Perceived self-efficacy and willingness to teach family planning among nursing and midwifery faculty in higher learning institutions in Rwanda

doi:10.21203/rs.3.rs-3229304/v1

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Research Article

Perceived self-efficacy and willingness to teach family planning among nursing and midwifery faculty in higher learning institutions in Rwanda

https://doi.org/10.21203/rs.3.rs-3229304/v1

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published 20 Dec, 2023

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Background

Promoting family planning is a key strategy for health, economic and population growth, and to achieve sustainable development goals (SDGs). However, there is a lack of research on the capacity of nurses and midwives to deliver FP at higher learning institutions (HLIs) in Rwanda.

Specific Aim

To explore and describe the perceived self-efficacy and willingness of the nursing and midwifery faculty to teach family planning to HLIs students.

Research design/Methodology

We conducted a mixed methods study using a sequential explanatory design among almost all the HLIs (n = 6, 1 institution declined) in Rwanda that train nurses and midwives. One hundred thirty-six nursing and midwifery teaching faculty who were actively teaching family planning either in class, simulation lab, or clinical practice were invited to participate in a self-administered questionnaire and four qualitative focused group discussions. Participants answered questions ranking their self-efficacy in four domains from 0 - not confident to 3 - completely confident. Scores were calculated for each domain. A semi-structured interview guide was developed based on the quantitative survey findings to gain a deep understanding of the ability and willingness to teach family planning. Data were analyzed using thematic analysis. Ethical approval was obtained from the University of Rwanda, College of Medicine and Health Sciences Institutional Review Board.

Results

A total number of 89 nursing and midwifery faculty participated in the study and only 85 completed the questionnaires fully yielding a response rate of 95.5%. The mean age was 40.39 and there were more females (62.4%) compared to their male counterparts (37.6%). Respondents scored highest for perceived self-efficacy for course preparation (mean = 2.37), evaluation and examination (mean = 2.12) and instructor behavior and delivery (mean = 2.35). However, the score was low for clinical practices (mean = 1.79). There was a significant correlation among the four items of self-efficacy (p < 0.05). Being a female, a midwife, and having more years of experience in nursing education were each significantly associated with the perceived self-efficacy to teach FP (p < 0.05). In the qualitative phase, 32 study participants participated in four focus group discussions. Four themes were identified: a) Educational background as determinant of confidence to teach FP; b) willingness to teach FP; c) enabling factors of teaching FP; and d) structural challenges.

Conclusion

Nursing and midwifery teaching faculty reported moderate self-efficacy in teaching family planning. They also reported inadequate self-confidence in teaching family planning in clinical practice, especially for long-acting, reversible contraceptives (LARC). There is a need for HLIs and different stakeholders to invest in training the nursing and midwifery teaching faculty on family planning practical skills to have a nursing and midwifery workforce providing up to date clinical FP service that will help Rwanda reach the SDGs.

Self-efficacy

family planning

nursing

midwifery

faculty

teaching

higher learning institution

Family Planning (FP) is a key strategy for health, economic and population growth, and to achieve sustainable development goals (SDGs) (Kasahun et al., 2021; Starbird et al., 2016). Unfortunately, unmet needs for FP continue to be worrisome in developing countries, including Sub-saharan Africa (SSA). About 218 million women in these countries have unmet contraception needs, i.e., they want to prevent pregnancy but they don't use a modern contraceptive. Approximately half (49%) of pregnancies in low and middle income countries (LMICs) are unintended, amounting to 111 million pregnancies each year (Sully et al., 2019). The common reasons for not using contraceptives are fear of side effects and health risks, having sex infrequently or not at all, family members' disapproval, breastfeeding, and/or amenorrhea (Gahungu et al., 2021; Sedgh et al., 2016). If all women in LMICs had access to modern contraception and received adequate prenatal care, unintended pregnancies and unplanned births would decrease by 68%. Moreover, unsafe abortions would decrease by 72% and 113,000 maternal deaths could be prevented annually, a reduction of 62% in maternal mortality (Sully et al., 2019).

Family Planning is an effective and inexpensive solution for reducing maternal mortality in high-fecundity countries (Kasahun et al., 2021), including developing countries. However, the low knowledge and skills of healthcare providers leads to poor quality of care in FP services (Gupta et al., 2019; Mazzei et al., 2021). These deficits in provider knowledge and skills can be attributed to poor pre-service education. Findings from program evaluation and research revealed that students in traditional medicine and midwifery education programs do not receive adequate FP training and could not provide these services as soon as they entered the field (Beza et al., 2019; Gupta et al., 2019). Moreover, training irregularities manifest themselves in clinical practice when recently trained clinicians lack the necessary practical skills to provide quality and evidence-based FP services (Beza et al., 2019; Gupta et al., 2019; UNFPA, 2018). Educating health workers before they enter the workforce is essential for developing their skills and knowledge (Beza et al., 2018; Beza et al., 2019; WHO, 2007), and pre-service training is key in improving the current updates. Including FP training in pre-service medical and nursing programs is an effective and cost-efficient way of enabling new clinicians to provide quality and evidence-based FP services (Muganyizi et al., 2014; Mugore et al., 2018; UNFPA et al., 2014).

