Difficulties in Clinical Nursing Education: Views of Nurse Instructors'

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International Archives of
Nursing and Health Care
Dağ et al. Int Arch Nurs Health Care 2019, 5:114
Volume 5 | Issue 1
DOI: 10.23937/2469-5823/1510114
Open Access
ISSN: 2469-5823
Citaon: Dağ GS, Kılıç HF, Görgülü RS (2019) Dicules in Clinical Nursing Educaon: Views of Nurse
Instructors’. Int Arch Nurs Health Care 5:114. doi.org/10.23937/2469-5823/1510114
Accepted: January 01, 2019: Published: January 03, 2019
Copyright: © 2019 Dağ GS, et al. This is an open-access arcle distributed under the terms of the
Creave Commons Aribuon License, which permits unrestricted use, distribuon, and reproducon
in any medium, provided the original author and source are credited.
Dağ et al. Int Arch Nurs Health Care 2019, 5:114 • Page 1 of 9 •
Dicules in Clinical Nursing Educaon: Views of Nurse Instructors’
*
Nursing Department, Faculty of Health Sciences, Eastern Mediterranean University, Turkey
*Corresponding author: Gülten Sucu Dağ, Nursing Department, Faculty of Health Sciences, Eastern Mediterranean
University, Famagusta, North Cyprus via Mersin 10, Turkey, Tel: +90-392-611-13-31, Fax: +90-(392)-630-3940
Clinical educaon serves as one of the primary edu-
caonal experiences for nursing students and as such,
has been an indivisible part of the educaonal process
in all phases of nursing educaon history [2,4]. Clini-
cal educaon gives students the opportunity to learn
in real-life condions. Nursing students must be fully
prepared by both “knowing” the issues required for
nursing funcons and “performing” these funcons. It
is therefore important that students be prepared for
their actual professional roles in the clinical area. In oth-
er words, clinical educaon and learning are a primary
educaonal experience that helps students gain nursing
skills [5-8]. Clinical educaon gives students opportuni-
es to prepare for their future roles. These opportuni-
es include parcipaon in teamwork, decision-making,
assessments, problem solving, crical thinking, coping
with actual paents and their problems, and applying
theorecal knowledge in actual pracce [9-11].
Nursing instructors are responsible for creang
an environment that can help students reach their
educaonal goals. Learning outcomes are aimed at
achieving high cognive, aecve and psycho-motor
skill levels in the classroom, laboratory and clinical
area [12]. While it may dier from country to country,
clinical teaching in nursing educaon tends to be done
by instructors on the faculty of universies or schools,
by clinical educators working in hospitals, by clinical
nurse educators, and by nurses working in hospitals
[13]. However, it should be kept in mind that the most
important factor determining the quality of educaon
is the adequacy of nurses’ educators. The World Health
Organizaon emphasizes the need to address the
quality of nursing educaon in order to train competent
nurses equipped with the knowledge, atudes and
skills necessary to provide quality care services, and
Abstract
Aim: The study was conducted to determine the difculties
that nurse instructors’ experiences in clinical education.
Material and methods: This is a descriptive study.
The sample of this study was comprised of 199 nurse
academicians. A socio-demographic data collection form
and a survey on the difculties that nurse instructors’
experiences in clinical education form was developed by
researchers to be used for data collection in an electronic
environment.
Results: It was determined that the difculties of nurse
instructors’ experiences included having a heavy workload
(41.7%); providing clinical practice area (30.29%); having
an excessive number of students (64.8%); being able to
implement the nursing care plan (25.6%); a poor physical
environment in clinics, and difculties with health care team
members (29.7%).
Conclusion: It was determined of nurse instructors’
experiences that some difculties in clinical education and
they have the opinion that these difculties have a negative
effect on teaching.
Keywords
Education, Nursing, Students, Challenge, Clinical nursing
instructor, Clinical teaching

Check for
updates
Introducon
The general objecve of nursing educaon is to
help students gain professional nursing qualies and to
prepare them for their future professional life. One of
the targeted terminal behaviors in nursing educaon is
“professional nurse” behavior [1] and nursing educaon
is fundamentally a process that serves to raise students’
awareness about nursing. This process involves two
main areas that are integrated and complementary
with one another, namely, Organizaonal/Theorecal
Educaon and Clinical/Applied Educaon [2,3].

