Clinical Supervision as an Integral Part in Training for Bridging Course Learners at Selected Hospitals of Vhembe District, Limpopo Province, South Africa

Purpose: The purpose of this study was to explore and describe the significance of clinical supervision amongst Bridging course learners at the selected hospitals in Vhembe district, Limpopo province. Methods: A qualitative, exploratory, contextual and descriptive design was used and this approach was regarded as the most appropriate for this study. The population of this study consisted of the learner nurses in the Bridging Course Programme (R683) leading to registration as a General Nurse. Purposive, non-probability sampling method was used to select the participants. Data collection: Data was collected by means of focus group discussion interviews during which participants were able to describe their experiences of the clinical placement in the real life setting and the support received from the professional nurses, data were collected until data saturation was reached. Data analysis: The researcher used the process of bracketing and remained neutral, setting aside previous knowledge and beliefs about the phenomenon under investigation. The researcher listened to the audiotapes used for data collection several times until the researcher completely satisfied with the interpretation of the verbatim data. Ethical consideration: The researcher sought for approval to collect data from the appropriate authority at the University of Venda, the Provincial Department of Health and the bridging students in each institution.


Introduction
Clinical Supervision for learner nurses is viewed as a process for improving clinical practice and reducing the emotional burden of those who are still on training and getting the feet in the profession. It assists in problem identification and provides solutions to problems. It also improves clinical practice, and increase understanding for learner nurses. It is significant in nursing as it can improve patient care. Clinical supervision is important in student nurse training as it socialises them into their future professional role and identity [1].
It also helps learners to be confident and competent during clinical practice. Learner depends on the quality of clinical supervision and experience obtained for their competency when they are placed in the clinical environment. This will influence their practice when they are in the clinical practice. The nurse educators, clinicians, professional nurses and nurse managers have the responsibility to ensure that the clinical supervision of learner nurses is done. They need to guide the learners so that they become the best nurse practitioners we expect them to be.

Background to the Study
Clinical supervision is defined as a formal, systemic and continuous process of professional support and learning for practicing nurses in which nurses are assisted in developing their practice through regular discussion with experienced colleagues with whom they share clinical experience [2]. Globally the training of learner nurses is seen as the basis of nursing practice. Learner nurses need to be supported and guided so that they can become responsible, accountable and independent professionals who are able to function within the precepts of the profession. In nursing we always talk about integration of theory and practice and this can only be achieved if those responsible for teaching theory supervise if the learners are performing as expected in the clinical area. In order to facilitate optimal learning for the student nurse, the student must be presented with a range of real life work experiences that are presented in a supportive environment [3]. Clinical supervision does not only provide learners with an opportunity to work on their own and grow professionally, it also allows them to have self-confidence in performance of nursing skills and functioning independently [4].
Clinical supervision aims to help learner nurses increase both their competence and confidence through exchanges with experienced professionals and the use of reflective skills. Clinical supervision covers all the aspects in nursing practice. A supportive environment and team work in the clinical setting lead to reduction in the workload when it comes to patient care [5]. The students are taught communication skills and interaction with patients.
The student is supervised until such time that he/she is confident and competent in performing the skill then the supervisory role will be reduced bit by bit and not totally taken away. For clinical supervision to be effective, nurse educators and professional nurses in the units need to have a sound knowledge of the learning needs of students as they are supervising them in the clinical setting [6]. Supervision also provides support on increasing students' own responsibility to nurse patients independently.

Problem Statement
Custodians of nursing education have often expressed their different views regarding clinical supervision for learner nurses in hospitals of Vhembe district in Limpopo Province learners. Clinical supervision is a serious concern to learner nurses as nursing is a practice -based profession. Even if the learner preforms exceptionally well in theory she still has to be very competent in clinical skills.
The concern was that learner nurses were not able to integrate theory, practice and skills and would not be able to function independently on completion of their training. From the discussions that were held with stake holders the researcher felt that there is a need to investigate the views of expressed by leaner nurses regarding clinical supervision. The researcher also wanted to investigate if the learners are satisfied with the clinical supervision that they are receiving.

Purpose of the Study
The purpose of the study was to explore and describe views of learner nurses regarding clinical supervision at sampled hospitals of Vhembe district in Limpopo Province, South Africa.

Research Objectives
• To explore learner nurses' views regarding clinical supervision at the sampled hospitals of Vhembe district in Limpopo Province. • To describe learner nurses' views regarding clinical supervision at the sampled hospitals of Vhembe district in Limpopo Province.

Significance to the learners, nurse educators and professional nurses
The study results can contribute enable nurse educators and professional nurses to assist to ensure high quality nursing education, produce competent nurses and promote the charm of the nursing profession. Nurse educators and professional nurses will be able to detect areas of concern which needs improvement and engage the parties involved on how improvements can be made in order to have an efficient and effective system of learner supervision.

Significance of the research
The findings of this study would contribute to nursing research because clinical supervision is such an essential and indispensable field of study in the nursing profession.

