FACTORS INFLUENCING APPLICATION OF CLINICAL INSTRUCTIONS IN NURSING PRACTICE AMONG NURSING STUDENTS IN MADONNA UNIVERSITY

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Learning is a change in behaviour over time that is brought about by experience during training in educational encounter. Training, as part of education, involves the acquisition of knowledge, skills, and competence through the teaching of practical skills and knowledge related to specific useful competences. Training helps the learner acquire certain useful skills and develop a critical mind for self-development. Therefore, the knowledge that comes from training is more of knowledge of how to perform specific tasks, and the modification in behaviour as its product can occur following newly acquired skills, knowledge, perception, facts, principles, and new information at hand (Carvello et al., 2024).

Nursing education is a term used to describe the overall body of knowledge that applies to the nursing profession. It encompasses a variety of knowledge, skills, concepts, and practices which revolve around the unique concepts of nursing, health, the person, and the environment. As articulated by the Global Alliance for Leadership in Nursing Education and Science (GANES), nursing education is now competency-based, focusing on observable abilities including knowledge, skills, values, and attitudes, with expected graduate learning outcomes encompassing: (1) knowledge and practical skills; (2) communication and collaboration; (3) critical thinking, clinical reasoning, and clinical decision-making; and (4) professionalism and leadership (Coyne et al., 2024).

Nursing education consists of acquiring a body of knowledge partly delivered in a classroom setting which forms the theoretical bases of nursing knowledge, and organised and supervised clinical training experiences that take place in clinical settings where the nurse-patient relationship is experienced directly or indirectly (Salifu et al., 2022). The training process in nursing education should aim at enabling students to gain skills and experiences up to their highest potentiality. Basic knowledge, attitude, skills, and the ability to apply knowledge into actual nursing practice should be developed and inculcated in student nurses. Training can be reinforced with learning aids and equipment of different varieties because they stimulate, motivate, and arrest learners' attention during the instructional process (Al-Worafi, 2024).

Clinical training, which is an integral part of nursing education, takes place in hospitals, other healthcare institutions, communities, and homes under the direction and supervision of trained nursing personnel. Clinical training prepares student nurses with the ability of both "doing" as well as "knowing" the clinical principles in nursing practice. The clinical experience, which is a vital part of nursing education, stimulates students to use their critical thinking skills for problem solving and provides opportunities for active self-learning, self-development, and the ability to apply theoretical knowledge to emergency and general public health care (Amoo et al., 2022).

In line with this, clinical education must help students acquire the necessary nursing skills and the ability to perform in order to establish their capacity to handle changing realities and situations in nursing practice. The nursing skills to be acquired consist of series of courses in the nursing curriculum and manuals. These are designed to equip students with the required clinical nursing skills needed for optimal practice. These include nurse-patient relationship skills, interactional skills, basic physical examination skills, clinical encounter across the life span, therapeutic communication skills, and positive attitudinal skills. Students must successfully complete all the components of the clinical courses to progress as nurses (Salifu et al., 2022).

Nursing skill acquisition is a continuous learning process. Extensive clinical experiences, supervision from mentors, preceptors, supervisors, teachers, considerable time on task, and involvement of students are all necessary to achieve a considerable level of nursing skill performance. A cross-sectional study by Vasli and Asadiparvar-Masouleh (2024) demonstrated that self-directed learning and a supportive clinical learning environment together explained 20.5% of the variance in clinical competence among internship nursing students. There is also supporting evidence that students' interest, professional commitment, and the practice environment for example, the hospital setting exert a significant influence on the development of nursing skills. Students' goals should therefore include increased self-knowledge and scientific awareness in addition to gradual improvement in professional nursing practice (Munangatire et al., 2024).