Evidence suggests that clinicians need training in a family planning that corresponds with the cultural context and the every-day realities of clinical practice. For example, it has been shown that nurses and midwives do not have enough knowledge and skills to provide long term and permanent contraceptive methods (Mazzei et al., 2021; Schwandt, Boulware, Corey, Herrera, Hudler, Imbabazi, King, Linus, Manzi, Merritt, et al., 2021) and fertility awareness-based methods, including natural family planning methods (Uwajeneza et al., 2023). According to a recent study by Schwandt et al.(2021) conducted in Rwanda, the most commonly used modern contraceptive methods in Rwanda were injectables, at a rate of 41%, followed by condoms at 22%, and implants at 19%. In another study conducted by Mukamuyango et al. (2020) and which was focusing on long-acting reversible contraceptives (LARC), only 37% of the participants were using Jadelle, a 5-year progestin-based implant, while 26% were using Implanon, a 3-year progestin-based implant, and only 11% were using copper intrauterine device. These statistics illustrate a need for clinician training in all the available up to date modern contraceptive methods and family planning strategies to ensure new clinicians provide quality of care and meet the population needs when they enter the labor market.

According to Bandura (1977), as a person’s professional career progresses self-efficacy may change. Scholars found that nurse educators develop efficacy through time and with greater teaching experience (Dozier et al., 2019; Roach, 2020). Several studies in other countries/regions outside Rwanda have found that nurse educators’ self-efficacy is influenced by clinical experience (Bourne et al., 2021; Kim & Shin, 2017; Li & Su, 2014; Nugent et al., 1999; Shin et al., 2021), formal education, on-the-job training, and continuous professional development (Dozier et al., 2019; Ferguson & Perry, 2020; Shin et al., 2021; Weston, 2018), as well as, teaching aids and infrastructure, including well-equipped simulation labs (Gupta et al., 2019; Muganyizi et al., 2014). Moreover, cultural beliefs about family planning may impact teacher self-efficacy among other factors, according to Voetagbe et al. (2010).

Nursing and midwifery training in Rwanda follows different paths based on institution-specific guidelines. Nursing and midwifery programs offer direct entry into postsecondary institutions (advanced diploma for three years and bachelor's degree for four years) and a bridging program from advanced diploma to bachelor's degree for two years. The literature from Rwanda on nursing and midwifery educators’ self-efficacy in teaching FP is scarce. The authors conducted this study to fill a gap in our understanding of how pre-service family planning and contraception education impact the practice of midwives and nurses once they are deployed in different health facilities. Since the existing ways of teaching contraception and FP among nursing and midwifery students could impact future service delivery in Rwanda, this study asked nursing and midwifery teaching faculty to self-identify training gaps and reflect on their efficiency in teaching those subjects. Thus, this study aims to describe the perceived self-efficacy and willingness of the HLIs nursing and midwifery faculty to teach contraception and FP as part of pre-service training programs with the aim of improving the quality of clinical service delivery among new graduates.

Design

This study used mixed methods for a sequential explanatory study design. The quantitative phase used a descriptive cross-sectional design whereas the qualitative phase used a descriptive exploratory design to gain in depth understanding of nursing and midwifery teaching faculty perceived self-efficacy and willingness to teach FP.

Study population and setting

A total population sampling was used to recruit all nursing and midwifery teaching faculty from all HLIs in Rwanda. HLI staff actively involved in administrative roles and part-time teachers were excluded from the study. A total of 136 nursing and midwifery teaching faculty who are actively teaching students in classroom, simulation lab, and in the clinic setting in seven HLIs in Rwanda were invited to participate in the study. One public and six private HLIs in Rwanda are accredited to train nurses and midwives either at advanced diploma and/or bachelors’ degree. Three of them are located in urban areas while four are in rural areas (Higher Education Council, 2019). One urban HLI refused the participation of its staff. Other staff from one private, rural HLI only participated in the pilot study of the quantitative instrument and the qualitative phase. Thus, a total number of 119 study participants were eligible to participate. Of these, fifteen study participants were recruited for the instrument pilot and were not included in the final sample. A total of 104 from five HLIs were invited to participate in this study. Only 89 consented to participate, and four questionnaires were incomplete. Therefore, this study considered 85 participants.

