Standards in the clinical learning environment

Participants expressed that educators did not trust the standards of the professional nurses because frequently no supervision took place to ensure that procedures were implemented correctly as students were taught. Standardisation is required in the CLEs to ensure trust in students’ experiences during WIL. Professionals with low standards, allowing and implementing incorrect procedures are not trusted. Participants were concerned that the low standards were regarded acceptable and this impeded the clinical learning for students.

“The standards ... I think there is a real break in the standards the students are experiencing in the ward.” (C1)

“Now the people in the clinical area they also ... we do not trust them in terms of ... they do not do the correct things, you find that even the procedures they are not being done the way it is supposed to be done.” (B1)

“Oh, I think our standards are [smiling and laughing] not even half way how it should be. I think we are accepting ... our standards are too low. I ... because people’s attitudes are … as well as ... what can we do about it. There is nothing we can do about it. If there is no money, there are no resources. So we just ...

have to accept that. And we accept that. So ... our standards ... [smiling and laughing]. I am embarrassed to say it.” (C3)

Participants maintained that teaching and learning during WIL were crucially important for students. Professional nurses were a key figure in these areas. Standards should be maintained during clinical learning to support the quality teaching and learning, quality of nursing care and ensure the trust in qualified competent professional nurses in the society. These standards of nursing care and professional nurses are evident in their professional behaviour.

3.6.3 Professional credibility

Participants expected professional nurses to set a professional example in the CLE for students to imitate. Professionalism is a basic requirement in nursing and should be demonstrated by all professional nurses. Professional nurses are trusted when they live out their values and ethical code of the profession.

“Look, your professionalism is … the foundation of everything. If it is not there, there is nothing. Without professionalism there cannot be trust between anybody or group. Because professionalism ... professionalism says that you are a person with certain values, certain ethical norms, certain discipline. This behaviour can be expected of them.” (D2)

The professional credibility of professional nurses relied on attributes which support their trustworthiness, professional values and behaviours.

3.6.3.1 Attributes of trustworthiness

Professional nurses are considered as trustworthy by the educators when they show caring qualities, integrity, openness, honesty, and reliability.

3.6.3.1.1 Integrity

Participants professed that educators trusted the integrity of the professional nurses when students were placed in the clinical environment. Professional nurses’ integrity

meant that they took responsibility to create learning opportunities for students as well as supervise and teach students. The educators could not always be in the CLE; therefore, they trusted professional nurses to create learning opportunities during WIL.

“We place a whole lot of trust in them [professional nurses], we cannot be there always. We are not their supervisors. When we get there, we sometimes see problems and then we discuss it with them. Then we trust that they will correct that, but we actually place the students there with the confidence and the assumption that they will look after them, and make sure they work the hours and not sign it if they haven’t, and teach them when there are opportunities for them. I think there is a lot of trust in them from our side, because we cannot always follow up and because we do not have any authority over them. I cannot tell them what to do. I can only ask them to help the students.” (A3)

As educators expected professional nurses to have integrity, participants considered that openness of professional nurses would contribute to positive learning experiences for students.

3.6.3.1.2 Openness

Professional nurses should be accessible and approachable for students. Participants mentioned that students obtained more openness from professional nurses in a private clinical environment than in the public clinical environments. In the private clinical environments professional nurses were open and supportive, and assisted and helped students.

“Related to that, there is more support and a lot of assistance, then they trust those staff members, also to help them.” (D4)

Professional nurses should be open to theory and practice integration and this would create a conducive and positive clinical environment which ensured learning opportunities. The professional nurses, who were not willing to teach the students, put forward different reasons why they did not teach and this caused confusion. A lack of openness on the side of the professionals caused educators to be unsure whether students really obtained the learning opportunities that were expected in the specific CLE.

“So you are, one is, never sure whether it is burnout or lack of supervision of the clinical to our students. In general they do not get enough supervision and enough mentoring in the clinical setting as one would want them to get. Now it takes you to check it, what is their attitude, what is making them do that. Is it the shortage or is it the personnel who just are not interested in the student.” (C2)

Participants had the view that professional nurses needed to open up to students in the CLE. Professional nurses with openness are trusted, and valuable in the CLE. When professional nurses were not open, honesty was the next concern.

