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Challenges in the clinical education of the nursing profession in Iran: A qualitative study
Accepted Manuscript Challenges in the clinical education of the nursing profession in Iran: A qualitative study
Madineh Jasemi, Bill Whitehead, Hosein Habibzadeh, Roghaieh Esmaeili Zabihi, Soheila Ahangarzadeh Rezaie PII: DOI: Reference:
S0260-6917(18)30169-2 doi:10.1016/j.nedt.2018.04.010 YNEDT 3833
To appear in: Received date: Revised date: Accepted date:
9 April 2017 19 March 2018 12 April 2018
Please cite this article as: Madineh Jasemi, Bill Whitehead, Hosein Habibzadeh, Roghaieh Esmaeili Zabihi, Soheila Ahangarzadeh Rezaie , Challenges in the clinical education of the nursing profession in Iran: A qualitative study. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ynedt(2018), doi:10.1016/j.nedt.2018.04.010
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Title of the article: Challenges in the clinical education of the nursing profession: A qualitative study Running title: Challenges in the clinical education of the nursing profession Word counts: 5000 For abstract: 210 For the text: 3953 Contributors 1. Madineh Jasemi Assistant professor in Nursing, Faculty of Nursing and Midwifery, Urmia university of Medical Sciences, Iran 2- Bill Whitehead BA(hons) PGCCE PhD RGN RNT FHEA Head of Department Nursing, Radiography and Healthcare Practice, University of Derby, Kedleston Road Derby. Uk 3 -Hosein Habibzadeh
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Associate Professor in Nursing, Faculty of Nursing and Midwifery, Urmia university of Medical Sciences, Iran 4- Roghaieh Esmaeili Zabihi Lecture in Nursing, Faculty of Nursing and Midwifery, Urmia university of Medical Sciences, Iran 5. Soheila Ahangarzadeh Rezaie (Corresponding Author) Assistant professor in Nursing, Faculty of Nursing and Midwifery, Urmia university of Medical Sciences, Iran
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Soheila Ahangarzadeh Rezaie (Corresponding Author) Assistant professor in Nursing, Faculty of Nursing and Midwifery, Urmia university of Medical Sciences, Iran Telephone: +98-09144462842 Email: jasemi. [email protected] Design: Madineh Jasemi, Soheila Ahangarzadeh Rezaie Literature search: Madineh Jasemi, Hosein Habibzadeh Data analysis: Madineh Jasemi, Soheila Ahangarzadeh Rezaie Manuscript preparation: Madineh Jasemi, Bill Whitehead, Roghaieh Esmaieli Zabihi Manuscript editing: Madineh Jasemi, Bill Whitehead Title Page (including article title, word count, full author details and all acknowledgements) Source(s) of support: This study was supported by a research grant from Urmia University of Medical Sciences, Iran Conflicting Interest: The authors declare no conflict of interest Acknowledgement: This study was supported by a research grant from Urmia University of Medical Sciences, Iran and was approved by the ethical committee. The authors would like to express their sincere gratitude to this canter and all the participants for their cooperating in this study
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Challenges in the clinical education of the nursing profession in Iran: A qualitative study
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Abstract Introduction: Clinical education is an important part of nurse training. It provides students with the opportunity to gain useful experience and has a key role in their professional preparation. The importance of clinical education in nursing students’ professional performance means that identifying the challenges in this field is crucial. Aim: The goal of this study is to identify challenges in the field of clinical nurse education. Design: A qualitative content analysis study. Setting: A faculty of Nursing and Midwifery, in Iran 2017. Participants : Nine student nurses, three qualified nurses and two nursing educators. Methods: This study has been applied to various depths of interpretation. Semi-structured interviews were used to collect the data. Nine student nurses, three qualified nurses and two nursing educators were interviewed. Results: The analysis of the interviews generated five categories. Two main themes were extracted as challenges in the clinical training of nursing professionals: 1. Inefficient educational structure and 2. Inefficient professional performance environment. Conclusion: Considering the inadequate professional performance environment and defective educational structure, designing and delivering lessons with clear goals is essential. Using objective and measurable scales for evaluating educational standards, the use of empowered instructors with high communicational skills is useful for increasing students' motivation and interest toward clinical education and solving existing challenges.
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Keywords: qualitative study, content analysis, clinical education, nursing
Introduction
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Improving the quality and quantity of every profession depends on increasing the knowledge and proper functioning of its staff. It also requires them to have professional and correct training (Admi, 2006). In fact, correct training is the basic foundation of each profession and has a key role in providing an educated and professional workforce (Paterson, 2007). In the nursing profession, a well trained and educated, experienced workforce is very important. The purpose of nurse training is to prepare graduate nurses to care for and promote the health and quality of life of people (Aliakbari and Aslani, 2013). Nurse education includes both theoretical and clinical training in which the clinical training often gets half of the educational program and it has special importance and place (Atash Sokhan et al., 2011). During training, students in the clinical setting, through active participation in learning and care, become professionally prepared and acquire a professional point of view (Smith-Strom and Nortvedt, 2008). Good clinical training facilitates student communication with patients in a real environment; specifies students` activities and goals; teaches them the concept of team work; builds creativity and motivation in students; increases problem-solving skills; judgment and decision making (Thomas, 2005). This training increases students` clinical experiences and performance and prepares them to enter the work environment (Abbeglen, 2006). In many ways, clinical training is different and more complicated than theoretical education. It takes place in the real professional environment and in line with skills training that cannot be gained from classroom based sources or simulation (Mongwe et al., 2009). Consequently, this training method needs special attention (Mlek et al., 2011). Despite the importance of clinical education, this training method continues to face many challenges (Saarikoski et al., 2013). Most nursing graduates are dissatisfied with clinical training (Paterson, 2007). In this regard a study was conducted in Iran which showed that 88% of nursing students believe clinical education has weaknesses (Heydari et al., 2012). Other studies have been conducted in Iran (Heydari et al., 2012) but the problem remains. Solving problems in the field of education first needs to better identify clinical education and challenges in this field. Assessing this phenomenon through qualitative research that involves multiple methods of gathering information and reviewing the facts, norms and values from the perspective of participants (Strubert and Carpenter, 2007), can identify and illuminate the issues in clinical nurse education. Application of the findings to practice can help to improve the quality of clinical education. This study, through assessing experiences of nursing students and nurses, will attempt to examine the research aim below. Aim: The goal of this study is to identify challenges in the field of clinical nurse education. Method This study employed conventional content analysis which consists of a definition of the phenomenon and interpretation of the context, through careful classification of codes and the identification of themes (Zhang and Wildemuth, 2009). The researcher identifies labels and categories that emerge from the data, and by immersion in the data, achieves new insights (Hsieh and Shannon, 2005). In view of the objective of the study - investigating challenges in the field of clinical nurse education - we initially selected nursing students with experience of clinical education. Subsequently, based on the results of the interviews and to verify the findings through triangulation, we performed theoretical sampling and interviewed three qualified nurses and two nursing educators.
