Teaching and learning in international nursing programmes are also not always as effective in facilitating the nursing skill development of students as they could be. This is reflected in a qualitative study by Corlett (2000) that investigated the theory-practice gap in nursing education through the shared perspectives of 69 British participants that consisted of nurse teachers, student nurses across three years, and clinical preceptors. The results of 23 group interviews showed all groups of participants felt this gap does exist. It was not always seen as a lack of knowledge, but was perceived as a difficulty that was experienced by students when attempting to apply principles to practical situations. It was argued that what the teacher had taught was seen as an idealised knowledge version, which often did not fit with the reality of practical situations. Preceptors and students in this study also described the difficulty in trying to manage effective teaching and learning, based on the shortness of practical placements and the workloads of preceptors. These factors were perceived as compounding conditions that deterred students and preceptors from working together. Similarly, an Iranian study (Sharif & Masoumi, 2005) that investigated the clinical experience of 90 nursing students from the second to fourth year, using focus groups, reported that students were unable to integrate what they learned in theory into real clinical situations. This was most reflected in the literature derived from clinical teaching and learning situations, both related to nursing instructors/preceptors/ward nurses and to the nursing students who had to learn in those clinical environments. The reviewed literature is, therefore, grouped in two sections addressing the clinical teaching and practical environment, and
32 student competencies.
CLINICAL TEACHING AND PRACTICAL ENVIRONMENT
Although nursing skills are mainly developed by clinical experiential learning (Napthine, 1996; Nolan, 1998), a number of international studies (Brammer, 2006; Hsu, 2006; Pearcey & Draper, 2008; Sharif & Masoumi, 2005) reported that clinical teaching, and practical environments are unsupportive of student learning. Sharif and Masoumi (2005) found that the ward staff were not concerned about what the students had to learn; they were busy with their duties and unable to act in both educational and service roles concurrently. Some staff were not aware of the skills and strategies which are necessary in clinical teaching and were not prepared to act as clinical instructors.
The issue of not paying attention to the teaching of nursing students was apparently confirmed by Brammer (2006) who explored the understanding of 30 registered nurses (RNs) about their role as facilitators of student learning in Australia. She revealed some registered nurses (RNs) perceived that students were not their responsibility, so they tried to avoid teaching students and were not interested in the students‘ learning. However, Brammer also identified a range of beliefs of RNs about how students learn that influence student learning opportunities. Some RNs believed that students would learn by being controlled and they needed to manage the learning opportunities of students, resulting in students having to learn under the RNs‘ expectations. Other RNs thought that students learn by completion of an allocated workload as time permits and liked to control student experiences with close supervision, without allowing any independence. They were also likely to allocate lower acuity patients to students as they felt students were capable of coping with these. The RNs who considered that students are future peers believed they have to assist students to learn the reality of nursing in order to prepare them as RNs. As a result, some students might have extended learning experiences while others will have limited learning opportunities. Nevertheless, by learning with different RNs, nursing students have to adapt themselves to the variety of characteristics shown by their facilitators at different times.
Research indicates that clinical nurses are not always good role models for students in relation to patient care. For example, Pearcey and Draper (2008) in a grounded theory study, identified core concepts of the clinical nursing environment through the views of
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12 British first year nursing students, representing 21 wards and five hospitals. Based on four weeks clinical placement experience, the students reflected on nursing, viewing it overall as paperwork completing, rather than reflecting personal values such as communicating, listening to patients. They explained that the nursing care that nurses provided for patients was implied in written documents instead of being implemented in practice, e.g. that several nursing care activities were done without verbal interaction. Nurses focused on tasks and routine work, but left caring for patients to auxiliary nurses. They were very concerned that they had to finish their tasks or routine work in- time, and that every activity was to be completed as quickly as possible. The participants thought that nurses focused on tasks, rather trying to find out what patients wanted. However, they made use of negative experience they had seen at settings to remind themselves that they did not want to become uncaring nurses. That staff nurses were not always good role models was also found in Sharif and Masoumi‘s (2005) research. It revealed that the students thought that some nurse work was ―not really professional nursing‖. They were confused by what they had learned in the faculty and what actual clinical practice was expected from them. The students also noted that they should have opportunities to provide nursing care as the professionals should do, and not just do the auxiliary nursing tasks that anyone can do.
