A SURVEY INTO THE SATISFACTION OF NURSING STUDENTS WITH THEIR PRACTICAL TRAINING

The training nursing students in the Republic of Bulgaria confirms with the contemporary European requirements. The training is theoretical and practical, with the practical training accounting for at least 50% of the total number of hours in the specialty. The practical training includes clinical practice and pre-graduation traineeship, which complies with the Ordinance on the Unified state requirements regarding the training of nurses. The clinical practice and the pre-graduation traineeship involve a total duration of 2740 hours for students majoring in Nursing (Ordinance on the Unified state requirements). The level of satisfaction of these nursing students is an important indicator of the quality of the practical training. The study involved a sociological method of direct group survey involving an original set of questions with one developed specifically for this survey and others adapted from the questionnaire on job satisfaction of the Institute of Psychology at the Bulgarian Academy of Sciences. This questionnaire on satisfaction comprises 36 statements with three subscales: 1) work organization or organization of the practical training; 2) social-psychological conditions; and 3) material. The approach uses a Likert-type scale from 1 to 4 (1 = “no”, 2 = “to a certain extent”, 3= “very much”, and 4 = “extremely”) to score responses. The opinion of 280 fourth-year nursing students from three universities: the Medical University of Plovdiv, Trakia University of Stara Zagora, and ‘Prof. Dr. Asen Zlatarov’ University of Burgas, is surveyed. The analysis of the results from the conducted empirical survey shows that in their professional activity the surveyed students are primarily motivated by love and care for people (78.8%) followed by the desire to perform an activity that is beneficial to society (63.3%). Then follows the respect on behalf of patients, the team, and society as a whole (52.5%) and subsequently, the emotional attractiveness of the work reflected in the desire to do work that brings pleasure and joy (job satisfaction; 42.4%). The level of student satisfaction with their practical training depends on the organizational-educational, social-psychological, and material and technical conditions of the hospital environment. The analysis of the survey data confirms the significant role of practical training for the professional qualification of these nursing students. However, certain negative trends are also identified. These trends are connected with the satisfaction of the students concerning the procedures they have the opportunity to perform, their relationships with their mentors and medical teams, and that at times they are required to perform inappropriate activities. This calls for increased control on behalf of the tutors. UDC Classification: 378; DOI: http://dx.doi.org/10.12955/cbup.v5.989


Introduction
The mission of the university level of medical education is to provide students with professional training that not only satisfies the social needs and those of the labor market but also meets student expectations concerning their professional careers and personal development.This mission is the main aim of education and training of nursing students: to prepare specialists who have mastered knowledge and skills, personal qualities, and professional competencies, necessary for providing quality health care.
The training of nursing students in the Republic of Bulgaria conforms with the contemporary European requirements.It is conducted at universities and colleges accredited under the Higher Education Act of Bulgaria.After the accession of Bulgaria to the European Union, significant changes have taken place in the training of nurses.In accordance with the unified state requirements, the required number of academic hours of education and training for nurses is 4600, and the duration of the program is four years (eight semesters) full-time (Ordinance on the Unified state requirements for completing higher education in Nursing and Midwifery and earning a Bachelor's degree, 2010).The training is theoretical and practical, with practical training accounting for at least 50% of the total hours for the academic major.The practical training includes clinical practice and pre-graduation traineeship, which complies with the ordinance under the unified state requirements regarding the training of nurses.The clinical practice and the pre-graduation traineeship are with a total duration of 2740 hours for students majoring in Nursing Students do practical clinical training from the first semester through to the sixth, and the duration of this training is at least 1140 academic hours.Pre-graduation traineeships are taken in the seventh and eighth semesters, and their duration involves at least 1600 hours.Thus, young specialists are provided with the opportunity to master the needed professional skills and competencies in a real-life hospital environment.Pre-graduation traineeships provide students with a practical basis of specialized knowledge in various areas of nursing (Ordinance on the Unified state requirements for completing higher education in Nursing and Midwifery and earning a Bachelor's degree, 2010).The practical training is conducted at hospitals and outpatient centers, social centers, and institutions approved and accredited to train students, and staffed by highly qualified professionals.Students work under the supervision of a tutor, mentor, or both.According to Andonova (2013, p. 22): "For mentoring to be efficient, it should be based on constructive partnership so that each trainee could be encouraged and assisted to realize their full potential."It is during their practical training that the theoretical knowledge, mastered by students, is transformed into skills and competencies, values, and respective qualities, which are expressed in their conduct.The involvement of future registered nurses in various types of activities and manipulations during their training in providing high-quality health care to patients facilitates the development of professional awareness and moral values and forms skills and abilities that demonstrate their developed qualities and competencies.On the other hand, this allows students to become aware that they belong to a social group of nurses and they adapt to the job more easily.The level of satisfaction of nursing students is an important indicator of their assessment regarding the quality of the practical training.The expression of satisfaction is a subjective way of assessing the training environment.This involves the conditions of work in the respective hospitals and clinics, the organization of the practical training, and the interrelationships in the medical team.Student satisfaction can also be regarded as an expression of personal well-being and not only as satisfaction with the conditions in which they perform the medical activities (Petkova, 2003, p. 192).The aim of this study is to survey and analyze the satisfaction of nursing students regarding the way in which their practical training is organized and conducted, as a factor in forming their professional competencies.

