Copyright © eContent Management Pty Ltd. Contemporary Nurse (2013) 45(2): 174–181.
Effectiveness of clinical teaching associate model in nursing education: Results from a developing country ZAHRA RAHNAVARD, ZAHRA HOSSEINI NODEH AND LADAN HOSSEINI Community Health Nursing Department, Tehran University of Medical Sciences, Tehran, Iran
Abstract: Background and objectives: The credit of the practice nurses in developing countries, due to a gap between theory and practice in nursing education and healthcare delivery, has been questioned by nursing professionals. Therefore, the aims of this study were to investigate the effectiveness of the application of the clinical teaching associate (CTA) model in nursing students’ clinical skills and to assess the participants’ (faculty members, staff nurses, and nursing students) level of satisfaction with the CTA model and with achieving the educational goals in Iran, as a developing country. Methods and materials: In this experimental study, random sampling was used to assess 104 nursing students’ clinical skills, and assess six faculty members and six staff nurses. After obtaining informed consent, the level of satisfaction was evaluated by a questionnaire and clinical skills were evaluated by standard checklists. Data were assessed and analyzed with SPSS version 15. Results: The results showed that the mean scores of all clinical skills of the students were significantly higher after intervention (P < 0.01). Moreover, the mean scores of instructors’ satisfaction with applying the CTA model was significantly higher (P = 0.004), but their satisfaction with achieving clinical education outcomes did not show a significant difference (P = 0.109). Similarly, students’ satisfaction with achieving educational outcomes did not show any significant differences between the two groups (P = 0.058). Conclusion: According to this study, the CTA model is an effective method for developing clinical skills in nursing students in Iran as a developing country. Therefore, application of the method is recommended in clinical nursing education systems of such countries. KEYWORDS: clinical teaching associate model, nursing education, developing countries
D
uring the past years, there have been considerable investigations to find effective ways to close the gap between theoretical education and practical training in nursing education (Chapman & Clegg, 2007; Crane, 1991). However, the gap between theory and practice in nursing education and health care delivery continues to be a major challenge in the nursing profession (Higginson, 2004; Scully, 2011). The concept of ‘theory–practice gap’ has been one of the cornerstones of nursing debates over the recent years and is well documented in the nursing literature (Crane, 1991; Landers, 2000; McKenna & Roberts, 1999; Packer, 1994). Nursing education is often divided into two distinctive types of courses, theoretical and practical, which are both important and provide different contributions to learning (Veltri, 2010). In addition, practical experience is a very important constituent for the socialization of nurses (Wong & Lee, 2001). A major criticism of nursing education is related to an overemphasis on concepts and theory rather than clinical practice in the nursing curriculum (Zareiyan Jahromi & Ahmadi, 2005).
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Nursing curriculum needs improvement in order to shift concepts into practice (Ward, Procter, & Woolley, 2004). Most graduated nurses barely have entrylevel competency in medical–surgical skills and knowledge (Nasiriani, Farnia, Salimi, Shahbazi, & Motavasselian, 2006), which indicates a gap between theory and practice in nursing curriculum (Abedini & Takhti, 2011). The literature shows that the theory–practice gap in nursing is one of the major challenges, which includes the discrepancy between teaching of theory and clinical practice, when theory should be integrated into practice to reduce the gap in between. Many initiatives have been taken to bridge the theory–practice gap; the changes in education are redefining the role of the nurse teachers (Goodfellow, 2004). A number of countries have evaluated alternative methods to narrow this gap. Ehrenberg and Häggblom evaluated the effect of problem-based learning, applying new models for supervision, and supporting nursing preceptors on Swedish nursing students’ clinical learning. The results showed that the
Effectiveness of clinical teaching associate model in nursing education intervention was overall perceived positively; however, preceptors sometimes had trouble with setting aside time (Ehrenberg & Häggblom, 2007). Murphy evaluated the effect of nurse practitioners’ and nurse lecturers’ collaboration on the improvement of clinical teaching activities within a small scale in the United Kingdom. Based on his results, the project was successful and had considerable benefits for the students, practitioners, and lecturer (Murphy, 2000). Nordgren et al. conducted a pilot study to evaluate the outcomes of using preceptors for teaching beginning nursing students in clinical settings of the USA. The students’ outcomes revealed that the pilot program was successful (Nordgren, Richardson, & Laurella, 1998). The World Health Organization (WHO) has reported that some countries still suffer from a defect in their healthcare systems due to the lack of nursing skills and decision-making abilities (Rifai, 2008). Moreover, due to the gap between theoretical and practical skills, many countries including Spain, Norway, Belgium, Finland, Sweden and the United Kingdom have reported current insufficiencies in the nursing ability (Spitzer & Perrenoud, 2006). The increasing realization of deficiencies in the quality of service provision and wide gaps between evidence