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CHAPTER I INTRODUCTION Background of the Study Nursing today, faces a lot of challenges.

Perhaps this is secondary to the fact that nowadays, the population of the student nurses and nursing graduate are rising and that there is a continuous decline in the national passing rate of the nursing professionals. These raised an alarming concern regarding the quality of nursing education here in the Philippines. Clinical Performance is a measure of the quality of the processes by which the knowledge learned in the classroom, the philosophies, procedures and its rationale are being applied. It also involves the measure of the outcomes that patients experience. In this study, clinical performance is defined as how well the 1st year nursing students of Lorma Colleges are able to integrate the theories theyve learned in providing care to patients during their first clinical exposure. New trend in the nursing course is the new curriculum wherein one of its features is to expose the students in the clinical area as early as possible. The newest program of the Commission on Higher Education (CHED) for the nursing students and nursing schools included the early exposure to clinical area, advanced learning of the nursing theories and procedures and early capping and pinning ceremony. According to the CHED Memorandum Order No. 14 Series of 2009, this curriculum is a four-year program consisting of general education and professional courses. Professional courses begin in the first year and threads through the development of competencies up the fourth

2 year level. The BSN program provides an intensive nursing practicum that will refine clinical skills from the first year level to ensure basic clinical competencies required of a beginning nurse practitioner. All college students face challenges such as financial restraints, challenging courses, adapting to new experiences, and peer pressure. However, nursing students may have additional stressful situations to consider. Research indicates that nursing students claim course structure, clinical experiences, and lack of support are common themes for producing stress (Gibbons, Dempster, & Moutray, 2007). Jones and Johnston (1997) reported an additional source of stress for nursing students is the demand of working with sick patients in a variety of settings while preparing for exams. Nursing students describe the experience of nursing school as unique in that there is additional anxiety associated with clinical placement, lack of free time, fear of failure, long study hours, and college response to the needs of students. The definition of nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations (American Nurses Association, 2003, p.7). Since health care professionals provide care to the public, the perception of unstable nurses causes serious concern among society and nursing professionals. Nursing education consists theoretical and practical training provided to nurses with the purpose to prepare them for their duties as nursing care professionals. It includes classroom instruction and supervised nursing practice in hospital and other health

3 facilities. It is in the classroom that nursing students learn theories, principles and ideas. We all know that the central purpose of classroom is to build and maintain a learning environment that fosters both effective and efficient instruction. Experienced nurses and other medical professionals who have qualified or experienced for educational tasks provide this education to nursing students (Stanfield & Hui, 1998). Nursing education has also been a part of all the issues concerning the quality education regarding on the academic performance and clinical performance of students. Academic performance really means three things; the ability to study and remember facts, being able to study effectively and see how facts fit together and from larger pattern of knowledge area, being able to think for yourself in relation to facts and thirdly, being able to communicate your knowledge verbally or down on paper (Raise Your Academic Performance, 2007). Nursing education requires some references to the environment of the clinical setting particularly the hospital. A hospital is a place where highly trained professional perform health services and a venues for diagnostic and therapeutic care devoid to maintenance and operation of facilities and treatment individual who are suffering from various illness. The clinical experience provides the opportunity for nursing student to start thinking like a professional. Clinical experience is a voluntary experience or employment in the medical field, preferably in the area that interests you the most as a potential career (Bridging the gap between knowledge and practice, 2005). A major task of nursing during this decade has been translating principles into responsible practice while keeping pace with the demands of modern society. The field of