Regarding training nursing students, it has been argued that not only clinical nurses, but their instructors also contributed to the unsuitable learning contexts. This is reflected in a Taiwanese study (Hsu, 2006) where the behaviours of 10 teachers were observed during regular clinical teaching time. All of the teachers had Master‘s degrees and the ratio of teacher per students was 1:10. The observations took place in the second or third week of four practical weeks in medical-surgical units. They included watching activities, recording, and listening to conversations; each teacher was observed for two days (16 hours). Preliminary findings were also validated by participants. The observations supported the notion that the educators were more focused on task completion than an awareness of the necessary nursing skills their students had to develop. They primarily emphasised routine work and took only a few opportunities to stimulate and develop students‘ critical thinking skills. Most teachers frequently focused their questions on treatment and pathophysiology, rarely touching on nursing care questions. Some of them had gaps in theoretical knowledge; i.e. they did not know exactly how to provide nursing care for some patients. A few clinical teachers focused
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only on supervising their students on how to perform procedures, but ignored patient concerns. Even in arranging enough learning experiences, seven teachers did not assist their students. However, some educators did give feedback after students completed tasks for patients; two of them provided opportunities for students to reflect on their clinical learning experiences. Others led theory discussion in relation to nursing care that students provided. They sometimes also asked students about the independent nursing care they should provide for their patients. Two teachers demonstrated emotional support when their students encountered stressful situations during clinical practice. Furthermore, in a related study by Sharif and Masoumi (2005) also found most students perceived that their instructors played a more evaluative role than a teaching role.
The clinical teaching and practical environments reported in these studies were not optimal for facilitating the nursing students‘ learning. Although students were in a variety of nursing care situations, when the clinical nurses and nurse instructors were not aware of skill training or not good role models of caring, learning opportunities were limited. Clinical skills not only relate to task implementation, but also the understanding of patients‘ problems and making appropriate decisions to respond their nursing care needs. If students spend most of their time assisting nurses with tasks, then little time is allocated to the development of other essential clinical skills such as problem solving abilities, and decision-making skills that are the heart of professional nurse work. Practical placements based in unsuitable clinical teaching environments cannot maximise the nursing skill development of the students.
STUDENT COMPETENCIES
Another point that must be taken into consideration when trying to understand learning conditions in international contexts is student competencies. For instance, several studies identified that international nursing students may have low skills in critical thinking (Shin, Ha, Shin, & Davis, 2006; Suliman & Halabi, 2007; Zhang & Lambert, 2008) and assertiveness (Begley & Glacken, 2004; Çelebioğlu, Akpinar, Küçükoğlu, & Engin, 2010), but also noted that these are required for nursing studies and nursing work. Regarding critical thinking skills, a descriptive study in Korea that assessed this ability of 301 senior students in three undergraduate nursing programmes—Associate Degree in Nursing (AND), Bachelor of Science in Nursing (BSN), and Registered
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Nurse-Bachelor of Science in Nursing (EN-to-BSN)—showed average scores of 41.59 on the Watson Glaser Critical Thinking Appraisal (WGCTA) tool, in comparison with nursing studies published in western countries that reported scores ranging from 50 to 61.1 out of a maximum of 80 points (Shin et al., 2006). The researchers explained that the lower scores occurred because of two reasons. Firstly, the educational objectives of nursing programmes in Korea did not fully focus on improving students‘ critical thinking skills during either the theoretical sessions or the clinical course. Secondly, they are also not clearly reflected in the overall nursing education system. There was no set standard for the level of critical thinking that the students should achieve, or any measures of the ability. Korean nursing education, however, has since promoted new efforts to enhance critical thinking skill for decision-making in nursing community care (Shin et al., 2006).
