The consequence of the ‘brain drain’ is an excessive workload, not only within the nursing profession but in many other professional occupations as well, for those remaining in the profession and in the country (McDonald & Crush 2000:5). The resultant work pressure, especially for nurses working in the public sector, increases the risk of burnout, a syndrome marked by emotional exhaustion and over-extension as well as a depersonalised attitude toward patients (Alacacioglu et al. 2009:543; Brysiewicz & Bruce 2008:129).

From the aforementioned, it is clear that a pressing need exists for nursing students to graduate and enter the workforce to alleviate the serious staff shortage. It is against this background, coupled with the large number of first-year students who drop out of training programmes, that it was decided to explore the experiences of nursing students during their first year of study. The research question that guided this research is: ‘What are the dimensions of well-being as expressed by nursing students?’ This is an important question because professional nurses are expected to promote the well-being of the people entrusted to them. For the purpose of this study, well-being refers to personal well-being, well-being in relation to people who form part of the community, and perceived well-being in relation to the broader context, which in this instance is the nursing profession (Nelson & Prilleltensky 2005:54). The adoption of this framework to understand nursing students within the broader context in which they function, gives the study an ecological perspective and subjects it to the assumptions underlying community psychology (Nelson & Prilleltensky 2005:5). A community psychology framework aids researchers to understand human behaviour in different contexts with the focus on the dynamic nature of people, relationships and situations.

Aims of the study
The aim of the research is to explore the different dimensions of well-being as described by nursing students.

Contribution to field
The purpose of the research is to promote the well-being of nursing students during their training. They are expected to promote the well-being of people and to enter the workforce to alleviate the serious staff shortage.

Visual data were obtained when participants were requested to construct collages that represented their dreams for their nursing profession. The objective was to explore the students’ motivation for studying nursing and possibly to identify factors that may contribute to the drop-out rates of nursing students. The participants grouped themselves for the purpose of the focus group discussion in the following manner:

• the 5 English speaking participants grouped themselves together (Group 1)
• the 23 Afrikaans speaking participants divided into 3 groups: 1 group with 4 participants (Group 2)
• another with 9 participants (Group 3)
• and the last group (Group 4) comprised 10 participants.

Discussions during the focus group were centred on collages and the meanings that the students attached to the pictures they included in the collages.

The Mmogo-method™ involves the construction of the participants’ lived experiences, by using malleable clay, dried grass stalks and colourful beads. These materials are used as a projective method because participants were asked to use the materials and to build anything about their experiences of being a nursing student. The visual data were regarded as participants’ reflections on the social structures of which they are part of (Roos in press).

During the in-depth interviews, four participants’ experiences of being nursed and nursing others were acquired. Interviews were recorded with the use of a digital voice recorder and were then transcribed verbatim. The interviews were used to gain a better understanding and to learn from the participants what they viewed as important factors during their training and how they understood their own experience.

Additionally, one focus group discussion was held during 2010. Four students participated in this focus group and the discussions allowed the participants to interact and to contribute valuable data and insights regarding their experiences of well-being, as well as in reflecting on their experiences during 2008. A focus group discussion is a socially oriented research method that facilitates the acquisition of data in a social environment (Babbie 2007:308). The participants were given an open-ended instruction: ‘Please tell us how you are experiencing your training as a nursing student at present and reflect on your first year of training.’

• Acquiring familiarity with the data. During this phase, the researchers repeatedly listened to audio recordings of the interviews so that they could familiarise themselves with the content and begin to formulate possible themes.

• Generating initial codes. Coding involved taking chunks of text and placing them in specific categories in such a way as to enable later analysis of the data (Babbie 2007:384). Data were organised into meaningful clusters that became salient during Phase 1, and the clusters were colour-coded on the transcribed data sets.

• Searching for themes. Codes were grouped into themes that were arranged in a mind map so that particular attention was paid to codes that linked up with the research question.

• Reviewing themes. Some themes from Phase 3 were grouped together, and some less important themes fell away. Data were reread to ascertain whether the themes represented the data adequately.

• Defining and naming themes. Each theme was defined and explained (Braun & Clarke 2006:82).

