Nursing Students’ and Teachers’ Perspectives on Clinical Education in Kuwait

Clinical education is the heart of nursing curriculum. An insight into the different perspectives could facilitate its improvement. AIMS : This descriptive, cross-sectional study aims to assess the nursing students’ and teachers’ perspectives on clinical education in Kuwait. METHODS: The study includes all faculty members of the Bachelor and Associate Degree in Nursing Programs from the College of Nursing, Kuwait (16 teachers and 12 trainers) and 120 students selected through convenient sampling from levels one to five of the Associate Degree in Nursing Program. Data were collected through self-administered questionnaire and were analyzed using the Statistical Package for Social Sciences (SPSS) version 22. Aside from descriptive statistics, T-test was utilized to compare the students’ perspectives with that of the teachers. ANOVA was used to determine any difference in the perspectives according to various factors . A significant p-value was set at less than 0.05. RESULTS: Main findings of the study illustrate six items related to the state of clinical education deemed significant by both students and teachers, namely: hospital management collaboration in resolving problems of students (p = .001); collaboration and supervision of education (p = .003); access to welfare facilities at bedside and adequacy to educational facilities at bedside with p values of .004 and .002 respectively; development of skills in nursing process implementation (p = .010) and development of patient education skills (p = .028). Factors which can potentially create problems were the lack of appropriate scientific background in the ward (p=0.047) and students wandering in the absence of instructor (p=0.025). CONCLUSION: Students’ and teachers’ perspectives on the state of clinical education in Kuwait and the factors which may potentially create problem areas have basic commonalities, focusing on the importance of collaboration between the clinical agency and the educational institution and between those actually involved in supervision of the students - the clinical staff and school faculty. RECOMMENDATION : This study recommends conducting similar studies on a wider scale, considering the technological thrusts prompted by global circumstances like the pandemic. Keywords: Nursing students; Teachers; Perspectives; Clinical Educatio DOI: 10.7176/JHMN/82-07 Publication date: November 30 th 2020


Introduction
Clinical education, the heart of nursing curriculum. is a complex and dynamic process (Moonaghi et al. 2015). It entails interactions among educators, students, staff, patients and environment, in which students gain experience and apply knowledge in practice. Clinical learning takes place in a complex social context of the clinical environment (Rajeswaran 2016).
The clinical area, which is an integral part for undergraduate nursing education, is a vital learning environment (Damodaran & Kandasamy 2013). Clinical competence, which is the final goal of nursing education, consists of a variety of skills, not only technical but communication and interpersonal skills, problem-solving and utilization of knowledge and information as well (Hakimzadeh et al. 2013). Members of the nursing faculty are of prime significance in promoting clinical competence.
The significance of optimal clinical nursing education in professional skills development is undeniable (Heidari & Norouzadeh 2015). Continuous quality improvements in clinical education make it mandatory to evaluate the strengths and weaknesses of the teaching-learning process in the clinical setting (Moonaghi et al. 2015). Continued checking of the prevailing situation, recognition of the strengths and modifications of the weak points are necessary to improve and promote the quality of clinical education (Hasanpour-Dehkordi & Shohani 2016). The ideas and opinions of students and instructors are therefore valuable inputs for planning.
Several perspectives on clinical education have been presented. From the legal standpoint, it is mandatory to achieve competence as a nurse through practice in the clinical placements. From the educational perspective, knowledge, skills, and attitudes acquired in the classroom should be integrated in the clinical settings (Newton et al. 2010). From the clinical perspective, the preceptors who guide the nursing students view them as potential recruits in their specialized field (Happel 2008). From a student perspective, clinical placements are both stressful and rewarding; nonetheless, they are considered as the most significant part of nursing education (Myrick et al. 2006). Regardless of the perspectives, studies have confirmed that students' attitudes related to the clinical placement are strongly influenced by their clinical experience (Happel & Gaskin 2013). Consequently, settings

Data Analysis
Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 22. Descriptive and inferential statistics was utilized and significant p-value was set at less than 0.05.

