University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA FACTORS THAT HINDER THE PERFORMANCE OF STUDENT NURSES IN PUBLIC HOSPITALS - A CASE STUDY OF THE GREATER ACCRA REGIONAL HOSPITAL BY RITA AMONOO-NEIZER (10598564) THIS LONG ESSAY IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC ADMINISTRATION DEGREE JUNE, 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I do hereby declare that this study is the result of my own research and that no part of this long essay has been presented for another degree in this institution or any other. All references used have been duly acknowledged. I bear sole responsibility for any short comings. ……………………………... ……..…………. RITA A. AMONOO-NEIZER DATE (10598564) i University of Ghana http://ugspace.ug.edu.gh CERTIFICATION This is to certify that this long essay was supervised in accordance with the laid down procedures of the University of Ghana. ………………………………… …………………… DR. RICHARDSON AZUNU DATE (SUPERVISOR) ii University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to all the National Service /Rotation Nurses who participated in the study. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I thank the almighty God for making it possible to conduct this study. My sincere gratitude to my supervisor Dr. Richardson Azunu who helped and directed me throughout the study. iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Content Page DECLARATION .................................................................................................................. i CERTIFICATION ............................................................................................................... ii DEDICATION ................................................................................................................... iii ACKNOWLEDGEMENT .................................................................................................. iv TABLE OF CONTENTS .................................................................................................... v LIST OF TABLES ........................................................................................................... viii LIST OF ABBREVIATIONS ............................................................................................ ix ABSTRACT ........................................................................................................................ x CHAPTER ONE .................................................................................................................. 1 1.0 Introduction ................................................................................................................ 1 1.1 Problem Statement ..................................................................................................... 2 1.2 Research Objectives ................................................................................................... 3 1.3 Research Questions .................................................................................................... 3 1.4 Significance of Study ................................................................................................. 4 1.5 Limitations ................................................................................................................. 4 1.6 Ethical Review ........................................................................................................... 4 CHAPTER TWO ................................................................................................................. 5 LITERATURE REVIEW .................................................................................................... 5 2.0 Introduction ................................................................................................................ 5 2.1 The Challenges of Student- Rotation Nurses at the Clinical Area ............................. 6 2.2 Theoretical Framework .............................................................................................. 7 2.3 Legal and Regulatory Framework............................................................................ 10 2.4 Nursing Education in Ghana .................................................................................... 11 2.5 Performance in the Clinical area .............................................................................. 12 2.6 Communication in the Clinical area......................................................................... 13 v University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE ........................................................................................................... 17 METHODOLOGY ............................................................................................................ 17 3.0 Introduction .............................................................................................................. 17 3.1 Study Area ............................................................................................................... 17 3.2 Justification for Study Area ..................................................................................... 19 3.3 Research Paradigm ................................................................................................... 20 3.4 Research Design ....................................................................................................... 21 3.5 Sources of Data ........................................................................................................ 21 3.6 Data Management .................................................................................................... 23 3.7 Ethical Consideration ............................................................................................... 23 CHAPTER FOUR ............................................................................................................. 25 DISCUSSIONS AND ANALYSIS OF FINDINGS ......................................................... 25 4.0 Introduction .............................................................................................................. 25 4.1 Comparison and Challenges of Student Nurses ....................................................... 25 4.2 Challenges During Training and Rotation ............................................................... 25 4.2.1 Educational Factors ............................................................................................... 27 4.2.2 Orientation Issues .................................................................................................. 34 4.3. Clinical Factors ....................................................................................................... 35 4.3.1 Interpersonal Relationship .................................................................................... 35 4.3.2 Inadequate Equipment........................................................................................... 39 4.3.3 Clinical Documentation ........................................................................................ 39 4.3.4 Additional Units Not Found in the Log Books ..................................................... 40 4.4 Socioeconomic Factors ........................................................................................... 41 4.4.1 Accommodation .................................................................................................... 41 4.4.2 Reporting Sick ...................................................................................................... 43 4.4.3 National Service Allowance.................................................................................. 43 4.4.4 Duty Roster and Safety ......................................................................................... 44 vi University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE ............................................................................................................... 46 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ..................................... 46 5.0 Introduction .............................................................................................................. 46 5.1 Summary .................................................................................................................. 46 5.2 The Challenges ......................................................................................................... 47 5.2.1 Educational factors ................................................................................................ 47 5.2.2 Orientation Issues .................................................................................................. 48 5.3 Clinical Factors ........................................................................................................ 48 5.3.1 Interpersonal Relationship .................................................................................... 48 5.3.2 Clinical Documentation ........................................................................................ 50 5.3.3 Inadequate Equipment........................................................................................... 50 5.3.4 Additional Units not found in Log Book .............................................................. 51 5.4 Socioeconomic Factors ............................................................................................ 52 5.4.1 Accommodation and Transportation ..................................................................... 52 5.4.2 National Service Allowance.................................................................................. 52 5.4.3 Duty Roster and Safety ......................................................................................... 53 5.5 Conclusion ............................................................................................................... 54 5.6 Recommendation ..................................................................................................... 55 REFERENCES .................................................................................................................. 63 APPENDIX ....................................................................................................................... 65 vii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1 : Gender, Age Range, Schools attended within Regions.....................................25 viii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS CNO Chief Nursing Officer CT scan Cardio tomographic Scan DDNS Deputy Director of Nursing Services ENT Ear Nose and Throat GARH Greater Accra Regional Hospital MRI Magnetic Imaging Resonance NHIS National Health Insurance Scheme NMC Nursing and Midwifery Council PIN Professional Identification Number RGN Registered General Nurse SRN State Registered Nurse WHO World Health Organization ix University of Ghana http://ugspace.ug.edu.gh ABSTRACT The study was on the factors or challenges that hinder or affect the performance of Student- National Service/Rotation Nurses in the clinical area (Greater Accra Regional Hospital). The study explored the challenges faced by these nurses during their three year and four year study in the training colleges and university respectively and again during their rotation. This was undertaken to address the issues and make recommendations using the qualitative approach. The study was conducted at the Greater Accra Regional Hospital (GARH), which is a four hundred and twenty bed hospital. It offers a twenty four hour service and is a public hospital. It has the departments of Surgery, Medicine, Paediatrics and Obstetrics and Gynaecology, Allied Surgery which includes Eye, ENT services, Diethetics and Physiotherapy. Apart from these, it offers Urological, Orthopaedic and Neurosurgical services. For diagnostics, it offers imaging (radiology), cardio-tomography, ultrasonography, mammography and laboratory services. Most of the medical, laboratory, radiology, physiotherapy, diethetics, nursing and midwifery students go to the hospital for their clinical practice and internship. The instrument used for the study was that of qualitative and in-depth interviews were held among which ten student-national service/rotation nurses from other facilities on internship at the hospital were individually interviewed whereas the seventy within the hospital had focus group interviews and discussion. The findings revealed the challenges these national service/rotation nurses had during their three and four year training as compared to their challenges currently as rotation nurses. The challenges were put under themes namely: Educational, Clinical and Socioeconomic. The national service/rotation nurses faced challenges such as the inability to apply the theory learnt in school to the practice at the clinical area. They faced the challenge of poor interpersonal relationship with the clinical staff and with socioeconomic, accommodation and transportation. x University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 Introduction Health care in recent times has been highlighted upon by various organizations such as the World Health Organization (WHO), Ministries of Health in Africa, Europe and Asia. The WHO holds a number of programmes to especially prevent diseases, improve life styles and make health affordable and accessible to all citizens in their respective countries. Nurses play a vital role in all facets of health care and it is important that they apply the theoretical aspect of nursing to the practical aspect to give out the best of care. There have been many issues on quality health care delivery in the country (Ghana). It has been attributed to the performance and attitudes of the different categories of staff. Nurses are said to spend more time with the clients, and thus their performance is very important. Student nurses go through formal training to work in the hospital. They are said to encounter many challenges that affect their performance at the hospitals (Sandelands, 1990, Jamshidi, 2016; Buerhaus et al. 2017). Notable among the challenges encountered by the student nurses have been highlighted by Gimenes & Faleiros (2014) that: there are general challenges in adopting a culture of safety when practicing, transferring available knowledge for clinical practice and the poor inclusion or the non-existence of patient safety as a discipline in the curriculum of nursing undergraduate. For one to emerge as a nurse, there are some mandatory requirements that must be complied to, as such, there are facilities for training nurses in the country. The training requirements for nurses entail three years for the Registered Nurse, four years for the Baccalaureate nurse and two years for the Nursing assistant. The training has two parts, namely; the theory and the practical aspect. The Nursing and Midwifery Council is the 1 University of Ghana http://ugspace.ug.edu.gh statutory body and regulator for nursing and midwifery profession in all countries where they are present. Examples include Ghana, United Kingdom and Nigeria. The Greater Accra Regional Hospital (GARH) is a public hospital, which was built in 1928 and gone through phases till its latest reconstruction as one of the modernized hospitals in Ghana. It is a secondary health facility and receives referrals from the district health centres and polyclinics. It currently has a bed capacity of four hundred and twenty. It provides a twenty-four-hour service. The different categories of student health professionals go for their practical training there. Looking at the capacity and health delivery prospects of the hospital, it makes it a viable study area to inquire into the factors that hinder the performance of nursing students in Ghana. 