Explaining the inhibitory characteristics of clinical instructors in the process of developing clinical competence of nursing students: a qualitative study.

BACKGROUND: Different inhibitory factors may play a role in the process of developing the students' clinical competence; among them, some of the characteristics of clinical instructors can be considered as the most important factors.
PURPOSE: The aim of this study was to determine the inhibitory characteristics of instructors in the process of developing clinical competence in nursing students.
METHODS: This qualitative study was conducted using the conventional content analysis. Seventeen senior nursing students were selected by purposive sampling method. Individual semistructured interviews were used to collect data. After recording and implementing the interviews, the content analysis was used to extract the concepts.
RESULTS: According to participants' experiences, the three themes, i.e. "autocracy," "low clinical competence," and "self-confidence weakness" were extracted as inhibitory features of clinical instructor in the process of developing the clinical competence of nursing students.
CONCLUSION: The findings of this study illustrate the characteristics of a clinical instructor, which play an important role in reducing the clinical development and lack of clinical competence development among students.

Introduction

Nowadays, competency, particularly the clinical competency, as a concept, continues to stimulate the debate and discussion among practice disciplines and remains a key topic of interest in healthcare disciplines, such as nursing.[12] Because dynamic and uncertain nature of healthcare environment such as demographic changes of the population, increasing the technological advancements,[34] and increasing the prevalence of chronic illnesses and disabilities requires the competent professional nurse to manage the rapidly changing environment.[56]

Clinical competence in nursing is difficult to define and there is no standard definition of the concept.[7] Various regulatory bodies have attempted to define the clinical competence, as follows: The United Kingdom-based Nursing and Midwifery Council defines clinical competence as “the overarching set of knowledge, skills and attitudes required to practice safely and effectively without direct supervision.”[8] The Nursing and Midwifery Board of Australia defines the clinical competence as “a combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a professional/occupational area.”[9]

The nursing literature continues to raise the concern regarding both the retention of the knowledge and skills acquired by nursing students, and the standard of competency in clinical skills among the newly graduated nurses.[101112] According to studies, clinical competency of new graduates has been identified as an area with statistically significant deficiency in nursing education.[1314] There are several factors involved in this issue, the most important of which is the inadequacy of some of the clinical educators.[1516] In the study of Sajadi et al., One of the most important barriers to the acquisition and development of expected clinical competencies in new graduate nursing students during the course of study was the Inefficiency of the clinical instructor.[17] In the study of Pourghane, the inefficiency of clinical instructors as one of the unfavorable experiences of clinical education was expressed by nursing students.[18]

Clinical instructors play a vital role in the acquisition of nursing students’ clinical competence.[19] Clinical instructors are responsible for how to apply theoretical content to the clinical practice of nursing students and gain clinical experience, and their clinical growth and excellence. In addition to conducting the educational activities, clinical instructors are responsible for creating a sense of autonomy, decision making, and increasing the power of creativity in students in various clinical settings.[20] Therefore, it seems necessary to determine the clinical instructor's characteristics that are playing an inhibitory role in the process of developing students’ clinical competence. Identifying these characteristics can provide proper guidance for doing the job for clinical instructors and, as a result, development of nursing students’ clinical competency.

Method

This qualitative study was conducted using a conventional content analysis approach from May 2017 to July 2018 until the data saturation and lack of the presence and access to a new class or code. The purpose of the content analysis method is to provide the knowledge and a deeper understanding of the studied phenomenon.[21]

Participants

In order to reach a wide range of experiences, views and maximum variance in data, 17 senior students of nursing who had a high, moderate, and low Grade Point Average (GPA) compared with the other subjects were included in the study using the purposive sampling method [Table 1].

