Type of study

This study used the constructivist-qualitative paradigm, ²⁷ according to which each participant has a subjective perception and discourse about the phenomenon. The research design used phenomenology, which is a philosophical method developed by Edmund Husserl (1859-1938),²⁸ it is concerned with how things or phenomena are experienced from a first-person perspective and describes common meaning, with the purpose of explaining the structure or essence of the lived experience of a phenomenon from the perspective of the unity of meaning, which is the identification of the essence of a phenomenon and its precise description through everyday lived experience.^27,29 This is descriptive phenomenology, which consists of directly exploring, analysing and describing particular phenomena as freely as possible. The three steps of descriptive phenomenology were followed: (1) intuit; (2) analyse; and (3) describe. When in the first stage, intuiting, one became totally immersed in the phenomenon under study, one began to get to know the phenomenon described by the participants. Any criticism, evaluation or opinion was avoided and rigorous attention was paid to the phenomenon under study as it was described; the second stage consists of phenomenological analysis, which consisted of identifying the essence of the phenomenon under study from the data obtained and the way it was presented, as the descriptions were listened to, common themes or essences began to emerge; the third stage is phenomenological description, in which the written and verbal descriptions of the phenomenon were collected, classified and grouped.²⁹ This methodological approach was instrumental in addressing the research question: What are the experiences of final-year nursing students at Universidade Católica de Moçambique regarding the clinical supervision provided by nursing technicians? Additionally, it facilitated the achievement of the research aim.

Sample

The research participants were students in the 4th year of the bachelor’s degree in Nursing, as they begin clinical practice in the 2nd semester of the 1st year, in the Medicine sectors (Fundamentals of Nursing) at Hospital Central da Beira (Beira Central Hospital), HCB in short, to put basic nursing skills into practice. In the 2nd year, students have internships throughout the year. First semester, medical surgical internship at HCB; second semester, obstetrics internship at the health centres of Macurungo, Manga Mascarenha and Munhava (Beira-Sofala-Mozambique), which means that the internship hours are more extensive. In the 3rd year, the first semester is a paediatrics, emergency and psychiatry internship at HCB; and in the second semester, a community health internship with vulnerable families (which takes place in a suburban neighbourhood); and in the 4th year, the internship time is longer in a pre-professional system, that is, 8 hours a day and with night shifts, as well as a supervision internship where the 4th year students accompany the 1st year students in the fundamentals of nursing internship. Therefore, 4th year students have more experience of clinical supervision by nursing technicians. Seventy-five percent (75 %) of the practicals are carried out at HCB, which is the second largest hospital in the country and is also located in the country’s second largest population centre. ²⁴ The participants were selected by purposive or convenience sampling, since the aim was to choose people who had experienced the phenomenon under study. Since the principal investigator was not in Mozambique, but had contact with some of the students at some point, the mobilisation was carried out by a research assistant, a doctor who is UCM alumnus and was not part of the faculty’s nursing department and had no contact with the final-year students. The role of the research assistant consisted only of applying informed knowledge and was not competent to understand the training context of the future nursing professional, as he was a general practitioner. There were 104 students, of whom 36 were male and the rest female. In this way, they were guaranteed voluntary participation and freedom to take part in the project.

The principal investigator prepared a video presentation detailing the purpose of the study and the conditions of completely voluntary participation, including information about the assistant and the researcher in charge, and sent it to the assistant who then forwarded it to the class WhatsApp group. This was followed by the recruitment phase, which culminated in 14 signed Informed Consents (ICs), applied in person by the assistant. The study had the following inclusion criteria: being a final-year nursing student at UCM-FCS; having completed their final internship (full internship) and expressing their willingness to take part in the study, formalised by signing the informed consent form. The exclusion criterion was not having completed the final internship (full internship). The exclusion criterion was not considered because of the COVID-19 pandemic, there was a delay in the programme, the entire group was still in the full internship, 2nd semester of the 4th year, and their participation was voluntary. Ten interviews were obtained with information saturation. ²⁷

Data was collected through in-depth interviews, between October 2021 and February 2022, with a single question: ²⁷ What has been your experience of the clinical supervision provided by nursing technicians during your professional training? The interview was conducted in Portuguese language and online by the principal investigator via the Zoom platform. The students were connected to the platform at UCM-FCS establishments, where there was a tablet with Internet access. The assistant connected the participant to the platform and left them in the room. Since it was not the principal investigator who applied the ICs, at the beginning of the interviews each participant was asked to review the terms of the signed IC form for clarification in case of doubts. The duration of the interviews varied from approximately 40 minutes to 3 hours.