and practice makes it increasingly important to influence the changes in health professionals’ clinical practice in developing countries such as Iran. The need to put ‘what works’ into practice is particularly important in resource-poor countries. The WHO calls for its members to focus on strengthening health systems, and in particular to bring existing evidence into practice. Because interventions to bring evidence into practice have not been developed and tested extensively in developing countries (Siddiqi, Newell, & Robinson, 2005). On the other hand, the credit of the advanced practice nurses in developing countries due to their inadequate educational preparation has been questioned by nursing professionals (Chen, 2001). Undergraduate nursing education in Iran The predominant form of nursing education in Iran is university-based education. Bachelor’s degree, Master’s degree, and PhD are the nursing programs in Iran. The teaching method in Iran
© eContent Management Pty Ltd
CN
is very formal. Although nursing students obtain much theoretical information, they do not utilize it all in practical settings. The system of nursing education in Iran involves a lot of examinations and memorization, but students often forget the information after the exam. Thus, nursing students are not very satisfied with this method of education. In contrast, there is no professional relationship between practical settings and academic centers, and no major changes have been made in the structure of nursing education in response to the acceleration of the university-based program. In addition, it is worth mentioning that the dominant form of nursing care in the practical settings is the traditional form, and the practice experience is not integrated with the theoretical content presented in the school blocks of study. In fact, in the 4-year program of nursing education for obtaining the Bachelor’s degree, it is required to study input, process, context, and output of educational processes in order to reach a suitable model compatible with the real health needs of the Iranian society (Cheraghi & Salsali, 2005). Clinical courses in the nursing baccalaureate program consist about 54% of the whole curriculum. Clinical placement begins in the third semester and includes 8 weeks per semester in the second and third years and 16 weeks per semester in the fourth year of the program. Nurse educators with MSc or PhD degrees, who are members of the nursing faculty, are generally responsible for teaching clinical nursing courses (Tabari Khomeiran & Deans, 2007). However, there is no systematic, evidence-based collaboration between nursing faculties and staff nurses in clinical education of nursing students (Nasrabadi, Lipson, & Emami, 2004; Salsali, 2000; Tabari Khomeiran & Deans, 2007). The results of a study showed that there were still gaps in the perceived curriculum needs of graduate nurses and the courses they study within nursing education, particularly in the amount of theory and practice courses in Iran. Better coordination between theoretical learning and its application in real practical environments is critically needed (Azar, 2007). These gaps affect the nurses’ ability to provide comprehensive, quality care – which is an issue, especially since there is also a global nursing shortage (Flinkman, Leino-Kilpi, & Salanterä, 2010).
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Zahra Rahnavard, Zahra Hosseini Nodeh and Ladan Hosseini
Clinical teaching associate model The clinical teaching associate (CTA) model has been established based on the collaboration between faculty members and staff nurses (CTAs) in educating a certain number of nursing students – usually between 8–10 people (Kost, 2005). In the CTA model, staff nurses are more responsible for supervising students in their own clinical units, which allows careful direction and better job performance of the students (Billings & Halstead, 2004; Emerson, 2007). Staff nurses are in charge of student supervision, education, and role modeling while faculty members are usually responsible for supervising staff nurses and sometimes students, and teaching and evaluation of the students (Baird, Bopp, Kruckenberg Schofer, Langenberg, & Matheis-Kraft, 1994; De Voogd & Salbenblatt, 1989). Faculty members may also share the responsibility of student evaluation, decision-making about learning experience, tasks, and assignments with CTAs (Kost, 2005). Nordgren et al. conducted a study to assess the effectiveness of the clinical participating model on nursing students’ clinical skills. They concluded that employing nursing experts for clinical education increased students’ satisfaction and clinical skills to the desired level (Nordgren et al., 1998). Killcullen conducted a research to evaluate the effect of the mentor nurse on nursing students’ clinical learning in an English university, and some data were collected by the focus group discussion technique. The results showed that the mentor nurse played an important role in the enhancement of students’ clinical education by supporting, role modeling, execution of social roles, and acting as assessors. In addition, students believed mentor nurses had a significant effect on their clinical learning (Kilcullen, 2007). The results of a study conducted by Wilson-Thomas in the USA showed that faculty professors and mentors were more welcomed by healthcare agencies in the execution of the collective model. Therefore, they managed to merge the applied healthcare methods and techniques with training theories and concepts in nursing. Moreover, following the emerging of mutual trust and respect among the nursing staff and the training officials, a new atmosphere was established to accept new students and additional collaborations (Wilson-Thomas, 1995).
