Building Nursing Students’ Confidence through the Integration of Night-Shift Clinical

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Te Impact of Night Clinical Rotations on Nursing Student
Satisfaction and Confdence.Te study examines students' perceptions of satisfaction and confdence after participating in night clinical rotations to explore the practicality of placing students in clinical during this shift.Te satisfaction and confdence will be compared between the students completing the day shift and the students completing nightshift clinical rotations.Te aim of the study was to determine if there was a statistically signifcant diference in student confdence and satisfaction when replacing a traditional dayshift clinical experience with a night-shift clinical experience.Tis study was completed as a result of shortages in clinical space, feedback from clinical partners, and night nurses expressing an interest in teaching without impacting their own scheduled nursing shifts.Tere has been little opportunity for night nurses to teach students until recent years, and there is a lack of knowledge regarding the impact of this type of clinical experience.

Literature Review
Te current global nursing shortage is expected to intensify and persist well into 2030 [1].Nursing programs have struggled to increase their capacity to meet the demand for registered nurses in the workforce.Tousands of qualifed students are turned away from nursing programs each year.One commonly identifed reason is the lack of clinical sites [1].Most healthcare institutions have multiple nursing programs competing for clinical placements at their facilities.Competition for clinical placements and saturation of clinical students on the nursing units, combined with the stafng shortage contributes to staf nurse fatigue and burnout.Tis may lead to a lower-quality clinical experience for nursing students [2].High-quality clinical experiences are integral to nursing education.Te clinical setting provides students with opportunities to apply theory to practice, gain experience with nursing roles and skills, and become socialized in healthcare [3].Quality clinical placements are needed to prepare future nurses for practice in today's healthcare environment and to meet the demand for more nurses in the workforce.
Few nursing programs incorporate night-shift clinical rotations in their clinical education.Tis may be due to the lack of research on the efectiveness of night-shift clinical.However, Leighton et al. [4] found in their systematic review that the efectiveness of the traditional clinical model used in nursing education programs for years has never been proven.Clearly, now is the time for innovation in the clinical setting.Nursing programs must look at new models of clinical education to increase the number of clinical placements for nursing students without impacting the quality of the clinical experience.
Te literature on night-shift clinical practice is limited and has generated varied results.Students typically prefer day-shift clinical over night-shift clinical [5,6].Boredom and wasted time are commonly reported themes for students during night-shift clinical [5][6][7].Students also commonly report challenges related to fatigue and interruption of sleep patterns as a result of the night-shift clinical, which can impact concentration and focus [6,8].Some studies have shown that students tend to experience negative or unwelcoming attitudes from the staf on the night shift [7,8], while others have reported positive experiences with the night-shift staf [9].Spending time on non-nursing tasks is another challenge commonly reported by students experiencing night-shift clinical, leaving some students feeling "exploited" by the staf [6][7][8].
A number of benefts of night-shift clinical have also been identifed.Because there is generally more time free of commitments on the night shift, there is more time for students to ask questions and engage in discussion with the nursing staf, which enhances learning as well as socialization to the profession [7][8][9].Te slower pace of the night shift on some units also provides students with more time to practice technical skills, gain competence, promote safety, and participate in risk reduction [6].Students also gain experience with managing patient problems that they may not be involved in on the day shift such as disorientation, insomnia, and falls [5].Because fewer resources and staf are available on the night shift, nurses often manage problems autonomously.Tis benefts the students by enhancing their critical thinking and clinical judgment skills and fostering independence [6,7].
Te question of whether the benefts of night-shift clinical work outweigh the challenges still exists.While student satisfaction with night clinical has been reported as lower than day-shift clinical, the diference is not statistically signifcant [6].Te literature suggests that night-shift clinical work should not be routine or primary placements but rather be ofered as a viable alternative to day-shift clinical rotations.Further, the literature supports night-shift clinical as an efective and valuable learning opportunity when the clinical is well planned and executed [5][6][7][8][9].Te purpose of this study is to determine if there is an impact on student confdence and satisfaction between traditional day clinical rotations and night-shift clinical rotations.

