Tackling student nurses’ absenteeism in clinical settings: recommended interventions from South African registered nurses. A qualitative study

Abstract

Background

Student nurse absenteeism has become a significant challenge when allocated in clinical areas in public and private nursing higher education institutions worldwide. This study aimed to explore registered nurses’ recommendations for interventions to address student nurse absenteeism in clinical settings in South Africa and to share their recommended strategies to mitigate this issue.

Methods

Employing an exploratory, descriptive, and contextual approach within a qualitative framework, the study engaged eleven volunteer registered nurses who were purposively selected. The study was conducted in three specialized mental health hospitals during the participants’ lunchtime. A pre-test of the instrument was done on two participants. Those participants and the pre-test results were not included in the main study. In-depth, individual, semi-structured interviews were conducted with consented participants. Data were analyzed using Tesch’s eight-step thematic analysis method. Rigorous measures were implemented to ensure the trustworthiness of the findings and adherence to ethical principles.

Results

The analysis revealed one overarching theme: interventions to reduce student nurse absenteeism, which was further divided into four sub-themes: intensive clinical orientation for students, clear articulation of clinical objectives for students, re-fining student selection criteria, and addressing transportation challenges faced by students.

Conclusions

The findings highlighted that providing comprehensive orientation for student nurses, particularly in the clinical areas, could significantly tackle student nurses’ absenteeism. Based on these recommendations, it is advisable to conduct further mixed-methods approaches should be conducted to assess the long-term impact of interventions to mitigate the absenteeism of student nurses in mental health institutions.

Clinical trial number

Not applicable.

Introduction

Absenteeism is the practice of missing regularly planned training sessions and classes, regardless of the reason(s) [1]. Without a good cause, missing classes or neglecting to turn in an assignment is known as absenteeism [2]. Even though nurses understand the importance of their role in giving clinical training to nursing students, studies highlight that there is a need for more studies on the perceptions of clinical nurses who instruct nursing students outside their regular working hours [3]. Hence, this paper sought recommended interventions for student nurses’ absenteeism by registered nurses in South Africa. Even yet, clinical education is a crucial component of curricula as it enables students to apply the knowledge they gained in the classroom while closely supervised by clinical instructors [4, 5]. This is supported by [6], who emphasized that nursing education highly values student learning to ensure that new nurses are competent and apply various skills during clinical placement. Before moving on to the next level, students in the UK must finish the requirements for each year of the course to register as qualified nurses. In total, 50% theory and 50% practice are needed for the program [7, 8]. A study by [5] indicates that 50% of Norway’s nursing bachelor’s degree curriculum comprises clinical practice, which incorporates classroom teaching in a simulation lab. On the contrary, unlike other countries, according to the Irish Nursing Council [9], nursing students must complete 100% of their required clinical assignments each year. On the other hand, Finland allows only 5% of nursing students to miss class. However, 95% of the attendance is required to pass the course, like the Nigerian University of Abadan requirements for nursing students, before they can take an examination for a particular subject [10].

The South African Nursing Council’s regulation leading to registration (SANC Regulation) [11] mandates that student nurses complete at least 80% of their required clinical hours to be eligible for final exams. Failure to meet this requirement can lead to significant negative consequences for their academic progress, such as the possibility of repeating a level for an entire year, a reduction in the number of students graduating within four years, and a worsening national shortage of qualified nurses. Additionally, at the start of the year and every semester, the students get orientation and education regarding these policies. As a result, the student will not be allowed to take the summative exam if they do not satisfy 80% of the clinical exposure hours in all the subjects or disciplines in the clinical and theoretical nursing education.

The researcher noticed a shortage of clinical hours during the clinical accompaniment of students at Limpopo College of Nursing because of a high absenteeism rate among student nurses. This is supported by the College Campus Annual Absenteeism Report and Statistics [12], which show a varying pattern in the absence rate of student nurses, which lends weight to this assertion. Additional evidence comes from several student nurses who halted their education due to a shortage of clinical hours and training extensions. According to research by Mogobolo and Dube [13], 97.3% of nursing students missed courses due to lack of clinical hours. Similarly, [1] raised the issue of absenteeism among university and college students in South Africa as a serious matter.