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Although there have been several efforts to minimize the gap between theory and practice and to deal with the shortage in clinical and faculty resources, few investigations have been done to find effective strategies for clinical nursing education in Iran as a developing country with traditional health education systems (Nasrabadi et al., 2004; Salsali, 2000; Tabari Khomeiran & Deans, 2007). Considering the fact that improvement of the clinical education of nursing students in developing countries increases the quality of healthcare, it seems that conducting such researches to bridge the theory–practice gap is necessary. Therefore, the aims of this study were to investigate the effectiveness of the CTA model application in nursing students’ clinical skills, and to assess the participants’ (faculty members, staff nurses, and nursing students) level of satisfaction with the CTA model and with achieving the educational goals. METHOD Design A single blind experimental design was employed in Tehran University of Medical Science (TUMS), Iran, in 2010. The study had no pre-test, because all participating students had no pediatric nursing experience. The independent variable was application of the CTA model. Dependent variables were: (a) students’ clinical skills (which included skill of temperature, pulse rate, respiration rate (TPR) and blood pressure (BP) measurement, oxygen therapy, drug therapy and pediatric nutrition procedures, child–family relationship, and intake and output control); (b) students’ satisfaction with achieving clinical education goals; (c) staff nurses’ and faculty members’ satisfaction with the method applied; and (d) staff nurses’ and faculty members’ satisfaction with clinical education goals. Study samples The study sample consisted of six faculty members, six staff nurses, and 104 nursing students. The inclusion criteria were as follows: faculty members were the official members of the Faculty of Nursing and Midwifery affiliated with TUMS; staff nurses were registered nurses in three pediatric wards of the selected hospitals. Participation was voluntary. The students were in the fifth
© eContent Management Pty Ltd
Effectiveness of clinical teaching associate model in nursing education semester of the nursing baccalaureate program in TUMS. Students were included through census and were randomly allocated to the intervention (N = 56) and control (N = 48) groups. All students accepted to participate in the study voluntarily and there was no loss to follow-up. Measures Clinical skills Students’ clinical skills were measured via eight researcher-made checklists assessing the following skills: (1) TPR measurement (10 items); (2) BP measurement (7 items); (3) oxygen therapy (9 items); (4) drug therapy (18 items); (5) pediatric nourishment procedure (7 items); (6) and (7) child–family relationship (7 items) and education (5 items); and (8) intake/output (I/O) control (8 items). The checklists assessed the accuracy of performing clinical procedures (appropriate performance: 1; inappropriate performance: 0). The total score of each checklist was obtained by summing the scores of its items. The total scores were then used to calculate the mean and standard deviation of the skill. Participants’ satisfaction Three different questionnaires were developed and completed separately by the three participant groups to assess their satisfaction level with: (a) the method applied (by faculty members and CTAs via 22 three-point Likert items); (b) achievement of clinical education goals (by CTAs via 24 threepoint Likert items); and (c) achievement of educational goals (by nursing students in both groups via 23 three-point Likert items) at the end of the course in each group. Each checklist also contained items on the demographic characteristics. The answer to each item was scored as follows: complete satisfaction received 3 scores, relative satisfaction received 2 scores, and dissatisfaction scored 1. The sum of the scores in each questionnaire was classified into three levels out of 100 as follows: high satisfaction (total score > 75); moderate satisfaction (50 < total score < 75); and low satisfaction (total score < 50). Validity and reliability The content validity of the satisfaction questionnaires (79%) and clinical skill checklists (87%) was
© eContent Management Pty Ltd
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confirmed through having the tools reviewed by a board of 20 nursing faculty members and pediatric nurse practitioners. Minor revisions on the sequence of some items were suggested by reviewers only for satisfaction questionnaires, which were applied before the data collection phase. Regarding the reliability of the satisfaction questionnaire, Cronbach’s alpha was applied, which was 78% for students’ satisfaction, 81% for instructors’ satisfaction (CTAs and faculty members) with the method applied, and 76% for instructors’ satisfaction (CTAs and faculty members) with the students’ achievement of educational goals. To assess the inter-rater and intra-rater reliability of the checklists, faculty members and CTAs scored clinical skills of 15 nursing students twice. The Pearson correlation coefficient was used to assess the correlation between faculty members and CTAs’ scores (inter-rater reliability: 0.73) and the correlation between the two scores of each instructor’s measurement (intra-rater reliability: all were more than 0.70). Intervention The students in both groups passed their internship in three pediatric wards for 5 weeks. Thus, the participants in the control group started their internship based on the routine educational schedule of the faculty (under direct supervision of the faculty members with no supervision or education from staff nurses) and their clinical skills were evaluated by the faculty member in charge at the end of the course via checklists. Then, the students in the intervention group started their clinical training in the same wards; however, their clinical education was conducted by both faculty members and staff nurses. These staff nurses who were called ‘CTAs’ were responsible for clinical training of the students, reported the students’ progress to faculty members every week, getting help from them if needed, solving students’ learning problems, and evaluating students’ achievement of educational goals using tools similar to those used for the control group. The participants’ (students, faculty members, and CTAs) level of satisfaction in the CTA model was evaluated in both groups at the end of the internship period.
