Factors Impeding Timely Completion of Clinical Practical Registers: A Study of Nursing Students at a Namibian University

Introduction

Nursing education relies fundamentally on the integration of theoretical knowledge with practical application, requiring students to develop clinical competencies through structured experiences across diverse healthcare settings. As a performance- based profession, nursing demands that students demonstrate proficiency through documented evidence of their learning and skill acquisition [1]. Practical registers serve as essential tools in this process, functioning as comprehensive portfolios that document students' clinical experiences, competency development, and professional growth throughout their training.

The implementation of practical registers as both learning and assessment instruments has gained considerable prominence across healthcare education globally, reflecting their recognized value in bridging the theory-practice gap [2]. These registers facilitate students' ability to integrate theoretical concepts with clinical practice while promoting critical self-reflection and professional self-awareness [3]. Fundamentally, practical registers constitute a systematic collection of evidence demonstrating progressive learning and competency attainment, serving as tangible proof of students' readiness to meet the prescribed scope of practice for registered nurses [4].

Within the clinical education framework, nursing students rotate through various healthcare departments to acquire specialized knowledge and skills specific to each discipline. The successful completion of practical registers for each major clinical area represents a mandatory requirement that directly impacts students' progression and eligibility for final examinations [1]. This requirement underscores the critical importance of practical skills as integral components of professional nursing education, ensuring that graduates possess not only theoretical knowledge but also the practical competencies, professional attitudes, and clinical judgment necessary for safe, effective patient care.

Clinical experiences provide the essential foundation for developing autonomous nursing practice, enabling students to make informed patient care decisions and contribute meaningfully to healthcare delivery [1]. Without adequate clinical preparation and documented competency achievement, nursing graduates cannot function effectively as patient advocates or contribute to broader healthcare initiatives. The practical register system thus serves as both a learning scaffold and a quality assurance mechanism, ensuring that nursing education produces competent, confident practitioners.

However, observations at an institution of higher learning in Namibia have revealed concerning patterns of student attrition linked to difficulties in completing practical registers within required timeframes. These completion challenges have resulted in students being unable to qualify for examinations, ultimately leading to program withdrawal. Given that practical register completion constitutes a fundamental requirement for academic progression in nursing education, understanding the barriers that impede timely completion becomes essential for supporting student success and maintaining program quality.

This study therefore seeks to explore and identify the factors that affect nursing students' ability to complete their practical registers timeously at a Namibian institution of higher learning. By examining these factors, the research aims to provide insights that could inform interventions to support student success and reduce attrition rates in nursing education programs

The Aim of The Study

The aim of the study was to explore the factors affecting the nursing students to complete their practical registers timely at the institution of higher learning in Namibia.

Objectives of the Study

The research objectives of the study were to:

• Explore the factors affecting nursing student’s inability to complete their practical registers on time at the institution of higher learning in Namibia.

• Identify the strategies that will enhance nursing students to complete their practical registers timely at the institution of higher learning in Namibia.

Materials and Methods

Research Design

A qualitative, phenomological approach was adopted using semi-structured individual in-depth interviews, to gain in depth information from the participants.

Population, Sample and Setting

The study was conducted at the institution of higher learning in Namibia among nursing students. Purposively sampling was used to recruit the participants. Ten students participated in the study and the sample was determined by data saturation.The transcripts were verified with each recording for proof reading and correct transcripts. The transcripts were read thoroughly to gain a sense of the content. The study used thematic analysis to analyses data. A coding sheet was created following the process of reviewing the transcripts. The categories and final themes were confirmed by researchers.

The sample size of this study was as a result of data saturation. The researchers collected data until no new information came up. Therefore, data saturation was achieved at 10 interviews. Interviews were audio-recorded and transcribed verbatim. The study used otter.ai to transcribe the recording.

Participants were recruited through a visit to the campus by researchers. The participants were approached individually. Information was shared with the participants with regards to the study aim, eligibility criteria, potential risks, rights to confidentiality, informed consent, the right to withdraw from the study at any time. The researcher set up an appointment with the participants who volunteered and were interested in participating in the study at their convenient time.

Inclusion Criteria: The inclusion criteria for the research study were the inclusion of student nurses at the institution of higher learning in Namibia irrespective of gender and age.

Exclusion Criteria: The criteria for exclusion were the exclusion of the institution of higher learning in Namibia who were those were not willing to participate in the study.

Research Instrument

In this study the researcher conducted in-depth interviews using an interview guide and a voice recorder to collect data. A semi- structured interview guide is a tool that is used when one conducts interviews and includes specific questions that are directed to the participants.

