Study design and approach
As explained by Creswell (19), there is no single study design that suffices the collection of reliable and validity data. Therefore, both qualitative and quantitative data collection was done at approximately the same time, from different samples and the integration occurred during the interpretation phase (20,21).
The mixed data was important to understand and explore the experiences of the nurse educators on the implementation of the competency-based curriculum. Thus, it increased the validity and reliability of the findings (19,20). Findings from the qualitative data triangulated with those of the quantitative data and hence broaden the understanding of the nurse educators’ experience on the implementation of competency-based curriculum for nursing and midwifery programmes.
This study was carried out in nursing and midwifery training schools across Tanzania. There are 94 such schools, out of which 29 are private, 34 run by faith-based organisations and 31 are government-owned. All schools implement the nursing and midwifery competency-based curriculum approved by TNMC and NACTE.
In each nursing school, there are 10 nurse educators on an average. According to World Health Organization (WHO), a person qualifies to be a nurse educator after completing a nursing training programme and attaining a license to practise nursing, with a minimum of two years’ full-time clinical experience and a formal teaching preparation either before or soon after employment as an educator (22).
The participants in this study included nurse educators from the selected nursing and midwifery schools. To establish trust, participants of the quantitative study were chosen to be the ones who had an experience of 3 years or more of implementing nursing and midwifery competency-based curriculum, whereas those recruited in the qualitative study had to have a teaching experience of 5 years or more (23).
Experienced nurse educators are usually expected to provide in-depth information (23).
Sample size and sampling procedure
A simple random sampling strategy (24,25) was used to select 240 nurse educators using a random number generator software. The schools involved in the study were identified after the random selection of the nurse educators. Then, the nurse educators were followed up at their schools, where they taught for the completion of the questionnaire. The school heads assisted the research assistants’ team in identifying nurse educators who were randomly selected to answer the questionnaire.
To ensure that participants with rich experience were included (26), a purposeful non-probability sampling technique was used to recruit 24 nurse educators for the qualitative study (27,28). However, the principle of saturation guided the sampling process (19). The school heads were asked to identify nurse educators who had an experience of 5 years or more in implementing the CBET curriculum.
Thereafter, the researcher met the identified nurse educators, explained the aim, objectives and the study procedures to them and those who agreed to take part in the study were requested to provide written consent. This was followed by scheduling interviews.
Research instruments and data collection
A modified questionnaire from the US, which was used to assess the proficiencies of learners in the field of Science, Technology, Engineering and Mathematics (STEM), was used in the study (29). The questions were modified to suit the nursing and midwifery programmes in the context of Tanzania and were based on educators’ characteristics, understanding of the concept of competency-based curriculum, preparation and usage of a lesson plan.
Four research assistants experienced in education and health research were trained to collect data. Soon after receiving the ethical clearance (Ref: UDOM/GR/209/Vol II/59) and the permission letter (Ref: MP 70933/78), a pilot test for the questionnaire was carried out for consistency and data collection time estimate, thereafter, data collection began.
Document observation fidelity checklist
Document audit fidelity checklist (30) was used to review documents retrospectively; such as CUM master rotation plan, lesson plans, skills laboratory and clinical rotation schedules. The observation focused on the availability and adherence of the teaching and learning activity plans and their alignment with the designed competency-based curriculum for the nursing and midwifery programme.
The observation data is generally considered more precise than the self-report as the former provides a more objective data (31). Observations of the implementation were important for measuring the alignment between the designed and the implemented curriculum. The observation focused on the adherence, dosage/exposure and quality of delivery as described below.
The observation on adherence focused on the availability of CUM master rotation plan and whether nurse educators were able to abide by it. Further, prepared classroom session plans, skills laboratory teaching plans and clinical rotation plans were also audited.
The aim was to validate the availability of the advance plan and the way students were placed and rotated in the whole programme. Moreover, to see the systematic records of educators thought about what was covered during classroom, skills lab and clinical teaching.
A sample of constructed question papers for a formative assessment was evaluated to see whether the constructed questions and the action verbs captured all three domains of knowledge, skills and attitude (32).
The dosage was focused on the number of sessions covered in the classroom, skills lab and clinical teaching compared to what was prescribed in the competency-based curriculum for the programmes. Further, the number of practical sessions, written assessments and assignments given to students were also audited. This was key in measuring the coverage of the sessions in comparison to what has been prescribed in the competency-based curriculum for nursing and midwifery programmes.
