Health Science Journal

Introduction

Clinical education is a vital component of nursing education. It plays a pivotal role in professional nursing, because it covers about half of the nursing curriculum [1]. It is a set of facilitating activities in clinical settings to provide targeted and measurable changes in students [2]. Clinical education is a complex and dynamic process in which students gain experience and apply knowledge in practice. It occurs through interactions among educators, students, staff, patients and environment [3]. It needs not only a broad and in-depth understanding of all contextual factors but also what is emerging from interactions among them [4]. In fact, clinical environment is a complex context for joining theoretical knowledge and clinical care [5], forcing students to learn how to integrate theory to practice [6,7]. Effective clinical education needs development of critical thinking, skill analysis and management, communication competence and promotion of students’ self-confidence, necessary for fulfilling professional role [8]. In addition, nursing students could develop their own theoretical knowledge by being in clinical environment and facing many challenges and issues [9,10].

Studies indicated that clinical field provides a unique opportunity that many educational objectives could be achieved; the most important ones is to develop professional competency [11]. Also, the major part of nursing socialization which is necessary for professionalism in nursing occurs in clinical environments during patient care. A supportive environment significantly facilitates socialization and also professionalism [12]. So it is important to understand the major factors that influence learning teaching process in clinical setting. In other hand, barriers and limitations in clinical setting can deteriorate efficacy of clinical education [11] and also create undesirable effects during the process of socialization in nursing profession [10]. Competent nursing students, as a main outcome of nursing education, are the most reliable source for investigating dimensions of clinical education that shouldn`t be marginalized [13]. Continuous quality improvements in clinical education make it necessary to evaluate strengths and weaknesses of learning-teaching process in the clinical field. Clinical education has mainly been studied using quantitative methods which they reported situation of clinical education as moderate [14], but the question remains, to what extent such result are valid to exhibit situation of clinical education? Due to a so complex and highly dynamic environment, their ability to express a meaningful description in behalf of students, educators and staff in the field has been questioned. In fact, studies that used quantitative method with structured questionnaires didn’t address how influencing factors are connected together and interact with each other.

Considering the methodological limitations of quantitative researches to assess complicated context of clinical education, therefore importance of utilizing qualitative method in studies on clinical education has been emphasized [4]. Qualitative methodologies provide a proper platform to discover interactions between students and educational system and bring a deeper insight into influencing factors on clinical education [15]. In addition it is necessary to give voice to students who have less opportunity to express themselves. Education as an interactive, mutual, humanistic structure demands qualitative method to entirely explore human’s interactions. Regarding the necessity of continuous monitoring of educational system and clinical education as a heart of nursing curriculum and uniqueness of qualitative method in deepening exploration and explaining interactions among influencing factors of clinical education and giving voice to the students, this study aimed to explore nursing students’ experiences of the factors influencing their clinical education.

Methodology

A descriptive, qualitative research design was used to explain and reach a deep understanding of nursing students’ experiences of the factors influencing their clinical education. The study was approved by the research ethics committee of Mashhad University of Medical Sciences. Study conducted from October 2012 to May 2013. Participants signed written informed consent to participate in the study before interview sessions. They were informed that results were published anonymously.

The study population included nursing students who were at that time studying in 3rd to 8th semester of an eight-semester BSN nursing program at Mashhad School of Nursing and Midwifery. First year nursing students were excluded because of the very limited clinical education experience. In this study, two-step sequential sampling was applied. In the first step, by using convenience sampling, researchers accessed all nursing students who were in the classrooms and asked them to fulfill a questionnaire if they are interested in participating in the study. Questionnaire included two open-ended questions: how do you describe the present status of clinical education? What are the facilitators and barriers for your learning in clinical education? Write your experience in-detail. Questionnaires were collected and reviewed carefully to find the richest descriptions of clinical education based on their experiences. One hundred fifty one out of 187 nursing students participated in the initial survey. Thirty two incomplete questionnaires were discarded, so 119 questionnaires were examined. Two expert researchers independently sorted student questionnaires according to degree of comprehensiveness and richness. Decisions were achieved based on content validity of students` replies. Disagreement was discussed to reach consensus. In the second step, students that were ranked highly experienced by researchers in the first steps were selected through purposeful sampling. Twelve selected participants, who had rich experience in clinical education, were interviewed in a 30 to 45 minute semi-structured interview sessions. Sample size justified until reaching data saturation. The following questions were asked to the students: “Please describe a day in the clinical learning”, “What experience do you have of clinical education?” “How would you describe the current situation of clinical education?” “In the current situation of clinical education what factors help and what hinder you in your learning in the clinical field?” “How would you describe the ideal situation of clinical education?”