An interview guide is useful when conducting qualitative research. Open ended questions were used to obtain information from the participants as it allowed participants to discuss their opinions, views and experiences fully in detail. The interviews were done in English as all participants could communicate in English. The interviews were audio taped with the permission from the participants to ensure an accurate account of the interview, which could be replayed for analytical purposes and validation reasons.

Data Collection

Participants were presented with information and informed consent. Participants were requested to sign an informed consent, when they have agreed to participate in the study. The researcher then set up appointments for interviews based on the time convenient to the participants. The participants were student nurses. All ethical issues were fully explained to the participants and were enforced during the research. To ensure participants’ anonymity and privacy during interviews, the researcher selected a room at the campus where interviews took place with the permission from the institution of higher learning management.

The interviews took at least 35-45 minutes and were conducted between September- October 2022 in a private room organized by the researcher on campus. Interviews were audio-recorded with the permission of the participants. The study used otter.ai to transcribe the recordings. Semi-structured individual interview schedule was used to elicit the factors affecting nursing students to complete their practical registers timely, perspective, transferability is primarily the responsibility of the one who seeks to generalize the findings of a study.

Pilot Study

The pretesting of in-depth individual interview was done to identify the feasibility of the proposed study and improve the research instrument [6]. The researchers benefit from carrying out a pilot study prior to the main study as it allows in identification of any weakness in the plans and allows time to rectify any necessary amendments. In the study, pilot study was used to test the sampling inclusion criteria, interview guide, frameworks for trustworthiness, audio recording sound and time frames. Pilot study was conducted on three student nurses who were not included in the main study because they would give the same responses.

Data Analysis

The study employed inductive thematic analysis using Brown and Clarke's ,2023 six-phase framework of qualitative data which focused on identifying themes- and patterns from data.Thematic analysis was used to understand the meaning behind Participants.

Rigor

Trustworthiness of the study was determined by implementing the criteria based on the model of Lincoln and Guba [6]. The four criteria are as follows: Credibility: Ensures that there should be confidence in the truth of the data and the interpretation. The researcher applied prolonged engagement until the scope of the data was adequately covered.

Dependability: The researcher ensured dependability by maintaining a record of all research activities and documenting all data collected and analyzing the procedures throughout the study.

Confirmability: The researcher ensured the confirmability of this research project by the safekeeping of raw data with the purpose of allowing the integrity of research results to be scrutinized and followed up on.

Transferability: The researcher addressed the concept of transferability by providing sufficient contextual information about the topic to the participants. From a qualitative perspective, transferability is primarily the responsibility of the one who seeks to generalize the findings of a study.

Ethical Considerations

This study was approved by the Decentralized Ethics Committee of the University of Namibia, Ethical Clearance Reference Number (SOC/0003). The participants responses and audio tape were kept confidential. The participants have signed informed consent prior participation. Participation in this study was voluntarily and participants were informed that they have a right to withdraw from the study, anytime without any penalty or prejudicial treatment.

Results

Majority of the participants were females (70%) as compared to males’ students (30%). The participants in this study were 40% (n=4) were 2nd years, with 3rd years, 40% (n=4), while four years, 20% (n=2) and total n=10.

The results of the study show that seven (70%) participants were aged from 18-24 years old while three (30%) were aged from 25- 34 years old.

                                                                        Table 1: The Age Categories of the Participants

The study had identified four themes, which are Inadequate time allocation in clinical areas for practical, Poor support from registered nurses and lecturers and the fragmented content in practical registers.

Themes and Sub-themes

The study findings are reported according to the identified themes and sub-themes which have been described in a table form below.

                                                                                      Table 2: Themes and Sub-themes:

Theme 1: Inadequate Time Allocation and Clinical Areas for Practical

Two sub-themes emerged from this theme, which are insufficient time allocation at practical areas, inadequate clinical areas for practicals and insufficient number of procedures required to attain clinical competencies.

Sub-theme1.1 Insufficient Time Allocation at Clinical Areas

The study findings revealed that inadequate time allocation within clinical placements constituted a significant barrier to timely practical register completion. Students consistently reported having limited time in clinical areas to fulfill their documentation requirements, with the maternity ward allocation being particularly problematic. Participants emphasized that the number of days allocated to maternity units was insufficient to achieve both clinical learning objectives and comprehensive register completion.

Below are some extracts from the participants (P)

“The time in clinical area is limited and we are expected to complete a lot of things” P 4.

“We are only allocated twice in a year at maternity ward, it is dificulty to start learning new things and to do procedures and record them in time” P2.

