Internship Challenges Encountered by Nursing Students: A Qualitative Study Conducted at the Highest Institutions in Ethiopia

Background

Nursing education comprises two harmonizing parts, theoretical and practical. A vast proportion of nursing education has been sustained in the clinical environment. In many countries, clinical education forms more than half of the proper educational courses in nursing. Thus, clinical education is central to nursing education. As nursing is a performance-based profession, the clinical learning environment plays an essential role in accomplishing professional abilities.^1–3 Furthermore, the clinical area of nursing education has vital meaning for nursing students in the choice or rejection of nursing as a profession. Clinical teaching and learning are a complex environment that is affected by many factors; nevertheless, it provides a chance for nursing students to learn and understand theoretical knowledge and expand the mental, psychological, and psychomotor skills that are significant for patient care.^4–6

The clinical learning environment is important for achieving the defined learning outcomes of a program¹ such as clinical settings, nursing staff, patients, and nurse tutors. As the clinical environment affects the career choices of nursing students and the quality of the clinical learning environment influences the achievement of learning outcomes, a plan is required to select the best clinical learning environment that is reportedly difficult to achieve, particularly in developing nations.⁷

Furthermore, the clinical environment is a potential source of anxiety, disappointment, and disgust, and the link between instructors, staff nurses, and patients is essential to form students’ clinical training, as well as to cope with and reduce real shock.⁸ Hence, student nurses are required to develop different skills such as independence, critical thinking, communication, time management, responsibility, and accountability through clinical practice. Developing clinical judgment is vital to the quality of clinical learning and helps attain learning results by averting upcoming institutional shocks.⁹ A good clinical learning setting has a positive effect on students’ professional growth, whereas a poor learning setting can have contrary effects on their professional development processes.^10,11

The nursing internship is an independent study designed to provide undergraduate nursing students with experience in implementing clinical experience with patient care while fostering professionalism, creating networking opportunities, and developing clinical knowledge. An internship aims to provide nursing students with an opportunity to strengthen their nursing skills, apply their knowledge to various clinical practices and demonstrate competency in practical skills and procedures.¹²

In Ethiopia, governmental and private institutions are paying more attention to nursing education and internships. Nursing educators are frequently assigned as clinical instructors for undergraduate students, which typically starts in the second year of the four-year course of study. The nurse educator is not usually accessible to the students at all times, and usually, a single individual is assigned to a large group of students in a clinical learning environment, which results in minimal one-to-one practical learning and demonstration sessions. One of the most difficult problems in nursing, both domestically and internationally, is the seeming gap between theory and practice. The practical component of nursing education is also crucial for nursing students in deciding whether to pursue a career in nursing or not.¹³

Detecting the challenges faced by nursing students in a clinical learning environment can help stakeholders implement appropriate interventions to achieve professional endurance.¹⁴ Failure to recognize challenges inhibits students’ learning and skill growth. Studies have shown that students’ ineffective contact with the clinical learning environment has a simplified failure rate, and some student nurses have gone from the profession because of the challenges faced at health institutions.¹⁵ Most students with bachelor’s degrees have reasonable theoretical knowledge but lack competence in clinical practice.¹⁶ To build up health systems that function effectively possible with adequate numbers of skilled, interested, and reinforced nurses who show good work ethics at all times, obstacles in clinical practice need to be identified and halted. Exploring the challenges encountered by nursing students at health institutions could help achieve the goals of the internship by helping stakeholders intervene in the significant problems hindering professional development and competence.^7,9,11,14,15 Furthermore, in Ethiopia, specifically in the study area, internship experiences of nursing students at the highest education institutions, and the challenges they faced during their stay in the hospitals, have not been thoroughly investigated. To bridge this gap and to point out the main challenges encountered during the clinical learning environment, conducting this qualitative study is needed. Therefore, this research aimed to explore the challenges experienced by nursing students during internships at the highest institutions in Ethiopia.