Table 1

Demographic characteristics of the study participants

Participant no.	Age (years)	Gender	Semester
P1	23	Male	Eighth
P2	22	Female	Eighth
P3	23	Male	Eighth
P4	22	Male	Eighth
P5	23	Female	Eighth
P6	23	Female	Seventh
P7	22	Male	Seventh
P8	23	Female	Eighth
P9	23	Male	Eighth
P10	23	Female	Eighth
P11	22	Male	Seventh
P12	22	Female	Eighth
P13	21	Female	Seventh
P14	21	Male	Seventh
P15	22	Male	Seventh
P16	23	Female	Eighth
P17	24	Male	Eighth

Collection and analysis of data

Semistructured interviews were used to collect the data. Interviews were conducted in a private and quiet place which could provide the greatest comfort and satisfaction for the participants. The interview with students was conducted in the interview room at the Faculty of Nursing. At the beginning of the interview, the researcher asked some questions to become more acquainted with the participants, as well as to create an intimate and lack of tension atmosphere. Then, the specific questions that were in line with the purpose of the research were asked. Participants were asked which characteristics of the clinical instructors, that had an inhibitory role, have been experienced by them during the development of their clinical competence. In order to ensure about the recording all of the participants’ statements, the researcher, by obtaining their consent, used an audio recorder during the interview. Each interview session lasted an average of 45 min.

Content analysis was used to analyze the data according to Graneheim and Lundman.[22] Graneheim and Lundman suggest the following steps for analyzing the content of qualitative data: 1) implementing the entire interview immediately after conducting any interview, 2) reading the entire text for the comprehensive understanding of its content, 3) determining the meaning units and elementary codes, 4) classifying the similar elementary codes in the more comprehensive classes, and 5) determining the main theme of the classes.

After each session, the content of the recorded interviews was carefully inscribed on the paper after several times listening. After accurate reading the contents, the meaning units were identified and coded. At this stage, the codes were generated as in vivo codes and implicit codes. Then, the codes were merged and classified according to similarities. It was tried to provide the most homogeneity within the classes and to provide the greatest heterogeneity among the classes. Data were classified using 10 R250412-MAX.Q DA software. Finally, three themes were obtained from the analysis of the data.

Ethical considerations

Prior to start the study, after obtaining the approval from the Regional Ethics Committee for Medical Sciences (with the ethics code: IR.UMSHA.REC.1396.113), the researcher, after introducing himself and explaining the research objectives to the participants, in order to observe the ethical considerations, received the written consent from all the participants, and assured that the information obtained would remain confidential.

Rigor

Goba and Lincoln have proposed four criteria, i.e. credibility, transferability, conformability, and dependability for the accuracy and robustness of qualitative data.[23] In this study, the validity and credibility of the data, in addition to long-term engagement with the data and spending enough time on collecting and analyzing the data, were evaluated through peer review and member-check methods. For this purpose, the content of the interviews was independently coded and classified by the research team, and then the obtained patterns were compared with each other. When there was no agreement on a pattern, the consensus about that pattern was obtained through the discussion among the aouthors. In the peer review method, the encoded content was returned to four contributors to examine the compatibility of the selected code with their experiences. Transferability was also examined by verifying the information obtained by two persons, who have not been included in the study and had similar situations to the participants in the study. To evaluate the conformability, the researcher systematically recorded and reported the research process and the path of the decisions, and provided the opportunity to follow up the research for others. To investigate the dependability, the external observer method (two nursing professors from other universities who were expert in context of qualitative reaserches) was used to examine the similarity of their perception with the researcher and to determine the contradictory items.

Findings

Based on participants’ experiences, three themes of “autocracy,” “low clinical competence,” and “poor self-esteem” emerged as inhibitory features of clinical instructors in the process of developing the clinical competence of nursing students [Table 2].

