Clinical Instructor's Behaviors as Perceived by Themselves, Students and Nursing Faculty Staff

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:

1. What are the clinical instructor's behaviors as perceived by them?
2. What are the clinical instructor's behaviors as perceived by their students?
3. What are the clinical instructor's behaviors as perceived by Nursing Faculty Staff?
4. Is there a relation between clinical instructors, students and Nursing Faculty Staff perception about clinical instructor's behaviors?

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: 

1. Staff member code, sex, years of experience, position, department, and clinical instructor code.
2. Clinical instructor code, gender, scientific degree, and department.
3. Student code, gender, age, academic year, last academic achievement and clinical instructor code.

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:

• The permission to collect the data from Nursing Faculty Dean and vice dean for education and student affairs and heads of all academic departments was obtained.
• All needed sheets of the tool were printed, and data were collected from clinical instructors, staff members and students.
• The data were collected during second semester of the academic year 2017- 2018 (from the beginning of February to the end June).
• The sheets were given individually to all of them and they were given a period of time to respond to it. The data were received according to each individual time.
• The researcher scheduled the visits to each department staff for (staff members and clinical instructors) and to classrooms for students which was done.

Ethical Consideration:

1. An informal consent was obtained from the identified Faculty staff members, clinical instructors and students to collect the study data before data collection, after explanation of the purpose of the study.
2. Confidentiality, anonymity and privacy were assured.
3. Participation was on voluntary basis of participants.

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

              * 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:-

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:

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 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:

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*)