• Producing the report. The report identified the emergent themes and related the analysis to the research question and the literature review. The data that were gathered during 2008 and 2010 were merged and reported jointly as themes in terms of the different relational dimensions of well-being.

The themes and subthemes were visually presented (Table 1).

Lack of autonomy
The data indicated that the participants did not experience autonomy in their first year of training. Autonomy is defined here as the independent judgement by people to effect a desirable outcome (Keenan 1999:561). The participants had no autonomy or say over their practical-training hours. They believed that they should have been given the freedom to allocate their own training times so that they could decide when they could go home on weekends and when they could not. They also believed that they were not allowed to use their own initiative when faced with difficult situations in their practical training. They felt as though all they were allowed to do was to stand back, to observe and to let things happen to them and around them.

The following extracts illustrate their experience of a lack of autonomy:

‘Our lecturers want to organise everything for us. They want to plan from what time to what time we have to work, when we must study, when we must do our assignments. It’s as though they want to organise every aspect of our lives and that irritates me immensely.’

‘You do just what you have to do, because someone else above you makes decisions for you.’

‘The old man gasps, but you just have to stand and watch until he dies, because there’s nothing we can do for him.’ (Study participants)

The focus group with the third-year participants confirmed the lack of autonomy they had expressed during their first year although it appears that they were granted more autonomy in their third year. The participants still experienced a lack of autonomy in government hospitals but reported that they had more responsibility in private hospitals, which made them feel more empowered:

‘By your third year you are given greater responsibility, now you have do something and that makes it more enjoyable.’

‘In the government you can’t take the initiative and do something yourself, because they will find fault with it.’ (Study participants)

Feelings of uncertainty
The participants reported feelings of uncertainty about how to handle some of the situations they were confronted with during their training. This was especially evident in their practical training where they described numerous unfamiliar situations that they did not know how to handle. They often felt that they were thrown in at the deep end and that they were expected to cope with situations that, realistically, they could manage only with time and more experience. They lacked a sense of competence in dealing effectively with the variety of stressful situations they were exposed to, which left them feeling overwhelmed and uncared for:

‘We didn’t know what to do. It was terrible.’

‘We just had no idea what to do and the nurse was carrying on so much that we literally and figuratively just ignored her.’

‘At the beginning we felt as though we had been thrown in at the deep end, and we can’t swim.’ (Study participants)

Feeling under pressure
Many of the participants reported that the emotional, time and academic pressures they had to contend with made them feel stressed and often unable to cope. These feelings were exacerbated by their practical-working hours and participation in first-year activities:

‘You are actually so tense because there are so many people around you and they expect that you already know how to do it when you get there.’ (Study participant)

It also seemed, however, that the participants devised ways of dealing with their stress. They realised, for example, that they had to plan and prioritise, which made it easier for them to handle the various pressures they were subjected to:

‘Some people do not allocate their time correctly enough and this becomes a problem, and they just feel like giving up, because I can’t take the pressure.’

‘Through that journey it was so hectic and all that, but it helped me manage my time, it helped me to work under a lot of pressure.’

‘Now it is a part of our lives, we are used to the work load, you don’t get the time to really be yourself . . . you have a headache and a stomach ache . . . but no one asks you how you are feeling.’ (Study participants)

The participants also reported that their third year was emotionally stressful for them:

‘The emotional stress was too much for us at that stage because we didn’t really know how to work with the cadavers or with people or patients dying.’

‘We didn’t know how to handle it.’ (Study participants)

Disillusionment with the nursing profession and training
The participants reported not knowing, and not prepared for what the nursing profession and the training entailed prior to their commencing the BCur degree course. The interviews with the participants revealed that their expectations did not correspond with the reality. Some of the participants said that they had consulted the internet about the course but could not find any clear outline of the course and the hours they would have to spend on practical work on top of the academic work load. Some of the participants were not aware that practical training was part of the first-year curriculum, and others expressed their disappointment when they discovered that they would neither be able to go home every second weekend nor for a portion of the university recess because of the compulsory practical-hours. The participants expected the profession to be one of caring and nurturing, but they found that the reality was a harsh environment where they had to abandon tenderness in order to manage the tough challenges that confronted them. They expressed themselves as follow:

‘I personally feel that no one prepared us and told us what the course really is about.’