Table 2

Themes, sub-themes, and the codes forming the inhibitory features of Clinical Instructor

Autocracy	Inappropriate behavior with students	Humiliation of the student in front of others
		disrespect to the students
	Lack of accepting the criticism	Lack of being open to criticism
		Insist on proving own knowledge, opinion, and ideas
	Confining the students authority	Creating the fear in students
		Eliminating the opportunity to independent experiences in students
	Suppression of student creativity	Excessive sensitivity to book rules
		Emphasis on compliance with the order of the work with details
Low clinical competence	Subjectivism	Excessive focus on the conference
		Tendency to theories in clinical education
	Lack of mastery of science and practice of nursing	Inability to apply the theoretical knowledge
		Lack of the clinical trial experience
		Inadequate knowledge of the department and clinical environments
		Weakness in performing technical skills
	Low commitment in teaching	Lack of spending enough time and energy
		Ignoring the educational goals and needs
		Lack of sharing the educational resources
	Routine-based education	Focusing on the routine skills
		Lack of training the practical issues
Poor self-esteem	Existence of fear	Fear and anxiety caused by inexperience
		Fear of an error occurrence
	Low self-esteem	Lack of confidence
		Lack of enough courage

Autocracy

This inhabitory feature has extracted from four subcategories: “Inappropriate behavior with students,” lack of accepting the ctiticism, limitation of student independence, and suppression of student creativity.

Inappropriate behavior with students

Based on the experiences of the participants, the disrespect to the students and being humiliated by master in in front of others (students, departmental staff, patients, and their accompanies) have mentioned as one of the most unpleasant experiences when a mistake or problem is observed in caring performance of the students.

” If a student fails to insert an IV (intravenous) cannula (venipuncture) properly and cause damage to the patient in this procedure (especially rupture of a vein during the procedure, haematoma), or during the dressing procedure, he/she will not unwittingly observe the sterilization, Clinical instructor do not respond well to this error, and this inappropriate reaction often occurs in front of the patient, while the clinical instructor can approach it appropriately and rationally. This can lead to the destruction of student's self-confidence.” (P7)

Lack of accepting the criticism

Many students believed that the instructors are not open to criticism during the scientific debates. In the meantime, some of the instructors come down heavily on any criticism when they feel it.

” Unfortunately, I had an argument with a clinical instructor who was not well-educated. He told us that “I am author of a pharmacology book which was published in 2002” and apparently he was proud of herself, but surprisingly he say that” fluoxetine and ciprofloxacin are the same drugs”. I told him that” you are not right, Sir. According to the pharmacology books and references, not only are they not the same drugs but also they are completely different.”When he found himself in trouble, He sent me to another ward to dress patient's woud as a punishment. He punished me while I was right and the students were witness to what he did to me ” (P3)

Confining the student's authority

Based on the experiences of some participants, some of the instructors provided the situation for the excessive dependence of students to the instructor and the fear in them toward the independent meet of clinical trials by scaring students due to fear of legal consequences, lack of sufficient confidence, or skills.

” You know, some instructors had a negative attitude towards learning clinical skills and unfortunately, they deterred us from learning these skills, for example, when we request them to let us perform some clinical procedures such as IV cannulation or Urinary catheterization, they told us that” you don’t have liability insurance and if you would have an error while you are performing the procedure or a side effect happens, especially when it causes damage to the patient, He/She will complain about it and you have to compensate him/her for damaging them.”

” There has been an instructor who did not let me insert the IV cannula while I was able to do that. Instead he/she did it and hurt the patient (he ruptured the vein wall) “(P4)

Suppression of student creativity

Participants considered the excessive sensitivity of instructor on the book rules as the barrier to developing the thought to define the alternative solutions when confronted with challenges in the real world of nursing.

” One of the instructors asked students to perform clinical procedures based on theoretical references and she also insisted on it, but in medical sciences, the theoretical and clinical science are far apart, and this is a general rule. This causes problems in the area of clinical practice. For instance, drug references mention that a drug should be drawn and injected with an insulin syringe, instead the nursing staff use 2 ml syringes. “(P1)

”Clinical instructors insist on implementing the clinical procedures such as IV cannulation etc., precisely in the order and manner of theoretical references, and this is certainly a fundamental principle. however, compulsion to performing these procedures precisely according to the theoretical references leads to the lack of creativity and innovation in clinical skills.”(P4)

Low clinical competence

This feature has extracted from the “Subjectivism,” “Lack of mastery of science and practice of nursing,” “Low commitment in teaching,” and “Routine-based education.”

