Experiences and impact of clinical practices on the development of emotional and ethical competencies in nursing students caring for older adults

Vivencias e impacto de las prácticas clínicas en el desarrollo de competencias emocionales y éticas en estudiantes de enfermería que atienden adultos mayores

Silvana Ximena López Paredes*, María Elisa Guanipatin Aguilar*, Nancy Elizabeth Milán Guacho*

Introduction

The aging of the world's population is one of the most important demographic and social challenges of the 21st century. According to the World Health Organization (WHO, 2021), it is estimated that by 2050, more than 2.1 billion people will be 60 years of age or older, representing more than 20% of the global population. This scenario calls for the implementation of public policies, reforms in health systems, and, especially, the training of competent professionals who can provide comprehensive, ethical, and humane care to older adults (WHO, 2021).

In this context, the training of future nursing professionals takes on a fundamental role. Care for older adults requires not only specialized technical knowledge, but also emotional and communication skills that enable an understanding of the biopsychosocial needs of this population (López-Fernández, 2015). Clinical practice in gerontological settings is an ideal environment for nursing students to develop these skills, as they are confronted with real-life situations that allow them to apply what they have learned in the classroom and strengthen their empathy and dedication to service (Uriarte et al., 2016).

However, clinical practice also poses significant emotional challenges. Students in training must deal with complex situations such as suffering, functional dependence, cognitive impairment, and the proximity of death, which can cause feelings of anxiety, frustration, and helplessness (Tessa, 2015). These stressors affect both students' emotional well-being and their academic performance, creating a need to include emotional coping strategies in training programs (Gutiérrez-Murillo et al., 2021).

According to recent studies, one of the factors that facilitates students' adaptation to these environments is the development of emotional intelligence (EI), defined as the ability to recognize, understand, and regulate one's own emotions and those of others (Goleman, 1995). EI not only contributes to stress management, but also allows for the establishment of healthy interpersonal relationships with patients, family members, and healthcare teams, which are key aspects of providing humanized care (López-Fernández, 2015).

Likewise, empathy is consolidating itself as one of the most relevant competencies in caring for older adults. This skill allows students to understand patients' emotional experiences, adapt to their needs, and treat them with dignity and respect (Gutiérrez-Murillo et al., 2021). Empathetic practice not only improves the quality of care but also strengthens the comprehensive training of future nursing professionals (Aguilar-Luzón & Augusto-Landa, 2009).

Developing these skills is not always easy. Research by Rosana Tessa (2015) identified that the main stressors in clinical practice include lack of skills, direct contact with suffering and illness, difficulties in relationships with colleagues, and the difference between theory and the reality of the clinical environment. These factors not only affect the learning process but can also lead to anxiety, insomnia, and low self-esteem in students (Tessa, 2015).

For their part, Uriarte et al. (2016) highlight that, despite the difficulties, nursing students value clinical practice in gerontological settings as highly meaningful experiences that contribute decisively to strengthening their technical, ethical, and emotional skills. These practices not only allow them to apply their knowledge, but also confront them with ethical dilemmas related to the autonomy, dignity, and quality of life of older adults.

The Amawta Wasi Samay Gerontological Center, located in the city of Guaranda, is an ideal setting for the development of these practices. This center provides comprehensive care to older adults in socially vulnerable situations, allowing students from the Bolívar State University to interact with diverse realities that involve not only physical care, but also aspects related to emotional support and the promotion of residents' autonomy.

The experiences gained at this center allow students to identify perceptions, emotions, challenges, and lessons learned, contributing to the design of pedagogical strategies aimed at strengthening academic training and promoting humane, comprehensive care that is sensitive to the needs of this vulnerable population (Suliman, 2010). In addition, these experiences encourage students to reflect on their own beliefs and attitudes towards old age, facilitating the construction of a more comprehensive and empathetic view of the aging process (Uriarte et al., 2016).

Within this framework, the present study aims to understand the experiences of nursing students during their clinical practice at the Amawta Wasi Samay Gerontological Center, identifying their perceptions, emotions, challenges, and learnings. This study seeks to contribute to the strengthening of nursing training programs by incorporating strategies that enable students to face the emotional challenges of clinical practice and promote person-centered, dignified, and humane care.

Materials and methods

This study was conducted using a qualitative approach, as the aim was to gain an in-depth understanding of the experiences, emotions, and lessons learned by nursing students in the context of caring for older adults. The qualitative approach allowed us to explore the participants' subjectivity, facilitating the identification of the meanings attributed to their experiences during clinical practice (Hernández Sampieri et al., 2014).

A phenomenological design was applied, which focused on describing and analyzing the experiences of the students from their own perspective. This design was ideal for understanding the meanings attributed to their professional practices, highlighting the emotional, formative, and ethical dimensions associated with gerontological care (Sandín, 2003). 

Phenomenology facilitated the analysis of subjective experiences, promoting understanding of the challenges and lessons learned in institutionalized settings (Colaizzi, 1978).