Research Methodology and Research Design
Research design aims at providing a plan for answering the research question. The researcher used the qualitative, exploratory, descriptive and contextual research approach, because the study focused on the views of learner nurses. The researcher used interviews to gain the knowledge that will make it possible to describe the learners' views in an effort to obtain complete and accurate information for use in this study.

Research Setting
The study was conducted at sampled hospitals in Vhembe District of Limpopo Province where learners doing Bridging Course are allocated for clinical exposure.

Population
According to Burns and Grove [8]; Polit and Beck [9] population refers to the entire group of persons or objects that is of interest to the researcher that meets the criteria that the researcher is interested in studying. The population was learner nurses doing Bridging Course for enrolled nurses leading to registration as a General Nurse, as stated in Regulation 683 of 14 April 1989. The sampled population was learners who were doing second year of study in Bridging course at sampled hospitals of Vhembe district of Limpopo Province. Purposive, nonprobability sampling method was used to sample participants. The study involved a total of twenty-eight (28) participants.

Data Collection
For this study, the researcher conducted unstructured focus group interviews. The unstructured in-depth focus group interviews lasted for approximately 60 to 90 min each and no new information was obtained after completion of the interviews. FGDs were used, rather than in-depth individual interviews, based on the need to identify the experiences, views and perceptions of the participants. The selections of FGD members require careful decision to optimise the usefulness of the focus group. For most purposes, the group of 6 to 10 members are optimal. The researcher stimulates exchange of ideas and encourages debates.
The FGD methodology provides in-depth information, but it does not produce quantifiable data and the findings cannot be generalised to a larger population.

Ethical Considerations
Protecting the rights of the participants The researcher avoided discrimination against the Bridging course learners on the basis of sex, race, ethnicity or other factors that were deemed to jeopardise the trustworthiness of the study results.
• Beneficence According to Polit and Beck beneficence is the most fundamental principle in research. To adhere to this principle, the well-being (physical, emotional, social of financial) of the respondent must be protected from discomfort and harm [10]. In this study the researcher did not harm and refrain from exploiting participants, and promoted The participants have the right to know what the research entails, how it will influence them, the risks and the benefits and that they may refuse to participate in the study should they choose to do so [11].

• Justice
The principle of justice means that participants need to be treated fairly [12]. The researcher respected the rights of the learners to privacy and the right to fair treatment in the context of research participation

Protecting the rights of the institutions • Legality
Before research can be commenced, permission needs to be obtained from the authority of the institutions where research will be conducted. The ethical principles that are applicable to participants also apply to the institutions. The researcher understood and obeyed relevant laws and institutional and governmental policies regarding research, protection of human subjects, and any other ethical consideration relevant to the study.

Data Analysis
Tesch's steps of data analysis were followed as stated in Creswell [13]. During the process of analysing, the researcher identified the essence of the phenomenon under investigation based on the data collected and how that data was presented. In a case of describing, the researcher describes critically, in written communication, the meaning of the phenomenon as it has been given by the participants. This step of describing is applied after all data have been analysed, and themes have emerged from the grouped categories and sub-categories. Data belonging to each category was assembled in one place and preliminary analysis was done. The data was sorted. During this process, main ideas were formed and information sorted into themes, categories and subcategories.

Trustworthiness of the Study
Findings were discussed between the researcher and the participants. Accuracy was maintained throughout the study by making use of member checks and allowing the participants who provided the information to check both the data and the interpretation.

Dependability
The researcher enhanced the dependability of this study by involving an expert in qualitative research to assist with data analysis and the interpretation of data. The researcher kept all records of all stages of the research process for the purpose of audits done by experts.

Transferability
The researcher enhanced transferability by providing an in-depth discussion and interpretation of data and by using focus group discussions.

Confirmability
The researcher maintained the confirmability of this study by taking comprehensive notes throughout the research. The researcher also ensured that data is accurately interpreted, and reflected the information that was obtained from the participants. Thus the findings were shared with participants to confirm the information they gave. Information was discussed with the supervisor and the qualitative research expert to prevent any form of bias.

