Document Type : Original articles
Authors
1 B.Sc. Nursing Faculty of Nursing-Minia University
2 Professor of Nursing Administration, Faculty of Nursing ,Minia University
3 Professor of Nursing Administration, Faculty of nursing – Minia University
4 Lecturer of Nursing Administration, Faculty of Nursing ,Minia University
Abstract
Highlights
Gehad Waheed Ahmed 1;Safaa Mohammed Abd el-rahman2; Sahar Ahmed Abood3; Mona Thabet Abd el-baset4
1 B.Sc. Nursing Faculty of Nursing-Minia University;
2Professor of Nursing Administration, Faculty of Nursing ,Minia University,
3 Professor of Nursing Administration, Faculty of nursing – Minia University,
4Lecturer of Nursing Administration, Faculty of Nursing ,Minia University
Introduction
Moreover, nursing practice in the 21st century faces a number of challenges that including: a growing population of hospitalized patients who are older and more acutely ill, increasing healthcare costs, and the need to be aware of rapid advances in medical knowledge and technology. These challenges are complicated by an existing shortage of nurses, an aging nurse workforce, and shortage of nursing faculty members, which affect nursing education (1-4).
Nursing is a practice-based discipline that is accountable to the public for quality of care, therefore staff members should teach students the art and science of nursing and it should be not only academically rigorous but also clinically competent (5, 6).
The overall goal of clinical nursing education is to prepare students for future practice through current learning experiences. Because of the rapid changes that can be occurred in the health care; understanding become more important than doing, and rationale more important than technique. Thus, for having effective clinical teaching; the clinical instructor (C.I) should permit students to have clinical experiences by which they reach the clinical competence (7, 8).
The clinical instructors must maintain a focus on the essential activities in a way that ensure patient safety, provide opportunities for students to perform successfully in the clinical area, and communicate the fullness of the nursing role (9). Although many new C.Is have experience in their clinical area of practice, they may not initially have the ability to convey the proficiency to their students. The reasons for this C.I proficiency are twofold, generally, they do not have formal training and supervision in teaching; also they are thrown into unplanned activities where there is limited control over the factors that affect student clinical teaching (10, 11).
Clinical instructors are the teaching faculty members who guide nursing students to gain fundamental knowledge, technical skills, and practice values. Also, they play a vital role in nursing students’ development by enabling them gain self-confidence for future practice (12- 14). They also play a significant role in creating positive learning experiences in the clinical setting that frame student perceptions of the work environment. Therefore, to create a positive learning environment for nursing students, a lot of hard work goes into the development and practice of clinical teaching. So, not only the instructors need to organize their clinical experience but they also need to facilitate the learning process (11, 15).
Effective C.Is behaviors divided into five major domains as following: First, teaching ability: it is the process of transmission of skills and attitudes, and the creation of an atmosphere that facilitate learning process. Second, nursing competence: it is the clinical teacher's theoretical and clinical knowledge used in the practice of nursing. Third, evaluation: it is the type and amount of feedback the student receives from the clinical instructor regarding clinical performance and written clinical assignments. Fourth, interpersonal relationships: it is a state of reciprocal interest or communication between student and clinical instructor; and fifth, personality; it is the totality of the individual's attitudes, emotional tendencies and character traits, which aren't specifically related to teaching, nursing or interpersonal relationships but may affect them (16).
Significance of the Study
Clinical practice is a significant component and critical part of nursing education which considered ''the heart'' of professional practice. The quality clinical practice delivered through clinical instructors are dynamic to success of clinical education and has direct impact on the quality of nursing which ensure students achieve positive outcomes in the clinical settings as well as in the future practice. Therefore, the clinical instructors as a cornerstone of nursing education, plays an essential role in preparing nursing graduates for their role as competent, capable and caring nurses.
There were many previous studies were conducted in this field one of them was in Oman by (Madhavanprabhakaran, Shukri, Hayudini and Narayanan, 2013) (17), who found that Omani nursing students rated professional competence of instructors as the most important characteristic and instructors’ relationship with students as the second most important characteristic without any discrepancy (p >0.05). And in Egypt, a study by Ismail, Aboushady, Eswi, (2016) (18) revealed that the highest ranked behaviors were teaching ability category followed by nursing competence and evaluation respectively. The personality and interpersonal relationship among nursing student set as the fourth and fifth factors that affect learning process in the clinical settings. All previous studies focused on determining the most effective and ineffective clinical instructor’s behaviors for learning process success as perceived by students' point of view about most important and less important behaviors only. Therefore, it is important to assess the clinical instructors clinical behaviors from different view of point.