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In total, 14 participants - four males and ten females - were selected and interviewed. Since lower grades are required to enter a private university in Iran, graduates of both public and private universities were sampled. Sampling was continued to the point of data saturation. To make the data more reliable, participants were selected from various cultural backgrounds and diverse hospitals and wards in Iran in 2017. This study lasted nine months. To better relate to the environments of the study and the participants and analyze the data realistically, the researcher also used field notes. Field notes are a brief summary of the observations made while collecting data. This is not limited to a particular type of activity or behavior and assesses the non-verbal behaviors of the participants and their interactions with others. It also depicts a picture of a social position. In this study, field notes also made a detailed presentation of the situation in the right place immediately after the interview and provided the opportunity to confirm the psychological and emotional reactions of the participants. For example, attending the ward where theoretical training of how to connect the patient to a ventilator, instead of practical training by the instructor was mentioned as a field note and confirmed the defects of clinical education methods. The data were collected via semistructured interviews with a focus on informants’ experiences and feelings toward clinical education. Subsequently, based on each participant's answers, more questions were asked and the difficulties which the nursing students had encountered in clinical education were brought into focus. Each interview, which lasted 60 to 90 minutes, was tape recorded, transcribed and analyzed.
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To analyze the data, the qualitative data software program MAXQDA, which facilitates classifying codes, placing them in categories and eliciting themes, was used (Strubert and Carpenter,2007),). After reading and interpreting the interviews, the researcher established meaningful units to analyze the data. Next, using MAXQDA, a proper code was assigned to each phrase or paragraph. Similar codes were placed in the same category; the codes were constantly compared and re-categorized. Finally, after comparing and contrasting the categories, the ultimate themes were extracted and edited. The data were verified by the participants, co-researchers and two external researchers. Taking field-notes during the interviews enabled the researcher to verify the validity of the findings while analyzing them. The manner of codification, categorization and formation of the final themes was explained to the observers and external researchers to make the results verifiable. Ethics The present study has been approved by the ethical committee at The Medical University of Urmia. Participant information sheets and consent forms were provided. Introduction papers were produced for the hospitals; the participants were informed of the objectives of the study and agreed in writing that the researcher could use their information. Results Categorizing the results of interviews showed two overarching categories emerged from the data as challenges in clinical education of the nursing profession needing special attention: 1.Inefficient educational structure and 2. Inefficient professional performance environment (table 1).
1. Inefficient educational structure
ACCEPTED MANUSCRIPT Educational structure is one of the factors in clinical training that can have an invaluable role in the education of nursing graduates and can be a professional background for their preparation. However, the experiences of the participants indicated that educational structure is not adequate in the field. Weaknesses in programming and educational content, shortcomings of clinical teaching methods, and limited competence of instructors were indicators of the defective educational structure.
a. The weakness of programs and educational content
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Programs and educational content constitute part of the educational structure. If it is comprehensive, it will prepare learners for clinical training and improve their ability to take the appropriate care of patients. However, participants believed that in most cases program and educational content were weak. In this regard neglect of the nursing process in the course of study, limited training time were the indicators of weakness in program and educational content. This will be illustrated in the issues below. Neglect of the nursing process in the course of study Learning the nursing process has an important role in providing diagnoses through the development of nursing students’ critical thinking. However according to most participants, teaching the nursing process has been neglected. As a participant has stated:
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“The number of lectures that were intended to be taught on the nursing process for us was very low. Now that I think about it, I see theoretically during the course, and in class, it has been neglected as an important subject to study.”(P.3)
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Unsystematic methods of training clinical nursing are another factor which has led to downplaying the nursing process in the course of study in a way that most participants refer to the issue. Many participants stated that the application of the nursing process was not properly taught to them. In this regard a participant stated:
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“The clinical education, nursing unit was taught in a limited way as a class assignment. For example we were asked to write a nursing process for a disease and it was about a particular disease that sometimes the disease was not in the ward and it was not in a way that we practically do it with the patients in clinical practice.” (P.4)
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Limited training time For clinical training to be effective in providing the skills to perform good fundamental care, it is necessary to provide enough time to familiarize students with a variety of procedures and expertise to do them. However based on the experiences of participants, time for clinical training is inadequate. In this regard one of the participants said: “Our training time for education of a variety of diseases and common care in ward was not enough. For example in the orthopedic ward there was not enough time for the instructor to come and teach different diseases, dressings, traction and care. As we wanted to learn something, our wards were changed. There was not enough time for clinical training.” (P.1)
b. Shortcomings of clinical teaching methods Another sub-category of faulty educational structure is the shortcomings of clinical education methods. According to participants, there are weaknesses in the methods of clinical education
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to familiarize students with the real clinical environment; better understanding of patients` problems; and their ability to provide care. Trainer centered education and use of theoretical training in clinical setting are characteristics of this theme, as illustrated in the issues below. Trainer centered education One of the reasons for the effectiveness of clinical education in preparing students to enter the profession is their more active role in the learning process, utilizing the power of reason and as a result, the growth of critical thinking. However according to testimony from the experiences of participants, clinical teaching methods in Iran often vary dependent on the instructor’s preferences and are trainer-centered. In this regard one of the participants pointed to lack of freedom and said:
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“In wards we mostly depended on the instructor. Anything we did for the patient such as nursing diagnosis, mode of care and the procedures we offer was based on the instructor`s ideas. He/she dictated to us and we did not have the freedom to select evidence based care approac hes” (P.12)
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Use of theoretical training in clinical setting Practical training, in professional care, has an important role in doing procedures and role modeling of students from the instructor and giving systematic care. However according to participants` experiences training was mostly theoretical. A participant pointed out the lack of practical training in the preparation for some skills and said:
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“When we went for training in ICU the instructor did not provide practical education for the ventilator, taking atrial blood gases (ABG) and other professional care. They taught most of them theoretically and this leads us not to learn most of the specialist care skills. Consequently, we faced a lot of problems later when we entered the workplace.” (P.14)