Study Design
Tis study was a comparative quasiexperimental study utilizing a convenience sample of nursing students in an undergraduate accelerated baccalaureate nursing program.Approval was obtained from the University Institutional Review Board before the data collection.Te inclusion criteria were participation in medical-surgical courses during the Spring, Summer, and Fall semesters.In addition, students scheduled for the day and night shifts in clinical rotations at hospitals in a designated system during the three 2021 semesters were invited to participate.Exclusion criteria were students in other courses at facilities other than the organization that was included in the study.
Permission was obtained from the National League for Nursing (NLN) to use a modifed version of the NLN Student Satisfaction and Self-Confdence in Learning tool [10].Te tools were tested for reliability with Cronbach's alpha for the satisfaction tool, which was 0.94, and for selfconfdence, it was 0.87 [11].Te original survey was part of a national, multisite, and multimethod research project sponsored by the NLN and Laerdal Medical [11].Two of the research questions sought to determine if there was a difference in student satisfaction and self-confdence between students participating in simulations involving high fdelity and a paper pencil case study [11].
Te study separated the students' satisfaction and selfconfdence in learning [11].Te frst tool examined student satisfaction in learning and included fve items that measured student satisfaction related to the simulation students participated in.Te second tool was an eight-item instrument that looked at student confdence levels related to the care provided in the simulation.Te current tool is a combination of the two (National League of Nursing, 2006).Te tool used a Likert scale that included fve options, with 1 � strongly disagree and 5 � strongly agree [10].
In this study, the tool was modifed from the original tool which examined satisfaction and confdence with simulation.Te modifcation was made to determine if there was a statistically signifcant diference in satisfaction and confdence between students who participated in clinical during the day, seven am to seven pm, and students who participated in clinical at night, seven pm to seven am. Te modifed tool included four questions related to satisfaction and eight to examine confdence.Students received an email with a link to an anonymous Google form after completing their medical-surgical clinical rotation.In addition to the 12 questions, students were asked to identify their hospital, unit, shift, and semester to ensure inclusion and exclusion criteria were met.
One of the clinical partners identifed medical-surgical units at three nonmagnet hospitals within the organization.Te three hospitals ranged from 599 to 1300 beds.

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Nursing Forum Permission from the unit managers was obtained to place a 12-hour night-shift clinical group and 12-hour day-shift clinical group on one unit at each hospital.Faculty was recruited for the night-shift clinical rotations who had a current Master's degree or were close to completion.Since students had not been notifed about the possibility of nightshift clinical before admission, they could select day-or night-shift clinical.Groups consisted of no more than 6 students with one instructor.Faculty collaborated with the program director and clinical coordinator to ensure the students did not have exams or lab in the days before or after the nigh-shift clinical so students had adequate sleep and time to adjust their circadian rhythms.No incentive, money, cost, or compensation was provided for participating.Tere were also no penalties for students completing or not completing the survey.A total of 12 questions were included in the survey.Four of the questions looked at student satisfaction and eight measured confdence.Of the four questions related to satisfaction, there was no statistical diference any of the questions between the day and night clinical students.Tese questions included the following: the teaching methods used in this clinical were helpful and efective, and the clinical provided me with a variety of experiences to promote my learning.Te last two questions were as follows: my clinical experiences were motivating and helped me to learn and I enjoyed how my instructor taught the clinical.

IBM
Confdence was measured in the remaining eight questions.Te questions included the following: overall my confdence has increased as a result of this clinical experience, I am confdent that I am mastering the objectives of the clinical experience, and I am confdent that this clinical reinforced the critical content necessary for the mastery of the course objectives.Te next few were as follows: I am confdent that I am developing the skills and obtaining the required knowledge from this clinical to perform necessary tasks in a clinical, I am confdent in my ability to collaborate with members of the interprofessional healthcare team, and I am accountable for my own learning in my clinical experience.Te following two were as follows: I am comfortable seeking assistance when I need to in the clinical setting, and I know how to use available resources to safely perform nursing skills.
In addition to evaluating the mean and standard deviation for all of the questions (see Table 1), an independent t-test was done to determine if there were statistical differences in the questions between the two groups, the day and night clinical groups.Levene's test for equality of variances indicated that there was no statistical diference between groups in any of the questions.For the question, "I am confdent that I am mastering the objectives of the clinical experience," the day clinical group had lower means related to confdence (m � 4.36, SD � 1.217) than the night clinical group (m � 4.82, SD � 0.393).Te signifcance was 0.054, greater than 0.05, indicating there was not a signifcant diference between the groups [12].

