The barriers of clinical education in nursing: A systematic review

Abstract

Considering the great significance of proper clinical education in training nurses qualifying for provision of quality care, this study has been conducted with the aim of investigating the obstacles against clinical education among the nurses. In this systematic review study, international databases (PubMed, Web of Science, Scopus, CINHAL, EMBASE, ERIC, Google scholar, as well as national banks including Magiran and SID) were searched from the time of inception until January 30, 2018. The obstacles of clinical education in individual areas (associated with students (Lack of motivation in students), professors (Absence of experience professor with a high academic level), and nurses (Personnel uncooperativeness)), managerial (Shortage of time), facilities (Deficit of facilities and working conditions), structures, and other areas were identified. Based on the obstacles identified across various dimensions, proper plans and strategies should be designed and implemented with each of the obstacles to enhance the quality of clinical education.

Full text

The barriers of clinical education in nursing: A systematic review.
Hosien Shadadi1, Mahmood Sheyback2, Abbas Balouchi1,3, Maryam Shoorvazi4*
1Department of Nursing, School of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol, Iran
2Student Research Committee, Bushehr University of Medical Sciences, Bushehr, Iran
3Nursing Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
4Department of Nursing, School of Nursing, Neshabur University of Medical Sciences, Neshabur, Iran
Abstract
Considering the great significance of proper clinical education in training nurses qualifying for
provision of quality care, this study has been conducted with the aim of investigating the obstacles
against clinical education among the nurses. In this systematic review study, international databases
(PubMed, Web of Science, Scopus, CINHAL, EMBASE, ERIC, Google scholar, as well as national banks
including Magiran and SID) were searched from the time of inception until January 30, 2018. The
obstacles of clinical education in individual areas (associated with students (Lack of motivation in
students), professors (Absence of experience professor with a high academic level), and nurses
(Personnel uncooperativeness)), managerial (Shortage of time), facilities (Deficit of facilities and
working conditions), structures, and other areas were identified. Based on the obstacles identified across
various dimensions, proper plans and strategies should be designed and implemented with each of the
obstacles to enhance the quality of clinical education.
Keywords: Clinical education, Nursing education, Barriers, Systematic review.
Accepted on October 16, 2018
Introduction
Today, considering the change in learning needs, changes of
the pattern of diseases, and increased care needs, on the one
hand, and the shortage of nurses as the largest part of the
healthcare team as well as very high cost in nursing and
medical education, on the other, the importance of caring for
proper clinical education has been multiplied [1-6]. Proper
clinical education alongside theoretical education is one of the
most important parts of education in nursing, in which the care
behaviors of nurses are formed [6-10]. Also, the objective of
nursing which is providing proper high-quality care is realized
through this [1,11-13]. Clinical practice is considered an
opportunity for learning skills by nurses, which unlike
theoretical classes, it is a very complex context packed with
challenges in different dimensions [14-16]. Proper educational
setting in clinical practice is one of the very important factors
in the learning of students and nurses to provide quality care to
patients [17-20]. Therefore, understanding the obstacles against
clinical education can result in better and faster recognition of
the obstacles against clinical education, finding solutions, and
resolving them through enhancing learning quality, preventing
expenditure of nonessential costs, and determining better
strategies based on the recognized obstacles [21-29]. The
studies conducted in this area suggest that most studies have
investigated the obstacles individually, and only in a few of
them which have reviewed the literature of obstacles of clinical
learning, the most important obstacles included time and
financial constraints as well as lack of access to evidence-
based literature [18,30-33]. Considering the crucial importance
of understanding the factors and search by the researcher, so
far no study has been conducted as systematic review to
examine the obstacles against clinical education as the most
important dimension of nursing education to train qualified
nurses for providing quality healthcare services [34-36]. This
systematic review study has been conducted with the aim of
investigating the obstacles against clinical education of nurses.