1.1 Problem Statement The growing importance of health practitioners has attained global significance, and the imperative of nurses have been highlighted. Nurses confront numerous challenges, and they have been studied overtime (see Sandelands, 1990; Jamshidi, 2016; Buerhaus et al. 2017). Even though such studies have highlighted the challenges health practitioners, particularly, nurses face, the literature remains somewhat silent on student nurses. With regards to student nurses, some work has, however, been done (Eg see Timmins & Kaliszer, 2002), but this work focused on the aspects of education programs that cause stress to nursing students such as academic stress and other social related stressors like family problems (Timmins & Kaliszer, 2002). Other studies have also highlighted academic stress alone, such as the work of Lindop (1999). However, the context of all the above-mentioned works differ from the Ghanaian context. Apart from this, their focus was not on the challenges that hinder the performance of student nurses in public hospitals. 2 University of Ghana http://ugspace.ug.edu.gh Some few studies exist on Ghana (See Talley, 2006). The work by Talley (2006) highlighted issues such as resource constraints and general poor working conditions. Looking at the few studies that exist on student nurses in Ghana, particularly, those on the Greater Accra Regional Hospital (GARH), this study will thus inquire into the challenges of student nurses in GARH. 1.2 Research Objectives The research objective looked at the general challenges or factors that hinder the performance of the student and rotation nurses. The study explored the possibility of whether the passion for the profession had a positive or negative effect on performance. • To determine the challenges of the student nurses at the clinical area and its effect on their performance. • To determine the student nurses desire for the profession, and the effect on their performance. 1.3 Research Questions The research questions seeks to analyze and probe into the study area to arrive at answers posed from an occurence. 1. Do the challenges of student nurses at the clinical area have an effect on their performance ? 2. Does the desire for the profession have an effect on their performance? 3 University of Ghana http://ugspace.ug.edu.gh 1.4 Significance of Study The significance of the study was to assess the impact of the challenges of student nurses at the clinical area and how they were affected either positively or negatively. The choice of the Greater Accra Regional Hospital (GARH) for the study was due to the fact that majority of the Student nurses as well as the Rotation/National Service Nurses go to the hospital for their clinical practice. Their three years in the training colleges was compared to being a National Service/Rotation Nurse. The study sought to also compare students who have the genuine desire to be nurses to those coerced into it. This was to help counsel those forced into it to branch into their fields of interest. 1.5 Limitations The limitation to the study is anticipated since one study cannot come out with all the answers. The sample size of those interviewed may be a fraction of the total number of national service/rotation nurses in the country. 1.6 Ethical Review The students were assured that interviews and data collected were for academic purposes only. Their identity and institution of training was not disclosed. They were taken through a thorough explanation of what would transpire during the interview in order to obtain the exact picture of their experiences and challenges. 4 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction Many scholars have tried to study the challenges that students face either in the academic area or clinical area. In Ghana, nursing is a profession and students could enter the training colleges or the university upon passing their secondary school certificate examination. The nurse assistant course is a two year programme and they sit a licensure examination at the end of the training to become enrolled nurses or nurse assistant clinical or public health who are termed or known as auxilliary nurses. The diploma course run includes general nursing, midwifery, psychiatry and community health nursing which is a three year programme.The university course earns the student a degree and this is a four year programme. Currently, the School of Nursing, University of Ghana, Legon, offers the Masters, Mphil and PhD programmes which runs between one, two, to four years respectively. There are about sixty-six nursing training colleges in the country. The Nursing and Midwifery Council (NMC) is the regulatory body for the profession. They design the programme and curriculum of the nursing course in collaboration with the training schools. The NMC is also responsible for monitoring the activities of the training schools and clinical area. They ensure that all nurses practice with a valid Professional Identification Number(PIN), renewable annually.Their main focus is to provide and maintain a high standard of nursing care to all citizens in the country through quality education of the nurses. Henderson (1966), posits that the unique focus of nursing practice is to either do for, help or work with the person to enable him/her become as independent as possible upon recovery or die peacefully. 5 University of Ghana http://ugspace.ug.edu.gh 2.1 The Challenges of Student- Rotation Nurses at the Clinical Area Many scholars have studied the factors that influence nursing students’ academic and clinical performance as well as the challenges they face. Nursing is a course where the theoretical aspect must be applied in the clinical environment in a practical manner to enable patients/clients recover from their sicknesses. All nursing procedures carried out on a client/patient have a rationale or basis for doing it and the aim is to help clients become independent once again.(Henderson 1966). It has been established that student nurses progress from first to second or to third or fourth year depending on the course chosen to become national service/rotation nurses. They have varying experiences between the first to the final year because it all depends on how much knowledge and practice they have acquired. According to Dunn (1995), apart from theory, the clinical aspect of the course is the most essential where the critical thinking skills, effective communication and the ability to perform tasks with competence is applied. The nurse should be able to effectively communicate with the patient, understand and identify with whatever the patient is going through. During assessment of the patient, the psychological and emotional, physiological changes or phases that the patient goes through should be identified as the nurse interacts with him/her. The nurses critical thinking skills should be at its peak at all times when caring for the patient. The patients encounter at a health facility is always commenced with the nurse being the first to have an interaction with as well as the last to bid farewell to especially if the patient is admitted. Since the practical aspect cannot be isolated from the theoretical part of the course, as also posited by Dunn and Hansford (1997), it is important to address the challenges of these students. This would go a long way to get the best out of them and to help sharpen their critical thinking skills and continuously improve upon their performance and practice. 6 University of Ghana http://ugspace.ug.edu.gh The clinical environment is very important since this is the place where nursing students and other medically inclined students practice real patient care.(Dunn and Hansford, 1997). It also provides a firm ground upon which the nursing student has his/her profession.(McKenna et al, 2010). Nursing is a practical job and the clinical environment cannot be left out when nurses are being trained because they can only sharpen their skills at the bedside of the patient. In the Greater Accra Regional Hospital(GARH), many students such as medical, laboratory, diethetics, dental, nursing and midwifery students have their clinical attachment at the hospital. In January, June and December, many students go to the hospital and some of the challenges include being too many to be effectively supervised and taught. There is so much pressure on logistics such as the gloves, used as a protective covering of the hands during procedures, equipment such as the blood pressure monitor which when over used within a short time may give false readings. Jamshidi (2016) posits that it is important to ensure that the competencies built among the nurses is beneficial to their clients and not lost to other countries. 2.2 Theoretical Framework The theory of goal attainment was applied.This theory was developed by Imogene King in the early 1960s.The theory explores three dynamic interactive areas which includes: The Personal system which delves into a person’s perception, space, body image and growth and development. The Interpersonal System which explores a person’s interaction, communication, transaction, stress and role. The Social System where there is organization, power, authority and decison making. All these systems are important since the nurse cannot do any work without the patient and the patient needs the nurse to help in his or her recovery (Tritsch, 1998). 7 University of Ghana http://ugspace.ug.edu.gh A nurse’s main goal is to render care to a patient who is sick to full recovery. For instance, patients who suffer from cerebrovascular accident which in lay man’s term is known as a stroke, can hardly do anything for themselves. The patient’s personal hygiene has to be taken care of by a nurse. In addition, patient has to be fed, has to be turned from side to side every two hours to aid circulation and to prevent bed sores, patient is worn a diaper. This needs to be checked every four hours and if soaked is immediately changed. Bed sores occur when there is pressure from the body on the bed. There is a lot of heat and moisture especially when a patient lies on his/her back without intermittent turning unto his/her side to ease the pressure and heat as well as good circulation of blood at the area. The drugs for the patient should be administered appropriately and if any adverse reaction occurs, the drug is stopped immediately. The Pharmacist should be informed and the drug returned to the pharmacy for further investigations which normally takes place at the Food and Drug Authority.The Physiotherapist helps the patient with partial to full range exercises when assessment shows that patient is ready for the exercises.When all these are done and the patient begins to move and is less and less dependent on the nurse to assist him or her to do the things that could not be done, job satisfaction from the nurses’ perspective is achieved. The goal attainment is reached when the nurse caring for the patient who was once helpless and dependent moves into an independent state and relies on himself or herself to do anything. This is an example of the personal system and the nurse feels good about her achievement and develops to the next competency level. The Interpersonal system has to do with the interactions, communication, transaction, stress and role and all these can be seen in the example above. However the interactions would be between the nurse, patient, relatives, other health care team members such 8 University of Ghana http://ugspace.ug.edu.gh as the physician, dietician and pharmacist. Constant communication with the patient whether he or she responds or not is essential to the patient’s recovery and again the transaction is between the nurse and the patient. The nurses are the ones who spend a lot of time with the patients than any of the other team members. They have a lot of information from the patients and are able to suggest to the other team members what is best for the patient under his/her current condition or state. They are the same team members who educate the patients on healthy life styles and how to adjust in their life long disease state. (A typical example is those who suffer a malfunction of an upper limb due to an accident. They have to resort to using their left hand because the right hand is not functioning. This takes quite a time with a lot of encouragement from the nurses who help them finally to make use of the left hand in doing everything.) The stress comes up when the nurse does all she can but patient‘s condition does not seem to improve and sometimes dies. In any case the role of the nurse is to do all she can to attain the goal of patient’s full recovery. The Social system has to do with the organization, power, authority and decision making.This is achieved when the nurse who is in an organization, which is the health facility, has the authority and power to take meaningful decisions in the care of her patients and this is in line with the main goal of the health facility and oversight organization. In the Ghana Health Service, the logo reads, your health, our concern and the mission is to provide quality health service responsive to the needs of all persons living in Ghana. (Source: Ghana Health Service) The challenges of the National Service/Rotation nurse are such that there are times when it affects their roles. They are stressed out especially when there is shortage of nurses due to the International Monetary Fund’s (IMF) ban on employment in 9 University of Ghana http://ugspace.ug.edu.gh developing countries of which Ghana is part. Currently as at May 2018, there are the youth aged between 18 and 25 years who are unemployed. All the three main factors mentioned above come into play with especially the characteristics of the interpersonal system being the most used. The National Service/Rotation Nurses, are not experienced because they completed their three and four year nursing courses and remained at home for almost a year till they were called to do their mandatory one year service to the nation in which they were trained. They entered the clinical area having forgotten most of what they learnt and are perceived as student nurses by the clinical nurses. Many tasks cannot be given to them to perform alone initially and have to be taught and supervised. They tend to have difficulty in applying the theory learnt in school to the practice on real patients at the clinical area. Rolfe (2003) posits that student nurses are the ones that actually have this challenge. They expect senior nurses to help address their challenging issues in order to attain the goal of being competent nurses. In Ghana, there have been a few studies on the challenges of the baccalaureate nursing programme, attitude of student nurses in the clinical setting, experiences of student nurses and midwives at selected hospitals in the Volta region. Other scholars carried out studies on the students within the clinical environment in Iran, and other countries. Zhi-xue(2008), also conducted a study on the nursing competence and performance. He reiterated that competence in nursing is very important and also contributes to the effective performance. 2.3 Legal and Regulatory Framework The Nursing and Midwifery Council of Ghana (NMC) is the statutory and regulatory body for all categories of nurses. The Council formed initially under NRCD 117 of 10 University of Ghana http://ugspace.ug.edu.gh 1972 and LI 683 of 1971 is currently under the enactment of the Health Professionals Regulatory Bodies Act 857 of 2015, Part 3. This mandates the Council to ensure high quality education and legal practice of all categories of Nursing. The legal practice is through the annual renewal of the Professional Identification Number (PIN). This is the unique number given to all categories of qualified nurses by the statutory body. (Source: NMC). The NMC is responsible for the curriculum for all the categories of nursing education and collaborates with the training schools to revise it from time to time due to global changes. At the Universities, the theoretical aspect is handled by the lecturers and at the end of the four years, the degree students sit the licensure examination with the diploma students. The written licensure examination assesses students on the application of theory to practical situation questions and this is part one of the examination. Part two is the practical examination where students are examined at the clinical area by being given tasks to perform on patients. Upon passing both part one and two examinations, the mandatory national service has to be done by the qualified nurse as and when the service is ready to post personnel to do it. This is also a contributory factor of the many months at home after completion of the nursing course. University graduates who do not sit the licensure examination are not licensed and therefore cannot practice at any clinical area be it private or public sector. 