Findings
The study found out the experiences of Bridging course learners as not satisfactory regarding clinical supervision received in the clinical areas. According to the study the findings were that: Clinical supervision is not adequately done in the clinical environment due to but not limited to the following factors: • Attitude of trained staff and learners Attitude of both professional nurses and learners was indicated as another barrier to proper clinical supervision. It was indicated that professional nurse see learners as extra work or burden when they have to supervise them. On the other hand, learners were seen as being arrogant and dodge form the unit most of the time. This worsens the relationship between learners and professional nurses. Another issue that emerged from the discussion was that often learners are less interested and are not inquisitive to ask more about what is happening in the clinical area, they only do routine just like any other staff member without asking anything.
• Shortage of equipment Shortage of equipment was another barrier to proper clinical supervision. Procedures had to be flawed because there are on equipment. In this instance proper clinical supervision cannot be done as procedures are compromised due to unavailability of equipment are.
• Learners used as part of working force Another issue was the fact that these learners because they are enrolled nurses, they were used as a work force to patch the shortage in the units. Learners in Bridging course have been trained for certificate courses before therefore they are assumed as "knowing it all". Whenever off-duties are written, they are used to balance the trained staff. Whenever there is shortage of trained staff learners are asked to work overtime. Because of that learners tend to focus on the ward routine than their learning needs.
• Insufficient learning opportunities The issue of a small and poorly equipped simulation laboratory was raised where learners indicated that they can't practice as much as they would want to in the simulation lab as they are overcrowded during procedure simulations. Learners also indicated that the professional nurses in the units keep them busy with ward routine hence there is not much time to practice their skills.
Generally, learners indicated that they feel that they are not adequately supervised in the clinical area. The learners indicated some dissatisfaction and frustration because they say that they are not properly supervised.
• Shortage of trained staff Students indicated that the wards are short staffed of professional nurses therefore they concentrate on ward activities and patient care. Students were left to be doing procedures alone without the supervision of the professional nurses.

Discussion
The study results indicated that the majority students were not satisfied with the clinical supervision in the units though few had a different perspective. Students cited many factors that were experienced which lead to clinical supervision not properly done. The study indicated that material and human resources challenges contributed to poor clinical supervision. In the material resources there was shortage of equipment s which compromised the performance of procedures. Professional nurses would flaw some procedures because there is no equipment to perform such procedures.
There were also insufficient learning opportunities created for students to go and practice clinical skills in the laboratories. In human resources the study found that there is shortage of professional nurses leading to the professional nurses concentrating on patient care and ward activities and not patient supervision. The study also revealed that the professional nurses and the student had a negative attitude towards clinical supervision leading to compromising clinical supervision.
During the study students indicated that at times they even forget that they were students as most of the time they were treated as employees of the institution and not students. They were involved in ward activities than in their learning expectations.

Recommendations regarding inadequate clinical supervision
It is recommended that clinical supervision of nursing learners should be prioritised by nurse educators and professional nurses in all the training institutions.
Having clinical supervisors or clinicians made available for the clinical supervision of learner nurses; Professional nurses to be more supportive towards the training of learner nurses.

Recommendations regarding the need for clinical training specialists and preceptors
It is recommended that the appointment of clinician and preceptors in the training institutions could provide the opportunity to oversee the education and training of learner nurses of different categories.
The clinicians and preceptors should be offered courses on coaching, mentoring and preceptor development.
They could also receive compensation so that they do not see supervision as extra responsibility.

Recommendations regarding the availability of a structured plan or programme
It is recommended nurse educators should provide professional nurses in the clinical setting with a structured clinical supervision programme.
A detailed schedule or programme should be in place in all the units to guide both the learner and supervisor concerning their training needs.
Learners should also have their clinical learning outcomes.
The roles and responsibilities of both supervisor and the student should be clearly defined in the contract, and the contract should clearly define the goals to be achieved through clinical supervision.

Recommendations regarding the use of learners as workforce
Nurse educators need to have good relationship and communication with the professional nurses in the units so that they treat learners as what they are and not a working force.
Learners should not be used to patch the shortage that is in the wars/units at the expense of their training.
They should be allowed the opportunity to be learners and be guided in the clinical placement.
They should work under direct or indirect supervision of the professional nurse allocated to them.
Learners should maintain their supernumerary status of being "learners" not workers.

Recommendations regarding the incorrect guidance and supervisory procedures
Learners should be supervised all the time whenever they are in the clinical placement. They should be under direct or indirect supervision of the professional nurse.
Professional nurses in the unit should take education and teaching of learner nurses seriously. Procedures should be done properly without any compromise in order to allow leaners to see the correct things being.

Recommendations regarding insufficient learning opportunities
The recommendations were: Simulation laboratory should be well equipped and special attention given to the number of learners taken in for training in the so that overcrowding is avoided.
During simulation learners should be taken in groups of ten in order to prevent overcrowding in the simulation laboratory.

Recommendations regarding learner nurse-professional nurse ration
Allocation of learners in the units should be in such a manner that there is no learner overcrowding in a particular unit.
Learners should be fairly distributed because when there is overcrowding, it is not easy to supervise those learners.
The training of the learners must be considered a high and important priority and every effort should be made to give learners the best clinical experience possible.
Institutions of higher learning using the same clinical environment should work together to ensure fair distribution of learners.

Limitations regarding the target population
This study only focused on learners following the Bridging Course for enrolled nurses that lead to registration as a General Nurse according to Regulation 683 of 14 April 1989, in their second year of study, maybe learners in their first year of study or learner following another training programme could have had different view.

Conclusion
Clinical supervision is regarded as the foundation for nursing practice therefore people who are tasked with training learner nurses should ensure that this is the priority in student learning. The positive outcome of clinical experience for learner nurses depends on joint actions by the nurse educators and professional nurses in the unit. They need to equip learner nurses with knowledge and skills so that they practice competently. The quality of patient care depends on the quality of training provided to the care giver.