Aim of the Study
The aim of the current study is to assess the clinical instructor's behaviors as perceived by themselves, students and Nursing Faculty Staff.
Research Questions:
Methodology
Research design:
The study was conducted using descriptive research design
Setting:
This study was conducted at the faculty of nursing at Minia University. This study included all nursing faculty academic departments.
Subjects:
The study subjects consisted of all clinical instructors, staff members and about 80% of students at (2nd, 3rd, 4th year) at the Faculty of Nursing, Minia University. All available clinical instructors at the time of collecting data (2nd semester 2017/2018) was (n= 74) and Faculty staff members (n=27)
N.B: the students of 1st year were excluded from the study because of lack of their awareness about how to evaluate a clinical instructor correctly and objectively.
Tool: one tool was used in this study: '' The Nursing Clinical Teacher Effectiveness Inventory'' ''NCTEI''
This tool was used to assess the clinical instructors’ behaviors as perceived by themselves, student and nursing faculty staff; it consisted of two parties as follow:
1) The first part is Socio- Demographic data sheet: was attached with tool to get information about Nursing Faculty staff, clinical instructors and students at Minia University. It was one of the following for the study subject:
2) The second part is '' The Nursing Clinical Teacher Effectiveness Inventory'' ''NCTEI''; it was developed by Knox & Magon (1985) (16). It consisted of 48 important instructor behaviors with 5 point Likert scale ranged as (Never= 0, scarcely=1, sometimes=2, often=3, and always=4).
It was divided into sub-scales as follows: teaching ability (16 items), nursing competence (10 items), evaluation (9 items), interpersonal relationship (6 items) and personality traits (7 items). The scoring system was ranged from 0 to 192, the higher the score, the higher effective behaviors of clinical instructor, the scoring system was divided as the follows: (0- 64= Low), (65- 128= Medium), (129- 192= High).
Validity of the tool:
The tool was submitted to a jury of 5 experts in the field of nursing administration and education field to determine its applicability and content validity. No modification was done.
Reliability of the tool:
Reliability of the tool was performed to confirm consistency of tool. The internal consistency measured to identify the extent to which the items of the tool measured what it was intended to measure. Also, the tool parts (teaching ability, interpersonal relationships, personality traits, nursing competence and evaluation) were tested for reliability, they were reliable and coefficient values were (α=.99 for clinical instructors, .97 for staff members, and .95 for students).
Pilot study:
A pilot study was conducted on a random sample of participants as (clinical instructors = 7) and (staff members=3) (students = 80) (from the total study subjects) prior to starting the field work in order to obtain information that may improve the research plan and facilitate the execution of the study. Results of the pilot study indicated that; the tool was applicable and don’t need any changes.
Data collection procedure:
Ethical Consideration:
Data processing and analysis:
The data of this study were processed and analyzed using number of sheets collected from the study subject as follows: For clinical instructor (sheets= 74), for Faculty Staff Members (sheets= 365), and for students (sheets= 1420)
Data were fed to the computer and statistical analysis was performed using Statistical Package for Social Sciences (SPSS version 20). Significance of the obtained results was judged at the 5 % level of significance. Quantitative data were expressed as frequency and percentage. For quantitative data, comparison between two variables was done using t-test, and comparison between more than two variables used ANOVA test. Relations between different numerical variables were tested using Pearson correlation. Probability (p-value) less than 0.05 was considered significant and less than 0.001 was considered highly significant.
Results:
Table (1):Distribution of clinical instructors according to their Socio demographic data
|
Studied group (n =74) |
Socio-demographic characteristics |
|
|
% |
No |
|
|
89.2% 10.8% |
66 8 |
Age groups
|
|
18.9% 81.1% |
14 60 |
gender
|
|
25.7% 52.7% 21.6% |
19 39 16 |
Years of experience
|
|
35.1% 64.9% |
46 48 |
Position
|
|
17.6% 14.9% 12.2% 13.5% 10.8% 31.1% |
13 11 9 10 8 23 |
Department
|
* Categorical data represented by number and (%).
Table (1) shows that, the majority (89.2%) of nursing clinical instructors age was ranged from (25-35) years old; in relation to sex the majority of them (81.1%) were females. Concerning to years of experience more than half of nursing clinical instructors (52.7%) had (5-10) experience years. As regard to position, about two thirds of them (64.9%) were assistant lecturers. About department, the highest percent as one third of them (31.1%) was in medical surgical nursing department, and the lowest percent was in pediatric and neonatal nursing department as (10.8%).
