Keywords

Nursing students’ perceptions; Effective clinical instructor; Clinical training policies

Introduction

Clinical experience is an indispensable component of nursing curricula as it provides real-life experiences involving actual patients. Clinical learning is considered as the heart of professional practice bridging the theory-practice divide. The integration of theoretical knowledge with clinical practice is of vital importance for the development of efficient professional nurses. Both quality classroom teaching and ability in demonstrating clinical competence greatly influence the success of graduates of a nursing program [1].

Effective clinical teaching is critical for producing knowledgeable and skillful nurses who can deliver safe quality nursing services to individuals, families, and communities [2]. As the nursing schools are always trying to improve their educational plans, and these plans are based on this assumption that courses and teaching atmosphere, train competency and efficiency in different aspects of theory and practice, and as the students as consumers of educational services have direct and straightforward connection with this process grow, they are the best source for detection of clinical education problems [3]. From the researcher experience as a clinical instructor, there is variability regarding the quality of effective clinical instructor and training policy characteristics as perceived by nursing students. So, this study was done to assess the undergraduate nursing students’ perceptions of the characteristics of an effective clinical instructor and their perceptions about clinical training policies.

Research Methodology

Study design

A descriptive cross-sectional analytical design was used. This design is easy, inexpensive, quick and can target a large sample size in a short time and convenient to the researcher

Setting of the study

The study was carried out in Palestine College of Nursing, The Islamic University of Gaza, University College of Applied Sciences, Al-Israa University and Al-Azhar University.

Sample size and sampling procedure

The research participants were selected through quota sampling, the population divided into homogeneous strata to ensure representation of the subgroups in the sample within each stratum subjects were sampled by convenience. The sample size included 298 nursing students from the 3^rd and 4^th levels (Figure 1 and Table 1).

Figure 1: Sample size determination.

Table 1: Selection of the sample of students from different universities and colleges through quota sampling.

Pilot study

A pilot study of 50 students were taken to develop and test the adequacy of the research questionnaires and estimate the time needed to fill the questionnaire and check the feasibility of the study, and to make modifications in the questionnaires as needed. The participants of the pilot study were excluded from the final sample.

Ethical considerations

Written informed consent was obtained from all participants. Ethical approval to conduct the study was obtained from the Helsinki Committee and administrative permission was obtained from each academic institution.

Eligibility criteria

• Nursing students: 3^rd and 4^th levels.

Study tools and instruments

The questionnaire adapted from Gardner and Suplee [4]. The questionnaire adapted for measuring students’ perceptions which divided into 3 parts. Part 1 consisted of demographic data of respondents, part 2 about clinical instructors’ characteristics while part 3 about effective training policies. The second part had 36 items divided into 7 subdomains (professional competence/ knowledge, supporting professional growth of students, effective clinical evaluation, communication, academic responsibilities, teaching/training skills and clinical instructor-student relationship) for determining effective clinical instructor characteristics while the third part consisted of 16 items divided into 3 subdomains (planning of training, implementation of training and evaluation of training) for determining effective clinical training policies. The questionnaire used the five points Likert Scale for measuring the second and third parts ranging from strongly disagree to strongly agree. The questionnaire was administered in English language.

Reliability and validity of the questionnaires

The questionnaires were evaluated by five experts. The reliability of both questionnaires was checked through the pilot study. The researcher was used the Cronbach alpha coefficient to estimate the internal consistency for the study instrument. Cronbach's alpha for the real study was 0.955.

Data collection

The data was collected through self-administered questionnaires. Data collection was done from 15/10/2019 to 8/11/2019. The participants were asked to fill the questionnaire form, which were distributed during their break time between lectures or training hours. The response rate of students was 100%.

Statistical analysis

Data were analyzed by using Statistical Package for Social Sciences (SPSS) version 23. Descriptive (mean, standard deviation and percentage) and inferential (T-test and One-way ANOVA) statistical tests were used as appropriate. P-values of ≤ 0.05 was considered statistically significant.

