Challenges of teacher-based clinical evaluation from nursing students' point of view: Qualitative content analysis.

INTRODUCTION: Clinical evaluation is very important in the educational system of nursing. One of the most common methods of clinical evaluation is evaluation by the teacher, but the challenges that students would face in this evaluation method, have not been mentioned. Thus, this study aimed to explore the experiences and views of nursing students about the challenges of teacher-based clinical evaluation.
METHODS: This study was a descriptive qualitative study with a qualitative content analysis approach. Data were gathered through semi-structured focused group sessions with undergraduate nursing students who were passing their 8th semester at Rafsanjan University of Medical Sciences. Date were analyzed using Graneheim and Lundman's proposed method. Data collection and analysis were concurrent.
RESULTS: According to the findings, "factitious evaluation" was the main theme of study that consisted of three categories: "Personal preferences," "unfairness" and "shirking responsibility." These categories are explained using quotes derived from the data.
CONCLUSION: According to the results of this study, teacher-based clinical evaluation would lead to factitious evaluation. Thus, changing this approach of evaluation toward modern methods of evaluation is suggested. The finding can help nursing instructors to get a better understanding of the nursing students' point of view toward this evaluation approach and as a result could be planning for changing of this approach.

Introduction

Clinical training is of great importance in the educational system of nursing and midwifery around the world and provides a unique opportunity to prepare the learners for determining their professional identity.[1] At this stage, through learning clinical activities, the learners would gain necessary skills, and an opportunity would be provided for the students to transfer their theoretical knowledge into mental, dynamic, and social skills which are necessary in taking care of patients.[2]

Some of the most important parts of clinical trainings are comprehensive personal traits, mentor, educational environment, programming, and evaluation.[1] Evaluation is the heart of any educational program, but in nursing, for making sure of graduates’ competence, it is of special importance[3] and is considered one of the most important roles of the clinical teacher.[4] Through appropriate evaluation strengths and weaknesses of an educational program could be determined and by strengthening positive aspects and eliminating the shortcomings, competent students could be trained.[5] About students’ evaluation, Hessler and Humphreys addressed the new academic members and mentioned: “Students’ evaluation is an effective method in changing educational plans and designing educational courses in nursing and is considered an important information source to determine the educational quality.”[6]

One of the most common methods of evaluation in Iran is evaluation by the teacher. In this method, the clinical mentor, based on desired traits which could even be designed by themselves or determined by the educational group, would evaluate the students and give them scores at the end of their internship, but this method is usually accompanied with dissatisfaction. For example, according to the study by Imanipour and Jalili, 59.9% and 37.9% of professors were completely dissatisfied with the current evaluation method, and 79.6% of students believed that the current evaluation method would reflect teachers’ personal opinions about the students rather than students’ performance.[7] In the study by Elcigil and Yildirim also, nursing students believed that evaluation by clinical teachers has been one the most problematic experiences during their internship.[8]

Since determining an appropriate strategy for evaluation of students’ clinical competence is one of the most important responsibilities of educational institutes that provide nursing trainings, at the first step to reach this goal, it is necessary to assess the current condition of clinical evaluation of students. According to the researchers’ findings, most of the previous conducted studies were about the condition and problems of clinical trainings,[910] and studies that have been conducted on evaluation have reviewed the characteristics of clinical trainers,[1112] have generally studies the challenges of clinical evaluation from students’ point of view,[1314] or have studied the perception of nursing teachers from challenges of students’ clinical evaluation[15] but the challenges that students would face in evaluation by teachers, which is the most common method of evaluation in nursing system of Iran, have not been mentioned. Therefore, since students are the most significant sources for determining different issues and problems of this process, and on the other hand, qualitative study is a valuable approach for expressing life experiments and would help in understanding human experiences,[16] this qualitative study was conducted to express the experiences and views of nursing students about the challenges of teacher-based clinical evaluation.

Methods

This study was a descriptive, qualitative study with a qualitative content analysis approach. Content analysis is a research method for interpreting contextual data through systematic classification, coding, and identifying themes and patterns.[17] In qualitative content analysis, based on presumption and explanation, raw data would be interpreted, summarized categorized into classes and themes.[18]

Participants of this study were nursing undergraduate students of Rafsanjan University of Medical Sciences (RUMS). Inclusion criteria were as follows: (1) senior students at the last term of university, (2) able to give informed consent, and (3) able to communicate verbally. Sample selection was based on a purposive and census sampling method. The goals of the study were explained to the students and those who have inclusion criteria and were willing to participate in the study were asked to attend a group discussion meeting. Desired data were gathered through semi-structured focused group sessions using interview by recording voices. Focused group sessions were held by the first researcher/author. This method was selected for obtaining appropriate information as a result of participants’ interactions.

