyback M, Balouchi A, Shoorvazi M. The barriers of clinical education in nursing: A systematic review. Biomed Res. 2018;29(19):3616–23. Tiwaken SU, Caranto LC, David JJT. The real world: Lived experiences of student nurses during clinical practice. Int J Nurs Sci. 2015;5(2):66–75. Tenfelde S, Fantasia HC. (2018). Navigating challenges for preceptors: Results from the WHNP Workforce Survey. Triemstra JD, Haas MR, Bhavsar-Burke I, Gottlieb-Smith R, Wolff M, Shelgikar AV, … Ellinas H. Impact of the COVID-19 Pandemic on the Clinical Learning Environment. Addressing Identified Gaps and Seizing Opportunities; 2021. 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Unsectioned Paragraphs Permission to conduct the study was obtained from the School of Nursing Post Graduate Studies Committee and The University of Namibia Post Graduate Studies Committee for ethical clearance from UNAM Health Research and Ethical Committee (HREC) on the 16 of August 2021, all research principles where adhered to and respected throughout this study. Written informed consent Written informed consent was obtained from each participant after the procedure either focus group discussion or interview was explained. A written informed consent was obtained from the nursing students after adequate information about the study were conveyed, possible risks were pointed out. This included the explanation that they are voluntarily participating and that no coercion will be enforced (Polit & Beck, 2017 ). The data that supports the findings are available from the corresponding author Joseph Galukeni Kadhila on a reasonable request. Disclaimer The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. Authors details *Joseph Galukeni Kadhila, School of Nursing and Public Health, Faculty of Health Sciences and Veterinary Medicine, University of Namibia. 2. Professor Louise Pretorius School of Nursing and Public Health, Faculty of Health Sciences and Veterinary Medicine, University of Namibia. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2277663","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":154771400,"identity":"144392bf-c854-481e-8ef1-07262ac03afa","order_by":0,"name":"Joseph Galukeni Kadhila","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYBACxh4GBmkGAwsGflK1SDBINhCthwekhUGCweAAsTqYew4/vF1QICFvfCP34KcbDHfkCTust83YeoaBhOG2G3nJ0jkMzwwJOpCxn8FMmsdAgnHbjRwDoJbDjERoYf8G0mK/eUaO8W+gFnvCWnp7wLYkbpDIMQPZkkhYS8+ZYmugluQZZ96YWecYHE4mqMWwJ33jbZ4/Nrb97TnGt3MqDtsS1oKqwoCQeiAgHA2jYBSMglEwCgBOgDffJRBNVQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Namibia","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"Galukeni","lastName":"Kadhila","suffix":""},{"id":154771401,"identity":"95d554cf-036d-4d2a-8198-c5f15b31cf5a","order_by":1,"name":"Louise Pretorius","email":"","orcid":"","institution":"University of Namibia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Louise","middleName":"","lastName":"Pretorius","suffix":""}],"badges":[],"createdAt":"2022-11-15 19:29:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2277663/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2277663/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":32419085,"identity":"250e1e42-7930-4d1e-bc00-07a2efe73736","added_by":"auto","created_at":"2023-02-03 06:59:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":712579,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2277663/v1/17f87a05-bf94-412e-9a8f-7b8d5991c635.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"CLINICAL LEARNING EXPERIENCES OF NURSING DEGREE STUDENTS AT THE PUBLIC TRAINING HOSPITALS: KHOMAS REGION, NAMIBIA","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNursing has been described as a unique and integrated discipline that includes both sciences e.g. biology, physiology, anatomy) and the arts of humanities (e.g. sociology, physiology, psychology, art, history and language (Mulaudzi, Mokoena \u0026amp; Troskie, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). It is a professional career that requires extraordinary range of knowledge and skills. Nurses are expected to deliver the highest possible quality of care in a compassionate manner to those in need. Therefore, they must access and evaluate extensive clinical information and incorporate it into their daily clinical decision making as nursing is a clinical practice-based discipline (Kaphagawani et al., 2013). Therefore, it is important that nursing education provides nursing students with the necessary skills to help them offer quality of care for patients with complex health problems, through scientific based clinical learning experiences in clinical practice. It is however in the clinical arena that nursing students learn to practice the art of nursing.\u003c/p\u003e \u003cp\u003eFor student nurses, clinical placements involve being in direct contact with unwell people, studying and learning how to assess and provide nursing care while integrating knowledge, theories and skills acquired in the academic setting. Achieving clinical competence in these placements also involves understanding how to work in teams and how general nursing is managed and organized in health care settings (Jacobsen, Onshuur, Frisnes \u0026amp;Gonzalez, 2020). Clinical training is regarded as the heart and essence of learning and education in nursing (Kalyani, Jamshidi, Molazem, Torabizadeh \u0026amp; Sharif, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Kalyani et al, further stated that a clinical learning environment is a combination of several physical, psychological, emotional and organizational factors affecting the students clinical learning and how they confront the environment. This environment has considerable effects on students positive learning and emotional well-being. Furthermore, students get acquainted with the realities of their profession and functions of nursing in this environment. However, the clinical environment has been referred to as a reason for either quitting or continuing the nursing profession.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003ePURPOSE OF THE STUDY\u003c/h2\u003e \u003cp\u003eThe purpose of the study was to explore and describe the clinical learning experiences of the nursing degree students practicing in general wards at the public training hospitals in Khomas Region.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOBJECTIVES OF THE STUDY\u003c/h2\u003e \u003cp\u003eThe objectives of the study were to:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eExplore the clinical learning experiences by Bachelor of Nursing Science degree students in general wards at the public training hospitals Khomas.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDescribe the clinical learning experiences by Bachelor of Nursing Science degree students in general wards at the public training hospitals Khomas Region.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Research design and methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eResearch design\u003c/h2\u003e \u003cp\u003eIn this study, the researcher selected a qualitative, explorative, descriptive and contextual design to explore and describe the clinical learning experiences of the students in the Bachelor in Nursing Science degree students, while placed in the general wards at the public training hospitals within Khomas region. This design was found to be most appropriate as the students were given the opportunity to elaborate on their learning during their time of clinical placement in general wards.\u003c/p\u003e \u003c/div\u003e"},{"header":"Study setting","content":"\u003cp\u003eThe study, to explore and describe participants clinical learning experiences in the general wards of the two training hospitals was conducted while at the School of Nursing and Public Health, University of Namibia. while students were on theoretical block.\u003c/p\u003e"},{"header":"Study population and sampling strategy","content":"\u003cp\u003eThe entire population in this study consisted of 312 undergraduate Bachelor of Nursing Science degree students. This number included 101 second years, 94 third years and 107 fourth years registered for the Bachelor of Nursing Science at the University of Namibia\u0026rsquo;s Main campus, Windhoek, Khomas region Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e to \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. These group of students all rotated through the general wards of the training hospitals as part of their compulsory clinical training.\u003c/p\u003e"},{"header":"Research instrument","content":"\u003cp\u003eThe main data collection tool in qualitative study is the researcher, as he formulates meaning through his engagement in the study (Botma et al, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). The data were collected through interview guides for face-to- face interview and focus group discussions. The interview guide for face-to- face consisted of an open-ended question: \u003cem\u003eTell me about your clinical learning experiences during your placement in general nursing wards of the two training hospitals in the Khomas region?\u003c/em\u003e\u003c/p\u003e \u003cp\u003e The interview guide for the focus group discussions consisted of semi-structured questions. Each focus group consisted of seven participants.\u003c/p\u003e"},{"header":"Data collection procedure","content":"\u003cp\u003eFace to face interviews with individuals and focus group discussions from each of the targeted cohorts of students were conducted until data saturation was reached per each cohort. The entire process of data collection was explained in detail by the researcher, including the recording of discussions. The researcher and the prospect participants agreed on a suitable date, time and venue for the individual face to face interviews and focus group discussion. The interviews were conducted in a quiet place to eliminate distractions, support confidentiality and allow quality audio recording; the researcher and the students were seated in a round table form side by side for the focus group discussion see Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e to \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and across the table for the individual face to face interview Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e to demonstrate equality and comfort.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData analysis is conducted to put data in order and give meaning to the data (Burns \u0026amp; Grove, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). As the study is qualitative, data collection and data analysis overlaped and the data were analyzed as it is received (Botma et al, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). The data was transcribed verbatim, organized, analysed, and interpreted by the researcher by means of eight steps of Techs method of data coding process as proposed by Creswell and Creswell (2018).\u003c/p\u003e \u003cp\u003eThe data were reduced into themes through the process of coding and condensing those codes and finally presenting the data in form of a discussion see Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. (Creswell 2014).