Table (2):Distribution of nursing students according to their Socio-demographic data:-
|
Students (n =798) |
Socio-demographic characteristics |
||
|
|
% |
No |
|
|
|
60.9% 39.1% |
486 312 |
Age / years
|
|
|
38.5% 61.5% |
307 491 |
gender
|
|
|
36.5% 37% 26.5% |
291 295 212 |
Academic year
|
Figure (1): Distribution of nursing students according to their last academic achievement.
Table (2) and figure (1) show that about two third (61.5%) of nursing students gender were female. In relation to age, about two thirds (60.9%) of nursing students ranged from (18-20) years old. As regards to their academic year, the highest percent of students (37%) were at 3rd academic year. About the last academic achievement, it was found that more than half of students (54.3%) had very good degree.
Table (3):Distribution of faculty staff members according to their Socio-demographic data:
|
Faculty staff members (n =27) |
Socio-demographic data |
|
|
% |
No |
|
|
0% 100% |
0 27 |
gender
|
|
37% 37% 26% |
10 10 7 |
Years of experience
|
|
(18.5%) (14.8%) (14.8%) (11.1%) (11.1%) (29.7%) |
5 4 4 3 3 8 |
Department
|
Figure (2): Distribution of nursing faculty staff according to their position
Table (3) and figure (2) show that, all of the staff members were female; regarding years of experiences more than one third had less than 15 years' experience and more than one had (15-25) years of experiences. About the position, there was about two third (66.7%) of nursing staff were lecturers. In relation to department, the highest percent (29.6%) of nursing staff were in medical surgical department.
Figure (3): Comparison between groups regarding to clinical instructors teaching behavior scores.
In figure (3) it was observed that highest level of clinical instructors behaviors were from clinical instructors themselves view with (89.2%), followed by students view (68.2%) and then view of staff members (59.2%) with statistically significant difference between clinical instructors, students and staff members view (P=0.001).
Table (4): Comparison between groups regarding to clinical teaching behavior score:
|
ANOVA (DF) P value |
Staff sheets (n =365) |
Clinical instructor sheets (n =74) |
Students' sheets (n =1420) |
Clinical instructors behaviors dimensions scores |
|
Teaching ability score |
||||
|
9.7 (2) <0.001* |
44.8 ± 10.5 13 - 64 |
50.4 ± 7.5 32 – 64 |
47.9 ± 15.3 0 – 64 |
|
|
Interpersonal relationship score |
||||
|
5.24 (2) 0.005* |
16.8 ± 4.9 1 - 24 |
19.1 ± 3.7 10 – 24 |
17.5 ± 6.5 0 – 24 |
|
|
Personality traits score |
||||
|
12.6 (2) <0.001* |
18.9 ± 6.3 0 - 28 |
22.2 ± 3.6 11 – 28 |
20.7 ± 7 0 – 28 |
|
|
Nursing competence score |
||||
|
7.6 (2) <0.001* |
27.9 ± 8.3 1 – 40 |
30.2 ± 4.7 21 – 40 |
29.9 ± 9.4 0 – 40 |
|
|
Evaluation score |
||||
|
11.9 (2) <0.001* |
24.7 ± 7.7 1 - 36 |
29 ± 4.4 20 – 36 |
26.6 ± 8.7 0 – 36 |
|
|
Total score |
||||
|
10.27 (2) <0.001* |
133.1 ± 34.7 21 – 192 |
151.1 ± 19.8 108 – 191 |
142.8 ± 43.4 0 – 192 |
|
*ANOVA test was used for quantitative data *: Significant difference in between groups (p value ≤ 0.05)
Table (4) shows that the highest mean scores were from clinical instructors view of themselves and the lowest mean scores were in favor to staff members view in all dimensions, with highly statistically significant difference. (p<0.001*) except for '' interpersonal relationship dimension'' (p<0.005*)
Also, it was noted from table that the clinical instructors had the highest total mean scores for their clinical teaching behaviors (151.1±19.8), while the lowest total mean score was for staff members' perception for their clinical instructors teaching behaviors (133.1±34.7), with statistical significant difference (p<0.001*) between students, clinical instructors and staff members.