Results

Demographic characteristics of the students

Table 2 presented that the students' age was between 19 and 27 years, 75.8% of students aged 21 years or less and 24.2% of students aged higher than 21years. The female students represented 53.4% of the respondents while the male students 46.6%. The data indicated with regard to the educational level of students found that slightly more than half of them were from the 3^rd level (56.4%) and the remaining from the 4^th level (43.6%). The highest percentage of participants from students live in Khan Younis (n: 96, 32.2%) and lowest percentage in North (n: 31, 10.4%). While 64 (21.5%) of students were from Gaza, 56 (18.8%) from Rafah and 51 (17.1%) from Middle Zone. the population of study was collected from five colleges in Gaza Strip according to the number of enrolled students in each college or university as follow PCN (n: 34, 11.4%), IUG (n: 130, 43.6%), Al-Azhar University (n: 36, 12.1%), Al-Israa University (n: 36, 12.1%) and UCAS (n: 62, 20.8%).

Table 2: The demographic characteristics of students.

Students’ perception about characteristics of an effective clinical nursing instructor

Table 3 showed that the total mean for characteristics of an effective clinical nursing instructor was 4.16 and the total weighted percentage of the mean was 83.26%. According to the results, the highest characteristic was “Professional Competence/Knowledge” with weighted mean 87.38%, followed by “Communication” with weighted mean 87.01% and “Teaching/ Training Skills” in 3rd rank with weighted mean 86.64%. While the lowest three characteristics were “Clinical instructor relationship with the student”, “Support the professional growth of students” and “Effective clinical evaluation” with weighted mean 83.19%, 83.32%, and 83.93% respectively.

Table 3: Ranking of the effective clinical instructor characteristics as perceived by nursing students.

Students' perception about effective clinical training policies

According to the findings of Table 4, item No. (3) in planning of training category “Selection of training site is relevant to achieve the clinical course objectives” has the highest rank with weighted mean 87.45%, followed by item No. (9) in evaluation of training category “The clinical instructor evaluates students in a fair and objective manner” with weighted mean 87.05%, item No. (2) in planning of training category “The allocated field clinical hours for clinical courses are adequate to achieve the objectives” in 3rd rank with weighted mean 86.51%, item No. (16) in implementation of training category “The training department specifies appropriate assignments to their students in clinical courses” in 4th rank with weighted mean 86.04% and item No. (10) in evaluation of training category “The role of training department in monitoring students' clinical training is obvious” in 5th rank with weighted mean 85.77%.

Table 4: Top five perceived effective clinical training policies according to students.

Discussion

The results showed that the highest characteristic was “Professional Competence/Knowledge” and this agreed with other studies Madhavanprabhakaran et al. [5], Moosavi et al. [6], Sabog et al. [7], Niederriter et al. [8], Adibelli & Korkmaz [9], and Reising et al. [10] stated that nursing students rated professional competence of clinical instructors as the most important characteristic. Also, according to Nabolsi et al. [11] Jordanian students view their instructor as a role model and supporter, reflecting the preference for older mentors with more knowledge and experience. The findings of the present study revealed that the professional competence of the clinical instructors was the first important effective clinical instructor characteristic as perceived by the nursing students. The researchers believed that may be due to nursing students’ feelings of security as a result of being with a knowledgeable and skilled clinical instructor who acts as a facilitator in the clinical setting.

A study with contrary findings, however, was that of Lawal et al. [12] who found that effective interpersonal relationship between clinical instructors and nursing students was important in creating a positive learning environment. Also, Robels [13] found that from the most important nursing clinical instructor characteristics and behaviors as perceived by nursing students was interpersonal relationships. Cilingir et al. [14], Ali [15], Baker [16], Yaghoubinia et al. [17], Koy [18], Meyer et al. [19], and El- Banan & El-Sharkawy [3] have revealed that the relationships between instructors and students have an important effect on students' learning experiences that also contrary the current findings. Parsh [20] revealed that students agreed on nursing competence as the lowest-rated category that inconsistent with the results of this study. In addition, Kube [21] stated that students might report more practical and objective characteristics as being effective in clinical learning and may consider other abstract characteristics or educational approaches to be less effective. These similarities and differences may be explained, in part, by the students’ demographic data, most specifically the students’ age and cultural and linguistic differences. In the present study, some characteristics were perceived as having a considerable effect on learning. However, the characteristics that were seen to be less effective could also be effective in learning because students might be unaware of them. Thus, the evaluation of these characteristics should be undertaken by individuals who are more familiar with clinical teaching and with the importance of these behaviors.

