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Exploring the environment of clinical baccalaureate nursing students' education in Iran; A qualitative descriptive study
Exploring the environment of clinical baccalaureate nursing students’ education in Iran; A Qualitative Descriptive Study Sepideh Mohammadi, Alireza Yousefy, Ahmad reza Yazdannik PII: DOI: Reference:
S0260-6917(15)00298-1 doi: 10.1016/j.nedt.2015.07.028 YNEDT 3028
To appear in:
Nurse Education Today
Accepted date:
30 July 2015
Please cite this article as: Mohammadi, Sepideh, Yousefy, Alireza, Yazdannik, Ahmad reza, Exploring the environment of clinical baccalaureate nursing students’ education in Iran; A Qualitative Descriptive Study, Nurse Education Today (2015), doi: 10.1016/j.nedt.2015.07.028
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ACCEPTED MANUSCRIPT Title: Exploring the environment of clinical baccalaureate nursing students' education in Iran; A Qualitative Descriptive Study
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Word count: 5100
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Authors:
Sepideh Mohammadi, Corresponding author, PhD Candidate in nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
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E-mail: [email protected]
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Alireza Yousefy, Associate Professor, Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: [email protected]
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Ahmad reza Yazdannik: Assistant Professor, Critical Care Department, Nursing and Midwifery Faculty, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: [email protected]
Acknowledgments:
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This study was part of the Ph.D. dissertation, so it is incumbent upon the authors to acknowledge the financial support offered by the Research Vice-Chancellor of Esfahan University of Medical Sciences. We would like to thank all study participants.
Conflict of interest: The authors did not have any conflict of interest to conducting this study.
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ACCEPTED MANUSCRIPT Exploring the environment of clinical baccalaureate nursing students' education in Iran; A Qualitative Descriptive Study
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Abstract:
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Introduction: Today's students are the nurses of tomorrow. They need appropriate clinical learning opportunities in order to shape their professional identity, attitudes and values.
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Despite undeniable progresses of nursing education in Iran, the quality of the clinical education in Iran is not favorable. There is need to exploring the environment of clinical baccalaureate nursing students' education for developing, maintaining and enhancing the
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quality of clinical program.
Method: this is a qualitative study and was conducted base on content analysis multimethod
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design. Data collected by individual interviews, focus groups and direct observations. 54 nursing students and 8 clinical educators from the four geographically diverse universities in
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the Iran composed the study sample. A purposive sampling was used.
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Result: five themes were emerged from data analysis including; Ambiguity in the nursing care role, Routine-based nursing care, Uncritical and dependent thinking climate,
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Incompetency of clinical educators and Patient education as important component of nursing. Conclusions: The findings of this study describe a clearer understanding of the real environment of the clinical education in Iran. All of themes that emerged from the study play an important role in student learning and nursing education. It is crucial to pay more attention
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to reconsider care concept as an operational component of nursing, maximize meaningful learning opportunities, reevaluate clinical instructor as role models and preparation effective operational plan to combine theoretical and evidence based knowledge with clinical practice.
Key words: nursing education, clinical educator, clinical education, nursing student
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ACCEPTED MANUSCRIPT Introduction: The mission of nursing education is to produce qualified nurses with the requisite knowledge, attitudes and skills. For achieving this goal, clinical teaching is the cornerstone in nursing
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education (Li, Chen et al. 2008). in most countries, approximately 50% of the curriculum in
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the nursing program is devoted to clinical studies. A perfect clinical program is crucial in
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order to shape the professional identity of nursing students, and is also the primary source of learning professional attitudes, values and norms(Killam and Heerschap 2013, O'Mara, McDonald et al. 2014). Students need meaningful and appropriate clinical learning opportunities, and support by evaluated models of facilitators to encompass the range of
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experiences necessary for the graduate nurse(Kristofferzon, Mårtensson et al. 2013, d'Souza,
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Karkada et al. 2015). Literature review:
Despite increased academic input into nursing education in Iran in recent years, the public
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and the government have criticized Iranian nurses and nursing students regarding the poor
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quality of patient care(Cheraghi, Salsali et al. 2010). It seems that nursing students have a lot of problems with their professional identity and they are not proud of being a nurse. Nursing
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students are embarrassed to say they are a nurse even in their family or to their parents(Yazdannik, Yekta et al. 2012). Even nursing teachers doubt their efficiency and independence in clinical education(Hajbaghery and Salsali 2005). A study in Iran revealed
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that, students after entering to the clinical stage had the feeling of professional inferiority and oppression. Also senior undergraduate students do not know who they are and what the values of their profession are(Yazdannik, Yekta et al. 2012). The result of the other study in Iran showed that nursing students frequently feel vulnerable in the clinical environment (Dehghan Nayeri, Nazari et al. 2006) and they were not satisfied with the clinical education. they experienced anxiety as a result of feeling incompetent and lack of professional nursing skills and knowledge to take care of various patients in the clinical setting(Sharif and Masoumi 2005).. Several years’ experience of authors in nursing education showed that many Iranian nursing students are not well motivated, and their negative attitudes and behaviors impede learning and threaten their progression and retention in nursing programs. The researcher came to 3
ACCEPTED MANUSCRIPT realize that nursing students have a great deal of confusion about their role and duty when they begin their clinical practice in the second year to forth year. On the other hand, many of the faculties and administrative board in nursing education are
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interested to know, what is happening in the clinical education environment? How is nursing
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identity formed in clinical education course? The answer to these questions and research on the clinical education climate may help to recognizing the clinical education defects and
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promote students’ motivation and their professional identity.
Most of the Iranian research studies in this regard conducted at one faculty by small number of research participant, so to achieve comprehensive results, we conducted our study in four
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geographically diverse universities in the Iran. It was assumed that the findings of the current study would provide support for nursing faculty in developing, maintaining and enhancing
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the quality of clinical program.
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Methods:
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Design:
A qualitative design could increase the understanding of nursing students' and clinical
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educators voices, views and thoughts about clinical education(Démeh and Rosengren 2015). Therefore, a descriptive study using content analysis was conducted. Though qualitative research relies on trustworthiness, transparency, verification, reflexivity and is also ‘informant-driven’, the design could be helpful to develop insightful and artful interpretations
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within the nursing education process (Polit and Beck 2013).
Setting and Participants: Participants were nursing students and clinical nursing educator selected from four major educational centers in Iran, that is, Tehran, Isfahan, Babol and Yasooj University of Medical Sciences(Table 1). For achieving comprehensive data, we selected different nursing universities in both aspects of geographical location and scientific level in Iran. Tehran University of Medical Sciences (located in capital of Iran) and Isfahan University of Medical Sciences (located on the main north–south and east–west routes crossing Iran) are in high scientific level of nursing universities in Iran. Babol University of Medical Sciences (located on the north of Iran) and Yasooj University of Medical Sciences (located on the west of Iran) are middle scientific level of nursing universities in Iran. A purposive sampling was used. 4
ACCEPTED MANUSCRIPT The study population for individual interviews comprised of 30 baccalaureate nursing students in different semester and 8 clinical nursing educators. Furthermore, four focus groups were conducted at four universities. Participants were 6
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fourth year baccalaureate nursing students in each group.
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Altogether 54 students and 8 clinical educators participated in this study.
To collect Supplementary information, 4 groups (students and clinical educators in the
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clinical component of the general medical-surgical course) was observed for two days (total 10 hours) during the second week of clinical practice (the first week is for orientation and warming up, and the third week the course is for winding down).
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Maximum variation in sampling in terms of age, gender, level of academic semester, years of experience as instructor and universities with different geographical locations were
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considered in order to collect participants with a wide range of experiences and perspectives. It was estimated that six months were needed to collect the data.
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Data collection:
To better understand the nature of contemporary clinical education environment, a descriptive
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qualitative, multimethod design, including individual interviews, focus group and direct observation was used.
Face-to-face semi-structured interviews were conducted in a private place that was convenient to the participants.