Another study (Zhang & Lambert, 2008) investigated the learning styles and critical thinking dispositions of 100 Chinese baccalaureate nursing students. It revealed the most common dimensions of four learning styles the students preferred. These were a) being reflective or learning by thinking things through and preferring working alone, b) sensing or using a concrete and practical orientation toward facts and procedures, c) preferring visual representations of presented material (such as pictures, diagrams, and flow charts), and d) having a global style which is the use of a holistic thinking process and learning in large leaps. The overall critical thinking ability of the students was reported as a weakness in that the average total score of California Critical Thinking Disposition Inventory (CCTDI) was 272.82, which was lower than the established mean score of 280 as measured by the same instrument. This result was also lower than the scores of nursing students reported in previous studies conducted in western countries. The researchers considered this was because the students‘ learning styles, which were much influenced by the Chinese educational system from elementary school through to higher education, were unlikely to encourage them to think critically within a traditional nursing education programme. Chinese nursing students have tended to learn by focusing on memorising facts related to diseases, rather than engage in any form of clinical practice until the final year. They are also not likely to take part in debates or discussions related to nursing, ask questions during class, and synthesise information through writing scholarly papers or verbal presentations (Zhang & Lambert, 2008).
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To further exemplify this issue, another research project by Suliman and Halabi (2007) applied a cross-sectional design to explore the existing predominant critical thinking disposition(s) of 105 first year and 60 fourth year nursing students in Jordan using the same instrument as Zhang and Lambert (2008). They found that both groups held marginal overall CCTDI mean score of 284.93 for critical thinking. The graduating students showed higher scores than beginners. They anticipated that the critical thinking of these students would significantly increase from the beginning to the end of the programme, but the findings were not significant, even though the nursing education in Jordan used problem-solving as one method of instruction. However, it may still not have emphasised the affective/attitudinal dimension of critical thinking in the teaching of nurses.
In relation to the assertiveness that is necessary for nurses in effective communication, many recent studies e.g. Begley and Glacken (2004); Çelebioğlu et al. (2010) have pointed out that international nursing students are rather low on this competence as it was not well developed as they progressed through their course. This issue is supported in a study by Begley and Glacken (2004) who surveyed the assertiveness level of 59 Irish nursing students by asking them to complete a questionnaire in the first week they entered a nursing course and again when they were near to graduating from their three- year programme. They found that the mean score on the pre-course questionnaire was 69.87, whereas the post-course questionnaire score was 73.73 from a maximum 112 points.
Low assertiveness means persons do not have enough skill and capacity of interpersonal communication to refuse, request and express their thoughts without causing upset to others they valued (Alberti & Emmons, 2001). It is a compounding problem if students are subjected to ‗violence‘ as asserted in a descriptive study by Çelebioğlu et al. (2010). The study reported that 50.3% of 380 Turkish nursing students were subjected to violence during their clinical practice, and 91.6% of them were subjected to verbal violence. The most violence (53.4%) was caused by patients and their relatives due to anxiety, fears, and lack of confidence in students‘ competence. This was followed by nurses, doctors, and other clinical staff, also mainly due to lack of trust in their ability. After confronting violence, the students most frequently experienced anger, fury, and enmity (84.3%), followed by anxiety (81.2%). However, most of them (66.0%) did not
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react to patients and continued to provide them with nursing care.
Learning with a lack of critical thinking and assertiveness skills means the nursing students have limited opportunities to learn. Not being able to refuse what they do not want to do, ask for help, and/or express their thoughts, reduces learning. As well, nursing education that cannot support them to develop these skills makes their learning less effective. Poor assertiveness skills also create negative feeling experiences, which could lead to students not being confident or reassured in their learning. These can be powerful factors that prevent nursing students in developing their nursing skills as they should be.
Although learning conditions in the Thai college nursing programmes and international nursing programmes are somewhat different, they both tend to cause limited learning opportunities and unsupportive learning environments for students. A number of factors together mean the students have to develop their nursing skills in difficult learning situations, especially when they are at clinical settings. The issue about how they can learn in such conditions needs more investigation, particularly, more needs to be clarified about how the students who seem not to be ready to improve their skills (due to having rather low learning competencies) develop their nursing skills when they encounter conditions that do not facilitate them to learn.