Through nursing education, nursing students will be able to obtain necessary knowledge and skills to assist public health [1]. Clinical education is an important and essential part of training nurses. In this type of education, a student make use of what he/she has learned in action while he/she is interacting with the instructor and with the environment [2]. Apprenticeship in the field, is part of the nursing education plan which is devised in a way that can create appropriate conditions to improve skills in the application of nursing knowledge in the field, consistent with the promotion of innovation power and inclusive autonomy observing the important principle of supervision in community teaching and protecting the clients and their families’ safety [3].
Different studies have shown that the existence of numerous problems such as lack of specific job descriptions for students and instructor, mismatch consistency between the acquired material and their use in the clinic, shortage of amenities and educational facilities, drop in the rate of students’ academic achievement and learning unscientific and incorrect methods [4], much workload and consultants’ shortage of time in responding to educational needs [5,6], lack of accurate evaluation by instructor, inconsistency between theoretical learning and nursing clinical services [7–9] prevents the instructor and the trainees from achieving the goals of the course.
Improving and promoting the quality of clinical education entails continued checking of the existing situation, recognition of the strengths and modification of the weak points. In this regard, the students and instructor’ ideas and opinions can contribute to the future plans. The present study was carried out with the purpose of determining clinical education problems regarding apprenticeship in the field from the viewpoints of nursing instructor and students at the nursing and midwifery college in Ilam.
Materials and Methods
In this descriptive cross-sectional study, the statistical population consists of the instructor and senior students of nursing at BSc. level. Convenience sampling was used in this study. The samples consist of 20 instructors, who work full-time or part-time, have BSc. or MSc. degrees in nursing and at least one year of clinical training for the apprentice nurses and 43 senior students of nursing who had finished a course of apprenticeship in a hospital ward. Written informed consent was provided by all the participants.
The research tools were a researcher made questionnaire particular to instructor and students and consisted of three sections: the first section was about demographic information (age, sex, marital status, employment status, educational status and students’ occupational status, semester at the college, being native or nonnative, years of service). The second section consisted of 14 closed-ended items regarding instructor and students’ ideas about the state of apprenticeship in clinical education against a scale (great, good, relatively weak and weak) and seven items related to factors that potentially create trouble in apprenticeship in clinical education on a frequency scale (always, usually, sometimes and never). The third section consisted of some open-ended items related to the subjects’ suggestions and ideas entitled Clinical Learning Evaluation Questionnaire (CLEQ). The method of work adopted in this study was as follows: After the selection of and getting consent from research subjects to fill out the questionnaires, the necessary instructions were given to the respondents. The questionnaires were distributed to the respondents individually and were returned on the same or the next day after completion. Content validity method was applied to ensure the validity of the study. This was done by reading the existing books and articles on the research topic and preparing a questionnaire based on that review. A study reported that total internal consistency (Cronbach’s α) of the questionnaire was 0.88 and demonstrated that CLEQ is a multidimensional and valid instrument [10].
A panel of experts examined the face and content validity. The scale was given to 10 faculty members of nursing and midwifery faculty to be examined for “relevance”, “clarity” and “fluency”, and the corrections were made based on the perspectives of the experts [11,12].
The questionnaire was then given to ten specialists and their corrective ideas were applied. In order to determine the reliability of the study test- retest method was used. Coefficient of reliability was estimated to be higher than 97%. Data analysis was carried out using SPSS v18 software applying descriptive and inferential statistics.
Results
The results show the average age was 38.05±6.3 for instructor and 22.63 ± 0.787 for students. The majority of the instructor who participated in the study were 55% female, 90% married, 65% holders of MSc. degrees, 50% faculty members and 70% had spent up to 20 years of service. The student participants were 76.7% females, 95.3% single, 51.2% were passing their eighth semester, and 97.7% were unemployed. [Table/Fig-1] shows nursing instructor and students’ ideas about the state of clinical education apprenticeship. Instructor and students’ viewpoints on problematic factors in clinical education apprenticeship are presented in [Table/Fig-2]. According to the results obtained from the responses given to open-ended items, it was determined that the majority of instructor and students did not report any differences between type of apprenticeship presentation and apprenticeship in the field. In addition, although one aim of apprenticeship in the field is to create a holistic and community-oriented approach, students considered that in practice measures such as following patients in their homes, acquiring autonomy and clinical expertise were not desirable during the courses they took. Moreover, the majority of the students referred to the length of the apprenticeship course in some hospital or clinic wards due to lack of essential facilities and appropriate scientific backgrounds and demanded revision by the officials in this regard.
Nursing instructor and students’ ideas about the state of apprenticeship in the field in clinical education.
