Lived Experiences of First Time Baccalaureate Nursing Students in the Clinical Practice

Introduction: Nursing students’ first clinical exposure may raise anxiety as they question their ability and experienced a lack of confidence as they adjust themselves in the clinical learning environment. Aim: To explore the lived experiences of first-time Baccalaureate nursing students in the clinical area. Methods: A phenomenological qualitative research design was utilized where 18 Baccalaureate nursing students were individually interviewed. Data were analyzed using the seven steps of Collaizi’s method. Result: Three main themes that emerged were clinical practice on the first-hand look; uncertainties in a new learning environment; and nursing as a life-changing experience. Subthemes were recorded and explained in the research report. Conclusion: Nursing students who had their first-ever exposure to clinical practice had various experiences both positive and negative. The Nursing College must emphasize comprehensive orientation before students’ exposure to clinical practice.


Introduction
Beginning a professional program is the hallmark that an individual is starting to build a future career. Nonetheless, starting on professional education can be crucial and challenging. Becoming a nurse requires courage and it is unique from the varieties of professions because it is not only focused on the acquisition of higher-order thinking and technical abilities but most importantly the development of human skills such as caring, compassion, and empathy which commonly acquired during clinical practice.
On the journey towards the attainment of the nursing profession, struggles may be experienced such as stress, depression, and anxiety, which can hinder learning and ruin clinical practice performance (Turner & McCarthy, 2017). Though clinical learning experience enhances the nursing skills, it may also bring out challenges, difficulties, and anxiety to the students (Baraz, Memarian, & Vanaki, 2015), and as stress arises it can affect their mental health (Galvin, Suominen, Morgan, O'Connell, & Smith, 2015). Students' anxiety rises during their first clinical exposure which as they may question their ability and experienced a lack of confidence as they adjust themselves in the clinical learning environment. Likewise, establishing rapport and gaining the trust of their patients was not easy for them (Sun et al., 2016). Hence, understanding students' anxiety and experiences and preparing them for their initial clinical exposure must be given an important emphasis by the nurse educators. Assisting students on their first clinical duty proactively help them to reduce their possible anxiety. On the other hand, 'academic demands such as paper works, interaction with others in the clinical environment, and caring for patients and families were the perceived stressors among Saudi nursing students (Al-Zayyat & Al-Gamal, 2014).
Nursing students' first clinical exposure can be a crucial and significant period in their educational journey. That is why it is relevant to understand the students' viewpoints and feelings during their initial clinical practice as they may experience anxiousness, fear, and self-doubt. These are most commonly observed in nursing students in their real-life experience during first clinical exposure. This can be seen during their interaction with the patients, collaboration with other health care providers, and when performing interventions as part of their nursing care. With this, the researchers perceived it beneficial to explore the lived experiences of students who have their first clinical exposure since the aim of the clinical learning experience is to prepare the students to learn and become better as they progress with the Nursing program. By this means, preparing students in the clinical practice requires understanding that they may face challenges in this learning environment, hence, extensive coaching is vital for them to surpass this struggle.

Aim of the Study
The study aimed to explore the lived experiences of first-time Baccalaureate nursing students in the clinical area. It elucidated their perceptions and feelings with the clinical practice based on their first-ever clinical lived experiences.

Design
This qualitative research utilized phenomenology to explore the lived experiences of first-time Baccalaureate nursing students in the clinical area. Phenomenology elucidates data based on in-depth analysis and personal meaning on the lived human experiences. It is focused on understanding the participants' meaning in their lived experiences (Smith, 2015). This design best captures the participants' facets of human experience in their totality, which appears to be suitable to attain a holistic viewpoint of the nursing students first time exposure in the clinical area.

Selection and Site
Informants were the 18 Baccalaureate nursing students from the male and female campuses of a university in Saudi Arabia who were exposed for the first time in the clinical area. Purposive sampling was used to select the informants and determined based on the following inclusion criteria; nursing students both male and female who are currently enrolled in the Baccalaureate Nursing program, having their current first clinical exposure and enthusiastic to participate in the study

Instrument
A semi-structured interview guide was made by the researchers to elicit participants' perceptions and feelings in their first exposure in the clinical setting. The trustworthiness of the drafted questions was checked by the expert in this field and was revised and enhanced based on the comments and suggestions. Questions in the interview guide were focused on participants' experiences with regards to orientation, coaching of instructors and preceptors, interaction with the client, and collaboration with other health care providers. It also includes the best and worst experiences in the clinical area.