Methods and Materials

Study Design, and Area

The study was conducted in Addis Ababa, the federal capital of Ethiopia, in public universities and private education institutions. This qualitative study with phenomenological design has been conducted to explore the challenges encountered by nursing students and to extract their lived experiences of them in clinical practice at the highest institutions in Addis Ababa city. The highest institutions are those that include public universities and private education institutions in Ethiopia, which are usually not specialized in one field of study. Instead, they offer study programs in various fields. Among other things, students can obtain bachelor’s and master’s degrees from those universities and colleges. In this study, both private and public institutions were included. Currently, there is a total of 17 universities and 32 colleges providing nursing education in Addis Ababa according to information obtained from the Addis Ababa Education Bureau. The study was conducted from May to July 2022.

Population

Source Population

All undergraduate nursing students who were attending their classes at the highest public and private institutions.

Study Population

All third- and fourth-year undergraduate nursing students attending their classes at the highest public and private institutions who were found during the data collection period and fulfilled the inclusion criteria.

Inclusion Criteria

All third- and fourth-year undergraduate nursing students attending their class at the highest public and private institutions who were available during the study period, willing to participate, had more than one clinical practice experience, and were able to provide detailed information about issues affecting their learning were purposively included.

Exclusion Criteria

Nursing students with only one clinical internship practice experience were excluded from this study because they may not experience every issue and may not provide detailed information about challenges in the internship.

Sampling Method

Purposive sampling was used to recruit seven nursing students willing to share detailed information about the challenges they faced during their internship and their experiences. Among the institutions providing nursing education in Addis Ababa, seven institutions were selected using simple random sampling techniques, and one student was selected from each of those selected institutions after we reviewed the student’s ability to share detailed information about the situations in the study. Finally, we have selected a balanced number of participants from third- and fourth-year undergraduate nursing students using the homogenous purposive sampling method.

Data Collection Methods, Tools, and Procedures

A phenomenological study design was employed for collecting data. Interviews were conducted using a semi-structured interview guide with open-ended questions to allow participants to provide detailed information about challenges they had experienced during the internship. The instrument has items to assess challenges in clinical settings using the local language, which is the Amharic language. An open, flexible, and inductive approach was used to obtain new insights into this phenomenon. Some of the questions asked during the interview were: Have you experienced any challenges in your clinical and practical attachment? If yes, explain those challenges. Who is responsible for those challenges? Do these problems resolve immediately? What would you recommend to the concerned bodies to help nursing students easily integrate theory into practice? During the interview, probing questions like, Tell me more about that briefly. Would you elaborate more on it? Would you repeat it? What do you mean when you say.? And so forth were asked according to the nursing students’ responses for clarity and a detailed understanding of the phenomenon under investigation. Data collection continued up to the level of information saturation. The telephone interview was held during their free time in a quiet place and took approximately 12 to 20 minutes. The recording process of the interviews was conducted after obtaining permission.¹⁷ Trained data collectors conducted the interviews, while one assistant facilitator had been assigned during the interviews to facilitate recording during telephone interviews. All the conversation during the interviews was recorded using an electronic voice recorder, and notes were also taken throughout the discussion. Then, the recorded data were transcribed into the original language in which the interviews were conducted and then translated into the English language. The data were collected by two trained BSc nurses recruited from health centers in Addis Ababa.

Data Analysis

The data collection and analysis were done simultaneously. As soon as the interviews and notes were also organized, the voice recordings were transcribed word by word in Amharic before analysis. The information was then translated into English. The translated data was then exported into ATLAS ti. Version 7.5.16 software for analysis. The data were then divided into many sentences, codes were formed, and content thematic analysis was conducted following the steps of Colaizzi’s descriptive phenomenological analysis method (1: familiarization, 2: identifying significant statements, 3: formulating meanings, 4: clustering themes, 5: developing an exhaustive description, 6: producing the fundamental structure of the phenomenon, and 7: seeking verification of the findings).¹⁸ The data was coded by the two independent data coders who were the principal investigators of the study, and intercoder agreement was checked by Cohen’s kappa measure of agreement, and the value of kappa was 0.70. Finally, data analysis has produced thorough descriptive summaries that accurately reflect the meaning participants attributed to the challenges they encountered during their internship practice.