Subjectivism

The concepts such as excessive concentration on the conference and the tendency to theory in clinical education were a clear demonstration of subjectivism in some clinical instructor. Many students complained about the loss of the time of clinical education through the frequent theoretical conferences that are considered by their instructors.

”The majority of clinical instructors insist on presentation of theoretical conferences in the area of clinical practice, and it has become a routine habit. While the students have passed the theoretical courses and there is no need for repeating these topics in the area of clinical practice. it is a waste of time for students to acquire clinical skills.” (P15)

Lack of mastery of nursing practice

This sub-theme includes the concepts such as lack of clinical experience, inability to apply the theoretical knowledge, inadequate knowledge of the department and clinical environments, and weakness in performing technical skills. Many of the participants mentioned that having a nursing work experience is considered as one of the most important requisite for instructors to acquire the competence to be the master and instructor of nursing, and they were complaining about the presence of an instructor who was not familiar with the clinical environments that did not have sufficient mastery of nursing practice.

”Unfortunately, some of the professors and clinical instructors do not have sufficient clinical experience and they just rely on their theoretical knowledge while they do not have much knowledge about clinical theories and skills. These instructors do not have the competence and ability to instruct the clinical skills accurately and truly. “ (P1)

” I witnessed that one of the clinical instructors failed to insert an IV cannula (venipuncture) properly and cause damage to the patient, He/She ended in dismal failure. Can a student trust a instructor with insufficient clinical skills like this? “(P9)

Low commitment in teaching

Based on the participants’ experiences, it was found that some instructors, by neglecting the students’ educational goals and needs, oversimplification of the clinical education and leaving their students, do not spend enough time and energy for students’ clinical education.

”Some clinical instructors are not keen on instructing clinical and theoretical sciences. They leave students on their own and do not supervise the students’ clinical skills acquisition properly.”(P6)

”Some instructors are not able to recognize the students’ level (beginner or advanced) and they are not informed about the educational and clinical purposes of each semester. However, these are some essentials that every clinical instructor has to know and be informed about. He/She should instruct and help students to obtain the related and necessary skills of each semester.” (P3)

Routine-based education

This sub-theme includes the concepts such as focusing on routine skills and lack of training the practical issues. Many students believed that instructors’ emphasis was greatly on routine nursing topics.

”Some instructors restrict nursing just to clinical science and skills, and this leads to a lack of academic and theoretical knowledge. In addition to instructing the clinical skills, instructors should also emphasize the acquisition of theoretical knowledge.” (P1)

Poor self-esteem

This inhibitory feature has been extracted from the two sub-themes: “Existence of fear in the instructors “ and “Low Self-confidence of instructors.”

The existence of fear in instructors

This sub-theme includes the concepts of fear and anxiety caused by lack of ability and fear of occurrence of a mistake. During the attendance in clinical practice and performing patient care skills, the instructors, who had less experience in nursing clinical practice, became fearful, anxious, and worried about the possibility of a mistake or a problem for the patient in carrying out the caring activity by themselves or by students.

”To conduct the correct and complete clinical procedures, especially invasive procedures, having self-confidence is an important key. Many instructors do not have the courage and confidence to perform clinical procedures well and truly. While the high experienced nurses are not the same and they are self-confident. “(P4)

”In many cases, instructors forbid the student from performing clinical procedures because of some reasons such as patient agitation and drowsiness. These reasons are an excuse, and in actual fact, they are afraid of an unpleasant incident for patient while he/she is undergoing clinical procedures.” (P 5)

Low self-esteem of instructor

This sub-theme includes the concepts of lack of confidence and insufficient courage. The lack of self-confidence and the fear caused by that during the clinical work was one of the issues that, by the negative effect on their self-confidence, leads to the lack of clinical skills expected in the students.

