Communicative reactions of nursing students regarding their first curricular internship period

Abstracts

Este estudo tem como objetivo descrever as reações que os alunos de enfermagem apresentaram quando do seu primeiro estágio curricular. É um estudo transversal e de campo, e o tratamento dos dados foi realizado com base no método de análise de conteúdo. Os resultados descrevem o campo de estágio, o relacionamento com a equipe da enfermaria, com os pacientes e com o docente durante este período. Nas conclusões, podemos afirmar que o estresse e as contradições vivenciadas no primeiro estágio são parte do crescimento e aprendizado do aluno. O professor é maior responsável por determinar o tipo de interação que haverá entre ele e o aluno, cabendo-lhe ouvir, incentivar e capacitar-se para apoiar os alunos nas experiências iniciais da prática, para que o primeiro estágio seja um fator motivador ao aluno.

Comunicação; Relações interpessoais; Educação em enfermagem; Bolsas e estágios

ORIGINAL ARTICLE

Communicative reactions of nursing students regarding their first curricular internship period

Reacciones de comunicación en los alumnos de enfermería frente a la primera práctica curricular

Lívia Silva Bosquetti^I; Eliana Mara Braga^II

^INurse by Faculty of Medicine of Botucatu, São Paulo State University "Júlio de Mesquita Filho" - UNESP. Nurse of the Family Health Program in Porto Ferreira, SP. Porto Ferreira, SP, Brazil. [e-mail]

^IINurse, PhD., Assistant Professor of the Nursing Undergraduate Course at Faculty of Medicine of Botucatu, São Paulo State University "Júlio de Mesquita Filho" - UNESP. Member of Grupo de Estudo e Pesquisa e Comunicação em Enfermagem (Study and Research Group on Communication in Nursing) - School of Nursing, University of São Paulo - EEUSP(Funded by CNPq). Botucatu, SP, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

The objective of the present study is to describe and analyze the reactions of nursing students, presented during their first curricular internship. It is a cross-section field study, with data analyzed according to the method of content analysis. The results describe the training field, the relationship with the nursing team, the patients and the professor in the period of training. In the conclusions, we can affirm that the stress and the contradictions experienced in the first period of internship are part of the student's growth and education. The professor is responsible for determining the type of interaction that the students will experience. He/She needs to be capable of listening, encouraging and for his/her own qualification, in order to support the students with the early experiences of the practice, so that the first internship a becomes motivating factor for the students.

Key Words: Communication. Interpersonal relations. Education, nursing. Fellowships and internships.

RESUMEN

Estudio que tiene por objetivo describir las reacciones que los alumnos de enfermería mostraron durante su primera práctica curricular. Investigación transversal y de campo. El análisis de los datos realizado en base al método de análisis de contenido. Los resultados describen durante este periodo el campo de práctica, la relación con el equipo de enfermería, con los pacientes y con el enfermo. Concluimos que el estrés y los obstáculos vividos durante esta primera práctica son parte del crecimiento y aprendizaje del alumno. El profesor es el mayor responsable por determinar el tipo de interacción establecida entre él y el alumno, responsabilizándose por escuchar, incentivar, capacitar y apoyar a los alumnos durante sus primeras experiencias prácticas, para que este momento sea un factor motivador para el alumno.

Descriptores: Comunicación. Relaciones interpersonales. Educación en enfermería. Becas y pasantías.

INTRODUCTION

This study deals with the reactions of nursing students when experiencing their first curricular internship, since we believe that it is important to know about these manifestations, and also to allow teachers to help them deal with fears, anxiety and emotions that are felt when students are in contact with the hospital environment.

The students' sudden entrance into an unknown situation triggers tensions and anxieties, and these feelings interfere negatively in their learning. It is indispensable for teachers in the internship site to be aware of that, so that they can understand the student. This universe of reactions happens particularly in the first curricular internship program and causes anxiety in the student, in addition to an uncomfortable situation for the professor. According to one study, most of the interviewed students express anxiety regarding the technical procedures and the relations with the patient and the teacher⁽¹⁾.