4 nursing is synonymous with specialization, hallmark of a mature discipline. The changes occurred in the health care delivery system must be accompanied by improvement in the nursing education to provide better practice in the profession whatever setting they are located ( Pascausio, 1989). Study shows that they learn more and their retention is higher if hands-on, minds on are used. These practical exercises are not limited to the classroom (Legaspi, 2005). As students begin nursing coursework and clinical laboratory experiences, they are challenged with how to provide secure, effective, and knowledgeable care to patients (Dzurec, Allchin, & Engler, 2007). The first year in the nursing education can be very tough and challenging. It is in this period that as a first year student they are molded and prepared to face the challenging profession. First timers in clinical rotation engage themselves in the initial stage of familiarizing and accustoming ones self to the practice becomes crucial. This is the point when printed theories in books and hand outs are recalled and reshuffled in the mind in order to carry out the best intervention suited for a particular situation. (http://www.studymode.com) For any student pursuing a nursing degree, the clinical rotations are where you really earn your pin. Clinical training is an important educational content. Shuber believes that clinical training gives the students opportunities to turn their theoretical knowledge to practical by learning a variety of mental and psychomotor skills. In fact, clinical training is the basis of developing and providing efficient, skillful, and knowledgeable human resources for the society. Nursing is a skill oriented domain and nursing care requires performance of clinical skills. Nurses should be master in the skills related to nursing interventions. Clinical skills are the basis and backbone of nursing

5 career and developing skills is one of the major goals of clinical training. The assessment of practical ability begins in the first year and the nature of the assessments increases in complexity as students move through the course. In year one the focus is on essential nursing care but by year three the emphasis has shifted to evidence based decision making and the ability to manage the care of groups of patients. In this context practical assessment is carried out by designated registered nurses, working in clinical areas, who have been prepared in the education and assessment of students during practical placements (NMC, 2008). The clinical experiences enable student nurses to minister the real clients in the management of real problems inherent in their practice. Students can also have experience where they can realize, discover patient responses to certain aspects of care, or how structuring an activity differently is more time- saving. These discoveries boost self-esteem when students see what they have learned on their own, or they have the ability to resolve certain problematic situation (Bradshaw & Lowenstein, 2004). The clinical experience is also the core of the nurses education. The information which nursing students reads on textbook, the lectures she hears in the classroom and the experiments she observes in college laboratory must be synthesized in the clinical area. The nursing student learns actual experience in patient care; she/he learns to nurse by nursing. The development of clinical is progressive and therefore should be consistently taught, regularly reinforced and continuously evaluated. Training makes one accurately aware of the facts that learning is a never ending process. Students were given the chance to work in the different clinical areas. During clinical experience, students hands, mind, eyes, and other senses are focused on the task at hand, thus enhancing opportunities for

6 cognitive and personal growth. When students mind are actively involved in activities they learn from mental pictures of systems and events. Creating pictures in mind allows them to add essence of order and rationality to their observations and enable them to suggest reasons for changes noted (Legazpi, 2005). As the students experience opportunities to become better and more effective in rendering nursing care, communication skills, observation skills, analytical thinking and planning nursing care and some things being developed when employed in the hospital (Tomey, 2000). Clinical assignments usually intimidate novices. On their first days, some students stand outside patients' rooms trying to figure out what they are expected to do next, according to the online article "Teaching Tools: 10-Minute Assessment for Patient Safety" published on the Nursing Center website. Barriers that sometimes preclude a student from excelling during her clinical include feeling a low level of self-confidence, holding a job outside of her studies or wrestling with family issues, says associate nursing professor Janet McMahon on the Delmar Cengage Learning website

(http://www.ehow.com). The clinical practice stimulates students to use the critical thinking skills for problem solving. Hands-on-learning is the way students can directly observe and understand science. As students develop effective techniques for observing and testing everything around them, they learn the what, when, why of things of which they interact (Haury & Rillero, 1994). Performance measurement has become one of the foundations of current efforts to improve health care quality. Performance measures play an important role in improving health care quality and will undoubtedly continue to do so; however, they are only one