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results and discussions","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDemographic data of individual and focus group discussions\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndividual face to face interviews\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipant code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYear of study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFFI P1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecond year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFFI P2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecond year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFFI P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecond year\u003c/p\u003e \u003c/td\u003e 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year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFFI P6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThird year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFFI P7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThird year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFFI P8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFourth year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFFI P9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFourth year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFFI P10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFourth year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFFI P11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFourth year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge and gender of the second-year focus group discussion (FGD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD \u0026minus;\u0026thinsp;2nd Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipant code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD1 P1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD1 P2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD1 P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD1 P4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD1 P5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD1 P6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD1 P7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD2 P8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD2 P9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD2 P10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD2 P11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD2 P12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD2 P13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD2 P14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThird year focus group discussions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD- 3rd Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipant code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD3 P15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD3 P16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD3 P17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD3 P18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD3 P19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD3 P20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD3 P21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD4 P22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD4 P23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD4 P24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD4 P25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD4 P26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD4 P27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD4 P28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD7 P43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD7 P44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD7 P45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD7 P46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD7 P47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD7 P48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD7 P49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFourth years focus group discussions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD 4th Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD5 P29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD5 P30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD5 P31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD5 P32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD5 P33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD5 P34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD5 P35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD6 P36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD6 P37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD6 P38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD6 P39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD6 P40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD6 P41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD6 P42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD8 P50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD8 P51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD8 P52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD8 P53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD8 P54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFGD8 P55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe demographic data indicates that sixty-four (64) females and seven (7) male participants participated in this study and their ages ranged between 19 and 35 years of age see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e to \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The participants for individual interviews where provided with codes as IFFI P meaning individual face to face interview participant and for the focus groups as FGDP standing for focus group discussion participant, to maintain confidentiality.\u003c/p\u003e \u003cp\u003eThe female domination in this study was due to the fact that nursing is a female dominated profession, and the School of Nursing and Public Health was no exceptional as it had a low intake of male nursing student throughout the years.\u003c/p\u003e \u003cp\u003eStereotyping and gender bias of men has helped create a less than inclusive, sometimes isolating and challenging experiences for men in nursing, who are frequently treated differently to their female counter parts (Ross, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and subthemes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTHEME 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSUB-THEMES\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.3.1. Non-conducive learning conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.1 Overcrowding\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.2 Lack of resources\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.3 Extended placement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.4 Sending students away\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.5 Unprofessional behaviour\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.6 Unfamiliar with role of preceptors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.7 No orientation or delegation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.8 Coerced evaluations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.9 Use of cell phones during evaluations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.10 No correlation with theory and practice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.1.11 Effects of Covid 19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTHEME 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSUB -THEMES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.3.2 \u003cb\u003eNegative\u003c/b\u003e attitudes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.2.1 Negative attitude towards teaching and demonstration\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.2.2 Taking of short cuts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.2.3 Name calling and comparing students from UNAM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.2.4 Harassment by male nurses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.2.5 Favouritism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.2.6 Unapproachable nurse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTHEME 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSUB -THEMES\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.3.3 Communicating barrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.3.1 Use vernacular language\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.3.2 Shouting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTHEME 4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSUBTHEMES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.3.4 Shortage of staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.4.1 Compromised time for teaching\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.4.2 Overworked students\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3.4.3 Lack of supervision\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Theme 1. Non-conducive learning conditions","content":"\u003cp\u003eA conducive clinical learning environment can help to reduce some of the anticipated challenges that students meet in the clinical area. Such challenges hinder positive student learning with detrimental in the field of nursing practice (Chiona,2020).\u003c/p\u003e \u003cp\u003eMost students felt that their clinical environment was not conducive for learning, and this was evident by the following sub themes that emerged from the study results: overcrowding in the wards, lack of equipment, less placement time, sending of students unnecessary, no orientation, no delegation, role of preceptors not known, using of cellphones during evaluations.\u003c/p\u003e \u003cp\u003eEkstedt, Lindblad \u0026amp; Lofmark, 2019 argues that a good clinical environment for students in clinical placements is depended on engagement and collaboration between preceptors and academic nurse teachers.\u003c/p\u003e \u003cp\u003eThe same observation was also observed by Rajeswaran (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) in a study done in Botswana stating that ward atmosphere directly influences students learning as it determines their perception whether the clinical area is suitable for their learning. Insufficient equipment, theory-practice gap, confusion causes stress, anxiety and may encourage the students to practice short cut method to complete their tasks quickly. Jamshidi et al (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) stated that nursing students exposure and preparation to enter the clinical setting are one of the important factors affecting the quality of clinical education. Since an optimal clinical learning environment has a positive impact on the nursing students professional development, a poor learning environment can have adverse effects on their professional development process. Kalyani et al (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) also concluded that factors causing problems between students and the department staff include lack of correspondence between education and treatment, rejection of criticism, insufficient equipment provided to students and failure to consider the students list of responsibilities.\u003c/p\u003e \u003cp\u003eThis theme is contradicting Kolbs theory of 1986 that state that learning is a cognitive process that involves constant adaptation to and engagement with one\u0026rsquo;s environment. Meaning for learning to take place, the learning environment should be friendly to the nursing students.