c. Limited competence of instructor
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The instructor`s competence is a key component of the educational structure that can have a fundamental role in learners` role modeling in the acquisition of capabilities and expertise (Whitehead 2010). Unfortunately, most participants talked of limited capability and weakness of instructors. The issues which emerged from the data in this theme were: deficiencies of evaluation method and limited capability of instructors, which are introduced as the two sub-categories of limited competence of the instructor below. Deficiencies of evaluation method Educational evaluation or assessment is one of the most important and challenging issues in clinical training which is considered the most important duty of the instructor. Evaluating method is a motivational factor for learners and guides their efforts in line with the instructor`s expected criteria. It is also vital to ensure that students have a sufficient level of proficiency to perform nursing skills safely. Despite the importance of the evaluation, participants` experiences indicated shortcomings in this field. Confirming this, one of the participants said: “Unfortunately most times the instructors made subjective assessments; there were no special criteria for evaluation. It was not clear what their evaluation criteria were. Sometimes a weak student got a good grade while a clever student got a low grade.” (P.9)
Limited capability of the instructor
ACCEPTED MANUSCRIPT More scientific and practical capability is required of instructors; they need to be more proficient in their presentation of routine and specialized techniques. If they had sufficient knowledge and skill they would receive more acceptance and role modeling from students. The role of instructor, if they demonstrate capability provides effective role modeling. Students’ interest in their profession and their motivation increase. Unfortunately, data from participants` experiences showed limited capability of instructors. In this regard one of the participants said:
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“During my studies I could find no pattern, there was no instructor who could practically and professionally execute ideal care in the clinical environment. Mostly they had low skills and capabilities, their practical skill was low and scientifically when we asked questions they didn`t know the answers.”(P.9)
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2. Inefficient professional performance environment
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Another category related to clinical education is the professional performance environment which has an essential role as a real environment for gathering experience in clinical education. This category includes two sub-categories of inappropriate professional interactions and limited conformity of clinical environment with professional standards.
a. Inappropriate professional interactions
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Professional interaction is a critical component of the professional performance environment that when appropriately communicated can increase professional self-esteem and make students become interested in their profession. However, unfortunately, most participants talked of inappropriate professional interactions in the form of unsuitable expectations and treatment by the staff and authorities. These will now be discussed in the two issues below. Inappropriate expectations of staff and authorities In Iranian nurse training, clinical education, especially in the final semesters is under the supervision of nursing staff and authorities of hospital wards. If the expectations of staff and authorities are illogical and inconsistent with the capabilities of the students, it will increase stress and tension in them and will engender a decrease of their self-confidence and a negative view of their profession. In this regard one of the participants said:
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“Previously when the instructor was with us we didn`t have these problems and we worked with one or two patients but now that we are in the internship course, expectations of the nurses are too much. They want us to do all the job; drugs, vital signs and dressin gs.” (P. 6)
Inappropriate treatment of students by staff Appropriate treatment of nursing students by nursing and medical staff increases their sense of belonging and confidence and also their motivation to learn skills. Unfortunately, based on available data treatment of staff with students is not mostly appropriate. In this regard one of the participants said: “We don`t have the right to approach the nursing station. The staff treat us in a way as if we are not going to be their colleagues in the future. Doctors and medical students are proud of themselves and when we are present on visits we don`t dare to ask questions or if we know something to comment. Nurses and doctors treat us in a way that we regret and these cause our self -confidence to be low.” (P.3)
b. Limited conformity of clinical environment with professional standards
ACCEPTED MANUSCRIPT Limited conformity of clinical environment with professional standards is another subcategory of the professional performance environment which is based on the participant testimonies. The poor educational facilities in clinical education and disregard for standards of professional care have a restricting role.
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Poor educational facilities The second sub-category of inefficient professional performance environment is inappropriate professional facilities. It is clear that the availability of facilities plays an important role in promoting clinical education and can be useful in professional preparation of students. However, according to participants they are often faced with limited educational facilities in clinical environments. In this regard one of the participants pointed out the limitations of educational space and stated:
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“For us there are no classes to present clinical conferences. The classes are available for medical students. We are always forced to have conferences while we are standing and we get very tired.” (P.10 )
Another participant pointed out the restricting role of lack of facilities in acquiring clinical skills and said:
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“Lack of facilities on wards causes us not to do lots of procedures. For example when we want to assign an IV line for the patients we have the right to use only one needle. If we can`t do it with that, it will be extra cost for the patient so most times the instructor him/herself does the job.” (P.7)
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Disregard for standards of professional care Observance of standards of care in the clinical environment by treatment staff encourages positive role modeling for students and professionally prepares them. According to participants in most cases they witnessed unprofessional performance of staff and disregard to standards of care. This caused more gaps between theory and practice in clinical setting and inappropriate role modeling for students. In this regard one of the participants said:
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“A lot of things that were theoretically emphasized in the skill lab I saw were not done when I entered the clinical environment. For example in catheterization we were so much emphasized to consider principals of sterility etc. but in the ward we saw that there was no attention to asepsis or in the case of on time administration of antibiotics we saw they were not on time and most students follow these wrong approaches and act based on the incorrect routines of wards.” (P.6)
Discussion Clinical education provides an appropriate opportunity to convert theoretical knowledge to psychomotor skills for nursing students in the care process, so paying attention to clinical education and effecting factors is important (Heidari and Norouzadeh, 2015) and provides professional preparation for nursing students (Ahmadi et al., 2011). Based on the findings above, undesirable educational structure and inappropriate professional performance environment are the main challenges in the clinical education field. Weaknesses in programming and educational content, flawed clinical teaching methods and limited competence of the instructors are the components of undesirable educational structure. The findings of this research indicate that content and lesson plans, which are the main components of the educational structure and potentially effective factors in the professional empowerment of nursing students, are faced with weaknesses. The nursing process has an effective role in forming critical thinking in nursing students and enabling them to provide