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• Page 2 of 9 •
Dağ et al. Int Arch Nurs Health Care 2019, 5:114
has dened 8 core competencies that nurse educators
should have [14].
Clinical environments have a mul-dimensional and
quite sophiscated social structure, wherein the low
and dicult control of condions characterizing the
structure has an eect on learning [2,15]. The factors
constung this social structure include the condions
of the clinical environment, the characteriscs of the
students and educators, and the instructor-student
interacon. It is highly important that students be able
to derive benets from these factors and condions [2].
Clinical teaching can pose various problems and dif-
cules for both students and educators. A systemat-
ic research study invesgated the strategies students
applied to address the dicules they experienced in
advanced pracces of nursing educaon [16]. In this
study, the dicules aecng clinical educaon were
examined and then labeled as either internal or exter-
nal problems [16]. Problems like excessive student de-
mands, increase in faculty workload and the shortage
of more nursing educators were idened as internal
problems, while problems like limited number of clinical
areas and preceptor programs and decline in educaon-
al programs in urban areas were idened as external
problems. Facilitang cooperaon between educaonal
instuons and hospitals, developing paent-oriented
research and increasing the use of simulaon are rec-
ommended as soluons to these problems.
A qualitave study where they dened the dicul-
es that instructors and clinical educators experienced
in the clinical teaching of nursing students conducted in
Japan. The dicules experienced were classied under
four categories: Dicules involving eorts to directly
change opinions; inconsistency in school curricula con-
tent and clinical educaon content; dicules in teach-
ing skills to insuciently educated students, and human
and me constraints in educaon [17].
In Turkey, the nursing programme resemble some
similaries to the nursing educaon programmes
worldwide [18]. The Turkish nursing educaon
programme lasts 4 years and leads to a bachelor’s
degree in nursing. These programs provide 4600 hours
of theorecal and clinical educaon, thus meeng the
European Union (EU) requirement for the number of
hours of nursing educaon [19].
In Turkey, clinical teaching in nursing educaon is
generally performed by instructors in nursing schools
[20], and clinical nurses working in hospitals. There are
some dicules in clinical educaon in Turkey. Clinical
educators generally experience the following problems:
increased numbers of students, students’ lack of
proper preparaon for clinical educaon, inadequate
me devoted to clinical educaon and me spent in
the clinic, inadequate clinical eld and an insucient
number of educators, inadequate collaboraon
between clinical sta and academia [17,21-25]. For
these reasons, nursing students graduate with lack of
clinical experience although they learned all skills during
their educaon [18].
It is widely known that there are serious problems
regarding instructor-student interacon in Turkey, par-
cularly on account of the rapidly increasing number
of students, especially in recent years. Some areas of
clinical environments are unsasfactory in terms of pro-
viding educaonal experiences that enable students to
learn and adopt targeted behavior and skills. In a study
analyzing stressful events commonly experienced by
educators in clinical work pracce, it was determined
that inadequate physical condions created an unfavor-
able environment for educaon [26]. Based on these
shortcomings, it is clear that reformatory measures
for clinical teaching should be taken by performing an
urgent review of the clinical teaching process and the
learning environments. Determinaon and analysis of
the dicules instructors experience during clinical
educaon are highly important for maintaining and de-
veloping quality-nursing educaon. The only way eec-
ve acons towards improving clinical teaching can be
implemented is by sharing experiences and developing
a comprehensive descripon of the extent of the prob-
lem.
Aim of the Study
This study was conducted to determine the
dicules that nurse instructors’ experiences in clinical
educaon. To achieve this, we sought to answer the
following quesons:
1. What are the dicules that nurse instructors’
experiences in clinical educaon?
2. What are the opinions of instructors about the eect
of these dicules on achieving the goals of clinical
teachings?
Material and Methods
Type of research
This is a descripve study.
The sample of the research
The populaon of this study was comprised of nurse
academicians on facules and in vocaonal schools that
provide nursing educaon in Turkey and in the Turkish
Republic of Northern Cyprus. According to ocial data
derived from OSYM(Student Selecon and Placement Center) that were
accessed prior to conducng the study, there were 1,208
instructors working in nursing educaonal instuons
during the 2012-2013 academic year in Turkey. The
study sample included 199 nursing instructors, who
were selected from the e-mail addresses that were
obtained (1,156) and had voluntarily responded to the
survey.