All interviews were audio-taped by the corresponding author and were transcribed verbatim at the end of the interview. Transcribed data were analyzed after each interview using inductive qualitative content analysis [16]. The aim of this technique is to achieve extended and cohesive description of phenomenon and getting concepts or categories, which could be described as themes [17]. Content analysis was performed in three steps: preparing, organizing and reporting phase. Considering that the focus of this study was on the influential factors on clinical education, the scripts of interviews were initially read several times for gaining an insight of the whole meaning of the interview. In the organization step, data were coded using inductive approach and categories were extracted. Open codes were transferred to code sheets and subcategories were formed. The subcategories with similar themes were integrated and improved to a higher level. Each theme was labeled based on implied nature of the subcategories [18]. Coding and categorizing process were discussed with other authors. MaxQData software was used in data analysis. Trustworthiness reported as credibility and dependability. Credibility was followed using several strategies including 5 months staying in and data analysis, biphasic sampling to guarantee finding rich informants, member checking and consistency in interviews. Thick description and peer examination of data analysis performed regarding dependability [17]. Two expert methodologists participated in peer debriefing process. In order to prevent bias in analysis, researchers bracket their attitudes before data analysis.

Results

The median age of participating students was 21.5 years old and 8/12 students were female and in the fourth year. Twelve participant were coded as 1,2,4,5,13,14,18,20,22,27,28 and 30. In the primary analysis 310 open codes were emerged and categorized in 3 main themes as “being a promoter” with subcategories of evidence–based care agent, establishing effective communication and course manager; “too hungry to learn” with subcategories of motivation and acquiring selfconfidence and “unwelcoming field” with subcategories of educational atmosphere of clinical environment and welfare facilities.

“Being a promoter”: Students consider clinical educator as a promoter who must promote and empower students based on evidence-based nursing. They asked educator to bring theory and practice together and establish an effective communication and course management.

Evidence-based care agent: students indicated that the most fundamental skill for a clinical educator is the application of scientific evidence in routine practice, especially against nonprofessional care. Incompetent teachers were considered as a major barrier to promoting students in the field and performing evidence-based care. Participant 1: “Most educators say something in the classroom; however, they could not apply their own sayings in practice. The gap between theory and practice causes routine and repetitive care not an evidence-based care.” Participant14: “If there is a real gap between theory and practice, the evidence-based clinical education makes no difference. Some procedures and caring methods performed by the staff are completely traditional implying us older models of care indirectly.” Participant 20: “In my opinion, we learn all basic practical skills necessary for all fields at the first department. In other departments, we perform routine care and procedures instead of emphasis on scientific issues regarding each departments and special diseases. So we work like other nurses and change serums, do injections, etc. whereas we should learn more about diseases and acquire related knowledge about their care and precautions. It`s teacher`s duty to design evidence-based care.”

Effective communication: according to the participants, the educator’s ability to establish and maintain effective communication with student plays a pivotal role in clinical education; it must be based on respect, openness, fairness and justice. Participants mentioned some desirable personality characteristics such as have a high spirit, lively, motivated, interested, humanistic and selfconfident which are required for an educator. Participant 18: “some teachers behave aggressively toward students when students make a minor medical mistake, [therefore] leading to suppress student’s self- confidence in patient care.” participant 30: “some educators behave improperly with students especially nursing students. Some of them call us badly with the pronoun such as “this”, ‘’that”, “it”, ‘’you” like one of the female nurses in department of internal medicine. I think mutual respect should be followed and all staff and even patients should be respected as well.”