\u003c/p\u003e"},{"header":"Sub theme Overcrowding","content":"\u003cp\u003eThe increase intake of nursing students in nursing colleges led to overcrowding in public academic hospitals, thus negatively compromising availability of clinical learning opportunities and influencing their learning experiences negatively (Motsaanaka, Makhene and Ally, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost participants revealed that there was overcrowding in the wards which led, to missed learning opportunities, scrambling for rare procedures and frustration from both students and nurses. This is illustrated below:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The Universities are a lot the wards are always overcrowded; we have shortage of staff also sometimes getting demonstration is very hard from the staff members as they are always overworked\u0026rdquo;. (IFFP 2 and IFFI P 7)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eKalyani et al (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) in a study on how nursing students experience the clinical learning environment reported that nurses found the physical space as inappropriate to the number of students in the department. This results where further supported by Ali \u0026amp; Ali (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) who contended that crowded clinical training places by large numbers of students impedes effective clinical learning and learning chances and self-confidence which leads to students not competed to some remedial tasks when completing training hence unable to provide quality care. A study by Motsaanaka et al., (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) in Gauteng revealed that nurses had difficulty in managing large number of students in clinical setting- and students were competing for clinical procedures.\u003c/p\u003e \u003cp\u003eZiba, Yakong \u0026amp; Ali, (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) states that crowding in clinical setting is a major challenge to clinical teaching and learning. Overcrowding in the wards makes it difficult for nurses and students to engage meaningfully. When students numbers are hig,h than the physical space can accommodate it becomes very difficult for staff to even assist them to learn clinical skills.\u003c/p\u003e \u003cp\u003eThe UNAM School of Nursing and Public Health places nursing students on a two-week rotational basis in the nursing clinical departments, but due to the fact that there are other nursing training institutions in the clinical settings, overcrowding has become a serious clinical learning burden affecting cohort participants in the study.\u003c/p\u003e \u003cp\u003eThese findings are in contradiction with Kolbs 1986 fourth stage in his cycle of learning about the active experimentation which advocates for learners to apply newly acquired concepts and ideas in practice. However, if the wards are overcrowded there will be no learning taking place as learning opportunities are limited.\u003c/p\u003e"},{"header":"3.3.1.2 Sub theme- Lack of resources","content":"\u003cp\u003eMedical equipment is a necessary tool for nurses to provide quality nursing care. Shortage of medical equipment has a negative impact on nursing care, patients, the hospitals and nursing profession as such it is a barrier to the health system to function (Moyimane, Matlala, \u0026amp; Kekana,2017).\u003c/p\u003e \u003cp\u003eSome participants raised their concerns on the lack of resources in the clinical wards that led to unsterile procedures and shortcuts being done in some wards. This situation challenged the students in the application of the principle of asepsis. The participants further mentioned that the nurses in the wards denied students opportunities to practice by hiding resources including gloves and aprons, the findings as indicated below.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The nurses hide gloves in the lockers and tell us there is nothing. Some nurses don\u0026rsquo;t want us to wear gloves and aprons because we are a lot, and they say we must buy gloves \u0026ldquo;(FGDP 9 and FGD14).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA study by Rajeswaran (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) in Botswana also concluded that lack of resources has impacted negatively on students teaching. Kalyani et al (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) in his study in Iran on how nursing students experience the clinical learning environment and respond to their experiences, the author argues that lack of facilities and unavailability of the needed equipment led to waste of time and delay in patient care, and that such an educational environment was unpleasant to the students. Kaphagawani and User (2013) also argued that the lack of resources was one of the most important factors which causes students to learn in a difficult way.\u003c/p\u003e \u003cp\u003eMcMahon, Peters, Ivers \u0026amp; Freeman (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) state that the world\u0026rsquo;s wealthiest countries have been gripped by resources shortage, including shortage of personal protective equipment (PPE) and ventilators during the pandemic, to guarantee these resources for their own nations health workers. Governments around the world are bargaining share in a global strangled supply chain.\u003c/p\u003e \u003cp\u003eAlthough the students raised concerns on the shortage of resources in the clinical setting the Ministry of Health and Social Services has the obligation to ensure that the Hospitals and wards are well stocked with equipment and supplies, to enable safe nursing practice and nursing care. However, that is not the reality on the ground as one will still find shortage of resources in the clinical settings due to the strangled supply chain and delayed orders.\u003c/p\u003e"},{"header":"Sub- theme: Extended placement","content":"\u003cp\u003eLimited educational opportunities were experienced by the participants during their time in clinical. The main reason cited for this problem was the short duration of the clinical education in different wards, large number of students in each clinical education group and lack of diverse cases on wards (Mamaghari,2018).\u003c/p\u003e \u003cp\u003eThe participants in this study highlighted that they were placed for a short period in the wards and wished for longer placement period. The participants mentioned that the two weeks\u0026rsquo; period was not sufficient for learning as the first week they still had to find their way around the ward and the practical registers are extensive to finish in two weeks. The participants expressed their views below:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t understand the time you get mainly you get allocated at a department for just a week, and you are expected to finish procedures there, the first day you are oriented and you do nothing much how do you expect me to finish all activities there in just a week?\u0026rdquo; (FGD P 31 and P 41).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis finding was in line with those of Ali and Ali (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) where most students complained from inaptitude of hours and time schedule allocated for clinical learning., The author further stated that among the important effective factors on students clinical learning is unsuitability of the number of hours and time schedule assigned for clinical learning. Gilbert and Brown (2012) emphasized that short placement period can result in a decreased sense of belonging and limited learning opportunities for student nurses due to the time required setting. In a study by Silva et al (2012) done in Sri Lanka, the authors also admitted that majority of the students were unable to finish all their procedures within the allocated time due to short stays in clinical setting.\u003c/p\u003e \u003cp\u003eThe School of Nursing and Public Health places nursing students on a two weekly clinical rotational basis. The students raised concern on the period of allocation as it was not enough for clinical learning and completion of log books. UNAM through the School of Nursing has received recommendations through the stakeholders on how to mitigate the situation and improve clinical placements.\u003c/p\u003e"},{"header":"Sub theme: Sending of students","content":"\u003cp\u003eMamaghani et al., (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) reported that when health personnel and clinical instructors try to forcibly impose their demands on nursing students and forcing student nurses to perform basic and routine tasks that were deemed by the student as non-important educationally, was a form of bullying. This caused students to believe they were wasting their educational time and negated form them the value of clinical education.\u003c/p\u003e \u003cp\u003eMost participants cried foul on the nurses sending them all the time and unnecessarily even for their own private errands and come use it against them if they refuse to be sent being really unprofessional. The participants further stated that the nurses don\u0026rsquo;t give them time to learn in clinical and work on their practical books. These quotes were captured from the Focus Group Discussions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026rsquo;The sisters will send you for her personal reasons, but when you refuse and bring your book later they refuse to sign because you did not go where she was sending you before. It is not supposed to be like that because I cannot be sent around every day it is my right to refuse to a sister sending me for her personal things\u0026rsquo;\u0026rsquo;. (FGD P8 and P17).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe findings from the study are supported by Ali and Ali (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) who argued that one of the most unprofessional behaviors of nurses with the students was to ask them to do things which are not particularly defined as their tasks. The findings were also supported by Jamshid et al., (2016) showing that students had missed opportunities for clinical learning when they were sent to perform errands, including going to the laboratory, x-ray, among other things instead of learning.\u003c/p\u003e"},{"header":"Sub -theme: Unprofessional behavior","content":"\u003cp\u003eThe professional behavior as an inseparable part of nursing profession is a set of values, norms suitable for profession related behaviors by acquiring knowledge, attitude and skills that results in a commitment towards a specialized field (Mousavisl et al., 2019).\u003c/p\u003e \u003cp\u003eSome nurses were upset by the students\u0026rsquo; entrance to the clinical wards because they believed that nursing students were the cause of clutter and disorganization in the clinical setting. (Mamaghani,2018).\u003c/p\u003e \u003cp\u003eSome of the students felt that some nurses lack professionalism, and they cannot be their role models as they behave in unaccepted manner. This was illustrated by the below quote:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The nurses lack professionalism because we need role models, we need to have someone to look up on to, cause our lecturers are not always around. They don\u0026rsquo;t do things professional it is just chaotic in the wards you are supposed to have role model and say I want to be like certain sister but at the end of the day you really don\u0026rsquo;t see who to follow because everybody does the things differently just chaotic there is no professionalism. For example, let me say you are going to do a procedure as a nurse you are supposed to have a trolley packed with your instruments, but for them they don\u0026rsquo;t take trolley they just their needles in their hands which is not professional they are supposed to have trolley and do everything in order\u0026rdquo;. (FGD P 40).