Clinical teaching of undergraduate nursing students: Are the nurses in practice in Uganda ready?

Background: Nurses with degree qualifications offer better nursing care compared to nurses prepared at lower levels. University based nursing degrees have been sanctioned as entry into professional nursing and several low-resource states have introduced university based nursing degrees. The clinical teaching of students enrolled in such degrees is challenged, as most nurses in practice do not have university degrees and are incompetent in moulding the clinical reasoning processes which is inherent within degree education. A university in Uganda established a bachelor’s degree in Nursing program and was expecting to use nurses in practice at a teaching hospital for the clinical teaching of undergraduate nursing students. This study reports on the perceptions of the nurses in practice regarding their readiness for the clinical teaching of undergraduate nursing students. Methods: A qualitative descriptive research study was conducted among 33 conveniently sampled nurses from ARRH who had been supervising Diploma and/or Certificate in Nursing students. Five focus group discussions and three informant interviews were used to generate the data. Data were transcribed verbatim and analysed using an inductive approach through thematic analysis. Results: The nurses in practice perceived themselves as ready for clinical teaching of undergraduate nursing students. Three themes emerged namely; “ Willingness to teach undergraduate students ” “ Perceived attributes of undergraduate students ”, and “ The clinical practice environment ”. Conclusion: The nurses in practice need support in the execution of the clinical teaching role of undergraduate nursing students. The nature of supports would include, continuing professional development specific to clinical teaching, engaging the educators in the clinical environment, positively engaging power gradients and address insecurities among the nurses and the students. Students in these programmes should be exposed to the clinical environment earlier within the programme, and be exposed to interprofessional and trans-professional education.


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Clinical teaching of university-degree nursing students: Are nurses in practice in Uganda ready?

Background
Nurses with university degrees offer better nursing care when compared to nurses trained in non-university nursing programmes (1). Several studies, conducted predominantly in high-income countries, have demonstrated that patients cared for by nurses with university degrees have better health outcomes compared to those with other qualifications (2,3). According to DeBack & Mentkowski (4) nurses with university degrees reason better, think critically and make sound clinical judgements when executing patient care (5).
The quality of University-based nursing degree programmes is mediated by universitywide quality assurance processes and professional regulatory councils (6, 7). The robust quality assurance mechanisms ensure university-based nursing programmes to meet both educational and professional nursing standards, which is not common practice in nonuniversity based nursing programmes (8). In addition to the generic nursing science courses, university-based degree programmes integrate basic and social sciences which are usually facilitated by experts. These basic and social sciences, such as Human Anatomy, Physiology, Microbiology, Pharmacology, and Psychology, are quintessential to the reasoning processes inherent in nursing care (9). Nurse educators facilitating in these university-based nursing degree programmes are also expected to have advanced educational and professional qualifications at a level higher than the qualification they are facilitating (6). The undergraduate nursing students are taught both in the university, and university/council-accredited clinical practice sites. 4 University-based nursing degree programmes are not without controversies. The nursing graduates from these programmes have been described as laden with content but without clinical practice and often perceived to struggle integrating theory and practice (10,11).
Other criticisms are that nurses from university degree programmes struggle to "hit the ground running" and require extensive induction processes (12). The graduates from such programmes have also complained of the limited clinical exposure, limited clinical accompaniment during training and the lack of structured practical components in their degree programmes (13). These frustrations have compromised the argument supporting degree-education for nurses resulting in a need for more robust evaluation of universitybased nursing degree programmes especially in resource-limited settings like Africa.
Nevertheless, the benefits of having nurses with degree qualifications outweigh the general stakeholder concerns, resulting in various countries developing and implementing university-based nursing degree programmes. Numerous countries have sanctioned university-based nursing degree qualifications as the minimum requirements for professional nursing practice whilst the majority of low and middle-income countries have established university-based nursing degree programmes in addition to other nursing education programmes (14). Such a stance is perceived as improving the status of nursing further elevating nurses to be at par with their interprofessional colleagues, in addition to the general benefits related to patient health outcomes (5).
University-based nursing degree programmes also have to meet the professional requirements as stipulated by nursing councils. These professional requirements include specific clinical competencies to be met by undergraduate nursing students in authentic clinical environments under the supervision of suitably qualified and experienced clinical facilitators (6, 15). The State of World Nursing report indicates that the majority of nurses 5 in practice do not have university-based nursing degrees, especially in low-resource settings (16). This situation compromises the clinical experience of the undergraduate nursing students enrolled in university-based nursing degree programmes as the nurses in practice may be incompetent in facilitating clinical learning as expected at degree level. Degree level nurses should be able to transfer learning in the clinical environment through demonstrating reasoning, appropriate clinical judgement and application of all relevant sciences, not only psychomotor skills (17). Nurses in practice may supervise and demonstrate psychomotor skills but may not be competent in facilitating the integration of knowledge and the development of reasoning processes as expected at degree level.
Low-resource settings are further challenged by a dire shortage of nurse educators with advanced educational and professional qualifications (18,19). The available nurse educators are usually over-worked and rely on nurses in practice for the clinical teaching of undergraduate nursing students enrolled in university-based nursing degree programmes (20,21). We argue that the quality of clinical learning for university-based nursing degree programmes, especially in low-resource settings, may be enhanced by understanding the perceptions of nurses in practice regarding their readiness for the clinical teaching of undergraduate nursing students. In this study, we explored the perceptions of nurses in practice regarding their readiness for clinical teaching of nursing students enrolled in a university-based nursing degree.

