Study context and design
The Muni University in Uganda established a 4-year Bachelor of Science in Nursing (BScN) direct-entry degree programme in 2015. The first two pre-clinical years of the programme focus on the basic and social sciences, while the latter two clinical years focus on the application of the nursing sciences in the clinical learning environment. Students enrolled in this programme are predominantly placed at the Arua Regional Referral Hospital (ARRH). ARRH is an accredited teaching hospital and the nurses in practice have been predominantly engaged in the clinical teaching of nursing students enrolled in non-university-based nursing programmes such as the Diploma in Nursing and the Certificate in Nursing. These nurses in practice were expected to facilitate the clinical teaching for university-degree nursing students enrolled in the BScN programme for the first time in August 2018. The nurses would allow the nursing students attached to their wards or units to shadow them, explain and demonstrate skills if there is an opportunity, give the students chance to demonstrate the skill as they observe and then give feedback. Depending on the students’ level of competence the nurses’ role may be supervisory and they then participate in clinical learning assessments. This study used qualitative research in describing the perceptions of nurses in practice regarding their readiness for the clinical teaching of undergraduate nursing students at the ARRH.
Study participants
The participants of this study were nurses working at ARRH. The nurses’ highest qualifications comprised a Diploma in Nursing and/or Midwifery, a Certificate in Nursing and/or Midwifery and BScN. All the nurses included in this study had been engaged in clinical teaching of nursing students enrolled in other programs for lower qualifications for more than a year. Some of the nurses were serving as unit/ward in-charges. Intern nurses, volunteer nurses and nurses in their probation period of employment were excluded because of short duration of working at ARRH.
Data collection
Secondary to the approval of this study, all the potential participants were invited to participate in this study. Five focus groups each comprising six participants and three key informant interviews were used to collect data between July and September 2018, before the first group of the BScN students was to be placed in the clinical environment. All the data were collected in English by the first author who had been trained in conducting interviews in qualitative research. The data were generated from the following central question;
“What is your perception regarding your readiness for the clinical teaching of the BScN students?”
Additional probing questions arose from the discussions. Data were collected in a private room within the hospital, which allowed for the digital recording of all the interviews. The author also wrote reflective notes during the data collection process. The interviews lasted on average 45 minutes.
Data analysis
The data were analysed through an inductive reasoning approach inspired by a data analysis framework by Saldaña (22). According to Saldaña (22), qualitative data analysis is executed in three sequential steps. In the initial step, the digitally recorded interviews were transcribed verbatim and the transcripts were assigned specific identifiers. The transcripts were formatted and stored in a password-protected electronic folder. Before coding, the researchers read and re-read the transcripts to understand the general ideas discussed in the focus groups. Initial, open, axial and in-vivo coding methods were used in coding units of analyses in the transcripts. The authors identified the units of analyses as sentences, phrases, and paragraphs that were related to the research question. The first author coded the data and the other authors acted as co-coders. The outcome of this second step was a final code list after a discussion involving all the authors. In the final step of the data analysis, the codes generated in the second step were further analysed through pattern coding methods. The researchers’ clustered codes with similar meaning and the outcome of this step were themes and these are presented as the findings of this study. The units of analysis are presented as verbatim quotes to support the generated themes.
Rigor
The trustworthiness framework was applied throughout this study (23). The researchers engaged already established approaches and frameworks in conducting this study. The data were collected by an experienced researcher, while the data analysis was influenced by contemporary frameworks in data analysis, and experienced researchers were used as co-coders.
Findings Thirty-three nurses participated in this study and all of them had been engaged in clinical teaching of nursing students enrolled in other programs seeking lower qualifications for more than a year. The majority of the nurses were female (29, 87.9%), aged 31-40 years (15, 45.5%) and worked for 11-20 years (18, 54.5%). The nurses’ highest qualifications comprised a Diploma in Nursing and or Midwifery (n=18), a Certificate in Nursing and/or Midwifery (n=12) and BScN (n=3) (table 1).