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Also we used focus group method for data gathering. The advantage of focus group is, instead of the researcher asking each person to respond to a question in turn, people are encouraged to talk to one another: asking questions, exchanging anecdotes and commenting on each other's experiences and points of view(Rabiee 2004, Krueger 2009). At the beginning of each interview and focus group, the participants were asked to describe one day of their clinical course, and then interviews continued with question like: What is your expectation of clinical experiences? How do you feel about being a nursing student in clinical setting? What does definition of nursing formed in your mind during clinical training? What is the main focus of educator in the clinical course? What did you learn as a nursing care? What comes to mind when you hear the phrase ‘clinical experience? And... 5
ACCEPTED MANUSCRIPT The questions were asked in an open ended manner. The interviewer probed participant responses by using questions/statements, such as ‘Could you say something more about that?’ ‘When you mention . . . what do you mean?.
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All interviews and focus groups were taped and the scripts were immediately transcribed
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verbatim. Some interviews and focus group were conducted in the researcher’s university office in the university and others in hospital meeting rooms. Each interview lasted between
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30 and 50 min, with an average of 40 min.
When the responses were repeated and no new data were added to previous interview, data
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saturation was determined and interviews were concluded(Polit and Beck 2013).
In addition to individual interview and focus group, observation was used to data collection
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based on the assumption that observation is a fundamental and critical method in all qualitative inquiry. Observers watch what people do, listen to what people say and record these activities. The focus of participant observation was on the students, staffs, and
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educators’ transactions and behaviors during students’ clinical training. Field notes and
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Data analysis:
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memos were written to describe the observations and later analyzed.
This is a qualitative study which employs content analysis in order to identify nature of contemporary clinical education in Iran. An inductive approach to content analysis was used.
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In line with the qualitative content analysis approach put forth by Elo and Kyngas (2008) data were analyzed via the following steps:
Transcribing interviews verbatim;
Choosing the unit of analysis;
Attaining the sense of whole via the reading the unit of analysis;
Taking codes (relevant ideas and concepts) out through open coding;
Collecting similar codes in sub-themes by comparing the codes, and labeling them;
Gathering similar sub-themes together in one group and labeling them (main themes) (Elo and Kyngäs 2008);
Trustworthiness of data
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ACCEPTED MANUSCRIPT The use of member checking during data collection, a structured analysis procedure, peer debriefing and use of an external auditor promote the creditability of the study. An external audit was conducted by a nursing PhD candidate who was familiar with qualitative data
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analysis and checked all steps taken in the analysis process. Minor differences in wording of
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themes were discussed. He then reviewed the complete audit trail for this study and agreed with the findings. The researcher shared the results of findings with the participants to give
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them an opportunity to verify that her interpretations are in correspondence with their realworlds .Maximum variation in sampling in terms of age, gender, level of academic semester, years of experience as educator and universities with different geographical locations were
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considered in order to collect participants with a wide range of experiences and perspectives.
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Ethical issues:
Ethical issues in this study involved the assurance of confidentiality and autonomy for the participants. The Internal Review Board of Isfahan University of Medical Sciences, School of
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Nursing and Midwifery, approved the study before data collection began. Permission, as
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written informed consent, was sought from the participants for the audio tape interviews and participant observation. All the participants were asked to participate under the premise that
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information would be annoymized and would remain confidential. The data were stored
Finding:
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safely where only the researcher could access it.
54 students, 19 to 25years of age (M=23.1), participated in the study. The majority were female (n=39). 8 faculty clinical educator, 30 to 51 years of age (M=40.2), participated in the study. The majority were female (n=5), n=5 held master’s degrees & n=3 held PhD degrees, all educator taught full-time. Although observations and interviews occurred at five different schools of nursing in Iran, investigator noted no overall differences in clinical activities observed or in core concepts in interviews. During the steps of data analysis four main themes emerged: 1- Ambiguity in the nursing care role; 7
ACCEPTED MANUSCRIPT 2- Routine-based nursing care 3- Uncritical and dependent thinking climate 4- Incompetency of clinical educators
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5- Patient education as an important component of nursing
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Ambiguity in the nursing care role;
Role ambiguity occurs when people are unclear or uncertain about their expectations within a certain role, typically their role in the job or workplace (Tunc and Kutanis 2009). Nursing educator and students saw caring as one important element of nursing, yet when I
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(researcher) asked what caring meant, clinical educators avoided defining it explicitly. As one of the clinical educators stated that; I know caring is really important role of nursing but it is
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hard to say what it is caring.
There was a less caring attitude among nursing students and educators. Some clinical educator reported a lack of clarity in relation to what was expected from caring in clinical
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practice and how this was formalized.
One senior student in focus group session described her experience as: We often feel
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confused and depressed; actually, we do not know what is expected of us as a professional nurse with special caring role in clinical setting. We are responsible for just about everything. We should be performing our nursing duties, not being treated as guards,
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physicians' assistance, cleaners, nurses’ aides. I don't know, who are we really? Field notes confirmed interviews and indicated that it is unclear how the caring dimension is actually taught. Maybe this is due to educators lack consensus on what caring actually is and how it can be taught. A third year student nurse put it: I know most important role in nursing is caring and having holistic view. But I feel a bit confused really; this is nebulous concept for me. Holistic view is a subjective concept for me. They (educators) really don’t have a clue what reality is and how to perform nursing care with holistic view in real world. Indeed actions speak louder than word. Field notes confirmed interviews and indicated that when clinical educator spoke about caring or professional nursing care they couldn’t express caring as an operational concept. 8
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Routine-based nursing care: In our study student frequently expressed that their work was 'not really professional nursing'
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they were confused by what they had learned in the faculty and what in reality was expected
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of them in practice. Students and clinical educators believed that present nursing care consisted of more technical and mechanical care without any individual and holistic care.
towards task completion and routine physical care.
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According to interview and observation the practice setting was predominantly oriented
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One final-year students in focus group session described her experience as: We just do basic nursing care. We are just a simple worker with some routine-based duties, such as giving the
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drugs and injections, changing the sheets, and dressing wounds.
One of the third-year students expressed: Where is the nursing process and professional
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knowledge? We spend four years studying nursing but we do not feel we are doing a
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professional job. This practice does not need 4 years training and professional knowledge, 1
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year or 6 months training, to do this type of nursing, is enough.
Clinical setting priority was not given to providing theoretical knowledge-based practice according to a learned knowledge of nursing. There was a gap between theory and practice, and little attention was paid to the implementation of evidence-based practice. A student said:
reality.
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I surprised and disillusionment when my expectations of nursing work did not match the
Large number of students in clinical education group mentioned as one of the barriers to doing professional nursing care and consistency in implementation of routine physical care. A clinical educator said that: There are at least 10 students in per clinical education group. In this condition we only have time to doing routine physical care and following doctors' order. Even sometimes we haven’t time to doing routine physical care let alone doing professional nursing care. Also students expressed that their behaviors in clinical setting affected by kinds of nurses behavior. This situation made students feel that carrying out the nursing tasks needs no special knowledge. As a result, they lost their motivation for learning professional nursing
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ACCEPTED MANUSCRIPT care . In fact students imagine their future career when observing the work conditions and the nurses’ clinical practice.
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One of the senior students stated; Most of the time the nurse sits in the nursing station and
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writes the nursing report and they unaware of her/his patients. According to my experiences and my observation to nurses, the primary goal of clinical education is to simply follow the
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doctor’s orders and provide basic routine care, not the patient’s individual needs. I think, I no need extra burden when i would be one nurse like this in the future.
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Type of student evaluation by educators mentioned as another reason for dominance of routine physical care. Most of student in focus group believed that; doing technical skills (like
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giving the drugs and injections, changing the sheets, and dressing wounds) correctly is one of the most important criteria for clinical evaluation of students. One third year student said
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that; the educators praised me when i carried out my routine tasks efficiently.