‘The idea that a person has when you get to the hospital and you see the nurses, is very different from the way you experience it when you get there and work.’ (Study participants)

The participants also expressed their disappointment with the state of the hospitals, as well as the manner in which patients were treated in hospital:

‘None of us expected that shock of the dirty, gross place.’

‘The other day I wiped an alcohol swab on a patient’s arm it was brown.’ (Study participants)

When the participants reflected on their experiences, they compared their current level and status of training and expressed some relief in realising that some of their expectations about nursing had been confirmed. They realised then that they could indeed make a difference to patients’ lives, which was not their experience in their first year:

‘The picture you have in your mind (of nursing) you only get to see now.’

‘I had the satisfaction of the things I could do.’ (Study participants)

Dispositional optimism
Dispositional optimism refers to an attitude where positive outcomes are generally expected, a mind-set that has been linked to a range of positive psychological and emotional benefits (Gillham 2000:165). It seems as though the participants focused on the positive aspects of nursing rather than on the negative, which might have been difficult in their first year of training:

‘Yes, I also remember the negative, but I just focus on the positive.’

‘It doesn’t only concern the negative things because in every negative thing, there’s a positive thing that can be taken from it.’

‘I think you make it pleasant for yourself.’

‘During your first year, you only see the unpleasant. That’s why everyone quits.’ (Study participants)

Sense of purpose and deeper meaning
To have a purpose in life and to see a deeper meaning in life means to pursue worthwhile goals and to achieve a sense of fulfilment (Recker & Wong 1988:221). Mascaro, Rosen and Morey (2004:845) refer to meaning in life as the intentions that underlie behaviour, that is, the reasons for doing something. The participants described their experiences during their training with a sense of knowing they had an important contribution to make as nurses. They conveyed the realisation that they had a specific role to fulfil regardless of their own personal challenges:

‘God is the light in our lives because He leads us to do His will in the hospital.’

‘I want at the end of it, when I’m 75 or 80 to stand in front of God and say: “With all that You have given me, I have not kept for myself. I have given all that I could to the people to the best of my ability, in the service of men.”’

‘The knowledge of higher meaning for yourself that there is somebody, a bigger presence.’

‘Nursing is not just a job, it’s a love you have, for the work, the people and to help people.’

‘I see it as another challenge to prove to them that I am here for a reason.’

‘We are going to be touching lives on a minute by minute basis. In that we will be building lives.’

‘I want to make a difference.’ (Study participants)

Friendship
Friendship forms where two or more people are involved in a relationship that requires loyalty and trust, that involves close and frequent interaction and that is regarded as social support (Bukowski, Newcomb & Hartup 1996:2). Social support is the protective role that a friendship relationship can play in mitigating the effects of stress and in contributing to the psychological and physical health of an individual (Marsh 1992:62). Close personal relationships play a significant role in the lives of most people. The nursing students formed close personal relationships with one another and supported each other during their studies:

‘My one friend with whom I am studying, we help each another a lot.’

‘Everyone in our group is friends.’

‘Through death and pain and heartache we remain the support for one another.’

‘Your family may perhaps be far away, so your friends are your only support.’

‘It’s those bonds that we have created when we work together that are going to make us forever friends.’

‘We support each other, we motivate each other.’

‘You search for that special friend that accepts you the way you are.’

‘You have at least one friend that pulls you through en shares in your heartache and anger and frustration.’

‘An important thing that we are missing is that you have at least one friend that pulls you through.’ (Study participants)

Family
The participants reported that their family, and in particular their parents, supported and encouraged them. Many of the participants had to move away from their families and were unable to visit them regularly. They missed spending time with their families and placed a high value on staying in touch with their parents, particularly with their mothers:

‘So if I have a problem I can immediately go to my mom and ask her what to do. Then she will first tell me to calm down, because then I am usually worked up.’