Course manager: from the participants’ stand, the course could be effectively managed by the educators considering factors such as coordination between educators, balance their expectations with the reality of the clinical setting and adjusting contents to fill theory and practice gap. It could also be possible by proper supervision on clinical care, objective evaluation rather than subjective evaluation, considering practical and efficient assignments instead of theoretical, repetitive and useless assignments. Participant 13: ‘’It is better to run internship course in 7th and 8th semesters. Now, students in the 7th semester begin practice independently and they pass their clinical course without clinical educator, but in the next term the clinical educator manage the course and make students feel dependency again, so this trend should be followed up after 7th semesters.’’ Participant 2: “It is important to explain contents and procedures specific to each department but we face same reporting and documentation in all departments by clinical educators. Educators preferred some issues based on their own style, expectation and background. It is better to hold some sessions for educators to prevent these broad discrepancies.’’ Participant 13: “it`s useless to force students doing written-assignments such as papers, pamphlets in clinical education, so low quality assignment has been produced.” Participant 5: “There are some problems in the course evaluation, because male students who work well get lower scores than female students who are well-spoken.” Participant 28: “Final evaluation is not good at all. Some educators just know their students by their appearance rather than their performance. Some students are treated unfairly and this is important for students who intend to achieve high GPA, even the decimals of their score are so important for them.”

“Too hungry to learn”: Student defined themselves as willing to learn intensively but they expect their educators and staff to help them promote their self-confidence. Subcategories included motivation and acquiring self-confidence. These factors could provide a proper atmosphere for learning.

Motivation: one of the effective factors in learning is motivation. Participants believed that students should be motivated and have high spirit for clinical care. Participant20: “The desirable state is a state in which both students and educators have enough knowledge; students pass the theoretical knowledge necessary for field before entering department; students should be enough interested and motivated and enthusiastic for patient care.” Participant 27: “Students go to the hospital in order to train in the clinical care and educators should not expect them more than a novice clinical student, however student motivation may deteriorate if teachers encounter harshly toward students` error and it is not helpful at all, but also causes disappointment.’’ Participant 13: “If the students are not motivated, the goals will not accessible. Some students prefer comfort and laziness and ignore critical thinking due to lack of motivation by the educator.’’

Acquiring self-confidence: Participants’ experiences indicated the importance of self-confidence in performing clinical tasks as one of the most crucial objectives in learning clinical practice. Participant 14: “If students are not allowed to do clinical care, students lose their selfconfidence. If we, ourselves, do not insist on repeating each technique or the educator didn`t make us repeat necessary techniques, we will never achieve the ideal state.’’ Participant 18: “Although misbehavior of the educator could not threaten patient’s health in students` medical error, it can reduce students’ self-confidence in patient care. If the staff, especially nurses, mock students during clinical techniques based on nursing standards, students will be deeply disappointed; consequently she/he will be disgusted with the clinical setting.”

“Unwelcoming field”: Students generally consider the clinical setting as a tough and difficult environment which has the least adjustment for student clinical education. Patients, staff, physicians and settings are all unfamiliar to students and it makes them feel uninvited in addition to many restrictions and limitations.

Educational atmosphere of the clinical environment: One of the important effective factors on the clinical education is the supportive atmosphere. Participants believed that the head nurse and the staff plays an important role in effective critical learning and standard based practice in during the clinical education. Participant 30: “When students are spending their clinical course in a department, staff and nurses are not accompanying students and almost few responsibilities are delegated to students, whereas they should support students step by step and transfer their experience to them.” Participant 22: “Many techniques are performed by nurses and staff in a different way and non-standard methods. We are obligated to follow their out-dated methods instead of affecting on them.”

Welfare facilities: Participants believed that welfare facilities are one of the important factors affecting on clinical education. They include conference halls, rest rooms, prayer rooms, changing rooms and drawers. Participant 1: “For example, we don`t have drawers and this always makes it a distraction. I always think of my properties fearing somebody will steal them.” Participant 4: “Providing welfare facilities are so important. At least a room is necessary for changing dress or holding conferences or at least having a commode to decrease stress related to picking up our properties.”

Discussion

The results of the present study showed a clear image of the nursing students’ experiences of the factors influencing their clinical education. Students have a unique and exclusive stand in clinical education. In spite of the fact that they have some shared concerns with their educators, they percept the world distinctively and prioritize issues differently [4-9]. therefore each clinical educator must be able to understand what's going on in the students' world [19]. So it`s very crucial to gain an in-depth insight and understanding of their world to promote clinical education. Indifference to students` expectations interferes in learning and professional socialization [8]. Several studies [14,20,21] support our findings in which effective communication is considered as an essential element in journeying to the students` world and teaching clinical competencies [22]. Clinical environments as a source of significant stress and anxiety for students were identified [9] so professional communication brings about significant reduction in student’s stress and facilitate clinical education [23]. Although communication skills could be taught, humanistic characteristics of teachers were recognized as an outstanding factor in developing an effective communication between educators and students [24]. Effective communication also involves effective feedback during clinical practice which is timely, based on first hand data and focused on behaviors [25] so it`s consistent with the findings of our findings in which students expected from their educators to give feedback avoiding humiliations.