Results
This study had a total of 120 students and 26 teachers responding out of 28. Among the students (Table 1), there are more females (60.8%). The age group with highest percentage ranges from 17 -20 (58.3 %), more are non-Kuwaitis (90%), and single (94.2 %). Most of the clinical assignment of the students is in the Medical Surgical areas, considering that they are exposed here in almost all levels except for level three (82.5%). A glimpse into the demographic variables of the teachers reveals that there are more females (73%), with most of the age group from 35 -40 years (30.4%), more Kuwaitis (53.8%), and married (80.8%). For their clinical assignment, 53.5% are in the Medical Surgical areas. Table 2 compares the students' and teachers' perspectives on clinical education. As far as state of clinical education is concerned, there are six items which have significant p value of <.05 as calculated by t -test. Of highest significance is the hospital management collaboration in resolving problems of students (p = .001). Collaboration and supervision of education is likewise significant at p = .003. Access to welfare facilities at bedside and adequacy to educational facilities at bedside have p values of .004 and .002 respectively. Development of skills in nursing process implementation (p = .010) and development of patient education skills (p = .028) are both deemed significant. Two factors which can potentially create problems, namely, the lack of appropriate scientific background in ward (p=0.047) and students wandering in the absence of instructor (p=0.025) have significant p values.

Comparison of Students' and Teachers' Perspectives
In comparing the students' and teachers' perspectives according to the different academic levels and their required clinical areas (Table 3) using the ANOVA, the students perceive collaboration and supervision of education supervisor as significant (p = .04) with levels one and two (Medical Surgical areas) obtaining the highest mean and level five (Intensive Care Unit, Casualty and Primary Health Care) having the lowest mean. On the other hand, the teachers perceive healthcare collaboration in students' clinical education as significant at p = .005. Obtaining the highest mean is level four (Psychiatric area and Advanced Medical and Surgical Area) while the lowest levels are one and two (Medical-Surgical areas).

Strong Points
In response to the open-ended questions, the students refer to the following as strong points: reality of the experience itself, adapting to the hospital environment wheren they are in contact with the different patients assigned to them, have communication with them, and perform actual nursing procedures. The diversity in clinical exposure to include the community leads to increased infomation and familiarization with several special areas. What has been learned in the classroom is given a chance to be correlated with what is seen in the area. Exposure to modern devices, submisssion of requirements, applying interventions and skills increase their knowledge. Opportunities for improving communication and for enhancing values such as discipline, cooperation and interconnectedness are provided by the clinical experience.
On the other hand, strong points in the clinical nursing experience as perceived by the teachers focus on the planning of the clinical rotation, mapping out of objectives, and preparation of clinial documents. The qualifications of the teachers in terms of academic background and experience are likewise perceived as a strong point. In the actual area itself, teachers see the application of the theoretical information into practice, the exposure to real life clinical scenarios, and the practice of the basic psychomotor skills as strong points.

Weak Points
As revealed in the open-ended questions, the students perceive as part of the negative points the non cooperation of the medical staff with them unless there is a teacher from the College itself. They still perceive lack of opportunities to actually develop skills in performing nursing procedures. The number of files to be written and submitted add pressure to them. The lack of days in clinical training wherin they are exposed to certain areas for only a day and the number of students being followed up by the teacher likewise pose negative points.
For the teachers, the perceived negative points include the remiss in punctuality among the students, the lack of clinical time and hands-on experience in actual patient care and performing procedures, the neeed for formulation and implementation of critical nursing care plan, and exposure to nursing informatics. The ratio of students to teachers is not appropriate for close monitoring. In some wards, there are a limited number of patients. Moreover, there are some patients who demonstrate lack of trust in the students by refusing being assigned to them. Staff nurses are sometimes not cooperative with students and may be giving inaccurate information or showing incorrect manner of doing procedures.