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Zahra Rahnavard, Zahra Hosseini Nodeh and Ladan Hosseini
Ethical issues The present paper is the result of a research protocol, approved and financially supported by TUMS. The ethical considerations were approved by the university ethics committee. Written informed consent was obtained from all participants. Participation in the study was voluntary and participants were assured that their information would be confidential and data would be collected anonymously. Data analysis The collected data was analyzed for descriptive (frequency, mean, and standard deviation) and inferential statistics (Chi-square, Fisher’s exact test, Mann– Whitney U test) on SPSS (version 15). RESULTS Students’ demographic characteristics No significant difference was found in the students’ demographic characteristics such as age, gender, and interest in and motivation toward nursing discipline between the two groups before the intervention. The participants’ characteristics are presented in Table 1. Students’ clinical skills Mann–Whitney U results showed no significant difference between mean scores of the students’ all clinical skills before intervention. While in the intervention versus control group, mean scores of the students’ all clinical skills were significantly higher after intervention (P < 0.01; Table 2).
TABLE 1: DEMOGRAPHIC CHARACTERISTICS OF STUDY PARTICIPANTS (NURSING STUDENTS, CTAS, AND FACULTY INSTRUCTORS) Participants
Nursing students Age 19–21 22–24 25–27 Age (mean ± SD) Sex Male Female Grade point average (GPA)† 13–15 15–20 GPA (mean ± SD) Interest in nursing discipline Completely interested Relatively interested Not interested CTAs Age 20–29 30–40 Marital status Married Single Academic degree Bachelor’s in Nursing Master’s in Nursing Clinical experience (years) 0–9 10–20 Pediatric nursing experience (years) 0–9 10–20 Educational experience (years) Yes I have had No I have not
Intervention group
Control group
N (%) 14(58.3) 9(37.5) 1(4.2)
N (%) 22(78.6) 3(10.7) 3(10.7)
21.21 ± 2.12
21 ± 1.96
0.884‡
N (%) 5(20.8) 19(79.2)
N (%) 23(82.1) 5(17.9)
0.786§
N (%) 1(4.2) 23(95.8)
N (%) 1(3.6) 27(96.4)
P value
16.52 ± 0.21 16.62 ± 1.11 0.325‡ N (%) 7(29.2)
N (%) 11(93.3)
16(66.7) 1(4.2)
13(46.4) 4(14.3)
0.275§
N (%) 2(28.6) 5(71.4) 4(57.2) 3(42.8) 6(85.7) 1(14.3) 5(71.4) 2(28.6)
6(85.7) 1(14.3)
3(42.8) Participants’ satisfaction 4(57.2) Educators’ satisfaction with the method applied † ‡ The GPA is calculated out of 20; t-test; §Fisher exact. Most CTA educators (intervention group educators) were highly satisfied (66.6%), while most faculty members in A significant difference was observed via Mann– the control group (66.6%) had moderate sat- Whitney U test between the groups (P = 0.004; isfaction with their clinical education method. Table 3).