7 part of the solution to improve health care quality. Good performance is not necessarily good care, and pressure to improve performance can come at the sacrifice of good care. In its current state, performance measurement is better suited to improving measured care than improving the care of individual patients (Werner, 1985). Assessing performance in nursing education is controversial and a current worldwide concern (Anderson, 2008; Lauder et al., 2008; Pincombe et al., 2007; Cowan et al., 2005). In each country national standards are intended to reflect the importance of safe practice by ensuring that students achieve a baseline level of performance with which to begin their professional careers (NCSBN, 2011; ANMC, 2010; SANC, 2008). The inability to transfer classroom knowledge to clinical nursing practice is common learning problem encountered by many nursing students. It is often true that students do not well with critical thinking in the clinical setting, even though they have done it well testing in class. Manifestations of this problem may involve both academics performance and personal development of the students; inability to solve problems in nursing situations; inflexibility and rigidity in the exercise of nursing care; fragmentation of nursing care and apathy towards clinical practice (Theory based nursing practice, July 1997). Assessment is not a single event. It involves observing students throughout the placement and making judgments about their performance both at specified intervals and at the end. According to Rutkowski (2007, p.37) the assessment is a complex process, based on direct observations by the preceptor and involves judgment values, which are subjective and can vary from person to person

8 First year nursing students are characterized by lack of experience in clinical situations. Their performance is very limited and inflexible. They are not sure about their abilities to perform the skills independently although they have acquired the basic knowledge on how to do skills and frequent practice can increase their efficiency and make them good at performing the skills. There is a multitude of factors which have been linked to students experiences of stress and anxiety in clinical setting: a) the interpersonal relationships with health care professionals; b)constant observation and evaluation by clinical instructors; c)perceptions of non-supportive, threatening faculty; d)ineffective teaching skills of the nursing educator; e)unrealistic expectations by staff and clinical instructors; f)fear of making a mistake or harming a patient; g)lacking the clinical knowledge to accomplish a task; h)feeling of inadequacy; and i)unfamiliarity with the clinical setting, among others. The data from the most recent qualitative study done by Melincavage (2008) on the subject of stress and anxiety provides a glimpse into the world of nursing students learning environments and their perceptions of anxiety in clinical settings. Students should relate learning in the classroom to their experience in the hospital. Nursing students of Lorma Colleges have their clinical duty or RLE (Related Learning Experience) that reflects their clinical performance, RLE is a facility planned and guided learning activities assigned to assist students to meet stated programs and course outcomes and to safely apply knowledge and skill when providing nursing care to clients across the lifespan as appropriate to the role expectations to the graduates. They are assigned to different affiliated hospitals with their respective wards where they could apply their knowledge and theories in their classroom lectures.

9 The findings of the study conducted by Julie Floyd indicate that nursing students have a significant amount of self-reported anxiety during the first year of nursing. Level I nursing students have the lowest GPA among the three levels which indicates the higher level of anxiety may potentially lead to poor academic achievement. The multiple regression analyses indicated statistical significance in predicting end of semester grade point average among Level I and Level III students. Students in Level I had the highest stress level and the lowest GPA among the three groups. Level III nursing students had the highest GPA among the groups with a lower mean depression score than Level I, but slightly higher than Level II. A survey conducted in China regarding early exposure of nursing students. Questionnaire was used to investigate 83 nursing freshmen in terms of specialty thinking, learning motive and teaching methods. Results in view of early clinical practice, 91.5% of the students thought their specialty thinking was consolidated, 98.79% thought they established correct nursing consciousness. 97.59% and 93.98% of them thought early clinical practice inspired their learning motives and stimulated their potential in learning and meanwhile their comprehensive ability was strengthened. A study done in Iran found that first-year students experienced greater stress than students in subsequent years whereby mean stress was significantly greater in first year than in fourth year nursing students with p = 0.009 4. A noted research study conducted by Kathleen Duffy (2003) about the issue of students passing clinical assessments where not sufficiently competent. Participants in the study confirmed that students are passing assessments when there is in fact some doubt