Suggestions Given in the Open-Ended Questions
Students suggest that before assigning them to an area, goals have to be clearly set. Moreover, they have to be oriented on how their scores and evaluation of their performance are computed. Coordination with the areas of assignment is viewed as significant, particularly in developing an attitude of helping students among the staff nurses and the head nurse. To have better monitoring and supervision of students, the number assigned to a teacher should be decreased.
In the ward, students suggest that as part of the endorsement, the teachers should initiate a round to the patients for the students to have an overall idea of the cases in the area. Teachers should work hard to create an atmosphere of encouragement; simplify and explain to the students whatever mistakes he makes, such as in writing Nursing Care Plans, browsing the files, doing nursing procedures, and giving nursing care. Focus should be on the practical side and the development of skills. Students should be allowed to practice alongside with the staff nurse. Patients assigned to the student should be cared for not only for a day to provide for continuity.
Among the student suggestions are for the total hours of clinical education to be increased. Moreover, theory and clinical experience should be separated and have different marks. Exposure to certain clinical areas like the Outpatient Unit, minor and major Operating Theaters should be increased while the number of hours in the Psychiatric Area and in the field should be decreased. The provision of more educational equipment (books, nursing tools, modern computers) to the students is suggested. Allocating a room for the use of the students in the area of assignment is seen as a need to be answered.
In coming out with reports, such as that required from students who observe in areas such as Hemodialysis, minor Operating Room, and Diabetic Foot Clinic, it is suggested that it should be individual rather than group to encourage more attention on the part of each student. Likewise, group case presentation is seen as not reflective of real individual student efforts; hence, individual reporting is suggested.
From the teachers' perspectives, the maintainance of the perceived strong points is highly encouraged. Clinical teachers should come only from the College itself and should undergo a comprehensive training prior to clinical rotation. The number of students assigned to one clinical teacher should be reduced to a maximum of eight. More clinical exposure to areas such as the Intensive Care Unit and the Casualty is deemed important. Likewise, more time in laboratory practice is recommended. In the clinical area, there should be an official place designated for discussing with students and for conducting a clinical exam.

On Students' and Teachers' Perspectives about the State of Clinical Education
The results of the study reveal that in comparing perspectives of students and teachers on clinical education, there are six items which have significant values. Highest among them is the "hospital management collaboration in resolving problems of students." This could be partly explained by the coordination between the College and the hospitals/clinical agencies where students are assigned at least three months prior to their actual rotation. In the study of Asirifi et al. (2017) participants indicated the need for enhanced collaboration between clinical settings and schools. This could resolve educational issues and could create student opportunities. The study of Majid et al. (2011) likewise confirms that collaboration can result to improved accessibility to resources, creation of clinical settings more supportive to teaching and learning and "reciprocity of roles" in the students' clinical education.
In this study, collaboration and supervision of education is deemed significant by both students and teachers. Students are followed up in the area by either a faculty from the College or a staff duly designated by the clinical institution who has undergone a minimum of one week orientation. A clinical environment which is "studentfriendly" can be created by a stronger interagency collaboration and reciprocity (Asirifi 2017). Similarly, studies of Jasson (2016), Bianchi et al. (2016), andKristofferson et al. (2016) highlight "collaboration, clear clinical objectives, supportive clinical teaching and learning environments" as factors which could enhance student learning outcomes in terms of "critical thinking skills, clinical competencies, interpersonal communication, self confidence, and willingness to ask. This could likewise be promoted by smooth interpersonal relationships between the staff in the clinical setting and the students, the staff and the clinical faculty, and clinical faculty and students (Asirifi 2017) questions." Collaboration likewise decreases the challenges in clinical rotation related to shortages, either in staff or student resources (Asirifi 2017).
The study of Al Sebaee et al. (2017) revealed that students working as a team with the staff willing to assist them in learning were satisfied with their placement and were able to meet their objectives. Newton et al. (2010) support these findings. Students in the study of Arkan (2018) perceive the nurses in the clinical areas as role models.
The gap between what is taught in theory and what is seen in practice produce anxiety on the part of the students (Arkan 2018). Findings in the study of Asirifi (2017) noted that for students to integrate knowledge and practice evidence-based nursing, and to enhance communication and psychomotor skills, there is a demand for good quality and adequate hands-on opportunities.
Findings in a study (Al Sebaee et al. 2017) show that while some staff nurses are interested and willing to help students, they are not prepared to perform their role as instructor because of non-awareness of the skills and strategies needed in clinical education. In like manner, other studies (Levett-Jones et al. 2006) indicated that nursing staff are limited in their education and service roles because of the demands of their staff duties.
Results of the study of Hasanpour -Dehkordi and Shahani (2016) highlight the favorable cooperation of the personnel with the instructors and the students. Similar findings are revealed in the study of Hadizadeh and Firooz (2005). In contrast, another study (Hassanpour Dehkordi et al. 2016) pinpointed the negative role of the health care team members. Relatively weak or even non-cooperation has been reported in other studies (Hassanpour -Dehkordi and Masoudi (2015).
In this study, access to welfare and educational facilities at bedside has been given a high significance (p = .004). There were some clinical settings wherein students were given access to a room for clinical discussions. Hasanpour -Dehkordi and Shahani's study (2016) confirms this finding. This, however, is in contrast to a study wherein welfare issues and unfavorable personnel behavior were given 80% and 40% ratings, respectively as the highest problems in apprenticeship (Supreme Council for Planning, Tehran 2012). The study of Alavi and Abedi (2008) showed that 73% of the students perceive as obstacles the lack of opportunity to perform procedures and "undesirability of clinical conditions according to theoretical principles." Results of other investigations and the study of Hasanpour -Dehkordi and Shahani (2016) confirm the necessity of providing students appropriate "educational and welfare amenities and facilities" in the clinical setting to practice skills.
The implementation of the nursing process and patient education skills were rated with prime significance in this study. Students as early as their first level till the end of the program are exposed to the crucial importance of the nursing process and health teachings. In 2019, Dag et al. mentioned that one of the difficulties confronted by nurse educators is the application of the nursing process.
Another finding in this study which was given a high significance was the wandering of students in the absence of the clinical instructor. From the nurse educators' perspectives, the study of Karlstrom (2019) underlies among others the value of honesty, the importance of scrupulousness and precision expected in the students' personal lives. Unsafe student behaviors are necessary to be identified to ensure adequate support and guidance.