Data collection instrument

For the quantitative phase, the Self-Efficacy Towards Teaching Inventory for Nurse Educators (SETTI-NE) (Garner et al., 2018), an individual self-assessment survey, was adapted and piloted with permission from the authors. This tool has two sections: the first section includes socio-demographic questions which were contextualized. The second section includes 54 items measuring self-efficacy in course preparation (10 questions), self-efficacy in instructor behavior and delivery (14 questions), self-efficacy in evaluation and examination (14 questions), and self-efficacy in clinical practice (16 questions). The items were shuffled and evaluated on a four-point scale: not confident, somewhat confident, moderately confident, and completely confident. Each question of each component was scored on a 0–3 scale. Each question within a component was averaged together to get the score for each of the four domains. The questionnaires were completed electronically using KoboToolbox. A pilot study was conducted among 12 study participants with an overall Cronbach's Alpha of 0.975. The reliability test of each component of SETTI-NE was for self-efficacy and ability in course preparation (0.914), self-efficacy in instructor behavior and delivery (0.919), self-efficacy in evaluation and examination (0.950), and self-efficacy in clinical practice (0.979). Using findings from the quantitative phase, we then developed a semi structured focus group interview guide to explore teachers’ willingness to teach FP.

Data collection procedures

The study was initiated after obtaining permission from the concerned authorities and informed consent from the study participants. Data collection occurred between July-August, 2022.

A question at the end of the quantitative survey asked if the respondent also wanted to participate in the qualitative phase of the study. Based on the responses, we formed four focus groups (FDGs) of ten participants from different institutions and professional backgrounds. The study participants were assigned with codes (MD: midwife respondent and NS: nurse respondent). The following questions were used to guide the discussions:

1. Tell me how you feel when teaching family planning.

2. Tell me about the challenges you face when teaching family planning

3. What factors influence your ability to teach family planning?

4. What factors hinder your ability to teach family planning in classrooms, simulation labs, and clinical settings?

5. How do personal beliefs impact your ability to teach family planning?

6. What do you think can improve your teaching of family planning?

7. What else would you recommend to improve teaching family planning?

Data were collected in English, as all participants spoke English fluently. The average length of the focus group interviews was 1h16mins

Ethical considerations

Ethical clearance was obtained from the University of Rwanda College of Medicine and Health Sciences Institutional Review Board (IRB) No 335/CMHSIRB/2022. After receiving this approval, the researchers sought permission from all HLIs which train nurses and midwives. After getting the permissions from the concerned institutions, researchers approached the study participants and explained the standards of the informed consent, and risks and benefits of participating in the study. Those who were willing to participate signed a written consent form and they were given a small compensation for their time, as well as transportation, and communication expenses. Data are kept in a locked and secured computer that is accessible to the research team exclusively and they will be destroyed according to the University of Rwanda ethical guidelines.

Analysis

For the quantitative phase, data were retrieved from KoboToolbox and exported to Data SPSS version 26. Descriptive analysis was computed using frequencies, percentages, means and standard deviation. A score assessment was used for the components of self-efficacy assessed with a scale. Score 0 was given for ‘not confident’; 1 = ‘somewhat confident’, 2 = ‘moderately confident’ and 3 = ‘completely confident’. An overall average was calculated by aggregating the items in each group. Pearson correlation coefficient was performed to assess the relationship among the different components of self-efficacy. Relationships between sociodemographic variables and faculty perceived self-efficacy was determined using the independent t test and one-way ANOVA and comparing the mean score for each component. Significance level was set at p value 0.05. For the qualitative phase, the focus group interviews were transcribed verbatim and Dedoose was used to organize the data. Four research team members performed thematic analysis (Braun & Clarke, 2006) to generate and report the emerging themes.

Quantitative data

Socio-demographic information of respondents

A total of 85 nursing and midwifery teaching faculty participated in this study. The average age of the participants was 40.39 years with 54.1% aged 30 to 39 years. There were more female respondents (62.4%) compared to males (37.6%). Most respondents taught at a public institution (72.9%) and resided in urban areas (80.0%). A majority (75.3%) had earned a Master’s degree and said their primary professional background was nursing (60.0%). Most (63.5%) were assistant lecturers and over a third (37.6%) had worked in nursing or midwifery education for 11 to 15 years. However, a majority of participants (55.3%) had worked less than six years in a clinical setting (Table 1).