2.4 Nursing Education in Ghana Nursing education was started in Ghana during the colonial era. The British nurses were appointed by the government to provide training to the people of the nation. Male Nurses were recruited and the females were left to help at home. (Twumasi,1979). The nursing school was started in Kumasi. Three years later, the State Registerd Nurse 11 University of Ghana http://ugspace.ug.edu.gh (SRN) programme was moved to Accra. There have been many changes since the post independence era and this stems from SRN which is the certificate course, Registered General Nurse (RGN) which is the (diploma) and to Graduate Nurse which is the degree course. The pre-requiste for training was the West African School Certificate. This enabled the student enter the training school and study for three years to be qualified as a State Registered Nurse. Currently with the West African Senior School Certificate Examination, one can enter the university having made the requisite grade and study nursing for four years. The masters and PhD programmes in Nursing are offered at the public universities while some of the private ones are yet to start the masters programme. Nursing in Ghana has seen some paradigm shift and is geared towards having more post graduate nurses and PhD holders with an affinity for increased research work and publications to help move the profession forward. The Ghana College of Nurses and Midwives inaugurated and commenced in 2015 seeks to turn out Specialist nurses in the field of Obstetrics and Gynaecology, Paediatrics(Child Health) and Oncology and Emergency Nursing to start with. 2.5 Performance in the Clinical area The past few decades have highlighted issues on performance either in organizations, educational sectors, health settings, private and the public domain. Performance is paramount in any health care setting and it is imperative that nurses give off their best through increased knowledge, competence, critical thinking and effective decision making. Since nursing is actually practiced at the patients bedside, it is imperative that students understand the theory aspect taught in the schools and understand how to 12 University of Ghana http://ugspace.ug.edu.gh apply it in the clinical area. The rational or basis for carrying out a task should be known and explained to the patient. This helps the patient understand their conditions and cooperate with the nursing staff to accelerate recovery. Likewise, the confidence and trust in the nurses who care for the patients is increased. Where the nurse genuinely loves the profession and has a calling, their performnce out weighs those who found themselves in it as a result of being coerced or using it as an avenue to enter the work force and finally branch into a field of their interest. Some of these attributes are detected during the clinical attachment. When all these are attained, it is expected to boost the performance, patient safety, confidence and trust in all areas of nursing. Zhi- Xue (2008), reiterates that competence in nursing is important and contributes to effective performance. Those coerced into the profession are normally not bothered when they are scolded infront of patients, cannot carry out tasks properly sometimes and brand patients who insist on their rights as difficult patients. They have tolerance and communication issues and tend to be easily irritable. In the current era of who knows someone at the highest authority (also known as protocol), they manage to be admitted into the training schools.They go through the programme and sometimes immediately after their licensure examination leave the country or branch into another avenue. 2.6 Communication in the Clinical area In nursing, communication is very important. It is the interaction between two or more people and it is used to put across intentions, explanations and actions. The types of communication includes the verbal, non verbal, visual and written. In nursing, to be able to care for an individual or patient, one needs to make use of all the types of communication. In the clinical area or bedside of the patient, every procedure on the 13 University of Ghana http://ugspace.ug.edu.gh patient must be communicated and explained to his/her understanding. It is when the patient obliges or gives their consent that the nurse would go ahead and perform her role. There are instances where the patient cannot talk but will beckon the nurse to come nearer the bedside to try to figure out what they need. For example, if a patient suffers a mild stroke that affects his/her speech, it would take the nurse sometime to figure out what the patient wants. This is because with such patients the speech would be slurred and so the nurse needs to use gestures and actions to do what the patient wants, to make him/her satisfied. Another example is with the unconscious patients who at a point seem lifeless but then are breathing. Though the patient does not communicate at all, the nurse needs to tell the patient what procedure she is about to perform on him/her before she actually does it. It is a fact that though unconscious, the patient hears everything that goes on around them. The nurse has to be very alert and observant to notice any adverse reaction the patient might be experiencing because it cannot be voiced out by him/her. The different sounds of the monitors connected to the patient must be studied and known so as to take the appropriate action when the need arises. For example the continuous intermittent beeping sound of the monitor may suddenly change to a long non-ending sound and this could mean that a connected electrode is off. It could mean that the patient made some movement and dislodged it. Documentation of all activities carried out is the written aspect of communication. Any written instruction especially to do with the patient, must be legible with no ambiguity. Where it is not clear, clarification must be sought before the instruction is carried out. Nursing a patient on the ward involves a lot of interaction between the two parties. The clinical nurse has to teach the student-national service/rotation nurse how to communicate with the other team members, superiors, colleagues, the patient and 14 University of Ghana http://ugspace.ug.edu.gh his/her relatives. The student-national service/rotation should learn that communication is vital in nursing especially at the clinical area. The clinical environment is important since it is the place where nursing students practice real patient care.(Dunn and Hansford1997). In this era of paradigm shifts, the profession, nursing is geared towards evidence based information. With the care of the patient, any procedure performed on him/her must be documented and the basis or rational for doing it must be explained to the understanding of the patient. The student-national service/rotation nurse should learn the importance of evidence based nursing such that any actions or inactions can be justified. Nurses in general have saved a lot of near misses in health care. This is because they spend most of the time with the patients and tend to have an idea of how the patient may end up. They always intervene just on time to save situations that would otherwise not have ended well. Nurses prompt other heath team members, stand in as advocates for the patient and are the shoulders on which patient’s relations cry on. It is these nurses who document and generate data for the health team to use and research on. The student-national service/rotation nurse should be serious with documentation and effective communication. The challenges they face with communication are numerous. They are sometimes unable to understand non-verbal cues from the clinical nurses. For instance, a patient sharing a room with three others as is found in the Greater Accra Regional Hospital, would want to discuss a personal issue with the nurse. He/she starts talking and at a point lowers his/her voice. Immediately the patient does that, means that he/she has noticed that the nearest patient is listening and this should prompt the nurse to either take the patient out of the room or decide to discuss the issue at a more convenient place later.The challenge for the student-national service/rotation nurse is 15 University of Ghana http://ugspace.ug.edu.gh that, not understanding these cues, may ask the patient to speak up. When the patient refuses to speak up or a clinical nurse around at that time sends the student-national service/rotation nurse out of the room without any explanation then and there, the student may misconstrue the action of the clinical nurse to be negative.These non verbal cues cannot be taught theoretically but practically and Rolfe (2003) posits that student nurses have this challenge. In effect, in caring for patients, there is no way communication can be left out be it verbal, non verbal or written. Student-national service rotation nurses should learn all the skills of communication and understand them, Theoretically,the nurse is taught how to communicate but it is at the bedside of the patient that the skills are fully displayed. Most of the skills are learnt at the clinical area where they communicate with all team members caring for the patient. Student nurses and some nurses brand patients who like probing into whatever is and is going to be done for them as difficult patients. However, it is the patient’s right to know everything that he/she has to go through to recover from his/her illness. On the other hand,if the patient does not give any information as to what he/she has been experiencing, it would be very difficult to diagnose and subsequently treat the patient. Communication thus forms an integral part of the nursing profession and student nurses should learn to communicate more and meaningfully with all team members, their colleagues, superiors, patients and their relations. 16 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter focuses on the methods used to conduct the research. There are many methods such as quantitative, qualitative and mixed method. This study adopts the qualitative type which helps explore all the challenges faced by the student nurses and national service/rotation nurses. In trying to find out the effect the challenges have on the student nurses’ performance, an interview would help to have an in-depth knowledge and reveal their real life experiences. 3.1 Study Area The study area chosen was the Greater Accra Regional Hospital (GARH). It is situated in the Greater Accra Region at Ridge. Its immediate catchment area is Nima, Kanda, Maamobi, Osu, Airport and Adabraka. The hospital was built and used in 1928 by the Europeans in the then Gold Coast. In 1957 after Kwame Nkrumah gained independence, the hospital was turned into a women’s hospital. Due to the different changes in regimes of the country, it became a district hospital in 1974 and finally a Regional hospital in 1996 under Act 525 of the Ghana Health Service. Currently it serves the whole Greater Accra Region with a population of almost about five (5) million people. It currently has a bed capacity of four hundred and twenty (420) and offers a twenty four (24) hour service. It is made up of the four main areas namely; Surgery, Medicine, Obstetrics and Gynaecology and Child Health. Aside these services is the Allied health which includes the Eye, Ear Nose and Throat (ENT), Dental and Chiropractic medicine. There is also the Public Health Unit which oversees the Child Welfare Clinic, Disease Surveillance or Control unit, Health Promotion and 17 University of Ghana http://ugspace.ug.edu.gh Quality Assurance units. Diagnostic services include the laboratory, pathology, cardiotomography(CT Scan) and Magnetic Resonance Imaging(MRI) and various ultrasonography(scan). The national Poison Office is also there. The following meanings give a little explanation on what these four main areas are as well as their function: Surgery – This area is a branch of medicine that deals with cutting and removal of parts of the body that should not be there. For example, a lump found in the breast. This, if left may later harm the patient and even cause his/her death if it is cancerous. Medicine- This is the area of medicine that deals with the diagnosis and treatment of an illness such as malaria, typhoid fever, hypertension and diabetes. Paediatrics – This is the branch of medicine which is also known as Child Health and as the name implies, it deals with the care of sick children. The age for admission into the children’s ward is from one (1) year to twelve(12) years. Those above twelve years are admitted to the adult wards. Obstetrics and Gynaecology – This is the branch of medicine that deals with the woman with pregnancy and then with a born child whereas gynaecology deals with just the woman or man with reproductive health issues. For example infertility where a a woman cannot conceive and of which the source could be from the man. Other examples are fibroids which are lumps clad together and fill the womb of a woman thus preventing pregnancy. Chiropractic Medicine – This is the branch of medicine that deals with manipulation of the spine using the hands. In addition, patients are advised on how to lift objects, sit in a correct chair and always assume a good posture to prevent muscle and bone pain. 18 University of Ghana http://ugspace.ug.edu.gh Students such as Laboratory, Nursing, Midwifery, Diethetic, Pharmacy, Physiotherapy, Medical Students and some Foreign Trained Students from the various health training instituitions at home and abroad go to the GARH for their clinical attachment. For the past three years, over one thousand five hundred students have had their clinical attachment annually with the nursing and midwifery students forming half of the total number. (Source: Greater Accra Regional Hospital; In-Service Training Unit 2015-2017). 3.2 Justification for Study Area In June 2017, the Greater Accra Regional Hospital (GARH) had been reconstructed under a turn key project by Bougyies Batiment as a grant for the Republic of Ghana. Currently the hospital is one of the best in Ghana in terms of infrastructure, equipment and all efforts are being put up by the management of the hospital to sustain it as a centre of excellence. Having all the different service areas with the Specialists in the various fields in the hospital, many training instituitions prefer their students to have their clinical exposure in the hospital apart from Korle-Bu Teaching hospital, 37Military hospital, the smaller hospitals and the polyclinics. Many different kinds of patients with diverse or similar conditions are admitted at the hospital. Most of the smaller hospitals and clinics refer their patients to the hospital for further management. In 2016, the total number for admissions to the hospital was sixteen thousand nine hundred and thirty- three (16,933), whereas in 2017, it was nineteen thousand one hundred and eleven (19,111). The total number of attendance for the year 2016, was one hundred and eleven thousand and fifty-nine (111,059) whereas in 2017, it increased to one hundred and 19 University of Ghana http://ugspace.ug.edu.gh twelve thousand and fifteen (112,015). (Source:Greater Accra Regional Hospital; Health Information Unit 2016-2017Report). The National Service Personnel; mainly the doctors, laboratory technicians or biomedical scientists, pharmacists and nurses/midwives have their rotations in the hospital for a year. For the past three years, the number of particularly national service/rotation nurses who did their service in the hospital was between sixty and seventy-five. (Source: GARH; In-Service Training Unit 2015-2017). Apart from the national service/rotation nurses who are originally posted to the hospital to do their service, the smaller facilities which do not have certain areas, for example no surgical unit, post the nurses to the hospital to acquire that aspect of the rotation for the specified number of weeks determined in their log books by the NMC. Once completed, they return to their facility and continue with their rotation. 