Data análisis

The ten interviews were analysed using the five steps described by Colaizzi, namely: 1) to become familiar with the information, the transcripts were read and the recordings were listened to, repeatedly, in order to gain a deep understanding of the experience; 2) the original transcripts were returned, and the significant statements were extracted; 3) the meaning of each significant statement was interpreted; 4) meanings were organised into sets of categories and subcategories; and 5) a comprehensive description was written. Bracketing was done, which according to Husserl means suspending or bracketing all judgment of the real (the researcher’s experience) in order to focus on the experience described by the participant, to get to the essence of the phenomenon. ²⁷ In addition, the software Dedoose version 9.0.46 was used for this analysis to ensure the efficient and rigorous use of all the information obtained in this study. ⁽²⁹

Data reliability

As this is a qualitative study, four rigor criteria were ensured: credibility, reliability, confirmability and transferability. ²⁹ In this research, the credibility of the study results was ensured in the following way: after completing the discourse analysis and results, the principal investigator prepared a presentation, shared it with the assistant and then he forwarded it to nine participants, and they felt identified with the social dynamics exposed. ^27,29 In terms of reliability, the interviews were audio and video recorded and transcribed immediately afterwards. The categories and subcategories emerged from the content analysis, thus confirming that the results of the study were determined by the interviewees’ experiences and not the researchers. To this end, field notes were also taken when necessary, throughout the data collection process. Finally, whether the results are appropriate or transferable depends on whether the results are applicable to another context. Therefore, in order to let other authors know whether the results are applicable to their context, this research provides detailed descriptions of the participants and the data collection and analysis process. ²⁹

Ethical aspects

The research is a response to a real situation that currently affects the training of nursing students at UCM-FCS, hence its scientific and social value. The research project was approved by Ethical-Scientific Committee of Pontificia Universidad Católica de Chile, ID: 210715007, 2021. Permission was sought and granted from the Rector of UCM, the Director of FCS and the Coordinator of the Nursing Department, from which the participants come. The students gave their consent to voluntarily participate in the audio and video recording of the interviews. During the interviews, the participants’ well-being was carefully monitored and followed up. No one except the researcher and her supervisors had access to the data, to ensure confidentiality. Each interviewee was identified by the letter “P” (participant) and a number.

Characteristics of the participants

The research participants were ten final-year nursing students aged between 22 and 25, all without children. Seven were male, nine were single, and also seven were from the central region of the country and mastered the most widely spoken local languages in the territory, which are Sena and Ndau, ³⁰ and the other three were from the north of Mozambique. Nine of them did not work before entering university, and more than half were not employed. Finally, nine were not academically delayed.

The analysis of the interviews unveiled four main categories, along with their respective subcategories and proposals for improvement concerning the students’ perception of clinical supervision, as detailed in Table 1.

Table 1: Categories, subcategories, and proposed improvements 

Students’ perception of the academic supervisor

The academic supervisor in this study refers to the teacher employed at the teaching institution (university), chosen to supervise and facilitate the trainees’ learning in clinical practice. Most of the participants reported good experiences of being accompanied by academic supervisors in the first two years of their training. The presence of academic supervisors was seen as positive because the supervisors and students were of the same level, the professionals respected the students and theoretical knowledge was integrated into practice. As one of the participants mentioned:

Thanks God we had supervision in the first and second year (...), regardless of whether they were UCM students or professionals, but it helped a lot because we spoke the same language with the same people (P5).

However, some participants noted a decline in academic supervision from the 3rd year onwards, with supervisors being absent or merely present as mentors. This absence was attributed to the limited number of lecturers unable to accommodate the increasing student population. Consequently, during internships, students felt unsupported, lacking guidance on their tasks, thus hindering their achievement of internship objectives and undermining the quality of their training. One of the participants said that:

From the 2nd or 3rd year onwards (...) supervision by lecturers has been a bit scarce, it’s normal for a week only twice (...) and it hasn’t been full time (...) just to check attendance, ask the heads or nurses who are our supervisors about how the internship is going (P9).

