Nursing Student’s Experiences in Critical Care Course: A Qualitative Study

Results: Participants described a variety of unique experiences throughout the course, however four main themes emerged: support, knowledge and skills, socialisation and moving on. Key factors that influence students’ experiences include: support from faculty and clinical supervisor, preceptors’ attitudes towards students and learning process, course content, and patients’ acuity in the unit. Strategies such as self-directed learning and preceptorship management were found to positively improve students’ experiences.


Journal of Intensive and Critical Care ISSN 2471-8505
providing nursing students sufficient clinical experiences before graduation [4]. As intensive care patients require more complex or acute nursing care, clinical practicum in an intensive care unit (ICU) is valuable for nursing students [5]. This allows students to apply wide array of skills and can observe interdisciplinary teamwork and decision making [6]. Clinical practicum in intensive care develops clinical reasoning by organizing information; however, students may have different experiences during their clinical practicum [7,8].
Baccalaureate nursing student's experiences in critical care setting was identified in the literature as early as 1977. As more nursing programs integrate critical care experiences within the curriculum, recent national surveys of accredited baccalaureate nursing programs have shown that the majority of curricula include critical care content among required courses [9]. Augmentation of critical care would not only enrich the undergraduate educational experience, but is also essential in the acquisition of generic skills these essential skills include assessment, management and effective communication concerning a deteriorating patient. If taught throughout the curriculum [10].
Undergraduate critical care nursing course provide an opportunity for students to develop basic knowledge and skills in critical care, expose them to the role of the critical care nurse and to develop positive perceptions of the role of the critical care nurse [11]. It may be more advisable to identify the students who have a specific interest in critical care [10,12].
Undergraduate nursing students should be taught essential skills in recognition of a deteriorating patient; these skills must include how to call for appropriate help early, correct interpretation of abnormal signs and how to implement measures to prevent further deterioration. Accurate documentation of findings and communication with colleagues should be incorporated into teaching programs [13,14].
Tastan et al [4] stipulates that practicing skills and familiarity with equipment may increase self-confidence. This issue of confidence is also supported by Aqel and Ahmad [13] who made a link between an ability to undertake clinical or technical skills and increased competence. Gallagher et al., [10] have postulated that the student's confidence would improve as their knowledge and understanding of managing these patients would be enhanced.
More advantages of clinical experiences providing opportunities to interact with nurses and physicians in critical care and gain an understanding of the importance of interpersonal relationships as part of the nurse's role [3,8]. However, Tait et al., [15] support the view that there is a need for critical care placements to enhance this interactions and improving interpersonal skills.
Study conducted by Gallagher, [10] to evaluate a critical care course for undergraduate nursing students showed that the results from this evaluation clearly demonstrate that undertaking the critical care course was a positive experience for the students and it is evident that the majority of students valued the critical care course.
Critical care is both emotionally and intellectually challenging, yet little is currently known about the experience of nurse's new to this environment [16]. Many baccalaureate programs offer brief experiences for students in critical care units and some limited only to the clinical experiences [4,17]. Some studies have focused on determining the adequacy of theoretical knowledge and skills of students than the multidimensional experiences of students [13,17].
There is limited research on educational experiences of students in critical care units at the undergraduate level and the effectiveness of such experiences in increasing basic knowledge and skills [18,19]. Traditionally some of presented baccalaureate programs offer brief experiences for students in critical care units within the curriculum of nursing programs so the methods used to provide extended critical care nursing experiences for larger numbers of undergraduate students are rarely discussed [19].
Internationally, a few publications were found that report nurses' student experiences in general [4] none of these studies was purely on undergraduate critical care course, with no published studies report that student experiences in multi-dimensions themes, specifically in Saudi Arabia.

Course Overview
Critical care nursing is a requirement for senior baccalaureate nursing students at our college. The course instructors are successfully addressing the student's needs. Critical care content and clinical experiences are included in required clinical course components at the senior level; fourth year of baccalaureate nursing curricula. The focus of this course addresses multisystem health problems of adult patients with care experiences in a verity of critical care areas through placements rotation schedule. The students are evenly divided in to clinical rotations, with maximum three students per group. The students are assigned to shared, participatory patient care experiences with the staff nurse preceptors. Students gain direct care experience with the supervision of faculty and or staff nurse preceptors through the semester. Patient care assignments are made in collaboration with the staff nurse, nurse managers and the faculty members. Direct patient care, not merely observation, is achieved by assigning student to one patient. The students' performance evaluated in collaborative efforts between faculty and preceptors using standardized evaluation tool. Daily post clinical conference is held for debriefing clinical experience, challenges, comments and suggestions. The purpose of this Qualitative study was to explore the experiences of Acute care teaching students enrolled in a compulsory critical care course in one of Saudi Arabia universities.

Study design
In order to explore the students' experiences, a qualitative contents analysis design was utilised to conduct the study.