Table (5) Total level scores of clinical instructors behaviors as perceived by students in faculty departments:
|
Scientific Departments |
Total Score Level of clinical instructors behaviors |
ANOVA (DF) or X2 (DF) P value |
|||||
|
Low |
Moderate |
High |
|||||
|
No |
% |
No |
% |
No |
% |
||
|
Nursing Administration (n=240) |
10 |
4.2% |
36 |
15% |
194 |
80.8% |
204.6 (10)
0.001* |
|
Women Health& Obstetric Nursing (n=220) |
0 |
0% |
38 |
17.3% |
182 |
82.7% |
|
|
Community Health Nursing (n =190) |
12 |
6.3% |
36 |
18.9% |
142 |
74.7% |
|
|
Psychiatric& Mental Health Nursing (n=206) |
11 |
5.3% |
72 |
35% |
123 |
59.7% |
|
|
Pediatric& Neonatal Nursing (n =160) |
25 |
15.6% |
96 |
60% |
39 |
24.4% |
|
|
Medical- Surgical Nursing (n =404) |
17 |
4.2% |
98` |
24.3% |
289 |
71.5% |
|
ANOVA test was used for quantitative data and chi square test (X2) was used for qualitative data
*: Significant difference in between groups (p value ≤ 0.05)
Table (5) shows that ''Women Health& obstetric health nursing'' had the highest level of clinical instructor’s behaviors from student's point of view (82.7%), while ''pediatric& Neonatal health nursing department'' had the lowest level of clinical instructor’s behaviors with (15.6%) with highly statistical significant differences (P=0.001*) between departments.
Figure (4): Relation between last academic achievements and total clinical teaching behavior scores as perceived by students
Figure (4) shows that, clinical instructors had the high level score from point of view of students who had ''Excellent'' achievement (71.6%), students who had ''Very good'' achievement (69.4%), and those with ''good'' achievement (59.9%). While the students who had ''Acceptable'' achievement viewed that clinical instructors had moderate level of their clinical behaviors (66.7%) with statistical significant difference (p=0.001*)
Discussion:
Clinical teaching is an important aspect of the nursing education. As through clinical teaching the students learn how to apply the abstract concepts of nursing into situations that are specific and concrete to acquire the characteristics and values that are needed in their nursing professional role (19). Therefore, the CI is responsible for managing, educating and supporting the nursing students during clinical practice that is most effective for facilitating learning process. When CIs are clinically competent, they can more easily establish a safe environment for clinical learning, facilitate student learning, and aid students to provide patient care (20).
Regarding the socio-demographic data of CIs it was noted that, the majority of CIs aged from 25 to 35 years old; and for the sex the highest percentage of CIs were female. Concerning to years of experience more than half of nursing clinical instructors had (5-10) experience years. As regard to position, about two thirds of them were assistant lecturers. About department, the highest percent as one third of them were in medical surgical nursing department, and the lowest percent were in pediatric and neonatal nursing department.
Regarding the socio-demographic data of students it was noted that about two thirds of nursing students were ranged from (18-20) years old and were female. As regards to their academic year, the highest percent of students were at 3rd academic year. About the last academic achievement, it was found that more than half of students had very good degree at all academic year.
Regarding the socio-demographic data of staff members, it was noted that all of them were female, and more than one third had less than 15 as well as more than one third had 15-25 years of experiences, regarding the position there were about two third of staff members lecturers. In relation to department, the highest percent of staff members were in medical surgical department.
The current study revealed that clinical instructors perceived themselves to have the higher clinical teaching behaviors than both students and faculty staff members perceived them with statistically significant difference. The cause of this perception may be result of individuals' view to themselves; as they always view own self perform well and better than others see them. Also most of individuals, had overestimation of their performance, success, character, abilities, or future prospects, and they are more optimistic than reality warrants.
Also, clinical instructors considered as a biased self-assessment as in which individual often attributes success and failure in a self-serving manner, so that success is attributed to internal factors, such as skill, competencies or intelligence, and failure is attributed to external factors, such as bad luck or distraction. CIs also, are more likely to remember self-enhancing information; in which they may always remember that they were the best ones among their colleagues at faculty.
This finding was consistent with Lane and Gottlieb (2004) (21), Cole et al. (2004) (22) as well as Houston et al. (2004) (23) who shown that instructors’ self-assessment scores were higher than the scores given by students. Also, in a study by Shakurnia and Karami (2011) (24) carried out about comparing scores of instructors evaluation by students with those of instructors’ self-evaluation, it was found that the mean score of instructor’s self-assessment was higher than the average score of students evaluation for instructors and the difference was statistically significant.
This is also, supported by a study of Mazar, Amir, and Ariely (2008) (25) who showed that individuals will generally engage in dishonesty and bias when they given the opportunity to assess their behaviors abilities, and performance; and generally not revise their self-concept to incorporate this dishonesty. Individuals always, had positive self –concept as sees themselves as intelligent persons, and view themselves as a hard-working and competent employee.
While this finding was not consistent with Barnett, Matthews, Jackson, (2003) (26) research who found that the difference between instructors’ self-assessment scores and the scores allotted to instructors by the whole students was not significant.