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Effectiveness of clinical teaching associate model in nursing education TABLE 2: COMPARISON OF STUDENTS’ CLINICAL SKILLS
TABLE 3: EDUCATORS’ SATISFACTION WITH DIFFERENT
BETWEEN INTERVENTION AND CONTROL GROUPS
ASPECTS OF THE PROGRAM
Clinical skills
TPR measurement Blood pressure measurement Oxygen therapy Drug therapy Pediatric nutrition Child–family relationship Liquid control Total clinical skills
Intervention group Mean ± SD
Control group Mean ± SD
P value
9.3 ± 0.7
7.1 ± 2.1
Effectiveness of clinical teaching associate model in nursing education: Results from a developing country ZAHRA RAHNAVARD, ZAHRA HOSSEINI NODEH AND LADAN HOSSEINI Community Health Nursing Department, Tehran University of Medical Sciences, Tehran, Iran
Abstract: Background and objectives: The credit of the practice nurses in developing countries, due to a gap between theory and practice in nursing education and healthcare delivery, has been questioned by nursing professionals. Therefore, the aims of this study were to investigate the effectiveness of the application of the clinical teaching associate (CTA) model in nursing students’ clinical skills and to assess the participants’ (faculty members, staff nurses, and nursing students) level of satisfaction with the CTA model and with achieving the educational goals in Iran, as a developing country. Methods and materials: In this experimental study, random sampling was used to assess 104 nursing students’ clinical skills, and assess six faculty members and six staff nurses. After obtaining informed consent, the level of satisfaction was evaluated by a questionnaire and clinical skills were evaluated by standard checklists. Data were assessed and analyzed with SPSS version 15. Results: The results showed that the mean scores of all clinical skills of the students were significantly higher after intervention (P < 0.01). Moreover, the mean scores of instructors’ satisfaction with applying the CTA model was significantly higher (P = 0.004), but their satisfaction with achieving clinical education outcomes did not show a significant difference (P = 0.109). Similarly, students’ satisfaction with achieving educational outcomes did not show any significant differences between the two groups (P = 0.058). Conclusion: According to this study, the CTA model is an effective method for developing clinical skills in nursing students in Iran as a developing country. Therefore, application of the method is recommended in clinical nursing education systems of such countries. KEYWORDS: clinical teaching associate model, nursing education, developing countries
D
uring the past years, there have been considerable investigations to find effective ways to close the gap between theoretical education and practical training in nursing education (Chapman & Clegg, 2007; Crane, 1991). However, the gap between theory and practice in nursing education and health care delivery continues to be a major challenge in the nursing profession (Higginson, 2004; Scully, 2011). The concept of ‘theory–practice gap’ has been one of the cornerstones of nursing debates over the recent years and is well documented in the nursing literature (Crane, 1991; Landers, 2000; McKenna & Roberts, 1999; Packer, 1994). Nursing education is often divided into two distinctive types of courses, theoretical and practical, which are both important and provide different contributions to learning (Veltri, 2010). In addition, practical experience is a very important constituent for the socialization of nurses (Wong & Lee, 2001). A major criticism of nursing education is related to an overemphasis on concepts and theory rather than clinical practice in the nursing curriculum (Zareiyan Jahromi & Ahmadi, 2005).
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Nursing curriculum needs improvement in order to shift concepts into practice (Ward, Procter, & Woolley, 2004). Most graduated nurses barely have entrylevel competency in medical–surgical skills and knowledge (Nasiriani, Farnia, Salimi, Shahbazi, & Motavasselian, 2006), which indicates a gap between theory and practice in nursing curriculum (Abedini & Takhti, 2011). The literature shows that the theory–practice gap in nursing is one of the major challenges, which includes the discrepancy between teaching of theory and clinical practice, when theory should be integrated into practice to reduce the gap in between. Many initiatives have been taken to bridge the theory–practice gap; the changes in education are redefining the role of the nurse teachers (Goodfellow, 2004). A number of countries have evaluated alternative methods to narrow this gap. Ehrenberg and Häggblom evaluated the effect of problem-based learning, applying new models for supervision, and supporting nursing preceptors on Swedish nursing students’ clinical learning. The results showed that the
Effectiveness of clinical teaching associate model in nursing education intervention was overall perceived positively; however, preceptors sometimes had trouble with setting aside time (Ehrenberg & Häggblom, 2007). Murphy evaluated the effect of nurse practitioners’ and nurse lecturers’ collaboration on the improvement of clinical teaching activities within a small scale in the United Kingdom. Based on his results, the project was successful and had considerable benefits for the students, practitioners, and lecturer (Murphy, 2000). Nordgren et al. conducted a pilot study to evaluate the outcomes of using preceptors for teaching beginning nursing students in clinical settings of the USA. The students’ outcomes revealed that the pilot program was successful (Nordgren, Richardson, & Laurella, 1998). The World Health Organization (WHO) has reported that some countries still suffer from a defect in their healthcare systems due to the lack of nursing skills and decision-making abilities (Rifai, 2008). Moreover, due to the gap between theoretical and practical skills, many countries including Spain, Norway, Belgium, Finland, Sweden