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe nurses in the clinical wards have all gone through nursing training, whereby ethics was a compulsory module to reinforce professional conduct and instill discipline in the work place among the nurses. It is therefore hard to comprehend reports on unprofessional behavior among nurses.\u003c/p\u003e \u003cp\u003eStudent nurses described professional nurse as being knowledgeable, approachable, skillful, excellent communicator, reflective practitioner and having a positive attitude (De Swardt, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e"},{"header":"Theme 2: Challenging conditions to learning","content":"\u003cp\u003eUnsupportive learning environment combined with unwelcoming clinical staff, clinical instructors lack of expertise, and a lack of sense of belonginess among nursing students are a few key challenging factors with negative impact on students learning in the clinical learning environment. Understanding these factors is essential to take appropriate action to overcome the challenges (Panda et., al 2021).\u003c/p\u003e"},{"header":"Sub theme: Unfamiliar role of preceptors","content":"\u003cp\u003eThe role of a preceptor extends beyond the technical aspects required of a supervisor in the clinical environment to also involving the social aspects of caring for preceptees wellbeing (Quek and Shorey,2018).\u003c/p\u003e \u003cp\u003eThe education of the future generation in nursing is dependent on the availability of qualified preceptors and appropriate clinical sites. Students need extensive real-life patient care experiences with knowledgeable, dedicated preceptors to achieve competency for practice (Tenfelde \u0026amp; Fantasia, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAsif et al., (2021) state that students also have a variety of concerns about precepted clinical experiences. Perceived barriers reported by students have included concern about competition at clinical sites and the inability to find preceptors in specialty practice.\u003c/p\u003e \u003cp\u003eSome participants questioned the role of the preceptors as the preceptors only came to take attendance and do examination evaluations in the wards. The participants mentioned that the preceptors needed to be visible in the wards all the time to guide and observe if the students are carrying out their skills correctly, and assist students in all clinical procedures. And not just come take register and assess them on clinical procedures; this quote is supported below.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The only time we see our preceptors and lecturers was time for osce or evaluations or when we go to the University for class, I feel like we missed out on information that could be important due to Covid 19\u0026rdquo;. (FGD P 35 and P36)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ethe findings of a study conducted by Rajeswaran (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) emerged that clinical tutors were only seen in the clinical area when they came to evaluate students. The same evidence was found by Eksdetd, Lindblad \u0026amp; Lofmark (2019) in Sweden stating that student\u0026rsquo;s dissatisfaction with clinical learning was not only associated with having limited preceptors, but also with the preceptor\u0026rsquo;s attitude and approaches; College instructors and preceptors should design a programe for accompaniment and avail themselves in clinical settings on continuous basis to guide student nurses. Ekstedt, Lindblad and Lofmark (2019) further indicated that a supervision model for students based on peer learning in students dedicated rooms with many preceptors can be more satisfying than a model with traditional supervision where each student is depended on a single preceptor. These findings were also supported by Kaphagawani (2016) acknowledging that in the absence of nurse educator in the clinical area, students were not able to integrate theory and practice.\u003c/p\u003e \u003cp\u003eKolbs, (1984) through his learning cycle argued that a student needs reflective observation. The student nurse makes sense of what they have observed and reflect on the clinical encounter. In the absence of clinical preceptors and lecturers in the wards, the students are denied reflective observation in clinical learning and are missing out on important clinical learning experiences as nobody is guiding them in the clinical settings.\u003c/p\u003e \u003cp\u003eThe lecturers as academicians are responsible for the organization, planning, coordination, implementation and evaluation of learning and teaching aspects of the studies. Therefore, lecturers are responsible to ensure efficient and effective implementation of the curriculum and ascertain that students have achieved the set learning objectives, through theoretical and practical teaching and evaluation of students.\u003c/p\u003e \u003cp\u003eAdditionally, preceptors are complementary/supporting staff responsible for accompaniment of students during clinical practice to mentor and guide student\u0026rsquo;s nurses towards professionalism and provide clinical bed side teaching and simulations to ensure clinical competencies for students.\u003c/p\u003e"},{"header":"Sub theme: No orientation and delegation","content":"\u003cp\u003eTo optimize teamwork, there is need to have a shared mental model in performing basic nursing care tasks, mutual support for workload management, better delegation practices, enhanced interpersonal relationships and better team orientation (Goh, Ser, Cooper, Cheng \u0026amp; Liaw,2020).\u003c/p\u003e \u003cp\u003eSome participants expressed that they did not receive any orientation until on their fourth day of work or no orientation at all and they were working without delegation which led them to work, get lost in the wards and found it difficult to find certain equipment in the ward. The participants felt that if orientation and delegation was done it could have made their clinical placement worthwhile for learning.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My clinical learning experience was terrible we were not oriented therefore got lost in the wards and in there is shortage of staff meaning that the staff members did not have time to teach\u0026rsquo;\u0026rsquo;. (IFFI P1, IFFI P9)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHubbard, (2016) states that delegation promotes efficiency and flexibility, it allows for work to be implemented by different people in different ways thereby ensuring a high level of success and achievement of objectives. This also results in balance workload and promote effective communication. Therefore,\u003c/p\u003e \u003cp\u003eThis finding is in analogous with Kalyani et al., (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) stating that there was no clear description of tasks for nurse and students, which was why they were irresponsible, for instance, caused a negative attitude towards nursing and confusion about nursing.\u003c/p\u003e \u003cp\u003eLortan and Maistray, (2019) concludes that the main reason for orientation are to enhance skills and knowledge in the new graduate, to facilitate the integration of theory and practice and to ease the new graduates\u0026rsquo; transition from university life to the clinical setting.\u003c/p\u003e"},{"header":"Sub theme: Coerced evaluations","content":"\u003cp\u003eSome participants raised concern on how preceptors treat them unfairly, stating that lecturer\u0026rsquo;s and preceptors do not care if you are ready for evaluation or not. What they care most was their marks, this experience made the students uncomfortable\u0026rdquo;. This is illustrated by the students below.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I was evaluated on a certain procedure I was not even given enough time to adjust to the wards because what they only think is for their procedure to be done as long as they obtain their marks you know for their CA they not putting in consideration that okay this student are they ready for evaluations\u0026rdquo;. (FGD p38)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis finding is coincident with the study by Kaphagani and User (2013) arguing that clinical nurse educator\u0026rsquo;s role is to enhance learning through provision of opportunities for learning supporting, guiding and conducting timely and fair evaluations. However, in this study, students felt that this role was not filled as lecturers, clinical instructors and preceptors took more time in evaluating then teaching. Tiwaken et al., (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) added that students were concern about the manner in which faculty staff interact with them, believing themselves to be worthy of respectful treatment.\u003c/p\u003e \u003cp\u003eThe lecturers and preceptors are supposed to prepare students well in advance for their clinical evaluations. Clinical evaluations are a delegate task for nursing students as the practical component contributes 50% to the passing marks. Student nurses are adult learners who have the different learning styles and learn differently as alluded in Kolbs learning cycle. Coerced evaluations contradict Kolbs learning style.\u003c/p\u003e"},{"header":"Sub theme: Use of cellphones during evaluations","content":"\u003cp\u003eThe use of the mobile phone by nurses for personal purposes is unequivocally considered unprofessional and often risky behavior. If not used with discretion, smart phones can have serious consequences both on patient safety and on healthcare professionals\u0026rsquo; approach with the risk of dehumanization care (Osorio-Molina et al,2021).\u003c/p\u003e \u003cp\u003e The participants expressed their frustration on the fact that some lecturers, clinical instructors and preceptors use their cellphones during evaluations. The participant alluded that, that behavior lead to preceptors having divided attention and ending up failing students: the participant\u0026rsquo;s quotes are captured below.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;As much as we are not allowed to use phones at work, there are some preceptors who use their phones, they are receiving calls during clinical evaluation. Imagine how distractive that is for me personally when I was evaluated a particular person that was evaluating me received 3 phone calls and later on when we had to go through after evaluation she is telling me you did not do that and that I was like I did how do you expect to get everything if you are on your phone. \u0026ldquo;(FGD P38)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis finding is supported by Ping-Huang et al., (2012) stating that student learning is hindered by teachers unclear and non-useful feedback or teaching without a respectful attitude.\u003c/p\u003e \u003cp\u003eThe findings where further supported by Fiorinelli et al.,2021 concluding that although mobile technology can improve nurse\u0026rsquo;s performance and the quality of care provided, however, the application of regulations and policies by health facilities is desirable to avoid inappropriate use of this devices by nurses.