Method
Inclusion criteria
This study has been composed based on the guideline for
conducting systematic review studies (Cochran) and using
PRISMA checklist [37]. This study protocol registered in
PROSPERO (ID: CRD42018096394). Inclusion criteria were
included: all observational studies (descriptive, descriptive
analytical, case-control, and cohort) published in peer-
reviewed journals were included. Only the papers in Persian
and English were included. All the studies which had examined
the obstacles of clinical education from the view of nurses,
professors, and students of nursing with quantitative
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Biomed Res 2018 Volume 29 Issue 19 3616

approaches were included. The minimum sample size of
studies included should have been at least 25. The main
objective in this study was to examine the obstacles against
clinical education, while the secondary objective was to offer
suggestions to reduce clinical education obstacles.
Search strategy
In this study, international databases (PubMed, Web of
Science, Scopus, Cumulative Index to Nursing and Allied
Health Literature (CINHAL), The Excerpta Medica database
(EMBASE), Education Resources Information Center (ERIC),
Google scholar) as well as national databases (Magiran,
Scientific Information Database (SID)) were searched from the
time of inception until January 30, 2018. The utilized
keywords were determined based on Medical Subject Headings
(MESH) and Emtree, and then merged together using NOT,
AND, and OR operators. The utilized keywords in Persian and
English included obstacles, barriers, clinical education, clinical
learning, and nursing.
Selecting the studies and extracting information
According to the study protocol and the inclusion criteria, two
researchers investigated the title and abstract of the studies
separately, and then the repeated cases were eliminated. In the
next stage, the full text of the papers was examined and the
necessary information was extracted. In cases where
disagreement occurred for selecting the studies, consensus
method was used to resolve the disagreement between the two
writers. The items of the extracted information included
general information (first author, year, country, sample size,
data collection method) and implication (the utilized
instrument, obstacles of clinical education, and suggestions).
Quality of studies
Investigation of the quality of studies was performed using
strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) standard instrument [38] which is
used for observational studies. Guided by the 22 items a score
was assigned independently to each study. Scores were
reviewed, and discrepancies were resolved by consensus.
Studies with scores of 14 or below out of 22 possible points
were categorized as low quality; those with scores of 15-17 as
medium quality, and studies with scores of 18 or higher were
categorized as high quality.
Results
General results
Selection of studies: Overall, based on the primary search
across different databases, 1748 papers were found, out of
which 1534 were non-repeated. In the next stage, the non-
repeated papers were investigated based on their title and
abstract, and 1504 papers were removed due to their
incongruence with the objective of this study and inclusion
criteria. In the next stage, 30 papers were investigated as full-
text, where 10 studies entered the final stage. Twenty papers
were excluded at this stage, where 7 were review, 11 were
qualitative, and one lacked full text. One paper had a target
population other than healthcare team (Figure 1).
Figure 1. Study selection process.
The characteristics of the included studies: All of the
included studies had been conducted in Iran in their final stage
(n=10) and descriptively on 1468 participants. The mean age
of the participants was 26.59 (8.1 y old). The sampling had
been conducted as census (n=8) in most of the studies (Table
1). All of the included studies had a quality above 50%.
Instruments: Most of the instruments used in the present
study have been researcher made, which had been developed
based on investigating the literature and by the researchers.
Only two studies had used standard instruments [13,39]. The
number of items in the instruments was 20-59. Further, in two
studies, the number of items had not been mentioned properly
[40,41]. The validity of the instruments had been investigated
by 9-10 experts. Further, regarding the reliability of the
instruments, the Cronbach alpha ranged from 0.75 to 0.94
across different instruments [13,40-48] (Table 2).
The obstacles of nursing clinical education
Defining the obstacles of clinical education in nursing is very
important and lead to increase of quality of education in
clinical nursing cares. The obstacles mentioned in different
studies varied considerably. However, based on main factors,
they can be divided into four areas: individual (the obstacles
associated with student, professor, and nurses), management,
facilities, and others. In the area of individual factors, the most
important obstacle against clinical education related to the
students based on the different studies was lack of motivation
in the students [40,41]. The most important obstacles against
clinical education associated with professors included shortage
of experienced professors with a high academic level, not
stating the educational objectives for the students, and not
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Biomed Res 2018 Volume 29 Issue 19 3617

assessing the students’ activities by trainers based on internship
objectives [13,40,41,45,47]. The most important obstacles
against clinical education associated with nurses included
inadequate knowledge and skill and uncooperativeness of the
personnel [13,40,41,43,48]. In the area of management, the
most important obstacles against clinical education included
the mismatch between clinical education objectives and the
expectations of the hospital personnel and shortage of time
[13,43,44,47]. In the area of facilities and structures, the most
important obstacles against clinical education included
shortage of facilities and their working conditions, lack of
access to conference room, and poor educational planning
[13,39-41,43-45,47,48]. Other clinical education obstacles
included not recognizing the role of nurses as teachers for
patients and the society, as well as uncooperativeness of the
patient and neglecting the education (Table 3) [42].