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professional care (Akbari and Farmahini, 2011). However, this has often been neglected in terms of the education method and limited dedicated course time. Lack of attention to the nursing process in the nurse education course is also evident and considerable in other studies done in Iran (Atashzadeh Shoorideh and Ashktorab, 2011). Insufficient clinical education' time to provide professional preparation and expertise for students in doing procedures are other problems of educational structure. The importance of a period of clinical education is clear (Milton-Wildey et al., 2014) so increasing hours of clinical training for nursing students` professional preparation is regarded as an effective method by different researchers (Hegneya et al., 2013 ; Rush et al., 2013). The other component affecting educational structure is the instructor`s capability (Whitehead, 2010). The instructor`s role in providing a practical model and institutionalization of professional care deserves attention. King and Gate (King and Gates, 2006) and Priest (Priest, 1999) also referred to the importance of the instructor`s role in professionally empowering nurses. Unfortunately based on the data from the experiences of the participants, instructors are not currently capable enough to prepare student nurses to provide a comprehensive care program. Clinical education methods are another component of educational structure that has a key role in educating and preparing nursing students. Educational methods as an effective factor in the professional preparation of nursing students and their ability to provide professional care have been confirmed in some studies (Orland-Barak and Wilhelem, 2006). The role of clinical teaching methods in the empowerment of nursing students has also been confirmed by Henderson. While based on the data present in this study, currently, clinical education methods do not have the necessary quality and are inhibitors of professional preparation for nursing. Need for more attention in this area has been proposed by Henderson (2002). The main effective factor in clinical education is the professional performance environment. The data from the participants` experiences indicates that the existence of inappropriate professional interactions and limited conformity of the clinical environment with professional standards has an inhibitory role in clinical education. Professional interactions are integral components of the clinical environment which has an essential role in increasing selfconfidence and the learning motivation of nursing students. The importance of professional interactions as a determinant factor in the ability of students has been clear in different studies. Yildirim et al`s study (2005) in Turkey and Hojjat`s study (2003) in Mexico, Italy and America worked on the amplifier role of professional interactions. However, in this study, professional interactions did not have a good quality. Olive`s study (2003) has similar results to this study and indicates the inhibiting role of these interactions in the professional performance of nurses and students. High expectations of nurses and authorities in wards and their bad communication was a feature of inappropriate interaction in the present study. According to participants, this caused frustration and negative views of their profession and decreased their learning motivation (Hegneya et al., 2013; Nash et al., 2009). Limited conformity of clinical environment with professional standards which has been mentioned as the cause of a gap between theory and practice in different studies (Henderson, 2002) was another component of the inappropriate professional performance environment. This has been repeatedly pointed to by participants and talked of as a limiting factor in clinical education. Limitations and lack of educational facilities and standards of care were
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some of these factors. Limited educational facilities were also identified as an inhibiting factor in other clinical studies in Iran (Salimi et al., 2012). Disregard to standards of care as one of the realities prevailing in the clinical setting have been identified in various studies (Yildirim,2005; Flood and Robinia, 2014). The study also revealed and confirmed its inhibiting role in the professional performance of nursing students. Conclusion Regarding the data of this study based on poor educational structure and inadequate professional environment as challenges in the field of clinical education, it is recommended to review the content of the courses and present lessons with clear goals to decrease the problems in the field of clinical education.
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Teaching nursing process step by step illustrated by real cases in clinical fields is also useful for expanding critical thinking and strengthening students' clinical decision making skills and their self-esteem. Other effective factors in increasing students' motivation and interest in clinical education are using objective and measurable evaluation scales based on educational standards in the clinical setting; and applying competent and interested instructors who have updated knowledge and appropriate communication skills with staff and students. This can create self-esteem, motivation and interest in students and lead to a more appropriate educational environment where theoretical knowledge is applied in practice.
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Clarifying the duties of students in wards also leads to increased motivation and self-esteem of those students, along with a reduction of inappropriate staff expectations. Providing suitable educational facilities, sufficient staffing and appropriate equipment to meet the standards in the clinical field are other strategies for reducing the gap between the theory and practice in the clinical area.
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Conflict of interest The authors declare no conflict of interest.
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Table1. Challenges in the clinical education of the nursing profession in Iran: A qualitative study:
Neglect of the nursing process in the course of study Limited training time
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Inappropriate professional interactions
Limited conformity of clinical environment with professional standards
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Inefficient professional performance environment
Low amount of nursing process course, limited training of nursing process, superficial pointing to nursing process, no practical training of nursing process Low amount of nursing process course, limited training of nursing process, superficial pointing to nursing process, no practical training of nursing process Trainer centered education Relying on instructor in doing cares, students` no independence in training, not having freedom in giving care, relying on instructor in doing procedures Use of theoretical training Theoretical training of ventilator instead of practical training, in clinical setting theoretical training of patient`s examination instead of practically doing it, use of conference instead of setting patient line to the dialysis machine Deficiencies of Loss of valid criterion for evaluation, subjective evaluation evaluation method method and instructor`s personal evaluation Limited capability of the Not having necessary mastery while training special instructor procedures like blood sampling, assigning IV line, not having enough experience of clinical work, not having necessary knowledge to examine patients Inappropriate expectations Devolving large amount of patients` care to students, of staff and authorities expecting no mistakes from students, expecting to speed up the duties Inappropriate treatment of Not accepting students as colleagues, not letting them to be students by staff close to nursing station, not letting students to take part in visits and comment Poor educational facilities No conference classes, limited facilities in wards during training and exercising procedures like limitation in IV use, dressing set, sterile gloves Disregard of care standards No on-time antibiotics administration, carelessness to sterile principles while catheterization and dressing, carelessness to dignity of patient during care. Categories, sub Categories and codes
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Shortcomings of clinical teaching methods
Limited competence instructor
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Weakness in educational program and content
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Inefficient educational structure