Table 1

Sociodemographic and employment data for 85 nursing and midwifery faculty at public and private Rwandan higher learning institutes (HLI) in 2022
Variables	n = 85	%
Age [years]
30 to 39	46	54.1
40 and above	39	45.9
Mean (SD) = 40.39(7.47)
Gender
Male	32	37.6
Female	53	62.4
Type of institution
Public institution	62	72.9
Private institution	23	27.1
Residence/locality
Urban	68	80.0
Rural	17	20.0
Level of education
Bachelor's degree	21	24.7
Master's degree	64	75.3
Educational background
Midwife	34	40.0
Nurse	51	60.0
Academic Rank
Tutorial assistant	27	31.8
Assistant lecturer	54	63.5
Lecturer	4	4.7
Work experience in nursing/midwifery education
< 6 years	10	11.8
6 to 10 years	29	34.1
11 to 15 years	32	37.6
> 15 years	14	16.5
Work experience in clinical setting
< 6 years	47	55.3
6 to 10 years	16	18.8
> 10 years	22	25.9
Teaching experience in other fields
Yes	48	56.5
No	37	43.5

Descriptive statistics of perceived self-efficacy across four domains among 85 nursing and midwifery faculty at public and private Rwandan higher learning institutes in 2022

The detailed distribution of each component for perceived self-efficacy in teaching FP is presented in Additional file 1. Respondents had a high average score of perceived self-efficacy for course preparation (mean = 2.37) and instructor behavior and delivery (mean = 2.35). However, it was low for clinical practices (mean = 1.79) as indicated in additional file 1.

Correlation between socio-demographic characteristics and FP teaching self-efficacy

Table 2 shows the relationships between demographic factors and perceived self-efficacy. It was observed that increased work experience was significantly associated with self-efficacy in course preparation (F = 5.07; p = 0.003). Similarly, experience in nursing/midwifery education (F = 6.15; p = 0.001) and clinical work experience (F = 3.20; p = 0.046) were significantly correlated with self-efficacy in instructor behavior and delivery. The mean score for self-efficacy in evaluation and examination was significantly higher among midwives (t = 3.59; p = 0.001), as well as those with more than ten years experience teaching nursing/midwifery (F = 2.90; p = 0.040). Being female (t = -2.12; p = 0.038), trained as a midwife (t = 5.03; p < 0.001), and having more years as a nurse educator (F = 3.23; p = 0.027) were significantly associated with perceived self-efficacy to teach FP. However, type of institution and locality showed no significant differences with FP teaching self-efficacy.

Table 2

Relationship between socio-demographic characteristics and perceived self-efficacy across four domains among 85 nursing and midwifery faculty at public and private Rwandan higher learning institutes in 2022
Variables	Course preparation		Instructor behavior and delivery		Evaluation and examination		Clinical practice
Variables	Mean (SD)	p value	Mean (SD)	p value	Mean (SD)	p value	Mean (SD)	p value
Age [years]
30 to 39	2.39(0.46)	0.735	2.32(0.44)	0.494	2.00(0.76)	0.088	1.73(0.99)	0.547
40 and above	2.35(0.49)		2.39(0.49)		2.27(0.64)		1.86(0.89)
Gender
Male	2.45(0.52)	0.268	2.40(0.50)	0.447	1.93(0.84)	0.056	1.52(1.08)	0.038
Female	2.33(0.45)		2.32(0.45)		2.24(0.61)		1.96(0.83)
Type of institution
Public	2.41(0.40)	0.266	2.38(0.40)	0.486	2.20(0.68)	0.121	1.91(0.89)	0.068
Private	2.29(0.64)		2.29(0.63)		1.93(0.79)		1.48(1.04)
Residence
Urban	2.42(0.42)	0.066	2.38(0.42)	0.247	2.09(0.74)	0.411	1.77(0.97)	0.660
Rural	2.18(0.64)		2.24(0.63)		2.25(0.62)		1.88(0.87)
Level of education
Bachelor's degree	2.24(0.44)	0.15	2.25(0.38)	0.287	2.04(0.68)	0.545	1.68(0.97)	0.534
Master's degree	2.42(0.48)		2.38(0.49)		2.15(0.73)		1.83(0.94)
Educational background
Midwife	2.41(0.40)	0.573	2.40(0.38)	0.45	2.44(0.41)	0.001	2.35(0.42)	< 0.001
Nurse	2.34(0.52)		2.32(0.52)		1.91(0.79)		1.42(1.02)
Academic Rank
Tutorial assistant	2.30(0.45)	0.609	2.35(0.42)	0.638	2.19(0.68)	0.273	1.78(0.94)	0.498
Assistant lecturer	2.40(0.48)		2.34(0.49)		2.13(0.74)		1.83(0.96)
Lecturer	2.37(0.47)		2.57(0.46)		1.57(0.51)		1.25(0.96)
Work experience in nursing/midwifery education
< 6 years	2.07(0.51)	0.003	2.08(0.45)	0.001	2.06(0.62)	0.04	1.81(0.87)	0.027
6 to 10 years	2.28(0.50)		2.28(0.53)		1.84(0.81)		1.38(1.00)
11 to 15 years	2.39(0.42)		2.32(0.37)		2.28(0.59)		2.01(0.81)
> 15 years	2.74(0.29)		2.77(0.29)		2.40(0.67)		2.12(0.97)
Work experience in clinical setting
< 6 years	2.29(0.53)	0.088	2.27(0.49)	0.046	2.02(0.73)	0.309	2.07(0.54)	0.129
6 to 10 years	2.59(0.34)		2.61(0.33)		2.32(0.71)		2.37(0.50)
> 10 years	2.38(0.39)		2.34(0.44)		2.19(0.68)		2.20(0.95)
Teaching experience in other fields
Yes	2.38(0.49)	0.785	2.40(0.48)	0.286	2.03(0.75)	0.192	1.69(1.0)	0.291
No	2.35(0.46)		2.29(0.45)		2.24(0.66)		1.92(0.86)
Bolded p values indicate significant association
Independent t test was used to compare means of two categories while one way ANOVA was used to compare means for more than 2 categories