\u003c/p\u003e \u003cp\u003eA circular 85 dated 05 September 2016 released by the Executive Director in the Ministry of Health and Social Services of Namibia states that usage of cellphones during official working hours is prohibited for all staff of the hospitals, health centers, clinics and outreach (MOHSS, 2016), However it is observed that this circular does not prevent staff from using their phones. \u003cb\u003eSub theme: No correlation with theory and practice.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTransferring theory into practice in a structural manner requires professional support in the workplace, trust and the opportunity for direct experience, using valid and up to date knowledge by clinical staff and bridging the simulated situations with real life scenarios (Hashemiparast, Negarandeh \u0026amp; Theofanidis, 2019).\u003c/p\u003e \u003cp\u003eSome participants felt that they were having difficulties adjusting in the wards, as what they were taught in class differs from what they were taught in practice. The participants further raised their concerns as there was a difference in the way things were done in the two training hospitals and they had to keep on adjusting to new skills or different skills from either hospital.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When you are taught theoretically compared to how it is done practically it is always a challenge, because in the theory you are expected to see in that sense that you understand it theoretically, it is a challenge because you imagine it like when you are taught theory, but when you have to do it is so different and also the way they do procedures from hospital to hospital is a challenge one has to keep on adjusting even the soaping differs and one has to be adjusting with clinical rotation\u0026rdquo;. (IFFI P 4).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn a study by Saleh (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) in the USA it is indicated that the primary purpose of theory in nursing is to improve practice by positively influence the health and quality of life of patients. The relationship between theory and practice is reciprocal. Practice is the basis for the development of nursing theory whereas nursing theory must be validated in practice.\u003c/p\u003e \u003cp\u003eSaifan et al., (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) argues that the nursing profession is composed of two parts, the theoretical part which reflects knowledge which is conveyed in the classroom and the practical part which focuses on improving skills in the clinical area and prepares student nurses to be able of doing as well as knowing.\u003c/p\u003e \u003cp\u003eMotsaanaka et al., (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) also support the findings that placing large number of students in the clinical setting led to overcrowding creating challenges for students to integrate theory into practice. Kaphagawani \u0026amp; User (2013) also argue that students become anxious and confused if they practice something different from what they learn in classroom.\u003c/p\u003e \u003cp\u003eThe participant\u0026rsquo;s experiences indicated that there was a theory practice gap as what was taught in class was not what was practiced in the wards., indeed this gap was already pointed out by the relevant stakeholders during consultations with UNAM School of Nursing and Public Health. The University of Namibia embarked on a curriculum transformation after consultation with relevant stakeholders to come up with strategies to strengthen the closure of the theory practice gap in the School of Nursing in order to produce ready to work nurses for the market.\u003c/p\u003e"},{"header":"Sub theme: Effects of Covid 19","content":"\u003cp\u003eThe highly contagious and fatal nature of the Covid 19 continues to place immense pressure on hospitals and psychological wellbeing of healthcare workers. This pandemic has also affected clinical education for nursing students whose programme is already known to be highly stressful even without additional challenges presented by Covid \u0026minus;\u0026thinsp;19. The corona virus disease has led to fears and increased stress levels among nursing students who strive to acquire the requisite skills and competencies necessary for patient care (Baluwa et al \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGlobally, Corona virus disease 2019 has had negative consequences for higher education such as universities closing in response to lockdown measures. The School of Nursing and Public Health at the University of Namibia was no exception.\u003c/p\u003e \u003cp\u003eSome student stated that their clinical learning was negatively affected by Covid 19 for the past year and a half as they were withdrawn from the clinical practice and the lecturers and preceptors were also absent from clinical due to the fear of contracting Covid 19; the negative encounter was that the students missed out on clinical learning opportunities. The participants had this to say:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026rsquo;My clinical learning was also affected by Covid \u0026minus;\u0026thinsp;19 so since Covid \u0026minus;\u0026thinsp;19 came we were withdrawn from clinical and we were unable to go to work for almost half a year and so on and we were also not allowed to work in other departments since they were either turned in Covid wards or something like that this affected our teaching and experiences\u0026rsquo;\u0026rsquo; (FGD P 53, P 51).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis finding coincides with Triemsta et al., (2021) stating that the Covid 19 pandemic has forced learners and educators to rapidly adapt within their altered clinical learning environments personal separation, social distancing, organizational changes and the shift from physical to virtual learning environments have significantly disrupted the status quo. Hoofman \u0026amp; Secord, (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) stated that the Covid 19 pandemic has affected and will continue to affect the delivery of knowledge at all levels of education including nursing.\u003c/p\u003e \u003cp\u003eAgu, Stewart, Stewart \u0026amp; Rae, (2021) stated that the impact of Covid 19 on developing countries may be greater than in developed countries due to disparities. Online learning has become the solution to complete the curriculum, however it does not address the clinical component. Ulenaers, Grosemans, Schrooten \u0026amp; Bergs, (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) state that the students indicated that clinical placement during the pandemic was more demanding than usual, using various objectives such as: busy, insecure, hectic, difficult, rare, overwhelming, heavy, stressful, weird, unsafe and psychologically stressful\u003c/p\u003e \u003cp\u003eThe Republic of Namibia reported their first case of Covid 19 on 13 March 2020 and on the 14 of March the President of the country declared a state of emergency for the country leading to a lock down of borders and educational institution. In the same vein the UNAM School of Nursing and Public Health also withdrew their nursing students from the clinical settings. This decision affected the students clinical learning negatively as the students missed on clinical learning experiences because clinical cannot be done on line as the theoretical part.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eNEGATIVE ATTITUDES\u003c/h2\u003e \u003cp\u003eNursing staff negative attitude towards students and clinical instructors was one of the major factors that caused inappropriate interactions and it included poor communication skills and short duration of clinical experience (Mamaghani, 2018).\u003c/p\u003e \u003cp\u003eMost of the students across all years of study in the clinical learning experienced negative attitude from the clinical staff and clinical supervisors during their clinical placement. This was also shown by emerged sub themes from the study Nurses refusing to teach, name calling, comparing of students from different universities, male nurses harassing students, shouting at students and favoritism.\u003c/p\u003e \u003cp\u003eThis finding was analogous to a study by Rajewaran (2016) in Botswana arguing that lack of harmony, communication, and interpersonal relationship between the educator and the student negatively affect the clinical learning. The attitude, approach, interpersonal relationship and neutrality of the lecturers create trust among the studentsThis finding is similar to research done by Kalyani et al., (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) stating that the interpersonal relationship between the instructors and clinical nurses and the students plays an important role in the development of students personal and professional identities. The author further added that hopelessness was another psychological reaction created under the influence of nurses attitudes.\u003c/p\u003e \u003cp\u003eThe theme is in contradiction with Kolbs 1986 cycle of learning theory, the Concrete experience which may be attained through the process of apprehension, that is the learner sense what he or she feels in the environment. If it is negative energy the student nurse will not learn anything. This theme is evidence by participants experiences of negative attitude towards teaching and demonstrations by nurses, taking shortcuts, name calling and comparing students from UNAM and harassment by male nurses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Negative attitude towards teaching and demonstrations","content":"\u003cp\u003eThe concept academic incivility does not seem to be completely established yet, but is characterized by a violation of the norms of mutual respect in interpersonal interactions among faculty members, administrators and students. Academic incivility hinders teaching -learning activities between faculty members and students which puts the purpose of higher education institution at risk (Park \u0026amp; Kang,2021).\u003c/p\u003e \u003cp\u003eMost participants raised concern on nurses that refuse to teach them and sign their log books in the clinical, saying that it was not part of their duties. The negative attitude affected the students learning negatively as the students found it hard to learn on their own without demonstrations. The findings are stated below.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes, some of the nurses are just rude, keeping information to themselves and don\u0026rsquo;t like helping giving demonstrations teaching students, and they don\u0026rsquo;t like signing also. Sometimes you work with them but at the end of the day when you have to give feedback they will say, I never saw you where did you work such things and it is- not really good someone answering you like that\u0026rdquo;. (IFFI P 7, P 8 and P 9, FGD P17).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eShadadi, Sheyback, Balouchi \u0026amp; Shoorvazi, (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) state that the most important obstacle against clinical education is associated with nurses include inadequate knowledge and skills and uncooperativeness of the personnel.