and the United Kingdom have reported current insufficiencies in the nursing ability (Spitzer & Perrenoud, 2006). The increasing realization of deficiencies in the quality of service provision and wide gaps between evidence and practice makes it increasingly important to influence the changes in health professionals’ clinical practice in developing countries such as Iran. The need to put ‘what works’ into practice is particularly important in resource-poor countries. The WHO calls for its members to focus on strengthening health systems, and in particular to bring existing evidence into practice. Because interventions to bring evidence into practice have not been developed and tested extensively in developing countries (Siddiqi, Newell, & Robinson, 2005). On the other hand, the credit of the advanced practice nurses in developing countries due to their inadequate educational preparation has been questioned by nursing professionals (Chen, 2001). Undergraduate nursing education in Iran The predominant form of nursing education in Iran is university-based education. Bachelor’s degree, Master’s degree, and PhD are the nursing programs in Iran. The teaching method in Iran
© eContent Management Pty Ltd
CN
is very formal. Although nursing students obtain much theoretical information, they do not utilize it all in practical settings. The system of nursing education in Iran involves a lot of examinations and memorization, but students often forget the information after the exam. Thus, nursing students are not very satisfied with this method of education. In contrast, there is no professional relationship between practical settings and academic centers, and no major changes have been made in the structure of nursing education in response to the acceleration of the university-based program. In addition, it is worth mentioning that the dominant form of nursing care in the practical settings is the traditional form, and the practice experience is not integrated with the theoretical content presented in the school blocks of study. In fact, in the 4-year program of nursing education for obtaining the Bachelor’s degree, it is required to study input, process, context, and output of educational processes in order to reach a suitable model compatible with the real health needs of the Iranian society (Cheraghi & Salsali, 2005). Clinical courses in the nursing baccalaureate program consist about 54% of the whole curriculum. Clinical placement begins in the third semester and includes 8 weeks per semester in the second and third years and 16 weeks per semester in the fourth year of the program. Nurse educators with MSc or PhD degrees, who are members of the nursing faculty, are generally responsible for teaching clinical nursing courses (Tabari Khomeiran & Deans, 2007). However, there is no systematic, evidence-based collaboration between nursing faculties and staff nurses in clinical education of nursing students (Nasrabadi, Lipson, & Emami, 2004; Salsali, 2000; Tabari Khomeiran & Deans, 2007). The results of a study showed that there were still gaps in the perceived curriculum needs of graduate nurses and the courses they study within nursing education, particularly in the amount of theory and practice courses in Iran. Better coordination between theoretical learning and its application in real practical environments is critically needed (Azar, 2007). These gaps affect the nurses’ ability to provide comprehensive, quality care – which is an issue, especially since there is also a global nursing shortage (Flinkman, Leino-Kilpi, & Salanterä, 2010).
Volume 45, Issue 2, October 2013
CN
175
CN
Zahra Rahnavard, Zahra Hosseini Nodeh and Ladan Hosseini
Clinical teaching associate model The clinical teaching associate (CTA) model has been established based on the collaboration between faculty members and staff nurses (CTAs) in educating a certain number of nursing students – usually between 8–10 people (Kost, 2005). In the CTA model, staff nurses are more responsible for supervising students in their own clinical units, which allows careful direction and better job performance of the students (Billings & Halstead, 2004; Emerson, 2007). Staff nurses are in charge of student supervision, education, and role modeling while faculty members are usually responsible for supervising staff nurses and sometimes students, and teaching and evaluation of the students (Baird, Bopp, Kruckenberg Schofer, Langenberg, & Matheis-Kraft, 1994; De Voogd & Salbenblatt, 1989). Faculty members may also share the responsibility of student evaluation, decision-making about learning experience, tasks, and assignments with CTAs (Kost, 2005). Nordgren et al. conducted a study to assess the effectiveness of the clinical participating model on nursing students’ clinical skills. They concluded that employing nursing experts for clinical education increased students’ satisfaction and clinical skills to the desired level (Nordgren et al., 1998). Killcullen conducted a research to evaluate the effect of the mentor nurse on nursing students’ clinical learning in an English university, and some data were collected by the focus group discussion technique. The results showed that the mentor nurse played an important role in the enhancement of students’ clinical education by supporting, role modeling, execution of social roles, and acting as assessors. In addition, students believed mentor nurses had a significant effect on their clinical learning (Kilcullen, 2007). The results of a study conducted by Wilson-Thomas in the USA showed that faculty professors and mentors were more welcomed by healthcare agencies in the execution of the collective model. Therefore, they managed to merge the applied healthcare methods and techniques with training theories and concepts in nursing. Moreover, following the emerging of mutual trust and respect among the nursing staff and the training officials, a new atmosphere was established to accept new students and additional collaborations (Wilson-Thomas, 1995).
