*Article* **Individual Circadian Preference, Shift Work, and Risk of Medication Errors: A Cross-Sectional Web Survey among Italian Midwives**

**Rosaria Cappadona 1,2,3 , Emanuele Di Simone 4,5 , Alfredo De Giorgi <sup>5</sup> , Benedetta Boari <sup>5</sup> , Marco Di Muzio <sup>4</sup> , Pantaleo Greco 1,2, Roberto Manfredini 1,3,5 , María Aurora Rodríguez-Borrego 3,6, Fabio Fabbian 1,3,5,\* and Pablo Jesús López-Soto 3,6**


Received: 27 July 2020; Accepted: 7 August 2020; Published: 11 August 2020

**Abstract:** Background: In order to explore the possible association between chronotype and risk of medication errors and chronotype in Italian midwives, we conducted a web-based survey. The questionnaire comprised three main components: (1) demographic information, previous working experience, actual working schedule; (2) individual chronotype, either calculated by Morningness–Eveningness Questionnaire (MEQ); (3) self-perception of risk of medication error. Results: Midwives (*n* = 401) responded "yes, at least once" to the question dealing with self-perception of risk of medication error in 48.1% of cases. Cluster analysis showed that perception of risk of medication errors was associated with class of age 31–35 years, shift work schedule, working experience 6–10 years, and Intermediate-type MEQ score. Conclusions: Perception of the risk of medication errors is present in near one out of two midwives in Italy. In particular, younger midwives with lower working experience, engaged in shift work, and belonging to an Intermediate chronotype, seem to be at higher risk of potential medication error. Since early morning hours seem to represent highest risk frame for female healthcare workers, shift work is not always aligned with individual circadian preference. Assessment of chronotype could represent a method to identify healthcare personnel at higher risk of circadian disruption.

**Keywords:** circadian rhythm; chronotype; midwives; Morningness–Eveningness Questionnaire (MEQ); near misses; nurses; rhythms desynchronization; risk of medication errors; shift work; sleep

### **1. Introduction**

Chronobiology is a biomedical discipline devoted to the study of biological rhythms. Biological rhythms exist at any level of living organisms and, according to their cycle length, are classified into: (a) circadian rhythms (from the Latin circa-dies, characterized by a period of ~24 h), (b) ultradian rhythms (period <24 h), and c) infradian rhythms (period >24 h) [1]. Circadian rhythms are the most commonly and widely studied biological rhythms, but they are not strictly the same in all persons, since an

individual circadian preference (the so-called chronotype) closely linked to biological and psychological variables, exists. Horne & Ostberg first spoke of possible individual differences in circadian attitudes, the so-called chronotype [2]. By means of a simple a self-assessment Morningness–Eveningness Questionnaire (MEQ), they identified Morning-types (M-type, more active early in the day), Evening-types (E-type, more active later in the day), and neither type or Intermediate (I-type). As for chronotype distribution, data based on human population in the temperate region seem to show a Gaussian curve, with 10% M-type, 10% E-type, and 80% I-type [3]. Moreover, differences by sex and age exist as well, with men on average more evening-oriented than women, although these differences reduce with time [3]. In fact, young women are more morning-oriented than young men, but older women are less morning-oriented than older men [4].

*Chronotype.* A growing body of research indicates that evening chronotype may be associated with a series of unfavourable conditions. A review from our group analysed the available literature to evaluate the relationships between chronotype, gender, and different aspects of health, such as general health and metabolism, psychological health, and sleep and sleep-related problems (Table 1) [5,6]. As a general rule, M-types cope better with the synchrony effect than E-types and are able to adapt to unfavourable circumstances. At suboptimal times, M-types solved the analogy detection task faster, with the same accuracy and without the investment of more cognitive resources. They also showed greater alertness and wakefulness. At optimal times of day, M-types had more cognitive resources available to allocate in the case of more demanding conditions. E-types appear less able to adapt to suboptimal times, because they have to deal with social jetlag and decreased self-control [7]. In fact, a recent systematic review reported that female nurses with an evening-oriented preference suffer more problems of insomnia, sleepiness, fatigue, and anxiety [8].


**Table 1.** Association between chronotype and main health issues [Fabbian 2016] (Symbols: ↑ Increased; ↓ Decreased).

*Shift work.* Circadian rhythms are entrained by the light/dark alternation and a series of desynchronizing factors, such as exposure to light at night, jetlag, shift work, and daylight saving time, play a crucial role in disrupting the individual organization of circadian rhythms. Among these desynchronizing factors, shift work certainly plays crucial role, due to the wide dissemination of social request for activities warranting 24/hours/seven days a week assistance [9]. According to data from the Italian Institute of Statistics (ISTAT) survey "Working time organization: the role of atypical work schedules", shift working involves about one worker of five in Italy (20.4%). By disaggregating according to industry, social services (which includes education, health and

social services, public administration) show the highest figures (26.8%), followed by manufacturing (21.9%) and trade services, including commerce, transport, and communications (21.7%). More men than women work with shifts (respectively 21.7% and 18.4%, respectively), due mainly to shift schemes which imply night work [10]. Different disorders have been associated with shift work, with stress and sleep disorders as the most frequent ones. For example, when comparing nurses and firefighters with day workers, sleep disturbances were more frequent in shift workers than day workers [11]. Moreover, different cardio-metabolic indices, including higher waist circumference, body mass index, fasting glucose, blood pressure, and cardio-metabolic risk score have been described in night workers [12], who also showed almost three times higher association with abdominal obesity independent of age and gender than day shift workers [13].