Data collection

After taking informed consent from the students, group sessions were held at a room that was specified for this matter with students’ agreement. Interviews were started with a general open question, “what is your experience of being evaluated during internship?”, and then, the interviews were guided toward clarifying ambiguous points and reaching more information. Some of the asked questions are “would you express your experience of being evaluated by the teacher during these past semesters? What is your opinion about this method of clinical evaluation?” What are the strengths and weaknesses of this method?”, “What do you think about this evaluation method?”. At the end of each focused group session, the researcher asked the participants to talk about anything that they considered important. Data collection and analysis were concurrent. As comparisons were made between two primary focused group and the evolving categories, interview questions were then focused on particular categories that required additional information. Data collection continued until no more new themes were emerging and the data reached saturation. From 30 students, 27 were willing to participate in the study, so 4 focused group sessions were held; each lasting from 60 to 80 min.

Data analysis

Data were analyzed using latent content analysis based on Graneheim and Lundman's proposed method.[19] This method is for analyzing narrative data which is conducted to determine the main themes and the patterns of those themes. In fact, the researcher is a commentator who studies the data to find meaningful parts, and after finding them, they would code, categorize, and organize the data. This process would continue until reaching a structure that could relate meaningful categories together. On this basis, in the present study, at first semantic units were determined, and then, related codes were extracted and similar codes were categorized in same subcategories. Subcategories were changes into categories, and eventually, themes were determined.

Ethical considerations

Ethical considerations of this study were getting permission for the study from nursing faculty and research and development center of RUMS, getting approval for the project from research chancellor and ethics committee of RUMS, (IR.RUMS.REC.1394.263), taking written informed consent from all the participants, keeping the names and information of participants confidential, justifying the participants about the study and its goals, considering the principles of confidentiality in publication of information and keeping them confidential, and freedom of participants in leaving the study at any desired time.

Rigor

For validity and reliability of the data, constant engagement with the subject and research data existed. Corrective opinions of experts about the process of interviews, their analysis, and extracted data were used. The context of interviews and extracted codes were shared with 2 expert colleagues in the field of qualitative studies, and their corrective comments were considered. Regarding the confirmability of the study, researchers tried to accurately record all of the performed activities including all the steps and the data. Transferability of the study was also evaluated through two individuals outside the study who had similar condition to the participants of the study.

Results

Participants of this study were 27 nursing undergraduate students. From the 27 students who participated in the study, 15 (55.5%) were female, and 12 (44.5%) were male. The mean age of participants was (21.70 ± 0.57) years. After data analysis, 3 categories and 1 main theme, which were named “factitious evaluation,” were extracted. “Personal preferences,” “unfairness,” and “shirking responsibility” were categories of the study which are discussed in follows.

Personal preferences

Participated students mentioned involvement of one-sided opinions of teachers in evaluation process and believed that teachers usually decide based on their personal preferences. In this regard, one of the boy students mentioned.

“During internship, teachers only decide considering whether the student has been late for a few minutes or not. On the other hand, they only consider one of students’ activities. For example, a professor has about 7–8 students in each ward and only sees whatever is right in front of them and decides on that basis.”

Another girl student also said:

“For example, sometime I had a confrontation with the professor early in the morning and that would change his/her behavior toward me until the end of the shift; or I had friends who did not study at all but the professor gave them good scores or they would cover up for themselves in a way that the professor would not realize it.”

As the answer to this question that “what are the problems of this method in your opinion?” one of the students said:

“In this evaluation method, the professor would accurately search for students’ faults, for example if a student has made just one mistake the professor would just consider that and the professor would decrease their score just because of that one mistake and because he/she did not like that student very much (laughing).”

Unfairness

Unfairness in giving scores was another challenge that was proposed by students; they believed that this method would not show the difference between the strong students and the weak students, and the scores are not real. In this regard, one of the girl students mentioned:

“I have seen some students I our own group that do not car for their work, they usually come late like 8:30 or 9 and even when they are on time they do not perform any specific activity, I tell this from my own experience, but the professors would consider all the students similar and score everybody on the basis of these students.”