Qualitative results

Overall, most respondents said they taught FP in either a classroom/ a simulation lab, or in clinical settings, or both. However, when asked about their feelings regarding their perceived ability and willingness to teach FP, the respondents expressed mixed feelings. Four themes were identified: a) Educational background as determinant of confidence to teach FP; b) willingness to teach FP; c) enabling factors of teaching FP; and d) structural challenges.

- Educational background as determinant of confidence to teach FP

Some study participants with experience highlighted that they are confident in teaching both natural and hormonal family planning methods. For instance, one study participant mentioned: “I feel confident when I am teaching FP as I have been trained for many years and have both experience in clinical areas and teaching areas. I feel a bit confident when I’m teaching the students.” midwife faculty (MD 06). Another respondent (MD 02) noted, “I feel very confident to teach FP in a higher learning institution because I have five years’ experience in teaching this course, reason why I am very comfortable to teach FP content”. Although many respondents were confident, a few of them mentioned that they were only confident in teaching the natural methods, and others expressed that they were not confident at all. For example, one participant said: “For me when I am teaching in FP, I am confident in some methods, not all methods... I am not really confident, for example, teaching Implanon or Jadelle…”, nurse faculty (NS 03). Similarly, another participant emphasized: “Related to teaching FP, I need more knowledge… because sometime[s] there are some FP methods I have confusion about. The reason why, I need to get need more clarification and knowledge.” (NS 01) A similar concern was raised by another participant who said:

I master theoretical component, but exposure to practices it is not sufficient to all FP methods. Like I would teach all the natural methods, the use of calendar, but when it comes to methods like insertion of implants and IUD my confidence becomes low. (NS 06)

The above quotes reveal that being a midwife or nurse influences one’s confidence level to teach FP. The midwives expressed that they felt confident enough to teach FP, while nurses reported a low level of knowledge and skills, especially in teaching some invasive FP methods.

- Willingness to teach FP

Some respondents expressed a positive perception and willingness to teach FP. They emphasized that FP is a human right and is crucial to reducing maternal morbidity and mortality. Interestingly, some respondents from both nursing and midwifery mentioned that they can only teach natural FP theory and skills, while others categorically said that they do not teach FP. They underlined that they would prefer to let others provide the course, as they do not believe in FP utilization or provision. One study participant, a nurse, said: “……I feel uncomfortable to deliver FP course because of my beliefs …… I do not believe in FP ". (NS 10) In a similar context, another study participant, who is a midwife, added: “…while I am teaching FP methods, I have judgement of those artificial methods because, basing on my beliefs, I believe that using those FP methods is committing a sin…”. (MD 14) However, another participant had a different idea about teaching FP:

“With regard to teaching FP, when I am teaching it, I am not judgmental, I do not have any judgment about any type of FP methods because in my understanding, FP is a human right; and it is fully voluntary, it is not an obligation. What I do I just explain, I give every information so that the student can either opt to follow to adapt every information and decide on whether to deliver during clinical practice, or after graduation, but what I do is to give all the information and skills.”NS 14 Nurse faculty

The above quotes suggest that the way teaching FP is taught varies depending of the instructor’s beliefs. Some instructors do not teach artificial methods because of judgmental attitudes secondary to their religious beliefs.

