INTRODUCTION:

Nursing education involves both theoretical and practical training processes (1, 2). Nursing is a practice-based discipline and therefore learning must be mostly in clinical settings with qualified instructors (3, 4). Clinical education is an essential and indispensable part of professional nursing education (2, 3). It provides nursing students with opportunities to acquire professional knowledge and skills for professional situations; with competencies for patient care and how to think and act like professionals (5, 6).

Evaluation is central to any educational program, but is particularly critical for nursing education to ensure that nurses are safe and competent practitioners (7). In all areas of nursing education, evaluation is important for obtaining information about students’ learning to judge their performance and subsequently to determine their competence to practice (5). In clinical evaluation, teacher assesses the extent of the student’s learning and quality of performance in clinical practice (8).

Any clinical evaluation program aims to facilitate the development of students into safe, ethical and accountable practitioners and to benchmark the students’ progress towards achieving clinical learning objectives (1, 9).

The clinical performance evaluation of nursing students is a long standing challenge. In recent years, ever increasing research interest has been devoted to this issue (1, 10). Problems in clinical evaluation are reflected in the complaints of nursing students; some manifestations are contradictory reports in clinical evaluation and frequent meetings with students and nursing instructors to discuss the problems (11). Some authors have mentioned that honesty, consistency across settings and teachers, and clinical indicators that depict the realities of practice and education are necessary in clinical evaluation (1, 12). Woolley, et al (1998) delineated the rights of students and the responsibilities of clinical faculty regarding performance evaluation (13). Bourbannais, et al (2008) said that faculties must be mentored to develop their observations in a logical fashion and implement strategies to improve student learning (1).

Evaluation by clinical educators has always been the subject of concern for nursing students. How well clinical educators evaluate students and how they provide feedback in clinical practice settings are important aspects of clinical teaching effectiveness (14). Therefore, it is necessary to conduct further investigations in this filed, especially from nursing students` point of view. This study was aimed to investigate the experiences of nursing students towards the role of clinical educators as evaluators.

MATERIALS AND METHODS:

This was a descriptive qualitative study. Qualitative descriptive designs are often eclectic and based on the general premises of naturalistic inquiry. These designs present comprehensive summaries of a phenomenon or events in everyday language (15).

This study was carried out on BSc nursing students. Participants (n=40) were purposively selected from nursing and midwifery schools of three Universities of Medical Sciences in Tehran (Iran) in their third and forth year of education, based on their experience of the clinical evaluation.

Data were collected through focus group interviews as well as audio taping and taking field notes. A semi-structured format was used for 6 focus groups conducted by a moderator and a note-taker. Interviewers met students in quiet and private classrooms. Interviews lasted between 60-75 min. Since students felt more comfortable with their counterparts, rich data were generated through their interactions.

Data were analyzed using content analysis (15). After each focus group interview, as soon as possible, the recorded data were transcribed verbatim. The data were double-reviewed by researchers against the recorded data to increase the data precision and the proficiency of researchers over data for good interpretation. Meaning units were then found, and the related codes were determined and subcategorized based on their similarities. The subcategories were put into categories to reveal themes (16).

To gain trustworthiness; credibility, dependability, conformability and transferability were considered. So there was a prolonged engagement with the subject, the findings were member- checked, and the participants were selected from different years of education. The activities were recorded precisely, and findings were confirmed by some students out of the study (15, 17, 18).

Purpose and procedure of the study were fully explained verbally to all participants. They were aware of recording of the interviews, and their right to refuse participation without any negative consequences. They also were assured of data storage and confidentiality. Written informed consent was obtained from all participants.

RESULTS:

The content analysis of the participants’ statements resulted in four themes related subthemes (table 1).

Table1. The themes and subthemes of the students’ perception of

the clinical educator as an evaluator:

Themes

Subthemes

1. Professional issues

2. Emotional environment

3. Basis of evaluation

4. Timing of evaluation

a. Role model

b. Specialist and expert

c. Consistent

d. Being Present

a. Relationship

b. Interest

c. Justice

a. Performance

b. Assignments

a. Formative evaluation

b. Summative evaluation

Theme1. Professional issues:

This theme focused on the professional qualities of the educator and included the following four subthemes: role model, specialist and expert, consistent, and being present.

a. Role model:

The students believed that their educator should be a role model i.e. the educator should first do the work before expecting them to do so. However, the students were disappointed by this aspect and did not believe that they could learn and then be evaluated appropriately. One of them claimed:

“For example, during the heart examination, I expected my educator to attend, do the auscultation and teach me how to listen to heart sounds, but this did not happen”.