*Errors.* Medications errors (MEs) represent a major concern of healthcare systems worldwide, and near misses represent the most reported incidents (69.3%) [14]. According to the World Health Organization, near miss is defined as "an error that has the potential to cause an adverse event (patient harm) but fails to do so because it is intercepted" [15]. Although inadequate staffing levels, workload, and working in haste have been called the most frequent causes of increased risk for omissions and other types of error and for patient harm [16], circadian misalignment, in addition to a series of health problems in shift workers secondary to the sleep deprivation, e.g., daytime sleepiness, i.e., the difficulty maintaining wakefulness and alertness during normal waking hours [17–20], can represent a crucial favouring factor for lack of performance and any kind of errors. Attentional networks are sensitive to sleep deprivation and increased time awake, and sleep duration variability appeared to moderate the association between sleep duration with overall reaction time and alerting scores [21]. Nurses' sleep quality, immediately prior to a working 12-h shift, was shown to be more predictive of error than sleep quantity [22] and functional magnetic resonance imaging (fMRI) studies showed that task performance in nonoptimal times of the day may result in cognitive impairments leading to increased error rates and slower reaction times [23]. Moreover, sleep deprivation represents a further source of risk, not limited to the short term. In hospital shift workers, being screened positive for a sleep disorder was associated with 83% increased incidence of adverse safety outcomes in the following six months, such as motor vehicle crashes, near-miss crashes, occupational exposures, and medical errors [24].

*Health professionals.* Recent data from Canada, with reference to the year 2011, show that approximately 1.8 million Canadians (12% of the working population), were exposed to night shift work, and 45% were female. By occupation, professional occupations in health ranked second place (35% of workers), following occupations in protective services (37%) [25]. However, despite these numbers, and even if nurses and midwives make up almost 50% of the global healthcare shift working workforce, much of the research addressed to the shift work area used men [26]. Female nurses working in rotating night shift were found to have significantly lower mean scores in job satisfaction, sleep, and psychological well-being as compared to day shift workers [27] and even impaired sexual self-efficacy and sexual quality of life [28]. There is an extreme paucity of studies conducted on midwives, although they play an important role in medical care: a systematic review of sleep-related/fatigue-management including more than 8600 participants, 89% females, did not find studies conducted in midwives [29]. In the same year, a survey study by the American College of Nurse-Midwives Sleep and Safety Taskforce, conducted on more than 4350 certified nurse-midwives and midwives to identify sleepiness, found that midwives working shifts >12 h had higher rates of excessive daytime sleepiness compared with those who worked shifts of ≤12 h [30].

Based on these premises, the aim of this study was to evaluate the possible association between chronotype, shift work, and risk of medication errors in midwives, inviting a representative sample of these health care professionals by means of a web survey. Social media, in fact, has increased the popularity since it represents a convenient method for communicating on the Web, for recruiting participants for health research, and for conducting survey studies by questionnaires [31,32].

### **2. Materials and Methods**

### *2.1. Sample*

A sample of Italian midwives willing to participate in the survey were invited through the most frequently used social media, i.e., Facebook and Instagram, to complete a questionnaire. We chose this extremely smart method in order to maximize the final sample size and the willingness to fill a self-administered web survey allowed us to obtain the informed consent to take part in the survey, Thus, participation was voluntary and confidential.

Midwifes were reached through social media, and those willing to fill the questionnaire were enrolled. In this case, they were told that their personal data would not have been recorded in any way; however, we asked them to declare their job activity, and we trusted health care professionals declaring to be midwifes at the time of starting the questionnaire. We could not analyse any other data nor the reason for refusing or agreeing to participate. All cases of incomplete questionnaire were excluded from the analysis.

The survey was built on Google Forms, and sent to Italian midwifes. Data was collected starting from 14 June 2019 to 31 August 2019. The statistical power of the sample to obtain statistically significant results was determined by a freely available on-line web platform. The authors considered the appropriate sample size for an adequate study power considering a confidence level of 99% and a confidence interval of 5% on a total of about 21,000 midwifes working in Italy. The analysis computed a representative sample size of 377 midwifes. The confidence interval also called margin of error is the plus-or-minus figure usually reported in opinion poll results, whilst the confidence level suggests the level of security in excluding wrong answers.

### *2.2. Instruments and Procedures*

The questionnaire consisted of a cover page (describing the purpose of the study, as well the methods to ensure anonymity and voluntary participation), and three special sections, including several different items each. In particular, the special sections dealt with:

A. demography, actual working schedule, and working experience information;

	- Based on the 7R rule, during the last shift, how many times did you (or any of your colleagues) run the risk of making a medication error?
	- Why medication error was about to occur?

### *2.3. Statistical Analysis*

For statistical analysis, first a descriptive analysis was performed, including results derived from either MEQ calculated score and personal self-perceived chronotype. The sample was classified according to the self-perception of risk of medication errors, and subgroups by age, working schedule, years of working experience, and chronotype were then compared. Second, a logistic regression analysis was done, considering the self-perception of risk of medication errors as the dependent variable and all the other parameters as the independent ones. Third, a cluster analysis was performed, to determine the phenotype of health care professionals exposed to risk of medication errors based on demography, type of work, and chronotype. IBM Statistical Package for Social Science (SPSS 13.0 for Windows, SPSS Inc., Chicago, IL, USA) was utilized.

### **3. Results**

### *3.1. Participants*

The final sample included 401 Italian midwives (98.8% women), and the main characteristics are summarized in Table 2.


**Table 2.** Characteristics of the whole population of midwifes.

### *3.2. Chronotype*

As for individual chronotype (MEQ score) and age, subgroups were represented as follows: age 23–30 years: 52 ± 8.3; age 31–35 years: 56 ± 8.2; age 36–40 years: 58.2 ± 7.6; age 4–45 years: 58.7 ± 9.2; age 46–50 years: 60.5 ± 8.3; age 51–55 years: 60.4 ± 8; age 56–60 years: 58.5 ± 8.2 (*p* < 0.001).

As for individual chronotype (self-perceived), subgroups were represented as follows: M-type *n* = 115 (28.7%), I-type *n* = 245 (61%), E-type: *n* = 41 (10.2%). Mean MEQ score in groups who perceived M-type, I-type, and E-type was 64.8 ± 5.1, 54.2 ± 5.1, and 44.7 ± 7.1, respectively (*p* < 0.001).

As for individual chronotype (MEQ calculated score), subgroups were represented as follows: definite M-type: *n* = 25 (6.3%); moderately M-type: *n* = 156 (39%); I-type: *n* = 202 (50.3%); moderately E-type: *n* = 16 (4%); definite E-type: *n*= 2 (0.4%).