3.6.3.1.3 Honesty

Participants were concerned that professional nurses were not always honest. Some would sign off duties of students without ensuring whether the students actually were on duty to utilise the correct learning opportunities and meet the required hours for their WIL. When dishonesty of professional nurses is noticed, the trust is broken.

“... so it is like when they sign their attendance registers - sometimes they just sign, so whether the students were there or not. We might find out if they were there, and then we checked on the attendance register and find that it was not signed for that day, so it is difficult to say ... I do not want to say that it is hard to trust them. ... So, but is it trust, hey? You trust them to do the job correctly and they don’t. So there is a little bit of a ... not well feeling.’ (C3)

The honesty and integrity of the professional nurses obviously were not trusted, for example when they signed documents without verifying whether the students really achieved the prescribed outcomes.

“A little bit of mistrust, believing. Did they actually do this or didn’t they? Because we know that some of the people, not all of them, some of them, are like the students who do their work - they just do it to get it done. They’ll just sign it, just to get it done.” (C3)

3.6.3.1.4 Reliability

Reliability refers to professional nurses who are available and support students. Participants indicated that students felt safe when professional nurses were accessible for support. They mentioned that students did not trust professional nurses who displayed unreliable behaviour because they put students in risky situations where students had to work outside their scope of practice. Professional nurses then did not take responsibility for mistakes that might be made.

“... also there is a lack of trust in the professional nurses themselves, because they absent themselves and then the students have to remain in the wards alone and you find that the professional nurses are absent and then they leave the student ... And then the student loses trust in the sisters because they are supposed to be there.” (B1)

“… you find that when the student is working in that section, they leave the student to do whatever, and the student is angry with the sister. You know there are those problems - we are experiencing them and sometimes you will sit down and talk to the sister and then talk to the student so that the student in the end will get the proper guidance.” (C1)

In the study of Strouse and Nickerson (2016:12-14) caring, altruism and trustworthiness were used to describe expected characteristics of nurses, and these are important for the culture of nursing. The findings of Laabs (2011:433) indicate that a nurse has moral integrity when honesty, trustworthiness and consistency in behaviour are observable. Professional nurses’ attributes of trustworthiness mentioned in the current study included integrity, openness, honesty and reliability. Professional nurses in the CLE should portray professional values to enhance nursing care.

3.6.3.2 Professional values

Participants were concerned that a lack of professionalism among professional nurses was due to the lack of internalising professional values. Educators reported that students complained about a lack of professional values in some professional nurses. These professionals expected students to bribe or do favours for them, before they would sign for achieved learning outcomes. Some professional nurses did not abide by

ethical codes; they did not disclose misconduct of students, for example, they did not expose students when they were not on duty.

“… because the person has probably not internalised it, because, I feel it has not such a strong bond with his own value system, will also then act unprofessionally due to the experience in the unprofessional side.” (D3)

“You will not be able to know anything about student absenteeism. And some of the professional nurses, they are sort of covering for the students - their wrong doings, and they do not even report to the college that so and so has been absent for this time until the lecturers go to the ward and discover that the student was absent. However, it is not all the sisters, some are really reporting.” (C1) “... I do not experience that, but students do say they refuse to sign unless they do something in return.” (A3)

Professional nurses are the leaders in the clinical area. Gaiter (2013:325) explains that leaders with integrity act consistently according to their own values and do not hide important information and break promises.

According to the participants, professional nurses should have taken responsibility to report absenteeism of students and to discipline them. The professional values of the professional nurse include reporting of misconduct of students. Participants also expected that the professional nurses’ personal and professional values should correlate to ensure trustworthiness. The steadfastness of the professional nurse is questioned when there is a lack of these values.