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Dağ et al. Int Arch Nurs Health Care 2019, 5:114
parcipang instructors, 98% were female, and
24.1% ranged in age between 31-35 and 36-40. It was
determined that 80.9% of the instructors had doctoral
degrees and that 34.7% of them worked as assistant
professors. Furthermore, the study found that 35.7% of
the instructors had worked as academicians for between
11 and 15 years in total, and 54.8% of instructors had
worked as clinical nurses for 5 years or less.
According to the data on the organizaons in which
the instructors worked, 71.3% oered master’s level
educaon as well as undergraduate educaon, 34.2%
had more than 26 instructors, 81.9% had 201 or more
undergraduate students, 59.1% had less than 5 graduate
students and 52.2% had less than 5 doctoral students.
Analysis of the teaching process of the parcipang
instructors showed that they mostly performed clinical
teaching in public hospitals (68.8%) and university
hospitals (67.8%). Regarding the instructor-student
rao, 32.7% of the parcipants stated that there were
11 students per instructor in clinics. In relaon to this,
94.4% of the parcipants reported that the instructor
was responsible for clinical teaching, 47.7% stated that
they had responsibilies in 3 or more clinics, 29.6%
stated that they set aside me for students as needed,
and 22.1% stated that sparing me for each student was
not possible.
In the instructors’ general views of their clinical
environment, 19.8% reported that the laboratory and
clinic equipment were incompable. In contrast, only
28.8% of the instructors stated that the clinic was
suitable for clinical educaon in general, while 24.9%
stated that the physical structure of the clinic was
adequate (Table 1).
The opinions of the instructors on the dicules they
experienced in the clinical environment were examined
under 6 categories: Instructor-related dicules, Stu-
dent-related dicules, Paent Care-related dicul-
es, Physical Environment-related dicules, Nurse
Team-related dicules and Health Care Team-related
dicules.
Regarding the issues related to the clinical
environment, it was found that 41.7%, 33.2%, and 30.2%
of the instructors, experienced quite serious dicules,
respecvely, concerning a) Having a heavy workload,
b) Providing an adequate clinical pracce area, and
c) Presenng educaonal experiences suited to the
educaonal goals of the course. It was also determined
that 65.8%, 63.8% and 61.3% of the instructors
experienced some dicules, respecvely, concerning
achieving the course objecve, creang an environment
that facilitates learning, and achieving cooperaon with
other members of the health care team.
Analysis of the dicules experienced regarding
issues about students determined that 64.8% of
instructors experience quite serious dicules about
Data collecon instruments
The data for the study were acquired [2,5,16,17,26,27]
using a survey form prepared aer analyzing research-
ers’ experiences and problems regarding clinical ed-
ucaon, as reported in the literature. The survey was
semi-structured. It was containing both open-ended
(six quesons) and (nineteen quesons) closed ended
quesons. The survey form consisted of two dierent
parts, with the rst part involving quesons about the
characteriscs of the instructors and the organizaons
wherein they worked, and the second part involving
quesons about the dicules instructors experienced
during clinical teaching. The second part also included
six open ended quesons inquiring into the instructors’
opinions about the eects of these dicules on clinical
teaching. The dicules experienced by the instructors
during clinical teaching were listed under six categories:
“Instructor”, “Student”, “Paent Care”, “Physical Envi-
ronment”, “Nurse Team” and “Health Care Team”. The
possible responses to the statements organized under
each category were: “I do not experience any dicul-
es”, “There are some dicules” and “There are quite
serious dicules”.
Data collecon
The study data were collected in the electronic en-
vironment from February to March, 2014. E-mail ad-
dresses of the instructors were acquired from university
websites, and from lists compiled by various organiza-
ons responsible for arranging congresses aer being
granted their permission. The lists of available congress
parcipants were used, from which a record containing
1,156 e-mail addresses was drawn up. In some incidenc-
es, there was more than one e-mail address for the same
person. Since researchers did not have the opportunity
to determine the instructors’ primary e-mail addresses,
an invitaon leer for the study and a link to the elec-
tronic data base allowing parcipants to respond were
sent to all e-mail addresses listed. The authors sent re-
minder emails twice. Parcipants were respond to the
quesonnaire for two months. A total of 199 instruc-
tors, which translated as 17.2% of the email addresses
listed, voluntarily responded to the survey.
