Nurses' experiences working with nursing students in a hospital: a phenomenological enquiry

Abstract Objective: this paper explores the experiences of registered nurses working with Spanish nursing students within the hospital. Methods: a qualitative phenomenological approach was followed. Purposeful sampling was employed. Twenty-one registered nurses, from a public hospital located in Spain, were included in the study. Data were collected by means of unstructured and semi-structured interviews and were analysed using Giorgi's proposal. The Consolidated Criteria for Reporting Qualitative Research were followed. Results: three main themes described the experience of registered nurses: "The nurse's relationship with nursing students"; most nurses emphasized the importance of the first contact with students and they considered students' attitude to be key. "Defining the role of the student in clinical practice"; it is necessary to unify the nurse's role and interventions to avoid misleading students and establish priorities in clinical practice. "Building bridges between clinical settings and the University"; the need to establish a common ground and connection between the university and hospital clinical settings was emphasized. Nurses felt that the training program should also be designed by the clinical settings themselves. Conclusions: understanding the meaning of nursing students with registered nurses might gain a deeper insight into their expectations.

nurses' attitudes and behaviour towards students can vary (3)(4)(5)(6) , influencing their integration into the clinical practice environment (2,6,(9)(10) . The aim of this study was to explore the registered nurses' experiences of working with Spanish nursing students.

Methods
A phenomenological qualitative study was conducted using Giorgi's method of analysis (12) . Qualitative studies are used to achieve a deeper understanding of, and find explanations for people's behaviour under specific circumstances, such as disease (13) . The main characteristic of this qualitative methodology is that the researcher is intimately involved in data collection and analysis; data collection requires the researcher to interact with the study participants and their social context (13) .
In the field of qualitative studies, phenomenology attempts to understand how individuals construct their world view on the basis of the meanings used by them, in other words it looks through a window into other people's experiences (14) . The aim of phenomenological studies is to identify the essence of living this experience, the lived experienced is the subjective reflection made by subjects in situations or events in a specific geographical, social and cultural environment. This experience always has a meaning for the person who lived it (14) . Qualitative phenomenological studies therefore use first-person narratives from the patients themselves as data source.
A 2-phase sampling strategy was adopted. The first phase involved purposeful sampling to gather information from registered nurses. The second phase involved theoretical, or in-depth, sampling in order to gain a deeper understanding of specific aspects of the information obtained during the first phase. Inclusion criteria consisted of RN from a hospital in Soria (Spain), whose length of duty in the hospital was greater than one year. Nurses were not excluded on the basis of the kind of units where they were working. Twenty-one nurses with a mean age of 46 were selected. None of the participating nurses withdrew from the study.
Researchers made an initial contact with the nurses through the Nurse Manager in each unit. During the initial face-to-face contact, researchers explained to the nurses the purpose and design of the study. A 2-week period was then allowed for nurses to decide whether or not they wished to participate. During the second face-to-face contact, they were asked to provide both informed consent and permission to tape the interviews if they wished to participate in the study.
A university hospital was used to obtain the data. This was a 250-bed facility, in which the human resources were distributed as follows: 15.88% medical staff; 47.83% nursing staff; and 36.29% management Lapeña-Moñux YR, Cibanal-Juan L, Orts-Cortés MI, Maciá-Soler ML, Palacios-Ceña D. and services staff. The nursing department employed 255 nurses, and there were a total of 70 students assigned to this department.
Data were collected over a period of one year, from April 2010 until March 2011. The first phase consisted of unstructured interviews (13) , beginning with the following question: "What is your experience with nursing students in the hospital?" The aim was to look for emerging themes and topics that could be further expanded upon, during the second phase of the study. The second phase consisted of semi-structured interviews based on an interview guide and aimed at eliciting further information regarding specific themes and topics of interest which had emerged from the first round of interviews.

Research topics Questions asked
Reception of students Which do you think is the most important aspect of the reception of nursing students?
Factors influencing students' acceptance What motivates you to accept and teach nursing students? What is your overall opinion of nursing students before their reception at the hospital?
Work organisation within the ward Can the organization of work in the ward influence students' learning? How? Regarding timetable, activities, job routines.
Relationship between the hospital and the university Which do you think is the most important aspect of the relationship between the university and the hospital?  A total of 26 interviews involving 21 nurses were conducted: 16 were unstructured interviews (phase 1), and 10 were semi-structured interviews (phase 2). The interviews produced recordings totalling 1988.78 minutes (33.14 hours). One personal letter and five diary entries were collected from the nurses, together with researcher field notes. All interviews were conducted at the hospital.
Full literal transcriptions of each of the interviews, researcher field notes and nurse's documents were produced. Texts were collated to allow qualitative analysis to be performed.
The method of analysis must be consistent with the type of qualitative design chosen (13) . Giorgi's proposal was selected in order to analyze the experiences of RNs (12) . The Giorgi data analysis proposal allows researchers to capture the essence of the experience through themes as they arise from each subject's story.
The transcribed texts were analyzed from a descriptive point of view (words, phrases, metaphors taken from the text) and then interpreted. This material reduction process is intended to extract the essence, or the common thread underlying the experience lived to identify the key contents or topics of this experience (12) .
An initial analysis aimed at collecting common material, data and information, also known as meaning units. This was performed to construct the emerging topics which describe the experience of RNs working with Spanish nursing students. The second analysis involved grouping Table 1 shows details of the socio-demographic data for the 21 nurses included in the study.

