Comparing the Relationship between Iranian Clinical Educators' Teaching Behaviors and Undergraduate Nursing Students' Professional Behaviors.

Background: The effectiveness and efficacy of teaching behaviors by clinical educators need to be determined and applied in caring environments, wherein students' seminal Professional Behaviors (PBs) are being shaped. Here, we endeavor to compare the relationship between Iranian clinical educators' teaching behaviors and undergraduate nursing students' PBs. Materials and
Methods: This descriptive correlational study was conducted on 189 students enrolled in the second, third, and fourth academic years at Urmia University of Medical Science in 2019. The instruments were the Nursing Students' PBs Scale (NSPBS) and the Nursing Clinical Teacher Effectiveness Inventory (NCTEI). Data were analyzed by Pearson correlations test and linear regression model.
Results: A significant positive correlation between the NSPB and NCTE in the fourth year (r = 0.42, p = 0.001) was about twice as much as the second (r = 0.28, p = 0.017) and third ones (r = 0.28, p = 0.033). Nursing competency, teaching skills, and communication domains were respectively the most effective ones related to the second- (r = 0.35, p = 0.003), third- (r = 0.32, p = 0.015), and fourth-year NSPBs (r = 0.46, p < 0.001). Teaching skills and nursing competency domains had the lowest significant relationships with the second- (r = 0.25, p = 0.034) third- (r = 0.30, p = 0.023) and fourth-year NSPBs (r = 0.35, p = 0,006), respectively. Conclusions: The comparison between the two mentioned variables in the academic year can provide appropriate information about potential problems of clinical education to develop clinical facilitation models. Copyright:

Introduction

With respect to the scientific nature of nursing, special emphasis is typically placed on clinical learning in a well-designed format.[1] The effectiveness of clinical education for nursing students in all countries, matching the characteristics of each community, also requires fundamental changes to enhance management status and to create opportunities for a platform-standardized evaluation.[2] After the Islamic Revolution of 1979, nursing education in Iran shifted from an internship model to an academic model. The progress in training nurses demanded the establishment of better principles to ensure that competent nurses would continue to improve their professional performances.[3] Thus, the proper training of nursing students in clinical environments, where they can acquire their significant clinical experiences, is a critical component of nursing educational curriculums. Clinical education should thus help nursing students attain the necessary professional skills during their training.[4] In this regard, nursing educators play a crucial role in the successful clinical education of students as they link theory and practice along with their educational, scientific, and accountability experiences.[5] In this process, various sociocultural, political, scientific, and technological factors may impede professional development and even behaviors in nursing students.[6] Recent studies have shown that educators' characteristics are one of the most important barriers to clinical education[7] and that the current clinical education fails to provide adequate flexibility for students' clinical competence.[8]

Competence as a behavioral characteristic can be developed based on individual interests and experiences affected by students' motivation and attitudes in clinical and educational settings. In addition, the main impacts of the mentioned parameter reflected in the principal skills of a person are professional responsibilities, autonomy, awareness of limits, explanation of nursing care standards to patients, respect for patients' rights, promotion of life-long learning, and maintenance of up-to-date knowledge and skills.[9] According to Yamani et al., teaching the principles of Professional Behaviors (PBs) by the relevant educators during educational programs has led to the great success of students in various areas of vocational education.[10] Research has also revealed that ignoring students' non-PBs is likely to create a culture of acceptable behaviors and cause inefficient communication in clinical environments.[11] In this sense, both students and educators were blamed for devaluating these professional principles[12] due to the failure of ethical codes related to clinical nursing education.[13]

Despite the delineation of perceptible features of an effective clinical educator, there are some performance gaps related to the inadequate professional preparedness of nursing graduates,[814] which may, over time, result in negative consequences, such as their burnout, reduction or loss of motivation and satisfaction toward their profession, and threats for nursing community and clients.[15] On the contrary, students should be endowed with enough capacities to develop proper behaviors during educational processes. Based on documented evidence, limited studies have been conducted in Iran till date, wherein the mentioned variables have been examined and described separately.[1016] As a result, comparing the relationship between educators' clinical teaching behaviors and professional behaviors demonstrated by undergraduate nursing students in different academic years can help professional values and practices in clinical environments and, consequently, provide an efficient platform for planning future goals. Hence, this study was conducted to compare the relationships between Iranian clinical educators' effective teaching behaviors and undergraduate nursing students' PBs.

Materials and Methods

This descriptive correlational study was conducted at Urmia University of Medical Sciences, Iran between October and December 2019. In total, 189 nursing students enrolled in the second (3rd and 4th semesters of study), third (5th and 6th semesters of study), and fourth academic years (7th and 8th semesters of study) were investigated through the census sampling method.