A study conducted in South Africa by [1] found that the students said the workload is too much, which makes it impossible for them to attend classes and be expected to go for experiential learning on some other days. This is supported by a study conducted at the KwaZulu-Natal College of Nursing, which aimed to explore the causes and effects of student nurses’ absenteeism; it revealed most respondents confirmed that they had a lot of work to complete and could not cope [14]. Another study in South Africa by [15] reports that most students agreed that problems experienced in the clinical area, such as staff shortage, being treated as workforce, non-supervision by qualified staff members, and large patient numbers, are why they absent themselves. Similarly, [16] the study conducted in Limpopo Province of South Africa revealed that students indicated they could not cope with the patient load in the ward as there is a huge shortage of nurses, hence a higher rate of absenteeism in the clinical area. Despite the policies, absenteeism persists as a problem in every university, especially in clinical settings [17]. [2], emphasized that absenteeism hinders students’ ability to acquire the necessary knowledge and skills to achieve their personal and professional objectives.

Similarly, [18] highlights that the absence of student nurses negatively affects their capacity to deliver high-quality care. [19] also points out that absenteeism can lead to low academic achievement and an increased likelihood of dropping out. Furthermore, poor school attendance is linked to adverse outcomes in later life, such as poorer health, poverty, and a higher likelihood of involvement in the criminal justice system. In line with this [1], demonstrates that absenteeism from clinical postings has resulted in various academic setbacks for many students, including poor grades, carryovers, and the need to repeat classes. [18] also found a correlation between chronic absenteeism and poor health and educational outcomes. [20] developed district strategies in the USA to reduce student absenteeism. Similarly, [21] in India provided recommendations for addressing this issue. [22] identified potential solutions to student absenteeism in Ethiopia. [23] also conducted a study in Iran on preparing nursing students for mental health clinical engagement. In Nigeria, [10] proposed various strategies to decrease the absenteeism rates of student nurses. Furthermore, Mbombi [24] recommended that nurse managers provide platforms to address psychological and professional problems experienced by student nurses in the clinical areas of a tertiary hospital in Limpopo province. While the studies mentioned above were conducted in different countries and contexts, there is a gap in research specifically focused on South Africa, particularly in mental health facilities where the Limpopo College of Nursing places students for clinical learning. Although various studies have explored student nurses’ experiences, perceptions, and interventions regarding absenteeism in clinical areas, and given the persistence of absenteeism despite existing policies, studies, rules, and laws, this study seeks to explore registered nurses’ recommendations for addressing the issue of student nurse absenteeism in mental facilities in Limpopo Province, South Africa.

Methods

Study design

The study used exploratory, descriptive, and contextual designs within a qualitative framework, following the methodology suggested by [25]. This approach allowed for a comprehensive exploration into registered nurses’ recommendations for interventions to tackle student nurse absenteeism in mental health facilities, considering both the specific context and the nuanced experiences of the nurses.

Study setting

The study was conducted in three specialized mental health facilities of Limpopo Province, where students were allocated for mental health clinical learning. The Greater Giyani sub-district, made up of rural areas with a population of various ethnicities, is located approximately 5.3 km outside of the town, and hospital number one is located on the major road of Giyani. The three main language groupings are Sotho, Tsonga, and Venda. Hospital number two is situated in the Sibasa rural area on the main road, next to Thohoyandou City. Venda-speaking people dominate the area. The second facility is only 50 km from the third hospital from Polokwane, located in the Lepelle Nkumpi local municipality of Lebowakgomo, South-East. The locals’ primary language at home is Sepedi. Buses transport student nurses 5.3 km to Hospital Number One from the Giyani Campus. The distances between the Thohoyandou Campus and Hospital Number Two are 13.6 km and 49.5 km, respectively, from the Sovenga Campus to Hospital Number Three

Study population and sampling

The study specifically targeted registered nurses working within selected mental health hospitals to understand insights and practices in a highly specialized area of healthcare. To ensure a focused and relevant participant base, purposive sampling was employed, allowing for the selection of male and female registered nurses with three or more years of experience working in the mental health wards where level three and level four students were allocated. This method facilitated the choice of eleven registered nurses across three different hospitals: four from the first, four from the second, and three from the third hospital. This approach was adopted to capture diverse perspectives within specialized mental health care, aiming to gather in-depth and applicable findings from professionals across various settings.