Data Quality Assurance Procedures

Interviews were conducted by trained data collectors. The pre-test was conducted through telephone interviews with the participants. Piloting of the items was employed to identify the difficulties, misinterpretations, feasibility of a study, the participant’s willingness to take part before the final data collection, and, consequently, to check the instrument before undertaking the actual data collection. Guba’s trustworthiness criteria were applied to ensure the study’s rigor, focusing on the study’s credibility, transferability, dependability, and confirmability throughout the study. The content thematic analysis was done by the authors, and finally, research experts from Addis Ababa University reviewed and compared audio records with transcribed notes before being translated for accuracy and completeness and also validated themes developed from interviews. The entire research process, including data collection, analysis, and reporting, was carried out logically and according to scientific procedures to minimize our preconceived personal biases.

Result

Sociodemographic Characteristics of the Participants

In this study, seven nursing students participated, with four in their fourth year and three in their third year. The participants were 5 females and 2 males, ranging in age from 22 to 32 years. Of the participants, four were from the government and three were from private institutions. Before the telephone interviews, the participants were requested to provide their demographic data. The interviews were conducted using a local language known as Amharic; all the participants were Amharic language speakers (Table 1).

Table 1 Socio-Demographic Characteristics of the Participants at the Highest Institutions in Addis Ababa, Ethiopia, 2022 (n=7)

Internship Challenges Encountered by Nursing Students

In this study, five themes and 17 subthemes were identified regarding the internship challenges encountered by nursing students at the highest institutions in Ethiopia. The themes extracted were: factors related to nursing students; role model-related factors; factors related to instructors; factors related to the responsibilities of the institutions; and factors related to time constraints. The themes and subthemes are shown as follows (Table 2).

Table 2 Presentation of the Themes and Subthemes of Internship Challenges Encountered by Nursing Students at the Highest Institutions in Addis Ababa, Ethiopia, 2022

Theme 1: Factors Related to Nursing Students

Nursing students go through different challenges related to themselves, and these factors appear to play a larger role in successful clinical learning. These challenges are categorized under five subthemes: low motivation and willingness to learn, student nurses’ limited capacity for resolving problems in the practical area, poor skill development among students, poor communication skills among students, and being an internship student itself.

Subtheme 1: Low Motivation & Willingness to Learn

Nursing students encounter different factors that demotivate and reduce their independence and willingness to learn as revealed by some as important aspects of achieving optimum learning benefits during clinical placement.

A 30 years old female fourth-year student said that

…nursing students come into clinical settings with negative perceptions about the staff and are not motivated and willing to engage with clinical responsibilities. Mostly staff nurses gave the procedures which need labor force and which do not want to be done by the staff nurses at the time. Sometimes they have no patience to answer when we ask them some unclear things in the procedures.

A 23 years old female third-year student remembered that:

…one day of the first practical attachment in the surgical ward, the staff instead of showing or guiding us to do procedures, they were fault-finders in what we were doing. This demotivated us not to ask and learn what we want from them.

Subtheme 2: Student Nurses’ Limited Capacity for Resolving Problems in the Practical Area

A 25-year-old male fourth-year student explained that

Even though we have internet access which could help us to fulfill the gap by referring to different sources to improve our clinical practice skill, it is difficult for us to get access to money since we are students.

A 26-year-old male fourth-year student explained that

I expect to fulfill this practical gap in the future in my carrier of nursing which makes me a skilled nurse professional. But I have limited capacity to fill the gap by myself, meaning that I cannot afford internet costs, because I am a student.

Subtheme 3: Poor Skill Development Among Students

A 23-year-old female third-year student explained that

I think as we are not having much skill to do procedures, the patients don’t want the nursing students to perform the procedures. Sometimes they are aggressive; they want to find some faulty doing.

A 26-year-old male fourth-year student explained that

I have seen in the practical area there are many limitations to becoming more skilled when you are a student and within a limited time of years learning. For a while I got some practical skill and I will rich it tomorrow.

A 25-year-old male fourth-year student explained that

We students have to increase our motivation to ask and gain knowledge and skills from the staff nurses or physicians as much as possible in practical attachment since we are not that much skilled as a student and we have to develop the knowledge and skill on nursing procedures.

A 32-year-old female third-year student pointed out that

It is based on the student’s motivation. Even, though I have my first diploma in nursing I felt as if I have a gap in the theoretical or skill part of a profession. And I want to be more grow in knowledge or skill aspect of the nursing specialization.

