Semantic divergence in clinical education: Student-centered or student democracy.

AIMS: Although several studies have confirmed the validity and the strength of the student-centered approach and most training centeres have put it as the heading of their agenda, there are still problems in the method of implementation, increasing the need for further research to review the mode of implementation. In this regard, the present study has been conducted to investigate students' and educators' perception in terms of interaction manner in clinical education process. SETTINGS AND
DESIGN: This study was performed in a qualitative approach and by the conventional content analysis method.
MATERIALS AND METHODS: Data were collected until saturation through use of individual semi-structured interviews. Twenty-one subjects including undergraduate nursing students (8 cases), faculty member educators (9 cases), head nurses (3 cases), and educational supervisor (1 case) participated in the study, and the data were analyzed using MAXQDA3 software.
RESULTS: "tudent democrac" was extracted through data analysis as the main theme of the study. Participants' experience in terms of the five sub-themes included instructor's loss of dignity, negligence in the evaluation of the students, poor discipline, lack of compliance with the educator, and lack of motivation.
CONCLUSIONS: Instructor's weaknesses in planning, guiding, and evaluating the students led to student's interference in these affairs and a challenge in effective student-centered approach. Although excessive emphasis on students' opinion for educational evaluation is apparently a sign of tribute to the students, it ultimately contributes to ignoring the process of learning to attract students' interest, occupational devaluation, and a decrease in students' motivation.

INTRODUCTION

Clinical training is so important to be interpreted as the heart of vocational training.[12] Although classrooms and skill laboratory are essential to upgrade students’ knowledge and skills, they cannot substitute experiential learning in clinical environments.[3] Using the theoretical discussion in the clinic is one of the challenges which has been most frequently referred to.[4] Students who are able to apply the theory in practice have been less subjected to mistake, loss of confidence, and leaving the nursing profession.[5] Strengthening students in communication, effective care for clients, critical thinking, problem solving, and lifelong learning ispossible through student-centered approach.[6]

Student-centered approach is a learning approach versus traditional content-centered and teacher-centered methods.[7] Several studies have confirmed the strength and the validity of this learning approach.[89] In student-centered method, the educator should plan to provide common learning opportunities for students’ decision making, and case studies; the trainer should also have formative evaluation for assignments and frequently involve students in new situations to gain experience.[10] In this way, every teacher should answer the following questions: Who is the learner? In what situation he/she will be and what does he/she need to learn in that situation? Through what method should he/she learn to be more consistent? Of course it does not mean that the teacher has to see and/or provide all the learners’ needs.[7] Despite application of this appropriate teaching style, there is yet lower than expected outcome in clinical competence of nursing students.[11]

Democracy plays a fundamental role in this method, in which a student actively participates in all the stages of education. According to John Dewey, fighting for democracy has a positive impact on cultural, political, economic, educational, scientific, and other aspects.[12] Lack of democracy in an organization is the cause for low productivity and performance in some organizations.[9] Several interpretations have been proposed for democracy, among which people’s vote, the vote of people who are present, the majority of votes, workers’ overconfidence, a free society, a civilized society, free economy, as well as other elements can be enumerated. Thus, democracy refers to transferring the government to the people.[13] In a student-centered method, the students decide what to learn and how to learn.[67]

The relationship of the quality of decision making with the level of knowledge has been already proved.[14] In previous researches, students’ low knowledge in various fields such as management and leadership,[15] taking care of the end-stage patients,[16] medications,[17] pain care,[18] paying attention to spiritual dimension in care,[19] and other cases have been already approved. So, accepting all students’ decisions by the teacher may not be to the benefit of the students. On the other hand, lack of students’ coping may bring about their lack of acceptance in the nursing team and ultimately reduce the motivation to learn.[20] Students are the future nurses, so weakness in the educational system endangers the nursing profession.

Researchers’ experiences showed that the mode of the instructors’ interaction with the students has taken the effectiveness of their role in attracting student’s participation under the question. The present study aimed to investigate students’ and educators’ perception in terms of interaction manner in clinical education process.

MATERIALS AND METHODS

Content analysis is a research method for valid inferences from data, with the aim of providing knowledge, new insights, opening view of the reality, and a practical guide to performance.[21] One of the benefits in content analysis approach is flexibility in the research design.[22] These characteristics are essential to the perception of the participants, and to provide practical suggestions, in this study. Therefore, this study was carried out in a qualitative approach and with the conventional content analysis method. In conventional content analysis, codes and categories are derived directly from the text data.[23]

Participants comprised 21 subjects including 8 nursing students (37.5% women and 62.5% men), 9 faculty member instructors who were all married (55.5% women and 44.5% men), 3 head nurses (2 men and 1 woman), and a female educational supervisor. The mean age of students was 21.28 (1.0) years, and the mean years of work experience was 40.27 (8.4) and 20.33 (9.2) for other participants. Among the group of participants, only students were not married. Inclusion criteria for students included being an undergraduate student of over semester five. Data were collected until saturation through individual semi-structured interviews.