Based on the literature published in the English language for bachelor nursing students' perception toward effective clinical instructor's characteristics in the different regions,[517] the main criteria for inclusion were as follows. A minimum of two successful clinical internship credits (55-h credit over 3 weeks for each clinical internship of the curriculum) with the care of one patient under the direct supervision of expert clinical educators, and exposure with at least five clinical educators to gain experience in hospital settings. The first clinical internship, entitled Medical-Surgical I, was conducted with a care plan and management of 1–2 patients per week, (including medical history, physical assessments, and specific nursing skills). The internship of Medical-Surgical II was completed by the theory of the same name in different units of the hospital (obstetrics, emergency, critical care, mental health, and community health clinical) based on the clinical rotation of the curriculum. First-year students were excluded due to the lack of hospital training experience to assess clinical instructor behaviors in the clinical environment. The unwillingness of the students to remain in the research and the incomplete questionnaires were considered as exclusion criteria. Among 200 eligible nursing students, 11 refused to fill out the relevant questionnaires for personal reasons. Of these 189 participants, 70, 58, and 61 students were from the second year, third year, and fourth year, respectively. After the agreement and consent of the faculty members, the data were collected face-to-face during the last day of the internship in 20 min in a quiet educational setting of the hospitals working second, third and fourth-year students. Moreover, due to the length of the questionnaires, they were able to individually deliver the questionnaires on the first day of the next internship to the project researchers.

Data collection tools administered in this study included the Demographic Characteristics Information Sheet (DCIS), the Nursing Clinical Teacher Effectiveness Inventory (NCTEI) by Knox and Mogan (1985),[17] and the Nursing Students' Professional Behavior Scale (NSPBS) by Goz and Geckil (2010).[18] The DCIS contained the parameters of age, the overall Grade Point Average (GPA), gender, marital status, clinical work experience, residential status, having a nurse in one of their relatives, as well as interest in the nursing profession.

The NCTEI was also a self-administered research instrument consisting of 47 items, scored based on a seven-point Likert-type scale (never using = 1 to always using = 7). There are five subscales in this scale: teaching ability (17 items), nursing competence (nine items), evaluation (eight items), personality (seven items), and interpersonal relations (six items). The highest and lowest scores in the questionnaire were equal to 329 and 47, respectively. The results were additionally reported based on the mean score of each sub-scale. The Content Validity Index (CVI) and the Content Validity Ratio of the NCTEI were respectively confirmed to be over 0.70 and 0.99 by 20 faculty members of Shiraz Nursing and Midwifery School. Cronbach's alpha coefficient was additionally used to determine the reliability of the entire scale, as well as the subscales of teaching ability, nursing competence, evaluation, personality, and interpersonal relations, and the obtained values were in the range of 0.87–0.95.[2]

The NSPBS developed by Goz and Geckil (2010)[18] comprised 27 items with a five-point Likert-type scale (never true = 1, always true = 5), wherein the lowest and the highest possible scores would be 27 and 135, respectively. In general, the stratified levels of professional behavior for nursing students could be designated as low (27–44.99), medium (45–89.99), and high (over 90). The content validity of the English versions of the NSPBS had been assessed in the preceding Iranian study. Face validity of Persian versions was tested during the translation process in the cognitive interviews. Therefore, the CVI of this scale (~0.81) was confirmed by 12 faculty members of Tarbiat Modarres University. Its reliability rate was calculated to be 76% according to Cronbach's alpha.[19]

Data were analyzed by SPSS software (version 16.0, SPSS Inc., Chicago, IL, USA) using descriptive statistics (frequency, percent, mean, and Standard Deviation (SD)) to determine the NCTE and the NSPB, the Kolmogorov–Smirnov test for normality, the statistic tests of one-way ANOVA, Chi-square test, Fisher's exact test, and Linear regression model with the significance level of p < 0.05.

Ethical considerations

After obtaining approval of the Ethics and Student Research Committee of Urmia University of Medical Sciences (Approval code: IR.UMSU.REC.1398.196), written informed consent was obtained from the participants before participating in the study. Additionally, research aims and procedures were thoroughly explicated to the participants while they were allowed to withdraw from the study at any possible stage. Next, all nursing students filled and signed informed consent.

Results

Among 200 students, 11 nursing students refused to take part in this research for personal reasons. Finally, 189 participants (94.5% response rate) completed the questionnaires; 70, 58, and 61 nursing students were enrolled in the second, third, and fourth academic year, respectively. The mean (SD) scores of students' age and overall grade point averages were 22.59 (1.75) and 15.93 (1.44), respectively. The majority of participants in the third and fourth year except for the second ones were male (55.22% and 57.40% vs. 41.40%). There were statistically significant differences between the groups in terms of age (p < 0.001), interest in the nursing profession (p = 0.001), and residential status (p = 0.005) [Table 1].