Subtheme 4: Poor Communication Skills Among Students

Nursing students explained that good communication skills with patients and staff nurses can enhance nursing students’ ability to have a good approach and learn from their experiences and skills.

A 25-year-old male fourth-year student explained that:

The challenge related to being unable to create confidence with the patients in a nursing student depends on our good approach, communication, and empathy that we gave to the patients. And the patients want us to communicate their health problems, especially if we are available most of the time at the bedside during a practical attachment. Some patients, when they looked at how we were doing with confidence, became more inclined to believe in what we were doing. If we have poor communication and approach and are unable to create a good rapport and relationship, the patients may be anxious and aggressive towards us, and we cannot work freely and confidently.

Another 23-year-old female third-year student explained that:

Communication with the patients was good when we were in a good approach to them, listening when they tell us their problem related to their disease or other socioeconomic problem and gave them some advice and reassurance.

A 25-year-old male fourth-year student explained that

I try to communicate with the staff nurses and practice more even on the night shift, which gives me the benefit of being more skilled with much more procedures than I get in a regular daytime practice.

Subtheme 5: Being an Internship Student Itself

A 22 years old female third-year student said that:

…Related to the other internship students, sometimes when they had a round with the senior physicians; the seniors do not want to permit us to attend round session with them. When they recognize us as we are nursing students and do not allow us to do or observe some procedures, I felt as if we are discriminated against.

Another 25-year-old male fourth-year student said that

The hospital has to limit the nursing students who came for practice that are received from the colleges. If we are too many, there will be a chance that some students don’t practice well. And also, practical time exposure for the students could be short.

Theme 2: Role Model-Related Factors

The most common way in which students develop their professional behaviors concerning the delivery of care is through role modeling. Moreover, staff nurses have a responsibility to act as mentors and important stakeholders in the training of student nurses. Three categories of subtheme have emerged from this theme: lack of support and guidance, staff nurses’ lack of time, and lack of good practice among the supervisors and staff nurses.

Subtheme 1: Lack of Support and Guidance

The awareness of staff nurses towards the nursing students in clinical settings, when they are exposed to clinical practice, is one part of becoming a role model. Clinical settings provide opportunities for nursing students to practice their clinical skills while being guided and supported by well-trained and experienced clinical staff who act as role models and increase the positive awareness towards nursing students. Nursing students reported that they needed to interact more with staff nurses, as they were most often at the patient’s bedside. This approach eased the students’ anxiety and assisted them in adapting to the ward setup. Below are some negative remarks delivered by the participants on how some staff nurses did not properly guide and support student nurses at health institutions:

A 27-year-old female third-year student said that

Some staff nurses were not willful to give us support and to create personal confidence for the next time in doing the procedure. But I promise myself to be a good mentor in the future for the next nursing students when I join the nursing career. In my opinion, I go through a way of challenges in raising the nursing skill in a practical setting. I read more and ask the nursing staff during the practical attachment depending on their willingness and free time and also ask our instructors if they are present at the time. The staff nurses should treat us as we will take their responsibility from them in the future of our career.

A 30-year-old female fourth-year student said that

The staff nurses should not load us with the only labor work they do not want to do like cleaning beds even walls in OR which is intended to decrease their workload.

Subtheme 2: Staff Nurses’ Lack of Time

A 25-year-old male fourth-year student said that

As the staff nurses were busy, they want to show us the procedure when they have adequate time. When they have not enough time, I can’t get more skill and knowledge from them.

Another 22-year-old female third-year student said that: “There are no volunteers to teach us: sometimes they are busy”.

Subtheme 3: Lack of Good Practice Among the Supervisors and Staff Nurses

Nursing students also complained about the lack of professional behaviors of staff nurses at the bedside, such as lack of cooperation and unscientific nursing care expectations.

A 22-year-old female third-year student explained that

Some nurse staff were not keeping the procedural way in the practical area; I saw them while they are not doing the procedures based on the scientific procedural way.

Another 32-year-old female third-year student said that:

The staff nurses work the procedures are not based on scientific principle, instead they did in a way of what they habituate.