Historically, nursing training was based mainly on clinical experiences whereby students spent more time in the wards. However, with increased complexity in today's nursing care, the importance of theoretical studies in nursing education became increasingly recognised, leading to a reduction in the proportion of time spent on purely clinical experience while theoretical courses were expanded (Al-Worafi, 2024). The clinical environment is complex and rapidly changing, with a variety of new settings and roles in which nurses must be prepared to practice, including families, schools, and community settings. Clinical training must therefore be aligned to meet the challenges facing nursing practice. Although clinical training remains an essential component of nursing education, its role and application have changed considerably in recent years, requiring students to apply in clinical practice what they have learned in the classroom, online, and through other exposures (Ugwu et al., 2023).

Evidence from Nigeria specifically underscores these challenges. A 2024 study by Maitanmi et al. conducted at a university teaching hospital in Nigeria found that while nursing students generally held positive perceptions of clinical nursing training, factors relating to clinical supervision and the support accessible during clinical placement significantly influenced students' compliance with clinical nursing practice (mean = 4.06, SD = 1.031). The study recommended the implementation of pre-clinical orientation and explicit dissemination of clinical learning objectives to enhance compliance rates during clinical placements. Furthermore, a qualitative study by Ugwu et al. (2023) conducted in a tertiary health institution in Nigeria documented students' lived experiences of theory-practice gaps during clinical practice, identifying inadequate supervision, limited clinical exposure, and poor integration of theory and practice as key contributing factors.

At the global level, a scoping review by Amoah et al. (2025) examined strategies to enhance clinical teaching and learning in undergraduate nursing education and found that multiple factors at the institutional, supervisory, and individual student levels simultaneously affect the quality of clinical nursing education. Critical obstacles identified in the literature include insufficient clinical placements, shortage of nurse educators, and inadequate infrastructure challenges particularly acute in developing-country contexts (Al-Worafi, 2024; Munangatire et al., 2024). Despite the large body of international literature, little has been done empirically in Madonna University specifically to identify the factors influencing the application of clinical instructions in nursing practice among its student nurses, so as to help find out what is involved in the training and practical application of instructions of student nurses in the clinical areas for efficient nursing practice.

1.2 Statement of the Problem

The Nursing and Midwifery Council of Nigeria (N&MCN) has repeatedly observed with dismay the general poor performance of nursing students in the General Nursing Council Examination, particularly in practical nursing examinations. These concerns were highlighted at a conference of principals of schools of nursing and have persisted over time. Anecdotal reports from nurses in clinical arenas continue to indicate a lack of clinical skills among graduates of the five-year generic degree programme, prompting a meeting of Heads of Nursing Departments with N&MCN to discuss BNSc graduate nurses' poor performance in clinical practice and to consider a one-year internship programme before registration as qualified nurses.

These national concerns align with broader regional and global evidence. Munangatire et al. (2024) found that over half (53%) of nursing students studied in Namibia were clinically incompetent at graduation, while Salifu et al. (2022) concluded in Ghana that the current overreliance on clinical placement and teacher-centred teaching approaches were ineffective in facilitating the development of clinical competence. Ugwu et al. (2023) documented from Nigeria that inadequate supervision, poor integration of theory and practice, and an unconducive clinical environment were major causes of the theory-practice gap experienced by baccalaureate nursing students. Maitanmi et al. (2024) similarly confirmed from a Nigerian teaching hospital that clinical supervision and accessible support significantly affected students' compliance with clinical practice. These findings imply that the Department of Nursing Sciences, Madonna University, as a degree-awarding nursing institution in Nigeria, may not be exempt from these systemic challenges. The critical question is: what are the specific factors influencing the application of clinical instruction and training among nursing students at Madonna University that could lead to poor performance in clinical practice?

1.3 Purpose of the Study

The general objective of this study was to investigate factors influencing the application of clinical instruction and training in nursing practice among nursing students in Madonna University.

The specific objectives of the study were to:

1. Identify the administrative factors that affect the application of clinical training and instruction of nursing students in Madonna University.