Data collection

After obtaining approval and permission to conduct the study, the researchers sought authorization from the relevant authorities before collecting data. The instrument was pre-tested using two participants who did not form part of the main study, and the results were not included in the main study. The researcher recruited participants telephonically a day before the interviews and informed them about the study’s objectives and design, ensuring they provided written informed consent. The semi-structured individual interview guide was used, and the key question was: You are working in one of the mental health institutions as a professional nurse supervising student nurses; what could be done to reduce student nurses’ absenteeism in this clinical setting? The probing questions followed this. The corresponding author conducted the interviews. The individual interviews were conducted using an in-depth semi-structured approach and audio recorded during the participants’ lunch break periods. They lasted between 35 and 45 min each, and field notes were taken. The ninth interview achieved data saturation; however, the researchers conducted two additional interviews to ensure all-important information was gathered. The interviews in this study are part of the main study of the thesis published [26]. The transcripts were returned to participants for comments and to check whether the information was correctly transcribed. Data were managed through the laptop, cloud, and USB.

Data analysis

Data were analyzed using the thematic analysis guided by Tesch’s eight steps, as described by [27]. A coding scheme was developed to identify themes and sub-themes. A theme and sub-themes were extracted from the collected data by the main researcher, and the co-researchers reviewed the extracted information to enhance validity. The final analysis yielded one main theme and four sub-themes on recommended interventions to tackle student nurse absenteeism. Difficulty in generalizing findings was experienced during data analysis due to the small sample size and the excluded years of experience in mental health nursing in participants’ demographic information.

Ethical considerations

Researchers sought ethical clearance from the University ethics committee, and provincial approval was sought from the Limpopo Department of Health. All three specialized psychiatric hospitals and the Limpopo College of Nursing campuses approved the study to be conducted. The population was accurately identified and knowledgeable about the phenomenon being studied. The participants also signed consent forms before participating in the study.

Measures to ensure trustworthiness

The methods employed by the research team to ensure trustworthiness are credibility, transferability, dependability, conformability, and authenticity. All research team members reviewed and discussed the extracted themes to reach a consensus. Credibility was also ensured through prolonged engagement, persistent observation, and member-checking. The researchers and the independent coder coded the data, and the recording device was retained to ensure the accuracy and consistency of the information. The research team followed rigorous data analysis and validation to ensure trustworthiness.

Results

Eleven registered nurses participated in the study, four from hospital one, four from hospital two, and three from hospital three. Data were collected until saturation was reached by the ninth professional nurse from hospital number three, who gave the same information. Nevertheless, the researcher continued with the other two to ensure no new information was left out. Hospitals and participants were numbered from Hospital number A to C and Participants number one to eleven. The table below indicates the demographic information of participants.

Table 1 indicates the registered nurses working in specialized psychiatric hospitals where student nurses were placed.

Table 1 Demographic information of participants

The table above represents the demographic information of the participants, with most of the participants being females (73%) rather than males (27%). This indicates that these mental facilities comprise more female than male registered nurses. Most participants (55%) were less than 40 years of age, and few (45%) were older than 40 years of age. This information indicates that most registered nurses working with student nurses were younger than old ones. This might impact student nurses’ absenteeism rate as they might undermine younger generations as their supervisors. Regarding years of experience, few (36%) participants had 10 years or less of experience as registered nurses, and most (64%) had more than 10 years of experience. One of the registered nurse’s roles is supervising and teaching students when allocated to their facilities. There was no specific training in clinical supervision done by the registered nurses except the part of supervision included in their training leading to the registration as a professional nurse.

The results presented below are in themes and sub-themes where one theme emerged from the findings: interventions to tackle student nurses’ absenteeism, which was further divided into four sub-themes: intensive student nurses’ clinical orientation, clear articulation of clinical objectives for students, refining student selection criteria, and addressing transportation challenges faced by students. They are discussed separately below with quotations.

Theme 1: Interventions to tackle student nurses’ absenteeism

Interventions are plans to achieve a particular purpose” [28]. This study’s interventions refer to plans to tackle student nurses’ absenteeism at specialized psychiatric hospitals. Experiential learning during clinical placements allows students to learn and demonstrate the combination of knowledge, attitudes, and skills in complex care environments. Therefore, learning cannot occur when students are absent, and interventions should be implemented to tackle students’ absenteeism in clinical areas. This theme emerged during data analysis when most participants recommended interventions to tackle student nurses’ absenteeism. Four sub-themes were identified: Intensive student nurses’ clinical orientation, Clear articulation of clinical objectives for students, refining student selection criteria, and addressing students’ transport problems by the college.

Sub-theme 1: Intensive student nurses’ clinical orientation

Most registered nurses said that students should have a thorough clinical orientation on managing patients receiving mental health care when they enter clinical settings. They indicated that this orientation should be done at the college before and during the time students are allocated to the hospital. Suppose they are oriented to the types of mental health care users and their conditions. In that case, they might allay student nurses’ anxiety, which might give them an interest in coming to the clinical areas without being absent.