\u003c/p\u003e \u003cp\u003eIn a study by Webster, Browno, Maich \u0026amp; Patterson, (2016) argues that nursing behavior, attitude and willingness to teach have an important influence. If students do not feel wanted, trusted, respected or supported, or feel bullied, intimidated or treated unprofessionally the work place culture causes them to lose confidence. This hinders growth, resulting in inadequate preparation for professional nursing practice.\u003c/p\u003e \u003cp\u003eZiba, Yakong \u0026amp; Ali, (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) states that in Ghana it was regarded the responsibility of every registered nurse or midwife to provide teaching or guidance for students who work with them on their shift. The registered nurses supervise students and do not receive payment by any of the institutions for this service.\u003c/p\u003e"},{"header":"Taking shortcuts","content":"\u003cp\u003eWorkers in health care organizations thus develop workaround behavior in response to four factors they perceived: prevent or weaken the care they provide to their patients, are not in the best interest of their patients, make the realization of their job difficult or longer or potentially threaten professional relationships. Work arounds are created under the pressure to respect rules or meet other work demands, they can also have negative consequence such as medical errors which can subsequently lead to injuries (Mansour and Tremblay \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSafe and timely patient care also requires optimal coordination of staff, resources, equipment, schedules and tasks. However, health care workers encounter barriers when implementing these standards and engage in workarounds to overcome these barriers (Mula, Human and Middleton, 2019).\u003c/p\u003e \u003cp\u003eSome students from the study felt that some nurses were taking short cuts and were not willing to demonstrate the actual procedures. This was quoted below.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Some nurses do short cuts, so you will end up doing shortcuts as you see them doing. They don\u0026rsquo;t want to demonstrate because they don\u0026rsquo;t want us to know the shortcuts\u0026rdquo;. (FGD P13)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStudent nurses described challenges they experienced when observing risks to patient safety. Registered nurses request students to engage or conspire in unsafe practices, leading them to experience discomfort and remain silent. Student acknowledge they frequently remain silent due to the fear of negative consequences (Fagan, Lea and Parker, 2020). Moreover, this finding contradicts KELT 1984 second stage of learning reflective observation that state that a student learns by reflecting, if procedures are done the wrong way, the students will end up not learning.\u003c/p\u003e"},{"header":"Name calling and comparing students from UNAM","content":"\u003cp\u003eNurse eat their young is an unfortunate idiom understood and used by nurses internationally. Dishearteningly, the idiom has been in use for over 30 years. Nurses eating their young does not literally refer to being cannibalistic with other nurses but refer to bullying behaviors experienced by nurses (Gillespie, Grubb, Brown, Boesch and Ulrich, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Most participants experienced name calling and ill treatment during their clinical placement by the nurses, the negative experience made the student nurses feel hopeless and demoralized leading to poor learning outcomes and a feeling to quit. This experience was mostly encountered by the second- and third-year group, as fourth year participants were most likely to be respected as they were seniors. The participants further felt downgraded and demotivated by belittling from nurses in the wards as they always compare them to other institutions training nurses. Discriminatory behaviors and an unsupportive atmosphere in clinical environments as well as the negative attitude towards nursing students in clinical departments and the society, caused an inferiority complex, a sense of humiliation or deficiency in self-confidence in students this was quoted as follow.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The nurses blame you for things that they did when you were not there you come in the morning then you are blamed for something that you don\u0026rsquo;t know, that causes a very uncomfortable situation for us they will either call you stupid or incompetent but what they don\u0026rsquo;t understand is if you want your student to know something teach them on the first and second day but they don\u0026rsquo;t do that, they rather ridicule us, make fun of us, say the meanest things to us and they demoralize us. So, when they want you to do something we are not even comfortable because you know if you do something in a wrong way they will judge you saying what do they teach you in UNAM you guys are just useless\u0026rdquo;. (FGD P5, P7, P 8 and P36)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Kaphagawani (2016) agreed with the findings that some staff would talk down on students in the presence of patients, calling them names. As a result, patients sometimes refused for procedures to be done on them by students. In addition, student in most cases receive destructive feedback. Students were reprimanded in the presence of patients, other staff and students, and if make mistakes they were humiliated, insulted and laughed at in presence of guardians, who made students seek for withdrawal from clinical learning site. Such type of feedback instilled fear and caused students to refrain from performing any procedures in case they made mistakes causing them to lose opportunities for clinical learning.\u003c/p\u003e"},{"header":"Harassment by male nurses","content":"\u003cp\u003eSome female students articulated their distress at being harassed by male nurses if they refused- to play along with their advances. The students felt that they had to learn to deal with the harassment which resulted in them focusing less on learning as illustrated by the following quotations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The male staff members when they feel like they like you, you also see in the way they treat you, that is also were favoritism starts from. You will be doing the least but they will still sign and they will let you get away with anything, but the moment they ask for your number or visitation outside clinical environment and you turn it down you become a problem, you will no longer get signed it goes beyond critic even things you do no longer get signed for. You become a problem child all because you don\u0026rsquo;t want to entertain their advances\u0026rdquo; (FGD P 38).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eKahsay, Negarandeh \u0026amp; Nayeri et al., (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) indicated that the female nurses were harassed verbally as in unwanted mail-blackmail or telephone calls for sexual relations, asked their private matters, asked for a sexual relationship unwillingly and asked to do something sexual in exchange with for favors.\u003c/p\u003e \u003cp\u003eBullying is a systemic, pervasive problem that begins well before nursing school and continues throughout nurses career. A significant number of nurses leave their first job due to the negative behaviors of co-workers and bullying is likely to exacerbate the growing nurse shortage. Edmonson \u0026amp; Zelonka, (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe clinical learning setting must be a conducive environment to promote teaching and learning, and not be bullying ground where students feel hostile. Bullying in nursing is unacceptable and the profession should not tolerate any bullying of an individual.\u003c/p\u003e"},{"header":"Sub theme - Favoritism","content":"\u003cp\u003eUncivil clinical environment behavior can have a detrimental effect on the nursing students\u0026rsquo; morale, aversively affecting their motivation and ability to learn (El Hachi, 2019).\u003c/p\u003e \u003cp\u003e The participants experienced a feeling of victimization and discrimination in the wards by the nurses, as some nurses were having their favorite students or were favoring some students from other institutions. The nurses were choosing who to work with, who to teach and who to sign for without doing the actual procedures. The following quotes evidence the above:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In some ward,s there are some nurses who only want to work with specific students from a specific University \u0026ldquo;(FGD P10).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis finding is supported by Farzi, Shahriari \u0026amp; Farzi, (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) stating that in the clinical environment, the doctors and nurses show more attention to medical students than other students of health science including nursing students and this led to negative attitude of other students. This can have negative effects in creation learning opportunities and also can reduce learning motivation.\u003c/p\u003e \u003cp\u003eSimilarly, Hagrass et al., (20202) reveals that students experienced favoritism between college and university students during their clinical placement as more attention was given to college students. These results are further in agreement with the results from a study done by Mwai (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) that showed that the majority of student nurses did not feel welcomed from the nursing team and even many of them did not feel accepted.\u003c/p\u003e"},{"header":"Unapproachable nurses","content":"\u003cp\u003eIncivility in nursing education is a persistent global problem that threatens the psychological and physiological health of faculty and students. Incivility in nursing education is defined as a range of disruptive behaviors or failing to take actions when action is warranted. These behaviors and inactions may result in psychological or physiological distress for people involved- and if left unaddressed, may progress into threatening situations (Urban, Smith, Wilson \u0026amp; Cipher,2021).\u003c/p\u003e \u003cp\u003eMost students experienced unapproachable nurses in the clinical setting, where nurses are always angry and answering students inappropriately. This experience made students feel unwanted and afraid of asking questions to learn clinically.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSometimes you will be in a ward and they won\u0026rsquo;t even listen to what you have to say they will really downgrade you, really so demotivate you that you won\u0026rsquo;t even want to come to that certain ward the next day (FGD P 31).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThis result coincides with results from a study by Siew Yen (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) where results shows that student nurses described uncaring behaviors of instructors as a lack of interest in student nurses being unapproachable, refusing to give clarification on student nurses questions openly criticizing students nurses in front of others and being rigid, this uncaring behavior left the student nurses feeling powerless, intimidated, angry and it interfered with their learning.