The Situation: Caring and Reality Shock

Knowledge and skills were identified as key concepts in all groups. Exposure to clinical practice was confronting for some respondents, particularly if they were left to do things on their own and as one participant recalled …it was my first shift and not only was I

overwhelmed but to be left with a patient, I felt scared that something was going to happen as I had no previous experience (ID: BH - Competent). Although nursing students work with a buddy, there are occasions when they are left on their own to manage situations outside of their control. One respondent noted …the cause of frustration and annoyance by both parties was caused by the break in communication… referring to a

misunderstanding between the patient and nurse. After involvement in an unavoidable, conflict situation, one student questioned their career choice… As a result of this experience I began to question my career path and whether I was equipped for the situation that the career holds… (ID: AJ - Competent).

However, the picture is not always negative; some participants sought positive outcomes; for example, one nursing student reflected that …being thrown right in really helps you get an idea what this career is about … (ID: BG - Competent). For example; one student revealed that they gained something from this experience: …I give each patient encounter the best care and notice the even the subtle things so that hopefully in the future I am able to help … (ID: CV - Consider Developing). Others tended to relate a lack of experience and knowledge to a deficit that they needed to overcome …to the limited experience I had not encountered this problem before … (ID: BL - Consider Developing) and … be able to accept the experience and am willing to acknowledge it as a learning opportunity …(ID: AE - Consider Developing). Some students reflected on what they would do differently in the future…Initially I was extremely anxious about providing complex care to a patient with such limited knowledge … If the situation was to arise again, I would use different verbal communication instructions, simple and short sentences … (ID: BO - Skilled).

The lack of experience or knowledge deficit was discussed in terms of the impact on their future learning… learning to be compassionate towards saddened family members … (ID: BA - Consider Developing). One student noted that …I am excited to broaden my

knowledge and skills that will help me finish my course in becoming a nurse ... (ID: BG - Competent). In general, most respondents were positive about their learning. Others

reflected that learning to stay calm and in control would be of benefit as patients would feel more confident in the skills of the nursing student.

One nursing student described an affective event from a personal perspective after not being able to keep up with a heavy workload, writing that…unfortunately, being proud the criticism negatively affected me …. The shift was quite intense, and I was feeling sad…

Further they described feeling …like an absolute failure and felt as though I did nothing to help…I was very anxious, but I tried my best to be calm. I asked myself “what the hell am I doing here?”(ID: AE - Consider Developing). One participant described their reactions on …being informed that the patient was terminal came as an overwhelming shock as he presented with no symptoms… (ID: AT - Consider Developing). Another student reflected on their feelings when a patient had been given a poor prognosis … I froze … I didn't know how to control the situation as I was just as heartbroken as the patient… (ID: CO - Skilled)

Some respondents reflected on concerns about lack of confidence and knowledge …was emotional for me as it was my first shift and not only was I overwhelmed but to be left with a patient, I felt scared that something was going to happen… had nothing to relate to so being left all of a sudden after only class skills sessions…was overwhelmed by the expectance that my nurse had of me … (ID: BH - Competent). Others recalled an

interaction with confused and agitated patients which created a sense of fear, for example; ...this influenced my confidence in dealing with the situation. I became quite distressed myself, as the patient proceeded to grab me and pull on me … (ID: AJ - Competent). These reflections implied a real sense of fear and lack of preparation for clinical placement mirrors other evidence in the nursing literature. The Skilled group discussed similar issues, particularly about their fears and feelings during patient interaction. One nursing student reflected on being confronted with an agitated patient… I sort of froze and had a ’mini panic attack’ as I had never faced this before… (ID: CT - Skilled). Although this nursing student viewed this as knowledge and communication skill development, they did experience some level of sadness on the realisation of the patients’ poor condition.

Unfortunately, the negative emotion of fear and anxiety occurred in several reflections. The nursing students tended to be quite descriptive in their recollections, for example, one student related that … I remained calm although I was extremely terrified! …When I was alone with the patient, I felt negative emotions because I thought I did something wrong … At this stage I was feeling extremely anxious and responsible for the situation … (ID: AW - Skilled).These reflections demonstrate that nursing students are faced with confronting situations, and each manages the effects differently in terms of coping strategies. Care was discussed in relation to workload, stress and lack of time; for example; one nursing student described concern when identifying that a patient was depressed and unsure of their prognosis. The respondent noted that spending time with patients was sometimes overlooked because of workload pressures: …this experience showed me just how important it is to build a good relationship with each patient through communication. This can sometimes be missed when nurses are busy; however, this experience taught me the importance of not letting this happen…(ID: AV - Consider Developing). In the

Competent group, respondents discussed similar barriers to care …it was difficult to feel that we had enough time to spend with the patient ... (ID: CD - Competent). Other

respondents discussed their perception of compassionate care in a rapidly changing care situation and how, as a result, their skills were developing, , …was forced to think quickly, as well as unexpectedly, and I also expanded my compassion skills towards the patient and learned from my nurse… (ID: CR - Competent).

A lack of time to provide care was highlighted by one respondent who commented that they felt as though they were … put into a situation that made me somewhat

uncomfortable. The ward was very busy and the nurse I was working with was being called in every direction by patients wanting all different things at the same time… (ID: AI -

Skilled). This extract demonstrates a level of compassion and emotional engagement as a result of challenges to both time and knowledge resources, such that the student felt as though they were personally responsible for care provision in less than adequate

conditions. Some respondents viewed the lack of time and knowledge as a challenge for which they felt personally responsible … was also hesitant as the patient had dementia as well as complex health care needs and I felt out of my own comfort zone… I felt sad that the patient was confused with her surroundings. I felt extremely responsible and a

“burden” of care that I had to provide so many aspects of care to her in a limited time and with such limited experience … (ID: BO - Skilled).

Reasons for fear varied from being left alone to being involved in emergencies. The skilled group tended to view their experiences through a future planning lens.;Some participants described goals for their learning …I would require additional knowledge if I was to encounter a similar situation in the future… better coping mechanisms for performing under stressors [sic]… (ID: BC - Consider Developing). Others described their interaction with the staff that they were working with. Being asked to perform tasks outside of the nursing student scope of practice was one area that caused distress. For example: … I explained that this was not within the scope of the work that I could do. She was not impressed and left the room telling me to stay with the patient… (ID: BY - Competent).

Another respondent reflected on being asked to work outside of the nursing students’ scope of practice, perceiving criticism from the buddy nurse with whom they were working.