The beginning of the nursing practice represents a difficult and frustrating experience for the student. This process can be facilitated when the beginner identifies help in the interaction with the teacher⁽²⁾. The nursing procedures, the teacher, the internship field, the physician, the co-worker, the patient, the time and the nurse are elements responsible for the students' impressions of the first contact with professional practice, observing the teacher's role in these impressions⁽³⁾.

The first curricular internship, which introduces the students into practice, causes ambivalent feelings: on the one hand, they will start the internship program and will feel, for the first time, inserted into the profession; on the other hand, they will experience the fear reported by classmates who have already undergone this course⁽⁴⁾.

The difficulties and fear the students experience in their relation with the patient, the teacher and the environment produce both positive and negative effects, referring to the first practical experiences of the students with patients. Negative reports include factors like care delivery for high complexity patients and experiencing death, in addition to the students' perception that healthcare professionals are insensitive to pain, death and dying. As positive reports, it is observed that nursing care delivery to high complexity patients allowed for the development of more complex procedures and integral healthcare. When the students delivered care to critical patients who recovered, they felt great satisfaction. It is worth noting that positive results were followed by the professors' understanding conduct⁽⁴⁾.

The teacher should encourage the students' interest, considering the psychological aspects involved in the teaching-learning process, since both teacher and student reveal qualities that facilitate communication, but also negative traits that hinder the relations⁽⁵⁾.

In this sense, the teachers need to see themselves as persons, not only as professionals. The teachers are ultimately responsible for determining the type of interaction that will happen between them and the students. In this context, the students should be understood as persons who expect to have their opinions heard and respected, besides receiving encouragement to participate and counting on good classroom dynamics⁽⁵⁾.

In all the activities described above, students' difficulties were identified and their experiences were reported, with the remarkable presence of the teacher in this early stage of learning.

Thus, the objectives of this study were to describe the reactions nursing students presented when undergoing their first curricular internship program, besides verifying their opinions about the internship site, work group, patients and the relation with the teacher.

METHOD

The research was developed as a cross-sectional field study with students in the first practical internship program in nursing wards of a public hospital.

The study population was made up of 49 third- and fourth-year undergraduate nursing students. We chose these students because they have already had the opportunity to take courses and perform practical activities with patients in nursing wards.

The study was started by submitting the research project to the Nursing Undergraduate Council. After being authorized, the project was sent to the Ethic Committee of Faculty of Medicine of Botucatu, São Paulo State University "Júlio de Mesquita Filho" - UNESP, which granted its approval, and then the subjects involved in this research were contacted to be informed about the research goals and sign the terms of consent to take part in the study. Data collection occurred in the second semester of 2005.

Participation in this study was voluntary, with all 30 third-year students taking part in the study, but only 19 out of 30 fourth-year students.

After agreeing to participate, each student was given a form with descriptive questions about the nursing ward where the internship program occurred, the relation with the team, the patients and the teacher. The students answered the questions upon receiving the forms, returning the study material later.

Data were treated by interpreting the answers on the form, based on the qualitative method of content analysis.

Content analysis is a group of communication analysis techniques, which aim to obtain, using systematic and objective procedures to describe the content of messages, quantitative or non-quantitative indicators that allow for inferences on knowledge related to the conditions of production/reception (inferred variables) of those messages. This method is made up of three stages: pre-analysis, exploration of material, treatment of results, inference and interpretation⁽⁶⁾.

RESULTS AND DISCUSSION

Data is presented below, extracted from the answers that the research subjects provided to the study questions.

Describing the nursing ward where you had your first internship program:

Nursing ward with several procedures

Students refer to a wide range of procedures by considering that the nursing ward where they had their first internship program offered them several opportunities to execute procedures:

it was a quiet environment, rich in procedures to be executed (E.2), dynamic and with a large variety of simple procedures (E.18), rich in procedures (E.32), good opportunities to practice techniques (E.43).

Messy, disorganized nursing ward, no planning

Students considered that the nursing ward where they had their first internship program was disorganized since it had no room for interns, with a different organization than what was taught during their classes:

it's very confusing (E.6), large rooms, with many beds, giving the impression of people being piled up, sort of messy (E.15), there wasn't enough room for us. The medical prescription room was too small and the nurses' station ended up housing us, interns and the employees (E.23), it's a good nursing ward, although there is not enough room for individual care, such as a separate room to talk with the patient and the family (E.27).