Similarly, a 30-year-old female fourth-year student said that

When we were in the ward it was wound dressing; the staff nurse is not doing with sterility techniques. Mostly I and my friends looked at each other and felt confused. The operation room is a room which needs high sterility techniques, and obeys to wear the personal protective equipment while doing the procedures; nevertheless, they don’t emphasize infection prevention guidelines. I think there should be some communication or suggestion trends and ways to give them feedback. As we are students, we shouldn’t tell them their mistakes.

Another 23-year-old female third-year student said that

Our supervisor instructors are present at the time; they could not have the courage to influence the staff nurses working out of the scientific nursing procedure principle. So, we become confused, when these procedures could mislead us.

Theme 3: Factors Related to Instructors

Many nursing students reported their experience of problems they encountered during their clinical internship related to instructors or supervisors. These are insufficient supervision and support, improper assessment methods, and lack of experience in clinical attachment.

Subtheme 1: Insufficient Supervision and Support from the Instructor

Insufficient supervision and support by clinical instructors are major challenges commonly experienced by nursing students at health institutions that interfered with effective clinical practice.

A 27-year-old female fourth-year student explained that

Instructors need to give satisfactory orientation at each practical area before internship to gain recognition by the patients and there should be ongoing follow-up.

Another 22-year-old female third-year student explained that “Instructors need to minimize our fear and anxiety in doing clinical practice by supporting us in practical areas”.

Another 25-year-old male fourth-year student explained that

Instructors must give attention more on detecting the needs of the nursing students and regularly supervise at clinical settings and should schedule the time to look through those needs. Therefore, they need to deal with quality-based skills and sited learning opportunities to nursing students during clinical practice.

A 22-year-old female third-year student said that

Instructors only come to take attendance, and they do not monitor us firmly. But once suddenly in a day, if they see us while standing or reading of internet; they think we didn’t do any procedure in the day and they evaluate us without considering the work done when they are not present and could give us a low evaluation mark.

Similarly, a 25-year-old male fourth-year student said that “At the clinical area most of the time there is no strict supervision either from our instructors or the hospitals”.

Subtheme 2: Improper Assessment Methods

It is important to assign students to specific tasks as soon as they report to the hospital, and these tasks should be evaluated by a preceptor or clinical instructor at the end of the shift. This study pointed out that the assessment methods during their internship in the hospitals are not based on their tasks and performance.

A 23-year-old female third-year student explained that

Evaluation was depending on only paperwork, not looked at our performance during the practical attachment. There are also instructors that evaluate the students without consistent follow up.

Another 25-year-old male fourth-year student pointed out that

Some instructors give assignments in the paper for practical attachment then they did not appear for a month in the practical area. Since we are doing in Human life, Instructors should follow up our practical gap strictly.

Subtheme 3: Instructor’s Lack of Experience in Clinical Attachment

Another challenge faced by student nurses on internship sites is that instructors assigned for internship attachment had limited or no experience in clinical attachment or internship.

A 25-year-old male fourth-year student pointed out that

As I have seen, a common problem is getting experienced skills from our instructors. They are efficient in the classroom for theoretical learning with adequate teaching methods such as giving assignments, and classroom activities, and helping us gain more knowledge via discussion. In applying theory to practice, the role of the instructor is high, since the nursing students are unfamiliar with the place for the first time. In my experience, the experience of most of our instructors who are assigned for clinical practice was low, or they might have only had three years or less exposure to practical areas when they were students when they joined the University with their high GPA results by fulfilling the requirement conditions. As I have seen at the college where I am learning, some of the supervisor instructors who are assigned in practical areas themselves are not exposed to more practice after their first degree or master’s level.

Another 32-year-old female third-year student said that

Only some of our instructors were experienced, such as those who had learned abroad in a country like India; they were committed to guiding and supporting us in every part of the procedures. On the contrary, some of the instructors were less experienced in clinical attachment. They need to be equipped with sufficient skills before being assigned for internships in the hospitals.

Theme 4: Factors Related to the Responsibilities of the Institutions

Participants pointed out that the inadequacy of the material in their institutions, inappropriate recruitment of the college, frequent changing of curriculum, and a large number of students per clinical attachment.