Figure 1 reports the distribution of groups by self-perceived and calculated chronotype. For ease of comparison, the MEQ calculated score was reported considering moderately E-type plus definite E-type as E-type and moderately M-type plus definite M-type as M-type.

### *3.3. Perception of Risk of Medication Errors*

As for perception of risk of medication errors, subjects with response "no, never" were 208 (51.9%), and subjects with response "yes, at least once" were 193 (48.1%). The MEQ score did not show significant differences between the two groups (56.7 ± 8.4 vs. 56.5 ± 8.9, *p* = NS). No differences between the two groups were found for subgroups by class of age, working shift, years of working experience, and chronotype either.

Logistic regression analysis did not show any independent association with perception of risk of medication errors, whereas cluster analysis showed that perception of risk of medication errors

**4. Discussion** 

shift.

[39].

was associated with class of age 31–35 years, shift work schedule, working experience 6–10 years, and I-type MEQ score. No perception of risk of medication errors was associated with age 46–50 years, daytime working, working experience 21–25 years, or M-type MEQ score (Figure 2). *Int. J. Environ. Res. Public Health* **2020**, *17*, x 6 of 11

**Figure 1.** Self-perceived and calculated chronotype distribution of groups. For ease of comparison, the Morningness–Eveningness Questionnaire (MEQ) calculated score was reported considering moderately E-type plus definite E-type as E-type and moderately M-type plus definite M-type as Mtype. **Figure 1.** Self-perceived and calculated chronotype distribution of groups. For ease of comparison, the Morningness–Eveningness Questionnaire (MEQ) calculated score was reported considering moderately E-type plus definite E-type as E-type and moderately M-type plus definite M-type as M-type. *Int. J. Environ. Res. Public Health* **2020**, *17*, x 7 of 11

**Figure 2.** Cluster analysis relating age, shift work schedule, working experience, and MEQ score. **Figure 2.** Cluster analysis relating age, shift work schedule, working experience, and MEQ score.

midwives. A recent multicentre Chinese study showed that sleep quality, social support, job satisfaction, occupational injuries, adverse life events, frequency of irregular meals, and employment type were statistically significant factors influencing fatigue among midwives [35]. We found that younger persons, with reduced working experiences, were more likely to report an increased risk of error. It is possible that experience may help in attenuating the decrease in performance during night

*Errors.* Medication error incidents are more likely to be reported in the morning shift [14,36], but it is common practice that morning therapy is prearranged by the night nursing crew at the end of their shift. Rhythm desynchronization exhibits also gender-specific differences [37], and studies on the circadian and sleep-wake-dependent regulation of cognition in a forced desynchronization protocol showed that accuracy exhibited the largest sex difference in circadian modulation, with the worse performance in women in the early morning hours (at around 6 a.m.) [38]. Even risk taking, a complex form of decision-making that involves calculated assessments of potential costs and rewards, may play a role in the determination of errors. Both gender-specific and chronotype differences exist, since males report higher propensity for risk-taking, in particular E-types. However, although there is no significant difference in risk propensity or risk-taking behaviour across chronotypes in males, E-type females significantly report and take more risk than other chronotypes

*Chronotype.* Chronotype is also strongly implicated in performance tasks, also making reference to the so-called "synchrony effects", i.e., superior performance at optimal and inferior performance at suboptimal times of day. A study aimed at evaluating the effect of individual differences in

The results of this study, addressed to investigate the possible relationship between chronotype

### **4. Discussion**

The results of this study, addressed to investigate the possible relationship between chronotype and risk of medication errors in midwives, showed that the risk of medication errors was associated with younger age, shift work, relatively low working experience, and being an Intermediate chronotype. This is the first report on the association of shift work and risk medical errors in midwives. A recent multicentre Chinese study showed that sleep quality, social support, job satisfaction, occupational injuries, adverse life events, frequency of irregular meals, and employment type were statistically significant factors influencing fatigue among midwives [35]. We found that younger persons, with reduced working experiences, were more likely to report an increased risk of error. It is possible that experience may help in attenuating the decrease in performance during night shift.

*Errors.* Medication error incidents are more likely to be reported in the morning shift [14,36], but it is common practice that morning therapy is prearranged by the night nursing crew at the end of their shift. Rhythm desynchronization exhibits also gender-specific differences [37], and studies on the circadian and sleep-wake-dependent regulation of cognition in a forced desynchronization protocol showed that accuracy exhibited the largest sex difference in circadian modulation, with the worse performance in women in the early morning hours (at around 6 a.m.) [38]. Even risk taking, a complex form of decision-making that involves calculated assessments of potential costs and rewards, may play a role in the determination of errors. Both gender-specific and chronotype differences exist, since males report higher propensity for risk-taking, in particular E-types. However, although there is no significant difference in risk propensity or risk-taking behaviour across chronotypes in males, E-type females significantly report and take more risk than other chronotypes [39].

*Chronotype.* Chronotype is also strongly implicated in performance tasks, also making reference to the so-called "synchrony effects", i.e., superior performance at optimal and inferior performance at suboptimal times of day. A study aimed at evaluating the effect of individual differences in chronotype on performance task, evaluated a sample of M-type and E-type women during a driving session in morning (8 a.m.) and evening (8 p.m.). A vigilance decrement was found when E-type participants drove at their nonoptimal time of day (morning session). In contrast, driving performance in the M-type group remained stable over time on task and was not affected by time of day [40]. By contrast, studies on subjects tested for mean reaction times, error rates, and efficiency of three attentional networks (alerting, orienting, and executive control/conflict) at two time points (time 1 or baseline at 8 a.m.; time 2, after 18-h sustained wakefulness at 2 a.m.), showed that E-types participants outperformed M-types on incongruent time, i.e., deep night [21]. On one hand, negative effects of sleep impairments seem to be confirmed to affect more E-types than other chronotypes. An Australian online survey study conducted on paramedics (age 39 ± 12 years; 54% women; 85% rotating shift-workers; 57% I-types, 32% M-types, 11% E-types), showed significantly higher depression scores, anxiety, poorer sleep quality, and reduced general well-being in the E-types, compared with M-types [41]. Our study identifies Intermediate-type as the group at higher risk of error. On one hand, this result is contradictory with respect to the available literature. On the other, this result, if confirmed, is extremely interesting since Intermediate chronotype represents the most frequent circadian preference and not only in our sample. Thus, the finding that younger midwives, with relatively limited working experience, and even with chronotype extremes, are exposed to higher risk of error during their night shift, raises serious concern.