However, some students considered that the nursing ward where they had their first internship program was well-designed and organized, considering that everything they looked for was readily found.

It is worth noting that the students who took part in the research were divided in two internship groups, going through different nursing wards, which yielded results like:

one of the most well-organized nursing wards, everything that was necessary was in place, facilitating and speeding up our work (E.7,8,13,22,23).

Planning is a management work process instrument that can be defined as the art of making choices and concocting plans to favor a process of change. However, if the instruments that we use to operate in reality are not the most appropriate, the intended goal may not take the desired direction, hampering the delivery of quality services⁽⁷⁾.

Difficult nursing ward, requiring too much physical effort

The students mentioned that the patients demanded lots of exhaustive hands-on care, resulting in great physical effort during their internship:

sort of heavy, since the patients demanded several types of care (E.38),heavy, because the clientele demands exhaustive hands-on care (E.42), very difficult practice field, demanding great physical effort (E.47).

The World Health Organization admits that typical ergonomic problems found in hospital workers, such as lumbago and spinal problems, seem to be caused by moving and transporting patients⁽⁸⁾.

Nursing ward as a stressful environment

Students classified the nursing ward as a sad place, due to insufficient lighting, making it dark, due to bad smells, in addition to admitting patients with serious diseases and without good prognoses, causing stress in their first internship program:

everything was new, nice and weird at the same time. It was one of the best nursing wards I've been on until now (E.1), I couldn't see the problems of the nursing ward (E.2), it's sort of dirty and smells bad (E.3), there's always stress in the first internship program (E.17), tension since it was the first internship program (E.19).

Stress is seen as the result of the struggle between a given difficulty and the individual capacity of overcoming it. Its consequences are strictly linked to the individual response in view of a given demand, i.e. what is seen and experienced as a gratifying, encouraging challenge for some, can be interpreted by others as a huge threat they have to face⁽⁹⁾.

Discouraging Nursing Ward

The students mentioned that most activities performed in their first internship program were bed baths, which they considered discouraging:

A very discouraging nursing ward, since the students' actions were restricted to bed baths (E.37), I learned bed bathing in this internship program, because all patients were bedridden (E.38), a nice field to learn bed bathing (E.45).

We understand that the students cared little for the bed bathing technique, since it is a procedure that does not require complex technical knowledge, but they considered it burdensome. The students' motivation is important, so that they do not reject this technique.

Professional attitudes like indifference, lack of commitment and lack of motivation are considered consequences of difficulties in developing the nursing work, highlighting the need to develop sensitivity in order to improve the healthcare provided⁽¹⁰⁾.

Describing the relations with the nursing ward team

Cooperative Relations

The students reported that the nursing ward employees were welcoming, receptive and always helped them:

the team, the employees in general were very receptive and were always willing to teach some technique, disease, among other things (E. 7), overall, the team was very helpful, helping every time there was some doubt, helping with the progress of the internship program (E. 14), there was always someone available when help was needed (E. 18).

Shy relations

The students mentioned that, since this was their first contact with the nursing team, the relations were shy; they felt insecure about having to relate to the employees and behaved as observers. However, some students reported that there was little contact with the team, because they left the students on their own and abandoned the nursing ward during the internship period:

At first I was a bit shy, didn't have the courage to ask about anything but, over time, the relations were improving and I became more communicative (E.4), maybe the relation was distant because it was the first experience, I was there to learn and I observed more than I spoke (E.9), I had no problem, especially because the employees vanish when we arrive (E.27), actually there was no actual relation, but I was never mistreated (E.33).

Simple information-transmission relations

Students said that the team was helpful, but they were treated as apprentices and abused when performing daily care. Often, the employees meant to teach the procedures as if they (the students) had no knowledge:

I felt I was seen as a simple apprentice, each of them wanted to explain things as they saw fit, because they felt that they knew more than I did anyway (E. 6), the team was very helpful, but they had this thing about teaching or bossing us around, which often resulted in arguments between employees and teachers (E.23), it was all right, because we only developed care like bathing, feeding and cleaning in the first internship program, and the employees ended up seeing the students as slaves (E.31).