2. Identify the training and supervisory factors that affect the application of clinical training and instruction of nursing students in Madonna University.

3. Identify students' factors that affect the application of clinical training and instruction among nursing students in Madonna University.

4. Determine the differences in the factors that affect the application of clinical training and instruction of nursing students in Madonna University.

1.4 Research Questions

As a guide to the researcher, the following research questions were formulated:

1. What are the administrative factors that affect application of clinical training and instruction of nursing students in Madonna University?

2. What are the training and supervisory factors that affect application of clinical training and instruction of nursing students in Madonna University?

3. What are the students' factors that affect application of clinical training and instruction among nursing students in Madonna University?

4. What are the differences in the factors that affect application of clinical training and instruction of nursing students in Madonna University?

1.5 Research Hypotheses

Three null hypotheses were formulated and tested at a significance level of p < 0.05:

Ho1: There is no significant statistical difference in the administrative factors affecting application of clinical training and instruction of nursing students in Madonna University.

Ho2: There is no significant statistical difference in the training and supervisory factors affecting application of clinical training and instruction of nursing students in Madonna University.

Ho3: There is no significant statistical difference in students' factors affecting application of clinical training and instruction of nursing students in Madonna University.

1.6 Significance of the Study

Studying the factors that might affect nursing students' application of clinical instructions in nursing practice during training will assist in identifying the constraining factors for proper acquisition and application of such skills. Identifying such factors will improve students' training in clinical areas. Findings will inform school administrators and the N&MCN on new approaches to improve the system by formulating appropriate curricula and procedures for clinical experiences and training.

This will give the right direction to nurse educators and supervisors and will facilitate the acquisition of nursing skills by students. It will widen the stakeholders' view on the provision of adequate personnel, including nurse educators and supervisors, in schools and clinical areas. It will also widen stakeholders' view on the provision of equipment and an enabling environment in order to motivate students' learning and thereby improve institutional efforts to enhance nursing practice.

The findings will help nurse educators, clinical supervisors, and preceptors to review how they carry out the role of clinical training of students under their care for better nursing skill acquisition. It will help them use appropriate measures and methods in teaching students to achieve clinical nursing skill acquisition. The findings will help students understand and play their own roles in improving their practical performance by putting in more effort and interest in their studies and clinical practice so as to achieve success. This will enhance their future practice as skilful and efficient nurses both in theory and practice. These findings could also stimulate further study.

1.7 Scope of the Study

The study was delimited to nursing students of the Department of Nursing, Madonna University Elele in Rivers State. The study addressed the institutional factors of staffing which include teachers and supervisors infrastructure and equipment, methods of training and supervising of students, and students' factors in the application of clinical instructions and training.

1.8 Operational Definition of Terms

Clinical training: Refers to how to assess clients or patients clinically, give account of clinical health problems, prescribe and implement appropriate nursing measures, for example through the use of a thermometer to measure the temperature of a patient and doing tepid sponging where necessary without being told.

Administrative factors: Refer to human and material resources needed in proper clinical nursing training. These include provision of nurse educators and clinical supervisors in schools and clinical areas (e.g., nurse educators, mentors, preceptors, clinical nurses, and clinical instructors). Administrative factors also include infrastructure and equipment in the schools and clinical settings (e.g., adequate laboratory, library, equipment such as oxygen cylinders, clinical thermometers, forceps, models, and objects for inculcating clinical nursing skills to nurses).

Training or supervisory factors: These include the techniques or measures used to drill students during clinical training in order for them to acquire the necessary nursing skills, for example through giving assignments, field trips, practical procedure demonstrations, and ongoing teaching and correction of students by their supervisors during clinical experiences.

Students' factors: These include students' interest and involvement in their training such as attendance to clinical experiences, punctuality, and active participation in assigned tasks.

Nursing Student: A person enrolled in the three-year diploma in General Nursing Education programme or the five-year degree nursing programme in an accredited educational institution by the N&MCN.

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