*Limitations.* We are aware of several limitations to this study: (a) cross-sectional design, based on data collected through a web survey, therefore the sample could be sized only by social media users only; (b) the MEQ score, even if used in the majority of studies for assessing morningness–eveningness preference, does not categorized for different ages [42]; (c) to evaluate the risk of medication error, we considered the general definition of near misses. Although it is largely the most frequent incident reported, we did not differentiate between near misses and no harm incidents [43]; (d) individual perception of the risk of medication errors is not a validated item yet; (e) logistic regression analysis did not identify independent factors; (f) we could not evaluate any gender effect, as most of the sample were women, as usually occurs for studies on nurses and midwives. However, there are also some

positive aspects: (a) the web survey method warranted speed, and even in a short timeframe all different classes of age were represented; (b) we found that perception of chronotype was different from the effective profile identified by a well-validated score. This concept could help for future studies and also for practical applications since when workers (health care personnel in particular) ask for health measures, they very often make reference to personal perception.

*Coping strategies*. Midwifery and nursing are acknowledged as stressful occupations, and the negative impact of high stress levels often requires coping strategies. Of these, the eleven most used have been identified via interview material: drinking alcohol, smoking, using the staff social club, using social networking websites, exercising, family activities, home-based activities, outdoor activities, avoiding people, displacement, and sleep [44]. Unfortunately, it is evident that some of these coping strategies are unhealthy and extremely concerning. Moreover, due to the stress burden, absenteeism is becoming a significant global problem, and taking a "mental health day" as sickness absence is a common phenomenon, taken by more than one half of nurses and midwives, according to an online cross-sectional survey in Australia [45].

### **5. Conclusions**

With this study, we found that younger midwives, with lower working experience, engaged in shift work and belonging to an Intermediate chronotype, seem to be at higher risk of potential medication error. At least to the best of our knowledge, this is the first web survey study addressed to the relationship between chronotype, shift work, and perceived risk of medication error in midwives. Since morning hours seem to represent highest risk frame for female healthcare workers and shift work is not always aligned with individual circadian preference, our preliminary reports could stimulate further specific research aimed to practical applications. For example, assessment of individual chronotype and sleep attitude in healthcare personnel, by means of validated questionnaires, just previously suggested in terms of prevention of metabolic diseases [46], could provide easy and inexpensive method to identify subjects at potential higher risk of circadian disruption. Again, possible countermeasures, such as time-scheduled naps during night-shifts, have been positively tested on female nurses, who showed significantly greater increments in performance between 3:00 and 7:00 a.m. on nap versus no-nap nights [47]. Last but not least, attention to shift work consequences, together with specific training programs, could help to reduce medication errors and improve patients' safety [48].

**Author Contributions:** Conceptualization: R.C., E.D.S., M.A.R.-B., P.J.L.-S.; Data curation: E.D.S., A.D.G., B.B.; Formal analysis: E.D.S., A.D.G., B.B., M.D.M., F.F.; Funding acquisition: P.G., M.D.M., R.M.; Investigation: R.C., E.D.S., A.D.G., B.B., M.A.R.-B., P.J.L.-S., F.F.; Methodology: R.C., E.D.S., A.D.G., P.G., M.D.M., R.M.; Project administration: R.C., E.D.S., A.D.G., B.B., F.F.; Resources: M.A.R.-B., P.G., M.D.M., R.M., P.J.L.-S.; Software: R.C., E.D.S., A.D.G., B.B., F.F.; Supervision: M.A.R.-B., P.G., M.D.M., R.M., P.J.L.-S.; Validation: R.C., E.D.S., A.D.G., B.B., M.A.R.-B., P.J.L.-S., F.F.; Visualization: R.C., A.D.G., P.G., M.D.M., R.M.; Writing—original draft: R.C., F.F.; Writing-review and editing: M.A.R.-B., P.G., M.D.M., R.M., P.J.L.-S. All authors have read and agreed to the published version of the manuscript.

**Funding:** This study is supported by a scientific grant by the University of Ferrara (Fondo Incentivazione Ricerca -FIR- 2020, Roberto Manfredini).

**Acknowledgments:** We thank Isabella Bagnaresi, Clinica Medica Unit, Department of Medical Sciences, University'of Ferrara, for precious technical support. We also thank Claudia Righini and Donato Bragatto, Biblioteca Interaziendale di Scienze della Salute, Azienda Ospedaliero-Universitaria "S.Anna", Ferrara, for helpful assistance.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*

### *Article* **Nursing Students' Experiences of Clinical Practices in Emergency and Intensive Care Units**

**María González-García 1,2,3, Alberto Lana 2,3,\*, Paula Zurrón-Madera 2,3,4 , Yolanda Valcárcel-Álvarez 1,2,3 and Ana Fernández-Feito 2,3**


Received: 4 July 2020; Accepted: 3 August 2020; Published: 6 August 2020

**Abstract:** Clinical practices are key environments for skill acquisition during the education of nursing students, where it is important to encourage reflective learning. This study sought to explore the experience of final year nursing students during their clinical placement in emergency and intensive care units and to identify whether differences exist between female and male students. Using qualitative methodology, a documentary analysis of 28 reflective learning journals was carried out at a public university in Northern Spain. Four themes were identified: "an intense emotional experience", "the importance of attitudes over and above techniques", "identifying with nurses who dominate their environment and are close to the patient in complex and dehumanized units" and "how to improve care in critically ill patients and how to support their families". The female students displayed a more emotional and reflective experience, with a strong focus on patient care, whereas male students identified more with individual aspects of learning and the organization and quality of the units. Both male and female students experienced intense emotions, improved their learning in complex environments and acquired attitudes linked to the humanization of care. However, the experience of these clinical rotations was different between female and male students.