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Uncritical and dependent thinking climate: Findings from contextual observation and interviews demonstrated that students were too
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dependent on their educators for doing procedures and solving patents problem. Most of the students experienced poor-self-confidence in clinical setting. They believe that poor-self-confidence in the clinical setting is a barrier for independent thinking or caring. The students in focus group stated that they needed clinical educator to be with them when
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they were carrying out nursing procedures. "We need educators observe our activity because we protect from making mistake" A sophomore student stated; When i wanted to do a nursing procedure, i was doubtful, i didn't trust myself, I needed educator to be with me and assure me that i was doing it right. According to observation, when educators asked question of their student, questions were straightforward and simple. Question weren't challenging and incentive to improve critical thinking in students. Also, usually student couldn’t solve simple problem or questions and asked their educator to answer the questions. They had little power of independent Thinking.
Large number of students in clinical education group mentioned as one of the barriers to progression critical thinking climate in clinical setting;
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ACCEPTED MANUSCRIPT A clinical educator said; In large clinical group, there is no opportunity to creation a challenging and critical thinking climate. With a little time and a lot of students, we just have
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time to walking in a line by straight forward manner.
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Incompetency of clinical educators:
However, clinical experience and specialty training among clinical educators was the most
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important causal condition that enhanced their ability to educate students effectively, (Hsieh and Hsu 2013) unfortunately, findings from the participants’ interview and observation revealed that; such clinical educators were not prepared and competent for being a role model
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practical setting.
A sophomore student in focus group said; usually we have novice clinical educators who
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have little experience in clinical setting and we have only observed the procedure because our educators have not had enough experience.
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One of the students in this regard stated: I haven’t seen our educators discussed with
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physicians. I feel they haven’t sufficient professional and medical information to discuss with physicians. I think if my educator with high level of knowledge escapes from doctors,
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certainly, I wouldn't have enough knowledge to discuss with physicians. They transfer low self-esteem to me.
Findings from contextual observation demonstrated that, educators preferred to work
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theoretically in hospital and most of their clinical instruction was spent in lectures and theoretical discussions without direct involvement in patient care.
In most of clinical education course, our time was only spent on preparation conference or lecture papers for presenting. Our educators in theoretical concept are stronger than clinical practice.
One of the reasons that mentioned as cause of incompetency of clinical educators was reluctance of educators for teaching in clinical setting. Most of educators preferred teaching in theoretical class to teaching in clinical setting, especially experienced educators. Indeed it is infra dig to them to go clinical setting for teaching.
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ACCEPTED MANUSCRIPT An educator stated that; I have PhD in nursing; I feel I am a better researcher and theoretical teacher than clinical educator. I prefer theoretical class to clinical course. Clinical course manager in nursing faculty tried to coerce me into accepting clinical course
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and now I'm here (hospital). Administrative boards of faculty don't pay any attention to our
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interest cause of educator shortage in faculty. I know I haven't competency for clinical
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educating.
Patient education as important component of nursing:
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Students and their educators are well aware of the importance of patient education and perceive a great deal of responsibility for their educating role. Most of the students believe
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that their educators emphasize to patient education.
One of the clinical educators expressed: it seems to me that, patient education is one of the
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objective and understandable part of nursing care and we can explain to the students how to
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perform it. For example when we speak about holistic care, it is a subjective concept and we
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can't explain steps of caring with holistic view.
One of the students in this regard stated; I believe that, patient education is a professional part of nursing care and one of the roles that nurses do better than other treatment team.
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Other student said: the main focus of our clinical educator after routine base and mechanical care is patient education. Observation confirmed interviews. Most of the educators emphasized on the patient education in their clinical education course. They explained to the students; Patient education is a valuable part of professional nurses' practice and nurses should be primarily responsible for patient education. Discussion:
The findings of this study describe a clearer understanding of dominant climate of clinical education in Iran.
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ACCEPTED MANUSCRIPT According to our finding there is considerable incongruence between what nursing students actually do as part of the nursing care in clinical practice, and the ethical, moral and altruistic principles of care presented by a number of nursing theorists and academics environment.
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This situation leads to conflict and role ambiguity in nursing students. This is not surprising,
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as the literature in nursing continues to refer to caring as a nebulous, elusive, and problematic concept in nursing education(Kyrkjebø and Hage 2005, Apesoa-Varano 2007). A conflict
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between theory and practice and having no plan during internship period is a common problem for nursing students, often leading to confusion and role ambiguity(Williams and Taylor 2008, Ewertsson, Allvin et al. 2015). Apesoa-Varano believes that while nursing
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student's think of the occupation as a profession, their understanding of what makes a “good” nurse is deemphasized in the model of professionalism espoused by their educational
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program. Consequently, prospective nurses must reconcile their expectations of nursing as a caring occupation with the professional ideology of the program. We suggested that for decreasing role ambiguity, nursing faculty should be seriously reconsider care concept as an
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operational component of nursing.
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Our findings indicate that a routine-based paradigm is the dominant part of Iranian clinical education at the baccalaureate level of nursing. Students thought that their work was doctors
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order follower and not really professional nursing care. This finding is supported by other studies in Iran(Nasrabadi and Emami 2006, Cheraghi, Salsali et al. 2010, Motlagh, Karimi et al. 2012). Pearcey and Draper also reported the same results in their study. They mentioned
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that despite the new theories of nursing, the tasks will not be focused for a long time but the routines still determine the style of the nursing profession (Pearcey and Draper 2008). Impression of nursing behaviors in hospital ward on students and large amount of students in clinical group mentioned as cause of routine-based paradigm dominancy in clinical education. We recommend that nursing faculties administrative boards should make the change in amount of students group in clinical setting and hospital administrative board guide nursing to professional care rather than routine-based care. The data emerging from this study show that climate of clinical education in Iran wasn’t motivation to critical thinking in students. Our findings suggest that the students were unable to develop the skills of independent and effective creative thinking. This finding is supported by Jahanpour et al. they indicated that Iranian nursing students could not make clinical decisions independently. Their findings of study support the need to reform aspects of the 13
ACCEPTED MANUSCRIPT curriculum in Iran in order to increase critical thinking, problem solving and prepare a conductive clinical learning climate that enhances learning clinical decision making (Jahanpour, Sharif et al. 2010).
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The findings of our study showed that such clinical educators were not present except on the
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clinical setting. Lack of education and experience in specialty clinical practice among clinical instructors render them less self-confident in teaching students effectively. Experience of the
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nurse students was their instructors’ low self-confidence and unwillingness to attend the medical rounds. one study in Turkey also revealed that nurse students have similar experiences during their internship program(Elcigil and Sarı 2007). Other studies in Iran
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confirmed this finding (Nasrabadi and Emami 2006, Motlagh, Karimi et al. 2012, Esmaeili, Cheraghi et al. 2014). Our finding indicated that clinical educators emphasized on theoretical
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concept for covering their weakness in clinical practice in hospital. Other studies in Iran support this assertation (Peyrovi, Yadavar‐Nikravesh et al. 2005, Dehghan Nayeri, Nazari et al. 2006, Esmaeili, Cheraghi et al. 2014).Students need instructors’ competency. Then
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instructors should develop their educational role model for the nurse students. salminen et al
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believe that to maintain and improve the competence of nurse educators, it is important to develop different evaluation methods to reliably measure the nurse educators' level of
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competence(Salminen, Minna et al. 2013). This study revealed that educators and students were well aware of the importance of patient education and accepted this role in clinical settings. A study in Iran reported that however nursing students were aware of the importance of patient education; they were not inclined to
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perform patient education and spent little time for it during clinical placements. In their study students stated that clinical instructors did not consider any privilege to patient education in their course final evaluation(Ghorbani, Soleimani et al. 2014). Other study in Iran reported that nurses spent a little time for patient education activities and performed patient education only when routine care was finished(Vaismoradi, Salsali et al. 2011). Our study when compared to the previous studies shows that, patient education position in clinical education is in progress.