Data analysis
The study data were assessed in an electronic
environment using SPSS 20.0 soware. Numbers and
percentage calculaon were used for data assessment.
Ethical approval
All instructors were fully informed of the research
aims, and agreed to instructors in the research process.
All instructors were voluntarily responded to the
survey. The research was undertaken the principles of
the Declaraon of Helsinki.
Results
Regarding the descripve characteriscs of the

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Dağ et al. Int Arch Nurs Health Care 2019, 5:114
Table 1: Instructors’ general viewpoints on the clinical environment (n = 199).
Appropriate Partially
Appropriate Not Appropriate Total*
n % n % n % n %
Health care team 58 29.1 112 56.3 29 14.6 199 100.0
Nursing team 60 30.3 120 60.6 18 9.1 198 100.0
Physical structure of clinic 49 24.9 117 59.4 31 15.7 197 100.0
Number of patients/capacity 78 39.2 89 44.7 32 16.1 199 100.0
Equipment used in clinic 61 30.6 114 57.3 24 12.1 199 100.0
Laboratory-Clinic equipment compatibility 51 25.9 107 54.3 39 19.8 197 100.0
Case diversity 92 46.9 79 40.3 25 12.8 196 100.0
Education experiences in clinic 49 24.9 118 59.9 30 15.2 197 100.0
Clinic in general 57 28.8 126 63.6 15 7.6 198 100.0
*Total number of instructors’ who answered the question.
Table 2: Opinions of instructors on difculties experienced in the clinical environment (n = 199).
I do not experience
difculties
There are some
difculties
There are quite serious
difculties
n % n % n %
Issues about instructors
Providing clinical practice area 26 13.1 107 53.7 66 33.2
Ofcial correspondences 71 35.6 100 50.3 28 14.1
Creating an environment facilitating
learning 19 9.6 127 63.8 53 26.6
Presenting education experiences suited
to learning outcomes of course 23 11.6 116 58.2 60 30.2
Achieving course objective 30 15.1 131 65.8 38 19.1
Being a role model for students 54 27.1 114 57.3 31 15.6
Cooperating with nurse team 64 32.2 111 55.7 24 12.1
Cooperating with other members of health
care team 45 22.6 122 61.3 32 16.1
Work load 21 10.6 95 47.7 83 41.7
Issues about students
Number of students 16 8.1 54 27.1 129 64.8
Motivation of students 21 10.5 118 59.3 60 30.2
Orientation of students to the clinic 28 14 140 70.4 31 15.6
Attendance status of students 100 50.3 86 43.2 13 6.5
Basic knowledge and skills of students 22 11 145 72.9 32 16.1
Students' knowledge and skills specic to
practice area 16 8 145 72.9 38 19.1
Daily monitoring of students 34 17.1 119 59.8 46 23.1
Assessment of students 29 14.6 128 64.3 42 21.1
Issues about patient care
Putting learned theory into practice 15 7.5 137 68.9 47 23.6
Application of care protocols existing in
the clinic 25 12.6 127 63.8 47 23.6
Patient monitoring 48 24.1 129 64.8 22 11.1
Patient care practices 35 17.6 120 60.3 44 22.1
Drawing up nursing care plans 40 20.1 112 56.3 47 23.6
Application of nursing care plans 23 11.6 120 60.3 56 28.1
Completing nursing care monitoring forms 37 18.6 127 63.8 35 17.6
Participation in decision-making
mechanisms about patient care 16 8 127 63.8 56 28.1
Issues about physical environment
Number of patients 53 26.6 113 56.8 33 16.6
Case diversity 77 38.7 88 44.2 34 17.1

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Dağ et al. Int Arch Nurs Health Care 2019, 5:114
organizaons, found that 69.3% of the instructors
worked in organizaons where 26 or more instructors
were responsible for clinical teaching (Table 3).