‘My mom isn’t a nurse, but she still gives the best advice.’

‘I still miss home a lot . . . my parents are getting older . . . I miss their company . . . because I hardly speak to them anymore.’

‘So I e-mail my mom and we mxit and we talk to each other daily.’

‘’Especially my mom, she was the driving force that made me feel I keep going. (Study participants)

Lecturers
The participants reported that they were very close to their lecturers and that they could talk to them and discuss problems with them:

‘They are supportive and let’s say, helpful, if you have problems you can go and talk to them about it.’

‘Nice, because the lecturers know your name and your results, they know you intimately.’ (Study participants)

It seems however, that some lecturers became too involved with the participants. A number of the participants said that the lecturers and fellow nursing students gossiped about one another and that nothing remained confidential. Other participants believed that the lecturers did not always respect their personal space and did not always maintain their role as lecturers:

‘I know of lecturers who spread stories about us amongst one another.’

‘Sometimes it gets too personal in our faculty.’

‘Everyone knows everything about everyone and your personal things are never your . . . if you are grumpy today, everyone wants to know why.’ (Study participants)

Challenging working environment
The environment that the participants were exposed to during training could be described as challenging because of a lack of equipment, or equipment that did not function properly. The participants mentioned instances where they could not assist patients because of the inadequate resources available to them. They also felt that some of the patients could have been saved had the appropriate resources been available.

In the following extract, a student describes a situation where she did not receive assistance from any of the nurses on duty because of staff shortages and consequently had no alternative, except to do her best for the particular patient:

‘I remember in ward eight, there was a patient that needed oxygen, but there wasn’t any at her bed so I had to run down the hall looking for oxygen for the patient. The emergency trolley wasn’t ready so I had to run to get the stuff. We had to call the doctor to come and shock her with those things, but there weren’t any in the ward. Who knows, maybe she would have survived if there were. By the time I had everything and got back to her room, she was already dead.’ (Study participant)

Other extracts relate a similar story:

‘He [the patient] fell out of his bed because he was confused. The nurse was told that he was confused and she was meant to put the sides of his bed up so that he wouldn’t fall off. But there weren’t any, she should have rather put him on the floor then he wouldn’t fall.’ (Study participant)

Another participant added:

‘Later she was on the phone with the doctor. She told him: Doctor I am a student and there’s no one else here to help me, you’ll have to tell me what to do over the phone, we can’t just leave the patient like this.’ (Study participant)

Lack of role models in clinical practice
A role model is someone who knowingly or unknowingly acts as a person whose behaviour is emulated by someone else. Role models hold certain positions in the nursing system, but the participants reported that their role models did not always act in a way that was consistent with their supervisory role (Searle & Pera 1995:198). Although nurse role models are meant to motivate student nurses in a clinical setting (Chabeli 1999:27), the participants often did not regard the nurses in a positive light (Searle & Pera 1995:253). Some of the participants cited instances where the nurses who were meant to guide them did not follow the correct procedures but merely tried to complete the work as opposed to carrying it out thoroughly:

‘You get staff that are [sic] just not interested in teaching you anything.’

‘They refuse to help you from first year to fourth year.’

‘In the government hospital there is no support. There is nothing. You feel like if you go to the hospital today, what is going to happen today, will I make it.’ (Study participants)

These participants felt ill equipped to deal with the challenges of the harsh training environment:

‘I remember STUDENT X and I looking at each other and we really want to help the man, but we don’t know what to do and she [nurse] just kept screaming about things that had no relevance to the situation.’ (Study participant)

Many of the participants said that the nurses had become hard and had somehow lost their compassion and their ‘heart’ for nursing. Exposure to such attitudes had a negative effect on the participants’ vision of becoming nurses:

‘Our first cadaver, they just left, they didn’t even pack him. He died eight o’clock that morning and no-one packed him until seven o’clock that evening.’

‘The staff working there no longer have [sic] the love for it that they had at the beginning. The patients are just another person [sic] to them.’