**Keywords:** clinical placements; emergency hospital service; intensive care units; nursing care; nursing education research; nursing students; nursing

### **1. Introduction**

During undergraduate nursing studies, the acquisition of competencies, in a broad sense, is essential. In addition to theoretical and practical learning and the development of nursing attitudes, it is important to establish transversal competencies, such as leadership, communication, or interpersonal skills, as well as competencies for adequate personal and professional development. To achieve these transversal competencies, it is important to encourage reflection [1].

Clinical practices are an essential element of learning for nursing students [2,3], as they enable the application of theoretical knowledge in a real environment, the training of technical skills through interaction with patients and health workers and the development of nursing attitudes [4]. In addition, this is an ideal opportunity for students to reflect on their learning. Emergency departments and intensive care units (ICU) are clinical environments that encourage competence development; however, they also pose a challenge for students and teachers. These units are very complex, with high pressure to care for serious patients, which can negatively influence the students' experience [5]. Careful planning, with guidance and follow-up by an instructor, are central elements in their development [6].

### **2. Background**

Significant learning is not possible without reflection [7]. The reflective analysis of lived experiences or problems faced during professional practice can serve as a stimulus for learning [8]. A reflective attitude can be even more useful than technical mastery when dealing with changing situations in professional practice. During nursing training, reflective learning can take place through a reflective learning journal (RLJ). The RLJ is a written document in which students carefully analyze their thoughts, actions or interactions with others over a period of time [3,7]. Several studies have documented the usefulness of RLJs in enhancing the learning experience during clinical practice [9–11], stimulating professional development [12] and even personal development in the process of becoming a nurse [13–15]. In this way, RLJ can be used as an additional tool for teachers to assess students' acquisition of nursing competencies during clinical education but also to learn about students' personal experiences, including their coping strategies, thoughts, emotions and feelings [4,7,13].

Addressing emotions during clinical practice is very important [3,10,13]. When students are asked to keep an RLJ, they are voicing emotions experienced during clinical placements that are usually relegated to the context of individual students [10]. In addition, writing and reflecting on their feelings and emotions can also be therapeutic for students, since it allows them to stop and externalize their experiences [9,16], which increases their confidence in their ability to face future difficulties [13,17] and increases their capacity to empathize with patients and their families [18,19].

In addition, RLJs provide a "snapshot" of the daily reality on the clinical level (e.g., characteristics of services, type of patients, quality of nursing care, etc.) and the teaching process (e.g., student–nurse interaction, clinical practice schedules, etc.). Knowing the day to day life of emergency department and ICU from the perspective of students can be an enriching way to identify areas of improvement in these two nursing dimensions: clinical practice and teaching activity.

There is some prior research on the experience of students during the first year of clinical practice training [2,3,17,19,20]; however, there are fewer approaches to the experience of clinical placements in senior year students and in complex care settings, even though these may be more representative of how students will cope with the impending start of their professional development. In addition, we were unable to find any papers that compared clinical practice experiences by gender. Only a few studies include the student's gender in the verbatim, without establishing a comparative analysis [9]. This is relevant because previous research has documented differences between male and female nursing students in relation to professional values [21], personal values [22], career choice and post-graduation outcomes [23]. In addition, socially constructed traditional gender norms can determine expected behaviors and attitudes in both male and female students in the context of a traditionally female profession [24]. During clinical practice, and through the RLJ, it is possible to observe whether there are differences in the preference or rejection of some activities based on gender—for example, whether men feel more attracted to management and coordination aspects or whether women identify more with the humanization of care, empathy with patients, etc., both of which are situations that are dictated by gender roles.

The aim of our study was to explore the experience of final year nursing students during their clinical practices in emergency department and ICU and to examine how this experience is interpreted by both female and male students.

### **3. Materials and Methods**

### *3.1. Design*

A qualitative study using documentary analysis of RLJs written by nursing students in their senior year during their clinical practices.

### *3.2. Participants and Setting*

In Spain, the Degree in Nursing is a four-year university degree with 240 credits (in accordance with the European Credit Transfer and Accumulation System, ECTS). During the final year, students at the University of Oviedo (Spain) take a specific course on clinical practices in the emergency department and ICU (12 ECTS credits). All students must perform at least two clinical rotations, one in the emergency department and another in ICU, to complete 230 h of training. In addition, students must submit a clinical case study and an RLJ of the subject, which accounts for 10% of the final grade. During the 2017/2018 academic year, 78 students studied this course at the University of Oviedo (Spain). Twenty-eight RLJs were selected from the students (15 from women and 13 from men) who obtained the highest grades in the January 2018 evaluation.

Clinical practices took place in the emergency department and ICU of six public hospitals. The center where the largest number of students performed clinical practices (*n* = 20) was a level 3 public university hospital (1000 beds), where around 300 patients are seen daily in the emergency department and which has 75 ICU boxes. The remaining hospitals that received students were level 2 (<500 beds).

### *3.3. Research Team*

The research team consisted of five nurses (four women and one man) from the University of Oviedo. The principal investigator had two years' experience in critical care. She was a doctor, associate professor in nursing and the head of the clinical practicum subject. Three of the nurses had professional experience in emergency department and ICU and teaching experience in the Degree of Nursing. One researcher was also the teacher of the "Research in Nursing" subject at the University of Oviedo. The students knew the researchers through their participation in other subjects during the nursing degree.