Table 1: Sociodemographic characteristics of the nurses (N=33)
Variable
|
Number (Percentage [%])
|
Age Group (years)
|
≤30
|
2 (6.1)
|
31-40
|
15 (45.5)
|
41-50
|
13 (39.4)
|
51-60
|
3 (9.1)
|
Sex
|
Male
|
4 (12.1)
|
Female
|
29 (87.9)
|
Highest level of Qualification
|
Certificate
|
12 (36.4)
|
Diploma
|
18 (54.5)
|
Graduate (BSN)
|
3 (9.1)
|
Work Experience (years)
|
≤10
|
9 (27.3)
|
11-20
|
18 (54.5)
|
21-30
|
5 (15.2)
|
31-34
|
1 (3.0)
|
Data source: 33 nurses who participated in five focus group discussions and three key informant interviews conducted between July and September 2018 at ARRH.
Three themes emerged from the data namely, “Willingness to teach undergraduate students” “Perceived attributes of undergraduate students”, and “The clinical practice environment”.
Theme 1: Willingness to teach undergraduate nursing students
The participants in this study expressed the willingness to teach undergraduate nursing students. Their willingness was tied to their perceived professional competence but was hinged on specific influential conditions and the need for formal training on clinical teaching.
The participants felt competent in the clinical teaching of undergraduate nursing students because of their extensive experience as nurses. The participants had also been engaged in the clinical teaching of nursing students enrolled in Diploma and Certificate programmes from other non-university nursing schools within the country. Also, the participants perceived themselves as having extensive practical experience and were aware of their environment which was deemed essential for clinical teaching. Some of the participants stated;
Personally, I have been in this field for quite a period. My colleagues all seated here practically have knowledge and skills. We are the colonial nurses, we are hands-on. We were trained under the Ministry of Health. (FG 1, Participant 6).
What makes me ready is this hospital being a regional hospital we receive so many referrals with different conditions which I feel I will be able to teach them.. (FG 3, Participant 3).
I feel I am ready because I am working in a regional referral hospital where most of the facilities are available for their teaching. (FG 5, Participant 5).
It is not the first time for me to interface with students. This hospital has been training the nurses at certificate and diploma level, and I have found myself in guiding and teaching them. With the added knowledge at bachelor’s level, I can equally be able to guide them well. (Informant 2). Several conditions were perceived as influential to the willingness of the participants to teach undergraduate nursing students. These conditions focused on undergraduate students and nurse educators from the university. The participants expressed that they were willing to teach the undergraduate nursing students in the clinical environment. These students were expected to be self-directed, able to ask questions, and seek their own learning opportunities.
I am ready to give them the knowledge, teach them if they are also cooperative and ready to learn. (FG 4, Participant 4).
These students need to be able to ask us questions when they don’t understand things in the clinic area…we won’t know if they don’t ask (FG3, Participant 1)
The participants felt that the clinical teaching of undergraduate nursing students, should not be the sole responsibility of the nurses in practice, but include the nurse educators from the university. A key informant expressed;
“…let this supervision not be left entirely to the staff of the hospital. The university staff who are teaching them will equally be assigned to follow these students to back us. (Informant 2)
The nurse educators from the university were further challenged to engage with current clinical nursing practice. The participants felt that the execution of their clinical teaching role would be compromised if nurse educators from the university were not engaged with current clinical nursing practice. Nursing students would be confused by the differences between the classroom-based theory and the expectations in clinical practice. A participant stated;
Some of the instructors just teach they do not do the practical work. So they keep on teaching the same things every year, you come to the ward, things have changed. You keep on telling the students new things and they tell you our teacher told us this. The teachers in the training schools do not have the current information but for us we do. (FG 1, Participant 2).
The participants expressed that they had not been trained formally in the mechanisms surrounding clinical teaching of undergraduate nursing students. They stated that they used their own experience when they were students, and what they observe when other health professionals are teaching students. The participants expressed that formal training in clinical teaching would enhance their willingness and effectiveness in teaching undergraduate nursing students. A key informant expressed;
The training (provided to students in the clinical setting) is just based on the experience of what we have been doing directly but not after being trained specifically on how to train the students in clinical area. We have not got that formal kind of training. (Informant 3)
Theme 2: Perceived attributes of undergraduate students
The participants in this study expressed their perceptions regarding some of the attributes of the undergraduate nursing students and how such perceived attributes influence clinical teaching within the referral hospital. The undergraduate nursing students were perceived as threatening, lacking interest in clinical practice, and would engage in general hospital misconduct. The participants based their perceptions on their experience with nursing students enrolled in Diploma and Certificate programs who were being placed at this clinical training platform from other national nursing schools.