Study context and design
The Muni University in Uganda established a 4-year Bachelor of Science in Nursing

Study participants
Thirty-three conveniently sampled nurses from ARRH were included in this study. The nurses' highest qualifications comprised a Diploma in Nursing (n=18), a Certificate in Auxiliary Nursing (n=12) and BScN (n=3). All the nurses included in this study had been engaged in the supervision of nursing students for more than a year.

Data collection
Secondary to the approval of this study, all the potential participants were invited to participate in this study. Five focus groups each comprising six participants and three key informant interviews were used to collect data between July and September 2018, before the first group of the BScN students was to be placed in the clinical environment. All the data were collected in English by the first author who had been trained in conducting 7 interviews in qualitative research. The data were generated from the following central question; "What is your perception regarding your readiness for the clinical teaching of the BScN students?" Additional probing questions arose from the discussions. Data were collected in a private room within the hospital, which allowed for the digital recording of all the interviews.
The author also wrote reflective notes during the data collection process. The interviews lasted on average 45 minutes.

Data analysis
The data were analysed through an inductive reasoning approach inspired by a data analysis framework by Saldaña (22). According to Saldaña (22), qualitative data analysis is executed in three sequential steps. In the initial step, the digitally recorded interviews were transcribed verbatim and the transcripts were assigned specific identifiers. The transcripts were formatted and stored in a password-protected electronic folder. Before coding, the researchers read and re-read the transcripts to understand the general ideas discussed in the focus groups. Initial, open, axial and in-vivo coding methods were used in coding units of analyses in the transcripts. The authors identified the units of analyses as sentences, phrases, and paragraphs that were related to the research question. The first author coded the data and the other authors acted as co-coders. The outcome of this second step was a final code list after a discussion involving all the authors. In the final step of the data analysis, the codes generated in the second step were further analysed through pattern coding methods. The researchers' clustered codes with similar meaning and the outcome of this step were themes and these are presented as the findings of this study. 8

Rigor
The trustworthiness framework was applied throughout this study (23). The researchers engaged already established approaches and frameworks in conducting this study. The data were collected by an experienced researcher, while the data analysis was influenced by contemporary networks in data analysis, and experienced researchers were used as cocoders.

Ethics
The Mbale Regional Referral Hospital Research Ethics Committee approved this study (MRRH-REC IN-COM 056/2018) and the management of the ARRH gave permission for the study to be conducted within the hospital. The Helsinki Declaration (24) was applied as the ethics framework for this study. All participants provided informed consent to be part of the study while confidentiality was maintained throughout the study.

Findings
Three themes emerged from the data namely, "Willingness to teach undergraduate students" "Perceived attributes of undergraduate students", and "The clinical practice environment".