Data Collection
Ethical approval from the university and informed consent from the informants were secured before the data collection. Face-to-face interviews were the main data collection method used which lasted for about 30-45 minutes. Informants were encouraged to talk freely and express their perceptions and feelings on their lived experiences. Finally, the researchers asked for clarifications on the data provided to enhance its validity. The interviews were ended by acknowledging the informants and assured them that the information they provided is treated with the utmost confidentiality. Notes were taken after the interviews were concluded to write down all remarks that may be pertinent in data analysis.

Data Analysis
Researchers interpreted the data using Collaizi's method (as cited by Natividad, 2017). This approach has seven consecutive steps: 1) Reading the interview transcription to grasp the whole idea or opinion of the subjects.
2) Extracting the significant statements or the key responses from the informants.
3) Formulating meaning for significant statements by finding keywords and phrases within each response. 4) Organized formulated meanings into clusters of themes 5) Integrating the findings into an exhaustive description of experiences of first-time nursing students in the clinical practice. 7) Validating the findings through member checking and verifying some significant statements by follow-up interviews of some subjects and incorporating changes whenever necessary.

Ethical Considerations
Before the start of the research, ethical approval was obtained from the Review Ethics Committee of the university. Informed consent was drafted with all the information on the study. The informants were given a copy of the informed consent for them to be reminded of the conditions agreed upon. Informants were oriented that their involvement is voluntary and they can withdraw from the study at any time.
With regards to confidentiality and anonymity, the researchers recognized that the interviews can reveal intimate information about their experiences. The informants' descriptions of their experiences were not stored with any identifying labels, and codes were used to replace names. After the analysis of the data, informants were contacted to validate the data they provided.

Rigor in Qualitative Research
Rigor in the study was assured through member-checking. This strengthened the credibility of the results of this qualitative research on the participants' perceptions and feelings by presenting the results, then, seeking feedback from them (Birt, Scott, Cavers, Campbell, & Walter, 2016;Cypress, 2017)

Results
Three significant themes with subthemes emerged based on Colaizzi's method of data collection. These include; (1) clinical practice on the first-hand look with subthemes of strange feelings and emotions, communication apprehension, and vague orientation in the unit (2)

