Background

Clinical education is an integral part of the nursing curriculum in which students synthesize the profession’s knowledge, skills, attitudes, values, and philosophies, accounting for about 50% of the nursing curriculum time (1, 2). Clinical education aims to acquire professional skills and set appropriate stage for use at the time of clinical care. At this stage, students experience the clinical setting by learning clinical activities and are guided toward the relationship between theory and practice to solve complex healthcare problems and provide safe care with critical thinking (3). On the other hand, nursing schools are supposed to train nurses who are able to provide clinical services based on the latest scientific advancements and can satisfy the patients’ needs with sufficient knowledge and clinical skills (4). Weak planning in this regard will create problems, leading to weak professional skills and decreased efficiency of graduates (5). The nurturing of competent nurses without appropriate clinical education is a far-reaching goal, and the presence of any problem in clinical education compromises its efficiency and effectiveness (4). The results of Torabizadeh et al.’s study indicated a direct and significant correlation between the use of educational behaviors by clinical instructors and the effect of these behaviors on nursing students’ learning. In terms of the amount of applying educational behaviors, the areas of teaching ability and personality traits, and in terms of effectiveness and learning, the areas of teaching ability and evaluation achieved the highest and lowest priority, respectively (6). In Shoja et al.’s study, the challenges of clinical education were determined in six main areas: Instructors’ insufficient mastery of clinical departments, students’ insufficient preparation to enter internship, lack of support from staff for students, lack of a codified educational program for clinical education, lack of a specific model for clinical assessment, and lack of patient cooperation and trust toward the students (7).
In the meantime, it seems that there are still some issues inhibiting students from effective learning because they cannot practically implement what they have learned. Even students who are theoretically well knowledgeable, most of the time face problems at the patient’s bedside and are not able to provide care and perform skills independently. Neglecting clinical education will lead nursing students to not perform proficiently in the clinical setting despite having sufficient theoretical knowledge, and by entering the treatment and healthcare system, the quality of service provision will lessen over time. Clinical internships are extremely important in the formation of professional identity and are indeed called the heart of nursing professional education. Nursing clinical education is an integral part of theoretical education and both complement each other. Clinical education is simultaneously different and very complex. The existence of standards for clinical education management and also the evaluation of factors affecting these standards will help narrow the gap between theoretical and clinical education and the nursing students’ process of achieving competence and will culminate in nurturing proficient nurses in patient care (8).

Overall, clinical education standards are related to five areas, including clinical instructors, students, educational programs, resources and facilities, and teaching-learning activities (9), which are assessed by internal and external evaluation programs in nursing faculties. However, it should be stated that clinical nursing education in clinical education centers in Iran is not at present at the acceptable level of these standards and is encountering many challenges. Therefore, conducting any research in this field can be a window to the realities or solutions to solve available problems in the future (10).

Objectives

According to the cases mentioned above and the importance of the topic, the current research was conducted aiming to determine the factors affecting clinical education standards in nursing in Iran.

Methods

This study was a systematic review conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement (11). In line with the research objective, the ProQuest, Magiran, Scientific Information Database (SID), ScienceDirect, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, and PubMed databases were searched and Persian and English articles conducted during the last 15 years (2007-2022) on nursing clinical education and factors affecting its standards in Iran were reviewed. The reason for selecting this period of time for studies was that the researchers sought to collect up-to-date and new information about the factors affecting the standards of clinical nursing education and to investigate a broad spectrum of information, factors, communications, and changes related to the topic. Moreover, the selection of articles from different periods of time can enhance the variety of information in review articles, contributing to a more extensive analysis and a more comprehensive evaluation of the topic. For searching related articles in the databases, appropriate keywords were initially selected from medical subject headings (MeSH), and then a search was performed using the keywords “Clinical nursing education, Nursing student, Clinical nursing education factors, Clinical nursing education problems, Clinical nursing education challenges, and Clinical nursing education standards” in Persian and English using the two operators AND and OR for 20 days from the 21^st January to the 9^th February 2023.