10 about their clinical competence and that some of these students achieve registration despite these misgivings. In a recent nursing study by Khomeiran et al. (2006) to determine what nurses of today perceive to be factors influencing professional competence, it was revealed that personal characteristics remain an essential factor. Other factors identified included, a willingness to know more, having a curious and inquiring mind, and the importance of being self-motivated to learn pre and post registration. On an article written by Berkowet et al. (2008) entitled Assessing New Graduate Performance, their survey shows that new graduate nurses now comprise more than 10% of a typical hospitals nursing staff. Concomitantly, only 10% of hospital and health system nurse executives believe their new graduates are fully prepared to provide safe and effective care. Since the assessment of nursing competence was a key issue for nursing, these researches entitled, CLINICAL PERFORMANCE OF 1ST YEAR NURSING STUDENTS OF LORMA COLLEGES offers to measure and compare their level of performance in skills laboratory and in the actual clinical set up. The result of this study could be beneficial to students for them in expanding is

their comprehension on how important the

Skills Laboratories

to their clinical performance. This could also benefit instructors to teach more effectively and facilitate good transmission of knowledge with their students. This study is also beneficial to patients as this would give the patient optimum level of wellness to be rendered by the student nurses that are well trained on their skills laboratories. The researchers will also be benefited as the study will give the researcher additional

11 knowledge and understanding about the effects of skills laboratories towards nursing students clinical performance. And finally, the result of this study might encourage others to conduct further studies and can be used to advance research in the concept of the effects of skills laboratory on nursing student clinical performance. Theoretical Framework/ Conceptual Framework The following theories were utilized by the researchers to serve as groundwork for the study: Patricia Benners theory of Skill Acquisition from Novice to Expert, Experiential Learning Theory of David Kolb, Goal Attainment Theory of Imogene King and Social Learning Theory of Albert Bandura. The theory Skills Acquisition from Novice to Expert of Patricia Benner is the main theory that guided this study. She concluded that a nurse clinical knowledge is relevant to the extent to which its manifestation in nursing skill makes a difference in patient care and patient outcome (Tomey&Alligood, 2006). The person who has no background experience of the situation in which he or she is involved is in the Novice stage of skill acquisition in the Dreyfud model. Since the respondents involved in the study were merely on their first year in nursing and are considered as novices, they are characterized by lack of experience and confidence in providing care to patients. This signifies that there was an existing problem which affects their performance in performing nursing skills. Having no background experience of a certain situation in which the subjects of this study is involved especially in their first exposure in clinical area serves as a factor that might have an effect on how they perform the basic nursing skills since they find it difficult to distinguish significant aspects of certain situation. Indeed they need to learn about the fundamentals of the

12 nursing profession and during clinical experience student nurses should be able to apply it with the guidance of their clinical instructors. Experiential Learning Theory of David Kolb was also used in the study. It is stated in this theory that learning engages students in critical thinking, problem solving and decision making in contexts that are personally relevant to them. This approach to learning also involves making opportunities for debriefing and consolidation of ideas and skills through feedback, reflection, and the application of the ideas and skills to new situations. (Cox, Calder, &Fien, 2010). Since there is an issue regarding theory and practice gap, integrating learned theories into practice is utmost importance. The students involve in this study were deployed in hospital for their first clinical exposure last summer 2013 following their discussion in NCM 100 second semester of school year 2012-2013. Since the concepts from school discussion was still fresh in their minds, they must be able to apply these concepts primarily the basic nursing skills efficiently and effectively in order to provide the best quality of care they can to their patients. Another theory that guided the study was the Goal Attainment Theory of Imogene King. If the students cant do the Fundamentals, How can they use advanced knowledge? says the theorist. Because of the fact that they are first year, they are taught of the Fundamentals in Nursing. In nursing, learning must start first from the basics before it gets complex. These freshmen are expected to have an exceptional skill and knowledge pertaining to their fundamentals and by this they can achieve their goals of providing safe and quality care to their patients and also advancement in their learning will take place.