Participants
The study was conducted at one of the universities in Saudi Arabia, King Saud Bin Abdulaziz University for health sciences (KSAU-HS) between year 2010 and 2013. The sample size included 180 female Saudi nursing students who enrolled and took the course during that period. Students were asked to report their experiences daily in writing during clinical training at King Fahad Hospital in Riyadh (KFH-RD). Before the study clear instructions about the form being used and permission from the students to use their entries notes and experiences in research purposes.

Data collections
Data were collected by using a special, self-reported learning experience template, which was designed to help students capture and organize their thoughts. Writing about experiences is a useful tool for reflection, because it enables nurses to make explicit the knowledge that is implicit in their actions [20]. Journaling helps nurses to sustain themselves emotionally in the work they do. It gives nurses the opportunity to tell their own story about what it is like to be a nurse, and what it is like to witness patients' experiences of illness [21]. Furthermore, daily post-clinical conference was conducted to discuss students' experiences and take notes of their comments.

Data analysis
The self-reported learning experience template and notes from post-clinical conferences were analysed qualitatively and emerging themes were presented. Process to categorize journal entries was based on a method developed by Burnard [20]. Development of common themes was based on systematic and detailed descriptions of ideas and issues in students' selfreports and linking these under a category system. Categories were developed by repeated working through the forms and identifying common themes throughout until agreed categories were established. This method would make the findings credible, dependable, transferable and rooted in the original data, constituting a constructive description of the experience of students participating in the study and more trustworthiness [21] in order to reduce the numbers of categories the researchers collect together all of the words from all of the self-reports on to a clean set of pages so these can then be worked through and all duplications crossed out [20]. However, to ensure that the analysis process is systematic and rigorous, the collected data were thoroughly analysed and 'constant comparison' was applied. This essentially involves reading and re reading data to search for and identify emerging themes in the constant search for understanding and the meaning of the data. [21].

Results
All of the participating students were female (N = 180). They described a variety of unique experiences throughout the course, however four main themes emerged: Knowledge and clinical skills acquisition, interpersonal support and confidence, socialisation and communications and selecting career path. We found that the sub key factors that influence students' experiences includes: support from faculty and clinical supervisor, preceptors' attitudes towards students and learning process, course content, and patients' acuity in the unit. Strategies such as self-directed learning and preceptorship management were found to positively improve students' experiences also. For each of the emerging themes will be described, using examples from transcribed data and discussed sequentially.

Knowledge & clinical skills acquisition
The level and amount of knowledge and skills dynamic required to care for critically ill patients impressive the participants, motivate them as a reason of being work in critical care after graduation and number of assigned patients was positively impacted also as described by a student: "To be assigned with one patient.... will be a good chance to get more information and practicing more skills" The students believe that the time of this course also was suitable of being last one will make them ready for practice and well prepared as described by a student: "A perfect way to end the senior year (level 8)" "We will be very prepared as new RNs by having this course" "Summarize all the information we have learned over the past 4 years together" "I will be able to know and practice many skills perfectly after I had experience with this course contents" All of these advantages made the students pointed that would be an area of selection after graduation as described by student: "Many students express..... I would like to work in this area after graduation" The students in this course reports some unique differences between this course and other courses taught within the previous year's even with presence of some difficulties and they decide that the amount of information, way of teaching and impact of these information on their performance were significant and new as described by a student: One of new things the students' reports about the importance and usefulness of orientation program in gaining the information and as a method of redirect the Learning during the course as described by a student: "One thing was interesting the orientation program its added allots to me...." "Orientation day was like a map for everything will take it in this course" "The best week was the first week ..... it is orientation for everything" "First week is a revision week ..... Was so much amazing" Study done by [16] supports that So much to learn. The level of knowledge required to care for critically ill patients surprised the participants. This led to the participants feeling overwhelmed by the amount of information they were expected to learn and some participants felt overloaded with information. Also some participants found clinical supervision helpful because it gave them an opportunity to share their fears and anxieties and discuss any problems they were having.

Iinterpersonal Support and Confidence
Support from faculty and clinical staff is a key for students' progress and success, Couched, student's centred approach, respect, appreciation of individual student's concerns also well prepared preceptors who enjoys teaching and learning were positively impacted. The following are examples on the student comments of this theme.