The participants expressed a fear of being undermined by the undergraduate nursing students. The fact that the students were enrolled in a university-based nursing degree programme threatened the nurses in practice, who predominantly had lower qualifications than what the students were seeking in the present program. These students were perceived as learning advanced content at the university and that the nurses in practice would struggle to facilitate learning in clinical practice resulting in being undermined by the undergraduate students. Some participants explained;
“…one can make a mistake, maybe not knowing something in-front of them as they are more learned. They may correct you and then feel big, that they know more and then start undermining staff. (FG 3, Participant 6).
Whatever little we have known, we would be in a position to give them. When they want to explore more, I expect them to ask questions. Since these undergraduates are more knowledgeable than us, I think when they will be with us on the ward, if they have seen us not telling the right things to them, they should also tell us. (FG 2, Participant 2).
According to the participants, students enrolled in a university-based nursing degree programme generally lacked interest in clinical practice and learning within the clinical platform. This perceived lack of interest in clinical practice was expected to influence the ability of the nurses in practice to teach these students. The heavy workload for the nurses in practice, where there is limited time for the nurses in practice to follow-up with each student compounded this situation. A participant expressed;
Some of these students do not show interest. They tend to move away from certain units, moving up and down, not concentrating. So your interest in training them with much workload we tend not also to concentrate on their training. (FG 2, Participant 3).
The participants further expressed some examples and outcomes related to the perceived lack of interest in clinical practice by undergraduate nursing students. The participants stated that some of the undergraduate nursing students would prefer and choose specific clinical duties over others, avoid certain clinical platforms and eventually be part of general hospital misdemeanours.
Sometimes the barrier is dodging of duties like in theatre. It is sometimes busy and some people don’t like the work there like the sluice room. Others start to dodge their duties. (FG 4, Participant 6)
Theme 3: The clinical practice environment
The participants in this study described the clinical practice environment as an enabler and barrier to authentic clinical teaching of undergraduate nursing students. On one hand, the participants described aspects of the clinical learning environment that enabled their role in facilitating learning among undergraduate nursing students. The referral hospital receives advanced cases from other hospitals or health facilities within the geographic region, presenting an opportunity for the students to experience advanced nursing care.
This is a Regional Referral Hospital (RRH), I think all the conditions are there, the patients are overwhelming in all the units, and there are even rare conditions which they can learn about. (Informant 3)
The availability of specialist services within the hospital setting including specialist doctors and other health service providers provided an opportunity for students to learn from other health professionals. The nurses in this study expressed that the other health professionals always seemed eager to teach students using several opportunities like grand ward rounds.
We have specialists to guide them in different professions. We can line up with them and transfer better knowledge for them. (FG 2, Participant 3)
On the other hand, the participants in this study reflected on barriers within the clinical practice environment that would influence their ability in teaching undergraduate nursing students. An example was the shortage of hospital equipment, which was perceived to influence the participants’ ability to teach undergraduate nursing students ideal nursing care and clinical practice.
Some of the hospital equipment which you need to show practically are not there. You will also teach them the theory and yet they have been sent to see some of the hospital equipment practically. (FG 4, Participant 4).
In addition to the shortage of equipment, the participants in this study described the shortage of nurses in practice. The nurses in practice are faced with a heavy patient load and prioritise patient care over the clinical teaching of undergraduate nursing students. The participants expressed;
In the hospital here we are very few; we have that challenge of not really mentoring these students properly. Sometimes you are alone on the ward and it will be very difficult for you to really monitor these students very carefully because our number is really few. (FG 3, Participant 5)
When you are so busy, and you have a long queue [of patients], you have no time to teach these students because you are looking at completing the queue [of patients], at the end of the day, so that will block you from teaching the students. (FG 2, Participant 4)