Subtheme 1: Lack of Learning Equipment/Materials

Most participants explained that the availability of learning equipment is the basis for practical learning and provides a sufficient learning experience. However, they affirmed the inadequacy of the material in their institutions, and as a result, their skill development practice became ineffective.

A 23-year-old female third-year student explained:

Our collage, first of all, did not fulfill the uniform gown for nursing students when they’re attached to the practical area. We are forced to buy the equipment from our pocket even though for some students with financial incapability it became a cause to join the practical attachment lately after weeks.

Similarly, a 30-year-old female third-year student said that:

Our university fulfills the necessary gown, what we challenged is in consumption of the hospital resource like glove, mask…because of many student’s placements.

A 26 years old male fourth-year student said that:

There is a limitation of equipment in our college, so it is difficult for us to learn more knowledge and skills depending on the hospital setup, in addition to our motivation to get adequate skills in clinical practice. Hospitals themselves have poor facilities for patients and staff, such as personal protective equipment. Similarly, even if the hospital can afford the equipment, I observed the patient attendant purchasing the equipment for bed bathing.

Subtheme 2: Inappropriate Recruitment of the College

Participant nursing students, especially those from governmental organizations, explained that they were assigned to their current nursing field without their interest.

A 23-year-old female third-year student explained that:

It is better to assess an individual student interest to join the field to get more motivated professional in nursing in the future career. To get more motivated and competent nurses in the career of nursing, it is basic to opt for the field based on a personal choice, but we were assigned without our interest.

Subtheme 3: Frequent Changing of Curriculums

Participants explained that regardless of the allocation times for clinical placements of 4–7 weeks, some participants indicated that the time was inadequate, implying that they failed to focus on clinical learning. The newly prepared curriculum for nursing in Ethiopia has massively reduced the time of clinical attachments, and it needs revisions. Despite the frequently changing curriculum, nurses graduating from nursing colleges are not sufficiently experienced in delivering quality care to patients in most hospitals.

A 30-year-old female third-year student mentioned that:

It is better to reinforce the new curriculum that some college accepts and uses for specific field specialization. The practical time is less than the time allocated for theoretical activities. (i.e. less than six weeks for clinical attachment)

Subtheme 4: A Large Number of Students per Clinical Attachment

Many participants also explained that another challenge that hindered the adequate acquisition of clinical skills by students was the assignment of a large number of students per clinical attachment which created overcrowding in the wards with high patient flow.

A 25-year-old male fourth-year student said that:

Last time when I was in one of the hospitals in Addis Ababa, there were more than seventy students assigned for clinical attachment. Staff nurses view nursing students as those who contribute to ward overcrowding rather than as learners and assistants for them and the patients. It was difficult even to stand and observe procedures.

Theme 5: Factors Related to Time Constraints

The nursing students frequently complained of the presence of time constraints, which bump them into gaining the expected skill and these were categorized into two subthemes: lack of sufficient time for simulations and poor time management for theoretical and practice activities.

Subtheme 1: Lack of Sufficient Time for Simulations (Skill Laboratory Demonstration)

The majority of participants raised the concern that the skill laboratory demonstration that they demonstrate before clinical attachment on dolls has a great influence on their skill development in real patients. The scarcity of time for this demonstration or simulation affects their practical skills during their internship in the hospital.

A 30-year-old female third-year student mentioned:

In our college, there are two rooms where students simulate dolls or manikins. These rooms are not opened on time, and we can’t get enough time to demonstrate before real clinical attachment. The time scheduled for demonstration may be one or two days in between theoretical classes, so that puts us on poor skill for attachment.

A 25-year-old male fourth-year student said that:

It is better if simulation practice rooms are opened on weekends to practice and apply the theory we have learned in a class easily in actual human life, as the time given for practical attachment was not enough. We have to use our time purposefully as there is no challenge-free learning, so we have to be ready for the future challenges even in our career of nursing.

Subtheme 2: Poor Time Management for Theory and Practice Activities

Many of the participants also explained that there was poor time management or poor planning for theoretical class and the attachment schedule that may overlap both theories and practical time, which is inappropriate and puts them on overload and busy.