Theme 1: Willingness to teach undergraduate nursing students
The participants in this study expressed the willingness to teach undergraduate nursing students. Their willingness was tied to their perceived professional competence but was hinged on specific influential conditions and the need for formal training on clinical teaching. 9 The participants felt competent in the clinical teaching of undergraduate nursing students because of their extensive experience as nurses. The participants had also been engaged in the clinical teaching of nursing students enrolled in undergraduate programmes from other universities within the country. Also, the participants perceived themselves as more hands-on and aware of their environment which was deemed essential for clinical teaching. Some of the participants stated; Several conditions were perceived as influential to the willingness of the participants to teach undergraduate nursing students. These conditions focused on undergraduate students and nurse educators from the university. The participants expressed that they were willing to supervise the undergraduate nursing students provided that the students were eager to learn from them, were self-directed, able to ask questions, and also able to seek their learning opportunities.
I am ready to give them the knowledge, teach them that if they are also cooperative and ready to learn. (FG 4,Participant 4). These students need to be able to ask us questions when they don't understand things in the clinic area…we won't know if they don't ask (FG3, Participant 1) The participants felt that the clinical teaching of undergraduate nursing students, should not be the sole responsibility of the nurses in practice, but include the nurse educators from the university. A key informant expressed; "…let this supervision not be left entirely to the staff of the hospital. The university staff who are teaching them will equally be assigned to follow these students to back us. The participants expressed that they had not been trained formally in the mechanisms surrounding clinical teaching of undergraduate nursing students. They stated that they used their own experience when they were students, and what they observe when other health professionals are teaching students. The participants expressed that formal training in clinical teaching would enhance their willingness and effectiveness in teaching undergraduate nursing students. The participants expressed a fear of being undermined based on the perception that undergraduate nursing students are threatening. The fact that the undergraduate students were enrolled in a university-based nursing degree programme threatened the nurses in practice, who predominantly had lower qualifications. These students were perceived as learning advanced content at the university and that the nurses in practice would struggle to facilitate learning in clinical practice resulting in being undermined by the undergraduate students. Some participants explained; "…one can make a mistake, maybe not knowing something in-front of them as they are more learned. They may correct you and then feel big, that they know more and then start undermining staff (FG 3, Participant 6).
Whatever little we have known, we would be in a position to give them. When they want to explore more, I expect them to ask questions. Since these undergraduates are more knowledgeable than us, I think when they will be with us on the ward, if they have seen us not telling the right things to them, they should also tell us. (FG 2, Participant 2).
According to the participants, students enrolled in a university-based nursing degree The availability of specialist services within the hospital setting including specialist doctors and other health service providers provided an opportunity for students to learn from other health professionals. The participants in this study expressed that the other health professionals always seemed eager to teach students using several opportunities like grand ward rounds.

We have specialists to guide them in different professions. We can line up with them and transfer better knowledge for them. (FG 2, Participant 3)
On the other hand, the participants in this study reflected on barriers within the clinical practice environment that would influence their ability in teaching undergraduate nursing students. An example was the shortage of hospital equipment, which was perceived to 14 influence the participants' ability to teach undergraduate nursing students ideal nursing care and clinical practice.
Some of the hospital equipment which you need to show practically are not there. You will also teach them the theory and yet they have been sent to see some of the hospital equipment practically. (FG 4, Participant 4).
In addition to the shortage of equipment, the participants in this study described the shortage of nurses in practice. The nurses in practice are faced with a heavy patient load and prioritise patient care over the clinical teaching of undergraduate nursing students.

The participants expressed;
In the hospital here we are very few; we have that challenge of not really mentoring these students properly. Sometimes you are alone on the ward and it will be very difficult for you to really monitor these students very carefully because our number is really few. (FG

3, Participant 5)
When you are so busy and you have a long cue, you have no time to teach these students because you are looking at completing the cue at the end of the day so that will block you from teaching the students. (FG 2,Participant 4)