Conclusion
The findings of this study describe a clearer understanding of the real environment of the clinical education in Iran and provide a platform for the further development of theoretical 14
ACCEPTED MANUSCRIPT explanations regarding clinical preparation in the Iranian context. As resulted, students cannot be effectively prepared clinically due to ambiguity in nursing care role, routine-based nursing care, uncritical thinking climate and incompetency of clinical educators. These items
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play an important role in student learning and nursing education. It is crucial to pay more
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attention to reconsider care concept as an operational component of nursing, maximize meaningful learning opportunities, reevaluate clinical instructor as role models and
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preparation effective operational plan to combine theoretical and evidence based knowledge with clinical practice. We recommend the conduct of action researches for improvement of
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the clinical nursing education.
References;
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Apesoa-Varano, E. C. (2007). "Educated caring: The emergence of professional identity among nurses." Qualitative Sociology 30(3): 249-274. Cheraghi, M. A., M. Salsali and M. Safari (2010). "Ambiguity in knowledge transfer: the role of theory-practice gap." Iranian journal of nursing and midwifery research 15(4): 155. d'Souza, M. S., S. N. Karkada, K. Parahoo and R. Venkatesaperumal (2015). "Perception of and satisfaction with the clinical learning environment among nursing students." Nurse education today. Dehghan Nayeri, N., A. A. Nazari, M. Salsali, F. Ahmadi and M. Adib Hajbaghery (2006). "Iranian staff nurses’ views of their productivity and management factors improving and impeding it: a qualitative study." Nursing & health sciences 8(1): 51-56. Démeh, W. and K. Rosengren (2015). "The visualisation of clinical leadership in the content of nursing education—A qualitative study of nursing students' experiences." Nurse education today. Elcigil, A. and H. Y. Sarı (2007). "Determining problems experienced by student nurses in their work with clinical educators in Turkey." Nurse Education Today 27(5): 491-498. Elo, S. and H. Kyngäs (2008). "The qualitative content analysis process." Journal of advanced nursing 62(1): 107-115. Esmaeili, M., M. A. Cheraghi, M. Salsali and S. Ghiyasvandian (2014). "Nursing students' expectations regarding effective clinical education: A qualitative study." International journal of nursing practice 20(5): 460-467. Ewertsson, M., R. Allvin, I. Holmström and K. Blomberg (2015). "Walking the bridge: Nursing students’ learning in clinical skill laboratories." Nurse Education in Practice. Ghorbani, R., M. Soleimani, M.-R. Zeinali and M. Davaji (2014). "Iranian nurses and nursing students' attitudes on barriers and facilitators to patient education: A survey study." Nurse education in practice 14(5): 551-556. Hajbaghery, M. A. and M. Salsali (2005). "A model for empowerment of nursing in Iran." BMC health services research 5(1): 24. Hsieh, S.-I. and L.-L. Hsu (2013). "An outcome-based evaluation of nursing competency of baccalaureate senior nursing students in Taiwan." Nurse education today 33(12): 1536-1545. Jahanpour, F., F. Sharif, M. Salsali, M. H. Kaveh and L. M. Williams (2010). "Clinical decision‐making in senior nursing students in Iran." International journal of nursing practice 16(6): 595-602. Killam, L. A. and C. Heerschap (2013). "Challenges to student learning in the clinical setting: A qualitative descriptive study." Nurse education today 33(6): 684-691.
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Kristofferzon, M.-L., G. Mårtensson, A.-G. Mamhidir and A. Löfmark (2013). "Nursing students' perceptions of clinical supervision: the contributions of preceptors, head preceptors and clinical lecturers." Nurse education today 33(10): 1252-1257. Krueger, R. A. (2009). Focus groups: A practical guide for applied research, Sage. Kyrkjebø, J. M. and I. Hage (2005). "What we know and what they do: nursing students’ experiences of improvement knowledge in clinical practice." Nurse Education Today 25(3): 167-175. Li, Y.-S., P.-S. Chen and S.-J. Tsai (2008). "A comparison of the learning styles among different nursing programs in Taiwan: implications for nursing education." Nurse Education Today 28(1): 70-76. Motlagh, F. G., M. Karimi and M. Hasanpour (2012). "Iranian nursing students’ experiences of nursing." Iranian journal of nursing and midwifery research 17(2 Suppl1): S107. Nasrabadi, A. N. and A. Emami (2006). "Perceptions of nursing practice in Iran." Nursing outlook 54(6): 320-327. O'Mara, L., J. McDonald, M. Gillespie, H. Brown and L. Miles (2014). "Challenging clinical learning environments: Experiences of undergraduate nursing students." Nurse education in practice 14(2): 208-213. Pearcey, P. and P. Draper (2008). "Exploring clinical nursing experiences: Listening to student nurses." Nurse education today 28(5): 595-601. Peyrovi, H., M. Yadavar‐Nikravesh, S. Oskouie and C. Berterö (2005). "Iranian student nurses’ experiences of clinical placement." International Nursing Review 52(2): 134-141. Polit, D. F. and C. T. Beck (2013). Essentials of nursing research, Lippincott Williams & Wilkins. Rabiee, F. (2004). "Focus-group interview and data analysis." Proceedings of the nutrition society 63(04): 655-660. Salminen, L., S. Minna, K. Sanna, K. Jouko and L.-K. Helena (2013). "The competence and the cooperation of nurse educators." Nurse education today 33(11): 1376-1381. Sharif, F. and S. Masoumi (2005). "A qualitative study of nursing student experiences of clinical practice." BMC nursing 4(1): 6. Tunc, T. and R. O. Kutanis (2009). "Role conflict, role ambiguity, and burnout in nurses and physicians at a university hospital in Turkey." Nursing & health sciences 11(4): 410-416. Vaismoradi, M., M. Salsali, M. Esmaeilpour and M. A. Cheraghi (2011). "Perspectives and experiences of Iranian nurses regarding nurse–physician communication: A content analysis study." Japan Journal of Nursing Science 8(2): 184-193. Williams, A. and C. Taylor (2008). "An investigation of nurse educator’s perceptions and experiences of undertaking clinical practice." Nurse education today 28(8): 899-908. Yazdannik, A., Z. P. Yekta and A. Soltani (2012). "Nursing professional identity: an infant or one with Alzheimer." Iranian journal of nursing and midwifery research 17(2 Suppl1): S178.
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Observation 1 group (10 students and one faculty members)
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Table 1. participant distribution in individual interviews and focus groups University participant Individual interview Focus group Tehran Clinical N= 2 (1= 10 years , 1= 5 University of educator years of experience in Medical clinically educating and Sciences faculty member) Student N=9 (3 in sophomore, 3 in 6 fourth junior and 3 in senior level) baccalaureate students Esfahan Clinical 2 (1= 7 years , 1= 2 years of University of educator experience in clinically Medical educating and faculty Sciences member) Student N= 7 (2 in sophomore, 3 in 6 fourth junior and 2 in senior level) baccalaureate students Babol Clinical N= 2 (1= 19 years , 1= 6 University of educator years of experience in Medical clinically educating and Sciences faculty member) Student N= 7 (3 in sophomore, 3 in 6 fourth junior and 1 in senior level) baccalaureate students Yasooj Clinical N= 2 (1= 8 years , 1= 4 University of educator years of experience in Medical clinically educating and Sciences faculty member) Student N= 7 (2 in sophomore, 3 in 6 fourth junior and 2 in senior level) baccalaureate students
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1 group (11 students and one faculty members )
year nursing 1 group (8 students and one faculty members) year nursing 1 group (9 students and one faculty members)
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year nursing
year nursing
ACCEPTED MANUSCRIPT Highlights:
Most of the Iranian studies in clinical education conducted at one faculty by small number of research participant, so to achieve comprehensive results, we conducted our study in four geographically diverse universities in the Iran and we used multi methods to data collection; individual interviews, focus groups and direct observations.