The current study also revealed that nursing faculty staff members agreed that their instructors regarding had low scores in their clinical behaviors. This finding may be related to staff members' higher expectations from instructors regarding clinical teaching. Also, faculty staff members are more aware of instructors’duties, their knowledge in the courses of study, and the relevant syllabuses, etc. They are aware of the teaching quality and teaching problems and how to solve it. Therefore, they can comment more accurately about the quality of CIs behaviors.
Staff members also had attended different courses more than instructors; these courses which related to curriculum development and effective teaching strategies, so staff members saw themselves more effectively able to deal with students than instructors as they didn't get these courses.
This finding was in consistent with Adhami, Reihani, Fattahi, Nakhaei, Fasihi Harandi (2005) (27) who found significance when comparing the scores of instructors’ self-assessment with heads of departments (P = 0.04), in which the scores of department heads were higher than those obtained from their instructor’ self-assessment.
Also, this finding of the current study was supported by Aksu, Çivitçi, and Duy, (2008) (28) who found in their study that teaching leaders perceive that the instructors should be given the chance to update their knowledge and achieve development as they always have lack of teaching and personal update.
Also, this finding supported by Bozpolat, Uğurulu, Usta, and Şimşek, (2016) (29) who indicated that staff heads reported that competencies of instructors regarding teaching methods/techniques was in low levels; as they don’t have enough preparation and experience about how to effectively prepare a teaching plan and manage a classroom.
As regarding to students assessment of their instructors, it was between the score of instructors' assessment to themselves and staff score to instructors. This may be considered as students had lack of knowledge and experience about effective teaching process, teaching behaviors and depth view of each behavior. They may not have true judgment about evaluation. Students also, may take some personality and interpersonal factors in their consideration when evaluating their instructors.
This finding supported by Greenwood (2009) (30) who opposed to evaluation of teachers by learners and believes that perceptions and judgments of people are affected by general personality traits and by environmental characteristics; hence, these factors can affect students and they apply them in their teachers' evaluation.
Findings of the current study also revealed that according to departments, instructors of obstetric& gynecological nursing and nursing administration departments get the highest ratings of using clinical instructor's behaviors by nursing student. This may be due to characteristics of clinical instructors in these department that affect students’ clinical teaching as those instructors may properly prepared for clinical teaching through knowing the course material, thinking about how the material can be most effectively demonstrated, writing an outline or take notes to follow during clinical procedures, they also are organized during their course. They also commented that they not prefer (pediatric nursing instructors) because they deal with them in a rigid and tough manner.
Also, during data collection from the 4th year students commented that nursing administration department is considered the most organized, committed department, they always have a plan for what they want to teach, and students of 3rd year commented that instructors of obstetric& gynecological nursing department are the most kind, humorous and empathetic one in the faculty and they offer support when students are in need.
This was consistent with Siamian et al. (2012) (31) and Gashmard et al. (2011) (32) as their studies showed that teacher’s competency and effectiveness from student’s point of view can be positive when they feeling responsible for the students and supporting them, being available, having a good, organized plan for teaching the clinical course having a close relationship with the student, and wining the student’s trust.
The findings of the current study also showed that according to academic achievement; the student with (Excellent, very good) perceived their instructors with high ratings of using clinical instructor’s behaviors. This finding may be as those students relate their success to effective teaching and intelligence of their instructors, those students also may be always concentrate with their instructors and try to ask questions to their instructors to get more information, they may also ask them about good references to read; so they felt that their instructors had broad knowledge about variety of topics taught. Also, the students tend to build good relations with instructors as they saw them as their role models and want to follow their steps.
Also students with high academic achievement are interested and concentrated in teaching and they do everything made them get high grades as (attendance in time, deliver sheets in time, always are with complete kits and uniform), so they get the highest marks so found that their instructors are fair in their evaluation. All above mentioned causes make those students see their instructors with high rating of using effective clinical teaching behaviors.
This finding was supported by Theall and Franklin (2001) (33) who see that the students who performed the best on final exams, get higher academic achievement provide the highest ratings in their clinical instructor’s evaluation. While, this finding come in contrast with Benton and Cashin (2012) (34) that their research yields no conclusive correlation between overall GPA of students and high ratings for individual instructors.
Conclusion
Clinical instructors had biased self-assessment regarding their perception about clinical teaching behaviors; as it was noted that high level of clinical instructors behaviors were from clinical instructors themselves view, followed by students view and then view of staff members, with statistically significant differences. Moreover, the highest mean score for clinical instructors' clinical behaviors were among obstetric and gynecological nursing departments followed by nursing administration department; while the lowest mean score were among the CIs of pediatric and neonatal nursing department staff
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