Discussion
In our study, nurses emphasized the key importance of the first contact with students. Previous studies (1,(4)(5)(6) , reported that the way students are welcomed on the first day makes them feel accepted and motivated to learn.
The attitude and motivation of students were positively evaluated by the nurses in our study during clinical practice training. Previous authors (3) similarly found that there are students who are eager to learn while others have little interest. However, the reason for this passive attitude might be influenced by nurses' attitudes. In this way, previous studies (1,(4)(5)(9)(10)18) described how nurses' attitudes affect students' eagerness to learn, and how students were more active when they felt supported by their nurse in the clinical practice setting. Nurses play an important role in enhancing students' clinical self-efficacy. Students gain many skills by watching what their peers do, and this helps them to gain self-efficacy and to achieve clinical self-esteem (4) .
Consistent with our results, previous studies (19) have described the rejection of students by nurses during clinical practice. We found that some nurses avoid having students as this increases their workload and can be problematic. The acceptance and informal socialization of students as an important mechanism for facilitating integration, the knowledge of the ward culture and the encouragement of student learning and motivation (19) . In our study, nurses did not reveal their role in learning, leaving all learning responsibility to nursing students. Plus, the role of the nurse was less active than described in previous studies (1,(3)(4)(5)(6) .
Nurses in this study stated that their length of experience may be a hindrance towards nursing students' training. Heavy workloads, workforce shortages in hospitals, busy wards, an overload of students and their being treated as workers are all obstacles to students' training during clinical practice as well as factors influencing nurses' teaching abilities (20) .
Despite this, nurses expressed a high satisfaction in relation to mentoring students, but admitted that this also necessitated extra work (10) .
Previous studies have concentrated on the qualities of a good mentor; student support, motivation and involvement during practice (2,(5)(6) . However, little has been said about the nurse who is not willing to have any nursing students under their care. In our study, two related features have been identified; negative experiences with the Nursing School and the absence of reward. This supports previous research (10) which stated that previous negative experiences with students (related to nurses' feeling unprepared for teaching and having to deal with time limitations ) influences nurses.
Such nurses tend to focus on their own needs and view students as an imposition.
In order to define the student's role in clinical practice, first of all, the role of the nurse must be defined. A range of aspects covered by nurses providing training include: the objectives of hospital nursing, the holistic perspective of nursing, professional development for their role as a RN, the rules of the ward, clinical procedures and how to take care of patients (4)(5)(6)9,11,(20)(21) .
In this sense, nurses consider their responsibility to explain to students the priorities in clinical settings.
Also, nurses are responsible for the training of nursing students both for their future role as competent nurses and for their capability of working as colleagues (5)(6)10) .
These aspects were not identified in our study.
The findings of this study confirm a reported tendency for using technology, to the detriment of direct patient contact. Millennial students, those born between 1980 y 2000, tend to learn through trial and error within active learning environments (22) . Furthermore, the importance of flexibility when scheduling clinical practice is highlighted by this study, together with the integration of technology into the learning process. These learning requirements may clash with clinical reality, however they can be implemented by using modern information and communication technologies (22) .
Our results show a lack of reflexivity on the part of students. The reflection process enhances autonomy, encourages personal growth, helps integrate theory and practice and develops a greater clinical experience (21)(22)(23) .
Nurses are essential for the development of this reflection process and the acquisition of clinical experience (21)(22)(23) .
When RNs and students are encouraged to participate in reflection processes, this facilitates the integration of different ways of thinking when dealing with clinical situations (21,23) .
The integration between theory and practice is more effective when strong links exist between the college and the clinical staff (24) . Consistent with our Lapeña-Moñux YR, Cibanal-Juan L, Orts-Cortés MI, Maciá-Soler ML, Palacios-Ceña D.
results, previous studies (1) found that staff nurses felt that nursing students were not trained for the actual care goals. These authors pointed out that more than half of the nurses studied believed that Nursing Schools were not providing a quality education, and that nursing students are unprepared. Not withstanding the fact that nurses thought the theoretical knowledge of students was of a high standard, they questioned their ability to apply it to real situations. Nurses consider their training to be far stricter than current study programs, as, in the past, students were part of the ward workforce (1) . Our study supports these findings,  (5,25) . Some aspects of this hidden curriculum are the nurse's behaviour, the nurse's perception as a reference model for students, and the clinical placements within which the clinical knowledge and skills are applied in the context of real patients, real diseases, real resources, and real social limitations (5,25) .
Monitoring students during clinical practice requires a person in charge to carry out a continuous assessment of their learning. In a previous study (1) (19,20) found that the candidates' teaching ability through reflective teaching and learning should be considered when recruiting associate professors. In Spain, and consistent with our results, the associate professors of Nursing Schools are selected without regard to the practice settings and their RN (19) . Therefore, a recommended strategy for favouring the implication of RNs in the learning and follow-up of their nursing students would be to recruit RNs directly from clinical settings.
This is a qualitative research study conducted within a specific context, that of a country in southern Europe.
However, to counter this, similar qualitative studies should be carried out in multiple environments in order to gain a better understanding of the phenomenon.

Conclusions
The attitude and involvement of the RN can influence students' attitudes. It is necessary to define