A 23-year-old female third-year student mentioned:

I remember a student telling me that, in a week, they were expected to be in the hospital and still be prepared for theory exams sometimes. This made them more anxious, and tired, and tried to work over high outcome anticipations in a short period. As it helps us to get more time and exposure to more skills and procedures, I also suggest appropriate planning or scheduling the classes for theory and practice at all after the second year of learning.

A 23-year-old female third-year student said that:

I remember a period when we took the fundamental nursing written exam in between our practical clinical attachment, and the exam was difficult for me because I focused more on practice than studying the theoretical exam. We preferred it and asked our instructor to take the exam after the practical attachment, but he refused. That time was difficult to deal with.

Discussion

This study aimed to explore the challenges experienced by nursing students during internships at the highest institutions. In this study, nursing students described encountering challenges associated with factors that demotivated and reduced their willingness to learn during their internship in the hospitals. They also described that the perception of staff nurses towards nursing students is the most common demotivating factor. This study is consistent with a study conducted in Botswana and Iran in which nursing students experienced factors that decreased their motives and willingness because senior staff nurses did not consider them learners during their stay in the hospital, which made them anxious.^6,14 Nursing students also revealed that poor skill development among students is also the most common challenge during their internship. They pointed out that most of the students had poor skill development, which put them under pressure because staff nurses and patients do not believe in them, and even staff nurses are more fault-finders. This finding is consistent with a study conducted in Iran in which inadequate preparation among students before entering the clinical environment creates a problem for them and others because students who have poorly developed skills lack the confidence to practice on real patients; therefore, before clinical attachment, students should have demonstrated on a manikin to develop their skills and confidence.¹⁴

In addition, nursing students also pointed out that a lack of good communication skills and approaches affected their relationships with patients, attendants, and staff nurses. This finding is supported by other studies conducted in Botswana, Saudi Arabia, Philippines, and Australia which found students’ communication skill was a vital to their approach with patients, listening to their problems, pain, and disease, and giving them hope and reassurance.^2,6,15,17 Well-organized preparation and orientation for the students might improve their communication skills and approaches with anyone in the hospital during their clinical learning.

The study also showed that nursing students were challenged by role model-related factors. The participants described that lack of support and guidance from staff nurses, staff nurses’ lack of time, and lack of good practice among the supervisors and staff nurses were common challenges the nursing students faced during their clinical environment. The participants reported the need for a role model, which demanded more interaction with them. This finding is supported by studies conducted in Tanzania and Cyprus, which revealed that the presence of role model support and guidance for students from qualified nursing staff and supervisors was essential to helping them learn in a conducive environment.^5,19 This could be a result of poor nurse-student relationships and staff nurses’ unwillingness to teach and help nursing students.

In this study, nursing students also described that factors related to the responsibilities of instructors were the most reported factor that challenged them during clinical learning. They explained that effective supervision and assessment can improve their performance during clinical practice, but they have problems with insufficient supervision and support from the instructor, improper assessment methods, and lack of experience in clinical attachment among instructors or supervisors. This finding was in line with the study conducted at Hawassa university referral hospital, Ethiopia, and Tabriz University, Iran in which lack of regular follow-up and proper assessment could lead to the presence of a gap in skills and knowledge among nursing students.^9,20 This might be because the low level of supervision of clinical instructors, inappropriate assessment methods as well as inappropriately designed clinical practice protocol affects the enhancement of clinical practice competency among nursing students.

Our study found that nursing students encountered several challenges in the clinical learning environment. One of the difficulties mentioned by nursing students was that factors related to the responsibilities of the institutions. They briefly explained that inadequacy of the material in their institutions, frequent changing of curriculum, and a large number of students per clinical attachment were common obstacles affecting their internship period in the hospital. This finding was supported by studies conducted in Hawassa University Referral Hospital, Ethiopia Botswana, and Western Cape which revealed that the unavailability of necessary equipment and sterile packs impacted their clinical practice and forced them to reuse some equipment.^6,9,21 Assigning a large number of students to a single ward of the hospital also affected their pursuit of necessary nursing skills and knowledge. This finding was also similar to the study conducted in Cyprus in which the limited number of students, supervisory relationship, and the good pedagogical atmosphere are pivotal concerning student preference.⁵ Regarding the college responsibility-related challenges, some of the nursing students reported that the hospitals have to limit the number of nursing student takeovers from the colleges, as some students could not get a chance to develop their skills as expected and also the practical time exposure for the students will be short. A study conducted in Iran had a supportive finding that to facilitate learning between internship students, hospitals should decrease the internship students’ handover, as they had insufficient resources to meet their needs.²²