Discussion
The core of the study was established by extracting the participants' verbalizations from the interview to create the meaning of their lived experiences. Upon exploring their lived experiences, three themes emerged with the core of the study as "metamorphosis". The participants' meaning elucidated "metamorphosis" experiences into first-hand look in the clinical practice, uncertainties with the new learning environment, and nursing as a life-changing experience.
Nursing students are overwhelmed with the glimpse of the clinical setting since they are a novice in the clinical practice. A sudden change from the usual activities in the skills laboratories to the real world of nursing practice makes them feel that they are somewhat awkward with the clinical environment. The reality that they are dealing with the actual client is a challenge. That is why the guidance of the clinical mentors and preceptors must be of great consideration. Lack of support from nursing educators in the application of practical skills could affect students' opportunities for experiential learning. They must orientate the students before the beginning of clinical placements to lessen the apprehension and anxiety in a real-life clinical situation (Lee & Yang, 2019). Student orientation enhances motivation and engagement towards the nursing program hence it will also develop a passionate desire to become a nurse (Ten Hoeve, Castelein, S. Jansen, W. Jansen, & Roodbol, 2017). Clinical orientation is one of the important pillars of students' engagement in learning and this will guide them on how they will adapt to this new environment. Likewise, the support and supervision from the clinical instructors and preceptors are needed by the nursing students as they explore the field of clinical practice ( Socialization strategy is beneficial for the students to adapt completely to the clinical learning environment. The role modeling of the clinical instructors and preceptors influences the confidence level of nursing students in the clinical practice (Baraz, Memarian, & Vanaki, 2015;Houghton, 2014). Nursing students wanted to allocate more time in clinical practice. Ineffectual assistance from the staff nurses and minimal guidance from clinical instructors gjhs.ccsenet.org Global Journal of Health Science Vol. 12, No. 13; hinders the students' learning opportunities in the clinical practice (Kamphinda & Chilemba, 2019). The number of hours allotted in clinical learning is not enough considering some predicaments like; late arrival of service vehicle; tardiness of some clinical instructors and early dismissal in the clinical area.
Students are expecting that clinical instructors will be the ones to facilitate their participation in clinical nursing activities, but it seldom happened. Henceforth, staff nurses should also provide clear directions to students whenever rendering nursing care (Bigdeli et al., 2015).
It is a common scenario that nurses and doctors prioritize medical interns rather than other health sciences students. This scenario creates a negative effect in which the nursing students may view the clinical environment as ineffective for learning opportunities (Farzi, Shahriari, & Farzi, 2018). Hence, an inter-professional partnership among nurse educators and clinical staff must be taken into consideration to enhance students' motivation thereby attaining a better learning experience.
It can be viewed that nursing students encountered difficulties in clinical practice, which originated from non-supporting instructors and clinical environment factors. However, the students themselves are also a factor in their difficulties which is evident in their inadequate self-confidence, and the lack of role modeling among clinical instructors and preceptors added on to this problem (Drateru, 2019). These difficulties produce anxiety that hinders the students from optimizing their learning in the clinical practice.
Moreover, the clinical requirements became a burden among nursing students (Galvin, Suominen, Morgan, O'Connell, & Smith, 2015). Assignment and clinical workloads were the perceived source of stress of the students in clinical training (Alsaqri, 2017;Hamaideh, Al-Omari, & Al-Modallal, 2017;Ismail, 2017). Due to this burden, students perceived the clinical training as merely complying with the paperwork requirements rather than honing their nursing skills. In that way, more attention must be given to actual training and minimize paper works so that students will be able to focus on rendering patient care (Al-Zayyat & Al-Gamal, 2014).
Aside from it, the experienced of 'being criticized by teachers' and 'fear of making errors' make the students feel pressured in their clinical practice (Bahadır-Yılmaz, 2016). If the students face such predicaments, it is unusual for them to focus on the tasks that are supposed to be done to enhance their skills and became equipped for their future work. By this means, self-directed learning paths must be established before the students' clinical placement to prepare them and enhance their learning opportunities. This will also enable them to set their goals and find ways to work on it. (Moquin, Seneviratne, & Venturato, 2018). Additionally, the evaluation in the clinical area must be done as it fosters positive and constructive feedback among students. Conducting pre-conference and post-conference in the clinical practice motivates the students to be fully involved in acquiring further knowledge and skills in the clinical practice (Yeldon et al., 2018). In the end, open communication between the clinical instructor and student provide meaningful learning in their clinical placement such as an opportunity to witness complex clinical cases and utilized advanced medical equipment and devices in implementing nursing care (Atakro et al., 2019).
Recognizing what others feel is substantial learning for the students. Nursing educators contribute a lot in promoting meaning in life to nursing students through proper guidance and motivation, so in that way, it creates a positive outlook towards their profession itself. (Tsai et al., 2018). The experience of caring for a client with 'cognitive and physical limitations' resulted in a completely changed perspective of caring, compassion, and respect indicative of rewarding, and life-changing experience (Brown & Bright, 2017).
Nursing students experience transition, in which stress and anxiety are not an excuse as they are exposed to the challenging clinical environment. Yet, the sequel of this transition is the acquisition of new knowledge, enhancement and development of skills, and effective transformation. Understanding this, nurse educators can devise an effective clinical training program that will progress students' clinical learning practices to produce caring and competent nurses of the future (Hart & Swenty, 2016).
To improve the clinical experience, the Evidence-Based Practice (EBP) Program can be utilized in the clinical learning environment. Its inclusion in the pedagogical nursing curriculum will promote the enhancement of competency of undergraduate nursing students (Kim, Gu, & Chang, 2019). Equally, a Preceptorship program can be an effective tool in improving nursing students' self-efficacy as being influenced by preceptors 'teaching experience, personal qualities, interaction with students, and professional development' (Rambod, Sharif, & Khademian, 2018). Partnership and collaboration between faculty of nursing colleges and staff of affiliating institutions matter a lot, as Woo and Li (2020) concluded that "Involvement" would complement "Personalization" and "Task orientation" and finally holistic clinical learning experience can be achieved.
of the program must be conducted which is deemed to be the weakness of the clinical program, thus, access to counseling and support services must be considered. An evaluation must be continuously done to discern how the students 'fit in' with the clinical practice. Recognizing this through the lens of novice student nurses in the clinical learning environment can create a better program that enhances successful experiential learning.

Conclusion and Recommendations
Nursing students who had their first-ever exposure to clinical practice had various experiences both positive and negative. They have unusual feelings in the clinical learning environment which were heightened by their hesitancy to collaborate with staff nurses as they feel that they have an inadequacy in doing nursing procedures. Insufficient time in the clinical area and inadequate guidance from instructors contributed to their feelings of reluctance. Contrariwise, these novice student nurses surpass these difficulties and were able to appreciate the real essence of "being a nurse" in the nursing profession.
The Nursing College must review the clinical program and must emphasize comprehensive orientation before students' exposure to clinical practice. There is a need to conduct evaluation and monitoring in the clinical area for both nurse educators and clinical preceptors. Proper coordination and collaboration with the affiliating institutions must be done to ensure success in clinical learning. Clinical portfolio with learning journals must be monitored to evaluate students' transitions in clinical practice.