The frequent solutions presented for reducing the obstacles
against clinical education included: developing proper facilities
and equipment in clinical centers, increasing the motivation of
students, and taking measures to incorporate clinical education
in nursing curricula (Table 2).
Table 1. The general characteristics of the studies included in the systematic review.
First author (year) Country Study design Study participants Age Gender (male/female) Sampling method
Salehabadi [41] Iran Descriptive 129 22.19 23/93 Census
Dehghani [42] Iran Descriptive cross-
sectional
271 29.6 53/218 Census
Gholami [43] Iran Descriptive 95 25.15 38/57 Census
Heidari [44] Iran Descriptive cross-
sectional
150 21.58 51/99 Census
Jahanpour [45] Iran Descriptive cross-
sectional
58 Not mentioned 35/21 Census
Jahromi [13] Iran Descriptive cross-
sectional
78 21.66 47/31 Census
Moghimi [47] Iran Descriptive cross-
sectional
108 22.37 86/22 Census
Rahimi [40] Iran Descriptive cross-
sectional
38 40.5 29-Sep Random
Rezaei Nik [48] Iran Descriptive - analytical 384 20-40 274/66 Multistage randomized
Tanomand [39] Iran Descriptive - analytical 157 34.64
professors
17/33 Census
23.18 students 18/89
Table 2. The utilized instruments, obstacles, and suggestions for resolving the obstacles against clinical education in nursing.
Author The utilized instrument Suggestions
1. Type and components
2. Number of items
3. Reliability and validity
Salehabadi [41] 1. Researcher made questionnaire, including three
sections: demographic information, problems of
clinical education, and solution for improving it for
trainers and students.
Creating a balance in the number of students in internship groups
2. Has not been mentioned. Making the students aware about the consequences resulting from mistakes
3. The instrument was provided for 20 students
and 10 faculty members, and the reliability was
confirmed by a Cronbach alpha of 0.85.
Assessing the students for relegating tasks
Dehghani [42] 1. Researcher made consisting of two sections:
demographic characteristics and the obstacles of
education to the patient.
2. 33 items Providing a sufficient number of personnel, prioritizing education of nurses in daily tasks
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3. It was given to 10 faculty members and the
reliability was confirmed by Cronbach alpha of
0.91.
developing the culture for approving education by patients
Gholami [43] 1. Researcher made consisting of two parts
(demographic-assessing the opinions of students
about the obstacles against clinical education)
Most of these obstacles can be amended and by resolving these obstacles, one can
achieve improved performance of students and eventually provision of effective and safe
care.
2. 59
3. It was given to 10 faculty members and the
reliability was confirmed by Cronbach alpha of 0.94
and 0.84.
Heidari [44] 1. Researcher made Since the opinions of students can effectively contribute to enhancing the quality of
clinical education, the nursing students’ opinions should be measured periodically
2. 31
3. It was given to 10 faculty members and the
reliability was confirmed with a Cronbach alpha of
0.93.
Jahanpour [45] 1. Researcher made-demographic and obstacles
of clinical education in pediatric ward
2. 30 It is suggested that the relevant authorities and planners of nursing education take steps
to improve the motivation and learning of students using the research results by
identifying the obstacles ahead of clinical education of the pediatric ward for students
and trainers.
3. It was given to 10 faculty members, and the
reliability was confirmed by Cronbach alpha 0.91.
Jahromi [13] 1. Standard-including the obstacles and facilitators
of clinical education
The educational methods are recommended to be used three useful strategies. The
educator nurses should have adequate skill. Educating patients should be taken more
seriously in academic curricula.