Data and Methodology
The survey was conducted in two consecutive academic years, 2014-2015 and 2015-2016.The respondents were 283 nursing students who were voluntary participants from three universities: Medical University of Plovdiv, Trakia University of Stara Zagora, and 'Prof.Dr. Asen Zlatarov' University of Burgas.The respondents had completed the full course of training, and at the time of the survey were in their pre-graduation traineeship, which was considered a prerequisite for obtaining objective responses for the assessment of practical training.The structure of the research tools corresponded to the overall concept of the study.A sociological method of direct group survey was used to collect the initial statistical information.A survey card was developed for the study.This survey card included an original set of questions developed for this survey with some questions adapted from a questionnaire on job satisfaction from the Institute of Psychology at the Bulgarian Academy of Sciences.The questionnaire of this current study comprised 36 statements in total, with three subscales: 1) work organization or organization of the practical training, 2) social-psychological conditions, and 3) material.A Likert-type scale from one to four (1 = "no," 2 = "to a certain extent," 3 = "very much," and 4 = "extremely") was used to score the responses.Pearson correlations were used to identify relationships in the data.The empirical data was statistically analyzed using the software package for statistical analysis in the field of social sciences (SPSS).

Results and Discussion
The analysis of the results showed that most of the respondents (81.6%) were in the 20-25 year age range.Of the respondents, 95.4% were females and only 4.6% were males.The nursing profession has traditionally been dominated by females, although in the past few years there has been a trend towards an increase in the number of males opting for this profession in Bulgaria.
The significance of motivation in the medical profession is directly connected with the quality of the care provided and the level of job satisfaction.The motivation for a professional career stems from internal personal reasons, mostly conscious ones that ensure students strive after gaining knowledge and mastering skills and working habits necessary for the job.The analysis of the results from the conducted empirical survey showed that in their professional activity, the surveyed students are primarily motivated by love and care for people (78.8%); the desire to perform an activity that is beneficial to society (63.3%); the respect on behalf of patients and the team and society as a whole (52.5%); the emotional attractiveness of the work reflected in the desire to do work that brings pleasure and joy (job satisfaction; 42.4%), with the sum total of the results exceeding 100%, since respondents could give more than one answer.The level of student satisfaction with their practical training depends on the organizationaleducational, social-psychological, and the material and technical conditions in the hospital environment.The ranking of the motives in this study shows that the respondents were strongly driven by humane reasons in choosing their career.The analysis of the results according to the first subscale regarding the organization of the practical training clearly shows that students highly appreciated the need for high-level knowledge (Xav = 3.24) and they were satisfied to a great extent (r = 0.69).In the education of nursing students, theoretical training serves as a basis for acquiring practical skills and competencies.The results show that 76.6% of the surveyed students considered their theoretical training sufficient for the subsequent practical training, 10.5% were not satisfied with the training, and 12.9% were undecided.Students were aware that the knowledge they had mastered was a solid foundation for acquiring practical skills.The satisfaction of the surveyed students with the quality of tutorials, clinical practice, and pregraduation traineeship is a significant factor for the professional development of future registered nurses.The results from the distribution of their answers to the components of this question according to the four-level scale are presented as mean values (Table 1).The respondents expressed the highest level of satisfaction with the quality of the tutorials followed by practical clinical training and then the pre-graduation traineeship.The difference between the perceived quality of the tutorials (Xav = 3.62) and that of the pre-graduation traineeship (Хav = 3.12), at р =0.00, was statistically significant.Therefore, students had the greatest satisfaction with the quality of the tutorials and were less satisfied with the quality of the clinical practical training and the pregraduation traineeship.
During their tutorials (practical exercises) students acquire practical skills and master their nursing obligations to a high standard.First, they practice respective manipulations on medical simulation mannequins in special rooms, and then on patients in their clinical practice.It is the practical applicability of the knowledge and skills they acquire during their tutorials that possibly account for the satisfaction of the students from the type of training they receive.