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Although there have been several efforts to minimize the gap between theory and practice and to deal with the shortage in clinical and faculty resources, few investigations have been done to find effective strategies for clinical nursing education in Iran as a developing country with traditional health education systems (Nasrabadi et al., 2004; Salsali, 2000; Tabari Khomeiran & Deans, 2007). Considering the fact that improvement of the clinical education of nursing students in developing countries increases the quality of healthcare, it seems that conducting such researches to bridge the theory–practice gap is necessary. Therefore, the aims of this study were to investigate the effectiveness of the CTA model application in nursing students’ clinical skills, and to assess the participants’ (faculty members, staff nurses, and nursing students) level of satisfaction with the CTA model and with achieving the educational goals. METHOD Design A single blind experimental design was employed in Tehran University of Medical Science (TUMS), Iran, in 2010. The study had no pre-test, because all participating students had no pediatric nursing experience. The independent variable was application of the CTA model. Dependent variables were: (a) students’ clinical skills (which included skill of temperature, pulse rate, respiration rate (TPR) and blood pressure (BP) measurement, oxygen therapy, drug therapy and pediatric nutrition procedures, child–family relationship, and intake and output control); (b) students’ satisfaction with achieving clinical education goals; (c) staff nurses’ and faculty members’ satisfaction with the method applied; and (d) staff nurses’ and faculty members’ satisfaction with clinical education goals. Study samples The study sample consisted of six faculty members, six staff nurses, and 104 nursing students. The inclusion criteria were as follows: faculty members were the official members of the Faculty of Nursing and Midwifery affiliated with TUMS; staff nurses were registered nurses in three pediatric wards of the selected hospitals. Participation was voluntary. The students were in the fifth
© eContent Management Pty Ltd
Effectiveness of clinical teaching associate model in nursing education semester of the nursing baccalaureate program in TUMS. Students were included through census and were randomly allocated to the intervention (N = 56) and control (N = 48) groups. All students accepted to participate in the study voluntarily and there was no loss to follow-up. Measures Clinical skills Students’ clinical skills were measured via eight researcher-made checklists assessing the following skills: (1) TPR measurement (10 items); (2) BP measurement (7 items); (3) oxygen therapy (9 items); (4) drug therapy (18 items); (5) pediatric nourishment procedure (7 items); (6) and (7) child–family relationship (7 items) and education (5 items); and (8) intake/output (I/O) control (8 items). The checklists assessed the accuracy of performing clinical procedures (appropriate performance: 1; inappropriate performance: 0). The total score of each checklist was obtained by summing the scores of its items. The total scores were then used to calculate the mean and standard deviation of the skill. Participants’ satisfaction Three different questionnaires were developed and completed separately by the three participant groups to assess their satisfaction level with: (a) the method applied (by faculty members and CTAs via 22 three-point Likert items); (b) achievement of clinical education goals (by CTAs via 24 threepoint Likert items); and (c) achievement of educational goals (by nursing students in both groups via 23 three-point Likert items) at the end of the course in each group. Each checklist also contained items on the demographic characteristics. The answer to each item was scored as follows: complete satisfaction received 3 scores, relative satisfaction received 2 scores, and dissatisfaction scored 1. The sum of the scores in each questionnaire was classified into three levels out of 100 as follows: high satisfaction (total score > 75); moderate satisfaction (50 < total score < 75); and low satisfaction (total score < 50). Validity and reliability The content validity of the satisfaction questionnaires (79%) and clinical skill checklists (87%) was
© eContent Management Pty Ltd
CN
confirmed through having the tools reviewed by a board of 20 nursing faculty members and pediatric nurse practitioners. Minor revisions on the sequence of some items were suggested by reviewers only for satisfaction questionnaires, which were applied before the data collection phase. Regarding the reliability of the satisfaction questionnaire, Cronbach’s alpha was applied, which was 78% for students’ satisfaction, 81% for instructors’ satisfaction (CTAs and faculty members) with the method applied, and 76% for instructors’ satisfaction (CTAs and faculty members) with the students’ achievement of educational goals. To assess the inter-rater and intra-rater reliability of the checklists, faculty members and CTAs scored clinical skills of 15 nursing students twice. The Pearson correlation coefficient was used to assess the correlation between faculty members and CTAs’ scores (inter-rater reliability: 0.73) and the correlation between the two scores of each instructor’s measurement (intra-rater reliability: all were more than 0.70). Intervention The students in both groups passed their internship in three pediatric wards for 5 weeks. Thus, the participants in the control group started their internship based on the routine educational schedule of the faculty (under direct supervision of the faculty members with no supervision or education from staff nurses) and their clinical skills were evaluated by the faculty member in charge at the end of the course via checklists. Then, the students in the intervention group started their clinical training in the same wards; however, their clinical education was conducted by both faculty members and staff nurses. These staff nurses who were called ‘CTAs’ were responsible for clinical training of the students, reported the students’ progress to faculty members every week, getting help from them if needed, solving students’ learning problems, and evaluating students’ achievement of educational goals using tools similar to those used for the control group. The participants’ (students, faculty members, and CTAs) level of satisfaction in the CTA model was evaluated in both groups at the end of the internship period.