b. Specialist and expert:

In the viewpoint of students, the educator should be a specialist and expert in the ward. Students said that the educator should be skillful at working in the ward to teach and evaluate them, but these qualifications were generally not present:

“In the emergency ward, there was a psychiatric nurse that acts as our educator, who had no experience of working in the ward. This could affect our education and evaluation adversely”.

c. Consistent:

Students believed that educators should possess a certain level of consistency. They said; when they were divided into 4 -5 groups for clinical education, the groups might have different educators with different teaching approaches in the same clinical course. Some educators emphasize on the theory and theoretical evaluation, while others evaluate them based on simple routine procedures which resulted in difference in students` evaluation.

d. Being present:

The presence and engagement of educators while working with the students were emphasized. Students stated that, in addition to be expert, educators should use their skills to educate students. Also because the students were under continuous observation when the educators were present, this should provide an accurate idea of the students’ performance; however, this does not always happen. One of them said:

“There were times when we had completed all of the work and would just sit to relax. The educator would arrive and think we were sitting all the time doing nothing. It had a very bad effect on our evaluation”.

Theme2: Emotional environment:

The relationship of educators with students, how they relate to the students’ self-esteem and express their interest in nursing by providing care along with students and being fair in the evaluation were repeatedly mentioned by all student groups. This theme consisted of 3 subthemes: relationship, interest and justice.

a. Relationship:

Participants were concerned about their relationship with the educator. Some of them complained that the most significant problem they confronted was relationship with and a lack of support from their educator. Students complained that some educators showed no respect for them even in the presence of clients and clinical nurses. One student claimed:

“They see us as problem makers and show it everywhere. This provides us with a lot of stress and we are the ones who never do the right thing and are blamed”.

The students concluded that these behaviors lowered their self-esteem and adversely affected their evaluation. They noted that the behavior of their educators even affect others behavior towards them. One of them said:

“Respect mostly depends on the educator. When we first enter the ward, if the educator respects us, every other person in the ward will do the same”.

b. Interest:

Another point noted by students was the educator’s interest in working as a nurse and working as a clinical educator. They emphasized that the educator is the most important person in their learning and evaluation. One of them stated:

“A confident and interested educator can transfer the interest to us. So, students will work harder and get better scores”.

c. Justice:

Almost all students emphasized on the necessity of justice in the evaluation. But they complained of precalculated scores and said that some educators had a fixed range of scores. They believed this causes injustice in scoring:

“Evaluation should persuade weak students to work harder, but when our scores are all in the same range, what is the difference? Both weak and strong students will lose their interest”.

Theme3. Basis of Evaluation:

This theme focused on the issues that the educator must consider as the basis for the students’ evaluation and consisted of performance, assignments, and expectations.

a. Performance:

Students generally believed that their evaluation should correspond with their performance in the ward. However, some believed that the evaluations were mostly based on the theory exam in the ward. The necessity of a practical evaluation was considered in the following statement of a student:

“When we are talking about the clinical course, it means practice, not theory. Instead, at the end, they take a theory exam of theoretical subjects that the educator told us during the clinical course, and this is our score in practice”.

b. Assignments:

Students stated that, in clinical education, assignments should provide the practicality of the knowledge in practice. However, most students felt that the assignments were mostly theoretical and written, which turned clinical education into theoretical education. One of them claimed:

“We have conferences in the ward. In fact, the same subjects taught in our classes are repeated in these conferences”.

Theme4. Timing of the evaluation:

This theme considered whether the evaluation was conducted at an appropriate time and included a formative and summative evaluation.

a. Formative evaluation:

Some students emphasized on a step-by-step evaluation but did not use the exact term of formative evaluation. Students believed that an evaluation through the stages of clinical education could improve their performance, but some of them complained of the lack of this kind of evaluation:

“But we are evaluated only at the end of the clinical course, ‘good or bad,’ and there is no time for us to change”.

b. Summative evaluation:

On the other hand, some other students did not use the term summative evaluation; although they believed that their final evaluation must be done immediately after the clinical course because time may decrease the accuracy of the evaluation. A student said:

“One problem in our final evaluation was that sometimes it is delayed even one to two months after the clinical course. The educator must do this on the last day of our course. She/he must review our work and evaluate us at the same time”.

DISCUSSION:

Findings of this study showed that students feel that there are certain characteristics in educators that affect their clinical evaluation.