The findings of this study describe a clearer understanding of the real environment of the clinical education in Iran.
All of themes that emerged from the study play an important role in student learning and nursing education.
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S0260-6917(15)00298-1 doi: 10.1016/j.nedt.2015.07.028 YNEDT 3028
To appear in:
Nurse Education Today
Accepted date:
30 July 2015
Please cite this article as: Mohammadi, Sepideh, Yousefy, Alireza, Yazdannik, Ahmad reza, Exploring the environment of clinical baccalaureate nursing students’ education in Iran; A Qualitative Descriptive Study, Nurse Education Today (2015), doi: 10.1016/j.nedt.2015.07.028
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.
ACCEPTED MANUSCRIPT Title: Exploring the environment of clinical baccalaureate nursing students' education in Iran; A Qualitative Descriptive Study
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Word count: 5100
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Authors:
Sepideh Mohammadi, Corresponding author, PhD Candidate in nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
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E-mail: [email protected]
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Alireza Yousefy, Associate Professor, Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: [email protected]
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Ahmad reza Yazdannik: Assistant Professor, Critical Care Department, Nursing and Midwifery Faculty, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: [email protected]
Acknowledgments:
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This study was part of the Ph.D. dissertation, so it is incumbent upon the authors to acknowledge the financial support offered by the Research Vice-Chancellor of Esfahan University of Medical Sciences. We would like to thank all study participants.
Conflict of interest: The authors did not have any conflict of interest to conducting this study.
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ACCEPTED MANUSCRIPT Exploring the environment of clinical baccalaureate nursing students' education in Iran; A Qualitative Descriptive Study
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Abstract:
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Introduction: Today's students are the nurses of tomorrow. They need appropriate clinical learning opportunities in order to shape their professional identity, attitudes and values.
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Despite undeniable progresses of nursing education in Iran, the quality of the clinical education in Iran is not favorable. There is need to exploring the environment of clinical baccalaureate nursing students' education for developing, maintaining and enhancing the
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quality of clinical program.
Method: this is a qualitative study and was conducted base on content analysis multimethod
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design. Data collected by individual interviews, focus groups and direct observations. 54 nursing students and 8 clinical educators from the four geographically diverse universities in
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the Iran composed the study sample. A purposive sampling was used.
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Result: five themes were emerged from data analysis including; Ambiguity in the nursing care role, Routine-based nursing care, Uncritical and dependent thinking climate,
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Incompetency of clinical educators and Patient education as important component of nursing. Conclusions: The findings of this study describe a clearer understanding of the real environment of the clinical education in Iran. All of themes that emerged from the study play an important role in student learning and nursing education. It is crucial to pay more attention
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to reconsider care concept as an operational component of nursing, maximize meaningful learning opportunities, reevaluate clinical instructor as role models and preparation effective operational plan to combine theoretical and evidence based knowledge with clinical practice.
Key words: nursing education, clinical educator, clinical education, nursing student
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ACCEPTED MANUSCRIPT Introduction: The mission of nursing education is to produce qualified nurses with the requisite knowledge, attitudes and skills. For achieving this goal, clinical teaching is the cornerstone in nursing
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education (Li, Chen et al. 2008). in most countries, approximately 50% of the curriculum in
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the nursing program is devoted to clinical studies. A perfect clinical program is crucial in
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order to shape the professional identity of nursing students, and is also the primary source of learning professional attitudes, values and norms(Killam and Heerschap 2013, O'Mara, McDonald et al. 2014). Students need meaningful and appropriate clinical learning opportunities, and support by evaluated models of facilitators to encompass the range of
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experiences necessary for the graduate nurse(Kristofferzon, Mårtensson et al. 2013, d'Souza,
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Karkada et al. 2015). Literature review:
Despite increased academic input into nursing education in Iran in recent years, the public
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and the government have criticized Iranian nurses and nursing students regarding the poor
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quality of patient care(Cheraghi, Salsali et al. 2010). It seems that nursing students have a lot of problems with their professional identity and they are not proud of being a nurse. Nursing
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students are embarrassed to say they are a nurse even in their family or to their parents(Yazdannik, Yekta et al. 2012). Even nursing teachers doubt their efficiency and independence in clinical education(Hajbaghery and Salsali 2005). A study in Iran revealed
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that, students after entering to the clinical stage had the feeling of professional inferiority and oppression. Also senior undergraduate students do not know who they are and what the values of their profession are(Yazdannik, Yekta et al. 2012). The result of the other study in Iran showed that nursing students frequently feel vulnerable in the clinical environment (Dehghan Nayeri, Nazari et al. 2006) and they were not satisfied with the clinical education. they experienced anxiety as a result of feeling incompetent and lack of professional nursing skills and knowledge to take care of various patients in the clinical setting(Sharif and Masoumi 2005).. Several years’ experience of authors in nursing education showed that many Iranian nursing students are not well motivated, and their negative attitudes and behaviors impede learning and threaten their progression and retention in nursing programs. The researcher came to 3
ACCEPTED MANUSCRIPT realize that nursing students have a great deal of confusion about their role and duty when they begin their clinical practice in the second year to forth year. On the other hand, many of the faculties and administrative board in nursing education are
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interested to know, what is happening in the clinical education environment? How is nursing
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identity formed in clinical education course? The answer to these questions and research on the clinical education climate may help to recognizing the clinical education defects and
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promote students’ motivation and their professional identity.
Most of the Iranian research studies in this regard conducted at one faculty by small number of research participant, so to achieve comprehensive results, we conducted our study in four
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geographically diverse universities in the Iran. It was assumed that the findings of the current study would provide support for nursing faculty in developing, maintaining and enhancing
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the quality of clinical program.
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Methods:
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Design:
A qualitative design could increase the understanding of nursing students' and clinical
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educators voices, views and thoughts about clinical education(Démeh and Rosengren 2015). Therefore, a descriptive study using content analysis was conducted. Though qualitative research relies on trustworthiness, transparency, verification, reflexivity and is also ‘informant-driven’, the design could be helpful to develop insightful and artful interpretations
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within the nursing education process (Polit and Beck 2013).
Setting and Participants: Participants were nursing students and clinical nursing educator selected from four major educational centers in Iran, that is, Tehran, Isfahan, Babol and Yasooj University of Medical Sciences(Table 1). For achieving comprehensive data, we selected different nursing universities in both aspects of geographical location and scientific level in Iran. Tehran University of Medical Sciences (located in capital of Iran) and Isfahan University of Medical Sciences (located on the main north–south and east–west routes crossing Iran) are in high scientific level of nursing universities in Iran. Babol University of Medical Sciences (located on the north of Iran) and Yasooj University of Medical Sciences (located on the west of Iran) are middle scientific level of nursing universities in Iran. A purposive sampling was used. 4
ACCEPTED MANUSCRIPT The study population for individual interviews comprised of 30 baccalaureate nursing students in different semester and 8 clinical nursing educators. Furthermore, four focus groups were conducted at four universities. Participants were 6
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fourth year baccalaureate nursing students in each group.
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Altogether 54 students and 8 clinical educators participated in this study.
To collect Supplementary information, 4 groups (students and clinical educators in the
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clinical component of the general medical-surgical course) was observed for two days (total 10 hours) during the second week of clinical practice (the first week is for orientation and warming up, and the third week the course is for winding down).
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Maximum variation in sampling in terms of age, gender, level of academic semester, years of experience as instructor and universities with different geographical locations were
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considered in order to collect participants with a wide range of experiences and perspectives. It was estimated that six months were needed to collect the data.
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Data collection:
To better understand the nature of contemporary clinical education environment, a descriptive
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qualitative, multimethod design, including individual interviews, focus group and direct observation was used.
Face-to-face semi-structured interviews were conducted in a private place that was convenient to the participants.