- Enabling factors of teaching FP

Several study participants highlighted that they are able to teach FP because of the knowledge and skills they learned from different trainings, infrastructure, and clinical exposure. Two study participants said: “Hmm…I feel confident to teach FP because of materials, the equipped skills laboratory, and also skills and knowledge I gained in various FP trainings”MD 11 Midwife faculty and NS 15 Nurse faculty. Another NS 07 Nurse faculty added: “I have been trained about different FP methods.” But she continued to explain her motivation: “I feel motivated to help these young mothers who have an issue of unplanned pregnancies and the problems they face.” The above quotes exemplify that a variety of factors facilitate the development of self-efficacy in teaching FP.

- Structural challenges

The respondents reported several challenges related to their institution including: lack of trainings in the new FP methods that had been introduced in the country; lack of exposure to FP methods in clinical settings; lack of, insufficient, or nonfunctioning teaching materials, particularly anatomic models; lack of infrastructure; increased workload, and short time allocated to FP teaching in both theory and practice. One study participant reported: “Barriers are the lack for materials…Most of the staff in academic are not trained on new methods introduced in the country”NS 15 Nurse faculty. Another study participant explained how the teacher-student ratio is a challenge to teaching about FP: “…when there is a big class with a big number of students, because it is a practical module, it won’t be easy to do demonstration to all these students to make sure that they are acquiring the knowledge and skills required in FP”NS 01 Nurse faculty. In this context, another study participant added: “Checklists and course syllabuses are organized, but there is a need to be always updated according to the needs and new guidelines and protocols.”MD08 Midwife faculty

Some of the respondents shared common concerns about the fact that some faith-based schools of nursing and midwifery send most of their students for clinical practice to faith-based health care institutions where patients do not have access to FP services. One study participant reported “The school itself frankly speaking it is religious-based school. Previously they wanted us to focus more about natural methods only”NS 12 Nurse faculty. This study participant continued, explaining how the institution changed,

…later we are working with partners; and they convinced my institution to integrate those modern contraceptive methods. As teachers we didn’t really complain before, but now I am really proud to be part of teaching as required as we have been trained about these modern methods by now we are teaching both natural and modern contraceptive methods.

From the above quotes, it is clear that the challenges that hinder self-efficacy in teaching FP among nursing and midwifery faculty are both individual and structural.

This study examined the perceived self-efficacy and willingness of the nursing and midwifery faculty to teach the FP to HLIs students in Rwanda in order to identify gaps and opportunities for teaching improvement. In the study context, self-efficacy was defined as the belief that an individual can perform particular behaviours in four ways or processes: cognitive, motivational, affective, and selection (Albert Bandura, 1984; Shorey & Lopez, 2021). In this study, perceived self-efficacy about teaching FP was assessed through specific and relevant components, including: self-efficacy and ability in course preparation; self-efficacy in instructor behaviour and delivery; self-efficacy in evaluation and examination, and self-efficacy in clinical practice (Garner et al., 2018).

The present study found that self efficacy for teaching FP among nursing and midwifery teaching faculty in Rwandan HLIs is inadequate. Many factors (personal and institutional) affect how nursing and midwifery faculty train their students. The findings of the present study are consistent with previous research conducted in other countries (Gupta et al., 2019; Hogmark et al., 2013; Muganyizi et al., 2014). The results of this study have several implications for producing skilled FP workers and providing quality FP services. This in turn may potentially affect the sexual and reproductive health and rights of the population who make decisions based on information from nurses and midwives. Nursing and midwifery educators' self-efficacy components, such as personal efficacy, may be influenced by clinical background (Bourne et al., 2021; Nugent et al., 1999) while teachers' efficacy may be affected by educational background or continuous professional development (Dozier et al., 2019; Shin et al., 2021; Weston, 2018).

We found respondents had high average score for both perceived self-efficacy for course preparation and instructor behavior and delivery. However, self efficacy was low for clinical practices. The self-efficacy of an educator can vary depending on what they teach. For instance, self-efficacy may be high in lab simulations and low in lecturing (Velthuis et al., 2014). Study participants mentioned that they do not feel confident in practice because of a lack of continuous exposure to practical skills. These findings are consistent with one study conducted in Tanzania that found that nurse educators feel more confident to teach theory than practice due to lack of exposure to practices and no FP clinics attached to their training schools (Muganyizi et al., 2014). It is well documented that having a clinical experience increases self-efficacy in teaching nursing and midwifery procedures (Kim & Shin, 2017). However, one study found that there was no correlation between clinical experience and self-efficacy development (Weston, 2018).