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ACCEPTED MANUSCRIPT *Research Highlights An investigation of challenges in the field of clinical nurse education Neglect of the nursing process in the course of study is detrimental Empowering instructors in the field of clinical education improves outcomes
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More conformity of clinical environment with professional standards is effective
Madineh Jasemi, Bill Whitehead, Hosein Habibzadeh, Roghaieh Esmaeili Zabihi, Soheila Ahangarzadeh Rezaie PII: DOI: Reference:
S0260-6917(18)30169-2 doi:10.1016/j.nedt.2018.04.010 YNEDT 3833
To appear in: Received date: Revised date: Accepted date:
9 April 2017 19 March 2018 12 April 2018
Please cite this article as: Madineh Jasemi, Bill Whitehead, Hosein Habibzadeh, Roghaieh Esmaeili Zabihi, Soheila Ahangarzadeh Rezaie , Challenges in the clinical education of the nursing profession in Iran: A qualitative study. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ynedt(2018), doi:10.1016/j.nedt.2018.04.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title of the article: Challenges in the clinical education of the nursing profession: A qualitative study Running title: Challenges in the clinical education of the nursing profession Word counts: 5000 For abstract: 210 For the text: 3953 Contributors 1. Madineh Jasemi Assistant professor in Nursing, Faculty of Nursing and Midwifery, Urmia university of Medical Sciences, Iran 2- Bill Whitehead BA(hons) PGCCE PhD RGN RNT FHEA Head of Department Nursing, Radiography and Healthcare Practice, University of Derby, Kedleston Road Derby. Uk 3 -Hosein Habibzadeh
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Associate Professor in Nursing, Faculty of Nursing and Midwifery, Urmia university of Medical Sciences, Iran 4- Roghaieh Esmaeili Zabihi Lecture in Nursing, Faculty of Nursing and Midwifery, Urmia university of Medical Sciences, Iran 5. Soheila Ahangarzadeh Rezaie (Corresponding Author) Assistant professor in Nursing, Faculty of Nursing and Midwifery, Urmia university of Medical Sciences, Iran
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Soheila Ahangarzadeh Rezaie (Corresponding Author) Assistant professor in Nursing, Faculty of Nursing and Midwifery, Urmia university of Medical Sciences, Iran Telephone: +98-09144462842 Email: jasemi. [email protected] Design: Madineh Jasemi, Soheila Ahangarzadeh Rezaie Literature search: Madineh Jasemi, Hosein Habibzadeh Data analysis: Madineh Jasemi, Soheila Ahangarzadeh Rezaie Manuscript preparation: Madineh Jasemi, Bill Whitehead, Roghaieh Esmaieli Zabihi Manuscript editing: Madineh Jasemi, Bill Whitehead Title Page (including article title, word count, full author details and all acknowledgements) Source(s) of support: This study was supported by a research grant from Urmia University of Medical Sciences, Iran Conflicting Interest: The authors declare no conflict of interest Acknowledgement: This study was supported by a research grant from Urmia University of Medical Sciences, Iran and was approved by the ethical committee. The authors would like to express their sincere gratitude to this canter and all the participants for their cooperating in this study
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Challenges in the clinical education of the nursing profession in Iran: A qualitative study
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Abstract Introduction: Clinical education is an important part of nurse training. It provides students with the opportunity to gain useful experience and has a key role in their professional preparation. The importance of clinical education in nursing students’ professional performance means that identifying the challenges in this field is crucial. Aim: The goal of this study is to identify challenges in the field of clinical nurse education. Design: A qualitative content analysis study. Setting: A faculty of Nursing and Midwifery, in Iran 2017. Participants : Nine student nurses, three qualified nurses and two nursing educators. Methods: This study has been applied to various depths of interpretation. Semi-structured interviews were used to collect the data. Nine student nurses, three qualified nurses and two nursing educators were interviewed. Results: The analysis of the interviews generated five categories. Two main themes were extracted as challenges in the clinical training of nursing professionals: 1. Inefficient educational structure and 2. Inefficient professional performance environment. Conclusion: Considering the inadequate professional performance environment and defective educational structure, designing and delivering lessons with clear goals is essential. Using objective and measurable scales for evaluating educational standards, the use of empowered instructors with high communicational skills is useful for increasing students' motivation and interest toward clinical education and solving existing challenges.
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Keywords: qualitative study, content analysis, clinical education, nursing
Introduction
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Improving the quality and quantity of every profession depends on increasing the knowledge and proper functioning of its staff. It also requires them to have professional and correct training (Admi, 2006). In fact, correct training is the basic foundation of each profession and has a key role in providing an educated and professional workforce (Paterson, 2007). In the nursing profession, a well trained and educated, experienced workforce is very important. The purpose of nurse training is to prepare graduate nurses to care for and promote the health and quality of life of people (Aliakbari and Aslani, 2013). Nurse education includes both theoretical and clinical training in which the clinical training often gets half of the educational program and it has special importance and place (Atash Sokhan et al., 2011). During training, students in the clinical setting, through active participation in learning and care, become professionally prepared and acquire a professional point of view (Smith-Strom and Nortvedt, 2008). Good clinical training facilitates student communication with patients in a real environment; specifies students` activities and goals; teaches them the concept of team work; builds creativity and motivation in students; increases problem-solving skills; judgment and decision making (Thomas, 2005). This training increases students` clinical experiences and performance and prepares them to enter the work environment (Abbeglen, 2006). In many ways, clinical training is different and more complicated than theoretical education. It takes place in the real professional environment and in line with skills training that cannot be gained from classroom based sources or simulation (Mongwe et al., 2009). Consequently, this training method needs special attention (Mlek et al., 2011). Despite the importance of clinical education, this training method continues to face many challenges (Saarikoski et al., 2013). Most nursing graduates are dissatisfied with clinical training (Paterson, 2007). In this regard a study was conducted in Iran which showed that 88% of nursing students believe clinical education has weaknesses (Heydari et al., 2012). Other studies have been conducted in Iran (Heydari et al., 2012) but the problem remains. Solving problems in the field of education first needs to better identify clinical education and challenges in this field. Assessing this phenomenon through qualitative research that involves multiple methods of gathering information and reviewing the facts, norms and values from the perspective of participants (Strubert and Carpenter, 2007), can identify and illuminate the issues in clinical nurse education. Application of the findings to practice can help to improve the quality of clinical education. This study, through assessing experiences of nursing students and nurses, will attempt to examine the research aim below. Aim: The goal of this study is to identify challenges in the field of clinical nurse education. Method This study employed conventional content analysis which consists of a definition of the phenomenon and interpretation of the context, through careful classification of codes and the identification of themes (Zhang and Wildemuth, 2009). The researcher identifies labels and categories that emerge from the data, and by immersion in the data, achieves new insights (Hsieh and Shannon, 2005). In view of the objective of the study - investigating challenges in the field of clinical nurse education - we initially selected nursing students with experience of clinical education. Subsequently, based on the results of the interviews and to verify the findings through triangulation, we performed theoretical sampling and interviewed three qualified nurses and two nursing educators.