3.3 Research Paradigm The paradigm is to enable the researcher delve into the challenges that student nurses/midwives face at the clinical area. The qualitative approach seeks to explore all the challenges the nurses/midwives face and the effect on their performance. This approach through interviews and snow balling would analyse what the national service/rotation nurses/midwives go through at the clinical area. Jamshidi’s (2016) study on the challenges student nurses face, looks at the real life experiences of these nurses at the clinical area and this was done through the qualitative process which threw more light on it than if a quantitative approach had been adopted. Safadi et.al. (2012) also looks at the nursing clinical mentors and how their mentoring strategies pose a challenge or fear in carrying out procedures at the clinical area. The comparison of the challenges of the National Service/Rotation Nurses’ three or four years in school 20 University of Ghana http://ugspace.ug.edu.gh to the current situation as service personnel is to determine whether they face the same challenges or not and to find out what exists that hinders their performance. 3.4 Research Design The research sought to focus on a qualitative study to analyze the real world experiences of the national service/rotation nurses at the Greater Accra Regional Hospital (GARH). Student nurses from various training institutions go to the clinical area during the course of their study. A qualitative approach was adopted to get in- depth knowledge on their challenges. Purposive sampling of the national service/rotation nurses was done and a comparison of their three and four years in school and that of their rotation was compared. The sample size for this study depended mainly on students who go to the Greater Accra Regional Hospital (GARH). These were seventy national service nurses for the year 2017/2018, and they were interviewed. The design was that of a case study in the Greater Accra Regional Hospital (GARH). This was because the focus was on a public hospital and every year sixty to seventy five national service nurses/midwives are posted to the Greater Accra Regional Hospital (GARH). The approach was adopted to enable the researcher compare the National Service/Rotation nurses/midwives experiences at the clinical area during their three or four year training to the current state as they do their service. So far, no such study has yet been conducted at the hospital. 3.5 Sources of Data The sources of data used were the primary sources in the form of interviews and secondary sources from journals, articles, reports and books. The primary sources 21 University of Ghana http://ugspace.ug.edu.gh included the rotation nurses/midwives who had graduated from being sudents to diploma and degree nurses. Student nurses include degree nurses who are from the universities and offer a four year course. The other categories are nurses who attend the training colleges and offer a three year diploma course in either midwifery, general nursing, community health and psychiatric nursing as well as the two year nurse assistant course. Target Group/Sample size The following are the various categories of students: First (1st) Year Nursing students Second (2nd) Year Nursing students Third (3rd) Year Nursing students Fourth (4th) year Nursing students National Service/Rotation Nurses There were interviews of one category of nurses from the various schools and these were the nurses doing their national service or rotation. This group of nurses was chosen because they were be able to compare the challenges faced during their three or four year course to the current challenges faced during their rotation and how it affects their performance In-depth interviews were conducted to explore and analyze the primary data from respondents. Open ended questions were asked to get enough information and also get a deeper insight into what brought about the challenges. The interviewees were twelve degree nurses and sixteen midwives, four registered community health nurses, thirty eight registered general nurses and ten registered nurses and midwives from other hospitals. Focus group discussions were held with 22 University of Ghana http://ugspace.ug.edu.gh majority of them and the individual interviews held among the ten who came from other facilties. The Rotation nurses declined to be recorded even though they gave their consent to be interviewed in groups and as individuals but did not want any disclosure of their schools and voices, so field notes were taken. Two tutors from different schools were interviewed as well as two clinical nurses and one senior clinical nurse who also had the researcher take field notes instead of recording. Content analysis was used to categorize the themes since the data collection was all qualitative with open ended in-depth interviews.. The secondary sources were the various articles, journals and books published on the topic under study. 3.6 Data Management The field notes were arranged manually and the data was analyzed in themes according to what pertained in their three year study and what pertains to their current situation as National service/Rotation Nurses. The Clinical nurses gave their views on the performance of the National service/Rotation Nurses they had in their wards. The reason for the comparison was to figure out whether the same challenges experienced from their training in the schools were the same or different to their current state as service personnel. 3.7 Ethical Consideration The purpose of the study was thoroughly explained to the respondents and they were assured of their anonymity. No recording took place since all respondents declined the offer of using it. Once consent was sought and interviewees were willing to take part in the study,the nature of the interview was elaborated upon as well as the reason for 23 University of Ghana http://ugspace.ug.edu.gh putting them into focus groups. Field notes were taken and they still remained anonymous. 24 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR DISCUSSIONS AND ANALYSIS OF FINDINGS 4.0 Introduction This chapter discusses and analyzes the findings in the study. The challenges or the factors that hinder the performance of the student-National service/Rotation nurses were analyzed. A comparison of their three and four year challenges were also analyzed. Due to anonymity, the gender, age range of the females and males were taken. Since the respondents did not want their training schools to be mentioned, the schools were categorised under the regions of the country in which they are found in the table below. 4.1 Comparison and Challenges of Student Nurses Table 1 : Gender, Age Range, Schools attended within Regions Gender Male Female 9 72 Age Range 22-25years 26-28yrs 68 12 Schools Attended Eastern Region 18 Northern Region 5 Greater Accra Region 28 Brong Ahafo Region 8 Ashanti Region 11 Central Region 10 (Source: GARH, In-Service Training Unit 2017) 4.2 Challenges During Training and Rotation The challenges the Nurses faced during their training were grouped into Educational, Clinical and Socioeconomic factors. A brief overview of each of the themes is outlined below: 25 University of Ghana http://ugspace.ug.edu.gh The Educational factors identified were the theory and practice gap phenomenon and orientation issues. The theory learnt in school was not applied practically because of lack of ineffective collaboration between the schools and the clinical area. Curriculum used was not known by the clinical staff and some changes in clinical practice was also not known by the schools. There was the issue of ineffective orientation either due to the large number of students from different schools for clinical practice within the same period of time in the clinical area. The Clinical factors identified were poor interpersonal relationship among some staff and students. For instance, scolding a student infront of a patient because he/she is not doing the right thing. This reduced the confidence of the student in performing his/her task and the confidence of the patient in the nursing staff. There was the issue of inadequate equipment at the clinical area due to the large number of students competing to use them because it is not enough. For instance the use of the manual blood pressure monitor which when used on a lot of people in a short time may give false readings. The students were not allowed to use the new equipment such as the monitors for fear of ill handling them and also because during their practical licensure examination, they would use the manual equipment in performing their assigned tasks. The challenge of clinical documentation was identified. The student nurses did not understand why some of the nurse managers in charge of the wards should sign their log book because they had never worked with them. They preferred their books being signed by the staff they worked with. The national service/rotation nurses had a challenge of having to go to the wards or units not found in their log book. They felt that the number of weeks for their entire 26 University of Ghana http://ugspace.ug.edu.gh rotation was fifty two weeks and these additional areas they were asked to go to would let them spend more time in the facility or clinical area. The Socioeconomic factors identified were accommodation fees and location.The national service/rotation nurses had no accommodation and transportation issues in school because they were living in the school’s hostels. The school bus conveyed them from school to the clinical area and vice vera. However as a national service/rotation nurse, they have to look for accommodation and pay for it as well as pay for transportation to and from the hospital on a daily basis. The national service allowance is not received regularly so other means of survivng may be resorted to. The duty roster prepared on the ward does not factor in how far they stay from the clinical area. When staff relieving them from their afternoon shift are not punctual, they leave the ward late after handing over and arrive home very late, sometimes close to midnight and the safety at night in the metropolis leaves much to be desired. 4.2.1 Educational Factors The nurses complained about being taught the theory and practical management of the patient using dummies or they the students in the demonstration/skills lab. During their first year, they went to the clinical area with fear and anxiety and not really knowing what it is like to nurse a real sick person with strange conditions. For instance they checked the temperature, pulse and respiration, known as vital signs of their colleagues in the skills lab in school. The tutors taught them the normal ranges of vital signs of a healthy person from the nursing textbooks. Their colleagues on whom they performed these tasks had the normal ranges and went to the clinical area to find ranges outside the normal ranges and wondered what was wrong. During one of the focus discussions Respondent one(1) recollected: 27 University of Ghana http://ugspace.ug.edu.gh “ I went to the ward with two of my colleagues and this happened to be our very first time on the ward. Though some of our seniors in the second (2nd) year had pre-empted us that we would find strange diseases on the ward, we never anticipated or imagined what we saw that day. The Nurse we met on the ward asked us whether we had been taught practically in our skills lab in school, such as bed making, changing patient’s position in bed and how to check and record vital signs. We replied in the affirmative and then I was asked to go and check an old lady’s own. I went for a tray and put the items needed into it and went to the old lady’s bedside. I explained to her my mission at her bedside as we had been taught in school to do and she obliged. I put the thermometer in her right armpit and proceeded to check her pulse with my fingers on her inner wrist. At a point I could not feel it any longer and I tried to start checking again and could feel nothing. I took the thermometer out and went to tell the nurse about my encounter. She went back to the old lady with me only to tell me the lady had died and that I should prepare to perform the last offices(preparation of the body for onward transmission to the morgue) with her. I nearly run out of the ward.” Respondent twenty one(21) recollected: “I went to the ward and though I was shown around by the nurses there, I did not know what to expect. One of them came to tell me that she was working with me so I had to follow her to one of the patient’s room. I saw an unconscious patient lying on the bed and was wondering what we were going to do for him. The nurse asked me to help her bath the patient and that I should just do as she says. I was so scared of the patient especially when we turned him from side to side to clean his back. Though I was supporting him on the opposite side, at a point, I felt that he had touched my hand. I screamed and the nurse told me to keep holding him till she finishes cleaning his back. I never thought that he would make any movement. When we funished with him, by which time I was shaking with fear, he 28 University of Ghana http://ugspace.ug.edu.gh opened his eyes and looked at me and closed it again. He was not dead though, but honestly if I had been alone without any nurse, I do not know what I would have done. Nursing is something else.” In this particular case the fear and anxiety of the student nurse was escalated and it is at this point that some opt out for other professions. On the other hand the clinical nurse should have orientated the students to the ward and gone with the student to perform the task, more so because this was their very first time in the clinical area. This would have minimized the fear and anxiety. The second respondent who was shown round and was working with one of the nurses was still full of fear and anxiety. This confirms the anxiety and fear that student nurses especially those in first year face.(Baraz, 2015). Respondent two (2) recollecting her second year in school also stated that: “The theory in the lecture room is different from the practice at the clinical area. Our tutors do not come to the ward to teach us the practical aspects in real life situations. Some of the hospitals in which I worked as a student use the patient’s bucket and the top surface of the patient’s locker to assemble bath items and then proceed to bath the patient. We were taught that a bath trolley should be used but there was none on the ward so I had to improvise. It really makes learning difficult. One gets used to improvising where the items needed are not available and then during the licensure examination it is produced and you would have forgotten how to use it.’ Respondent twenty eight(28)recollected her experience: “ On the ward, nurses are to lay the beds of patients with the appropriate bed linen and mackintosh. In school, we are taught the theory and it is demonstrated in the skills lab However, in the clinical area the linen is not enough so only one or two sheets are used. This makes learning the right thing difficult because one has to improvise all the 29 University of Ghana http://ugspace.ug.edu.gh time. During licensure examination when all the linen is produced, we cannot even remember which linen comes before or after the other.” Respondent seven (7): “I noticed that in school, we are taught how to use the nursing care plan but it is not used on the wards. Though they plan the care of patients, no such form is used. It is very difficult to try to apply theory in the practical area. Whenever we have to use the care plan in the hospital, we face difficulties because the nurses on the ward are not interested in using it. This is why I always want my tutor to be around to ask her all my questions. Rolfe (2003) posits that student nurses really feel this theory-practice gap phenomenon. Having less experience and not being able to take meaningful decisions at this stage makes it really difficult to determine what is the standard or the right way for carrying out tasks in the clinical area. According to Bendall (1976), the difference between what is taught in the school and what is practised at the clinical area has been an issue for the past three decades and something needs to be done about it. Respondent three (3) talked about her 3rd year experience at the clinical area and she recollects :“Even though I was in my final year as a diploma nurse, I realized that some of the drugs used in treating patients on certain conditions had changed. They were different from what was taught in school. I also felt handicapped with interpreting laboratory results of a patient. For instance a patient had a high white cell count before surgery and it was still high after surgery. I did not even know till one of the senior nurses called me to ask what I intended to do for the patient if I was the one in charge of the ward. Some of these things I do not remember being taught in school so I told her, I do not have a clue as to what to do.” 30 University of Ghana http://ugspace.ug.edu.gh Other scholars such as Cook (1991) and Scott (1994) argue that the practice at the clinical area must conform to the theory taught in the schools and vice versa. Rafferty, Allcock and Lathlean (1996) argue that theory must conform to practice though it cannot be fully achieved but should be as close as possible and this also calls for constant research in the area. Respondent forty (40) recollects : “ Our tutors do not come to the hospitals when we are there and so sometimes when we face challenges we do not know where to go and resort to calling them on their phones.However some of the Training Coordinators within the hospitals tell us to come to them when we face any challenges and they help us out. They do so during orientation at the hospital. Other Coordinators do not do the orientation nor tell us what to do and where to go to when we face challenges. So if you are in such a hospital, you will revert to calling your tutor. An example is when one of my colleagues was sick. She did not have her NHIS card so had to pay for consultation and treatment.” According to Ashrifi M, et al (2017), lack of supervision by the tutors at the clinical area is a big issue. The number of students enrolled in the training schools and the number of hospitals they are placed in during the semester makes it impossible to go to each clinical area to supervise or provide mentorship.This is due to the fact that the students far outnumber the tutors. For instance Respondent T(Tutor): “ I teach first (1st) and third (3rd) year students who are two hundred and two hundred and ten respectively in my class. I am the same person to follow them up to the clinical area if the first year students are in the hospitals and also teach the third year students at the training school within the same period of time. It is extremely difficult too because they might be placed within six different hospitals and within the hospitals are found in different wards. When will I 31 University of Ghana http://ugspace.ug.edu.gh finish with one ward to move to another when it is time to go back to school to teach the third year students? I normally rely on the training coordinators in the hospital and some of the ward nurses in charge of the ward to help me with this aspect.” Respondent thirteen (13): “The rotation is very stressful and we are entitled to only one day off when on day shifts and three days off on night shift. Sometimes when I get to work by the fifth day, I feel so worn out. However I still need to report to the ward or will be asked to stay on that ward for an extra day or two. Some of the staff leave everything for us to do and being so worn out, I sometimes find it very difficult to cope with the situation. Sometimes when you call them to come and guide or supervise you to carry out a procedure, they get angry and carry it out themselves without relating to you. They then brand you as a lazy person.” Respondent seventy-five (75): “As a Rotation Nurse, and having stayed at home for about eight months after completing school, it is as if you are back to learning. Even though as I work on the wards now and upon observing the clinical nurses in the performance of carrying out the nursing care duties, I am beginning to remember how to do some of them. The Clinical nurses expect so much from us but do not know that we are like the students because we have forgotten almost everything. We are treated sometimes like staff nurses especially when there is shortage of staff and other times like student nurses which sometimes makes me feel demeaned.” This is a peculiar situation of not having the confidence to carry out duties since Rotation nurses have forgotten what they were taught in school. They had to stay home after completion of their training as a result of the merger by the Nursing and Midwifery Council with the National Service Secretariat on rotation or one year 32 University of Ghana http://ugspace.ug.edu.gh mandatory service to the nation. The nurses are posted to the various health facilities when the secretariat is ready to post all students due for it during the year. It is also as a result of the ban on employment imposed by the International Monetary Fund (IMF) on the developing countries such as Ghana. Respondent Senior Clinical Nurse (SCN): “I have realized that the reason why the students and rotation nurses are not performing well in the clinical area is because some of us do not take the time to teach them when they are assigned to our wards and units.Though the students are more than the rotation nurses, we should allot time to teach them.Most of them do not know that they are to achieve all the objectives set for them by their schools. I normally resort to having them make copies of their objectives and as they do them they tick it. By the end of the second or third week they should have ticked all. Within their last week on my ward, I start to interview them. Those who are unable to carry out the tasks within the objectives are made to stay on the ward another week to sharpen their skills. The Rotation nurses go through the same drill and I demand the rationale for carrying out procedures. There are times when I test their critical thinking skills especially when I give them tasks and make them assume that there is no one to fall on for direction or advice. Some appreciate it and others do not because they think I am wasting their time. All nurse managers whom students and rotation nurses are assigned to, need to assess all the rotation nurses and students to make them understand what they do and not forget that they are the ones to take care of us when we retire. Therefore it is important to groom them to gain all the skills and understand what they do in order to give off their best when caring for the sick”. Respondent Clinical Nurse (CN): “ From my perspective and my knowledge in nursing, I attribute the challenges students and rotation nurses face at the clinical area 33 University of Ghana http://ugspace.ug.edu.gh to be an issue from the clinical area and the training schools. There is very little collaboration between the two parties. Sometimes when you try to correct the students and Rotation nurses, they will tell you that this is not what the tutors taught us. In trying to find the rational or basis for what was taught, I get no convincing or tangible reasons. As an individual, I try to teach them when I get a little time or let them move with me as I carry out procedures on the ward and explain the rational for all actions taken. There are times when we google the internet together to be sure of an information given them.” This confirms Rolfe (2003) assertion that there must be constant research in the area of theory-practice gap.There must be an effective on-going collaboration between the training schools and clinical area where ideas, literature and actual practice can be researched and discussed to come up with an almost uniform way of managing patients without getting the student nurse and the Rotation nurse confused. 4.2.2 Orientation Issues Other issues that were discussed by the respondents were that as students, when they report at the clinical area, some hospitals take them through orientation, others do not. At the ward level, most of the ward managers take them through orientation and expect them to know everything on the ward within the next few days. Some ward managers do not look at their objectives and place them where they like defeating the purpose of learning practically what has been taught in class. The Clinical Nurses had a challenge signing their log books. These are books brought to the clinical area together with evaluation forms that have to be filled by the students and the National service/Rotation nurses and then signed by the ward manager. There are times when some of the students do not bring their books but come along from the 34 University of Ghana http://ugspace.ug.edu.gh school with only their evaluation forms. Sometimes the students on the ward are from different schools and the evaluations need to be a one-on-one interview to know what each student has acquired practically on the ward. This seldom happens during the peak periods-January, June, July when there are over four hundred students to be assessed.(Source: GARH, In-Service Training Unit 2017). So the true picture of what they have learnt is not seen and they go back to school with whatever clinical information and skill they have acquired. 4.3. Clinical Factors 4.3.1 Interpersonal Relationship Issues on the manner in which some of the National service/Rotation Nurses were talked to by the staff left much to be desired. The clinical nurses should have more patience and be able to tolerate the students and their flaws all the time. They should appreciate the fact that the students and rotation nurses are still learning and can make mistakes. On the other hand, they are to develop a good interpersonal relationship with the students and rotation nurses and desist from scolding, humiliating and disgracing them especially infront of the patients. This tends to lower their morale and confidence. Respondent sixty-five (65) recollects her experience : “ I was asked to prepare a patient on the ward to theatre for a minor surgery. I did what I thought was right for the patient by checking his drugs,and vital signs and going for the stretcher that would be used to convey him to theatre.The charge nurse came to the bedside and asked the patient whether he had been shaved and the operation site marked. He said no and straight away, I was told how useless I was as a graduate nurse and she wondered what I learnt fom the university. I felt so humiliated and excused myself fom the patient and went to hide somewhere. I later saw one of the staff 35 University of Ghana http://ugspace.ug.edu.gh nurses wheeling the patient to the theatre. I went to the Out Patient Department (OPD) and saw a doctor who gave me an excuse duty for my last two days left for me to leave the ward to another. I honestly could not see myself infront of that patient again when he returns to the ward.” Respondent thirty-five (35) recollects her experience: “I am amazed to find myself still doing my rotation/National Service. I nearly stopped a few weeks ago because of the humiliation I suffered at my original posting. I had difficulty performing some tasks such as wound dressing. I just could not get round doing it aseptically without any flaws. The nurse who was supervising me really disgraced me infront of the patient the first time. Two days later, on the same ward, I was asked to do wound dressing. When I got to the patient infront of whom I had been humiliated, he told me without mincing his words that he would not allow me to dress his wound. There was another patient on the last bed in the same room. As I turned to wheel the dressing trolley towards him, he also told me he was not a toy or dummy to be played with. I felt so bad and gathered courage to move to the next room. As I got ready to screen the patient, one of the patients from the other room came to tell the patient that this nurse does not know how to dress wounds. You allow him to at your own risk. So he also refused. I wheeled the trolley to the room where we keep the trolleys, cleaned it and went to tell the sister in-charge about my ordeal. She directed me to the training coordinator of the hospital. I told her what happened and she asked me to go home and return the next day with a clearer mind. I did and she called another nurse in this facility and wrote a letter for me to continue my rotation here. I am happy here and now an expert at wound dressing. Thanks to that training coordinator.” Respondent fifteen(15) recollected yet another experience: 36 University of Ghana http://ugspace.ug.edu.gh “I had a good experience when during my first year at the clinical area, my colleague and I were asked to wheel a patient to the radiology department for an x-ray. The patient looked very ill so we prepared to wheel her out of the ward. One of the senior most nurses was on monitoring rounds. She asked us to wait by the patient and went to call one of the staff nurses who accompanied my friend to the department. She asked me to follow her to the ward and called my other colleagues to find out how the staff were teaching us and what we had learnt so far. She took us through a few nursing procedures and had to leave to continue on the other wards. Again during my rotation here, I was about to discard a used needle into a sharp box that was already full, when the training coordinator came around with another senior nurse who was about to yell at me. The coordinator called me out of the room and told me to get another box to put the needle into. As I was leaving to get the sharp box, I overheard her telling the other nurse not to scold or yell at the nurses infront of patients or she will confuse them and the patients would not have any confidence in them.” Respondent twenty(20) recollected : “As a student, I was always afraid to be on duty with certain nurses on the ward. The reason being that, you will be humiliated when you do the wrong thing. There were times when I was even afraid to carry out tasks assigned me because I would not even finish and the nurse supervising me would start disgracing me infront of everyone. At a point, I wanted to stop the course but my friends would tell me that it is not every nurse that behaves that way and therefore those one or two nurses who did that were not on all the wards. I remember one particular instance where I was humiliated and started to cry on the ward. The patients in the room at that time were elderly men. They told me to stop crying and called the nurse and told her to desist from that 37 University of Ghana http://ugspace.ug.edu.gh behaviour and that did she not learn from other nurses. They even went further to report the matter to the senior nurse on the ward. Fortunately for me, my shift was changed after that unfortunate incident and I was always on duty with the senior nurse who assigned me to a more friendlier nurse till I left the ward. I would never forget the advicethe elderly men gave me, which was that I should never disgrace or humiliate any student or junior nurse under my charge in future when I qualify as a registered nurse, because it is not worth putting people through what you suffered.” The relationship between staff, the student and rotation nurses has always been an issue. Most of the nursing staff expect too much from the students and national service/rotation nurses because they see some of them coming to their hospital for clinical attachment. A few years later, these same students come as National service/Rotation nurses and so they expect them to know everything. However, some scholars have reiterated that the staff nurses on the ward have issues on shortage of staff and therefore do not have the time to teach the students.They expect the students and especially the rotation nurses to have acquired enough knowledge to be able to carry out tasks with minimal supervision. In other words, the workload increases and so there is no time allotted to teach the students. The interpersonal relationship is not encouraging because they are overwhelmed with the work load, get easily irritated and sometimes think that the students are lazy. It is also at this time that they use the National service/rotation nurse as part of their staff on the ward.The shortage may be as a result of staff taking their annual, study, maternity or leave without pay. They also stated that the collaboration between the clinicians and the academicians is not effective and modalities have to be put in place to solve the issue.