Based on the Patient, Intervention, Comparison, Outcome (PICO) criteria, the inclusion criteria for the present study include Persian or English language, type of article (descriptive, qualitative, review, and descriptive-analytical), access to the full text, the population under investigation (nursing instructors, nursing students, and nurses), the research subject (direct relationship with clinical education), the place of conducting research (Iran), and the article publication time (2007 to 2022). The exclusion criteria included the article language other than English or Persian, the article type (other than descriptive, qualitative, review, and descriptive-analytical), such as interventional articles, meetings, and letters to the editor, lack of access to the articles’ texts, absence of nursing students or graduates in the investigated samples, the lack of relationship between the research topic and the current research’s objectives (factors affecting clinical education standards in nursing), such as studies on theoretical education in nursing, conducting research in other countries, and articles published outside the intended time period (2007 to 2022). All searched articles were reviewed by two researchers and any disagreements were reconciled via discussion between them and according to the research objectives.

The article selection process was performed based on the following protocol:

• Searching articles (titles with or without abstract)
• Assessing the relationship between the article’s abstract and the study objectives
• Assessing the article’s full text and its relationship with the study objectives
• Performing main screening (in terms of the sample size, the study year, the related field of study, the field under investigation, the quality and methodology of the studies obtained by two researchers)

Detailed evaluations were carried out by two researchers independently based on the checklists related to the methodology of each research [the Strengthening the Reporting of Observational Studies in Epidemiology (STORBE) statement for descriptive studies, Consolidated Criteria for Reporting Qualitative research (COREQ) statement for qualitative research, and the PRISMA statement for review studies] and studies that gained less than 80% of the scores of these checklists were excluded from the study. After reviewing the articles, 30 articles were finally entered into the research (Figure 1). The intended data were then extracted from the qualified articles and recorded in Excel software. The data extracted from the articles encompassed the following sections: The authors’ names, the study year, the study language, the study type, the study title, the sample size, and the summary of results.

In the current research, the data were analyzed using the content analysis method. Two researchers extracted and classified the results of the articles independently, and the data accuracy was assessed by the process double check by another researcher in the research team. Then, the data collected from the articles were organized in the relevant tables.

Results

The results obtained from various studies on the factors affecting clinical education in nursing in Iran, which also influence clinical education standards in nursing, are summarized in Table 1. It is worth mentioning that the articles used in the present research consisting of 14 English and 16 Persian articles have been arranged according to the publication year and provided in Table 1.

In the present research, the factors affecting clinical education standards in nursing were classified into several primary and secondary areas and based on priority. The three primary areas include educational goals and planning, educational process, and educational structure, each of which has its own secondary areas prioritized in Table 2 according to their repetition and importance in previous studies. In the educational goals and planning area, 9 factors affecting clinical nursing education had been mentioned in the investigated studies, the most important of which include the presence of a codified educational program for clinical education (13 articles), the presence of a specific model for monitoring and evaluation
(9 articles), and the university and hospital clinical education coordination (the short practical period before entering the hospital, the longtime interval between the practical period and entering the hospital setting) (9 articles).

Figure 1. The article selection process based on the Preferred Reporting Items for Systematic Reviews and
Meta-Analysis checklist

Table 1. Studies on the factors affecting clinical education standards in nursing in Iran

Table 2. The most important factors affecting clinical education standards in nursing in Iran

In the educational structure area, 10 items were mentioned, the most important of which are interactions (the relationship between instructor and student, the relationships of student and instructor with hospital staff) (14 articles), educational environment and facilities (13 articles), and students’ personal traits (attitude, fear, and self-confidence) (10 articles). Furthermore, the educational process area included 12 related factors affecting clinical education in nursing, the most important of which are the instructor’s mastery of educational content and appropriate clinical practice
(9 articles) and the instructor’s respectful behavior toward students (9 articles).

Discussion

The present systematic review was conducted aiming to determine the factors affecting clinical education standards in nursing in Iran, and the factors affecting clinical education standards in nursing were divided into three general areas: Educational goals and planning, educational structure, and educational process. The most important cases in the educational goals and planning area were the presence of a codified educational program for clinical education, the presence of a specific model for monitoring and evaluation, and university and hospital clinical education coordination. In the educational structure area, the most important affecting factors included interactions (the relationship between instructor and student, the relationships of student and instructor with hospital staff) and educational environment and facilities. In the educational process area, the instructors’ mastery of the educational content and appropriate clinical practice and the instructor’s respectful behavior toward students are among the most essential factors affecting clinical education standards in nursing.