In this study, it was observed that increased work experience was significantly associated with self-efficacy in FP course preparation; the more years of experience teaching FP a faculty member has the more their self-efficacy in teaching FP increases. As a career progresses, self-efficacy may also change (Bandura, 1977). Previous studies reveal that nurse educators develop efficacy through time and experience in teaching (Dozier et al., 2019; Roach, 2020). We found that having experience in clinical setting was significantly correlated with self-efficacy in instructor behavior and delivery, consistent with other studies (Kim & Shin, 2017; Li & Su, 2014; Shin et al., 2021). According to Albert Bandura (1982) practicing skills leads to performance accomplishments, resulting in increasing self-efficacy. In Tanzania, nurse educators expressed the lack of practical exposure as the leading cause of producing graduates lacking the skills to practice FP (Muganyizi et al., 2014). We also found that having an extensive experience in nursing and midwifery education was also significantly associated with self-efficacy in instructor behavior and delivery. This is also documented by several scholars that showed that when clinical instructors have formal nursing education, or are well-orientated to their role, they may be able to function effectively (Dozier et al., 2019; Ferguson & Perry, 2020; Shin et al., 2021; Weston, 2018).The results of the present study indicate the particular need for building FP teaching efficacy among nurses and midwives who lack clinical exposure to FP and who lack formal competency-based FP training.

With regard to self efficacy in educational evaluation and examination, midwives and those who had more than ten years teaching, had a significantly higher mean score compared to nurses and less experienced nurse educators, respectively. In the qualitative part of this study nurses expressed their lack of confidence in teaching long acting FP methods or procedural skills, such as insertion of implants and IUDs, while midwives reported being confident in all methods. This aligns with another study that found that nurse educators are more comfortable teaching FP theory than practice (Muganyizi et al., 2014). These results are similar to findings from two studies in Rwanda which found that nurses and midwives do not have enough knowledge and skills to provide LARC (Mazzei et al., 2021; Schwandt, Boulware, Corey, Herrera, Hudler, Imbabazi, King, Linus, Manzi, Merritt, et al., 2021). We found that being a female was significantly associated with the perceived self-efficacy to teach FP although a study, conducted in a different setting in a different context found that general self-efficacy among male nursing and midwifery educators was higher than of female instructors (Cayır & Ulupınar, 2021). Some scholars have found that in academia gender doesn’t change self-efficacy perception (Başerer & Başerer, 2019; Yalçin & Kiliç, 2018), although others have found the opposite (Nargundkar, 2014; Özgüngör, 2013). This may be related to socio-cultural factors or discipline. We also found that being midwife was significantly associated with higher self-efficacy in teaching FP. This might be related to the long-term exposure of midwives to midwifery interventions, including reproductive health, compared to nurses during education and practice. In the current study, those with more years working in nursing and midwifery education had high self-efficacy in teaching FP. A person's self-efficacy is influenced by a variety of factors, including mastery experiences, vicarious experiences, and verbal persuasion, as well as their emotional and physiological states (Shorey & Lopez, 2021).

The majority of respondents expressed a positive perception and willingness to teach FP. They emphasized that FP is a human right and a crucial need in reducing maternal morbidity and mortality. Interestingly, few respondents mentioned that they are able to provide natural FP theory and skills, while others categorically said that they do not teach FP because of their personal and religious beliefs. A meta-analysis study found that healthcare professionals are guided by different biases and misconceptions when providing FP services (Soin et al., 2022). Therefore, it is essential to consider these biases and misconceptions when allocating teachers to different academic activities related to FP teaching.

Some enablers such as trainings from different stakeholders who partner with the HLIs help the teaching faculty to develop the self-efficacy to teach FP. It is noted in the literature that continuous professional development plays an important role in the teacher’s self-efficacy (Dozier et al., 2019; Shin et al., 2021; Weston, 2018). Few other participants highlighted that teaching materials and well equipped skills laboratory are among the facilitators to teach FP. This aligns with the findings from studies which have been conducted in India and Tanzania (Gupta et al., 2019; Muganyizi et al., 2014).

Our study found that insufficient or nonfunctioning teaching materials (especially anatomic models) increased workload, and short time allocated to FP teaching, affects teacher self-efficacy. These findings corroborated the findings from another study (Muganyizi et al., 2014). found that the lack of basic FP teaching materials, e.g., medical eligibility chcklist (MEC) wheels, at some colleges with simulation labs, influenced how teachers train their students (Gupta et al., 2019). In our study some respondents shared common concerns that faith-based schools of nursing and midwifery send most of the students for clinical practice to faith based institutions where they do not have access to FP services. These findings are consistent with another study conducted elsewhere which showed that faith authorities intimidate those who teach FP (Muganyizi et al., 2014). A complex relationship exists between faith and family planning at the individual, community, civil society, and government levels. Advancing family planning will be more effective if secular actors, faith leaders, and faith-based organizations understand this (Hoehn, 2019). The study participants mentioned that the curriculums and other academic documents at their institutions are not updated according to the current guidelines and protocols. Substantial lierature has found that pre-service information taught is outdated, so it differs significantly from current guidelines that are based on evidence. Consequentlty, it often requires continuous training for new graduates to meet these standards for quality of care for service delivery, even as they enter the workforce (Berdzuli et al., 2009; Gupta et al., 2019). This has also been found to occur in India where the teaching faculty prefer teaching using standards textbooks rather than using the current national protocols and guidelines (Gupta et al., 2019). Of concern is that this can lead to the mismatching of the theoretical knowledge with the current contextualized, real-life protocols.