The main question was inquired that how is the students’ and teachers’ perception of their interaction in the clinical education process. The axial questions included: “Describe your experience on nursing students’ internship,” “Express your experience in terms of students’ status in the process of clinical education,” and “What are the instructor’s expectations from the students and vice versa?” These questions were designed as the interview guide, and participants’ answers led the interview process.

Individual interviews lasted for 20-75 min. The participants were asked to easily and freely express their experiences in terms of students’ position in internships in the internal and surgical wards. All the interviews were tape-recorded, fully transcribed, and read for several times.

In order to determine the accuracy and integrity of the data, the objective method, as one of the features of qualitative researches, was completely carried out as follows: 1) Continuous evaluation of the data by the allocation of sufficient time to actual realization of data and establishment of appropriate associations; 2) reviewing the extracted codes and themes by two research partners as observers, and having consensus over the selected codes in the themes classification; 3) reviewing participants’ manuscripts and approval of the first level codes by the study participants; and 4) searching to find the inconsistent data and to analyze negative data in the written text of each participant and among all of them.

After the implementation of audio recordings, implicit and explicit meanings were identified through the aforementioned method. Participants’ description and concepts were encoded, summarized, and classified, and the themes were extracted. To confirm data, manuscript review and further comments were applied similar to the quantitative approach. Data were analyzed by the qualitative data analysis software, MAXQDA3 (2007), and level one, two, and three codings were done.[2425]

Ethical considerations

The study was approved by the Ethical Committee. At the beginning of each interview, a written informed consent was obtained from the participants after they had been explained about the interview objectives. All the data were kept confidential by the first researcher, and were given to other colleagues anonymously, if necessary, with a code name.

RESULTS

A total of 454 code numbers and five sub-themes were extracted through the analysis of the data obtained in the study. The main theme was “student democracy” [Table 1]. Five other sub-themes were as follows.

Table 1

The main themes, sub.themes, and meaning units

Loss of instructor’s dignity

Loss of instructor’s dignity is one of the sub-themes which was emphasized by the instructors. According to the trainers, being evaluated is very dependent on the students’ opinions. In this regard, one of the male educators stated:

“If you have a bad encounter with the students in training, you should expect to be evaluated a low score.” (E8)

Namely, training educators understand while interacting with the students, they have to behave by ignoring their “own” rights, as each of the educator’s behavior is considered to be inappropriate by the students and they take a retaliatory behavior. Instructors, therefore, perceive their respect to be threatened by the students; in this regard, a male trainer says:

“I asked for a patient’s report from one of the students; he/she said, ’It’s better for you not to be strict with us; or we leave a comment on instructors’ quality’.” (E2)

Managers’ attention toward research affairs and publishing more articles has resulted in educational weakening. Participants believe that little attention of policymakers occasionally brings about loss of dignity. In this regard, a male trainer mentions:

“Conducting research and publishing articles have been everything to us; instructors leave training and the students, and when they are asked about it, they say that they have a paper presentation in a research centre. When the instructor does not mind training and students, what you can expect from the students?” (E5)

Negligence in the evaluation of the students

Students’ teachers evaluation plays an effective role in education process. Negligence, in this regard, is actually a failure in the implementation of training program. Leniency in evaluation may be brought about when inexperienced educators are pressurized by the students. One of the male instructors with 5 years of work experience who had been recently employed in the faculty stated:

“One of the students says, ’we leave comments on educators’ quality and some of th instructors are not much satisfied with our opinions.’ First, I became so upset by his/her words, but I controlled myself and tried to let go of him/her since he/she was inexperienced.” (E2)

Also, a 27-year-old experienced female trainer said:

“I try to let the boys free and have nothing to do with them.” (E8)

Students’ teachers evaluation is sometimes an effective disadvantage as some trainers take a prudent behavior in interaction with the students. A female educator says:

“We had an instructor who didn’t receive his/her annual base salary. Although colleagues’, the manager’s, and department’s opinion are also considered, students’ view is more important. It affects the trainer’s job, rating score and his/her leniency towards the students. Students behave in the way that we have to adjust the training with them and go along with their philosophy, but it shouldn’t be like that; a trainer dismisses the students before 12 o’clock to attract their attention. I saw a trainer evaluating the students giving their evaluation paper to fill out at the same time.” (E7)

Disciplinary weakness

Most of the complaints about the ward’s indiscipline have been proposed by the head nurses. One of the supervisors stated:

“No matter how hard I tried, I couldn’t bring students in order; they would come and go whenever they like; they made flimsy excuses for being late; when I inform the faculty officials, they tell me to take it easy.” (H1)

Students’ democracy by the instructor has led to ignoring the punctuality attribute instead of strengthening it; lack of discipline has been justified by a female trainer as follows:

“Because there is not much work in the ward during the first hour of morning, students are not required to be present at that time; I myself give them the related reports of that time later.” (E4)

The severity of the problem is so much that it has made the students really comfortable to express it. The following experience shows how lack of discipline may lead to damage to patients. A sixth-semester student who had already gotten a student work job in one of the public hospitals expressed his experience on discipline:

“We have to be totally indisciplined in nursing; for example, 6 o’clock drugs should be started to be given at 5 or 7, or 10 o’clock drugs at 8.” (S4)

Failure to comply with the instructors’ training program

Failure to comply with the educators’ training programs or lack of students’ professional suitability is the other sub-theme emphasized by the instructors and the head nurses. A female trainer complained about students’ lack of compliance:

“Trainings are highly varied; students were obedient those days but now they are not; one of the students says to me, ’You treat us as if all thirteen of us are going to be a head nurse’.” (E4)

Also, a female head nurse stated:

“I saw an instructor asking a student to do something, and the student did not do that claiming that it was not his duty.” (H3)

More surprisingly, the student implicitly admitted his lack of compliance:

“We don’t certainly have to do the nurses’ duty; a head nurse is not entitled to give us orders, as the educator doesn’t command us either.” (S8)

Lack of managers’, logistics’, and ultimately the trainers’ coordination in education is another factor for students’ failure to comply. Regarding the existing irregularity, a male trainer said:

“The course plans are different with each other; there is no integration; even the instructors are dealing with the students in different ways; then, when we say why, they say that decentralization enhances the educator’s creativity! This kind of creativity or lack of coordination only harms the faculty and the students’ comply.” (E3)

Reduction in student’s motivation

Reduction in students’ motivation is among the sub-themes emphasized by all of the educators and the students implicitly. The experience of a male student in terms of motivation for doing the qualitative work as well as the opinions of two male instructors with 25 and 33 years of work experience and a female educator with more than 40 years of experience are respectively as follows:

“It will take a long time if we want to perform whatever you’ve taught us; we don’t practically need all those accuracy and quality; nobody cares about the work quality. Once I wanted to work basically, I realized that the medications usually taking less than half an hour took two hours.” (S7)

“Currently, there seems to be disorganization, and that sense of necessary responsibility does not exist anymore. Students and instructors would show up usually when the patients are delivered, and leave the ward before the patients are delivered.” (E4)

“As long as there is student domination, it’ll be always the same old story; as long as the student dominates the educator, he/she won’t take command from the trainer, won’t be disciplined. Profession is important either scientifically or disciplinarily. Scientifically, most instructors are affected by the physicians, and lack of coordination and discipline is also widely seen among the training staff. So, what is the result? Profession will be trivial from the students’ perspective; even those who were interested in nursing may lose their fondness after entering into this profession.” (E8)

“Interest and incentive should be created by the instructors, and making love to nursing is the best motivating way; an educator must be in love with nursing and show the love in action to the students; should teach it. Once it happened to me to go out to the street with nursing uniform to buy a pacifier for a baby named K. with malnutrition and extreme cachexia; the patient was skinny and bony. I never forget his/her name as I work with love, with incentive and interest. I took those patients to the bathroom myself and washed them; we collected alms from the colleagues, so that within a few months, we observed a weight gain from 2 to 12 kg. That student who worked whit me later became a teacher and said, ’I was not fond of children, but I loved them later.’ He/she became a paediatric instructor and is retired now. You think how many trainers we have who love their career! I do not think they are many in number. That’s why students are lethargic and uninterested.” (E9)

DISCUSSION

In the first step of the study, participants’ perception of their interaction and passive role of the faculty authorities toward students could be seen. The obtained themes are discussed below.

Loss of instructors’ dignity

Loss of instructors’ dignity was among the sub-themes emphasized by the educators. Respecting the dignity of people is one of the main indicators of responsiveness in any health system.[26] Although trainers’ education has increased during the recent decade and teaching methods have been improved, instructors have felt a lack of respect from the side of the students. Respect and reverence are the behaviors ignored by the students. Lack of exact investigation over the strategies used by the instructors leads to individuals’ dignity damage, lack of motivation, and increased resistance among students.[27] Students’ satisfaction with the instructor has been so exaggeratedly demonstrated that it has affected the instructors’ planning and evaluation of the student. It seems that this kind of misconception on student-centered method has been the reason behind the educators’ loss of dignity.