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In total, 14 participants - four males and ten females - were selected and interviewed. Since lower grades are required to enter a private university in Iran, graduates of both public and private universities were sampled. Sampling was continued to the point of data saturation. To make the data more reliable, participants were selected from various cultural backgrounds and diverse hospitals and wards in Iran in 2017. This study lasted nine months. To better relate to the environments of the study and the participants and analyze the data realistically, the researcher also used field notes. Field notes are a brief summary of the observations made while collecting data. This is not limited to a particular type of activity or behavior and assesses the non-verbal behaviors of the participants and their interactions with others. It also depicts a picture of a social position. In this study, field notes also made a detailed presentation of the situation in the right place immediately after the interview and provided the opportunity to confirm the psychological and emotional reactions of the participants. For example, attending the ward where theoretical training of how to connect the patient to a ventilator, instead of practical training by the instructor was mentioned as a field note and confirmed the defects of clinical education methods. The data were collected via semistructured interviews with a focus on informants’ experiences and feelings toward clinical education. Subsequently, based on each participant's answers, more questions were asked and the difficulties which the nursing students had encountered in clinical education were brought into focus. Each interview, which lasted 60 to 90 minutes, was tape recorded, transcribed and analyzed.
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To analyze the data, the qualitative data software program MAXQDA, which facilitates classifying codes, placing them in categories and eliciting themes, was used (Strubert and Carpenter,2007),). After reading and interpreting the interviews, the researcher established meaningful units to analyze the data. Next, using MAXQDA, a proper code was assigned to each phrase or paragraph. Similar codes were placed in the same category; the codes were constantly compared and re-categorized. Finally, after comparing and contrasting the categories, the ultimate themes were extracted and edited. The data were verified by the participants, co-researchers and two external researchers. Taking field-notes during the interviews enabled the researcher to verify the validity of the findings while analyzing them. The manner of codification, categorization and formation of the final themes was explained to the observers and external researchers to make the results verifiable. Ethics The present study has been approved by the ethical committee at The Medical University of Urmia. Participant information sheets and consent forms were provided. Introduction papers were produced for the hospitals; the participants were informed of the objectives of the study and agreed in writing that the researcher could use their information. Results Categorizing the results of interviews showed two overarching categories emerged from the data as challenges in clinical education of the nursing profession needing special attention: 1.Inefficient educational structure and 2. Inefficient professional performance environment (table 1).
1. Inefficient educational structure
ACCEPTED MANUSCRIPT Educational structure is one of the factors in clinical training that can have an invaluable role in the education of nursing graduates and can be a professional background for their preparation. However, the experiences of the participants indicated that educational structure is not adequate in the field. Weaknesses in programming and educational content, shortcomings of clinical teaching methods, and limited competence of instructors were indicators of the defective educational structure.
a. The weakness of programs and educational content
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Programs and educational content constitute part of the educational structure. If it is comprehensive, it will prepare learners for clinical training and improve their ability to take the appropriate care of patients. However, participants believed that in most cases program and educational content were weak. In this regard neglect of the nursing process in the course of study, limited training time were the indicators of weakness in program and educational content. This will be illustrated in the issues below. Neglect of the nursing process in the course of study Learning the nursing process has an important role in providing diagnoses through the development of nursing students’ critical thinking. However according to most participants, teaching the nursing process has been neglected. As a participant has stated:
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“The number of lectures that were intended to be taught on the nursing process for us was very low. Now that I think about it, I see theoretically during the course, and in class, it has been neglected as an important subject to study.”(P.3)
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Unsystematic methods of training clinical nursing are another factor which has led to downplaying the nursing process in the course of study in a way that most participants refer to the issue. Many participants stated that the application of the nursing process was not properly taught to them. In this regard a participant stated:
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“The clinical education, nursing unit was taught in a limited way as a class assignment. For example we were asked to write a nursing process for a disease and it was about a particular disease that sometimes the disease was not in the ward and it was not in a way that we practically do it with the patients in clinical practice.” (P.4)
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Limited training time For clinical training to be effective in providing the skills to perform good fundamental care, it is necessary to provide enough time to familiarize students with a variety of procedures and expertise to do them. However based on the experiences of participants, time for clinical training is inadequate. In this regard one of the participants said: “Our training time for education of a variety of diseases and common care in ward was not enough. For example in the orthopedic ward there was not enough time for the instructor to come and teach different diseases, dressings, traction and care. As we wanted to learn something, our wards were changed. There was not enough time for clinical training.” (P.1)
b. Shortcomings of clinical teaching methods Another sub-category of faulty educational structure is the shortcomings of clinical education methods. According to participants, there are weaknesses in the methods of clinical education
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to familiarize students with the real clinical environment; better understanding of patients` problems; and their ability to provide care. Trainer centered education and use of theoretical training in clinical setting are characteristics of this theme, as illustrated in the issues below. Trainer centered education One of the reasons for the effectiveness of clinical education in preparing students to enter the profession is their more active role in the learning process, utilizing the power of reason and as a result, the growth of critical thinking. However according to testimony from the experiences of participants, clinical teaching methods in Iran often vary dependent on the instructor’s preferences and are trainer-centered. In this regard one of the participants pointed to lack of freedom and said:
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“In wards we mostly depended on the instructor. Anything we did for the patient such as nursing diagnosis, mode of care and the procedures we offer was based on the instructor`s ideas. He/she dictated to us and we did not have the freedom to select evidence based care approac hes” (P.12)
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Use of theoretical training in clinical setting Practical training, in professional care, has an important role in doing procedures and role modeling of students from the instructor and giving systematic care. However according to participants` experiences training was mostly theoretical. A participant pointed out the lack of practical training in the preparation for some skills and said:
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“When we went for training in ICU the instructor did not provide practical education for the ventilator, taking atrial blood gases (ABG) and other professional care. They taught most of them theoretically and this leads us not to learn most of the specialist care skills. Consequently, we faced a lot of problems later when we entered the workplace.” (P.14)