The findings from this research demonstrate that the nursing and midwifery faculty's self-efficacy in teaching FP is inadequate. Our findings suggest that students might not be well-trained to confidently deliver FP services to clients, contributing to the higher than necessary unmet FP needs among clients. Higher learning institutes in Rwanda could address this by making FP training for the faculty a top priority. Practicing nurses and midwives who might have graduated without enough knowledge and skills to provide FP care should be provided with orientation and on job training. Future research should include an assessment of the curriculums related to family planning methods, as well as an assessment of the simulation labs to ensure that the teaching faculty are well supported. In order to understand ongoing needs for knowledge and skills, it is important to evaluate the training of teaching faculty. Finally, students should be assessed for perceived self-efficacy before entering the workforce to ensure they are supported to provide quality care.

Strengths and limitations

The present study has several strengths and limitations that are necessary to consider when interpreting the findings. First, to the best of our knowledge, this is the first large study conducted in Rwanda to assess self-efficacy in teaching FP among nursing and midwifery faculty in HLIs (public and private). Second, all HLIs in Rwanda were represented except one institution, which declined to participate. Third, a mixed-methods study design was used to provide an in-depth understanding of how FP is taught in HLIs.

On the other hand, there are several limitations to our study. First, we did not observe how the teaching faculty taught FP in class, simulation lab, and clinical setting, triangulating our survey and qualitative evidence. This study did not review the curriculum and other teaching materials, such as checklists and logbooks. We also did not assess simulation labs to explore the extent to which they are equipped to facilitate teaching FP. Key informants such as heads of departments, deans, and centers of learning and enhancement were not also consulted. Third, it is important to say there may be response bias at both the institutional and individual level. At the institutional level, it is possible that the institution which refused to participate is systematically different from others. On the individual level, since only 85 participants are included in the quantitative analysis (i.e. Table 1) of the 104 at participating institutions reported in the methods, it is possible that individuals with lower self-efficacy were less likely to respond. Lastly, there might be a social desirability bias due to the nature of the topic under study.

We found that perceived self-efficacy and willingness among nursing and midwifery teaching faculty in HLIs in Rwanda is inadequate in teaching FP. Teaching faculty said personal and religious beliefs, lack of training in new FP methods introduced in the country, lack of exposure in clinical settings, lack / insufficient or nonfunctioning teaching materials, a high number of students which increases the facilitator-student ratio, and short time allocated to FP teaching in both theory and practice, all affect their self-efficacy as teachers of FP. There is a need for HLIs and different stakeholders to invest in training the nursing and midwifery teaching faculty on family planning practical skills to have a nursing and midwifery workforce providing up to date clinical FP service that will help Rwanda reach the SDGs.

Acknowledgements

The author would like to thank the HLIs and study participants to make this study possible.

Pre-Publication Support Service (PREPSS) supported the development of this manuscript by providing author training, as well as pre-publication peer-review and copy editing

Author’s contribution

All authors conceived and designed the research; AN, JB, JBHH, MLBI, and YDNU collected data and conducted the research; MH, RR, and AN analyzed and interpreted the quantitative data; AN, YDNU, JB, MM, and JDU analyzed and interpreted the qualitative data, AN, MH, MM, and TE wrote initial paper; The author(s) read and approved the final manuscript.

Funding

This study was funded by The Center for International Reproductive Health Training at the University of Michigan (CIRHT-UM), USA.

Availability of data materials

The data associated with this study are included within the manuscript. The datasets used in the analysis in this study are available from the corresponding author on reasonable request.

Declarations

Ethical approval was obtained from the University of Rwanda, College of Medicine and Health Sciences Institutional Review Board (No335/CMHS IRB/2022). Participants’ rights were protected.

Consent for publication

Not applicable.

Competing interests

The author declares that they have no competing interests.

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No competing interests reported.

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Additional file 1: Extent and descriptive statistics among the items of FP teaching self-efficacy

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Perceived self-efficacy and willingness to teach family planning among nursing and midwifery faculty in higher learning institutions in Rwanda

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Quantitative data

Socio-demographic information of respondents

Correlation between socio-demographic characteristics and FP teaching self-efficacy

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- Educational background as determinant of confidence to teach FP

- Willingness to teach FP

- Enabling factors of teaching FP

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