2. 20 items
3. for obstacles: 0.75; for facilitators: 0.78.
Moghimi [47] 1. Researcher made-demographic, factors, and
obstacles
2. 20 items Reviewing and taking suitable measures by academic authorities seem to be essential
for a suitable clinical education setting including facilities and equipment of clinical
setting and reviewing the instruments and processes of clinical education
3. It was given to 10 experts and the reliability was
confirmed with a Cronbach alpha of 0.81.
Rahimi [40] 1. Researcher made including four sections:
demographic, clinical obstacles, solutions, and
problems).
More attention by nursing planners and authorities for proper planning for clinical
practice
2. Not mentioned exactly Employing experienced and skilful trainers
3. It was given to nine nursing experts, and the
reliability was confirmed by Cronbach alpha of
0.89.
Encouraging and developing interest in students
Rezaei Nik [48] 1. Researcher made One of the most important current obstacles is individual obstacles. To reduce or
improve this challenge, cooperation should be developed between trainer, clinical
nurses, academic supervisor, head nurses, nursing managers, the educational planner,
and other top-level management authorities.
2. 26
3. It was given to 10 nursing experts, where the
Cronbach alpha reliability for obstacles and
facilitators was 0.78 and 0.86, respectively.
Tanomand [39] 1. Standard The facilities and equipment of clinical setting and reviewing the system of recording and
reporting according to nursing standards should be improved.
2. 22
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3. The reliability was confirmed by Cronbach alpha
of 0.87.
Table 3. Classifying the obstacles against clinical education.
Dimensions of obstacles Sources Obstacles
Individual dimension Student Lack of motivation in students [40,41]
Lack of proper communication between students and the ward personnel [47]
Not adhering to order and discipline by the student [47]
Lack of proper communication between students and professor [47]
Professor Absence of experience professor with a high academic level [13,40,41,47]
Lack of suitable motivation in trainers [41]
Emphasizing theoretical aspects in educational work [41]
Not stating the educational objectives for students [45,47]
Being unfamiliar with educational methods [47]
Absence at essential hours in the ward [47]
Not assessing the students activities based on the internship objectives by the trainers [45,47]
Inadequate feedback to students [43]
Relegating heavy and difficult tasks to students [43]
Lack of proper communication between students and professor [47]
Not emphasizing pre-study by trainers [43]
Nurses Mismatch between the job of personnel and scientific principles [41]
Not implementing the process by the personnel [41]
Lack of physical and psychological preparation [13]
Fatigue [48]
Inadequate knowledge and skill [13,40]
Not planning education to the patient in the daily task of nurses as a duty [42]
Personnel uncooperativeness [41,43,48]
Improper treatment of the personnel [43]
Management dimension Large number of students in internship groups [41]
Discrimination between nursing students and the students of other medical sciences [41]
The patient or their companions complaining about performing nursing affairs by students [48]
Unsuitable internship time [47]
Mismatch between the objectives of clinical education and expectations of the hospital personnel [43,44]
Shortage of time [13,47]
Not prioritizing education in the description of duties [42]
Not gaining score for the nurse to train the patient [42]
Mismatch between the number of patients and number of nurses [42]
The dimension of facilities and structures Deficit of facilities and working conditions [13,41,43,45]
Limited cases in the wards [41]
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The hospital being non-academic [41]
Lack of access to the conference room [39,43]
Poor educational planning [40,44,47,48]
Others Not recognizing the role of nurses as teachers for patients and the society [10]
Uncooperativeness of the patient and neglecting education [42]
Discussion
The present systematic review study was conducted with the
aim of investigating the obstacles against clinical education of
nursing in internal and foreign databases until January 30,
2018. In the present study, the most important obstacles against
clinical education mentioned in different studies were
categorized into four groups: individual area (obstacles
associated with students, professors, and nurses), management,
facilities, and others. Similar studies conducted in the area of
obstacles against clinical education were in the form of review
of literature. For this reason, after investigating them, the
results of qualitative studies have also been used in the
discussion. An integrated review study conducted by Santos
indicated that the most important obstacles against nurses’
learning were time constraints, financial constraints, the culture
of the workplace, access, and matching of new technologies to
acquire knowledge. In the dimensions of time constraints and
culture of workplace, access, and matching through new
technologies to acquire knowledge based on evidence, it
confirms the results of the present study [1]. Another study