Table 1

Comparison of demographic characteristics of nursing students in three academic years (n=189)

Variables		Year of study			Statistics of test	df	p
		Two (n=70)	Three (n=58)	Four (n=61)
Age, mean (SD*)		21.81 (1.37)	22.56 (1.21)	23.52 (2.11)	F=18.41	2	<0.001
GPA**, mean (SD)		16.07 (1.10)	15.91 (0.98)	15.78 (2.05)	F=0.64	2	0.529
Gender, n (%)***	Female	41 (58.60%)	26 (44.80%)	26 (42.60%)	χ2=3.96	2	0.138
	Male	29 (41.40%)	32 (55.20%)	35 (57.40%)
Marital status, n (%)	Single	63 (90%)	56 (96.70%)	55 (89.10%)	χ 2=4.46	2	0.245****
	Married	7 (10%)	2 (3.40%)	6 (9.80%)
Clinical Work Experience, n (%)	Yes	13 (18.65%)	5 (8.60%)	11 (18.03%)	χ 2=2.92	2	0.232
	No	57 (81.45%)	53 (91.40%)	50 (81.96%)
Interest in the nursing field, n (%)	Yes	20 (28.60%)	34 (58.60%)	25 (40.98%)	χ 2=14.92	2	0.001
	No	50 (71.40%)	24 (41.40%)	36 (59.02%)
Being a nurse in their relatives, n (%)	Yes	20 (28.60%)	16 (27.60%)	16 (26.65%)	χ 2=0.09	2	0.956
	No	50 (71.40%)	42 (72.40%)	45 (73.85%)
Residential status, n (%)	At home	31 (44.28%)	12 (20.68%)	14 (22.95%)	χ 2=10.61	2	0.005
	In dorm	39 (55.72%)	46 (79.32%)	47 (77.05%)

*SD: Standard deviation, **GPA: The overall grade point average, ***n (%): Number (percentage), ****Fisher’s exact test

The mean score of the NCTEI in third-year students was higher than that for the second- and fourth-year students; however, the mean score of the NSPB in the fourth academic year was higher than that for the other years. In addition, the PB levels of the groups were high. Nevertheless, there were no statistically significant differences in the abovementioned variables among the groups (p > 0.05) [Table 2].

Table 2

Comparison of the mean (SD) scores of the Nursing Clinical Teacher Effectiveness (NCTE) and the Nursing Students’ Professional Behavior (NSPB) among the groups

Variables	Year of study			F	df	p
	Two	Three	Four
The NCTE, Mean (SD)	209.65 (58)	214.16 (38.84)	203.16 (50.32)	0.72	2	0.484*
The NSPB, Mean (SD)	109.04 (14.04)	108.65 (12.66)	110.80 (16.12)	0.387	2	0.680*

*One-way ANOVA

Regarding the results presented in Table 3, the positive correlation coefficient (r) between the NCTE and NSPB is statistically significant in the three groups (r = 0.42, p = 0.001). The higher and lower mean scores of PBs in the second academic year were respectively related to nursing competence (r = 0.33, p = 0.003) and teaching ability subscales (r = 0.25, p = 0.034), whereas these relationships were reversed in the third year (r = 0.30, p = 0.023 and r = 0.32, p = 0.015). Moreover, the domains of communication and professional competence respectively had higher and lower relationships with the NSPBs in the fourth year (r = 0.46, p > 0.001 and r = 0.35, p = 0.006) [Table 3].

Table 3

Comparison of correlation between the subgroups of the Nursing Clinical Teacher Effectiveness (NCTE) and the Nursing Students’ Professional Behavior (NSPB) in the three groups

The subscales of the NCTE	Year of study
	Two			Three			Four
	Mean (SD)	r*	p	Mean (SD)	r*	p	Mean (SD)	r*	p
Teaching Ability	84.24 (20.30)	0.25	0.034	84.37 (13.07)	0.32	0.015	81.27 (19.69)	0.39	0.002
Nursing Competence	37.81 (11.08)	0.33	0.003	39.40 (6.91)	0.30	0.023	37 (9.51)	0.35	0.006
Evaluation	33.08 (11.08)	0.35	0.007	34.03 (7.52)	0.22	0.093	31.27 (9.54)	0.37	0.003
Interpersonal Relations	25.18 (8.98)	0.21	0.077	25.96 (5.43)	0.23	0.080	25.31 (7.62)	0.46	p<0.001
Personality	29.32 (10.11)	0.18	0.140	30.20 (6.24)	0.09	0.458	28.29 (8.36)	0.37	0.004
Total	209.65 (58.00)	0.28	0.017	214 (34.84)	0.28	0.033	203.16 (50.32)	0.42	0.001