The quotes below demonstrate this recommendation:

One participant said:

It is simple to supervise students, control them, cope, and teach them if they are oriented. That preparation should be done in class before they go to the hospital; I think proper orientation should be done so that they cannot fear anything and be well prepared for what they will face daily. Participant 7B.

Another participant said:

I think before and after students are allocated to the hospital, nurse educators should orientate and teach the students at the college how to behave when they go to the clinical area as students. Yes, this awareness must not be done only here at the hospital but also at the college. Participant 8B.

Sub-theme 2: Clear articulation of clinical objectives for students

During data collection, some registered nurses stated that the lack of clarity of clinical learning objectives contributes to students’ absences from clinical settings, as the delegation to the activities related to their learning objectives is the key to tackling the absenteeism challenges. Because without allocating them, they can be absent due to not knowing what to do.

The quotes below support the findings:

One participant said:

Yeah, there should be communication when the students are brought; their job description should be clear on the objective so that we know how to allocate and delegate them. But here, we have not seen anything written that this is what they are here for; these are the learning objectives for that moment; to say these are level III and their objectives, this is what we expect them to learn. Participant 7B.

Another participant said:

Yes, it is preparatory for us to say they are coming, and these are their objectives, and for us to go and revise so that we can go back and study about a particular objective they will be here for. When engaging with these things, reflecting and studying is always important; it can reduce their absenteeism when they are being taught according to their objectives. Participant 11C.

Sub-theme 3: Refining student selection criteria

Registered nurses said that one of the interventions is for the college to ensure that the selection criteria include determining the student’s interest in nursing and passion, especially in mental health nursing clinical placement. This would assist in enrolling students who are interested in nursing, not those who came because they need a job, because, without interest, they could be absent more. The following quotes confirm the findings:

One participant said:

One of the selection criteria should be to check interest and passion in that job, even if it is not nursing, but having an interest prepares your mind well before facing reality then you will stay in the ward. I think there should be a selection test, yes, because normally they apply, and if someone has good results, they call them to attend, but if they can do a selection test, then they will see that this person is well prepared to face whatever is covered in the nursing career. Participant 7B.

Another participant said:

I think during the interview, there should be a portion where you must see the interest and values like caring because it is useless to say he has got an exemption; he passed very well, he has got maths, but when he comes here, he becomes a parcel and that even though he passed, they don’t stay in nursing and they absent themselves from the wards. Participant 10 C.

Sub-theme 4: Addressing students’ transport problems by the college

One of the reasons student nurses were absent was because hospitals and college campuses were so far apart; registered nurses said that to reduce student absenteeism, the college should assign extra drivers to transport students to fix the transportation issues.

The quotes below confirm the findings:

One participant said:

The factors that I gave, yes, I think college management should also intervene when it comes to transport to monitor that there is enough transport for students and someone who will ensure that there is a driver or transport available for them every day. They say there is no driver. Yes, the others yesterday said the driver was not there. Sometimes, if their driver is absent or sick, they cannot come because there is no replacement. So maybe having enough staff to transport them will help. Participant 7B.

Another participant said:

They will tell you that if “Malume” (the driver) leaves you behind, you won’t be able to reach the hospital in time. For example, let us say “Malume” leaves at 7 o’clock and then you leave behind; going to the taxi rank to get a taxi and waiting for the taxi to get full is a lot of work. And you must take three taxis to get to the hospital so they will probably not be here on time. It would be better if they could liaise with the hospital regarding nurses’ homes to accommodate students or to hire more drivers. Participant 9 C.

Discussion

According to the findings, student nurses should receive a thorough clinical orientation before being assigned to the clinical settings. Once they arrive at the hospitals, they should learn how to handle mental health care users. This is supported by [29], who found that many students focused on challenges such as their fear of being harmed by mental health care users. Some thought the learning environment was more favorable when the theory and the patient’s clinical appearance aligned. This aligns with [30], who indicates that many student nurses have little to no experience working in a psychiatric setting and are, therefore, unsure of what to expect when they do so. This lack of knowledge might instill the student nurses’ anxiety about their psychiatric clinical experience, leading to absenteeism. Additionally, they might have preconceived ideas about individuals with mental illnesses. The above is supported by [24], who argues that it is necessary to prepare students to overcome fears and worries and to meet expectations, which is mental preparation. This includes overcoming fears and anxieties, creating a positive attitude toward the patients, and reducing absenteeism. On the other hand, [4] said that the orientation of students is the first step in creating a conducive learning environment to prevent them absent from the learning institution.