Several studies have indicated clinical educators had unique role as a facilitator for students in clinical setting [3,8,26]. Our results demonstrate that students call for a more demanding role as a promoter in which educators actively make arrangements for learning situations, organize clinical courses, accelerate students` learning and empower students in clinical field. Clinical educators also are expected to minimize the theory-practice gap in clinical care, which is consistent with several studies [4,7] Evidence-based practice [EBP] is considered as a profound strategy to fulfill theorypractice gap in nursing clinical education [10] so studies revealed that educators are required to use EBP to establish significant and meaningful connections between theoretical knowledge and clinical care. 8 In addition students indicated that unsupportive environment for EBP which is set up by staff have a negative impact on learning and professional socialization [27,28]. One study demonstrated that factors affecting EBP in clinical setting are possessing professional knowledge and experience; having time and opportunity; becoming accustomed; self-confidence; the process of nursing education; and the work environment and its expectations [3] Motivation and self-confidence are necessary to overcome learning complexity [29]. Therefore, it is crucial to apply strategies such as simulations, peer modeling, story-telling, skill review sessions and journaling for motivating students and enhancing self-confidence in them [30].

Staff has a unique role in providing an educational atmosphere in the clinical environment [31]. Staff-student relationships have been reported as an important factor that contributes to the students’ experiences of belongingness and socialization. Nursing students’ motivation and capacity to learn, self-concept and confidence are affected by the extent to which they experience belongingness [15,32]. In the current study, educational atmosphere of clinical environment was reported by the students as an essential element in clinical learning, because they didn`t believe that the atmosphere was supportive enough to enhance the teaching-learning process. Several studies emphasized the role of the head nurse and staff in affecting the educational quality. An effective educational atmosphere of clinical environment was defined as receptiveness, legitimization of the student role, recognition and appreciation, challenge and support [12]. Apart from welfare facilities, other themes concentrated on human resources and their interactions which imply most essential parts could be enhanced by empowerment programs.

One limitation in our study was that this research was conducted only in one large teaching faculty and the findings may not reflect experiences of other students in this faculty. Therefore we tried to select rich informants among all students using biphasic sampling method to guarantee most diverse experiences to be included in the study. Exploring experiences of the students among disciplines is recommended for further studies.

Conclusion

A journey across unwelcoming field was an expression of what students have felt during clinical education in the field. Incompetent educators, unsupportive staff and lack of evidencebased practice essentially form unpleasant experiences that interfere with effective clinical education. Humanistic approach in the clinical field strongly promotes students learning and socialization.

Acknowledgement

Special thanks to nursing students, education development office in school of nursing and midwifery and Education development center in Mashhad University of Medical Sciences. This research is funded by grants from vice chancellor for research and technology in Mashhad University of Medical Sciences.