*Pearson Correlation test

According to Figure 1, the correlation coefficient of fourth-year students PB with NCTE was 0.194 (r2 = 0.28) and 0.176 (r2 = 0.08), respectively. These findings indicate that more than twice the PB of fourth-year nursing students (17.61%) compared to second-year students (8.10%) can be explained using the instructors' influential behaviors variable [Figure 1].

Figure 1

Comparing the scatterplot figure of the correlation between the Nursing Clinical Teacher Effectiveness (NCTE) and the Nursing Students' Professional Behavior (NSPB) in the second, third, and fourth academic years

The results of the analysis of variance have been presented to validate the regression analysis. Considering the F values and the presented significance level, it could be stated that the results of the regression analysis are valid and significant (R2 = 0.38, F188= 21.61, p < 0.001).

Discussion

The aim of this study was to compare the association between effective clinical teaching behaviors and the NSPBs in three academic years. Clinical training categories as practical methods of clinical principles provide a broader perspective on the overall utilization of these behaviors than the exclusive response elements.[20] Even with the high levels of PBs in the study groups, the students enrolled in the third academic year reported that clinical educators had exploited more effective teaching behaviors in clinical conditions. However, they were not significant in the present study. These results had been further confirmed by several investigations.[2122] However, Lovrić et al. (2017)[16] in Croatia found that the mean effectiveness of clinical educators' teaching behaviors in the second and third academic years had been statistically higher than that in the first one. The mentioned studies in different regions produced very different estimates about such behaviors.[16202122]

Based on the results of this study, nursing competency, teaching skills, and interpersonal communication by the clinical educators were strongly correlated with the NSPB in the second, third, and fourth academic years, respectively. However, teaching skills, nursing competency, and interpersonal communication domains had the weakest relationships with the PBs in the second-, third-, and fourth-year students, respectively. The students enrolled in the second and fourth academic years also had similar expectations about evaluation. The findings of this study are partly consistent with those of other investigations.[102324] Nevertheless, Lovrić et al.[25] found that nursing students enrolled in the first academic year had more emphasized than the second-year counterparts on teaching skills, evaluation, interactions with patients, personality, and interpersonal communication. In addition, in Jamaica, the second-year nursing students had correspondingly classified interpersonal and teaching skills as the most focal behaviors, while only third-year nursing students had emphasized evaluation practices and professional competence as the most significant behaviors. Personality traits were identified in both groups of nursing students as the least important characteristics among clinical educators.[26] These findings might stem from the fact that the second-year students were at an early stage and their last-year counterparts were at the end of defining their competencies, which would affect their overall perceptions of the importance of educators' competencies.

There were some limitations in the study despite the measures taken to ensure its rigor. First, the current study was conducted with a limited number of nursing students in a small region in Iran. Thus, we should be careful in interpreting and applying the generalization of the findings to nursing programs in other countries. Hence, we suggest that a large-scale repetition study with a large sample size should be conducted to generalize the study results on a standard scale for separate implementation procedures. Second, based on the literature review, the mentioned variables were separately investigated in all nursing groups without comparing students' different academic years. This underlines the need to repeat the study and include alternative nursing programs and different levels of students. Finally, the mental state of the participants might affect their responses while completing the questionnaires. To prevent fatigue and intolerance in this process, the students completed the questionnaires in a quiet class in the hospital setting.

Conclusion

From the conducted research, we conclude that there are specific and clear differences in the correlation between clinical teachers' effective behavior and the PB among second-, third-, and fourth-year undergraduate nursing students. While the nursing teachers should be able to model, teach, and assess effective student behavior, the school may not have the appropriate skills and guidelines to do so. Because of the critical collaboration of the perceived clinical behavior that instructors create in the integrated functions for the competencies of participants, our findings can provide a suitable framework for refining high standards of clinical behavior in the different years of nursing students. Indeed, it can impressively put forward a high satisfaction and constructiveness in nurse programs. To sum up, the current results point to the need for continuous monitoring, evaluation, and training by the clinical faculty to certify that the clinical training process is the most important. Quality education is a precondition for ensuring the quality of clinical practice and patient safety, which are priorities in daily health care.

Financial support and sponsorship

Urmia University of Medical Sciences

Conflicts of interest

Nothing to declare.