The lower level of satisfaction of the students with their clinical practical training is most probably associated with their anxiety and uncertainty when applying the acquired skills in an actual hospital setting.It might be because some rules are ignored in the course of performing nursing activities, some patients refusing to allow students to perform the prescribed procedures and manipulations, a high number of students in the training, or the shortage of personal protective equipment and other consumables in the university hospitals and clinics.These reasons predetermine the second and third position of practical training forms in the opinion of the students.According to the students (Хav = 2.19), their practical training poses a threat to their health (Figure 1), being held in an actual hospital setting.In hospitals, students confront suffering and death and the experience of patients and their families, and this possibly places additional pressure on them.The greater the threat to their health seemingly corresponds to a lower level of satisfaction with their training (r = 0.48).The level of student satisfaction regarding the statement "I will choose a better-paid job" was relatively high (Figure 1).Their training appears to play a significant role in contributing to the successful professional career and prospects of a better-paid job of those surveyed (Хav = 2.66).This rationale results in an increased level of satisfaction with the practical training because it is seen that they acquire useful practical skills that endow them with higher competitiveness and employability (r = 0.74).
One of the most important activities of practical training is the mastering of procedures and manipulations to that of the highest level, where the manipulations become automatic.This requires numerous drills and performing certain manipulations many times though creates the impression of monotony for the students (Хav = 1.91; Figure 1).There is a moderately expressed dependence between student satisfaction and the monotony of the performed activities (r = 0.56).In this regard, tutors and mentors could involve students in various types of activities on a daily basis during their The survey showed that the majority of students were satisfied with the number of manipulations as a set requirement in the different sectors (81.5%), while 8.0% stated "no", and 10.5% answered "cannot decide".Notably, only 72.7% of the trainees coped with the required manipulations, while approximately 27.3% could not.The reasons they quoted varied from the lack of patients on whom to perform certain manipulations or activities, an unwillingness on behalf of the medical staff to include them in administering manipulations, to fear and uncertainty on behalf of the students.This result is somewhat alarming and calls for optimizing the organization of work of students and mentors in the respective units.
The results show that 72.8% of the respondents felt most confident when administering intramuscular injections and over half, 59%, felt the same when administering intravenous infusions (students were allowed to provide more than one answer).The lower percentage of students feeling confident when performing intravenous manipulations -41%, and infusions (55.1%) is a signal to tutors that as early as during their tutorials, students should be encouraged and motivated to overcome their fear from these manipulations (Table 2).In the clinical training in the actual hospital environment, the future registered nurses expressed keen interest to master the functional activities and are models of professional conduct and decisionmaking.In the training of nurses, the main focus is on the patients and their families.The respondents stated they had the opportunity to make decisions independently (Хav = 3.00; Figure 2), which they found satisfying to a great extent (r = 0.74).The analysis in regard to the second subscale investigated the satisfaction of the students with the material and technical conditions (facilities) in the university hospitals and clinics where they performed their practical training.
During their practical training on clinical matters and their pre-graduation traineeship, in particular, students develop and master professional skills and competencies needed for their future independent work.The opinion of the respondents on the level of their satisfaction with the opportunities and working conditions provided by hospitals and clinics for their practical training can be classified as follows: 48.16% of the surveyed students were fully satisfied, 41.84% were partially satisfied, 7.35% were unable to decide, and 3.14% were dissatisfied.Notably, the level of dissatisfaction was especially low, yet, almost half of the respondents were "partially satisfied" and demonstrated a critical attitude.This may be due to the lengthy duration of the pre-graduation traineeship, held in certain medical establishments that lack the dynamics of medical practice, contrary to what students would prefer, as well as students not being allowed to practice for longer at hospitals and clinics of their choice.Approximately 11% of the surveyed students were unable to decide or were dissatisfied with the working conditions at the university hospitals and clinics where they performed their practical training.Probably the difficulties encountered in the performance of their nursing tasks in a real-life hospital environment are connected with organizational problems relating to medical supplies and consumables, and that most university hospitals are outdated and not well maintained, resulting in poorer living conditions for the patients in some units.This situation, along with organizing work, possibly constitute the main reasons for the lower level of student satisfaction with the facilities where they perform their practical training (Хav = 2.62; Figure 2).There is a clearly expressed dependence between good working conditions and a high level of student satisfaction with their practical training (r = 0.80).