References

1. Hossein KM, Fatemeh D, Fatemeh OS, Katri VJ, Tahereh B (2010) Teaching style in clinical nursing education: a qualitative study of Iranian nursing teachers' experiences. Nurse Educ Pract 10: 8-12.
2. Adib-Hajbaghery M (2007) Factors facilitating and inhibiting evidence-based nursing in Iran. J Adv Nurs 58: 566-575.
3. Lambert V, Glacken M (2005) Clinical education facilitators: a literature review. J Clin Nurs 14: 664-673.
4. Sharif F, Masoumi S (2005) A qualitative study of nursing student experiences of clinical practice. BMC Nurs 4: 6.
5. Elliott M (2002) The clinical environment: a source of stress for undergraduate nurses. Aust J Adv Nurs 20: 34-38.
6. Ciliska D (2005) Educating for evidence-based practice. J Prof Nurs 21: 345-350.
7. Ehrenberg AC, Häggblom M (2007) Problem-based learning in clinical nursing education: integrating theory and practice. Nurse Educ Pract 7: 67-74.
8. Carlson E, Pilhammar E, Wann-Hansson C (2010) "This is nursing": nursing roles as mediated by precepting nurses during clinical practice. Nurse Educ Today 30: 763-767.
9. Pearcey PA, Elliott BE (2004) Student impressions of clinical nursing. Nurse Educ Today 24: 382-387.
10. Abedi HA, Heidari A, Salsali M (2004) New Graduate Nurses’ Experiences of their Professional Readiness During Transition to Professional Roles. Iranian Journal of Medical Education 4:69-78
11. Watson R, Stimpson A, Topping A, Porock D (2002) Clinical competence assessment in nursing: a systematic review of the literature. J Adv Nurs 39: 421-431.
12. Levett-Jones T, Lathlean J, Higgins I, McMillan M (2009) Staff-student relationsh ips and their impact on nursing students' belongingness and learning. J Adv Nurs 65: 316-324.
13. Kelly C (2007) Student's perceptions of effective clinical teaching revisited. Nurse Educ Today 27: 885-892.
14. Karimi Moonaghi H, Zobin F, Mazloom R, Derakhshan A, Balouchi Bidokhti T (2010) Desired status and the current state of nursing curriculum for clinical education. J Mashhad School Nurs Midw 10:1-8
15. Levett-Jones T, Lathlean J, McMillan M, Higgins I (2007) Belongingness: a montage of nursing students' stories of their clinical placement experiences. Contemp Nurse 24: 162-174.
16. Hsieh HF, Shannon SE (2005) Three approaches to qualitative content analysis. Qual Health Res 15: 1277-1288.
17. Graneheim UH, Lundman B (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 24: 105-112.
18. Elo S, Kyngäs H (2008) The qualitative content analysis process. J Adv Nurs 62:107-115
19. Sutkin G, Wagner E, Harris I, Schiffer R (2008) What makes a good clinical teacher in medicine? A review of the literature. Acad Med 83: 452-466.
20. Makoul G1, Schofield T (1999) Communication teaching and assessment in medical education: an international consensus statement. Netherlands Institute of Primary Health Care. Patient Educ Couns 37: 191-195.
21. Alweshahi Y, Harley D, Cook DA (2007) Students' perception of the characteristics of effective bedside teachers. Med Teach 29: 204-209.
22. Gillespie M (2002) Student--teacher connection in clinical nursing education. J Adv Nurs 37: 566-576.
23. Moridi G, Valiee S, Khaledi S, Fathi M, Shafiean M, et al. (2012) Clinical Education Stressors from the Perspective of Students of Nursing, Midwifery, and Operating Room: A Study in Kurdistan University of Medical Sciences. Iran J Med Educ 11:675-684
24. Korthagen FAJ (2004) In search of the essence of a good teacher: towards a more holistic approach in teacher education. Teaching and Teacher Education 20:77-97
25. Molloy E, Delany C, Molloy E (2009) Time to pause: giving and receiving feedback in clinical education. Churchill Livingstone
26. Dickson C, Walker J, Bourgeois S (2006) Facilitating undergraduate nurses clinical practicum: the lived experience of clinical facilitators. Nurse Educ Today 26: 416-422.
27. Cheraghi MA, Salasli M, Ahmadi F (2008) Factors influencing the clinical preparation of BS nursing student interns in Iran. Int J Nurs Pract 14: 26-33.
28. Heydari A, Yaghoubinia F, Roudsari RL (2013) Supportive relationship: Experiences of Iranian students and teachers concerning student-teacher relationship in clinical nursing education. Iran JNurs Midwifery Res 18: 467-474
29. Ahanchian M, Mirhaghi A (2013) Nursing Postgraduate Students Experience of Preparing for Nursing Postgraduate Entrance Exam. Iran J MedEduc 13:270-279.
30. Lundberg KM (2008) Promoting self-confidence in clinical nursing students. Nurse Educ 33: 86-89.
31. Atack L, Comacu M, Kenny R, LaBelle N, Miller D (2000) Student and staff relationships in a clinical practice model: impact on learning. J Nurs Educ 39: 387-392.
32. Maniou M (2012) Labour conflicts between administrative, medical and nursing personnel in the hospital. Health Science Journal 6:234-245.