The quality of delivery focused on the types, relevance and frequency of the usage of teaching and learning methods/techniques. For instance, the usage of participatory teaching methods that facilitate students’ understanding and develop skills in various aspects of learning (32) and using simulation to enable a learner develop clinical skills and reduce the shock of entering clinical practice (33).
These factors made teaching techniques important to be observed in order to appreciate the type of instructions the nurse educators used and answer questions such as what tasks were the students doing; the type of interaction used during teaching and why.
The observation for implementation fidelity was important to generate evidence-based practice to quantify the implementation of competency-based curriculum for the programmes among nurse educators.
The CUM master rotation plan, lesson plans, skills lab plan, clinical rotation plan, curriculum and the assessment plan were the documents required to make a reference for authentication. In addition, the skills laboratory teaching activities were also observed at the schools, after an appointment was made through e-mail/phone with the school head. On arrival, self-introduction was done and the purpose of the visit was explained. Introduction, permission and ethical clearance letters were also provided to the head. They in turn provided all the necessary support, including the required documents, as mentioned above, for validation.
The implementation fidelity checklist was used to gather the retrospective information (30). Thereafter, a visit was made to observe the availability of CUM master rotation plan, clinical rotation plan, skills lab plan, time table and equipment for teaching as well as learning purposes.
Semi-structured interview guide
A semi-structured interview guide was used to collect data from the nurse educators (34); the questions were based on a pre-decided topic which guided the data collection (27). The interview guide was translated to Kiswahili—Tanzania’s national language.
The interview guide consisted of demographic information, preparation of lesson plan, usage of scheme of study in preparing the lesson plan, experience in employing participatory teaching and learning on the implementation of the competency-based curriculum for nursing and midwifery programmes.
Semi-structured interviews were conducted in a quiet room at school premises. An experienced nurse educator and a senior nurse midwife identified participants who met the inclusion criteria and clarified the aims of the study and issues around confidentiality (35). Furthermore, she conducted all 24 interviews in Kiswahili to ease participation.
The interviews were conducted until data saturation had been reached in terms of no new information and themes being procured (36). To ensure dependability of data, the interviews were audio-recorded (28). The audio-recorded interviews’ duration varied from 60 to 120 minutes per session.
The data from the questionnaire were analysed using IBM SPSS Statistics, version 24 for Microsoft Windows. Descriptive analysis, frequency, proportion and mode were used to summarise the data. The Chi-square statistic was used to test the associations between variables (37). The quantitative data were triangulated with the semi-structured interview to complement the data (38).
The thematic analysis method, as described by Braun and Clark (39), was used for qualitative data analysis and the NVivo 10 software was used to generate a coding system. Prior to starting the analysis, the audio-recorded interviews were transcribed verbatim, where non-verbal cues were also captured. The interviews were read and re-read to get an understanding of the data (36,40). The data were organised in a meaningful way and were coded to reduce the data volume. The codes were developed and reviewed throughout the coding process and were then organised under descriptive themes. Finally, four themes were generated (40).
Confirmability refers to the degree to which the results could be confirmed or corroborated by others (35). Since the experiences of the researchers could have influenced the interpretation of the results, this was avoided by ensuring that the research team belonged to a mix of various professional backgrounds, including nursing and midwifery, nurse education, curriculum developer and a professor of education. The mixed professional background of the team promoted the interpretation and understanding of results that required an analytical reflection on each researcher’s own preconceptions. This also strengthened the results through constructive deliberations and broadened the understanding of the implementation fidelity of the competency-based curriculum for nursing and midwifery programmes in Tanzania.
Ethical approval (Ref: UDOM/GR/209/Vol II/59) was obtained from the Research and Publication Committee of the University of Dodoma (UDOM). Permission to conduct the study in nursing and midwifery schools and review of documents was obtained from MoHCDGEC (Ref: MP 70933/78). Further, an informed consent was obtained from the participants beforehand.
Participants were briefed about the objectives and procedures of the study and were informed about their right to agree or disagree to participate or withdraw from the study at any point in time. Special permission was obtained from informants for audio-recorded information they provided during the interview.
Participants were made clear that the information they provided, whether orally or in writing, would be treated with strict confidentiality and they were assured that the data analysis and report findings will not identify them in any way. Participants’ names were not used and the designated numbers as well as the material collected (including hand written notes, transcripts, checklist and tapes) were locked in a cabinet that only the research team could access. A consent to adapt the tools was granted by the authors.