(Ashrifi M, et al, 2017). 38 University of Ghana http://ugspace.ug.edu.gh 4.3.2 Inadequate Equipment A few years back, there was a challenge with equipment at the hospital in all the wards. There were times when there were not enough blood pressure monitors, thermometers, gloves and other items. This made it very difficult for students to gain meaningful practical experience on the wards. Currently the GARH has undergone upgrading and reconstruction on a turn key project(this is a project carried out by an international company that constructs, equips and hands over the completed project for a remuneration). The building is the best among the hospitals in Greater Accra with ultra modern equipment such as monitors to check the vital signs of patients, cardiotomogram to check the uterine (womb) contractions and the unborn baby’s heartbeat. There is central airconditioning which makes the environment less stressful and conducive for working. Unfortunately, students who go to the hospital are not encouraged to use the equipment for fear of ill handling them because of their large numbers and that during their licensure examination, they would be asked to use the manual equipment. They are being encouraged to get used to the manual equipment so that they do not become handicapped in its use during their examination. The large number of students who go for clinical practice during the peak times in January, June and July compete to use the few manual equipment on the wards and every now and then the equipment break down. However, the National service/Rotation nurses are allowed to use the monitors and are under strict supervision so that they do not damage the equipment. 4.3.3 Clinical Documentation The students report at the hospital with their clinical schedule books from NMC and evaluation forms from their schools. The Rotation nurses report with log books from 39 University of Ghana http://ugspace.ug.edu.gh the NMC, National Service posting letter and are given evaluation forms at the facility level approved by the Regional Health Directorate. These books and evaluation forms are to be signed by the nurse manager in charge of the ward upon completion of clinical practice there. The challenge faced by the nurses was that sometimes the ward manager did not interact at all with the students and rotation nurses, yet she signed their books and evaluation forms. The student nurses think that the ones they worked with should sign their books and forms. However, scholars again reiterate that the clinical books and forms are not being handled properly by the clinical nurses.(Ashrifi M, et al, 2017). At the Greater Accra Regional Hospital(GARH), the training coordinator sees the Rotation Nurses at each stage when they are changing over to another ward. Upon collecting the evaluation forms and looking at the activities recorded in the log book, questions are asked to see if the nurse really performed those documented procedures. Where flaws are detected, the nurses are corrected and where questions could not be answered, the nurses are asked to go back to that ward for a minimum of two days to a maximum of seven days. This to ensure that learning has taken place. Edwards et. al.(2002) confirms this in a study conducted in South Africa. The Rotation nurses see this as a challenge because they then spend more than the fifty two weeks at the hospital. Their national service lasts for one year which is equivalent to fifty two weeks. However, the patient stands to benefits from this because it shows that competent nurses are being raised to take over the workforce in the near future. 4.3.4 Additional Units Not Found in the Log Books This is another challenging area for the Rotation Nurses and they do not like it at all. The rotation nurses use the Nursing and Midwifery Council (NMC) approved log book 40 University of Ghana http://ugspace.ug.edu.gh for their national service. The log books have almost all the categories of nursing in it and the rotation nurses have to work in all the areas indicated. The categories include medical, surgical, obstetrics and gynaecology, psychiatry, public health, Out Patient Department (OPD), Eye, Ear Nose and Throat (ENT) nursing. They are assessed at the end of the period and their log books are signed by the nurse manager in charge of the ward. For instance, the log books of the midwives do not have anything on tuberculosis and some other conditions. However in recent times, tuberculosis has been detected in some pregnant women and if neglected can be transmitted to the midwife handling the delivery if it is the air borne type and the midwife’s immunity level is low at the time. Due to some of these issues, they spend a week in each of these areas that are not stated in their log books but are assessed with an evaluation form. 4.4 Socioeconomic Factors Most of the challenges in this category were compared with the issues in the training schools when they were students and currently as National service/Rotation nurses. These issues were better handled at the training school level than as rotation nurses. Some of the challenges include accommodation, transportation, duty roster and safety and no modalities in place for reporting sick. Almost all the challenges identified were sort of overlapping into each other and this made it a bigger issue. 4.4.1 Accommodation In the training schools, the student nurses had accommodation because they were put in hostels either on campus or off campus. Anytime they had to go for clinical practice, 41 University of Ghana http://ugspace.ug.edu.gh the school bus conveyed them in and out of the hospitals and clinics and back to their hostels in the school. Currently as National service/Rotation nurses, they have to look for accommodation, especially for those posted for national service in Accra from their homes in other regions. Sometimes some of the rotation nurses help their friends out by allowing them to share their home and rooms.There have been instances of misunderstanding among the two people. It is normally resolved at the hospital and if the two are on the same ward, they are separated. This is a big challenge especially when they get accommodation far from the hospital. They normally have transportation fare issues, safety issues -getting home sometimes around eleven (11) pm when put on afternoon shift and performance issues- arriving late the next day on the morning shift. This they claim makes them tired and therefore performance is compromised. There have been times where some had to go and do some other jobs elsewhere to pay their accommodation fees, again confirming the negative performance issues. The Regional Health Directorate of the Greater Accra Region helps as much as it can when the situation outlined above especially regarding accommodation becomes a big issue at the Greater Accra Regional Hospital (GARH). If the accommodation issue is found to have an adverse effect on the output of theNational service/ rotation nurse at the hospital level, the nurse is asked to go and discuss the issue with the Chief Nursing Officer (CNO) who would have had prior information from the Deputy Director of Nursing Services (DDNS) of the hospital. She, the Chief Nursing Officer at the Regional Health Directorate in turn liaises with the National Service Regional Administrative Officer and the Chief Nursing Officer in the region of choice of the rotation nurse. Once the modalities are put in place and sorted out, at this stage, the rotation nurse is officially released from the hospital to the Regional Health Directorate 42 University of Ghana http://ugspace.ug.edu.gh for onward transfer to the region of his/her choice.(Source: GARH, In-Service Training Unit, 2016 – 2017) 4.4.2 Reporting Sick In school, the student-national service/rotation nurse reported to the nurse in charge of students when sick and were taken to the hospital to be seen and treated. Another challenge was the issue of having the valid National Health Insurance Scheme (NHIS) card for service delivery. If the card is not valid then the rotation nurse has to pay for consultation and treatment. All respondents found this issue as a challenge and wondered why the hospital had such a policy. Due to the number of students and rotation nurses posted to the hospital either for clinical attachment or as national service personnel, the hospital with its main source of funding from the Internally Generated Fund (IGF), cannot take care of all these students should they fall sick. The staff of the hospital abide by the policy and once in a year, the NHIS, Osu Klottey scheme goes to the hospital as their social responsibility as well as a mutual collaboration with the hospital to renew the staffs’ NHIS cards and issue new ones where applicable.(Source : NHIS Unit 2017). 4.4.3 National Service Allowance The Rotation Nurses complained about the irregularity of the national service allowance stating that they do not receive it monthly as stated in their letter. They then have to fall on their parents and siblings for money to eat and travel to work. Others resort to walking a distance in order to save money to board a bus home. Performance issues are compromised again because the rotation nurse arrives at work totally exhausted from walking. Unfortunately this issue falls outside the hospital’s domain 43 University of Ghana http://ugspace.ug.edu.gh to effect a change. Some staff who have friends at the National Service Secretariat were tasked to talk to them about the essence of the allowance being paid monthly and on time. 4.4.4 Duty Roster and Safety Nurses on the wards run a shift system which is a morning, afternoon and night shift. Depending on the bed capacity and how busy it is on a daily basis, a number of nursing staff are allocated by the Deputy Director of Nursing Services(DDNS) in charge of the hospital to work in the different departments. In other words, the busy wards or units such as the emergency ward, neonatal intensive care units, labour ward and the theatres are allocated with more staff than the other units. The specialist areas such as the ENT, Eye and Intensive care units are allocated with nursing staff who have specialized in these branches of medicine. The duty rosters on the wards are prepared by the nurse manager in charge of the ward. The rosters are prepared in such a way that staff are distributed on every shift with an appropriate staff mix so that any issues arising can be handled by the senior most staff on each shift. For instance if the nursing staff on the ward are made up of nursing officers, registered general nurses and enrolled nurses, each shift would have one or two of the enrolled nurses,one or two registered nurses and a nursing officer on each shift. The nursing officer becomes the charge nurse for each shift and supervises and directs all affairs while on duty. When there are few nurses or shortage of nurses on the wards,the staff mix and number per each shift dwindles as a result of some taking their annual leave study leave or maternity leave. The rotation nurses are then added to those on the roster to enhance the smooth running of the ward. However, if another rotation nurse on a different shift on the ward arrives early, the other on duty is not 44 University of Ghana http://ugspace.ug.edu.gh allowed to go till the regular staff report for duty. Handing over the whole ward takes place, after which the staff on the just ended shift leave the ward to go home. This brings about the issue of rotation nurses arriving home around 11pm from an afternoon shift. It also brings up the safety issue, since every now and then people especially ladies are accosted by robbers who might be armed, and try to harm them, in all areas of the metropolis. Respondent eighty (80) suggests : “ If practicable,the duty roster should be discussed with all staff and the Rotation nurses so that those who live far off can either come on morning or night shift and then those who live close by come in the afternoons. Nursing work is continuous so procedures could be carried out at anytime when necessary just as is done in the mornings. The students are excluded since their bus conveys them to and from the clinical area.” 45 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 5.0 Introduction This chapter presents the summary, conclusions and recommendations for a better experience for the students and rotation nurses at the clinical area. 5.1 Summary The study conducted was on the challenges or factors that hinder the performance of student nurses who had progressed to National service/Rotation nurses. The objectives of the study was to ascertain the factors that hinder their performance at the clinical area and whether the passion for the profession has implications on their performance. The findings revealed that the rotation nurses face challenges and it affects them negatively with some nearly opting out of the profession. The qualitative study approach was employed and indepth interviews were conducted on the ten student-rotation nurses who were from other health facilities. Focus group discussions were held for the seventy originally posted to the hospital for their national service/rotation. The study area was the Greater Accra Regional Hospital(GARH) and the justification of the choice was because it is a Regional hospital and recently reconstructed with ultra modern equipment. The other reason was that many different categories of students go there for clinical placement. The case study was on the student nurses who had progressed to National service/rotation nurses and they were chosen over second/third year students since they were able to recollect their student days and the challenges they faced in comparison to what they are currently facing. 46 University of Ghana http://ugspace.ug.edu.gh 5.2 The Challenges The findings were arranged in themes which included educational, clinical and socioeconomic factors. 