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Also we used focus group method for data gathering. The advantage of focus group is, instead of the researcher asking each person to respond to a question in turn, people are encouraged to talk to one another: asking questions, exchanging anecdotes and commenting on each other's experiences and points of view(Rabiee 2004, Krueger 2009). At the beginning of each interview and focus group, the participants were asked to describe one day of their clinical course, and then interviews continued with question like: What is your expectation of clinical experiences? How do you feel about being a nursing student in clinical setting? What does definition of nursing formed in your mind during clinical training? What is the main focus of educator in the clinical course? What did you learn as a nursing care? What comes to mind when you hear the phrase ‘clinical experience? And... 5
ACCEPTED MANUSCRIPT The questions were asked in an open ended manner. The interviewer probed participant responses by using questions/statements, such as ‘Could you say something more about that?’ ‘When you mention . . . what do you mean?.
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All interviews and focus groups were taped and the scripts were immediately transcribed
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verbatim. Some interviews and focus group were conducted in the researcher’s university office in the university and others in hospital meeting rooms. Each interview lasted between
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30 and 50 min, with an average of 40 min.
When the responses were repeated and no new data were added to previous interview, data
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saturation was determined and interviews were concluded(Polit and Beck 2013).
In addition to individual interview and focus group, observation was used to data collection
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based on the assumption that observation is a fundamental and critical method in all qualitative inquiry. Observers watch what people do, listen to what people say and record these activities. The focus of participant observation was on the students, staffs, and
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educators’ transactions and behaviors during students’ clinical training. Field notes and
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Data analysis:
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memos were written to describe the observations and later analyzed.
This is a qualitative study which employs content analysis in order to identify nature of contemporary clinical education in Iran. An inductive approach to content analysis was used.
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In line with the qualitative content analysis approach put forth by Elo and Kyngas (2008) data were analyzed via the following steps:
Transcribing interviews verbatim;
Choosing the unit of analysis;
Attaining the sense of whole via the reading the unit of analysis;
Taking codes (relevant ideas and concepts) out through open coding;
Collecting similar codes in sub-themes by comparing the codes, and labeling them;
Gathering similar sub-themes together in one group and labeling them (main themes) (Elo and Kyngäs 2008);
Trustworthiness of data
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ACCEPTED MANUSCRIPT The use of member checking during data collection, a structured analysis procedure, peer debriefing and use of an external auditor promote the creditability of the study. An external audit was conducted by a nursing PhD candidate who was familiar with qualitative data
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analysis and checked all steps taken in the analysis process. Minor differences in wording of
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themes were discussed. He then reviewed the complete audit trail for this study and agreed with the findings. The researcher shared the results of findings with the participants to give
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them an opportunity to verify that her interpretations are in correspondence with their realworlds .Maximum variation in sampling in terms of age, gender, level of academic semester, years of experience as educator and universities with different geographical locations were
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considered in order to collect participants with a wide range of experiences and perspectives.
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Ethical issues:
Ethical issues in this study involved the assurance of confidentiality and autonomy for the participants. The Internal Review Board of Isfahan University of Medical Sciences, School of
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Nursing and Midwifery, approved the study before data collection began. Permission, as
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written informed consent, was sought from the participants for the audio tape interviews and participant observation. All the participants were asked to participate under the premise that
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information would be annoymized and would remain confidential. The data were stored
Finding:
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safely where only the researcher could access it.
54 students, 19 to 25years of age (M=23.1), participated in the study. The majority were female (n=39). 8 faculty clinical educator, 30 to 51 years of age (M=40.2), participated in the study. The majority were female (n=5), n=5 held master’s degrees & n=3 held PhD degrees, all educator taught full-time. Although observations and interviews occurred at five different schools of nursing in Iran, investigator noted no overall differences in clinical activities observed or in core concepts in interviews. During the steps of data analysis four main themes emerged: 1- Ambiguity in the nursing care role; 7
ACCEPTED MANUSCRIPT 2- Routine-based nursing care 3- Uncritical and dependent thinking climate 4- Incompetency of clinical educators
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5- Patient education as an important component of nursing
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Ambiguity in the nursing care role;
Role ambiguity occurs when people are unclear or uncertain about their expectations within a certain role, typically their role in the job or workplace (Tunc and Kutanis 2009). Nursing educator and students saw caring as one important element of nursing, yet when I
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(researcher) asked what caring meant, clinical educators avoided defining it explicitly. As one of the clinical educators stated that; I know caring is really important role of nursing but it is
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hard to say what it is caring.
There was a less caring attitude among nursing students and educators. Some clinical educator reported a lack of clarity in relation to what was expected from caring in clinical
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practice and how this was formalized.
One senior student in focus group session described her experience as: We often feel
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confused and depressed; actually, we do not know what is expected of us as a professional nurse with special caring role in clinical setting. We are responsible for just about everything. We should be performing our nursing duties, not being treated as guards,
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physicians' assistance, cleaners, nurses’ aides. I don't know, who are we really? Field notes confirmed interviews and indicated that it is unclear how the caring dimension is actually taught. Maybe this is due to educators lack consensus on what caring actually is and how it can be taught. A third year student nurse put it: I know most important role in nursing is caring and having holistic view. But I feel a bit confused really; this is nebulous concept for me. Holistic view is a subjective concept for me. They (educators) really don’t have a clue what reality is and how to perform nursing care with holistic view in real world. Indeed actions speak louder than word. Field notes confirmed interviews and indicated that when clinical educator spoke about caring or professional nursing care they couldn’t express caring as an operational concept. 8
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Routine-based nursing care: In our study student frequently expressed that their work was 'not really professional nursing'
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they were confused by what they had learned in the faculty and what in reality was expected
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of them in practice. Students and clinical educators believed that present nursing care consisted of more technical and mechanical care without any individual and holistic care.
towards task completion and routine physical care.
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According to interview and observation the practice setting was predominantly oriented
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One final-year students in focus group session described her experience as: We just do basic nursing care. We are just a simple worker with some routine-based duties, such as giving the
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drugs and injections, changing the sheets, and dressing wounds.
One of the third-year students expressed: Where is the nursing process and professional
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knowledge? We spend four years studying nursing but we do not feel we are doing a
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professional job. This practice does not need 4 years training and professional knowledge, 1
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year or 6 months training, to do this type of nursing, is enough.
Clinical setting priority was not given to providing theoretical knowledge-based practice according to a learned knowledge of nursing. There was a gap between theory and practice, and little attention was paid to the implementation of evidence-based practice. A student said:
reality.
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I surprised and disillusionment when my expectations of nursing work did not match the
Large number of students in clinical education group mentioned as one of the barriers to doing professional nursing care and consistency in implementation of routine physical care. A clinical educator said that: There are at least 10 students in per clinical education group. In this condition we only have time to doing routine physical care and following doctors' order. Even sometimes we haven’t time to doing routine physical care let alone doing professional nursing care. Also students expressed that their behaviors in clinical setting affected by kinds of nurses behavior. This situation made students feel that carrying out the nursing tasks needs no special knowledge. As a result, they lost their motivation for learning professional nursing
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ACCEPTED MANUSCRIPT care . In fact students imagine their future career when observing the work conditions and the nurses’ clinical practice.
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One of the senior students stated; Most of the time the nurse sits in the nursing station and
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writes the nursing report and they unaware of her/his patients. According to my experiences and my observation to nurses, the primary goal of clinical education is to simply follow the
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doctor’s orders and provide basic routine care, not the patient’s individual needs. I think, I no need extra burden when i would be one nurse like this in the future.
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Type of student evaluation by educators mentioned as another reason for dominance of routine physical care. Most of student in focus group believed that; doing technical skills (like
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giving the drugs and injections, changing the sheets, and dressing wounds) correctly is one of the most important criteria for clinical evaluation of students. One third year student said
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that; the educators praised me when i carried out my routine tasks efficiently.