Discussion
Based on the fndings of this research study, satisfaction between the day-and night-shift clinical groups was the same.Tis is consistent with the fndings of the other studies that found no statistical signifcance in satisfaction between groups [6].Downtime during night clinical or the busy atmosphere on days are factors identifed that may impact satisfaction.Downtime during night clinical was perceived negatively by some students, others identifed it as an opportunity to look things up and enhance their learning [6,9].Bahramirad et al. [7]; (Dobrowolska et al. 2019) had several themes that demonstrated decreased satisfaction with night clinical rotations.Many of these centered around lack of communication, poor communication, and bullying which lead to a lack of ability to new important tasks and being delegated simple tasks [7].Despite many diferences in patient problems, types of activities performed, and units identifed by Dobrowolska et al. (2019), satisfaction was identifed by students in night clinical at all fve countries.
Most of the questions related to confdence showed no statistically signifcant diference between students participating in day or night clinical rotations.Night-shift students did report having higher overall confdence during their clinical rotation.Tis is consistent with themes that emerged in the other studies having more time to perform tasks commonly delegated during the day shift, skills, patient care, patient education, and having more time to ask questions and explore the "why" behind challenging situations [6,9].Positive themes that may contribute to confdence identifed by Rad et al. [7] include increased autonomy, socialization, and learning how to manage time.Finally, having the ability to see the continuity of care and understand the role of the nurse also may contribute to this overall confdence (Dobrowolska et al. 2019).Dobrowolska et al. (2019) did have one theme that may impact both confdence and satisfaction that emerged, the workload of the nurses.Te heavy workload resulted in less interaction between the nurses and students, identifed as a positive impact of night clinical in other studies [6,9]; (Dobrowolska et al. 2019).
With many graduates starting on the night shift, developing this confdence may also ease the transition when they begin in practice.Having options may entice students who work night shift in their current positions, increasing admission.In addition, the opportunity to teach for nurses who prefer night shift opens up opportunities to attract faculty who may not want to work during the traditional Nursing Forum

Limitations and Recommendations
Limitations of this study included the small sample size since it was a convenience sample.In addition, it was over one year, in one program, at one academic site.Tis study also did not include demographic details such as age, marital status, having children and other family responsibilities, and experience working in the healthcare feld that may have allowed further understanding of the results.
Recommendations for future research include using larger cohorts, diferent types of programs, and clinical experiences in areas other than medical-surgical nursing.It is recommended that night-shift clinical be performed on units with patients and patient problems that align with the course objectives, be structured, have adequate stafng, and allow optimal patient care experiences for the students.Tese units should be carefully selected in collaboration with the facilities, faculty, directors, and clinical coordinators.Tey should include opportunities for patient care, assessments, medication administration, various interventions, and documentation.
Developing an orientation to the night-shift clinical rotation is another recommendation.Te orientation could guide students who select the night rotation and help acclimate them to changing times and circadian rhythms.Recruiting night-shift nurses to teach the night clinical rotations would also help the students learn from their instructors while in their rotation.
A follow-up study on perceptions of student confdence by the faculty instructors for both day and night clinical instruction and the nurses on the designated units would be interesting information to add to the body of knowledge using a modifed version of the same tool for comparison.Adding a qualitative component to the survey or focus groups would also add triangulation as a mixed-method study and enable themes to be identifed in the research to compare to prior qualitative studies.

Conclusion
Te use of night-shift clinical rotations in the medicalsurgical courses was found to have increased access and exposure for nursing students.Satisfaction was not impacted when comparing day-and night-shift clinical experiences.While night-shift clinical should not replace the experience of day-shift clinical, it has demonstrated the ability to increase confdence and exposure to care and situations students may not be able to participate in during the day-shift rotation.Tis also addresses the demand and competition for traditional day-shift clinical rotations, opens up opportunities for night-shift nurses to teach on a shift consistent with their work schedules, and enables an increase in enrolment by increasing the number of available clinical placements.
Careful consideration of the distance students traveling to the sites, course schedules, and other factors that may preclude the student from participating in night clinical rotations should be included when assigning night clinical rotations.Whenever possible, students should be provided the opportunity to experience the night shift, further reducing the stress on the day-shift nurses, providing nightshift nurses the ability to teach, and reducing the number of students on the units at one time.
SPSS version 29.0 was used to analyze the data.Tere were a total of 41 participants who completed the survey.Of these, 23 participated in a 12-hour day-shift medical-surgical clinical, and 17 participated in 12-hour night-shift medicalsurgical clinical.Students in semesters two and three each consisted of 31 percent, and senior students consisted of 38 percent of the respondents.Of those who participated, 40 percent attended medical-surgical clinical in the spring semester, 43 percent attended during the summer semester, and 17 percent of students attended clinical in the fall semester of 2021.

Table 1 :
Student satisfaction and confdence results.Te p value represents the signifcance of the diference between groups.A p value < 0.05 would demonstrate statistical signifcance.