5.2.1 Educational factors The educational factors highlighted on the gap between the theory and practice.This was found to be studied by some scholars and clearly showed that there are many issues on it all over the world. However a modality or strategy needs to be put in place to address the issue. Rolfe (2003) suggests that research must be encouraged and Ashrifi M, et al (2017) believe that the academician and the clinician need to have good collaboration between themselves. The National service /rotation nurses stay home for some months after completing their course and so by the time they are posted for national service on the wards, they do not remember anything. At this stage they are like the student nurses but the difference is that once they observe a few procedures, they are able to remember and can be left later to work with minimal supervision. Suggestion: The student nurses and the rotation nurses should be encouraged to read a lot. At the school level, practical examples should be given to enable them understand the application of the theory better. At the clinical level, the theory must be applied and explained to them in order to understand what goes on in the care of a patient. For instance, if the patient has a fever, the students must understand which anatomical structures are affected and why. If an intervention is put in place to stop the fever, they must understand how the intervention stopped or reduced the fever. In addition, the rotation nurses must be supervised at the clinical area with all procedures until certified 47 University of Ghana http://ugspace.ug.edu.gh to be competent enough to handle the patients with little and subsequently no supervision. 5.2.2 Orientation Issues Other factors were on orientation issues. In some facilities it was well done while others had a great challenge. For instance, they were not shown round the facility, they did not know the reporting sick policy of the hospital and the reason for clinical attachment was not considered. In otherwords, their objectives were sidelined so at the end of the period in the hospital, they did not achieve anything. Suggestion: It is mandatory in the Ghana Health Service to orientate all new staff, students, national service personnel and newly promoted staff to the facility and their new roles respectively. When done, students and staff alike get to know the policies, rules and regulations of the facility and always know where to go to clarify issues should they arise. 5.3 Clinical Factors 5.3.1 Interpersonal Relationship From the clinical challenge perspective, the Rotation nurses as students had very bad experiences especially with regards to interpersonal relationship. They were either humiliated infront of the patients and that definitely had an impact on their performance. Those who had the bad experiences could not even afford to face the patient again. Others nearly stopped their rotation but had a caring coordinator to help them out. Suggestion: All clinicians need to learn how to talk to their fellow colleagues, team members, seniors, subordinates and students. Customer care should be encouraged in 48 University of Ghana http://ugspace.ug.edu.gh all health facilities. Correcting students or other clinicians infront of the patient is highly discouraged and all senior staff should desist from that kind of behaviour. The students and rotation nurse or other junior staff should be called away and taught the correct way with the rational for the action. It is only when the patient is at the point of losing their life or about to be harmed that the staff is rebuked there and then and stopped from carrying out the procedure.Continuous supervision of all staff under the ward manager should be encouraged till each staff is competent enough to manage patients without supervision. However, the students and rotation nurses should be continuously supervised. It is from the supervision that they learn and appreciate the basis and rationale for carrying out procedures and tasks.They understand the patients better and join in ensuring the patient’s safety. The clinicians also had a challenge seeing to the many students who came to the ward for practical attachment. Some tried very hard to pull the students along and taught them the rational for carrying out tasks or procedures. Others could not be bothered. Others reiterate that most of the students were not serious nor ready to learn. Suggestion: The students from the various schools should not go for clinical practice at the same time. This has been attributed to the semester period where they all vacate and reopen around the same time. The schools should liaise together with the clinical facility so that they draw a timetable as to when each school should go to the facility. This would reduce the number of students in a facility at a time. Supervision and teaching would then be more effective and beneficial.The students would be more serious and appreciate their clinical practice. 49 University of Ghana http://ugspace.ug.edu.gh 5.3.2 Clinical Documentation Clinical documentation was a challenge for both the clinician and the students. The challenge from the students’ perspective was that the students were placed in the care of a staff nurse and at the end of the entire period on the ward, the nurse manager signed their schedule or log books. The students did not think it was right because some of the nurse managers never interacted with them but were able to grade them on their performance. From the perspective of the clinician, there were times when the students were too many and so signing their schedule books became a challenge if she had to call each and everyone of them to interview and then sign their books. Suggestion: The nurse managers should know all the students that come to her ward. She has to assign them to the junior nurses to work with. At the end of the day, the junior nurses are to state in a designated students book the tasks they performed with these students and comment on each student’s performance. The nurse should write her name and their names, school, period of time spent on the ward,( that is the students she worked with) with the date and shift. This should be done on all shifts. At the end of the period, the nurse manager with the information from the book can further interrogate each of the students and evaluate them and sign their schedule or log books. Where the nurse manager upon using her discretion thinks that the student did not grasp or learn anything, the student may be asked to repeat the ward. 5.3.3 Inadequate Equipment Inadequate equipment was another challenge and in this case, the students had to resort to improvising when carrying out procedures or tasks on a patient. At the Greater Accra Regional Hospital(GARH), the students are currently not allowed to use the equipment for fear of ill handling them and more importantly during their licensure 50 University of Ghana http://ugspace.ug.edu.gh examination, they would have to adopt the manual way of carrying out tasks. This is to enable them acquire the skill in using the manual equipment so that in future when they find themselves anywhere in a facility without modern technology they would still be able to function effectively. For instance, when the cuff of the monitor is applied to the arm of the patient, it will record all the vital signs(blood pressure, pulse, respiration and temperature) at periodic intervals as well as record the electrical activity of the heart. The National service/rotation nurses were however supervised to use the new equipment. Suggestion: The students could go to the clinical areas with their own blood pressure apparatus known as sphygmomanometer, thermometer and stethoscope.(These are used to check the blood pressure, temperature and pulse of patients). This measure also teaches the students how to handle their own equipment and with time, they learn how to handle that of the hospital with that same caution. 5.3.4 Additional Units not found in Log Book Additional Units not found in the log book was a challenge to the rotation nurses. They could not understand why their log books from the Nursing and Midwifery Council (NMC) had specific areas that they had to go to and then other units which were not in it were being added to their rotation areas. For instance, the midwives’ log book had no Tuberculosis unit in it, yet they were asked to go there for a week. Unfortunately they were not aware that in recent times, there have been reported cases of pregnant women with tuberculosis which was discovered when the woman got to the labour ward. It is important for the rotation nurses to identify such conditions and be able to diagnose, treat or refer them to the appropriate unit in future. Little did they know that they were being equipped to be efficient and effective when they become ward 51 University of Ghana http://ugspace.ug.edu.gh managers one day and the public would also benefit from this. This confirms Ashrifi M, et al (2017) study that the curriculum should be reviewed from time to time. Suggestion :The Nursing and Midwifery Council (NMC) should review the areas in which the rotation nurses should rotate in, which implies that additions could be made. The number of weeks for the rotation should be reviewed to ensure that all relevant areas are covered. 5.4 Socioeconomic Factors 5.4.1 Accommodation and Transportation Socioeconomic challenges came up because in comparing the challenges at the clinical area during their training to their current status as rotation nurses, some of them realized that at the hostel they were better off. This is due to the fact that they were conveyed with the school bus to the clinical area and back to their hostel so there was no worry about accommodation or transport. However, some of the rotation nurses have to make ends meet by walking half way to work in order to save money for transportation on a daily basis. For those who came from other regions, they had to look for accommodation and sometimes work extra hours elsewhere in order to pay their accommodation fees. All these factors were found to have an effect on their performance because they were exhausted by the time they got to work and therefore the output was not favourable. 5.4.2 National Service Allowance The national service allowance is not regular and makes life difficult for the rotation nurses. They sometimes find it difficult to ask their parents or working siblings for money. Due to this they sometimes resort to borrowing from their friends or find other means of making ends meet. 52 University of Ghana http://ugspace.ug.edu.gh 5.4.3 Duty Roster and Safety The Duty Roster issue is very much related to safety issues. When the rotation nurses live very far from the hospital and are placed on the afternoon shift, it has an effect on their performance. This is because if they have to wait and hand over with the regular staff on the ward and their relievers come in late, then they tend to get home around 11pm. In the metropolis, it is not safe to be walking about late in the night. Unfortunately if they are placed on the morning shift the next day, they are almost always late. Especially when they do not have money, they have to walk half the journey and then board a bus for the remaining part of the journey to work. This nurse would arrive late and exhausted and performance would be compromised. This issue addresses both the safety and performance issues. The findings and analysis so far depict the relationship between the challenges the nurses face and the effect it has on their performance. It is imperative that the root cause of the challenges need to be addressed as a matter of urgency in order to curtail any adverse performance from the student and rotation nurses. Modalities have to be put in place to address these challenges so that the nurses at the student and rotation level can perform their tasks very well. Suggestion: The national service secretariat should post the nurses to the regions where they have easy access to accommodation. They should also try and pay the allowances on a monthly basis. If need be, the authorities should inform the government about the challenges the personnel face so that the money comes on time. The clinical ward managers should consider where all the nurses and rotation nurses stay so that those who live far off would do the morning and night shifts while those who stay closer to the facility would do the afternoon shift.The staff on each shift must endeavour to report for duty early so that by the time they finish handing over, it is not late. 53 University of Ghana http://ugspace.ug.edu.gh 5.5 Conclusion The factors that hinder the performance of student and national service /rotation nurses can be outlined under the three main themes adopted from the findings which include: The Educational factors, Clinical factors and the Socioeconomic factors. All these factors cut across the student nurses, the national service/rotation nurses and affects to some extent, the clinicians and tutors not forgetting the patients who are at the receiving end. In order to appreciate how the challenges cut across all parties stated in the preceding sentence, the explanation below depicts it: A student nurse and a rotation nurse is assigned to the ward. The clinical nurse is short of staff on the ward. She adds the rotation nurse to the staff duty roster as though she the rotation nurse is a regular staff. The rotation nurse is not orientated but is assigned a task and does it with the student nurse she reported on the ward with. She performs it as she thinks she can remember and then the shift ends. She hands over with the other regular staff, is rebuked for poor performance of task assigned, leaves the ward late and demoralized. Walks half her journey and boards a bus for the remaining half of the journeyand gets home exhausted. Owner of the rented accommodation comes to ask for the due rent and gives an ultimatum. The rotation nurse goes around the next day in the morning to look for an additional job to do to get some money. It is time to go to work in the afternoon, so does half walking and half bus journey and arrives on the ward very late and exhausted. She is humiliated infront of the patient while performing a task and ends the shift very late and makes her journey back home at the mercy of an accoster who asks that she hands over her phone or be molested. She gives up her phone and gets home safely, exhausted, demoralized and wonders whether to stop the rotation or what next. 54 University of Ghana http://ugspace.ug.edu.gh Some scholars have seen similar challenges in their course of study but this is the first seen in the case study at the Greater Accra Regional Hospital (GARH). The onous lies on all the nurses both junior, senior at the clinical area, tutors in the training schools and the lecturers in the university to collaborate with each other to help solve all the issues. The NMC and the National Service Secretariat should also collaborate effectively with each other as well as with the clinicians to make the training and national service a worthy course for these young nurses. 