conducted by Foster et al about the challenges of clinical
education of nurses indicated that the obstacles of clinical
education included unclear description of duties which take
much of the nurse’s time, and instead of dealing with more
essential duties, they seek to resolve the peripheral problems of
patients; high working load as well as time and financial
constraints which prevent use of robust clinical evidence in
education, which is in line with the present study [49]. The
results of a qualitative study by Abbaszadeh et al. suggested
that the most important challenges of clinical education
included development of learning potentials in practice (the
professor presentation power and student presentation power),
confronting the conflicts of real practice (ineffective planning
and executive obstacles of acquiring clinical skill), efficient
clinical education (assessment-oriented flexible planning,
effective clinical professor, and moving beyond dependence
towards independence in practice), and professional challenges
in the future (professional version and unsafe clinical setting)
[2]. In this regard, the results of the present study in individual
dimensions related to professor and students confirm the
management dimensions. However, it also mentions
professional challenges in the future, which were not found in
the present study [2]. Another study conducted by Alavi et al.
indicated that the most important obstacles against clinical
education according to students were tension, conflict, and lack
of access to direct experience [50]. Conflict indeed represented
problematic communication, which is in line with the results of
the present study. However, the dimensions of conflict and lack
of direct access to experience were not observed in the present
study, which can be due to the qualitative nature of the
investigative the study and the different sample size of subjects
[50]. The study by Jamshidi et al. showed that the most
important obstacles against clinical education were ineffective
communication, inadequate preparation for emotional
reactions, which regarding ineffective communication and
inadequate preparation, it confirms the results of the present
study [46]. However, regarding the dimension of emotional
reactions which refer to tensions in clinical education, it was
not found in the present study [46].
The most important solutions of the present study to reduce the
obstacles of clinical education were: creating suitable facilities
and equipment in clinical centers, increasing the motivation of
the students, and taking measures to incorporate clinical
education in nursing curricula, which are in line with the
results of different studies [1,2,46,50].
Limitations
The most important limitations of the present study were:
1. In spite of searching different databases, the information
resources in this regard with systematic review approach were
limited.
2. In spite of using systematic search strategy with the relevant
words, all of the included studies were related to one country.
3. In some cases, the information of the studies was not
available. To resolve this, the authors were contacted.
Strengths
1. The present study is the first systematic review study for this
purpose.
2. Use of systematic review approach for searching and
organizing studies.
Conclusion
The present systematic review study indicated that the most
important obstacles of learning were categorized individual,
management, facilities, and equipment dimensions.
Considering the importance of each dimension, regarding the
individual dimension associated with students, some plans
should be developed to increase the motivation of the students
and hold effective communication workshops. More important
is employing more experienced professors with a higher
academic level in the clinical practice, so that they can
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Biomed Res 2018 Volume 29 Issue 19 3621

generate interest in the students effectively to acquire clinical
skills. Further, in the dimension of nurses, since they are the
so-called best individuals for education because of being in the
clinical setting and alongside the patient bed, and it is
recommended to care for management dimensions of obstacles
and through incorporating the clinical education curriculum
into the description of nurses’ duties, proper planning of
nurses’ shifts, and granting score to individuals interested in
clinical education, their attention to clinical education should
be improved. In the management dimension, the most
important strategy can be proper planning for the number of
nursing students in the right wards, so that all the students can
equally use the opportunities developed in the clinical practice
for learning. In the dimension of equipment and facilities, the
necessary financial resources for equipping the libraries of
hospitals and creating evidence-based centers through new
technologies should be taken seriously.
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*Correspondence to
Maryam Shoorvazi
Department of Nursing
School of Nursing
Neshabur University of Medical Sciences
Iran
The barriers of clinical education in nursing: A systematic review
Biomed Res 2018 Volume 29 Issue 19 3623