The comprehension of the human being is the main point for personal and professional development. It should be performed through an educational process, with experience and interest, where the human beings see their existence recognized in the relations they maintain with the other⁽¹¹⁾.

Difficult relations

The students considered that the relations with the team were difficult, because they had no contact with physicians, and the nursing auxiliaries and technicians were not welcoming:

it was very difficult, they were very reserved, I really felt lost, and when I asked for information, they wouldn't give it, and when they gave it, they looked angry and the information was insufficient (E. 1), I thought there was not enough openness and receptivity towards the students (E.18), at first it's always difficult but, after some time, relations improved and the team offered great support (E.4).

A group is a gathering of people motivated by similar needs, who join around a specific task⁽¹²⁾. In our case, the nursing team is fully involved in care delivery to the patient.

In a study performed at a public educational institution, students from several healthcare courses pointed at good professional interaction as the main facilitator for group work communication, and the difficulties for group communication were lack of professional and personal interaction and the unclear definition of roles and responsibilities⁽¹³⁾.

We verified that the students need to receive support from the whole team in order to feel more confident to perform the proposed tasks.

Describing relations with the patients

Good relations

Students mentioned that their relations with the patients were rewarding and therapeutic, since the patients accepted them well and had no problems:

very good, I met wonderful people, with very particular and interesting life histories (E. 6), it was very good, I could approach well all patients under my responsibility and I was very well accepted too (E. 13), relations with patients were very good, rewarding and therapeutic (E. 23), relations with the patients were very gratifying (E.26), they were very good, I experienced things for my professional life as well as my private life (E.43).

Relations of anxiety and insecurity

Students mentioned feeling anxiety and insecurity to perform the procedures, especially since this was their first contact with patients and also because they were afraid that the patients would not accept them:

there was a block when I first met the patient, and that made me afraid of performing the procedures, I was afraid they wouldn't like me (E. 1), it was different, since this was the first internship experience, we didn't know how to approach the patient and had many doubts, and the patients noticed it, becoming wary of our care (E.14), they accepted our treatment and presence well (E. 18), I was afraid during the first contacts, especially regarding them seeing me as incompetent and getting in the way of care (E. 25), they were always understanding and collaborated with us so we could provide care (E. 47), I was anxious at first, but as the internship program went by, it went more smoothly, there was anxiety regarding the procedures to be performed (E. 48).

Difficult relations

The students considered the relations difficult because of some of the barriers found, as well as the several feelings they experienced, dealing with grave patients and having to deal with death:

it was difficult, since we experienced several feelings at the same time without being prepared enough for that. Feelings of acceptance, anger many times, pity, among others. It's the moment when we really start to know ourselves and understand our role (E.19), dealing with the patients was difficult, since almost all of them were in a grave state, I found them depressive, in bad moods, full of angst and fear (E. 22), we developed small bonds, due to the short hospitalization time of most patients, who are very submissive, as are all others who come to the institution (E. 31), there was greater concern with the techniques to be performed and scripts to follow (E. 33), we tried to be concerned about what they were feeling, but the focus was on the techniques (E.45).

Overall, people are afraid of what is new or unknown. In nursing, the relation between the student and the patient and the discoveries of the care process at the beginning of the professional process are considered as something new, bringing feelings of anxiety⁽¹⁴⁾_.

We are aware that, since this is their first internship program, the students are not capable of facing the barriers that occur in the relations with the patient. Therefore, in order to soften the situation, the competence in communication is more and more necessary, since this is the only possible way to keep offering interdisciplinary, individual, competent and humanitarian care⁽¹⁵⁾.

Describing relations with the professor at the internship program site

Good relations

The students considered that the teachers were helpful, polite and patient. They reported that they always had their doubts solved when asking, and had their doubts and insecurities eased:

the professors were helpful, polite and patient. Overall, relations were good (E.4), with the teacher, my relations were good, she helped me do what I didn't feel secure to do and oriented me on how to help the patient in better ways (E.19, E.32), in view of my difficulties during the internship program, the teachers were always very understanding, I could talk a lot with them and they were very important for my continuity in the internship program (E-35).