5.6 Recommendation This case study has revealed certain hinderances as to why the student nurses and national service/rotation nurses are not performing according to standards. The current issues in the health sector in Ghana keep emphasizing on the the performance of health care practitioners. All over the world there have been issues on performance management reforms in all public institutions. The factors that have been found to affect the performance of the student and national service/rotation nurses needs to be addressed both at the clinical, training school, university statutory body and regulator level. None of the afore mentioned can work in isolation and therefore there must be collaboration between all the parties. The training of a nurse can be likened to a cycle as follows; Enrollment into the nurses training school or university depending on the grade made, Trained for three years (diploma) or four years (degree) Entails theory(in school) and practice (clinical area-hospital) Taught by nursing tutors/lecturers and nurses at the clinical area Pass out as Diploma nurse and Degree nurse (after passing the NMC licensure examination) 55 University of Ghana http://ugspace.ug.edu.gh Work in the clinical area and after gaining some experience teach students either at the clinical area or go to the training schools or university to lecture, and the cycle continues. It is however recommended that all the challenges revealed under the themes be addressed and improved upon as follows: EDUCATlONAL: The training of nurses needs to be suspended for a year or two in the country. The reason for this recommendation is that there are quite a large number of nurses trained, have passed their licensure examination, have their PIN (which enables them to practice)but are at home because they are not yet employed.They need financial clearance from the Ministry of Finance before they can be employed as new entrants. Till the financial clearance goes through they have to stay at home or find something else to do. In the public hospitals they cannot be employed and a few are fortunate to be employed temporarily in the private clinics and hospitals. Therefore it is important to mop up the unemployed nurses in the country before training more in the schools who would add up to the huge number already at home. Improved Health and Housing Infrastructure The country has a growing population with infrastructure that has not seen much significant change. The polyclinics should be upgraded to hospitals with the requisite category of staff such as specialist nurses and doctors as well as the other team members to see to patients with minor ailments. Minor and major surgeries such as appendicitis, hernias, caesarean sections, removal of lumps to mention a few should be done at these upgraded hospitals. These hospitals should be in each area within the cities, towns and villages. Each region should have at least four or five referral hospitals apart from the regional hospitals. This should factor in the population within 56 University of Ghana http://ugspace.ug.edu.gh it. Decent accommodation or housing should be constructed for the health staff on rotation or national service to cut down the cost of transportation and accommodation. Upon completion of the national service, they should vacate the rooms for the next batch of rotation staff. This measure should improve the performance of the rotation/ national service staff especially the nurses. Effective Collaboration of the Clinical Area and the Training Schools: The training schools should have an exchange programme with the clinical staff for each party to be abreast with the changes that take place both systems in order to adjust the curriculum to bridge the gap between theory and practice. Once both parties collaborate effectively, the congestion of students at the clinical area would be minimized. The clinical staff would be able to assist the students and rotation nurses to apply the theory to practice efficiently and effectively. This measure would encourage the clinical nurses to continue to read and learn new ways of caring for the patients as well as boost the drive for continuous research in the clinical area. Additional areas to be added or inserted in the NMC Log books The Nursing and Midwifery Council (NMC), the statutory body and regulator for nursing and midwifery in the country should add a few more clinical areas to the rotation/national service log book for midwives. These areas include tuberculosis and Acquired Immune Deficiency Syndrome(AIDS) and Cholera. It is essential for the midwives to go to these areas to learn how to nurse patients with these conditions. There are recorded cases of pregnant women with such conditions and once they are able to detect the signs and symptoms early enough, they could advice, treat and have a safe delivery. For some of the hospitals that the other ten rotation nurses came from 57 University of Ghana http://ugspace.ug.edu.gh to continue with the rotation because their original placement did not have departments such as medicine, surgery, neonatal intensive care unit, Ear, Nose and Throat (ENT) and Eye clinics, they did not insist on the rotation nurses to do the rotation in the areas that were not found in their log books.The rotation nurses were sent to the areas that were not found in the log book and though upset admitted that they had gained some valuable knowledge in those areas. It is recommended to the NMC to add the afore mentioned areas to ensure uniformity and conformity in all the hospitals and clinics where the rotation/national service nurses and midwives are placed. CLINICAL FACTORS Training Corner : It is recommended that all wards and units should create a training corner where the students and rotation/national service nurses could be taught while working on the ward. The training corner should have a resuscitation kit and dummy, sphygmomanometer (used to check the blood pressure of patients), thermometer (used in cheking a patient’s temperature), blood sugar monitor, stethoscope, the different kinds of tubes, dressing wound kit and charts for documentation to mention a few. The corner would also be used as an orientation area for all new students, rotation staff and staff placed on the ward or unit either on transfer or as a newly employed personnel. The regular staff on the wards could also benefit from this corner by sharpening their skills to improve upon their strengths and weaknesses. It could also serve as an evaluation corner where the nurse manager on the ward could test the students and rotation/national service nurses. Based on the assessment there, the nurse manager could fill in their evaluation forms and sign their log books which would depict the true competence of the students and rotation nurses. It would also resolve the issue of the students and rotation nurses complaint about being evaluated by a nurse manager 58 University of Ghana http://ugspace.ug.edu.gh whom they claim does not know them. Each day or at least thrice a week, demonstrations and teaching sessions should take place at the training corner. It would help the nurse managers identify students, rotation nurses and the regular staff who have challenges either applying theory to practice or in performing a procedure to be assisted to improve upon their skills. It would also serve the purpose of helping the students and staff to learn how to gather data on patients and write reports. Cubicle Nursing In order to help the student/rotation nurses achieve the objectives set for them, it is important for them to nurse all patients with their different conditions on the ward. It is recommended that cubicle nursing is adopted to give total nursing care to all the patients. In the Greater Accra Regional Hospital (GARH), almost all the wards have four patients in a room who share a restroom. In otherwords, if there are ten rooms, there are also ten restrooms, so each of the rooms has a restroom shared by four people. These rooms are known as cubicles. In modern nursing, there has been a paradigm shift from task oriented nursing to the use of the nursing process. Task oriented nursing is the process of giving one task to a personnel to perform on all the patients. For instance, supposing there are forty patients on the ward, a nurse is given the task of checking the temperatures of all these patients. It becomes boring, the nurse knows next to nothing else about the patient except the temperature taken. The nurse cannot comment on any other issue about the patient. However, with cubicle nursing, the nurse could be assigned to two rooms which implies that she has a total of eight patients. These eight patients would have different conditions. In applying the nursing process, the nurse would assess each patient separately, identify problems associated with the condition, plan the care to be carried 59 University of Ghana http://ugspace.ug.edu.gh out, prioritise what should be done first, implement action to be taken and then evaluate to ensure that the expected outcome has been achieved.When the nurse does this to all the patients assigned to her for the day, she is able to explain and comment meaningfully about all the patients. When the rotation nurse is assigned to work with the clinical nurse who enjoys teaching, they learn a lot of procedures,how to effectively communicate with the patients, educate them on their conditions and how to manage it as well as the rational behind all actions carried out. The nurse enjoys job satisfaction if all expected outcomes on each of the patients are achieved. This helps the student/rotation nurse have a better understanding of what the profession entails and is able to identify similar conditions when they are admitted. They gain knowledge, skill and the ability to gradually manage different conditions on the wards. Interpersonal Relationship between Clinical Staff and Students/ Rotation Nurses It is recommended that the Clinical staff build a cordial relationship with the students/rotation nurses. The clinical staff should orientate the students/rotation nurses well, work with them on the wards, command respect and discipline. The clinical nurse should be approachable, tolerant, firm and fair when handling students and rotation nurses. When students are not carrying out procedures correctly, they should not be scolded infront of the patient. Eye contact or gently telling the student/rotation to excuse his/herself from the patient and out of the cubicle is the best way to handle incompetency or wrong way of performing a procedure.Outside the student/rotation nurse is taught what to do and then to buttress what has been corected, the clinical nurse should go back to the cubicle with the student/rotation nurse and guide the student-rotation nurse to carry out the procedure. This boosts the confidence and morale of the student-rotation nurse, makes the patient feel secured and safe and does 60 University of Ghana http://ugspace.ug.edu.gh not panic when he/she sees a student-rotation nurse in his/her cubicle to perform a procedure. When there is a cordial relationship between the clinical nurse and student-rotation nurse, they are able to ask a lot of questions on conditions seen, they learn how to communicate with the patients and other staff members. The patients respect them and the students-rotation nurses get a lot of information from them. The student- rotation nurse gets over any anticipated anxiety, fear and the feeling of not belonging to the clinical area. SOCIOECONOMIC FACTORS Duty Roster and Safety The recommendation is that all the rotation nurses should be punctual to work on all shifts. This is an important attribute of a nurse. The clinical nurses should also be punctual on all shifts. Since handing over is key and takes some time, it is essential that for each shift, nurses arrive at least forty minutes before the shift starts. This is to ensure that everything in the ward is handed over and there is ample time to finish off and than leave for the day. Those rotation/national service nurses should always move out of the hospital in groups.This a safe way of moving out of the facility and minimizes pick pocketing or any other form of theft within the metropolis. National Service Allowance should be paid at regular times so that they can manage with it. It would help them to an extent, of not going around to borrow money from their colleagues and friends. The Nursing and Midwifery Council should be informed about the irregularity of the national service allowance and to ensure that the rotation nurses are paid till the end of their service. This is essential because once the additional 61 University of Ghana http://ugspace.ug.edu.gh units are added to the log book, the number of weeks would extend beyond the fifty two weeks. In effect every nurse encounters some challenges at each stage of their career and every effort must be made to keep improving and minimize challenges to the barest minimum to boost performance at all levels. 62 University of Ghana http://ugspace.ug.edu.gh REFERENCES Asirifi, M., Ogilvie, L., Barton, S., Aniteye, P., Stobart, K., Bilash, O., ... & Kwashie, A. (2017). Assessing challenges of clinical education in a baccalaureate nursing program in Ghana. Journal of Nursing Education and Practice, 7(10), 109. Baraz, S., Memarian, R., & Vanaki, Z. (2015). Learning challenges of nursing students in clinical environments: A qualitative study in Iran. Journal of education and health promotion, 4. Bendall, E. (2006). Learning for reality. Journal of Advanced Nursing, 53(1), 14-17. Buerhaus, P. I., Skinner, L. E., Auerbach, D. I., & Staiger, D. O. (2017). Four challenges facing the nursing workforce in the United States. Journal of Nursing Regulation, 8(2), 40-46. Cook,S.H.(1991). Mind the theory/practice gap in nursing. Journal of Advanced Nursing, 16(12), 1462-1469. Dunn, S.V. (1995). The development of a clinical learning environment scale. Journal of advanced nursing, 22(6), 1166-1173. Dunn, S. V., & Hansford, B. (1997). Undergraduate nursing students' perceptions of their clinical learning environment. Journal of advanced nursing, 25(6), 1299-1306. Edwards, S. (2002). Nursing knowledge: defining new boundaries. Nursing Standard (through 2013), 17(2), 40. Gimenes, F. R. E., & Faleiros, F. (2014). Nursing Challenges for the 21st Century. J Nurs Care, 3(143), 2167-1168. Henderson, V. (1966). The Nature of Nursing A Definition and Its Implications for Practice, Research, and Education. Jamshidi, N., Molazem, Z., Sharif, F., Torabizadeh, C., & Najafi Kalyani, M. (2016). The challenges of nursing students in the clinical learning environment: a qualitative study. The Scientific World Journal, 2016. Lindop, E.(1999). A comparative study of stress between pre‐and post‐Project 2000 students. Journal of Advanced Nursing, 29(4), 967-973. McKenna L, McCall L, Wray N (2010). Clinical placements and nursing students' career planning: A qualitative exploration. Int. J. Nurs. Pract.16(2):176-182. 63 University of Ghana http://ugspace.ug.edu.gh Rafferty-AM; Allcock-N; Lathlean-J (1996). The theory/practice”gap”: taking issue with the issue. Journal of Advanced NursingApr;23(4):685-91. Rolfe, G. (1993). Closing the theory and practice gap: a model of nursing praxis. Journal of clinical Nursing 2(3), 173-7. Safadi et al. (2012).Students opinion about the expectations of effective nursing clinical mentors. Journal of Nursing Education, 47 (3) 118.12 Talley, B. (2006). Nurses and nursing education in Ghana: creating collaborative opportunities. International nursing review, 53(1), 47-51. Timmins, F., & Kaliszer, M. (2002). Aspects of nurse education programmes that frequently cause stress to nursing students–fact-finding sample survey. Nurse Education Today, 22(3), 203-211. Tiwaken, S. U., Caranto, L. C., & David, J. J. T. (2015). The real world: Lived experiences of student nurses during clinical practice. International Journal of Nursing Science, 5(2), 66-75. Tritsch, J. M. (1998). Application of King's theory of goal attainment and the Carondelet St. Mary's case management model. Nursing science quarterly, 11(2), 69-73. Twumasi, P. A. (1979). A social history of the Ghanaian pluralistic medical system. Social Science & Medicine. Part B: Medical Anthropology, 13(4), 349- 356. Zhang, Z. X., Luk, W., Arthur, D., & Wong, T. (2001). Nursing competencies: personal characteristics contributing to effective nursing performance. Journal of advanced nursing, 33(4), 467-474. 64 University of Ghana http://ugspace.ug.edu.gh APPENDIX INTERVIEW GUIDE FOR STUDENT-ROTATION NURSES 1. What does it feel like to be a nurse? 2. Why did you choose the profession? 3. Did you ever have any anxiety about working in the clinical field? 4. Can you elaborate on some of your clinical experiences? 5. What are some of your worries as a rotation nurse? 6. Can you suggest ways of improving nursing clinical practice for students and rotation nurses? INTERVIEW GUIDE FOR TUTORS 1. How many students do you teach in your school? 2. How do you cope with teaching students and following them up on the wards? INTERVIEW GUIDE FOR CLINICAL NURSES 1. How many students do you supervise in your ward? 2. Are the students willing and eager to be taught? 3. Do they ask meaningful questions on the ward? 65