This study also found that inappropriate recruitment of the college or field of study applied in Ethiopia is another factor that affected their motivation and learning behavior during clinical practice. This finding was in line with the study conducted among Iranian nurses that showed that students who joined nursing school without their free will faced challenges in the clinical learning environment and lacks initiation to learn from staff nurses.²² This might be due to the fact that, when selecting higher education institutions, students typically take their abilities into account. They make these decisions in order to effectively complete their education and find rewarding jobs after graduation. However, the placement of students in various departments at higher education institutions in Ethiopia does not simply depend on their interests. It is challenging to place all students in different departments according to their top choices due to a shortage of funding, qualified personnel, facilities, and so forth. Some or all students would be assigned based on their first, second, third, etc. preferences on a competitive basis, depending on the department’s capacity to take students, the number of students, and their academic performance from grade 12th national exam.²³ Similarly, Ethiopia’s public university admissions process is centralized. The Ethiopian Ministry of Education performs the task annually using a computer-based placement mechanism. Students’ performance on the secondary school leaving examination has largely determined their university acceptance and placement. Students who do not fit the bill are assigned to departments that do not align with their inclinations.²⁴

Our study further identified that nursing students stated the factors related to time constraints had a great effect on their acquisition of clinical skills. The participants pointed out that lack of sufficient time for simulations or skill laboratory demonstration and poor time management for theory and practice activities were the main problems they encountered. Nursing students demonstrate different nursing skills on manikin before clinical practice to be familiar with the nursing procedure and to have enough confidence to perform nursing procedures on real patients. However, the scarcity of time for this demonstration or simulation affects their practical skills during their internship in the hospital. This finding was congruent with the study conducted in Northern Ethiopia and Malawi in which nursing students were not satisfied with their preparation before hospital clinical learning which might be the result of a lack of appropriate planning and time management for skill development activities.^10,25 This might be because of a lack of preparation among technical assistants working in the skill laboratories, lack of comfortable rooms or having only one room for the demonstration that cannot accommodate all students, poor quality of equipment to demonstrate, and poor attention given by nursing instructors. Nursing students wished all these challenges to be fixed and wished to have sufficient time and room to develop their skills even at night and on weekends.

Strengths and Limitations of the Study

The strength of this study was that, to the best of our knowledge, this study is the first qualitative research in Ethiopia to examine the nursing students’ viewpoint on internship challenges encountered by nursing students at the highest institutions. Despite the study’s strengths, this research has its limitations. Even if every effort was made to improve the study’s transferability, there is still inherent researcher bias in the study, which must be considered when transferring the current study’s results.

Conclusion

The findings from this study confirmed that the challenges of nursing students during their clinical learning environment were diverse and complex. Nursing students go through different challenges related to students themselves such as low motivation and willingness to learn, student nurses’ limited capacity for resolving problems in the practical area, poor communication skills among students, and poor skill development among students. Lack of support and guidance from staff nurses, staff nurses’ lack of time, and lack of good practice among the supervisors and staff nurses were also common challenges nursing students faced during internships in the hospitals. Factors related to instructors or supervisors were insufficient supervision and support, improper assessment methods, and lack of experience in clinical attachment also played negative roles in clinical practice among nursing students. Nursing students were also challenged with problems of inadequate supply of equipment which are helpful for their clinical practice, new curriculum, assignment of a large number of students per clinical attachment, lack of sufficient time for simulations, and poor time management for theoretical and practice activities. To minimize these challenges, every effort should be made by stakeholders such as the management of highest institutions, hospitals, and nursing students themselves. Improving the supply of equipment, increasing appropriate clinical instructor support, appropriate clinical site placement, utilization of an assessment checklist, and increasing nursing student’s motivation and willingness to learn has to be considered.