” Some instructors have very low self-esteem and lowers the student's self-esteem also. An instructor with high self-esteem can boost his/her students’ self-esteem.” (P5)

Discussion

The findings of this study illustrate the characteristics of a clinical instructor, which play an important role in reducing the clinical development and creating the lack of clinical competence development of students. The existence of autocratic behaviors was one of the factors that many students described as one of the instructor's inhibitory features in their development process of clinical competence, which was associated with the lack of motivation, disappointment toward the nursing, isolationist behaviors, and escaping the clinical situations in students. In the study conducted by Braz et al., the nasty, rough, inappropriate behaviors of instructors with students, and lack of accepting the criticism among them reported as one of the obstacles to clinical learning by students.[24] Cowan et al. also described that the bad behavior of clinical instructors was one of the sources of fear and anxiety among nursing students in a clinical setting.[25] Loffmark and Wikblad stated that learning processes cannot progress well when students are faced with such behaviors and it will result in the loss of time or energy.[26] Confining the student's authority and suppression of student creativity was one of the other inhibitory features of an autocrat instructor. Applying the magisterial rules and the one-way relationship between instructor–student created an incompatible area with the principles of nurturing care behaviors and the development of clinical competence of nursing students.[2728]

In this study, subjectivism, lack of mastery in science and practice of nursing, low commitment to teaching, and routine-based education were a clear demonstration of low clinical competence, which had an inhibitory role in the process of developing the clinical competence of students. Nursing is a practice-based discipline[29] and the training of qualified students is not possible without regard to nursing practice.[30] Subjectivism and the concentration of clinical instructors on theoretical issues lead to the marginalization of nursing practice and clinical inefficiency of students. In the study conducted by Gholami et al., more than half of the students considered the excessive concentration on the theoretical issues in clinical education as a barrier to their clinical development.[3132] The findings of the Yazdan nik et al. also confirmed the fact that most of nursing clinical instructors mostly emphasize on theoretical education, so that most of their clinical education time is focused on lectures and theoretical discussion without direct involvement in patient care.[33]

Various studies indicated the insufficient knowledge, low clinical experience, and lack of adequate clinical proficiency in conducting procedures in the hospital environment as the student's usual criticism.[113435] In the study of Rostami et al., 94.5% of the students reported that the scientific and practical competence of instructors is inappropriate.[36] In Reising et al., Students also described the inadequate knowledge and practical skills of clinical instructors as one of their clinical experience problems.[37]

The low commitment of the instructor in teaching was one of their inhibitory features, which was described by students. An instructor with such characteristics cannot direct the students to independence in practice and cannot reduce their anxiety and fear in the clinical setting. The sense of responsibility of the instructor toward the education of the students can be somewhat searched in personality type, which, by interviewing and carefully selecting the instructors, can be possible to choose the instructors who are interested in their work and have sufficient motivation for student clinical education.[38]

The results of this study revealed that summarizing the nursing in the insertion of IV or serum and injection by the instructor is led to repeating a series of routine nursing practices throughout the clinical education. Many students considered the clinical education as a series of routine tasks that it did not meet their educational needs.

Self-esteem, one of the effective characteristics of clinical instructors, is a result of the instructor's skill and expertise in the field of teaching.[39] In this study, many students consider the self-esteem and courage of instructors as an important factor in the creation of their self-esteem in doing the clinical trials. In the meantime, the instructors with low self-esteem caused the students’ anxiety and fear in the clinical setting, which consequently results in a defective bed for the collapse of self-esteem and development of clinical competence of the students.

Study limitations

The dependence of the results of the research on time and location conditions is one of the limitations of qualitative studies,[40] which this study is not excluded from this governing rule.

Conclusion

The clinical instructors have a significant importance in improving the clinical competence of the nursing student. However, the characteristics such as autocracy, low clinical competence, and weak self-esteem in clinical instructors, in addition to their ineffectiveness, have an inhibitory role in the formation and development of clinical competence of the nursing students as an underlying factor. It is hoped that the results of this study could be a useful guide for clinical instructors for developing the students’ clinical competence.

Financial support and sponsorship

This study was supported by Vice Chancellor of Research and Technology of Hamadan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.