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Uncritical and dependent thinking climate: Findings from contextual observation and interviews demonstrated that students were too
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dependent on their educators for doing procedures and solving patents problem. Most of the students experienced poor-self-confidence in clinical setting. They believe that poor-self-confidence in the clinical setting is a barrier for independent thinking or caring. The students in focus group stated that they needed clinical educator to be with them when
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they were carrying out nursing procedures. "We need educators observe our activity because we protect from making mistake" A sophomore student stated; When i wanted to do a nursing procedure, i was doubtful, i didn't trust myself, I needed educator to be with me and assure me that i was doing it right. According to observation, when educators asked question of their student, questions were straightforward and simple. Question weren't challenging and incentive to improve critical thinking in students. Also, usually student couldn’t solve simple problem or questions and asked their educator to answer the questions. They had little power of independent Thinking.
Large number of students in clinical education group mentioned as one of the barriers to progression critical thinking climate in clinical setting;
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ACCEPTED MANUSCRIPT A clinical educator said; In large clinical group, there is no opportunity to creation a challenging and critical thinking climate. With a little time and a lot of students, we just have
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time to walking in a line by straight forward manner.
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Incompetency of clinical educators:
However, clinical experience and specialty training among clinical educators was the most
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important causal condition that enhanced their ability to educate students effectively, (Hsieh and Hsu 2013) unfortunately, findings from the participants’ interview and observation revealed that; such clinical educators were not prepared and competent for being a role model
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practical setting.
A sophomore student in focus group said; usually we have novice clinical educators who
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have little experience in clinical setting and we have only observed the procedure because our educators have not had enough experience.
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One of the students in this regard stated: I haven’t seen our educators discussed with
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physicians. I feel they haven’t sufficient professional and medical information to discuss with physicians. I think if my educator with high level of knowledge escapes from doctors,
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certainly, I wouldn't have enough knowledge to discuss with physicians. They transfer low self-esteem to me.
Findings from contextual observation demonstrated that, educators preferred to work
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theoretically in hospital and most of their clinical instruction was spent in lectures and theoretical discussions without direct involvement in patient care.
In most of clinical education course, our time was only spent on preparation conference or lecture papers for presenting. Our educators in theoretical concept are stronger than clinical practice.
One of the reasons that mentioned as cause of incompetency of clinical educators was reluctance of educators for teaching in clinical setting. Most of educators preferred teaching in theoretical class to teaching in clinical setting, especially experienced educators. Indeed it is infra dig to them to go clinical setting for teaching.
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ACCEPTED MANUSCRIPT An educator stated that; I have PhD in nursing; I feel I am a better researcher and theoretical teacher than clinical educator. I prefer theoretical class to clinical course. Clinical course manager in nursing faculty tried to coerce me into accepting clinical course
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and now I'm here (hospital). Administrative boards of faculty don't pay any attention to our
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interest cause of educator shortage in faculty. I know I haven't competency for clinical
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educating.
Patient education as important component of nursing:
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Students and their educators are well aware of the importance of patient education and perceive a great deal of responsibility for their educating role. Most of the students believe
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that their educators emphasize to patient education.
One of the clinical educators expressed: it seems to me that, patient education is one of the
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objective and understandable part of nursing care and we can explain to the students how to
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perform it. For example when we speak about holistic care, it is a subjective concept and we
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can't explain steps of caring with holistic view.
One of the students in this regard stated; I believe that, patient education is a professional part of nursing care and one of the roles that nurses do better than other treatment team.
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Other student said: the main focus of our clinical educator after routine base and mechanical care is patient education. Observation confirmed interviews. Most of the educators emphasized on the patient education in their clinical education course. They explained to the students; Patient education is a valuable part of professional nurses' practice and nurses should be primarily responsible for patient education. Discussion:
The findings of this study describe a clearer understanding of dominant climate of clinical education in Iran.
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ACCEPTED MANUSCRIPT According to our finding there is considerable incongruence between what nursing students actually do as part of the nursing care in clinical practice, and the ethical, moral and altruistic principles of care presented by a number of nursing theorists and academics environment.
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This situation leads to conflict and role ambiguity in nursing students. This is not surprising,
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as the literature in nursing continues to refer to caring as a nebulous, elusive, and problematic concept in nursing education(Kyrkjebø and Hage 2005, Apesoa-Varano 2007). A conflict
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between theory and practice and having no plan during internship period is a common problem for nursing students, often leading to confusion and role ambiguity(Williams and Taylor 2008, Ewertsson, Allvin et al. 2015). Apesoa-Varano believes that while nursing
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student's think of the occupation as a profession, their understanding of what makes a “good” nurse is deemphasized in the model of professionalism espoused by their educational
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program. Consequently, prospective nurses must reconcile their expectations of nursing as a caring occupation with the professional ideology of the program. We suggested that for decreasing role ambiguity, nursing faculty should be seriously reconsider care concept as an
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operational component of nursing.
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Our findings indicate that a routine-based paradigm is the dominant part of Iranian clinical education at the baccalaureate level of nursing. Students thought that their work was doctors
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order follower and not really professional nursing care. This finding is supported by other studies in Iran(Nasrabadi and Emami 2006, Cheraghi, Salsali et al. 2010, Motlagh, Karimi et al. 2012). Pearcey and Draper also reported the same results in their study. They mentioned
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that despite the new theories of nursing, the tasks will not be focused for a long time but the routines still determine the style of the nursing profession (Pearcey and Draper 2008). Impression of nursing behaviors in hospital ward on students and large amount of students in clinical group mentioned as cause of routine-based paradigm dominancy in clinical education. We recommend that nursing faculties administrative boards should make the change in amount of students group in clinical setting and hospital administrative board guide nursing to professional care rather than routine-based care. The data emerging from this study show that climate of clinical education in Iran wasn’t motivation to critical thinking in students. Our findings suggest that the students were unable to develop the skills of independent and effective creative thinking. This finding is supported by Jahanpour et al. they indicated that Iranian nursing students could not make clinical decisions independently. Their findings of study support the need to reform aspects of the 13
ACCEPTED MANUSCRIPT curriculum in Iran in order to increase critical thinking, problem solving and prepare a conductive clinical learning climate that enhances learning clinical decision making (Jahanpour, Sharif et al. 2010).
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The findings of our study showed that such clinical educators were not present except on the
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clinical setting. Lack of education and experience in specialty clinical practice among clinical instructors render them less self-confident in teaching students effectively. Experience of the
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nurse students was their instructors’ low self-confidence and unwillingness to attend the medical rounds. one study in Turkey also revealed that nurse students have similar experiences during their internship program(Elcigil and Sarı 2007). Other studies in Iran
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confirmed this finding (Nasrabadi and Emami 2006, Motlagh, Karimi et al. 2012, Esmaeili, Cheraghi et al. 2014). Our finding indicated that clinical educators emphasized on theoretical
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concept for covering their weakness in clinical practice in hospital. Other studies in Iran support this assertation (Peyrovi, Yadavar‐Nikravesh et al. 2005, Dehghan Nayeri, Nazari et al. 2006, Esmaeili, Cheraghi et al. 2014).Students need instructors’ competency. Then
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instructors should develop their educational role model for the nurse students. salminen et al
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believe that to maintain and improve the competence of nurse educators, it is important to develop different evaluation methods to reliably measure the nurse educators' level of
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competence(Salminen, Minna et al. 2013). This study revealed that educators and students were well aware of the importance of patient education and accepted this role in clinical settings. A study in Iran reported that however nursing students were aware of the importance of patient education; they were not inclined to
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perform patient education and spent little time for it during clinical placements. In their study students stated that clinical instructors did not consider any privilege to patient education in their course final evaluation(Ghorbani, Soleimani et al. 2014). Other study in Iran reported that nurses spent a little time for patient education activities and performed patient education only when routine care was finished(Vaismoradi, Salsali et al. 2011). Our study when compared to the previous studies shows that, patient education position in clinical education is in progress.