According to the opinions the instructors had about
the eects the dicules they experienced in clinical
pracce had on teaching, 85.9% of the instructors
stated that the teaching of certain nursing pracces was
not carried out (Table 4).
Discussion
Clinical educaon pertains to the applicaon
part of nursing educaon and provides students the
opportunity to learn under real condions. However,
the lack of control of the condions constung the
clinical environments can aect learning. Idenfying the
challenges in clinical educaon in nursing is crucial [28].
Various problems are known to exist in clinical educaon,
including those related to the educators, the health
care personnel, and the learning environment. Limited
the number of students. In terms of the dicules
experienced in paent care, 28.1% of the instructors
experienced quite serious dicules in nursing
care planning pracces. Considering the dicules
the instructors experienced regarding the physical
environment, 57.8% of the instructors stated that they
experienced quite serious dicules, about providing a
changing room for students. Concerning the dicules
about the nurse team, 25.6% of the instructors reported
that the most dicult issue was providing enough
guidance for students. Moreover, 21.1% and 15.6% of
instructors stated that they experienced quite serious
dicules, respecvely, about providing enough
support and acceptance of students. To connue, it
was determined that 29.7% of the instructors had
quite serious dicules about parcipaon in decision-
making mechanisms regarding paent care (Table 2).
Analysis of the individuals responsible for clinical
teaching, in terms of the number of instructors in the
Providing meeting rooms 20 10 75 37.7 104 52.3
Providing changing rooms for students 16 8 68 34.2 115 57.8
Issues about nurse team
Being accepting of students 47 23.6 121 60.8 31 15.6
Being supportive of students 48 24.1 109 54.8 42 21.1
Providing guidance to students 41 20.6 107 53.8 51 25.6
Issues about health care team
Information and opinion exchange with
members of health care team 42 21.1 128 64.3 29 14.6
Participation in decision-making
mechanisms about patient care and
treatment
17 8.5 123 61.8 59 29.7
Creating an environment facilitating
learning with members of health care
team
23 11.6 127 63.8 49 24.6
Table 3: Clinical educators by the number of instructors (n = 231*).
The number of instructors in the
organization
Instructor Clinical nurse Guide nurse Total
n % n % n % n %
5 or less 14 66.7 6 28.5 1 4.8 21 100.0
6-10 18 64.3 4 14.3 6 21.4 28 100.0
11-15 25 61.0 10 24.4 6 14.6 41 100.0
16-20 28 60.8 9 19.6 9 19.6 46 100.0
21-25 12 60.0 4 20.0 4 20.0 20 100.0
26 or more 52 69.3 17 22.7 6 8.0 75 100.0
*More than one answer is given.
Table 4: The opinions of instructors about the effect of the difculties experienced in clinical practice on teaching (n = 199).
The effect of the difculties experienced in clinical practice on teaching n %
Teaching of some nursing practices was not carried out 171 85.9
It prevented effective teaching and learning 137 68.8
It caused me to have difculties in clinical teaching 127 63.8
The motivation of students in clinical teaching decreased 123 61.8
Clinical teaching did not achieves its goals 107 53.7
Clinical learning outcomes were not achieved 86 43.2
My motivation as a teacher in clinical teaching decreased 74 37.1
Clinical teaching became boring 70 35.1
Evaluation of students became difcult for me 70 35.1

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Dağ et al. Int Arch Nurs Health Care 2019, 5:114
year, this number had risen to 14,048. In other words,
the nursing student quota had increased by 21.8 mes
in the last 20 years. On top of that, while the number
of students per instructor had been 25, this number
has increased to 30 as of present [31]. The increase
in the student-to-instructor rao aected the ndings
of this study, as witnessed by the fact that the highest
percentage of instructors reported the excessive
number of students as being a diculty that they had
experienced. This same issue resulted in instructors
experiencing serious dicules in movang students
regarding clinical pracce and in the daily monitoring of
students (Table 2). Furthermore, the parcipants noted
that the increase in the number of students also caused
other quite serious problems, especially in carrying
on educaon in schools with poor infrastructure and
an insucient number of instructors. These problems
occurred in clinical educaon in parcular. The lack
of sucient laboratory and clinical pracce areas
hampered the quality of educaon.