This was consistent with a study by Gemuhau, Kalolo, Mirisho, Chipwaza & Nyangena that nursing students who reported at clinical placement, did not provide them with adequate opportunity for effective learning due to inadequate time in clinical area [7]. Their rotation in some units was short, hence, unable to acquire all clinical competencies.

Sub-theme 1.2 Inadequate Clinical Areas for Practical

The majority of participants (65%) identified severely limited clinical placement opportunities as a critical barrier to effective practical training in nursing education. The study findings revealed significant overcrowding in hospital wards and clinics, where nursing students struggle to complete their practical registers due to insufficient space and resources. This problem is compounded by the high enrollment numbers of students from multiple higher education institutions pursuing nursing and medical-related courses, creating intense competition among students for access to clinical procedures and hands-on learning opportunities.

The following statements support the findings.

“There are limited clinical placement for us to go and practice” P5.

“Sometimes, there are a lot of students placed in one unit, it’s dificult to finish the practical registers because it is not only UNAM students but other institutions, the competition to complete procedures is high” P8.

According to, they indicated the challenge of overcrowding of nursing students in the nursing departments, which constrains students from completing their clinical registers [9].

Sub-theme1.3 Insufficient Procedures to Attain Clinical Competencies

The study findings revealed that there are insufficient cases for the nursing students’ practical registers. The challenge was mainly on procedures related to Midwifery practical register. Nursing students indicated that it is difficult to get the required number of deliveries during the period of allocation in the maternity ward.

The following statements support the findings.

“Sometimes , when we are placed in clinical areas , some of the cases of the procedures we are expected to complete , we are not there when it happens, you won’t be able to complete the practical register” P4.

“The requirements of deliveries of babies (children) are high and with many students in ward and all are required to conduct deliveries, it is a challenge, women who deliver are not enough” P8.

According to Changiz et al., completion of clinical assessment serves as a stressor among nursing students. The inability to complete the required competencies impedes their abilities to complete their course in time [9].

Theme 2: Poor support from Registered Nurses and Lecturers

In this theme, there are two sub-themes emerged: Inability to get signatures from registered nurses, lecturers and preceptors visits at the clinics.

Sub-theme 2.1: Inability to Get Signatures from Registered Nurses

The study findings revealed that nursing students were struggling to get signatures from registered nurses. The participants stated that if the registered nurses are not satisfied with the performance of the procedure, they will opt not to sign. The study findings also stated that registered nurses work schedule is tight, hence they do not have adequate time to sign the student practical registers.

The information below is evidence from the following statements:

“We are expected to be practically competent and fully understand the procedures we are taught. If the nurses are skeptical about signing your practical registers, they will not do it” P7.

“The registered nurses are so busy do not get time to sign practical registers, then keep postponing the signing” P3.

British Columbia College of Nurses and Midwives stated that professional nurses have a role in supervising students during their clinical allocations and make decisions about what the students are offering to the clients. They have a role to complete the required documents if they are satisfied with what was executed [10].

Sub-theme 2.2: Lecturer and Preceptors Visits

The majority of the participants stated that lecturers visit the health facilities where they are allocated. However, the study findings revealed that lecturers visited them occasionally. The participants further stated that the lecturers indicated their availability during clinical evaluations of continuous assessment and examination marks. However, the participants indicated that preceptors come almost every day to check student progress and they engaged highly with students during their clinical placements.

The following statements support their findings:

“The lecturers come in on a weekly basis but there are procedures to be evaluated for continuous assessment and for examination purposes, they will be available anytime when they are informed” P6.

“The preceptors come frequently and see how far we are with our practical registers and if there are procedures to be performed , we can do it with them” P4.

Nursing clinicians who work as preceptors to the students are expected to train nursing students in the clinical area in order to apply their theoretical knowledge to the practical [11]. Whereas Killam and Heerschap found that preceptors play an important role in clinical teaching when lecturers are not available for daily student follow-up [12].

Theme 3: Content of the Practical Registers

In this theme, two sub-themes have emerged; Unclear content in practical registers and duplications of procedures in various practical registers.

Sub-theme 3.1: Unclear Contents in the Practical Registers

The majority of the participants indicated that there are some contents in the practical registers that are not clear to the students and nurses. The study findings revealed that some concepts are confusing , hence , it’s difficult for the nurses to allocate marks to the students.

The participants made the following assertion.

“Some of items/aspects in the practical registers are not clear and nurses do not understand them” P5.

“I think some concepts used are confusing or perhaps it was a printing error. Nurses do not understand how to allocate the marks in some procedures” P9.