Students’ perception of the clinical supervisor

The nursing technician (NT) clinical supervisor in this study is a professional nursing technician employed in the hospital institution (clinical field), with a training duration of 2 years for the middle-level and 1 year and 6 months for the specialised middle-level, who supervises the university nursing student in a clinical setting. However, it should be noted that most of the interviewees said that because the clinical supervisors are NT, they showed some difficulties in supervising university students, such as the lack of clarification of doubts, and they felt threatened because the students were from higher education. One of the participants said:

This made it a bit difficult, because it's well known that a technician supervising a higher education student has limitations, no matter how much experience the person has in practice, but a higher education student has have a certain theory that they haven't seen it (...) and they also think that you don't know anything, now that we're supervising you, how basic will you be afterwards (...) they'll come here to be our bosses and with the highest salary (...) so I don't have that tendency to be able to supervise you (P5).

This created tension in the relationship between clinical supervisors and students.

The participants also reported that the clinical supervisors, in retaliation for the threat, contradicted the theoretical knowledge that the students brought from university to apply in the clinical field. In addition, the lack of remuneration for clinical supervisors made them unmotivated to accompany the students. The interviewees also noted that the poor guidance provided by some of the clinical supervisors was due to a lack of ongoing training in student supervision. As one of the participants pointed out:

I was inserting a venous catheter, I failed (...), but my supervisor didn't have the cooperation, the patience to say (...), look how I'm going to get the catheter and how I'm going to insert it so that next time you can do the same (...) he got angry with me and said that these students don't know anything, that they come here for a walk (P1).

The interviewees also pointed out that, in response to the threat and lack of pay, the clinical supervisors showed a bad disposition and reaction in the practice environment, i.e., aggressive and abusive behaviour, such as a lack of respect, exclusion from the work team and resistance to the students' initiatives because they were from university. As one of the participants mentioned:

You spend a month in a sector, obviously (...) you're treated dangerously badly, because they talk to each other (the clinical supervisors), so when they don't like you, they talk to other colleagues (P6).

The students' perception of the context

The context in this study refers to the clinical setting where students can learn and develop clinical nursing skills in a real-life situation, under the guidance of an experienced professional (31). When reporting on their experience, some participants mentioned the lack of materials as one of the reasons for poor patient care. They also noted with displeasure that health professionals no longer followed the rules of asepsis. One of the interviewees revealed:

In some sectors, due to lack of material, mothers had to buy (...), and sometimes they shared syringes, and due to lack of conditions, catheters lasted more than 2 or 3 weeks, this can cause infection in the child (...), and the COVID-19 pandemic affected (...), there was a time when we stopped for more than 5 months, year 2020, when we came back in the 3rd, 4th year everything was rushed, even internships. Maybe we could have had lecturers supervising us, but they couldn't (...) some modules we did in a week (P10).

In addition, some interviewees mentioned the lack of human resources. There are fewer nurses with bachelor’s degree and NT in the internship field, who end up overloaded and, therefore, giving 3rd- and 4th-year students a lot of work on the grounds that they should already be experienced in some procedures. One of the participants said:

There are too few nursing professionals to supply all the students coming in (...), and they end up putting a lot of pressure on us, giving us the full load (...), like we have to do all the activities (P2).

Participants reported both positive and negative experiences of cultural diversity in the practice environment. Some said that clinical supervisors in some sectors kept their cultures in reserve, being neutral, while others used their mother tongue to criticise students. For polyglot students, it was a good experience. For others, it wasn't easy to do an internship in a hospital with professionals from different cultures who interacted better and paid more attention to students from the same ethnic group. Some interviewees said:

My culture helped and helps me a lot (...), because I understand Ndau and Sena, there are professionals who talk to me, I answer them and then, if the conversation isn't relevant, it's not prolonged, they realise that I understand (P6).

Supervisors take a greater interest in and become much closer to those students who are from the same ethnic group, for example I speak Guitonga to a patient, a supervisor who is from Inhambane realises that he is from Inhambane, he becomes closer, they become friends and they give him more attention compared to colleagues who are from a different ethnic group (P9).