An important issue which almost all students noted was the role model necessity of the educator. The students stated that, during the clinical course, observing the educator’s performance and behavior is an essential factor for learning. Therefore, in evaluation, the educator can expect the students to do the same things; however, students mostly believed that they do not have such an opportunity. In a study conducted by Lee, et al (2002), students believed that to be a good role model was the most significant characteristic of clinical educators (14).

Furthermore, they concluded that the educators’ specialty and expertise were very important to the students. The students thought that educators must know how to work in the ward and only in this situation educators could teach effectively. However, most students believed that these qualities were not present. It is said that educators need to be clinically credible to effectively teach up-to-date nursing and have the knowledge and skills of caring for patients in both routine clinical procedures and advanced techniques but some students considered some educators to be separate from practice and lacking clinical credibility (19, 20).

Participants in this study believed that consistency in the performance of educators is necessary. However, students thought there were inconsistencies between the evaluation performance of different educators and even different evaluations of one educator. In some studies, students stated that there were differences among educators that adversely affected their evaluation. They believed that educators had different ideas and criteria, and the resulting inconsistency in the assessment process was an important issue (2, 21). The participants emphasized on the importance of educator`s attendance, involvement in the ward and working with students. Also they believed that regular observations performed by educators, over their performance results in better evaluation. In a study conducted by Meskell, et al (2009), they emphasized on the involvement of educators in clinical settings and their active interactions with students (19). They indicated that the educator’s clinical presence would assist in providing better supervision and support to students. Furthermore, McSharry and Murphy (2008) emphasized the value of regular visits to assess the mechanism and performance of caring interventions conducted by students (22).

An important challenge emphasized by the majority of participants was the relationship between educators and students. They complained that they have expected some respect but did not get it. It is believed that students value those clinical teachers that like them and show empathy; thus, teachers should encourage a climate of mutual respect (14). The level of mutual respect between teachers and students can enhance the success likelihood of any learning experience (12). However, in a study conducted by Elcigil and Yildirim Sari (2007), students indicated that they cannot always communicate easily with their educators, pointing out that they found their educators inaccessible (2). Another interesting point mentioned by students in the present study was the educators’ interest in nursing and education. Some students believed that confidence and interest were essential characteristics of educators. When educators are not interested in what they are doing, it can decrease the students’ motivation. Previous studies emphasized that having willingness to teach, do extra work, take responsibility, devotion to students and self-confidence shows the educators’ interest in their job (14, 19). Justice was another important issue in the evaluation. Students complained of a subjective evaluation and injustice in the evaluation by their educators. Cassidy (2009) mentioned, providing a consistent and honest evaluation of the students’ performance in clinical settings is a critical part of a rigorous assessment (12). Furthermore, Meskell, et al (2009) believed that the major challenge of any assessment process is performing objective measurement. They also indicated that, assessment of clinical competency is particularly difficult (19). While (1991) believed, the issue of uniformity and unbiasedness in the measurement of behavioral skills constitutes an ongoing debate of clinical evaluation (22).

The participants of this study contended that evaluation should be based on their practical work; however, most students believed that the evaluation is often based on the theoretical examinations. Students complained that even assignments were not practical and clinical education was theorized. McCarthy and Murphy (2008) stated that a part of the curriculum design of any nursing educational program is to ensure that the methods of assessment reflect the content, structure and learning outcomes of the program, and assessment of the students’ clinical competence should include both theory and practice (7). In addition, it is stated that the clinical evaluation in practical disciplines involves a direct observation of students engaged in the actual practice and other strategies, such as anecdotal notes and care plans (1).

Although the participants did not use the exact terms of formative and summative evaluation, some discussed these issues in their own words. The students emphasized on the need for evaluation at some stages to correct and improve their performance. They also emphasized that final evaluation should be conducted immediately after the clinical course. Studies show that feedback makes students aware of their deficiencies and provides a chance for self-development and improved future performance (2, 23). Clynes and Raftery (2008) explained that formative feedback is ongoing and summative feedback takes place at the end of a clinical course and includes the grading of the clinical performance (24).

Determining nursing students` achievements in clinical education is an important role of clinical educators. The educators` characteristics and behaviors influence the evaluation process of students in clinical settings. It is clear that students have specific view and opinions about this important issue. Students express some difficulties with their clinical evaluation by educators. They discussed their experiences and opinions of being evaluated by their clinical educators and mentioned their expectations of clinical educators as evaluators and the challenges they were confronted with. Students are the ones being evaluated. Therefore, to eliminate the challenges of the clinical evaluation, the students` opinions should be considered in nursing schools by individuals planning clinical education, especially educators.

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