\u003c/p\u003e \u003cp\u003eThis finding was supported by Chapman (2002) as cited by Tiwaken et al (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) emphasizing that personal characteristics of a nurse and clinical instructor such as being supportive, encouraging, resourceful, confident, approachable, friendly, available, helpful. Understanding, welcoming and having students interest at heart were all important aspects which the students perceived as enhancing their clinical performance. The findings are also constant with the results from Kalyani et al (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) participants expressed feeling of missing out on many training opportunities because of the authoritarian and intimidating instructors who were unapproachable, difficult to communicate with and sarcastic.\u003c/p\u003e"},{"header":"Theme 4: Communication barrier","content":"\u003cp\u003e Communication is important in order to provide quality nursing care to the patient. Some participants reported that language barrier impeded their learning in the clinical setting. As much as English is the official language some nurses where teaching and reporting in their native languages felt that they were discriminated as some staff members where giving report and teaching in their native languages. A lack of common language between the clinical mentors and students made the clinical practice rather frustrating at times. Opportunity to observe and learn clinical procedures were most of the time missed because the students were busy trying to understand the language rather than clinical procedures, Mwai (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). This theme is supported by sub-themes of\u003c/p\u003e"},{"header":"Use of vernacular language and shouting at student nurse","content":"\u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme: Use of vernacular language\u003c/h2\u003e \u003cp\u003eNursing students with a native language other than that of the majority of their peers, might face an additional challenge when it comes to communication skills. Language competence is described as a prerequisite for good communication skills. Internationally, good communication skills are described as an important part of nurses core competencies, crucial for nursing practice and patients- centered care (Furness, Kvaal \u0026amp; Hoye,2018).\u003c/p\u003e \u003cp\u003eStudents acknowledged seeing disadvantages and limitations in their learning possibilities because of their different cultural background. The author further states that it was a serious challenge because language competence and good communication skills are crucial in enabling successful outcomes that lead to positive experiences in the clinical learning environment (Mikkonen et al., 2020).\u003c/p\u003e \u003cp\u003eSome participants felt that they faced discrimination, racism, neglect and isolation in the wards by the nurse in the wards. This feeling lead to lost learning opportunities as some students did not understand what the nurses where reporting or teaching fellow students doing it in a non-official vernacular language rather than in English. The students had this to narrate.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Language usage in certain wards where we go I will say certain sisters, and will just blame one tribe, most of the wards where we go the sisters think all students know how to speak local even when they are handing over they do it in a local language and some of us don\u0026rsquo;t understand and that makes us feel left out so it is better if they start using English as it is the official language for everyone, for all to be accommodated\u0026rdquo;. (FGD P7).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWeyman, (2018) argues that language barrier and culture differences can become detrimental stumbling blocks barring the way to clinical learning success.\u003c/p\u003e \u003cp\u003eEl Shamsi, Almutairi Al mashrafi \u0026amp; Kalbani, (2020) state that language barrier can make the delivery of high-quality healthcare very challenging, it has a negative impact on the quality of healthcare, patient safety and the satisfaction of medical professionals and patients\u003c/p\u003e \u003cp\u003eIn another studies Mwai (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) and Baraz, Memarian and Vanaki, (2015) a student stated that documentation, giving and receiving report clinical staff was challenging because even if they knew what they wanted to say, they couldn\u0026rsquo;t express it completely in Finnish language. Students with good command of Finnish language seemed to settle in their clinical environments easier.\u003c/p\u003e \u003cp\u003eIt was also pointed out that useful professional communication of the instructors and nursing personnel with the students is important to facilitate learning and socialization of nursing students.\u003c/p\u003e \u003c/div\u003e"},{"header":"Sub-theme: Shouting","content":"\u003cp\u003eNursing students mentioned shouting, isolation, humiliation and being assigned work below their competency level as their commonly experienced bullying behaviors. The majority of the students shared that they have experienced shouting and described it as a bad experience that should be stopped (Amoo, Menlah, Garti and Appiah, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome participants felt that some nurses are rude as they don\u0026rsquo;t know how to approach and reprimand students they just shout in front of other students making look useless and making them feel hopeless.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The general nursing lecturers and nurses don\u0026rsquo;t have that heart on speaking to students without freaking them out and show them some love. They will come to you in a way that no-one? wants want to be approached, you cannot come to a student shouting in front of the other students. The other preceptor shouted at a student saying you cannot dress like that you look like an ambulance driver\u0026rdquo;. (FGD P40 FGD P 35)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis finding relates to a report from Rahman (2013) that students reported being yelled at or shouted at or were behaved toward in an inappropriate, nasty, rude or hostile way, or were belittled or humiliated. Ali \u0026amp; Ali (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) agree with findings from this study where students complained about poor communication between students and clinical staff and the cooperation was barely with each other and which inevitably lead to frustration and demotivation thus, negatively affecting students learning in acquisition of knowledge and skills. The authors further state that proper communication between key stakeholders can support and simplify the clinical learning community and help to illustrate the roles of both students and clinical nurses.\u003c/p\u003e"},{"header":"Discussion and Conclusion","content":"\u003cp\u003e \u003cb\u003eObjective One: Explore the clinical learning experiences by Bachelor of Nursing Science degree students in general wards at the public training hospitals Khomas.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eClinical learning experiences in the Bachelors of Nursing Science degree in general wards at the public training hospitals, Khomas region was explored by conducting focus group discussions and face to face interviews with the concerned group of students.\u003c/p\u003e \u003cp\u003eIt can be concluded that there are limited learning opportunities for nursing students in the clinical setting in all the levels of year studies. The study revealed that students encountered several constraints during their clinical placement that negatively affected their clinical learning during their placement. Some of the negative experiences included overcrowding in the wards, resulting in to reduced learning opportunities and frustrations in the clinical setting. The participants also mentioned that there was a shortage of equipment and manpower in the clinical setting that affected their learning as the procedures were not executed up to the expected standard and there was no body to monitor when procedures where performed clinically.\u003c/p\u003e \u003cp\u003eIt was further revealed that students fell victim in the clinical setting by the nurses as they were called names, were bullied and compared to other training institutions. They also encountered favoritism and faced a language barrier. As a result of the use of local languages instead of English, declared as national language in the country.\u003c/p\u003e \u003cp\u003eThe participants from the study also mentioned that they missed out on important learning opportunities due to Covid \u0026minus;\u0026thinsp;19 pandemic as they were withdrawn from the clinical setting by the University in concern to their health safety in the clinical setting, or they were either confined to a few wards as other wards did accommodate Covid \u0026minus;\u0026thinsp;19 patients and there was no learning taking place.\u003c/p\u003e \u003cp\u003e \u003cb\u003eObjective two: Describe the clinical learning experiences by Bachelor of Nursing Science degree students in general wards at the public training hospitals Khomas Region.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIt was noted that across all the years of study, that all participants from the IFFI Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and FGD Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e to \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e experienced an unconducive clinical learning environment, due to the fact that there was overcrowding, less placement time, no orientation on placement and delegation in the clinical environment these led to students competing for procedures among themselves to learn and complete their log books. The participants also felt that they were getting lost in the wards as they had nothing to do because there was no orientation and delegation. The participants further mentioned that there were discrepancies on what is taught in class and what is practiced in the clinical settings because of the lack of equipment in the clinical area. This finding also provided evidence that the preceptors were forcing students to do practical exams without prior preparation. This finding made students very uncomfortable as they were working under pressure and did not feel they are learning.\u003c/p\u003e \u003cp\u003eThe participants also agreed that Staff shortage affected nursing students negatively as all participants mentioned that they were not taught, or demonstrated to and were working unsupervised. They also feel they are overworked. The participants agreed that this experience made them work under fear of making mistakes and risking their own education as they had minimal skills to practice. The participant also felt that the shortage of staff led to them students to become fatigued and less functional, leading to poor concentration, poor learning and being less productive to carry out nursing care.\u003c/p\u003e \u003cp\u003eAs much as the students were concerned about clinical learning the attitude of the nurses in the clinical, preceptors and lecturers were not welcoming towards students. This was noted by all year levels revealing that the nurse was calling them names, comparing them to students from other Universities, shouting at them and refusing to teach them, that experience made them feel useless, demoralized and some mentioned that they felt like quitting. The female participants also expressed their uncomfortable clinical learning experiences whereby some male nurses are proposing to them in the clinical area which leads to hostility, favoritism and nurses refusing to sign if advances are rejected or disapproved.