An increase in the number of students created
problems with students’ movaon and the placement
of students in suitable clinical areas [5,21,22,32]. It
is thought that regulaons like decreasing student
quotas, improving the physical condions of schools,
and increasing the number and improving the quality of
instructors should be considered. In addion, connuing
educaon acvies, departmentalizing courses, and
placing students in private hospitals, special funconing
hospitals, and in general hospitals, like public and
university hospitals, should also be considered for
improving clinical educaon. Increasing the number
of clinical rotaon areas would also be benecial in
reducing or prevenng problems that arise from the
excessive number of students.
One of the dicules that instructors experience is
movang students in clinical pracce. Its importance in
clinical educaon is fairly evident, as studies have clearly
shown that the biggest obstacle in clinical educaon is
student lack of movaon and interest [33-35].
Nasrin, et al. [34] conducted a qualitave study to
research the dicules involving nursing students’
movaon in clinical educaon and found that the most
important theme was “anxiety about being a nurse”
[34]. This theme was comprised of three categories:
nurses’ perspecves on the future, monitoring of
clinical competencies and clinical educaon, and being
a role model. Researchers have determined that the
performances and professional atudes of nurses
have an important role in movang students in clinical
educaon. Furthermore, insucient communicaon
between students and team members, non-acceptance
of students in pracce areas, and negave prejudices
about nursing that aect the students’ movaon were
the most common problems that students experienced
in pracce areas [24,36-38].
number of studies have been conducted in Turkey and
throughout the world, on the dicules instructors in
parcular experience in clinical educaon [29].
The situaons in the clinical environment that are
regarded as unfavorable by instructors stem from var-
ious factors, such as excessive numbers of students,
insucient paent capacies of hospitals, and limited
number of diverse cases. There is also the problem of
clinics/hospitals having poor infrastructure, insucient
clinical pracce areas, inadequate infrastructure in
laboratories, or conversely, having advanced laborato-
ries but insucient clinics. Being provided with conve-
niences and opportunies that facilitate learning, and
having access to physical condions that foster clinical
learning are fundamental to developing clinical skills
[30]. Doğan, et al. [26] conducted a study to research
the most common stressful situaons instructors expe-
rience in clinical pracce [26]. They determined that the
paent care systems applied in clinics were not in ac-
cord with the philosophies of educaon, that physical
condions were not sucient, that there were commu-
nicaon problems, that instructors were unable to par-
cipate in decisions about paent care, and that treat-
ment and physical condions were inappropriate for
educaon. Similar dicules were also reported in the
present study. In the parcipang instructors’ general
view of the clinical environment in clinical educaon,
they idened the incompability between laboratory
and clinical equipment, the insucient capacity within
the clinics to handle the number of paents, and the
poor physical structure as the negave aspects of the
clinical learning environment (Table 1).
In Turkey, it is the nursing instructors who are
largely responsible for carrying out the clinical
educaon, as well as the theorecal educaon, of
the nursing educaon curriculum [20]. This study
found that the issue reported by the highest number
of instructors to be dicult was the heavy workload.
The heavy workload was aributed to such factors as
excessive number of students, insucient number
of instructors in universies, being responsible for
both undergraduate and graduate educaon, being
responsible for management of laboratory skills,
and the pressure of academic promoon. Moreover,
because most of the parcipang instructors were
responsible for supervising more than one clinic during
clinical educaon, this also increased their workload.
Strengthening the number of instructors, improving the
quality of instructors, creang a system to guide clinical
educaon nurses, and gaining the support of nurses
working at hospitals may all be eecve in reducing
instructors’ workloads.
In recent years, the number of nurses who aend
universies has increased to meet the nursing needs
in Turkey. While the student quota in the 1996-1997
academic year was 644, by the 2015-2016 academic

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Dağ et al. Int Arch Nurs Health Care 2019, 5:114
knowledge into pracce [36,44]. Based on the results
from this study, it is believed that cooperaon between
schools and hospitals plays a key role in providing
soluons to the dicules that instructors experience
with nurses and health care teams in clinical educaon.
The dicules that instructors experience in clinical
educaon have negave eects on clinical educaon.