"Although I felt much supported, I did feel a bit anxious every day" "I'm anxious about having my first patient and anxious about not knowing how to do things"
"What I really like is the idea that we're in a group together and our instructor respects us and understand we are students" "Your preceptor makes all the difference when you have a cooperative one you will enjoy the day and learn a lot" "Orientation day... first day was supportive for us" The students pointed about importance of giving them the space of expressing their feelings by instructors and allowing them in writing the comments and feedback was positive and increasing self-confident as the student described: "Instructors ask us to express their feeling, concerns, feedbacks and suggestions frequently was positive for us" "Asking us to write our feeling was supportive and helpful" New things were the importance of clinical placement rotation by groups in making the students more comfortable and relieving of their anxiety which might have been experienced during the clinical rotations as the students' described: "Selecting a group from three students during the clinical rotation relieving the stress and anxiety for us" "Placing us in different clinical area as a group (clinical rotations) was effective and enjoyable and supporting each other" More advantages which enhance the support and moving forward towered high self-confidence was not limited to the preceptors assigned with but also the staffs in the areas as the students described: "Every day I feel scared but when i start working with my preceptors everything are changed and I feel enjoying" "Assigned one preceptor for each student 1:1ratio help us to understand the situations, giving us the chance to ask any questions, and feeling supportive always" "To be assigned with only one preceptor is better than different one" The unit staffs were friendly and supportive" "The unit staffs try to explain many things even when they are busy and loaded" "I am still able to compare the help and support from the unit staffs before and now it made the work easier and straightforward" One more and new thing the students pointed that with a time progress the level of self-confidence about their knowledge, patient care and emotions control were increased which refer to course contents/organization, practice standardized every morning patient hand over, being involved in patient care and discussion/rehearsal session from teaching staffs as the student described: Gallagher [10] reported the nature of clinical placement areas may also influence a student's ability to engage with the critical care course and clinical placement could impact on the students' ability to develop an understanding of the skills taught.
In addition the students expressed their greatest satisfaction in their interactions with others. This interaction component included opportunities for formal and informal contact with co-workers, relationships among nurses, and nurse-physician interactions. Effective preceptorship is related to the ability to form a relationship between preceptor and preceptee and can increase professional socialisation over time [23].

Selecting Career Path
Students express their feeling and concerns in progressing to the next steps and they focused on the future career. It was a result of merging themes of knowledge and skills, socializations and communications, support and confidence.
The following are some examples on selecting career path theme: "I will choose this area in my career path after I finished" "With all difficulties I have in this course but I feel that I got allots of information and skills made me looking to be recruited in this area after graduation" "I was frightening at the beginning but now I feel it is ok to practice freely and it is better going to next step which internship" "I will take phase two in internship program in the critical care areas" "I am comfortable now in things that I have did" "The good thing to feel you are catch up everything" "The beautiful day when you come in feel confidant, supportive and knowing everything, I will work in this area later on" "I take the decision to work in these areas after internship program" "I believe to gain more knowledge, skills and experience I need to select critical care areas to work in" These finding are consistent with those of Farnell and Dawson [16], schools & smith described a similar process of learning whilst highlighting safety as a major concern. Several sub-themes relate to this theme of moving on. These include good and bad days, confidence and conscious incompetence. It is appear that the interactions between support, knowledge and skills and socializations enabled participants to move on [17] and selecting career path and where the students need to be. In addition to the interpersonal interaction between students, staff preceptors and faculty members.

Discussion & Conclusion
This study captures the unique experiences of undergraduate nursing students enrolled in compulsory critical care course and suggests that these experiences are influenced by a multitude of factors. Some of these factors have direct impact on students' knowledge and professional development and subsequent socialisation to the critical care environment, clinical placements and then selecting career path.
These findings of this study are consistent with other studies which demonstrate the need for support in the form of educational activities to provide the skills and knowledge required to care for the critically ill patient [3,13]. Effective preceptorship appears to be significant in attaining socialisation, improving interpersonal skills, and gaining confidence to the unit and facilitate learning process which will affect later on the students affinity and choice of selecting the critical care area as apriority one for practice.
Further discussion of these key factors that influence students' experiences which includes; support and confidence from faculty and clinical preceptor attitudes towards students and learning process, course content, and patients' acuity in the unit showed by students comments and feedback through the emerging themes [8]. Furthermore, sstrategies such as self-directed learning and preceptorship management were found to positively improve student's experiences.
The goal of our study was not to develop our students into critical care nurses, rather to strengthen their knowledge and skills while also introducing them into an important specialty area within the profession. This study findings are consistent with other studies which showed that the interaction between knowledge, support and socialization enabled students' to move on confidence [1,24]. The inclusion of critical care course in undergraduate curriculum provide students nurses to have sufficient knowledge

Journal of Intensive and Critical Care ISSN 2471-8505
and acquired skills making them to be able to access and manage critically ill patient appropriately.
Understanding the experiences of nursing students in critical care course will help nurse managers, clinical nurse educators, and nurses appropriately support and facilitate nursing education. It is important to give organizers of planned clinical education suggestions and solutions especially about the critical care units' placements rotation. It is improving for collaboration between academia and clinical services in term of providing efficient and much experience of students related to clinical objectives and tasks.

Limitations
The study with all participants being female, the results may not be representative of all nursing students. The reason that all of the participants were females was that the nursing school within the university was for female only. In this study student experiences with critical care course were evaluated in general.
In later studies, this topic can be evaluated to a broader extent by including male students and comparing with other nursing schools.