\u003c/p\u003e \u003cp\u003e Some participants agreed that there was indeed a language barrier in the clinical area were some nurses refused to communicate in the official language and only communicate in their native language. In the same vein the students also showed their dismay on the fact that some nurses don\u0026rsquo;t know how to communicate at all and only shout and scream in the clinical area which affect their clinical learning in negative way as they missed out on important morning reports and teaching opportunities that were done in a non-official language. The experience made them feel isolated, discriminated, demoralized and unwanted in the clinical setting.\u003c/p\u003e"},{"header":"Study limitations","content":"\u003cp\u003eThe following were identified as limitations during the study:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe sample of the study was expected to include 312 nursing student\u0026rsquo;s participants but saturation was reached at 61participants from 9 individual face to face interviews and 8 focus group discussions consisting of 7 participants each (Sunders et al., 2018). Therefore, generalization to other campuses cannot be done.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe exclusion of first year bachelor\u0026rsquo;s nursing students from the study due to their limited clinical exposure.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe study was further limited to the two training hospitals Khomas Region, Windhoek Central Hospital and the Katutura Intermediate Hospital and findings cannot be generalized to other hospitals.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eNotwithstanding its limitations this study has provided important information regarding the clinical learning experiences of nursing degree students at the public training hospitals Windhoek: Khomas region, Namibia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDeclarations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e \u003cb\u003eEthical considerations\u003c/b\u003e \u003c/p\u003e \u003c/p\u003e\u003ch2\u003eDeclarations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eConsent to Publish\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eDeclarations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eCompeting interest\u003c/strong\u003e \u003cp\u003eThe authors declared no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was received for this study\u003c/p\u003e\u003ch2\u003eAuthors contribution\u003c/h2\u003e \u003cp\u003e* Joseph Galukeni Kadhila was the principle investigator, conceptualized the study, responsible for literature review and data collection and manuscript preparation University of Namibia 2. Louise Pretorius was responsible for supervisory role and the guaranteed the integrity of the study.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e \u003cp\u003eSpecial thanks go to the students nurse who participated in the study, as well as the university for granting me permission for their facilities to be accessed for completion of the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbd E, Rahman RM. (2014). Perception of student nurses' bullying behaviours and coping strategies used in clinical settings.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgu CF, Stewart J, McFarlane-Stewart N, Rae T. COVID‐19 pandemic effects on nursing education: looking through the lens of a developing country. Int Nurs Rev. 2021;68(2):153\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Shamsi H, Almutairi AG, Mashrafi A, S., \u0026amp; Kalbani A, T. Implications of language barriers for healthcare: a systematic review. Oman Med J. 2020;35(2):e122.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Qadi MM. Workplace violence in nursing: A concept analysis. J Occup Health. 2021;63(1):e12226.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli GEN, Ali NM. Clinical learning environment and the influential factors from nursing students perspectives. ດ຋௾ຑ ໲໧اد௾໣ໟا مໟ໌ທໟا ل໣او໌ໟاو. kufa J Nurs Sci. 2017;7(2):1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmoo SA, Menlah A, Garti I, Appiah EO. Bullying in the clinical setting: Lived experiences of nursing students in the Central Region of Ghana. PLoS ONE. 2021;16(9):e0257620.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsif H, McInnis C, Dang F, Ajzenberg H, Wang PL, Mosa A, Winthrop A. 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Theory guided practice in nursing. J Nurs Res Pract. 2018;2(1):18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShadadi H, Sheyback M, Balouchi A, Shoorvazi M. The barriers of clinical education in nursing: A systematic review. Biomed Res. 2018;29(19):3616\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiwaken SU, Caranto LC, David JJT. The real world: Lived experiences of student nurses during clinical practice. Int J Nurs Sci. 2015;5(2):66\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTenfelde S, Fantasia HC. (2018). Navigating challenges for preceptors: Results from the WHNP Workforce Survey.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTriemstra JD, Haas MR, Bhavsar-Burke I, Gottlieb-Smith R, Wolff M, Shelgikar AV, \u0026hellip; Ellinas H. Impact of the COVID-19 Pandemic on the Clinical Learning Environment. Addressing Identified Gaps and Seizing Opportunities; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUlenaers 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.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUrban RW, Smith JG, Wilson ST, Cipher DJ. Relationships among stress, resilience, and incivility in undergraduate nursing students and faculty during the COVID-19 pandemic: Policy implications for nurse leaders. J Prof Nurs. 2021;37(6):1063\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWyman MF, Shiovitz-Ezra S, Bengel J. Ageism in the health care system: Providers, patients, and systems. In: Contemporary perspectives on ageism. Cham: Springer; 2018. pp.\u0026nbsp;193\u0026ndash;212.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYen AL. UNIMAS Nursing Students\u0026rsquo; Experiences During Clinical Attachment in Sarawak General Hospital (SGH), Kuching. \u003cem\u003eUniversiti Malaysia Sarawak\u003c/em\u003e; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZiba FA, Yakong VN, Ali Z. Clinical learning environment of nursing and midwifery students in Ghana. BMC Nurs. 2021;20(1):1-.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Unsectioned Paragraphs","content":"\u003cp\u003ePermission to conduct the study was obtained from the School of Nursing Post Graduate Studies Committee and The University of Namibia Post Graduate Studies Committee for ethical clearance from UNAM Health Research and Ethical Committee (HREC) on the 16 of August 2021, all research principles where adhered to and respected throughout this study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eWritten informed consent\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWritten informed consent was obtained from each participant after the procedure either focus group discussion or interview was explained. A written informed consent was obtained from the nursing students after adequate information about the study were conveyed, possible risks were pointed out. This included the explanation that they are voluntarily participating and that no coercion will be enforced (Polit \u0026amp; Beck, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe data that supports the findings are available from the corresponding author Joseph Galukeni Kadhila on a reasonable request.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDisclaimer\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAuthors details\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e*Joseph Galukeni Kadhila, School of Nursing and Public Health, Faculty of Health Sciences and Veterinary Medicine, University of Namibia. 2. Professor Louise Pretorius School of Nursing and Public Health, Faculty of Health Sciences and Veterinary Medicine, University of Namibia.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-2277663/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2277663/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eIntroduction\u003c/b\u003e: Clinical placement provides an opportunity for socialization of students into the health system, and to acquire practice clinical skills in a real life setting while observing the deliverance of care by others. Despite the obvious benefits of clinical placements for students, poor relationships with the supervising nurse, environments that fail to promote belongingness and a lack of supervision hinders learning in the clinical setting. The purpose of the study was to assess the clinical learning experiences of the nursing degree students in general wards at the public training hospitals in Khomas Region.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAims\u003c/b\u003e: of the study were to explore and describe the clinical learning experiences by nursing degree students in general wards at the public training hospitals Khomas.\u003c/p\u003e \u003cp\u003eThe study aimed at answering the following central question: \u003cem\u003eTell me about your clinical learning experiences during your placement in general nursing wards of the two training hospitals in the Khomas region?\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e: In this study, the researcher selected a qualitative, explorative, descriptive and contextual design and 51 participants from the undergraduate second years, third years and fourth years were recruited. The data collection included 11-individual face to face interviews and the 8 Focus Group Discussions using semi structured interviews. Data was manually coded and analyzed using the Tesch\u0026rsquo;s method of data analyzes.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e: Four themes emerged from the exploration and description of nursing students clinical learning experiences. These were non-conducive learning environment, negative staff attitude, communication as barrier and shortage of staff.\u003c/p\u003e \u003cp\u003eThe results show that there were indeed constraints to learning in the clinical setting across all the years of study.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e: Recommendations were made to the School of Nursing, the training hospitals and the Ministry of Health and Social services. Further research is needed on the clinical learning experiences of nursing students in other regions, and the lecturer\u0026rsquo;s experiences on clinical accompaniments. Hence, this study assessed clinical learning experiences of nursing degree students at the public training hospitals: Khomas region, Namibia.\u003c/p\u003e","manuscriptTitle":"CLINICAL LEARNING EXPERIENCES OF NURSING DEGREE STUDENTS AT THE PUBLIC TRAINING HOSPITALS: KHOMAS REGION, NAMIBIA","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-26 17:59:00","doi":"10.21203/rs.3.rs-2277663/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aef2aaa6-924a-4637-92dd-58dac4534c9d","owner":[],"postedDate":"November 26th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-02-03T06:59:24+00:00","versionOfRecord":[],"versionCreatedAt":"2022-11-26 17:59:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2277663","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2277663","identity":"rs-2277663","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}