13 The theory entitled Social Cognitive Theory of Albert Bandura is another theoretical framework chosen for this research study. According to Banduras theory, human functioning is influenced by ones environment, by ones personal factors, and by ones behavior (Pajares, 2002). Human functioning, therefore, is seen as the product of a dynamic interplay of personal, behavioral, and environmental influences (Pajares, 2002). As the first year nursing students were exposed to clinical setting, they are given a chance to observe and familiarized themselves in the hospitals. It is in here that they got to observe the practice of staffs and how they behave. In that case, learning was taking its place because through observation, the students may be able to acquire the behaviors of the staffs and also the clinical instructors that supervise them. Also being exposed to hospital and its staff will give them confidence and to enhance their abilities. Fundamentals of Nursing Practice provide the students with the overview of nursing as a science, an art and a profession. It deals with the concept of man as a holistic being comprised of bio-psycho-social and spiritual dimensions. It includes a discussion on the different roles of a nurse emphasizing health promotion, maintenance of heath as well as prevention of illness utilizing the nursing process. It includes the basic nursing skills needed in the care of individual clients. Related Learning Experiences (RLEs) are teaching-learning opportunities designed to develop the competencies of students utilizing processes in various health situations. In the CHED CMO #14 , 2009 nursing curriculum, a nursing student is required to complete 2346 hours of Related Learning Experience (RLE).

14 The skills laboratory is to serve both the undergraduate and graduate programs in the School of Nursing. For the undergraduate students, they provide a safe and private environment that is conducive for learning basic nursing skills and health assessment techniques before they go into the clinical area. Lab groups for the undergraduate students are kept small to facilitate individualized instruction. The labs are available for graduate students taking advanced health assessment to further develop skills for their specialty areas. Clinical Performance refers to the application of learned skills by nursing student in the clinical area. These could be sourced from, but not limited to: lying-in clinics, schools, industrial establishments, community, out-patient clinics and general and specialty hospitals. According to the Theory of correlation by Galton, the strength in one trait is closely related with strength in another trait, if these have many elements in common. A person who stands high in one trait or ability stands high in another as well. A pupil who is generally proficient in Mathematics or English is equally proficient in subjects like history, economics, and other studies. This theory is otherwise known as the theory of Positive Correlation. Positive Correlation also means correspondence among the abilities compared. Based on the studies made, the general tendency is for all types of desirable traits to show some degree of positive correlation (Gregorio,1974). In nursing education, theory is related to practice. Theoretical foundation of nursing practice enhances scientific practicing. The relationship between theory and practice is reciprocal to each other because theory is rooted in practice and refined by research and it should be reapplied in practice.

15 Figure 1 shows the paradigm of the study that used the independent - dependent variable model. The first box contains the independent variables such as the level of performance of the first year nursing student of Lorma Colleges in NCM 100 RLE and the level of performance of the first year nursing students of Lorma Colleges in Clinical Duty. While the second box represents the dependent variable which is the clinical performance of the first year nursing students of Lorma Colleges.

16 Research Paradigm

Independent Variable The level of performance of the first year nursing student of Lorma Colleges in NCM 100 Skills Laboratory The level of performance of the first year nursing students of Lorma Colleges in Clinical Duty

Dependent Variable The clinical performance of the first year nursing students of Lorma Colleges

Figure 1 Clinical Competency of 1st year Nursing Students of Lorma Colleges

17 Statement of the Problem 1. What is the level of performance of the 1st year nursing students of Lorma Colleges in NCM 100 RLE? 2. What is the level of performance of the 1st year nursing students of Lorma Colleges in Clinical Duty? 3. What is the relationship between the level of performance in NCM 100 RLE and Clinical Duty of the 1st year nursing students of Lorma Colleges?

Hypothesis:

1. The level of performance of the 1st year nursing students of Lorma Colleges in NCM 100 RLE is average. 2. The level of performance of the 1st year nursing students of Lorma Colleges in their Clinical Duty is average. 3. There is a significant relationship between the level of performance in NCM 100 RLE and Clinical Duty of 1st year nursing students.