The performance and the dignity of each professor depend on the priority which has been emphasized by the policymakers of the country.[28] High research activity has led to lack of supervision on education, so that evaluation of the training quality is merely based on the students’ opinion in most cases and not the direct supervision of the expert observers.

Clinical evaluation is one of the challenges in nursing education.[29] Negligence in the evaluation of students is another sub-theme discussed in this research. However, the effect of giving a high score to the students has been previously approved in achieving a high rating score.[30] Negligence in the evaluation of the students undermines this important step in education process. Weakening the evaluation in the nursing program may lead to the failure of the course and even be a legal confrontation.[31] Such a leniency can damage clinical evaluation as one of the most significant duties of the instructors, which finally imposes some hazards to the patients. Clinical evaluation is necessary to ensure providing an effective, safe, and ethical care.[32]

The matter has not been only expressed by the instructors and the students, but also has been frequently observed in researchers’ experiences. Weakness in discipline has been also reported in the hospitals of developing countries,[33] and moving toward that in the educational systems has been warned.[34] Discipline should be taught by the instructor to the students.[35] The transition process of discipline is difficult, and educators’ leniency has also played a role in students’ unwillingness, leading to increased irregularity.

Failure to comply with the instructor’s training program

Lack of compliance has also been reported among the students of other courses.[36] Some have attributed this problem to students’ inability in practical performance and recommended the implementation of educational strategies as a solution to overcome such a functional weakness;[20] however, the problem is that students participating in the present study were the last semester undergraduate students, and relative recalcitrance was seen in some repetitive tasks such as monitoring the vital signs, communication with patients, performing the nursing process, and so on.

The greatest cause of failure to cooperate or leaving the nursing profession, discussed in the researches, is the existing insufficiencies in the faculty.[37-39] In addition to the mentioned failure, some studies have also proposed intrinsic, intra- and extra-individual and extra-faculty factors.[40] Although all the above reasons are acceptable and effective, the study participants have mainly pointed to the existing lack of managerial coordination. According to the available pieces of information, there is failure in the planning and evaluation of the students to attract their satisfaction; this issue has led to a reduction in the importance and respect of the profession and subsequently lack of compliance among the students.

Of course, some have a one-dimensional definition for compliance and have considered each kind of compliance contradictory to the creativity.[20] Consider an instructor with features such as creativity, motivation, with love and devotion to the profession; obviously, a student takes advantages of these characters if he/she follows the instructor.[4142]

Reduction in students’ motivation

The importance and the benefits of students’ motivation have been cited in various researches.[4344] This problem is, of course, comprehensive as keeping the nursing students interested to stay in profession is the challenge of almost all of the universities around the world.[45] Students’ motivation is influenced by several factors such as learning environment, teaching style,[46] cooperation in research,[47] interest to help others, and financial incentives.[48] The reason discussed in this study, similar to the control theory,[49] is the effect of students on the controlling and evaluating methods of the trainers toward them, causing leniency in their own clinical evaluation. According to a famous quote, “easy come, easy go.” Occupational failure in professional level due to instructors’ simplification has resulted in vocational devaluation from the students’ points of view. Students’ personality and self-esteem are influenced by a valuable profession. Students’ self-esteem is directly effective on their learning motivation.[50]

CONCLUSION

The sub-themes including instructors’ loss of dignity, negligence in evaluation of students, disciplinary weakness, failure to comply with training program, and lack of students’ motivation can be considered as the consequences of student-centered replacement by student democracy. Student-centered approach is not running correctly due to the following reasons:

Misconception over the student-centered approach

The existing gaps in instructors’ planning, guiding, and ultimately evaluating

Too much emphasis on getting the students’ opinion instead of direct supervision on the training process

Even one of these factors is sufficient to bring damages to correct implementation of student-centered approach. Misinterpretation leads to wrong implementation of this method, and the disadvantages will be more than the advantages.

The void in planning, guiding, and evaluating the students leads to their interference in teachers’ evaluation process indiscipline in all the three steps. Although exaggerative emphasis on students’ opinion for educational evaluation is indicative of a reverence for students, it eventually contributes to ignoring the training process to attract students’ satisfaction, professional devaluation, reduction in students’ motivation and interest, and eventually creation of a vicious cycle of occupational weaknesses [Figure 1].

Figure 1

Replacement of student democracy by student-centered method until the creation of the occupational weakness cycle

Conducting, planning, and coordinating meetings among the instructors of each faculty in the first step; among instructors, clinical nurses, and educational officials in the second; and among educators and students in the end can be an effective strategy to overcome this challenge. In this regard, investigation over the implementation of student-centered method using the action research approach is recommended prior to and after the above-mentioned meetings.