In a study by Jamshidi, Molazen, Sharif, Torabizadeh and Kalyan stated that nursing students appear not to be adequately prepared when entering clinical environment [13]. Students alluded that sometimes they did not understand content in their logbooks sufficiently, this had led to stress among nursing students which affect their performance in clinical environment.

Sub-theme 3.2: Duplication of Procedures in Various Practical Registers

The majority of the participants indicated that there are duplications of procedures in the practical registers. This leads to the overload of students work with a lot of activities expected to be performed in a short space of time.

Below are the direct quotes from the participants:

“In some practical registers, especially from second year, third and fourth years, some of the things are duplicated at each level” P10.

“One of the challenges that we are faced with is the overload of activities because of the content, we can’t complete the practical registers in time” P9.

In a systematic review by Panda, Dash, John, Rath, Debata, Swain indicated that inconsistencies and duplications of student’s evaluation procedures in clinical practice was found to be a demotivating factor as student nurses have a lot of similar clinical procedures [14].

Discussion

This study identified multiple interconnected factors that impede nursing students at the University of Namibia, Southern Campus, from completing their practical registers within the required timeframe. The findings reveal systemic challenges that affect both educational outcomes and clinical competency development, with implications for nursing education quality and healthcare workforce preparation.

The most prominent barrier identified was insufficient time allocation for students to complete required procedures and competencies. Participants consistently reported that the volume of procedures required within limited clinical rotations creates an unrealistic expectation for competency demonstration. This finding aligns with Sharif and Masoumi's research, which documented similar time pressures in clinical environments that compromise students' ability to achieve core competencies [15].

The limitation is particularly problematic given the nature of practical register completion, where students must first observe, then perform procedures under supervision, and finally demonstrate independent competency. This progression requires adequate time for skill development and confidence building, which current clinical schedules do not accommodate. The study revealed significant congestion in clinical areas, with multiple training institutions simultaneously placing students in the same healthcare facilities. This overcrowding creates a competitive environment where students must compete for limited procedural opportunities, fundamentally undermining the collaborative learning environment essential for nursing education.

This finding is consistent with Mostaanaka, Makhene, and Ally's research at public academic hospitals, where large student placements resulted in insufficient clinical learning opportunities [16]. The problem is compounded by the presence of students from various healthcare disciplines, including medical students, physiotherapists, and emergency medical practitioners competing for the same clinical experiences. This multi-disciplinary congestion suggests a need for better coordination between educational institutions and healthcare facilities to ensure adequate learning opportunities for all students.

The research identified particular challenges in specialty areas, notably midwifery modules, where the unpredictable nature of clinical procedures (such as deliveries) creates additional barriers to register completion. The episodic nature of obstetric care, combined with student overcrowding in maternity wards, creates a perfect storm of limited opportunities and high demand.

This specialty-specific challenge highlights the need for differentiated approaches to clinical education, particularly in areas where procedures cannot be scheduled or simulated easily. The unpredictability of clinical opportunities in certain specialties requires more flexible assessment methods and extended clinical placements to ensure adequate exposure.

The study revealed a concerning gap in support from both registered nurses and academic lecturers. Registered nurses, who serve as primary clinical supervisors, appear to be overwhelmed by high patient loads and multiple responsibilities, limiting their ability to provide adequate mentorship to students. This finding reflects broader issues in healthcare staffing and workload management that extend beyond nursing education.

Lecturers' limited presence in clinical areas represents a significant weakness in the educational support structure. While lecturers remain available for assessments and examinations, their absence during day-to-day clinical learning activities creates a disconnect between theoretical knowledge and practical application. This suggests that academic institutions may be prioritizing theoretical teaching over clinical supervision, potentially due to resource constraints or competing academic demands.

Notably, the study identified preceptors as a positive factor in supporting students' clinical learning. Students acknowledged that preceptors provide adequate support and play a vital role in ensuring practical register requirements are met. This finding supports Killian and Heerschap's research on the importance of preceptors in bridging the theory-practice gap [12]. The effectiveness of preceptors compared to other support systems suggests that dedicated clinical educators, specifically trained in student supervision, may be more effective than relying solely on busy registered nurses or distant academic lecturers. This finding has important implications for clinical education models and resource allocation.

The study identified significant communication barriers related to unclear definitions and expectations in practical registers. When clinical supervisors cannot understand what is expected from students, or are unfamiliar with assessment criteria, the entire evaluation process becomes compromised. This suggests inadequate orientation of clinical staff to educational requirements and assessment standards. The lack of clarity in practical registers may also indicate poor communication between academic institutions and clinical facilities. If nurses are uncertain about how to grade assessments or what constitute satisfactory performance, this reflects a fundamental breakdown in the partnership between educational and clinical settings.