‘At that stage I thought it was okay and everything, but it feels as though I have to become tough on the inside in order to study nursing.’ (Study participants)

Incongruence between theoretical and practical training
The participants reported that clinical situations did not always match the descriptions in their textbooks. The real-life situations that nurses and nursing students encounter cannot always be resolved or explained through the linear application of theories but rather involve more complex processes that require juggling demands, intuitional experience and knowledge (Kim 1999:1206). The lecturers do not accompany the participants during practical training, and consequently they cannot act as role models and mentors for the participants during practical work. As a result there is incongruence between the theoretical training and the actual procedures that participants are told to follow in the practical training:

‘I also know that our text books say one thing and what happens in practice is a totally different thing.’

‘It is really like that because on the one hand you have what the books say and on the other hand you have what happens in the hospital.’ (Study participants)

The participants also expressed a need for help from the lecturers on how to deal with the gap between their training and the actual nursing practice:

‘The lecturers are only in the classroom and teach us there. But in practise there is no one to teach and help us. We actually want them there.’ (Study participants)

The students reported high levels of stress and anxiety during their training and described feelings of pressure because of the long hours and heavy workloads. Similar findings are reported by Jones and Johnston (1997:480) as well as by Evans and Kelly (2004:479). The cumulative effect of these new experiences might have affected the adaptive resources of the students and left them overwhelmed and disempowered. The loss of control and the pressure the nursing students experienced, especially during their first year, might have impacted on their self-efficacy and made them particularly vulnerable to stressor events (Dolan 2007:105). Self-efficacy is closely linked to the belief that one is able to achieve a difficult task and also acts as a buffer against the negative impact of stressors (Sivanathan, Arnold, Turner & Barling 2004:2). The students reported their loss of control and the high demands made on them especially during the initial stages of the training.

Despite the pressures the nursing students mentioned, many of them maintained a positive attitude and retained the desire to become nurses. The choice to view situations positively, and consequently experience more positive emotions over time, can improve a person’s psychological resilience and personal well-being (Csikszentmihalyi & Csikszentmihalyi 2006:95; Huppert, Baylis & Keverne 2005:230). Students with a positive disposition will be more inclined to transform seemingly negative external events into something meaningful, regardless of the current negative impact (Cooper, Duggleby & Penz 2009:2381). There is evidence that an optimistic attitude and problem-solving behaviour helps nursing students to deal with stress more effectively (Sheu, Lin & Hwang 2002:174).

The majority of nursing students in their first year reported that the nursing science course did not fulfil their expectations of nursing as a profession. Similar results are mentioned by Wright (2005:67) and, according to Montmarquette, Mahseredjian and Houle (2001:479), students may drop out if they become disillusioned with their career choice. The students in the study started out with a desire to help people or to work in a medical field, but apart from this, they did not have any real idea of what would be expected of them as nursing students and ultimately as nurses. The students expressed disappointment at choosing a study direction they experienced as being different to what they had expected. Although this sentiment usually changed during the students’ progression in their studies, it is a factor that requires attention.

Many of the students expressed the hope that they would make a contribution as nurses, which kept them focused on achieving their goal. Hope and optimism are typical amongst individuals who have identified a purpose in their lives (Bronk et al. 2009:506). According to Lopez and Snyder (2002:610), a sense of purpose involves the intention to achieve a goal that has personal significance as well as a positive impact that is external to the self. The nursing students in this study expressed a desire to care for sick patients and to make a contribution. Identifying their own purpose might thus have contributed to their ability to persevere in the achievement of their goals (Corey 2008:100).

Relational well-being includes support from friends, family members and lecturers. The students’ reports indicated that the relationships they developed during the course of their training as well as the relationships with their families were important sources of comfort and encouragement. The social support the students experienced contributed to their ability to cope with stress which is supported in literature (Pierce 1997:141; Hobfoll 1986:233; Fink 2000:481). The findings also indicated that the students’ social support had a beneficial effect on their psychological well-being (Huppert et al. 2005:509). The communal sense experienced by the nursing students contributed to their feelings of membership, the fulfilment of their needs and shared emotional connection, factors that have been found to contribute to personal coping ability and overall health (Farrell, Aubty & Coulombe 2004:21). This is consistent with the findings of Manning et al. (2009:170) as well as Roberts (2009:370).