Items | Excellent | Good | Weak | Relatively weak |
---|
1.Discipline and inconsistency in planning |
instructor | 2(10%) | 15(75%) | 3(15%) | |
student | 4(9.3%) | 27(62.8%) | 10(23.3%) | 2(4.7%) |
2. Previous coordination between schools and health units |
instructor | 1(5%) | 16(80%) | 2(10%) | 1(5%) |
student | 4(9.3%) | 25(58.1%) | 13(30.2%) | 1(2.3%) |
3. Specified objectives of field training for instructors and students |
instructor | 0 | 10(50%) | 7(35%) | 3(15%) |
student | 4(9.3%) | 20(46.5%) | 16(37.2%) | 3(7%) |
4. Specified the duties of the instructor and the student |
instructor | 1(5%) | 10(50%) | 8(40%) | 1(50%) |
student | 7(16.3%) | 21(48.8%) | 13(30.2%) | 2(4.7%) |
5. The appropriateness of the number of students for each instructor |
instructor | 0 | 1(5%) | 17(85%) | 2(10%) |
student | 6(14%) | 15(34.9%) | 17(39.5%) | 5(11.6%) |
6. Healthcare collaboration in students clinical education |
instructor | 2(10%) | 13(65%) | 5(25%) | 0 |
student | 2(4.7%) | 21(48.8%) | 17(39.5%) | 3(7%) |
7. Manner of supervision of instructor during field training |
instructor | 3(15%) | 13(65%) | 4(20%) | 0 |
student | 8(18/6%) | 18(41.9%) | 12(27.9%) | 5(11.6%) |
8. Access to welfare facilities at the bedside |
instructor | 0 | 1(5%) | 5(25%) | 14(70%) |
student | 0 | 5(11.6%) | 18(41.9%) | 20(46.5%) |
9. The adequacy of the educational facilities at bedside |
instructor | 0 | 5(25%) | 12(60%) | 3(15%) |
student | 1(2.3%) | 5(11.6%) | 31(72.1%) | 6(14%) |
10. Development of skills in nursing process implementation in students |
instructor | 0 | 7(35%) | 11(55%) | 2(10%) |
student | 0 | 21(48.8%) | 18(41.9%) | 4(9.3%) |
11. Development of patient education skills in students |
instructor | 1(5%) | 3(15%) | 13(65%) | 3(15%) |
student | 3(7%) | 26(60.5%) | 12(27.9%) | 2(4.7%) |
12. Development of comprehensive prospectisive and community oriented attitude to nursing profession in nursing student |
instructor | 1(5%) | 3(15%) | 14(70%) | 2(10%) |
student | 2(4.7%) | 23(53.5%) | 15(43.9%) | 3(7%) |
13. Collaboration and supervision of the educational supervisor in nusing students clinical education |
instructor | 0 | 3(15%) | 10(50%) | 7(15%) |
student | 3(7%) | 23(53.5%) | 12(27.9%) | 5(11.6%) |
14. Hospital management collaboration in resolving the problems of students |
instructor | 0 | 3(15%) | 12(60%) | 5(25%) |
student | 0 | 5(11.6%) | 25(58.1%) | 13(30.2%) |
Nursing instructor and students’ ideas about problematic factors that affect apprenticeship in the field in clinical education.
Items | Always | Often | Sometime | Never |
---|
1. Undesirable communication of center staff |
instructor | 1(5%) | 6(30%) | 12(60%) | 1(5%) |
student | 7(16.3%) | 9(20.9%) | 27(62.8%) | 0 |
2. Lack of appropriate scientific background in ward |
instructor | 2(10%) | 13(65%) | 5(25%) | 0 |
student | 3(7%) | 31(72.1%) | 8(18.6%) | 1(2.3%) |
3. Follow wrong habits on the environment |
instructor | 3(15%) | 12(60%) | 5(25%) | 0 |
student | 2(4.7%) | 4(9.3%) | 29(67.4%) | 8(17.6%) |
4. Student disinterest and escape of clinical practice |
instructor | 0 | 13(65%) | 7(35%) | 0 |
student | - | - | - | - |
5. Student wandering in the absence of the instructor |
instructor | 6(30%) | 7(35%) | 6(30%) | 1(5%) |
student | 8(18.6%) | 30(76.9%) | 3(7%) | 2(4.7%) |
6. Lack of basic skills of students in the care of patients |
instructor | 1(5%) | 12(60%) | 5(25%) | 2(10%) |
student | - | - | - | - |
7. No program for learning and the specific criteria before entering the filed |
instructor | 2(10%) | 11(55%) | 6(30%) | 1(5%) |
student | 2(4.7%) | 35(81.3%) | 4(9.3%) | 2(4.7%) |
Discussion
Clinical education is the most important part of knowledge and skills acquisition for graduates in medical sciences and due to complexity of education in a clinical environment, gaining experience is always important to students and it is usually accompanied by a lot of problems. In spite of this, clinical education as a whole is a valuable scientific source that brings about a new perspective to the students and teachers. At the beginning, the process of being trained in clinical education is a stressful activity for students and the acquisition of different skills takes place gradually and by creating motivation to win in the students by the instructor. The results of this study are consistent with the results of other studies on the problems of apprenticeship in clinical training in the field of nursing [13].
This study on the clinical education status of apprenticeship in field indicated that the studied items were acceptable to partially weak from perspectives of instructors and students of nursing. This highlights deficiencies of some areas which need more attention.