Some registered nurses recommended that students’ clinical objectives be available to reduce student absenteeism because registered nurses could assign them to the wards according to their learning objectives and scope of practice. This aligns with a study by [31] that says instructors may provide students with more significant opportunities to mutually reinforce each other’s understanding of course content with classmates. On the other hand, [21] indicates that students are more interested in attending class when their coursework corresponds to their identities. They further indicated that this is one of the techniques used to tackle absenteeism. Similarly, [22] indicates that one of the key recommendations of the participants was to use new technologies to teach learning objectives. They believed that simulation and orientation could prepare the students well to understand the conditions of these patients. This aligns with [32] findings that indicate that students experienced the availability and guidance of clinical supervisors as reassuring because some clinical facilitators employed at the clinical facilities were unwilling to assist the student nurses because of remuneration issues and a shortage of registered nurses. To tackle student nurses’ absenteeism, some registered nurses indicated that the college’s selection criteria for new students should consider their interest in nursing, particularly the clinical allocation to mental health institutions. This finding agreed with the study conducted in Pakistan by [33], who highlighted that student nurses indicated that a lack of interest in their studies is another reason for absenteeism in clinical settings. Similarly, [1] concluded that absenteeism can be linked to a lack of interest in the caring of mental health care users. On the contrary, [29] found that many participants emphasized a growing interest in the psychiatric nursing facility. Registered nurses suggested that the college effectively handle students’ transportation issues to reduce student nurses’ absenteeism. The same tactics were established by [21], who claim that a safe clinical atmosphere and transit to and from hospitals encourage everyday attendance. On the other hand, [34] discovered that financial constraint affects transportation to the facilities, feeding, fees, and payment for some educational materials. This can directly demotivate the student with subsequent absenteeism.

The study recommended numerous interventive measures that may be taken to lower the absenteeism of student nurses in South African mental health facilities. Therefore, to facilitate the implementation of these recommended interventions, registered nurses, mental health nurses, and college mental health lecturers must collaborate to attend to student nurses’ absenteeism through meetings. This can also be achieved by identifying factors leading to absenteeism and developing solutions collaboratively. A negative attitude towards the collaboration of the hospital staff members and the college lecturers can be a potential barrier to implementing the recommended interventions. The hospital orientation of student nurses by registered nurses could be a challenge since registered nurses always talk about the staff shortage on their side. For the sustainability and feasibility of these interventions, registered nurses, mental health lecturers, and student nurses should unite to implement the recommended interventions. This will tackle student nurses’ absenteeism, which results in poor skill application and prevents them from accessing the necessary knowledge and resources for effective learning. Additionally, it has been linked to poor academic achievement, unprofessional behavior, and a lack of professional socializing. The recommended interventions could also impact other settings like midwifery, general nursing science, and community health since some challenges could be found in all settings. Challenges like unclear objectives of the student nurses, transport challenges, and lack of orientation can also be found in general clinical facilities. Further mixed-methods approaches should be conducted to assess the long-term impact of interventions to reduce the absenteeism of student nurses in mental health institutions. This study might reduce absenteeism among student nurses, increase retention and more graduates, and increase the number of registered nurses nationally and in other countries.

Limitations

This study was restricted to three of the five districts of the Limpopo Province. Therefore, the registered nurses’ recommendations from other districts with hospitals that admit mental health care users were omitted. Furthermore, this study was contextual in that only registered nurses working in specialized psychiatric hospitals were interviewed; thus, the study could not get the recommendations of registered nurses working in psychiatric wards of general hospitals where students from the Limpopo College of Nursing are also allocated. Therefore, the results of the study cannot be generalized. This study only focused on registered nurses without the voices of student nurses, as their voices were already heard in another study. Another limitation is that the data was collected only during the participants’ lunch break. Therefore, time constraints might have caused the potential limitation of getting superficial rather than in-depth information from participants. There was a challenge to generalizing findings because the participants’ experiences checked were not specifically in mental health institutions but in general.

Conclusions

This study concluded that it is important for student nurses to be thoroughly orientated before they are allocated to the clinical areas, especially if they will be facing mental health care users for the first time, to allay anxieties and to impart them with necessary skills for interacting with those patients in the ward. Lack of student nurses’ clinical objectives, lack of college drivers, and transportation problems may negatively impact students’ clinical attendance. The study also recommends that nursing colleges review the selection criteria as it affects students’ attendance due to a lack of interest in mental health nursing.