In the analysis of the third subscale, student satisfaction with the social and psychological conditions was investigated.The social and psychological environment finds its expression in interpersonal relationships.A supportive educational environment is characterized by a positive and creative atmosphere of trust and partnership among the participants in the process of training, and among the students themselves; support motivation, and active involvement of the students in the process of practical training.The job of the nurse is likely to be an emotionally tinged.The encounters with human pain, suffering, and problems underpin this profession and coincide with the shortage of funds for their profession.
Possibly, the future nurses, facing human suffering on a daily basis cannot but feel a certain disappointment with their choice of a career.At the end of their training, however, they also discover the other side of their profession.They appreciate patients' gratitude for their work and care, the process of recuperation and recovery, and the satisfaction with their valuable work and hence influence the statement that practical training "is of great importance for my improvement as a professional" (Хav = 3.26; Figure 2).There is a significant correlation, that is, the better students become in their profession, the higher is their level of their satisfaction with practical training (r = 0.62).The results of the survey show that 69.0% of the respondents were exceptionally satisfied with the atmosphere in their team or working group (r = 0.85).This was directly connected with the opportunity for students to practice (r = 0.74) and develop their skills and abilities (r = 0.72).The Pearson correlations were strongly expressed.The better the psychological atmosphere in a group of students of the medical team, the higher the level of satisfaction of the respondents.In the process of their practical training, students master the skill to communicate with patients and their families, as well as with the medical team; they adopt models of professional conduct.Hence, the members of the medical teams are of great importance as role models.
The mentor plays a key role in the practical training of nurses.The majority of the surveyed students, 81.5%, were satisfied with the assistance they received from their mentors.It is the mentors who exercise direct control and supervision of the activities of the nursing students in the respective unit.
According to most students, their mentor acknowledges their achievements (Хav = 3.24) in coping well with the assigned tasks and consider their opinion (Хср = 3.00).The analysis of the results showed significant correlations, r = 0.63 and r = 0.85, respectively, in these areas.The friendlier and more supportive is the attitude of the mentor, the more satisfied are the students.The answers to the other question concerning their satisfaction with the assistance they received from the medical staff were similar.Some surveyed students (25%) were dissatisfied with the attitude of the medical staff in the university, hospitals, and clinics.They attributed this attitude to the lack of time and unwillingness of mentors to communicate and provide students with independent activities.The attitude of the staff in the university hospitals and clinics affected the level of student satisfaction.Improving the connection between tutors and their colleagues in the university hospitals and clinics along with resolving the need for control in the practical training may help overcome negative trends in communication.

Conclusion
The conducted survey established the organizational, educational, technical, and social-psychological conditions for optimizing practical training in the context of student satisfaction.The analysis of the collected data confirmed the significant role of practical training for the professional development of students majoring in Nursing.Certain negative trends were also identified, mostly connected with student satisfaction with the manipulations they access, their relationships with mentors and medical staff, and that sometimes students have to perform unusual activities.All these trends call for greater control on behalf of tutors.

Figure 1 :
Figure 1: Satisfaction with the organization of the practical training

Figure 2 :
Figure 2: Satisfaction with the social and psychological conditions

Table 1 :
Satisfaction with the quality of practical training

Table 2 :
Confidence in performing manipulations