Finally, some participants reported that the COVID-19 pandemic was a positive impact on their internship because the clinical supervisors were closer and more attentive to the students. On the other hand, some reported negative experiences because they had little time in clinical practice. Some of the interviewees said:

The COVID-19 pandemic has had a positive impact, because we have to pay a lot of attention when carrying out any activity (...) and the supervising professionals have become a little more attentive and closer to the students, (...) clarifying doubts, thinking that perhaps the inspection could come and the trainees could carry out procedures without their presence (P9).

Some participants also said that the way HIV-positive patients are treated is very different from others and that there is a lot of stigmatisation, procedures are done badly to these patients, they are mistreated and this can even lead to death. On the other hand, depending on their social status, low-status patients are less respected and mistreated, as the interviewees reported:

I saw a lady who was 33 and had been HIV-positive for 5 years and was already on ART (antiretroviral treatment), (...) and she had a hysterectomy (...), the suture itself is regrettable, and the other health professionals ended up commenting (...), poorly done suture, they opened the abdomen too much, it went from the pubic symphysis to the hypogastric region, which is the xiphoid process, they opened the whole abdomen (...). This shows that an HIV-positive patient (...) is treated very differently (P5).

I also remember the visiting part, (...) when someone comes in wearing pants and a coat (upper class), they can come in until 10 o'clock to visit their sick relative, but when it's anyone else they can't come in (P7).

Students’ perception of themselves

The students in this study refer to those attending bachelor’s degree in Nursing at UCM-FCS in the clinical field. The participants reported that they felt very disoriented during the clinical practices, due to the lack of follow-up from the academic supervisors, which contributed to the internship's objectives not being met. For the interviewees, this calls into question the quality of the training of future UCM’s nursing students, as well as from other institutions. As some of the participants pointed out:

Sometimes the hospital supervisors give us tasks that have nothing to do with nursing, while we would be learning techniques that they know and could teach us, but (...) when there's no agent on duty, students go to clean floors, carry water, bins, where we do all this they can spend two hours (P10).

We've heard that next year they're going to introduce the classic method, it's going to be the worst (...) for UCM, even with PBL now they're not managing to control the students, the quality isn't what it was before, even half of us, we're leaving with a bit of that quality, due to the supervision we have, but from the 3rd year downwards nothing (P6).

In addition, the students considered the moments of clinical practice as a nightmare, due to the treatment given by the clinical supervisors, which demotivated them and did not make them enjoy learning as much as they should. As one of the participants put it:

Every situation in the internship setting is sad, you just want hours to leave this sector (...), because you arrive, the nurses understand, they insult you (P6).

The participants said that even though they are demotivated and experience clinical practice as an unpleasant time, they hope to complete the course one day, so they dedicate themselves a lot to the internship and, as a result, gain more experience and skills in practice. One of the interviewees revealed:

We’ve endured a lot since the first year, it's not today that we're already at the end, although they say that the baggage weighs a lot at the end, to unload it is difficult, there are no easy things, so sometimes we hold our hearts, we go to the locker room, we cry and it passes (...) it's to be reckoned with in the future (P6).

Proposals for improvement

Some proposals for improvement emerged from the participants with a view to quality clinical supervision and the successful learning of nursing students. Participants suggested that there should be academic supervisors in the internship setting because they teach theory and know how to accompany each student. One of the participants said:

For me, we should have supervision from the 1st to the 4th year, the lecturers who give us theoretical lessons should be the same even in our practical field, (...) they already know us from the classroom that this student needs a lot of attention (P8).

The participants also proposed implementing some strategies to improve the clinical supervision process, such as a training programme for NT clinical supervisors. In addition, health professionals and students should find out about the culture of the community in which they will be working, in order to have fundamental information. Some of the interviewees attested to this:

They say that those who educate should set an example to motivate the student (P7).

Supervisors should have ongoing training in terms of supervision, because not everyone knows how to supervise. They could learn to be more patient with this process (...) and try to know exactly what language is spoken there. At least to know the basics, this can help in the relationship with patients (P8).

Finally, the interviews allowed the participants to vent about their day-to-day experiences of supervision during clinical practice, as one of the interviewees revealed:

After this conversation I feel a bit more relieved because no one now comes up to ask, (...) how was the internship? From the beginning to now, there's a lot we need to get out of the way (...) and you've just done that (...) by listening to me (P9).