Collective well-being seemed to be challenged the most and the nursing students were outspoken about the unhealthy broader context in which they had to function. In terms of the behaviour-setting theory of Barker (1968:137), nursing students who enter new settings in their first year have to adapt without knowing exactly what is expected of them. According to this theory, a social setting is a well-defined spatial area, a boundary zone, and when it is entered it causes people to change or adapt their behaviour in a more or less conscious way (Barker & Schoggen 1973:49). The nursing environment, which includes the nurses in the clinics and hospitals as well as the lecturers and fellow students, affects students in different ways.

The staff shortages and the conditions in hospitals lead to a situation where nurses are exhausted, frustrated and stressed. These nurses now have the added pressure of creating a positive image of nursing for the students they have to train. As a consequence of the current state of nursing in South Africa, professional nurses may appear to have a negative attitude that first-year nursing students interpret as lack of consideration toward patients. They may conclude that nurses no longer have a passion for nursing because of their failure to do their work thoroughly in hospitals. Oermann (1998:197) and Thomas and Hume (1998:41) argue that unsupportive staff and the failure to provide students with support are stressors for the students.

The practical component of nurses’ training is a vital part of students’ training. Their first contact with practical training comes as a surprise, and the environment they have to work in may not be what they expected. What they deal with and experience at the outset of their training is to a large extent a reflection of the nursing profession in general, namely strenuous workloads, high stress levels, poor working conditions, low autonomy and limited free time. Shortages of staff and equipment are also mentioned by Makupu and Botha (2000:14) who state that the lack of equipment and poor working conditions make it difficult for student nurses to achieve meaningful learning.

Students experience confusion when a discrepancy exists between what is taught to them in their academic training and what is actually experienced in the clinical environment (Carlson, Kotze & Van Rooyen 2003:36). This theory-practice gap is a source of stress for many students, which may contribute to the emotions nursing students often describe as exhaustion and pressure (Lindop 1999:971). The findings of the present study mirror those of a study conducted at the University of Port Elizabeth, namely that factors that contribute to student anxiety are shortages or the absence of equipment needed to fulfil nursing duties as well as the unavailability of support from experienced nurses because of time constraints (Carlson, Kotze & Van Rooyen 2003:30).

Prospective nursing students should spend some time in a clinical environment to see first-hand what nursing involves and to expose them to the conditions they will be expected to train and work in, once they are registered nurses.

The course should be re-scheduled to allow students more time to practise crucial skills before applying them in the practical environment. With more time allocated for simulation of clinical tasks, students should be able to accomplish more tasks at an earlier stage during their practical training, and they should be exposed to different aspects of nursing from early on in the course.

Senior and first-year students should be allocated to the same wards for shift work. The presence of more experienced nursing students will make the practical training less stressful for the less experienced students.

Nursing students have to undergo 4000 hours of clinical training during their studies. Granting them more freedom to decide on their own study times may improve their levels of autonomy and self-determination. If students were allowed to work the hours they preferred, they might work extra hours during the semester so that they could go home during the holidays and spend time with their families who are a valuable support system for them.

Most students enter the world of nursing when they are very young and inexperienced, and they are exposed to difficult situations and a high-stress environment. Teaching students stress management techniques as part of the course may help them to cope with the pressures and demands they are exposed to. Weekly group sessions, where students can share experiences outside the classroom environment, may also be beneficial to the students. Such sessions could even be incorporated into the more senior students’ timetable so that all nursing students could become acquainted in a relaxed setting and the younger students could receive on-going guidance from the more senior students.

An intern psychologist should be available to students for counselling. Students should not have to consult with their lecturers or arrange counselling via them.

The nurses in charge of supervision during clinical training often make students feel uncomfortable and unwelcome. These nurses are going to be responsible for the practical training of the students and consequently they should be alerted to their influence on the students as well as the nurturing needed by the newcomers. Nurses involved in training should be encouraged to be positive in their interactions with the students, to build the students’ self-esteem and to reinforce the value of nurses in hospitals.

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