Conclusion
The findings of this study describe a clearer understanding of the real environment of the clinical education in Iran and provide a platform for the further development of theoretical 14
ACCEPTED MANUSCRIPT explanations regarding clinical preparation in the Iranian context. As resulted, students cannot be effectively prepared clinically due to ambiguity in nursing care role, routine-based nursing care, uncritical thinking climate and incompetency of clinical educators. These items
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play an important role in student learning and nursing education. It is crucial to pay more
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attention to reconsider care concept as an operational component of nursing, maximize meaningful learning opportunities, reevaluate clinical instructor as role models and
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preparation effective operational plan to combine theoretical and evidence based knowledge with clinical practice. We recommend the conduct of action researches for improvement of
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the clinical nursing education.
References;
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Apesoa-Varano, E. C. (2007). "Educated caring: The emergence of professional identity among nurses." Qualitative Sociology 30(3): 249-274. Cheraghi, M. A., M. Salsali and M. Safari (2010). "Ambiguity in knowledge transfer: the role of theory-practice gap." Iranian journal of nursing and midwifery research 15(4): 155. d'Souza, M. S., S. N. Karkada, K. Parahoo and R. Venkatesaperumal (2015). "Perception of and satisfaction with the clinical learning environment among nursing students." Nurse education today. Dehghan Nayeri, N., A. A. Nazari, M. Salsali, F. Ahmadi and M. Adib Hajbaghery (2006). "Iranian staff nurses’ views of their productivity and management factors improving and impeding it: a qualitative study." Nursing & health sciences 8(1): 51-56. Démeh, W. and K. Rosengren (2015). "The visualisation of clinical leadership in the content of nursing education—A qualitative study of nursing students' experiences." Nurse education today. Elcigil, A. and H. Y. Sarı (2007). "Determining problems experienced by student nurses in their work with clinical educators in Turkey." Nurse Education Today 27(5): 491-498. Elo, S. and H. Kyngäs (2008). "The qualitative content analysis process." Journal of advanced nursing 62(1): 107-115. Esmaeili, M., M. A. Cheraghi, M. Salsali and S. Ghiyasvandian (2014). "Nursing students' expectations regarding effective clinical education: A qualitative study." International journal of nursing practice 20(5): 460-467. Ewertsson, M., R. Allvin, I. Holmström and K. Blomberg (2015). "Walking the bridge: Nursing students’ learning in clinical skill laboratories." Nurse Education in Practice. Ghorbani, R., M. Soleimani, M.-R. Zeinali and M. Davaji (2014). "Iranian nurses and nursing students' attitudes on barriers and facilitators to patient education: A survey study." Nurse education in practice 14(5): 551-556. Hajbaghery, M. A. and M. Salsali (2005). "A model for empowerment of nursing in Iran." BMC health services research 5(1): 24. Hsieh, S.-I. and L.-L. Hsu (2013). "An outcome-based evaluation of nursing competency of baccalaureate senior nursing students in Taiwan." Nurse education today 33(12): 1536-1545. Jahanpour, F., F. Sharif, M. Salsali, M. H. Kaveh and L. M. Williams (2010). "Clinical decision‐making in senior nursing students in Iran." International journal of nursing practice 16(6): 595-602. Killam, L. A. and C. Heerschap (2013). "Challenges to student learning in the clinical setting: A qualitative descriptive study." Nurse education today 33(6): 684-691.
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Kristofferzon, M.-L., G. Mårtensson, A.-G. Mamhidir and A. Löfmark (2013). "Nursing students' perceptions of clinical supervision: the contributions of preceptors, head preceptors and clinical lecturers." Nurse education today 33(10): 1252-1257. Krueger, R. A. (2009). Focus groups: A practical guide for applied research, Sage. Kyrkjebø, J. M. and I. Hage (2005). "What we know and what they do: nursing students’ experiences of improvement knowledge in clinical practice." Nurse Education Today 25(3): 167-175. Li, Y.-S., P.-S. Chen and S.-J. Tsai (2008). "A comparison of the learning styles among different nursing programs in Taiwan: implications for nursing education." Nurse Education Today 28(1): 70-76. Motlagh, F. G., M. Karimi and M. Hasanpour (2012). "Iranian nursing students’ experiences of nursing." Iranian journal of nursing and midwifery research 17(2 Suppl1): S107. Nasrabadi, A. N. and A. Emami (2006). "Perceptions of nursing practice in Iran." Nursing outlook 54(6): 320-327. O'Mara, L., J. McDonald, M. Gillespie, H. Brown and L. Miles (2014). "Challenging clinical learning environments: Experiences of undergraduate nursing students." Nurse education in practice 14(2): 208-213. Pearcey, P. and P. Draper (2008). "Exploring clinical nursing experiences: Listening to student nurses." Nurse education today 28(5): 595-601. Peyrovi, H., M. Yadavar‐Nikravesh, S. Oskouie and C. Berterö (2005). "Iranian student nurses’ experiences of clinical placement." International Nursing Review 52(2): 134-141. Polit, D. F. and C. T. Beck (2013). Essentials of nursing research, Lippincott Williams & Wilkins. Rabiee, F. (2004). "Focus-group interview and data analysis." Proceedings of the nutrition society 63(04): 655-660. Salminen, L., S. Minna, K. Sanna, K. Jouko and L.-K. Helena (2013). "The competence and the cooperation of nurse educators." Nurse education today 33(11): 1376-1381. Sharif, F. and S. Masoumi (2005). "A qualitative study of nursing student experiences of clinical practice." BMC nursing 4(1): 6. Tunc, T. and R. O. Kutanis (2009). "Role conflict, role ambiguity, and burnout in nurses and physicians at a university hospital in Turkey." Nursing & health sciences 11(4): 410-416. Vaismoradi, M., M. Salsali, M. Esmaeilpour and M. A. Cheraghi (2011). "Perspectives and experiences of Iranian nurses regarding nurse–physician communication: A content analysis study." Japan Journal of Nursing Science 8(2): 184-193. Williams, A. and C. Taylor (2008). "An investigation of nurse educator’s perceptions and experiences of undertaking clinical practice." Nurse education today 28(8): 899-908. Yazdannik, A., Z. P. Yekta and A. Soltani (2012). "Nursing professional identity: an infant or one with Alzheimer." Iranian journal of nursing and midwifery research 17(2 Suppl1): S178.
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Observation 1 group (10 students and one faculty members)
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Table 1. participant distribution in individual interviews and focus groups University participant Individual interview Focus group Tehran Clinical N= 2 (1= 10 years , 1= 5 University of educator years of experience in Medical clinically educating and Sciences faculty member) Student N=9 (3 in sophomore, 3 in 6 fourth junior and 3 in senior level) baccalaureate students Esfahan Clinical 2 (1= 7 years , 1= 2 years of University of educator experience in clinically Medical educating and faculty Sciences member) Student N= 7 (2 in sophomore, 3 in 6 fourth junior and 2 in senior level) baccalaureate students Babol Clinical N= 2 (1= 19 years , 1= 6 University of educator years of experience in Medical clinically educating and Sciences faculty member) Student N= 7 (3 in sophomore, 3 in 6 fourth junior and 1 in senior level) baccalaureate students Yasooj Clinical N= 2 (1= 8 years , 1= 4 University of educator years of experience in Medical clinically educating and Sciences faculty member) Student N= 7 (2 in sophomore, 3 in 6 fourth junior and 2 in senior level) baccalaureate students
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1 group (11 students and one faculty members )
year nursing 1 group (8 students and one faculty members) year nursing 1 group (9 students and one faculty members)
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ACCEPTED MANUSCRIPT Highlights:
Most of the Iranian studies in clinical education conducted at one faculty by small number of research participant, so to achieve comprehensive results, we conducted our study in four geographically diverse universities in the Iran and we used multi methods to data collection; individual interviews, focus groups and direct observations.
The findings of this study describe a clearer understanding of the real environment of the clinical education in Iran.
All of themes that emerged from the study play an important role in student learning and nursing education.
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