Difficult relations

The students also report that the professors were very contradictory regarding the doubts that came up. They mention that they worried too much about the techniques and had no patience to teach:

[...] our relation was indifferent, but everybody could see that they (professors) had their favorites [...] (E.3), there were two, and both contradicted themselves very often, so much that I noticed that it would be better to show my notes and request corrections from one of them only. I could see that both liked me, I was well-evaluated, but they were restricted to perfecting the employed techniques (E.6), the professors were too demanding, overzealous, and even somewhat inhuman (E.7), it was not very productive, because the teacher was impatient sometimes and forgot that this was our first time in the field (E.10), they pressured the students too much during the procedure and were often impolite (E.13), in the first internship program, the teacher was very oppressive, different from the other internships, he pointed our mistakes in front of the classmates and patients unnecessarily, required details of the techniques that today I know were not essential (E.16), the professors were very pressuring and I did not feel at ease, had no freedom and sometimes they admonished me in front of the patients (E.20), the relations with the professor were complicated, because I was afraid of showing doubt or insecurity. The professor did not convey tranquility or trust, her attitude was austere and aloof (E.29).

In another study, students say that they feel welcomed by the professor when they can expose their feelings about difficult situations they face. Therefore, through dialogue, the professors can become closer to the student, exposing some of their own limitations as well⁽¹⁶⁾.

Teacher-student communication becomes, therefore, the basis of the teaching process, and it is influenced by the daily routine of each of its protagonists. It is important for the professors to regard dialogue, exchange and interpersonal relations well, believing that it is possible to learn by talking, discussing and exchanging ideas with their apprentices⁽¹⁴⁾.

We believe in the need for reflective professors in nursing teaching practice, so that they are able to reflect on their own everyday actions as educators, to commit themselves to research, to their own education and professional development⁽¹⁷⁾.

Nursing students need to receive attention from the educators, and professors are expected to be involved in these proposals and to offer students conditions to achieve them through exchange-based learning⁽¹⁸⁾.

For the development of learning, the teacher's attitude in the relation to the student should be grounded on respect for the individual, on trust, on the perception of the students as whole beings, so that they can see themselves better as persons, moving on to seeing the others better and, consequently, playing their role as persons and professionals better ⁽¹⁹⁾.

The results of our study point to stress and contradictions experienced in the first internship program as part of the students' growth and learning. Receiving help from the professors and classmates, seeing and welcoming the patient, orienting and evaluating the physical position for routine nursing activities and helping the patient are part of the learning process, and these situations become the source of encouragement for their knowledge construction about the practice of techniques and relations.

FINAL CONSIDERATIONS

The students made it evident that their first internship program was a source of stress and that the new experience at an unknown site did not allow them to notice possibilities or difficulties at that moment.

Communicative reactions with contradictory feelings are expected, regarding the physical environment and the organization and planning of activities when the student enters the healthcare environment, especially when practice occurs in high complexity hospitals.

Students have expectations about the opportunities to perform in practice, but they also expect a supportive and welcoming healthcare team, professors and even patients. We know that they are eager for adequate physical spaces, for dialogue and welcoming, but nursing practice does not always happen in such conditions. Students are often faced with patients whose care demands physical labor, with stressful environments and situations, contradictions between theory and practice, difficulties in relations with patients, team and professors, and this all certainly causes feelings of anxiety and insecurity.

Hence, we understand that it is a good opportunity to reaffirm the professor as the main responsible for determining the type of interaction that will exist between teachers and students, and also to orient them on how to handle their relations with patients and the healthcare team, because the student feels the need to receive support from the professor and establish dialogues. It is up to the professors to listen, encourage and qualify themselves to support the student in their early practical experiences, so that this first contact can be a motivating factor for the student.

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Correspondência:

Lívia Silva Bosquetti

Rua 29 de Julho, 1285 - Centro

CEP 13660-000 - Porto Ferreira, SP, Brasil

Publication Dates

• Publication in this collection
  15 Dec 2008
• Date of issue
  Dec 2008

History

• Received
  22 Aug 2007
• Accepted
  28 Nov 2007