“Your values of your profession will cause you to adhere to them or not. There must be a marriage between the values of the profession and your values and I must recognise that this is so and you must be able to see it in me, then we can have a trust relationship. More so, if I do not see the profession’s values, then I cannot trust you.” (D5)

“Then one wonders about the value system of the people who are in practice. I feel if you have an ingrained value system it has to do with how you look, present yourself and how you act, what service you render - then one wonders about the

value system. One is making an assumption, ’What value systems do they have in practice ... the person in practice?’ Their behaviour is unprofessional.” (D4)

Professional nurses as leaders in the clinical area should build a trusting character, be morally decent and have integrity with continuous honesty (Gaiter 2013:325).

Strong and consistent values of the professional nurses portray an image of professionalism and render them trustworthy.

“I think it is important because a person who has a fixed system, is sort of linked to a person who appears to be more professional. Because this person is proud of his values; he takes pride in himself and his own inner value system.” (D4)

Gaiter (2013:327) concludes that leaders who stand for their own values receive in return self-trust and trust from their subordinates.

Participants viewed that professional nurses could not be trusted if they do not display professionalism. Any image of unprofessional behaviour causes a lack of trust in the professional nurse who is not competent in some skills.

“If there is no professionalism then I do not trust the rest. If a person throws away the basic ethical things, then for all I know that person is no longer competent ... Once you have that image, it gives you trust for the rest. If you have that basic professionalism, you have the skill and you will be professional enough to acquire those competencies.” (D2)

The values of the professional nurses were built on integrity, honesty and respect. These values of professional nurses would have an impact on the behaviour of the professional nurse.

3.6.3.3 Professional behaviour

Adherence to professional guidelines and behaviour is expected of professional nurses. This includes knowledge and the implementation of policies. Participants viewed ethical considerations as a high priority in the clinical practice of the professional nurse.

Complying with expectations such as critical thinking, problem solving and experience of professionalism created trust in professional nurses.

“So everything must come from this professional behaviour. You cannot just do what you want to, one day this and the next that, you have guidelines. I believe a professional person is someone who can think quickly, has knowledge, knows the policies and procedures, knows how things are done, because that is the only way in which she can do things correctly in a professional capacity. It also lies within yourself, your self-respect, your ethical environment and what is right is right, fairness … you know such professional ways of doing things.” (D4)

According to the participants, professional nurses’ professional behaviour creates and enhances an atmosphere of trust in the CLE where students have to work and be trained. A participant construed that professional behaviour inspired students to provide nursing care in the same way as the professional example they were exposed to.

“Because from it … is trust, it will definitely create trust. When you think about a sister, with whom I worked, I think of a ward where I worked or a unit where I worked when I was a student ... and how professional those were, it built me and taught me how to nurse.” (D4)

The professional nurse should be a role model in the CLE. However, participants expressed that few role models were evident in the CLEs. This lack of role modelling by professional nurses was a concern for participants.

“... As a professional nurse you should be a role model. If you walk, it should be seen as this is how the professional nurse walks.” (B1)

“The professional role model - there are very few, very few role models if there are any, because most of the time you find that when the students are working in that direction, they leave the student to do whatever, and the student becomes angry towards the sister.” (C1)

“Well ... we are on the below 50 side of the availability of role models in the clinical setting. That is my personal view. And you’ve got 60% plus of personnel you would not prefer to be a role model. And then, unfortunately, the professional nurses that we are getting now, clinical areas are our products that we made,

then ... and one is not sure ... is it us or the clinical setting that is the creators of these ‘role models’?” (C2)

“Students are really negative towards the clinical area and persons in practice. Here and there you will find a person who stands out where they will say, ‘This Mr or that sister was really helpful and made an effort to assist us’. There are, however, many more who tend to be negative and then say, ‘The sisters are so rude towards us, we do not really get support from them’ ...” (D4)

Russell (2014:313) construes that professional conduct and role models in teaching virtue and ethics to students cannot be overstated. Role models strive to achieve professional ideals and foster professional growth. When educators place students in clinical areas, they should be aware of the negative atmosphere that may exist and be aware of the influence it might have on students.

Professional credibility is based on the integrity and values of the professional nurse. This has an impact on their behaviour and how available they would be to respond to students’ needs and support students in the CLE.