c. Limited competence of instructor
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The instructor`s competence is a key component of the educational structure that can have a fundamental role in learners` role modeling in the acquisition of capabilities and expertise (Whitehead 2010). Unfortunately, most participants talked of limited capability and weakness of instructors. The issues which emerged from the data in this theme were: deficiencies of evaluation method and limited capability of instructors, which are introduced as the two sub-categories of limited competence of the instructor below. Deficiencies of evaluation method Educational evaluation or assessment is one of the most important and challenging issues in clinical training which is considered the most important duty of the instructor. Evaluating method is a motivational factor for learners and guides their efforts in line with the instructor`s expected criteria. It is also vital to ensure that students have a sufficient level of proficiency to perform nursing skills safely. Despite the importance of the evaluation, participants` experiences indicated shortcomings in this field. Confirming this, one of the participants said: “Unfortunately most times the instructors made subjective assessments; there were no special criteria for evaluation. It was not clear what their evaluation criteria were. Sometimes a weak student got a good grade while a clever student got a low grade.” (P.9)
Limited capability of the instructor
ACCEPTED MANUSCRIPT More scientific and practical capability is required of instructors; they need to be more proficient in their presentation of routine and specialized techniques. If they had sufficient knowledge and skill they would receive more acceptance and role modeling from students. The role of instructor, if they demonstrate capability provides effective role modeling. Students’ interest in their profession and their motivation increase. Unfortunately, data from participants` experiences showed limited capability of instructors. In this regard one of the participants said:
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“During my studies I could find no pattern, there was no instructor who could practically and professionally execute ideal care in the clinical environment. Mostly they had low skills and capabilities, their practical skill was low and scientifically when we asked questions they didn`t know the answers.”(P.9)
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2. Inefficient professional performance environment
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Another category related to clinical education is the professional performance environment which has an essential role as a real environment for gathering experience in clinical education. This category includes two sub-categories of inappropriate professional interactions and limited conformity of clinical environment with professional standards.
a. Inappropriate professional interactions
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Professional interaction is a critical component of the professional performance environment that when appropriately communicated can increase professional self-esteem and make students become interested in their profession. However, unfortunately, most participants talked of inappropriate professional interactions in the form of unsuitable expectations and treatment by the staff and authorities. These will now be discussed in the two issues below. Inappropriate expectations of staff and authorities In Iranian nurse training, clinical education, especially in the final semesters is under the supervision of nursing staff and authorities of hospital wards. If the expectations of staff and authorities are illogical and inconsistent with the capabilities of the students, it will increase stress and tension in them and will engender a decrease of their self-confidence and a negative view of their profession. In this regard one of the participants said:
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“Previously when the instructor was with us we didn`t have these problems and we worked with one or two patients but now that we are in the internship course, expectations of the nurses are too much. They want us to do all the job; drugs, vital signs and dressin gs.” (P. 6)
Inappropriate treatment of students by staff Appropriate treatment of nursing students by nursing and medical staff increases their sense of belonging and confidence and also their motivation to learn skills. Unfortunately, based on available data treatment of staff with students is not mostly appropriate. In this regard one of the participants said: “We don`t have the right to approach the nursing station. The staff treat us in a way as if we are not going to be their colleagues in the future. Doctors and medical students are proud of themselves and when we are present on visits we don`t dare to ask questions or if we know something to comment. Nurses and doctors treat us in a way that we regret and these cause our self -confidence to be low.” (P.3)
b. Limited conformity of clinical environment with professional standards
ACCEPTED MANUSCRIPT Limited conformity of clinical environment with professional standards is another subcategory of the professional performance environment which is based on the participant testimonies. The poor educational facilities in clinical education and disregard for standards of professional care have a restricting role.
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Poor educational facilities The second sub-category of inefficient professional performance environment is inappropriate professional facilities. It is clear that the availability of facilities plays an important role in promoting clinical education and can be useful in professional preparation of students. However, according to participants they are often faced with limited educational facilities in clinical environments. In this regard one of the participants pointed out the limitations of educational space and stated:
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“For us there are no classes to present clinical conferences. The classes are available for medical students. We are always forced to have conferences while we are standing and we get very tired.” (P.10 )
Another participant pointed out the restricting role of lack of facilities in acquiring clinical skills and said:
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“Lack of facilities on wards causes us not to do lots of procedures. For example when we want to assign an IV line for the patients we have the right to use only one needle. If we can`t do it with that, it will be extra cost for the patient so most times the instructor him/herself does the job.” (P.7)
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Disregard for standards of professional care Observance of standards of care in the clinical environment by treatment staff encourages positive role modeling for students and professionally prepares them. According to participants in most cases they witnessed unprofessional performance of staff and disregard to standards of care. This caused more gaps between theory and practice in clinical setting and inappropriate role modeling for students. In this regard one of the participants said:
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“A lot of things that were theoretically emphasized in the skill lab I saw were not done when I entered the clinical environment. For example in catheterization we were so much emphasized to consider principals of sterility etc. but in the ward we saw that there was no attention to asepsis or in the case of on time administration of antibiotics we saw they were not on time and most students follow these wrong approaches and act based on the incorrect routines of wards.” (P.6)
Discussion Clinical education provides an appropriate opportunity to convert theoretical knowledge to psychomotor skills for nursing students in the care process, so paying attention to clinical education and effecting factors is important (Heidari and Norouzadeh, 2015) and provides professional preparation for nursing students (Ahmadi et al., 2011). Based on the findings above, undesirable educational structure and inappropriate professional performance environment are the main challenges in the clinical education field. Weaknesses in programming and educational content, flawed clinical teaching methods and limited competence of the instructors are the components of undesirable educational structure. The findings of this research indicate that content and lesson plans, which are the main components of the educational structure and potentially effective factors in the professional empowerment of nursing students, are faced with weaknesses. The nursing process has an effective role in forming critical thinking in nursing students and enabling them to provide