### *3.4. Instruments*

In this course, students are required to complete a compulsory portfolio on clinical practices. The portfolio consists of two sections. The first was a descriptive section with administrative and clinical data on the clinical practices, including data on the hospital and the practice unit, type of pathologies and nursing activities performed. The second was a reflective part (RLJ) on the contributions of the placements to their learning, on the level of satisfaction with the clinical practicum and suggestions for improvement. Specifically, students are strongly required to reflect on the following competencies achieved in three areas (knowledge, skills and attitude): (1) providing nursing care to critically ill patients; (2) correctly performing the most common techniques in emergency department and ICU; (3) respecting ethical values related to privacy, confidentiality and respect for patients; (4) meeting the information and communication needs of patients and families. This is delivered by email at the end of students' clinical practice training in a text document of unlimited length. At the beginning of the course, there is a two-hour face-to-face information session at the university on how to perform the RLJ, emphasizing its reflective nature, which must be more than just a description of the activities performed. Students were asked to engage in a reflective exercise concerning their daily actions [8] and to only record in their RLJ those aspects that were most relevant. They were given instructions on how to record each reflection, including the actions taken, the context, their emotions and how they could improve. In addition, several examples were provided. They were also encouraged to reflect

on how the same activity could be done differently depending on the unit and the nurse carrying it out—for example, communication with a sedated patient.

### *3.5. Data Analysis*

According to the methodology proposed by other authors [25,26], a three-phase content analysis of the RLJs was carried out. In the first phase, the texts were prepared for analysis. Within each journal, the sections "Identification of contributions to learning", "Description of the competencies acquired (knowledge, skills and attitudes)" and "Suggestions for improvement" were selected. In the second phase, the information was organized and the actual content analysis was carried out [27]. The meaning units identified in the reports were assigned codes. The codes were then grouped and gathered into subcategories and categories. Finally, the main themes that summarized the students' experience were formulated. According to the format of the RLJ, a previous thematic category, "knowledge, skills and attitudes competencies", was used as a starting point; however, the remaining topics emerged after the documentary analysis. In the third "reporting" phase, the results were presented. The complete analysis process was presented (codes, subcategories, categories and themes) as well as the description or storyline of the results.

The analyses were carried out without the use of software. The analyses were conducted independently by two researchers and, after pooling the analyses, they were triangulated with the participation of another researcher from the group.

### *3.6. Ethical Considerations*

All students provided informed consent to the use of their journal for research purposes. Each participant was assigned a code to maintain anonymity, which was identified using "W" for women and "M" for men. Participation in this study had no influence on the grade assigned in their evaluation since this investigation was initiated months after the students completed the course. Our study was exempt from ethics committee approval, although it was conducted in accordance with the ethical standards set out in the original Declaration of Helsinki and its subsequent amendments.

### **4. Results**

### *4.1. Experience of Nursing Students in Emergency Department and Intensive Care Units*

Overall, the student experience reflected in the RLJs was positive in terms of learning, although a high emotional burden related to attendance at these units was noted. Most students perceived a high degree of coordination in these units and the importance of nurse/medical collaboration.

During the analysis, four themes were identified from the students' reflection on the competencies (Figure 1). The first referred to the student's feelings of undergoing "an intense emotional experience" and the second referred to the skills and attitudes achieved "the importance of attitudes over and above techniques." The third theme was related to nursing professionals and some characteristics of clinical practice units "to identify with nurses who dominate their environment and are close to the patient in complex and dehumanized units". Finally, the fourth theme referred to patients and their families: "how to improve care for critically ill patients and support their families."

### 4.1.1. Intense Emotional Experience

For all the students, these clinical placements involved intense emotions. Prior to the clinical practices, negative emotions predominated, as the previous confrontation of female and male students was characterized by fear, pressure, emotional block, etc. However, during the clinical training, they experienced emotional ambivalence. Thus, they experienced positive feelings, especially linked to the patient's favorable evolution and identification with the nursing profession. Concurrently, they also experienced negative emotions, associated with facing the care of patients in very serious clinical situations and death, causing them to reflect on life (Table 1).

**Figure 1.** Experience of nursing students in emergency department and ICU during clinical practices. **Figure 1.** Experience of nursing students in emergency department and ICU during clinical practices.


**Table 1.** Main categories, sub-categories and codes about the theme "intense emotional experience".

Satisfaction for good patient progress Gratification humanizing care Progressive safety/self-monitoring As for the previous expectations, there were no great differences between girls and boys, in both groups, and feelings of fear, pressure, being "frozen" or blocked, etc. predominated. During the clinical practices, positive feelings of satisfaction and personal growth were expressed.

Feeling like a nurse Identification with the nursing profession Thoughts Professional and personal enrichment

Helplessness poor patient evolution

Emotions during clinical practices

"These clinical practices have been a turning point in my career as I have been able to grow as a person and as a future nursing professional." W4

"In this clinical module I have shown myself how right I have been in choosing a profession like this, how close one is to the patient and how much chance one has of, with very little, improving the condition of the patient and his or her family." M10

Both the female and male students showed progressive confidence as the clinical practicum progressed, facing these with greater ease and feeling more satisfied if the patients progressed well.

Some acknowledged their difficulty in coping with death, either because of inexperience or because they felt overwhelmed by the situation.

### 4.1.2. Importance of Attitudes over and above Techniques

The acquired competencies were articulated in three areas: knowledge, skills and attitudes (Table 2).

**Table 2.** Main categories, sub-categories and codes about the theme "importance of attitudes over and above techniques".


In terms of theoretical knowledge, some categories common to both sexes were learning how to handle critically ill patients or how to prioritize emergency care through triage. They also recognized learning new and specific knowledge, required in these units.

Regarding the competencies linked to skills or abilities, all mentioned the handling of devices and the refinement of new techniques as well as the improvement of other already known techniques. They also learned to act quickly, adjusting to the urgency of the moment.

Attitude-related competencies were extensively analyzed as they constituted a very large section within the RLJs. Two themes were appreciated: firstly, in relation to their personal experience as students where the acquired responsibility or autonomy stands out; secondly, almost all referred to learning related to the humanization of care, based on respect for the patient, empathy and accompaniment.

"I have learned that many times there is no need to speak or, rather, "fill the silences" with words, we should simply be there, giving company and human touch if necessary." W12

"When the intubated patients were thirsty I would dip a gauze in water and place it between their lips and they would thank me. I also, for example, put the radio on for a patient because it's quite tedious for everyone, I suppose, to be in bed all day without any entertainment." M12

In addition, students mentioned acquiring cultural competencies in dealing with people with social problems and patients from other countries/ethnicities.