The results also showed that the most important effective clinical training policies from perception of nursing students is selection of training site is relevant to achieve the clinical course objectives. According to Nabolsi et al. [11] Jordanian students viewed that clinical instructors shape the learning environment to meet the learning needs of students by appropriate placement selection. Algoso and Peters [22] stated that the current clinical learning environment is characterized by shortages of staff, heavy workloads, and inadequate resources, which negatively affect the clinical practice of nursing students during placements. Bigdeli et al. [23] mentioned that clinical placements play an essential role in the learning process of nursing students. Additionally, nursing students may think that the clinical environment is the most influential educational component to acquire nursing knowledge and skills. Froneman et al. [24] revealed that students need a caring and supportive environment. These studies were in alignment with the finding of the present study that the selection of the training site is important and should be relevant to achieve the clinical course objectives.

Also, nursing students perceived that the ability of clinical instructor to evaluate them in a fair and objective manner as an effective clinical training policy. This finding is in alignment with the finding of Parsh [20], Ali [15], Baker [16], Madhavanprabhakaran et al. [5], and Rafiee et al. [25] mentioned that objective evaluation from the most effective factors on clinical educational learning. Vaismoradi and Parsa-Yekta [26] stated that the issue of the students’ gender was highlighted as a potential cause for unfair and unexpected evaluation outcomes. The male participants claimed that female instructors discriminate between the students of the opposite sex. Another study conducted by Rafiee et al. [25] revealed that the most important clinical evaluation problem was lack of a comprehensive, objective and appropriate evaluation tool for assessing the students. Also, Khodaveisi et al. [27] pointed out to a major challenge for evaluation in nursing education is facing with unqualified evaluators regarding inexpert, disinterest and biased evaluators, which consequently cause inefficacy of evaluation process. All of these studies were consistent with the finding that the clinical instructor should evaluate students in a fair and objective manner.

Also, among the most five effective clinical training policies was providing an adequate clinical hour for clinical courses to achieve the objectives. This result was congruent with Abdulmutalib et al. [28] stated that from the common hindering factors among all students were evaluation by faculty and lack of time to accomplish the required tasks. In addition, Parvan [29] mentioned that a lack of time for learning was one of the considerable weaknesses in clinical teaching. Moreover, Chuan and Barnett [30] stressed that providing adequate time to perform procedures is one of the factors that enhanced student learning. Danner [31] and Reising et al. [10] stated that students perceived that the longer time on the unit provided more learning opportunities than a shorter day. Warne et al. [32] stated that the duration of clinical placement appeared to influence the level of overall student satisfaction and how the quality of the supervisory relationship and the pedagogical atmosphere on the ward was experienced. All of these studies support the finding of the current study that the allocated field clinical hours for clinical courses should be adequate to achieve the training objectives.

Jamshidi [33] mentioned that the challenges of clinical teaching in nursing skills and from the standpoint of nursing students included student's duties in the hospital wards are not clear. This supports our finding that the training department should specify appropriate and clear assignments to the students in clinical courses. Abdulmutalib et al. [26] also stated that from the common hindering factors in the clinical training setting perceived by students was insufficient supervision from faculty. This was congruent with our finding that the role of the training department in monitoring students' clinical training should be obvious.

Conclusion

The study aimed to assess the nursing students’ perceptions about the characteristics of an effective clinical instructor and clinical training policies in Gaza Strip. This descriptive, analytic, cross-sectional study included 298 students from five colleges and universities. The most important characteristics of an effective instructor as perceived by nursing students were professional competence, communication, and training skills with weighted mean 87.38%, 87.01%, and 86.64% respectively. Findings also showed that the most important clinical training policies as perceived by the nursing students were appropriate selection of training site, objective evaluation, and adequate clinical hours for clinical courses to achieve the objectives with weighted mean 87.45%, 87.05%, and 86.51%, respectively.

Recommendations

Based on the results of this study, it is recommended to:

• Develop specific criteria for the selection of future clinical instructors included professional competence and communication skills as a basis of selection.

• Establish programs for clinical instructors to develop their knowledge, training, and evaluating skills.

• The nursing faculties should take into consideration the viewpoints of students about the characteristics of an effective clinical instructor and clinical training policies because they are the main stakeholders in the training process.

Disclosure

Authors have no conflict of interests, and the work had no financial support.

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