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Zahra Rahnavard, Zahra Hosseini Nodeh and Ladan Hosseini
Ethical issues The present paper is the result of a research protocol, approved and financially supported by TUMS. The ethical considerations were approved by the university ethics committee. Written informed consent was obtained from all participants. Participation in the study was voluntary and participants were assured that their information would be confidential and data would be collected anonymously. Data analysis The collected data was analyzed for descriptive (frequency, mean, and standard deviation) and inferential statistics (Chi-square, Fisher’s exact test, Mann– Whitney U test) on SPSS (version 15). RESULTS Students’ demographic characteristics No significant difference was found in the students’ demographic characteristics such as age, gender, and interest in and motivation toward nursing discipline between the two groups before the intervention. The participants’ characteristics are presented in Table 1. Students’ clinical skills Mann–Whitney U results showed no significant difference between mean scores of the students’ all clinical skills before intervention. While in the intervention versus control group, mean scores of the students’ all clinical skills were significantly higher after intervention (P < 0.01; Table 2).
TABLE 1: DEMOGRAPHIC CHARACTERISTICS OF STUDY PARTICIPANTS (NURSING STUDENTS, CTAS, AND FACULTY INSTRUCTORS) Participants
Nursing students Age 19–21 22–24 25–27 Age (mean ± SD) Sex Male Female Grade point average (GPA)† 13–15 15–20 GPA (mean ± SD) Interest in nursing discipline Completely interested Relatively interested Not interested CTAs Age 20–29 30–40 Marital status Married Single Academic degree Bachelor’s in Nursing Master’s in Nursing Clinical experience (years) 0–9 10–20 Pediatric nursing experience (years) 0–9 10–20 Educational experience (years) Yes I have had No I have not
Intervention group
Control group
N (%) 14(58.3) 9(37.5) 1(4.2)
N (%) 22(78.6) 3(10.7) 3(10.7)
21.21 ± 2.12
21 ± 1.96
0.884‡
N (%) 5(20.8) 19(79.2)
N (%) 23(82.1) 5(17.9)
0.786§
N (%) 1(4.2) 23(95.8)
N (%) 1(3.6) 27(96.4)
P value
16.52 ± 0.21 16.62 ± 1.11 0.325‡ N (%) 7(29.2)
N (%) 11(93.3)
16(66.7) 1(4.2)
13(46.4) 4(14.3)
0.275§
N (%) 2(28.6) 5(71.4) 4(57.2) 3(42.8) 6(85.7) 1(14.3) 5(71.4) 2(28.6)
6(85.7) 1(14.3)
3(42.8) Participants’ satisfaction 4(57.2) Educators’ satisfaction with the method applied † ‡ The GPA is calculated out of 20; t-test; §Fisher exact. Most CTA educators (intervention group educators) were highly satisfied (66.6%), while most faculty members in A significant difference was observed via Mann– the control group (66.6%) had moderate sat- Whitney U test between the groups (P = 0.004; isfaction with their clinical education method. Table 3).
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Volume 45, Issue 2, October 2013
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Effectiveness of clinical teaching associate model in nursing education TABLE 2: COMPARISON OF STUDENTS’ CLINICAL SKILLS
TABLE 3: EDUCATORS’ SATISFACTION WITH DIFFERENT
BETWEEN INTERVENTION AND CONTROL GROUPS
ASPECTS OF THE PROGRAM
Clinical skills
TPR measurement Blood pressure measurement Oxygen therapy Drug therapy Pediatric nutrition Child–family relationship Liquid control Total clinical skills
Intervention group Mean ± SD
Control group Mean ± SD
P value
9.3 ± 0.7
7.1 ± 2.1