In the current research, the most crucial factor in the educational goals and planning area was related to the presence of a codified educational program for clinical education. Educational planning programs and methods affect the clinical education manner and depth and the staff under training and help the clinical education development and progress process (37). In Delaram’s study, educational goals and programs were also among the most crucial strengths of clinical education (38). Since clinical education is practice-based, it requires precise and coherent educational planning to provide students with the opportunity to develop clinical skills. Hence, clinical education will fail without precise and correct planning (37).

The presence of a specific model for monitoring and evaluation was another important affecting factor in the educational goals and planning area. Some of the clinical evaluation challenges include the non-uniformity of the assessment process, not applying modern assessment systems, impairments in objective assessment, and instability of the used tools (39). Conducting an assessment impacts motivation and it can particularly affect the learners’ willingness to accept responsibility for learning, independent progress, and display constant motivation in learning (40). Thus, assessment is the main factor in achieving the final goal that an individual seeks by performing a task (41).

Coordination between university clinical education and hospital clinical education is also one of the significant factors affecting clinical education standards in nursing in Iran. One of the chief missions of the nursing faculty is nurturing proficient and efficient human resources. Before entering the real clinical setting, nursing students must have received the required and sufficient education in the faculty and have been assessed appropriately (25). Previous studies also regarded the appropriateness of the educational setting regarding required facilities and equipment, enough time and opportunity to repeat clinical skills, and the presence of a rational time interval between learning the clinical skills in the practical and clinical setting as essential for effective clinical education (25, 42, 43).

Other important factors affecting clinical education standards in nursing in Iran include the relationship between instructor and student and also the relationships of student and instructor with hospital staff. In Jahanpour et al.’s research, the instructors’ interpersonal relationships were also mentioned as a chief theme affecting clinical education (44). Furthermore, in Moridi and Khaledi’s study, the most important factor facilitating learning clinical skills among students in the field internship was the relationship between instructor and student (45). In this regard, it can be stated that benefitting from capable instructors with high communication skills is helpful in order to enhance students’ motivation and interest in clinical education and resolve existing challenges (32). Training communication skills to students with an emphasis on the difference between the classroom and the clinical setting can also be very beneficial (7).

Another affecting factor is the importance of the clinical education environment and facilities, which has been mentioned in numerous studies. Some studies report students’ dissatisfaction with educational facilities. One of the most important clinical education problems reported in the studies conducted by Aboutalebi et al. (5) and Rezakhani Moghadam et al. (36) is the shortage of welfare and educational facilities for students. The presence of appropriate space and required facilities to implement care procedures, as well as physical and environmental security, is one of the significant and influential prerequisites in clinical education, which should be provided by educational institutions based on the existing standards. The conducted studies also indicate that special attention should be paid to equipment and facilities (46).

In the present research, the most important factors affecting clinical education standards in nursing in the educational process area are related to the educational instructors’ traits. A nursing instructor is the most important factor and role model in learning and can play a vital role in training students by recognizing his/her profession carefully, leading to fostering students’ self-confidence and self-esteem (47). Improving the performance of clinical instructors requires equalizing the teaching principles with the learning principles. It is worth mentioning that since students are always dissatisfied with the low quality of the teaching process, emphasis must be placed on the importance of education, high quality of new instructors’ performance, instructors’ continuous professional growth, careful evaluation of instructors’ teaching, and the adoption of managers who change management strategies effectively (48). In addition, the instructors’ inappropriate behavior can lead to reducing students’ self-confidence and motivation (49). Given the cases mentioned above, educational planners need to pay attention to the clinical instructors’ educational role, increasing the number of consultants to monitor the activities of instructors and students, and also enhancing instructors’ motivation to provide more effective clinical education in order to promote the quality of clinical education.

Limitations: One of the limitations of the current study was that the factors affecting clinical education standards in nursing were examined only from the perspectives of nursing students and clinical instructors. Moreover, due to the lack of access to the full texts of some articles, some factors affecting clinical education standards in nursing may not have been evaluated in this research.

Conclusion

According to the results of the present research, it can be stated that the key actions to help improve nursing clinical education and its standards encompass preparing a codified educational program for clinical education and improving instructors’ performance and skills for training nursing students. Also, the presence of a specific model for monitoring and evaluating students and the use of a modern assessment system by instructors can have considerable effects on improving nursing students’ learning. Furthermore, trying to find strategies to elevate cooperation and improve interactions between nursing staff and nursing students and providing an appropriate learning environment can culminate in increasing nursing students’ motivation and improving clinical education standards in nursing.