Another student also said:

“During your internship you thought that you have been a good student and have performed all of your tasks well, but the professor would score you 16, why 16? It happens that when two students have been the same during their internship one is scored 16 and the other 17.”

Another boy student said that:

“Sometimes I ask my friend who had a score of 17 what have you done to get this score and they answer nothing, I have missed classes. In comparison to them I have done everything right but my score has been 11 or 12.”

One of the boy students confirmed his friends’ words during group session and mentioned:

“Usually at the end of the internship, professors would forget the numbers and score us unfairly. All of this time we have been given scores less than what we have really deserved. Everybody deserved a score of 15 or 16.”

Shirking responsibility

Another subject that all the students agreed on during group sessions was feigned nature of doing the homework. They believed that in this method, the professor would assign homework for students to give them score and they are obliged to do them but in most cases, homework are copied by students. In this regard, one of the boy students mentioned:

“One example of this method is the score of nursing process in writing. For example I should make up a process 3 months after my internship but the patient might be dead by then, so I go online or go to my friends and copy a process. But the correct way was for me to study and extract all the nursing measures to perform them on the 2nd or 3rd day of my internship and educate my patient. But this method is not executed and the professor would score those papers, even if you educate the patient, if you do not turn in the papers you would not get any score.”

One of the girl students in the group discussion added: “The processes that we would write are not useful at all, we have never seen anybody who works from their heart and write its process, they usually copy it from a book or internet, by searching online you could find thousands of processes and you could use one of them.”

Discussion

Based on the results of the present study, personal preferences, unfairness, and shirking responsibilities were the challenges that were proposed by students in teacher-based evaluation method. This evaluation method, which is also known as the traditional evaluation method, has been performed in most of the universities of Iran for many years. In the present study, participants believed that this method could accurately not reflect their capabilities. In the study by Hadizadeh et al. also 41% of students rated the evaluation method as bad.[20] However, the difference between this mentioned study, and the present study is that it was quantitative study, but the present study was qualitative and its results were derived from students’ experiences. In the study by Vaismoradi and Parsa-Yektaalso students used the term “unfair” for describing their experiences of the evaluation method.[14] In the study of Narenji et al. evaluation by teacher was mentioned to be one of the inhibiting factors for fair evaluation.[21]

Personal preferences were one of the extracted categories in the present study and students believed that professors’ preferences are more emphasized in this method and so they could make the evaluation unreal. In a quantitative study by Imanipour and Jalili, 79.6% of students believed that the current method of evaluation would reflect professor's personal opinion about the students not students’ real performance, which is similar to the results of the present study.[7]

Studies that have been conducted outside of Iran also have revealed that traditional clinical evaluation methods are mostly based on unorganized observations of professors and their personal preferences and are subjective.[2223] Participants in the study of Pazargadi et al. mentioned evaluation with personal preferences, predetermined scores, and effects of students’ characteristics and relations with the professor on evaluation and suggested that fairness was one of the most necessary matters in conducting evaluations.[12] Evaluation based on personal preferences was also one of the extracted categories in the study by Sabzevari et al. (which studied the challenges of clinical evaluation of nursing students from clinical teachers’ point of view.[15] Hence, it could be said that this matter is a challenge which has also been confirmed by the teachers, and it is necessary to eliminate this challenge using solutions or replacing other evaluation methods such as 360-degree feedback method that would evaluate students from different approaches.

Shirking responsibilities was another extracted category in this study and students believed that in this evaluation method, students also performed many of their duties superficially. Although different studies that have been conducted on evaluation methods have shown no such result, but this result could even be considered as the strength point of this study because one of the most important points of evaluation is learning, and we could recognize the strengths and weaknesses of our trainings through appropriate evaluation and move toward evolving and modifying the educational system by reinforcing positive aspects and eliminating deficiencies.[5] Therefore, according to the results of this study and other conducted studies in this field, changing the approach of evaluation from teacher-based evaluation toward modern methods of evaluation is suggested. One of the limitations of this study was limitation in generalization which is related to the nature of qualitative study. Choosing participants from one school of nursing in an urban area of Iran was another limitation. Therefore, it is recommended to conduct further qualitative studies among other majors.

Conclusion

Factitious evaluation is one of challenges of teacher-based clinical evaluation from nursing students’ point of view. The finding can help nursing instructors to get a better understanding of the nursing students’ point of view toward this evaluation approach and as a result could be planning for changing and modifying of this approach.

Financial support and sponsorship

This study was financially supported by Rafsanjan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.