The study population consisted of nursing students from the Bolívar State University who completed their clinical practice at the Amawta Wasi Samay Gerontological Center. Convenience sampling was used, selecting 15 students who met the following inclusion criteria: having completed their internship at the aforementioned center, agreeing to participate voluntarily, and signing the informed consent form. The exclusion criteria considered students who did not complete their clinical internship at the center or who did not give their consent.

The sample was determined according to the principles of theoretical saturation, considering that the repetition of themes in the participants' discourses indicated the sufficiency of the data obtained (Glaser & Strauss, 1967).

Semi-structured interviews were used to collect information, which were divided into three blocks: opening, development, and closing questions. This type of interview allowed for an in-depth exploration of the participants' perceptions, emotions, and learnings, encouraging the free expression of their experiences (Kvale & Brinkmann, 2015).

Opening questions: These were aimed at building trust and exploring the students' expectations before their first contact with elder care.

Development questions: These delved deeper into the challenges faced, the predominant emotions, and the strategies used to provide humanized care.

Closing questions: These allowed us to learn about the students' reflections on what they had learned and its impact on their future professional practice.

The interviews were audio recorded, with the participants' permission, and then transcribed verbatim to ensure the accuracy of the information collected.

The information was analyzed using ATLAS.ti version 9 software, applying the thematic content analysis technique. Open, axial, and selective coding was performed to identify emerging categories and establish relationships between them (Strauss & Corbin, 2002).

To ensure the rigor of the study, the criteria of credibility, transferability, dependency, and confirmability proposed by Guba and Lincoln (1985) were applied, which strengthened the validity of the results. Data triangulation was performed by comparing the participants' discourses and the emerging categories, facilitating a deeper interpretation of the experiences studied.

Results

The experiences of 15 nursing students from Bolívar State University during their clinical practice at the Amawta Wasi Samay Gerontological Center were analyzed. Based on the analysis of semi-structured interviews and using ATLAS.ti version 9 software, three main categories were identified: Expectations and first experiences, Emotions and humanized care, and Significant experiences, which provided insight into the challenges, emotions, and lessons learned from interacting with vulnerable older adults.

As part of this analysis, a conceptual network was developed to visualize the relationships between the categories and subcategories identified during data processing. This graphical tool facilitated the interpretation of the findings, showing in a structured way the connections between the experiences, emotions, and lessons learned by nursing students in the context of caring for older adults (Figure 1).

Graph 1. General analysis network

The network is organized around three main categories: Expectations and first experiences, Emotions and humanized care, and Significant experiences, from which various subcategories are derived.

1. Demographic Data of Participants

The group of participants was mostly made up of women (60%), which is in line with the trend toward feminization in the nursing profession (World Health Organization, 2021). In terms of age, most of the students were between 20 and 22 years old (53.3%), while the rest were between 23 and 25 years old (33.3%) and a small percentage were over 25 years old (13.4%), as shown in Table 1.

Table 1. Demographic Profile of Participants

Variable	Frecuencia (n)	Porcentaje (%)
Género
Masculino	6	40%
Femenino	9	60%
Edad
20-22 años	8	53.3%
23-25 años	5	33.3%
>25 años	2	13.4%
Semestre cursado
Séptimo	10	66.7%
Octavo	5	33.3%

Note: Prepared by the author based on data collected in interviews.

Category 1: Expectations and First Experiences

Before beginning clinical practice, students expressed high expectations for applying the theoretical knowledge they had acquired. Most expressed enthusiasm for gaining real-life experience in geriatric nursing, although they also expressed fear and uncertainty about the possibility of not being sufficiently prepared to care for people in complex situations.

One participant commented: “I hoped they would teach me to communicate emotionally, not just technically; I wanted to know how to reach the hearts of older adults.”

The first experiences were characterized by the confrontation of idealized expectations with institutional reality. The difficulty of establishing effective communication with patients with cognitive impairment and language barriers, such as the Quichua language, were situations that generated anxiety and feelings of frustration. However, as the weeks progressed, these challenges became learning opportunities, allowing for the development of nonverbal communication skills and empathy.

Category 2: Emotions and Humanized Care

During their practice, students experienced a wide range of emotions. Joy and satisfaction arose when establishing emotional bonds with older adults, while sadness and helplessness appeared when observing cases of family abandonment, advanced diseases, and severe physical limitations.

Table 2. Predominant Emotions During Clinical Practice

Emoción	Frecuencia (n)
Alegría	9
Tristeza	5
Impotencia	4
Satisfacción	8
Frustración	3

Note: Prepared by the authors based on interview data.

The main strategy used to overcome these challenges was the implementation of a humanized care approach based on empathy, patience, and active listening. As one student pointed out: “I discovered that sometimes just listening and accompanying is enough; a gesture or a word can change an older adult's day.”

The students emphasized that effective communication was key to establishing trusting relationships. Faced with verbal language limitations, they resorted to eye contact, smiles, caresses, and other nonverbal gestures that facilitated the emotional expression of older adults, reinforcing the importance of person-centered care.