"On the other hand, I have been in contact with people who are drug addicts as a result of a serious social problem and with a major underlying mental illness." W4

"Respecting the patients' beliefs and cultures, always seeking their integration in the hospital." M7

4.1.3. Identifying with Nurses Who Dominate Their Environment and Are Close to the Patient in Complex and Dehumanized Units

The perceptions of nursing professionals in the context of the emergency department and ICU are presented in Table 3. All the students appreciated the warm welcome to the units, the involvement of the nurses who taught them and their "willingness to teach".

**Table 3.** Main categories, sub-categories and codes about the theme "identify with nurses who dominate their environment and are close to the patient in complex and dehumanized units".


"I've discovered a part of nursing that's exciting and that, if there's one thing professionals have in this service, it's passion and drive." W1

In addition, the students were grateful for the nurses' attitudes.

"On a day-to-day basis in the special services, doubts and learning opportunities arose in which the nurses were always willing to help and explain things to me." M6

Both female and male students identified the emergency department and ICU as highly technical and labor-intensive environments. They also appreciated that nurses in these units worked more independently and autonomously than their colleagues in other units, e.g., inpatient units, and that they fulfill an important role in informing and reassuring patients:

"They are in control of the complexity of the situation at all times, always preventing it from overwhelming them." W3

"Nurses are not only the professionals who know how to inject, administer medication or put a bandage on. The most important thing is to know how to listen and be close to their patients, who at certain times only need someone close by, to feel their support and understanding." M7

4.1.4. How to Improve Care in Critically Ill Patients and How to Support the Families

Both female and male students recognized that patients in these units presented very specific pathologies, which involved advanced practice care. They also understood the importance of informing and explaining the techniques to the patients in advance, as a measure to reassure them and avoid conflicts, especially due to long waits in the emergency department (Table 4). In this overall context, the students identified a certain depersonalization in patient care and proposed a more humane treatment, with simple verbal and non-verbal communication actions, such as calling each patient by their name or holding their hand.


**Table 4.** Main categories, sub-categories and codes about the theme "how to improve care for critically ill patients and support their families".

Regarding the families, all stressed the importance of adequately addressing their needs, creating a climate of trust and support, as they are under great pressure. The information that they receive plays an important role in this relationship as it can help to reassure them (Table 4). Both female and male students identified the importance of visiting times and how students and professionals should act during these encounters.

"Always showing them that we are there and that they can trust us to take care of their relatives." W3

"From my point of view I think it is important that the moment of family visits be as comfortable as possible for the relatives and the patient." M1

Lastly, several male and female students stressed the importance of reinforcing training on humanization in care before the start of the placements.

### *4.2. Di*ff*erences in the Experiences of Clinical Practices in Critical Services by Gender*

Female students reflected on a much more intense and negative emotional experience, linked to the environment of critical care practices with critically ill patients or by identification with young patients. Personal gratification after providing emotional care to patients was also common, as was concern for ensuring the best care:

"I have realized that if you treat them with affection and try to help them in any way you can, not only are they very grateful to you, but you also go home with a good feeling, and knowing that your work has served a purpose." W10

"Since we also usually have to make decisions or act very quickly which sometimes made me nervous because it can lead to confusion very easily." W13

However, for male students, perceived satisfaction was related to the identification of emergency department and ICU as an employment option.

"I must admit that it was the rotation that I enjoyed by far the most, especially in the area of emergencies, so I am seriously considering continuing to study to work in this type of care area in the future." M2

"The student's autonomy has to take a step forward in order to prepare for the professional world." M8

In relation to competencies, the majority of female students stated that the techniques were not the most important aspect but rather the provision of basic care, such as those related to comfort, rest or pain relief.

"Anyone with training can channel a venous line or perform an electrocardiogram. As a nurse, you are there to support that person, reassure them, and accompany them in their distress. Sometimes the best cure is a smile, a hand on the shoulder or an "I'm there for you."" W15

"Here, I learned how to take care of a patient, to keep an eye on him all the time, to wash him, to comb his hair, to take care of his nails... things that are less technical and more humane." W8

However, the male students gave importance to specific knowledge, such as how to change shifts properly or how to adapt to changing environments. The importance of teamwork was mentioned by virtually all male students.

"I see it as very important to be able to give shift changes in a proper manner. I have paid a lot of attention to those who, in my opinion, perform good shift changes and I have tried to assimilate this way of working." M3

"Teamwork, the willingness to always help one's partner is one of the attitudes that I have encouraged during the rotation, there is no "so-and-so's patient", we are all there for everyone and we help each other with everything." M10

In terms of identifying with the nurses and the environment in these units, several female students reflected on attitudes that caused them to feel rejection and that they did not want to imitate.

"I have learned how I do not want to work in terms of how some health professionals describe and treat patients, not respecting their privacy, making value judgments and talking about patients in a derogatory way." W7

Finally, in relation to patients, the female students outlined the negative feelings perceived in patients with great detail (e.g., fear, nervousness, stress, worry) and the importance of ensuring intimacy.

"People who are conscious, in addition to their illness, are afraid and isolated and alone." W7

"From my point of view and according to what I have been able to learn while I was there, we can and must guarantee assistance, always respecting the patient's physical and emotional intimacy." W3

### **5. Discussion**

According to the results of our study, for the nursing students, clinical practice in the emergency department and ICU implied an intense emotional experience, demanding the importance of attitudes towards the techniques. The profile of the nurses highlighted their human nature and their role as a reference for students in these complex units with high care demands. They also identified the need to adequately inform and support critical patients and their families. Differences were detected between female and male students regarding the experience during this clinical training.

RLJs have been a useful tool for learning more about the experience of nursing students in complex units. Some authors [3,8] had already reflected on the usefulness of the journal as a method for venting and expressing feelings and for stimulating personal growth during the process of becoming a nurse [13,28]. Moreover, writing can be considered a therapeutic tool, in the same way as it is for patients admitted to ICU [29], and it can be useful for nursing students facing stressful situations such the emergency department and ICU [30,31].