Similar to the ndings from this study, the results from
the study by Eta, et al. [5] showed that the dicules
encountered in clinical educaon made teaching
dicult, prevented eecve learning and teaching
and led to negave learning results [5]. The dicules
experienced in clinical educaon are considered to be
the most signicant obstacles in achieving objecves.
The Limitaons of the Study
The two limitaons impacng the outcomes of this
study were that data collecon was performed in an
electronic environment due to access problems, and
that, according to the number of outgoing emails, there
was a response rate of just 17.2%.
Conclusions
It was determined that instructors experience various
dicules, including those related to having a heavy
workload, providing an adequate clinical pracce area,
having an excessive number of students, implemenng
nursing care plans, having a poor physical environment
in clinics and gaining the support of health care team
members. Instructors stated that these dicules
negavely aect the educaon of some nursing
pracces, as well as eecve learning and teaching.
It is clear from these results that there should be
careful planning regarding the number of students
receiving clinical educaon. The physical and
educaonal opportunies of organizaons must
be considered in order to increase the eciency of
clinical educaon. Clinical pracce areas should be
selected from instuons that have a suitable physical
infrastructure to create posive learning environments.
When laboratories in educaonal instuons are
not adequate, clinical areas should be equipped with
advanced technology simulators (e.g. realisc high-
delity procedural simulators, and high-tech interacve
human simulators). Eecve communicaon and
cooperaon should be provided between clinical teams
and instructors, and cooperaon protocols should be
signed between schools and clinical pracce areas.
Acknowledgements
We would like to thank all the Instructors who
parcipated in this study.
Author Contribuon
GSD, HFK and RSG was responsible for the study
concepon and design. GS and RSG performed the
data analysis. GS, HFK and RSG was responsible for
Highly movated students in clinical pracce areas
contribute to eciently maintaining the educaon
process. Therefore, when students are supported
and accepted by their colleagues they will be able to
gain greater sasfacon from educaonal acvies
[23,24,39-41]. In addion to this support and acceptance
from the nurses, members of the health care team and
instructors, the funcon of clinical nurses as role models
and leaders can also increase movaon. Moreover, the
eecve use of a reward system to acknowledge the
achievement of students, the arrangement of regular
meengs to share experiences with colleagues, who in
their funcon serve as role models, and the connual
support of instructors are considered as important
measures for increasing students’ movaon.
Another diculty in clinical teaching that instructors
experience pertains to the preparaon and applicaon
of nursing care plans by students. One of the primary
concerns of nursing educaon is that students are not
able to put knowledge into pracce. When educators
mostly focus on theorecal informaon, students do
not learn to suciently comprehend how theorecal
informaon is put into pracce. There are dierences
between praccing nursing in the actual environment
and learning theory. Lack of support from instructors
and nurses, short paent care me in the clinic, and
inappropriate pracce areas can hinder learning goals.
These are regarded as the main reasons for the dicul-
es students experience in transferring knowledge to
the pracce area; in other words, it is a shortcoming in
the preparaon and applicaon of nursing care plans.
One of the seven items dened in a systemac inves-
gaon carried out by Jokar and Haghani [27] to research
the dicules of clinical educaon was students’ lack of
autonomy in care planning [27]. Providing as many case
studies and examples as possible to students during
theorecal educaon on nursing care planning will help
to facilitate students’ ability to put theorecal knowl-
edge into pracce. It is believed that being supporve of
students, discussing the daily care plan and use of meth-
ods (concept map, etc.), and facilitang the learning of
planning and applicaon of care will contribute to the
soluon of the problem [42,43].
Clinical educaon gives students the opportunity
to use and improve the professional knowledge and
skills specic to nursing, to make the right decisions, to
increase self-understanding, and to prepare themselves
for professional roles [22,23,39]. However, clinical
educaon can present a number of problems and
dicules for students, educators, nurses and other
members of the paent care team. Successful clinical
pracce can be achieved through the close cooperaon
of the school and the hospital [22,24,36]. Studies
researching student opinions about school and hospital
cooperaon have reported that close cooperaon
can help students adapt to the profession, increase
movaon and self-condence, and help put theorecal

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• Page 8 of 9 •
Dağ et al. Int Arch Nurs Health Care 2019, 5:114
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