The identification of duplicated procedures across various practical registers reveals inefficiencies in the assessment system that may contribute to completion delays. When students must repeatedly demonstrate the same competencies in different registers, valuable clinical time is wasted, and assessment fatigue may compromise learning outcomes. This redundancy suggests a need for comprehensive curriculum review to eliminate unnecessary duplication while ensuring that all essential competencies are adequately assessed. Streamlining assessment requirements could free up time for students to focus on developing new skills rather than repeatedly demonstrating previously mastered competencies

Recommendations

The following recommendations were inferred from the study:

• Extended Clinical Rotations: Implement longer clinical placement periods to provide adequate time for the observe- practice-demonstrate competency progression. Current timeframes should be reviewed and expanded to accommodate realistic skill development timelines.

• Flexible Assessment Scheduling: Develop more adaptable assessment methods, particularly for specialty areas like midwifery where procedures are unpredictable. This could include extended assessment windows or alternative competency demonstration methods.• Inter-institutional Coordination System: Establish a centralized coordination mechanism between multiple educational institutions and healthcare facilities to manage student placements more effectively. This would prevent overcrowding and ensure equitable distribution of clinical learning opportunities.

• Capacity-based Placement Limits: Implement maximum student-to-clinical-area ratios that consider both the facility's capacity and the diversity of students from different healthcare disciplines competing for the same experiences.

• Dedicated Clinical Educator Model: Expand the preceptor program, which has proven effective, and reduce reliance on overburdened registered nurses for primary supervision. This could involve hiring dedicated clinical educators or training more specialized preceptors.

• Comprehensive Orientation Programs: Develop mandatory orientation sessions for all clinical staff involved in student supervision, clearly explaining practical register requirements, assessment criteria, and grading standards.

• Practical Register Audit: Conduct a comprehensive review of all practical registers to identify and eliminate duplicated procedures while ensuring essential competencies remain adequately assessed.

• Specialty-specific Solutions: Develop targeted approaches for challenging specialty areas, potentially including simulation- based learning to supplement unpredictable clinical opportunities.

Limitations

The study was limited to Bachelor of Nursing students at the University of Namibia, Southern Campus and may not be generalized to other University of Namibia campuses or other institution of higher learning offering nursing course.

Conclusions

The study concludes that nursing students are faced with various challenges that hampers the completion of practical registers timely. These factors include insufficient time allocation at clinical areas, inadequate clinical areas for practical, insufficient procedures, inability to get signatures from registered nurses, limited visits from lecturers, unclear content in the register and fragmented content in practical register. Therefore, the study recommends that increment of time in clinical areas to enable the students to complete their registers timely. The study also suggested the expansion of clinical facilities for placement to avoid overcrowding of wards so that the procedures would be sufficient for all students. The study also recommended a reduction of workload among lecturers to enable them to get time to visit their students in practice or recruit more preceptors to support the lecturers with clinical practice to close the gap between theory and practice. The study also suggested the review of the practical registers in order to reduce duplicates.

The study conclusively demonstrates that nursing students at the University of Namibia, Southern Campus face a complex of interconnected systemic barriers that significantly impede their ability to complete practical registers within required timeframes,ultimately compromising both educational outcomes and clinical competency development. The study reveals that insufficient time allocation for the natural progression from observation to independent competency demonstration, combined with severe overcrowding in clinical areas where students from multiple institutions and disciplines compete for limited procedural opportunities, creates an environment fundamentally unsuited to effective nursing education. These challenges are exacerbated by inadequate supervision from overwhelmed registered nurses and absent academic lecturers, poor communication between educational institutions and clinical facilities regarding assessment expectations, and inefficient assessment systems that require students to repeatedly demonstrate the same competencies across different registers. While preceptors emerge as a positive support factor, their effectiveness only highlights the deficiencies in the broader support structure. The findings suggest that these are not isolated administrative issues but rather systemic failures. This requires comprehensive structural reform, including better inter- institutional coordination, redesigned clinical placement schedules, enhanced dedicated clinical education support, streamlined assessment processes, and improved communication protocols. Most critically, the study reveals that these barriers extend beyond mere completion delays compromising the development of essential clinical competencies. In addition, transforming nursing education what might appear to be an educational administration challenge, into a significant healthcare workforce development crisis with implications for future healthcare quality and patient safety [17-37].

Acknowledgments

We wish to thank all the authorities that granted us the permission to conduct this study as well as the Bachelor of Nursing students at the University of Namibia, Southern Campus who gave up their time to be involved in this study. Thank you.

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