The expectation surrounding these placements was very similar to that described by other authors: nervousness and worry before facing a new post, the need to apply knowledge and techniques previously explained in theory and progressive confidence and security over time [32]. In our case, this transition could be affected by the complexity and severity of the patients in specific services, which could accentuate the expression of negative feelings, which became evident during a very intense emotional experience [3,17,28].

The students expressed the same feelings that the patients displayed: nerves, fear, freezing up in urgent situations, etc. [32,33], as if they were acting as a mirror reflecting the same negative emotional reaction, whereas the nurses assumed a reassuring and controlling role in the situation, as identified by both male and female students.

Student autonomy in complex services is limited [5], thus generating greater dependence on the nursing preceptor and greater observation of his/her clinical performance. The students in our study, as in other reports [34], have felt supported by the nurses during their clinical practices, who have integrated them into the team. During the process of becoming a nurse, which is more complex than simply having practical knowledge or skills [19,35], it is very important for students to have models and feel supported and accompanied during the mentoring process. The importance of this mentoring should be emphasized, not only through the nurse preceptors in the practice units but also on behalf of the university faculty, accompanying the students throughout the process, especially during the senior year [13]. To achieve this objective, it could be very useful to integrate this reflexive student learning into the creation of an environment of mutual trust and growth between teacher and student [10,12]. It is also important to consider the working conditions in these units, where high care loads and staff shortages can make it difficult for nurses to teach [36].

Both through the attitudes learned and the nursing care observed in the units, the humanization of care was essential. The students assigned great importance to respecting patients and the need to attend to their feelings and demonstrate empathy. Indeed, developing an empathic attitude is one of the fundamental pillars of the relationship between health professionals and patients/families [37]. Sensitivity to patient suffering was increased in our study since they were in a hostile environment, where patients were vulnerable, separated from their families and almost entirely dependent on the health professional, from making a rapid and effective diagnosis in the emergency unit to covering a human being's basic needs in the ICU. Most of the plans for the ICU integrate the elements proposed by students, which is positive since it shows a growing awareness among future nursing professionals to improve the environment in these units [38].

In general, our results coincide with research conducted in Spain on RLJs as an assessment tool during the learning process of nursing students [11]. Many of the journals included reflections on the techniques but also frequently addressed patient and family related care, interactions with the team and the nurse preceptor and even death. Moreover, this study mentions very interesting aspects, such as the importance of providing clear guidelines for the implementation of these journals, the figure of the teacher as a guide in the process of reflection within the framework of a relationship of trust and the importance of assigning importance to the evaluation, in the understanding that, if it is proposed as a voluntary activity, students generally fail to participate.

In our study, a different experience was found among female and male students. The female students described their negative feelings in more detail during the clinical training and showed a more reflective attitude. This reality could be related to a greater ease of expressing emotions among the women, whereas the men may have had similar experiences or thoughts, although they may have ultimately decided not to include them in the journal or not to delve into the experience.

Regarding the competences achieved, female students focused more on the humanization of care whereas male students more frequently mentioned aspects linked to their individual learning or organizational aspects in these units. This different approach by gender coincides with the results observed in nurses working in the ICU [39]. Further research is necessary to better understand these differences and to assess whether students may be imitating or reproducing the model identified by the nurse preceptors.

Female students were also more concerned about poor patient progression or fear of making mistakes, which is consistent with the study by Fernandez-Feito et al., [21] where female students considered it more important to seek help when they could not meet patient needs.

### *5.1. Implications for Clinical Practice*

Enhancing the use of these reflective tools can contribute to a better understanding of the experience of nursing students during their clinical placements and encourage personal and professional growth, which is difficult to achieve through theoretical training. In addition, it would be important to encourage male students to share their experience and their personal feelings. After being aware of this experience, it would be appropriate to design interventions to reduce the associated emotional impact and provide the students with strategies (e.g., coping styles) to reduce anxiety or negative feelings.

In turn, teachers and nurse preceptors play a key role in accompanying the student in the process of "becoming" a nurse, and, in this process, creating and sharing a reflective narrative (student–preceptor–teacher) can be very helpful.

### *5.2. Limitations*

In our study, the RLJ represented a percentage of the final grade. It would be very interesting to comment on the narratives with the students in a session not only aimed at modifying the assigned grade but also analyzing the overall experience in these services, as a group. The differences found according to gender should be interpreted with caution since the analysis was not performed blinded to the students' genders, which may have biased the interpretation of the results. The results obtained were not subjected to the process of triangulation with other techniques, such as individual interviews or focus groups with students; this will be addressed in future research.

### **6. Conclusions**

For nursing students, clinical practices in emergency department and ICU represent an intense emotional experience that allows them to improve their learning and cope with complex environments. In addition to acquiring new knowledge and refining already learned techniques, these clinical practices allow students to acquire attitudes clearly linked to the humanization of care. Female and male students experienced these clinical rotations from different viewpoints. Female students were more emotionally and reflectively focused on patient care, whereas male students identified more with individual aspects of learning and the organization and quality of the units.

**Author Contributions:** Conceptualization, M.G.-G. and A.F.-F.; methodology, M.G.-G., A.L. and A.F.-F.; formal analysis, M.G.-G., Y.V.-Á. and A.F.-F.; data collection, P.Z.-M., Y.V.-Á. and A.F.-F.; writing—original draft preparation, M.G.-G., A.L., Y.V.-Á., P.Z.-M. and A.F.-F.; writing—review and editing, A.L. and A.F.-F. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was supported by grants from the Instituto de Salud Carlos III, Spanish State Secretary of R+D+I, Fondo Europeo de Desarrollo Regional (FEDER) and Fondo Social Europeo (FSE) (grant number PI18/00086) and the Health Research Institute of Asturias (ISPA). The study funders had no role in the study design or in the collection, analysis or interpretation of data, and the authors have sole responsibility for the manuscript content.

**Acknowledgments:** We would like to thank all the senior nursing students for their reflections and the nurse preceptors at the emergency department and ICU for their contribution to the training of these students.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


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International Journal of *Environmental Research and Public Health*