Figure 1 shows the frequency of the most relevant emotions experienced by nursing students during their clinical practice at the Amawta Wasi Samay Gerontological Center.

Joy was the most frequently reported emotion (n=9), indicating that, despite the challenges inherent in caring for older adults, the students managed to establish satisfying emotional bonds, creating moments of well-being for both themselves and the patients.

Satisfaction was the second most frequently mentioned emotion (n=8), mainly associated with the fulfillment of their humanized care objectives and the perception of having made a significant contribution to the quality of life of older adults.

In contrast, emotions such as sadness (n=5) and helplessness (n=4) were also present, reflecting the emotional impact of situations of family abandonment, deterioration of patients' health, and institutional limitations in providing optimal care.

Finally, frustration (n=3) was reported to a lesser extent, linked to difficulties in applying some of the knowledge acquired in theoretical training and challenges in communicating with patients who had language barriers or cognitive impairment.

Graph 1. Emotions Expressed During Practice

Category 3: Significant Experiences

The students highlighted that their time at the Amawta Wasi Samay Gerontological Center provided them with lessons that went beyond technical knowledge. These experiences allowed them to strengthen skills related to emotional intelligence, stress management, resilience, and professional ethics.

One testimony illustrates this learning: “I learned that caring is not just about healing, it is about accompanying, listening, and being present in the most vulnerable moments of life.”

In addition, 46.7% of students expressed interest in specializing in geriatric nursing after this experience, which shows a positive impact on their professional vision.

Table 3. Interest in specializing in geriatrics

Respuesta	Frecuencia (n)	Porcentaje (%)
Sí, desea especializarse	7	46.7%
No lo ha considerado	5	33.3%
Indeciso	3	20%

Note: Prepared by the author based on interviews.

These experiences helped redefine their perception of palliative care. Participants acknowledged that they initially associated it only with pain management and end-of-life care; however, after the internship, they understood that it also involves providing emotional support and improving patients' quality of life until the end of their days.

This study provided an in-depth understanding of the experiences, emotions, and lessons learned by nursing students during their clinical practice in caring for older adults, confirming the relevance of practical experiences in the development of technical, ethical, and emotional skills.

The findings coincide with those of López-Fernández (2015), who points out that clinical practice is a key setting for acquiring communication and emotional skills, especially in contexts of high emotional demand such as geriatric care. The presence of intense emotions such as joy and satisfaction, but also sadness and helplessness, highlights the emotional burden involved in direct contact with people in vulnerable situations, as pointed out by Uriarte et al. (2016).

On the other hand, difficulty in communication, identified as one of the main challenges, is a recurring theme in the literature. Previous studies highlight that cognitive impairment and cultural and language differences constitute significant barriers to the provision of effective care (Gutiérrez-Murillo et al., 2021). However, the implementation of nonverbal communication strategies and the creation of bonds of trust, identified in this study, confirm the students' ability to adapt and apply a person-centered approach.

In terms of meaningful learning, the results show that clinical practice not only strengthened technical skills but also transformed students' perceptions of geriatric care and palliative care. This finding is consistent with the findings of Anaya et al. (2023), who argue that exposure to end-of-life care settings allows future professionals to develop a more comprehensive and humanized view of the aging and dying process.

Finally, it is important to note that almost half of the students expressed an interest in specializing in geriatrics, reflecting the positive influence of clinical practice on the definition of professional vocations, as suggested by Vallejos et al. (2020). This result underscores the need to strengthen practice spaces in contexts of care for older adults, promoting training that is more conscious and committed to respect for human dignity.

Conclusions

Clinical practice in geriatric settings is a key setting for developing humanized skills in caring for older adults. Students not only applied theoretical knowledge, but also learned to manage complex emotions, establish trusting relationships, and provide care focused on the dignity and autonomy of patients.

The emotions experienced during the internship had a significant impact on the students' perceptions and vocation. Joy, satisfaction, and a sense of accomplishment were combined with feelings of sadness and helplessness in the face of physical limitations, cognitive decline, and situations of neglect observed in older adults. These experiences reinforced the need to strengthen emotional intelligence and communication skills in nursing education.

A gap was identified between theoretical training and the emotional and ethical demands of the real-life practice context. This finding highlights the need to review curriculum plans, incorporating spaces for critical reflection, simulations of complex scenarios, and activities that promote empathy and emotional support.

Experiential learning transformed the students' perception of palliative and geriatric care, motivating them to adopt a comprehensive and humanized approach in their future professional performance. Proof of this is that a significant percentage of participants expressed interest in specializing in areas related to care for older adults.

It is concluded that clinical practices in settings such as the Amawta Wasi Samay Gerontological Center are highly valuable training experiences that contribute not only to the development of technical skills but also to the formation of professionals committed to the ethics of care, respect for human dignity, and the promotion of active and dignified aging.

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