The results of this study indicate that the co-operation of the personnel with the students and instructor is favourable. This is consistent with the findings of Hadizadeh & Firoozi [13]. However, in another study the role of the health care-medical team’s members has been reported to be negative [14]. This co-operation has been reportedly weak or rarely-existent in some other studies [15]. Also, Mohammadi described the most important problems as the lack of co-operation and improper communication with students in clinical education [2]. The researcher believes that this lack of co-operation is due to lack of personnel’s acquaintance with their responsibilities and the students’ curricula in related fields.
In a study [3], the highest percentage related to the problems of apprenticeship in nursing was 80% which was for welfare issues and 40% of the students referred to the unfavourable behavior of the personnel at clinical centers. Another study [4] also reported that 73% of the students referred to lack of the necessary opportunity to perform standard procedures and undesirability of clinical conditions according to theoretical principles. This was not consistent with the results of the present study.
Based on the results of this study and other investigations, it is necessary to take measures that provide appropriate educational and welfare amenities and facilities for students to practice skills in a clinical environment. In addition, in order to attract more co-operation of the health-care-medical team and prevent students’ disorientation in the absence of their instructor, it seems necessary to prepare a clinical apprenticeship curriculum for trainees that takes into account the provision of facilities for the clinic workers for their co-operation with student nurses. Since, one result of the study was students’ weakness in performing basic tasks to take care of the patients, it is essential to prepare and execute a disciplined and systematic plan to develop a practical technical room for students to do more practice in the areas of work they lack sufficient expertise [15].
In the studies performed outside Iran, the researchers found that novice nurses’ abilities and clinical expertise are insufficient to satisfy patients, health-care-medical system and managers’ expectations. They stated that clinical training of the students must be carried out with the co-operation of the clinical personnel and it is necessary to revise clinical skills [16].
According to the findings of this study, instructor and students’ general viewpoints on apprenticeship were positive. However, in another study of the students, they had a positive attitude [5] towards the topic. This difference in results shows that at some points the training plan’s goals for instructor and students are not clear and must be reviewed and revised. Student subjects stated that in their view, there is not any difference between apprenticeship and filed apprenticeship especially in different sections and the so-called plan must be revised. Therefore, curriculum developers and the plan’s supervisors must continually review the existing problems and take measures to solve them.
The type of supervision carried out by instructor has been reported to be desirable but there was not reportedly a proportion between the number of students and that of the instructor. According to Heidari and Nurouzadeh study, “sufficient number of patients for learning” was the strength [17]. In another study, too much work and the consultants’ shortage of time to meet the educational requirements are important issues in field apprenticeship [4,12,18]. High number of students and their dispersion in different sections has practically led to the instructor’ solely calling the roll and field apprenticeship in clinical education’s departing from its goal.
In some studies, a mismatch has been observed between what is expected from the instructor and the educational goals and yet in some others the students had assessed curricula and instructor’ method of work to be bad [19]. Fakhr Movahedi’s in his study showed that nursing students scored the clinical instructors’ behaviors above average [20].
The researcher believes that mismatch among instructor regarding how to control and prepare plans for students is another important point during this course so that it sometimes causes confusion for students and the training will not be practically fruitful for the trainees. Therefore, it seems necessary for the instructor to co-operate with the heads of department in presenting the educational material and in giving assignments. Regarding the assessment of the students’ work (in investigation of open-ended items), they had reported that such assessment is inappropriate and unfair and this finding was consistent with the results of other studies [13].
Lack of access to a precise and objective criterion for the measurement of students’ practical skills can be a reason for inappropriate assessment of their performance. In any case, assessment is an important topic that needs to be paid attention to by supervisors since it shows how much students have achieved the expected goals and skills and can be a feedback to students. In addition, according to the results of the study regarding the topic of developing expertise in students to perform the process of nursing and creating the skill of training patients in students, there is difference between the ideas of the instructor and those of the students. While students assess their skills as good, their instructor’ evaluation of those skills is that they are weak. The researcher believes that the reason for this difference can be differences in instructor’ expectations of students in the so-called matters as well as the students’ unawareness of those expectations. This point must be taken into consideration by instructor and consultants in clinical education. Another issue is the unfavourable supervision of the educational supervisors in clinical training of the students. This problem can be due to mismatch between the educational supervisor and the educational department regarding the topic of supervision. In this case, other activities of the educational supervisor and the heavy load of these activities as well as irresponsibility towards students’ education because of not being paid for the services. This important point must also be taken into account by the authorities.
Limitation
Small sample size enrolled in this study limits the generalization of the study findings.
Conclusion
Clinical education is a complicated process and entails many domains. The findings of the study relate to the clinical education and differences between the perspectives of instructor and students. Regarding the effect of nursing education on community health, in order to improve the quality of nursing course, there is a need for welfare amenities and educational assistance facilities in the clinical environment as well as planning and ensuring co-operation between two departments of theoretical education and apprenticeship. Considering that the students’ perspectives can improve the quality of nursing clinical education, doing other studies on nursing students’ perspectives using cross-sectional or longitudinal methods and its comparison with postgraduate period is recommended.
Conflict of Interest
The authors of the present work declare no conflict of interest.