Discussion
This study sought to describe the perceptions of nurses in practice regarding their readiness for the clinical teaching of nursing students enrolled in a university-based nursing degree programme in Uganda. The participants in this study, who were nurses in practice at one teaching hospital, generally perceived themselves to be ready and willing to be engaged in the clinical teaching of undergraduate nursing students. Their readiness for clinical teaching was associated with their perceived competence, the perceived attributes of undergraduate students and the clinical practice environment.
Most of the nurses in practice in low-resource settings such as Uganda have professional qualifications below the university-degree (16). However, these nurses have invaluable professional experience and expertise which are fundamental to the clinical teaching of undergraduate nursing students (10). In this study, the participants perceived themselves Traditional content-driven curricula separate the teaching of the content from the clinical aspects of a nursing programme. In a content-based programme, nursing students are taught and assessed on specific content in the classroom while learning in the clinical environment runs parallel and may not be aligned with the content being taught (27). Due to the heavy content load and content-driven assessments, nurse educators are often found teaching in the classroom and relinquishing all clinical teaching to nurses in practice (28).
The literature further describes several disadvantages of content-based education, which include content that is not based on practical realities, overloaded curricula and nurse educators who are distant from the clinical practice environment (29). In this study, the nurses in practice expressed the need for nurse educators to be more involved with the clinical teaching of their students and to be up-to-date with current nursing practice. In their argument for competency-based nursing education (CBE), Gruppen, Mangrulkar, and Kolars (30) explain that CBE is driven by professional competencies that enable the integration of clinical practice and clinically driven assessments within a nursing programme. Integrating CBE in the BScN programme at the Muni University will inevitably force nurse educators to be updated with the current clinical practice, engage in best available evidence and drive for clinically driven assessments (31). In addition, this would improve the presence of nurse educators within the clinical practice environment hence improving the quality of clinical education for undergraduate nursing students. However, with this approach, educators may feel challenged and incompetent due to lack of updated clinical skills.
Students enrolled in a higher qualification program may be perceived as threatening and intimidating to teach. The participants in this study revealed their fear of being undermined by undergraduate students. Research confirms fear and intimidation as a barrier to authentic learning for nursing students and genuine clinical teaching by the nurses in practice (32)(33)(34). Rebeiro, Edward, Chapman, and Evans (35) explains the origins of such fear as linked to power dynamics amongst the nurses in practice, who ordinarily leverage on their experience and expertise as power over nursing students. The fact that the undergraduate nursing students are enrolled for a qualification higher than the nurses in practice threatens this power dynamic and is evidenced by the general fear and intimidation (36). The nurses in practice retaliate to this perceived threat to their power through creating a hostile environment for learning, ignoring undergraduate nursing students and in some cases executing unnecessary punitive measures. Halman, Baker, and Ng (37) (38) warn that the other non-nursing professionals need to be aware of the expected professional and educational outcomes of the undergraduate nursing students before they can be engaged 18 to teach them. Awareness of the professional and educational outcomes enables the nonnursing facilitators to pitch their educational sessions appropriately for the benefit of the undergraduate nursing students.
Typical of resource-limited environments is the lack of resources to facilitate clinical teaching. This lack of resources has been demonstrated to affect the quality of clinical teaching and the overall clinical education of all health professions education programmes. The participants in this study perceived a lack of resources for clinical teaching which influenced their ability to teach undergraduate nursing students. Linegar, Whittaker, and van Zyl (39) reflect on the essentiality of training institutions or teaching hospitals to be accredited using a set of minimum accreditation standards that reflect clinical resources. Only accredited institutions would then be used for the clinical teaching of students. However, Bates, Schrewe, Ellaway, Teunissen, and Watling (40) explain that some resources would never be available and further implore nursing education institutions to engage contextual driven-programmes. In his argument for contextually driven-programmes, Obadeji, A. (41) states that in addition to designing health professions programmes aligned with the local disease profile, education institutions should also design programmes based on locally available resources.
Contextually driven-programmes move away from Western-generated or global prototypical programmes which often create gold standards that are not based on contextual realities.

Conclusion
University-based nursing degree programmes have been demonstrated to produce graduates who can positively influence the health outcomes of the patients under their 19 care. In as much as these programmes are underpinned by strong quality assurance mechanisms within the university and from professional regulation, the clinical teaching within such programmes remains a challenge within low resource settings (28). In these settings, the nurses in practice do not have university degrees but are expected to be engaged in the clinical teaching of the nursing students enrolled in university-based nursing degrees.
Through qualitative research, we explored the perceived readiness of nurses in practice for the clinical teaching of students enrolled in a University-based nursing degree programme. In as much as the nurses in practice perceived themselves to be ready to engage with the students enrolled at university-based degree programmes, several other issues were expressed as influencing their perceived readiness. These issues included their perceived competence, the perceived attributes of the students and the clinical practice environment.
Several recommendations are made to proponents of university-based nursing degree programmes in low resource settings, namely that; -Continuing Professional Development programmes tailor-made to the nurses in practice regarding clinical teaching must be developed and implemented; -Competency-based nursing education grounded on contextual realities and needs should replace content-driven programmes and underpin the design and development of undergraduate nursing programmes to enhance the practical abilities of educators and students; -Students in university-based degree programmes should be exposed to the clinical environment earlier within their programmes, and 20 -Universities must harness and fortify opportunities for interprofessional and transprofessional education for their undergraduate students.
The findings of this study may have been influenced by several limitations, namely that only nurses in one placement site were used to inform the findings of this study. The voices of other health professionals involved in the clinical teaching of nursing students could have been explored to enhance the quality of the study findings. Nevertheless, lowand middle-income countries must promote quality education of nurses and the introduction of university-based nursing degrees offers opportunities to improve health outcomes and improve the status of nursing. The nurses in practice bear the potential of influencing and improving the quality of the education of students enrolled in universitybased nursing programmes.