Study design and approach
As explained by Creswell (24), there is no single study design that suffices the collection of reliable and validity data. Therefore, this study adapted cross-sectional design using concurrent mixed methods. Both qualitative and quantitative data collection was done at approximately the same time, from different samples and the integration occurred during the interpretation phase (25,26).
The mixed data was important to understand and describe the experiences of the nurse educators on the implementation of the competency-based curriculum. Thus, it increased the validity and reliability of the findings (24,25). Findings from the qualitative data were triangulated with those from the quantitative data hence broadening 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 them, 40 schools were involved in the study. Among them 14 Government schools, 8 Private school and 18 Faith based owned schools. All schools implement the nursing and midwifery competency-based curriculum approved by TNMC and NACTE.
The participants in this study included nurse educators from the selected nursing and midwifery schools. 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 (27). While the inclusion criteria for the quantitative study were nurse educators with working experience of 3 years or more of implementing nursing and midwifery competency-based curriculum, nurse-educators recruited in the qualitative study had to have a teaching experience of 5 years or more (28). It was s expected that nurse-educates with a longer teaching experience would provide in-depth information about implementation fidelity of Nursing and Midwifery CBET curriculum (28).
Sample size and sampling procedure
Sample size was calculated using a formula documented in a descriptive study by Fox & Hunn, (29). Nurse educators at the school level were obtained by using proportionate formula (30). This is because the number of nurse educators are not equal in all nursing schools. Sampling was done using a three stage sampling approach. The first step was the selection of the regions from the eight training zones of Tanzania. Second step was to select nursing schools. The schools involved in the study were purposefully selected to ensure equal representation of private, faith based and government owned schools (31). The third stage was the selection of nurse educators implementing competency based curriculum.
A list of nurse educators was obtained from the Heads schools of nursing and midwifery. A simple random sampling strategy (32,33) was used to select 240 nurse educators, a random number generator software was used to assign participants with numbers for identification. 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 (34), a purposeful non-probability sampling technique was used to recruit 24 nurse educators for the qualitative study (35,36). Specifically, these were nurse educators who had nursing education background and a teaching experience of five years and more. However, the principle of saturation guided the sampling process (24). 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 of 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 (37). 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 It was composed of open and closed questions with 28 items. The questionnaire was used because all participants were asked the same set of questions in the same sequence and this increased the objectivity of the collected data even though the data were triangulated with information from the interviewers (38).
The questionnaire was tested for reliability using Cronbach's alpha test and scored r=0.712. Furthermore, component and factor analysis was done and four out of 28 items were removed due to its complexity and remained with 24. Thereafter the pilot study was conducted for consistency and time estimate. The pilot study was conducted on 5% of the study sample consisted 12 nurse educator in one private school in Dodoma (39). The findings from the pilot study was not included in the major study, rather helped to modify questions narrated in the questionnaire and time estimated which varied from 20-30 minutes. After this, the questionnaire was found to be acceptable for the study.
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),
Semi-structured interview guide
A semi-structured interview guide was used to collect data from the nurse educators (40). The questions were based on a pre-decided topic, guided the data collection process (35). The interview guide was prepared in English language and later on translated into Kiswahili, the national language spoken fluently by participants and researchers. The interview guide included questions focusing on participants’ demographic information, preparation of lesson plan, the use of the scheme of study, and experience in employing participatory teaching and learning methods during implementation of the nursing and midwifery competency-based curriculum.
Twenty-four (24) interviews with nurse educators were conducted in a quiet room in the school premises out of reach from other educators and students. All interviews were conducted by the researcher using the interview guide and all were audio recorded. Following each interview, the researcher listened to the recorded interviews and read the field notes to understand the material and determine if there emerged issues that needed follow up with subsequent interviews. This exercises facilitated realisation of reaching saturation of data at 21 interviews where there was no newer information generated. However, the researcher decided to continue with 3 more interviews to be sure that there were no more emerging information (26). The length of interview sessions varied from 60 to 120 minutes
Quantitative and qualitative data were analysed separately and integration was made during the interpretation.
Quantitative study Data Analysis
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 (39). The quantitative data were triangulated with the semi-structured interview to complement the data (41).
Qualitative study Data Analysis
The thematic analysis method, as described by Braun and Clark (42), 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 (43,44). 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, five themes were generated (43).
Confirmability refers to the degree to which the results could be confirmed or corroborated by others (45). 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 to carry out this study was obtained from the Research and Publication Committee of the University of Dodoma (UDOM) (Ref: UDOM/GR/209/Vol II/59). The MoHCDGEC granted permission to conduct the study in nursing and midwifery schools (Ref: MP 70933/78). Further, written informed consent was obtained from the participants for them to be included in the study and for using audio-recorded to record conversations during the interview. 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.
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 permission to adapt the tools was granted by the authors.
Limitation of the study
There was a limited literature on the implementation fidelity of the competency based curriculum for nursing and midwifery programme. However, studies of the same from other fields including of education provided some light for this study to make references. The interviews were translated from Kiswahili to English language, it is likely that during the translation the meaning may be altered. To ensure that the meaning of participants accounts was not derailed, the translated transcripts were cross checked with original Kiswahili transcripts for accuracy translation. Further, two transcripts were back translated by another person and there was no significant difference in meaning.