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professional care (Akbari and Farmahini, 2011). However, this has often been neglected in terms of the education method and limited dedicated course time. Lack of attention to the nursing process in the nurse education course is also evident and considerable in other studies done in Iran (Atashzadeh Shoorideh and Ashktorab, 2011). Insufficient clinical education' time to provide professional preparation and expertise for students in doing procedures are other problems of educational structure. The importance of a period of clinical education is clear (Milton-Wildey et al., 2014) so increasing hours of clinical training for nursing students` professional preparation is regarded as an effective method by different researchers (Hegneya et al., 2013 ; Rush et al., 2013). The other component affecting educational structure is the instructor`s capability (Whitehead, 2010). The instructor`s role in providing a practical model and institutionalization of professional care deserves attention. King and Gate (King and Gates, 2006) and Priest (Priest, 1999) also referred to the importance of the instructor`s role in professionally empowering nurses. Unfortunately based on the data from the experiences of the participants, instructors are not currently capable enough to prepare student nurses to provide a comprehensive care program. Clinical education methods are another component of educational structure that has a key role in educating and preparing nursing students. Educational methods as an effective factor in the professional preparation of nursing students and their ability to provide professional care have been confirmed in some studies (Orland-Barak and Wilhelem, 2006). The role of clinical teaching methods in the empowerment of nursing students has also been confirmed by Henderson. While based on the data present in this study, currently, clinical education methods do not have the necessary quality and are inhibitors of professional preparation for nursing. Need for more attention in this area has been proposed by Henderson (2002). The main effective factor in clinical education is the professional performance environment. The data from the participants` experiences indicates that the existence of inappropriate professional interactions and limited conformity of the clinical environment with professional standards has an inhibitory role in clinical education. Professional interactions are integral components of the clinical environment which has an essential role in increasing selfconfidence and the learning motivation of nursing students. The importance of professional interactions as a determinant factor in the ability of students has been clear in different studies. Yildirim et al`s study (2005) in Turkey and Hojjat`s study (2003) in Mexico, Italy and America worked on the amplifier role of professional interactions. However, in this study, professional interactions did not have a good quality. Olive`s study (2003) has similar results to this study and indicates the inhibiting role of these interactions in the professional performance of nurses and students. High expectations of nurses and authorities in wards and their bad communication was a feature of inappropriate interaction in the present study. According to participants, this caused frustration and negative views of their profession and decreased their learning motivation (Hegneya et al., 2013; Nash et al., 2009). Limited conformity of clinical environment with professional standards which has been mentioned as the cause of a gap between theory and practice in different studies (Henderson, 2002) was another component of the inappropriate professional performance environment. This has been repeatedly pointed to by participants and talked of as a limiting factor in clinical education. Limitations and lack of educational facilities and standards of care were
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some of these factors. Limited educational facilities were also identified as an inhibiting factor in other clinical studies in Iran (Salimi et al., 2012). Disregard to standards of care as one of the realities prevailing in the clinical setting have been identified in various studies (Yildirim,2005; Flood and Robinia, 2014). The study also revealed and confirmed its inhibiting role in the professional performance of nursing students. Conclusion Regarding the data of this study based on poor educational structure and inadequate professional environment as challenges in the field of clinical education, it is recommended to review the content of the courses and present lessons with clear goals to decrease the problems in the field of clinical education.
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Teaching nursing process step by step illustrated by real cases in clinical fields is also useful for expanding critical thinking and strengthening students' clinical decision making skills and their self-esteem. Other effective factors in increasing students' motivation and interest in clinical education are using objective and measurable evaluation scales based on educational standards in the clinical setting; and applying competent and interested instructors who have updated knowledge and appropriate communication skills with staff and students. This can create self-esteem, motivation and interest in students and lead to a more appropriate educational environment where theoretical knowledge is applied in practice.
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Clarifying the duties of students in wards also leads to increased motivation and self-esteem of those students, along with a reduction of inappropriate staff expectations. Providing suitable educational facilities, sufficient staffing and appropriate equipment to meet the standards in the clinical field are other strategies for reducing the gap between the theory and practice in the clinical area.
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Conflict of interest The authors declare no conflict of interest.
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ACCEPTED MANUSCRIPT
Table1. Challenges in the clinical education of the nursing profession in Iran: A qualitative study:
Neglect of the nursing process in the course of study Limited training time
MA
of
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Inappropriate professional interactions
Limited conformity of clinical environment with professional standards
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Inefficient professional performance environment
Low amount of nursing process course, limited training of nursing process, superficial pointing to nursing process, no practical training of nursing process Low amount of nursing process course, limited training of nursing process, superficial pointing to nursing process, no practical training of nursing process Trainer centered education Relying on instructor in doing cares, students` no independence in training, not having freedom in giving care, relying on instructor in doing procedures Use of theoretical training Theoretical training of ventilator instead of practical training, in clinical setting theoretical training of patient`s examination instead of practically doing it, use of conference instead of setting patient line to the dialysis machine Deficiencies of Loss of valid criterion for evaluation, subjective evaluation evaluation method method and instructor`s personal evaluation Limited capability of the Not having necessary mastery while training special instructor procedures like blood sampling, assigning IV line, not having enough experience of clinical work, not having necessary knowledge to examine patients Inappropriate expectations Devolving large amount of patients` care to students, of staff and authorities expecting no mistakes from students, expecting to speed up the duties Inappropriate treatment of Not accepting students as colleagues, not letting them to be students by staff close to nursing station, not letting students to take part in visits and comment Poor educational facilities No conference classes, limited facilities in wards during training and exercising procedures like limitation in IV use, dressing set, sterile gloves Disregard of care standards No on-time antibiotics administration, carelessness to sterile principles while catheterization and dressing, carelessness to dignity of patient during care. Categories, sub Categories and codes
SC
Shortcomings of clinical teaching methods
Limited competence instructor
Codes
PT
Weakness in educational program and content
Sub-Categories 2
RI
Inefficient educational structure
SubCategories 1
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Categories
ACCEPTED MANUSCRIPT *Research Highlights An investigation of challenges in the field of clinical nurse education Neglect of the nursing process in the course of study is detrimental Empowering instructors in the field of clinical education improves outcomes
AC C
EP T
ED
MA
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SC
RI
PT
More conformity of clinical environment with professional standards is effective