On Comparison of the Students' and Teachers' Perspectives in Relation to the Academic Levels and the Different Clinical Areas
In this study, using as variables the academic levels and the different clinical areas where the students are rotated, students give collaboration and supervision of educational supervisor a significant value (p =0.04), while teachers give healthcare collaboration in students clinical education a high significant value of p=0.005. For the teachers, Psychiatric Area had the highest mean, most probably since this is regarded as a specialty area. This is in contrast with the findings of a study (Al Sebaee et al. 2017) wherein this area does not appeal to students' sensitivity, particularly the male ones. The Medical-Surgical areas were given the lowest score by the teachers, considering that rotation here almost covers the whole time frame of the students' clinical rotation, starting from the first level and continuing to the second level, fourth level up to graduation.
At their starting level, the students are exposed to the general Medical and Surgical wards. These areas of placement are continued when they reach level two and are further exposed to other specialty areas such as the Hemodialysis, Endoscopy Unit, Minor Operating Area, and Diabetic Clinic. On their third level, the female students are assigned to the Maternal and Child care areas while the male students are to the Urology wards. This arrangement is prompted by cultural exigencies. The fourth level students are exposed to the Psychiatric Unit and again to the advanced Medical Surgical units. The fifth level students or the graduating students are placed in the Intensive Care Units, Casualty Areas, and Primary Heath Care Settings.
As supported by a study of Kristofferzon et al. (2016), students' learning outcomes are enhanced through increased collaboration, well-defined clinical objectives and supportive teaching and clinical learning environment. In this study, the difference in perspectives lies in the areas which got the highest mean and the lowest mean. Students gave Medical-Surgical areas the highest mean and the Intensive Care Unit, Casualty and Primary Health Care Settings, the lowest mean. In the study of Al Sebaee et al. (2017), students showed motivation and interest during their initial step in their career, which is the clinical placement in a Medical-Surgical area where they tend to cope up with challenges and achieved well. Students in other studies (Al Sabaee 2017) perceived rotations in the Pediatric area as more satisfying, most probably because of the "uniqueness of skills and experiences related to this specialty." Henricksen et al. (2012) in their study indicated that a positive learning environment is not provided by all practice settings. Kyei et al. in their study (2014) revealed that as students move up to higher levels and therefore have a wider range of clinical exposure, they perceived their clinical placement as richer in experience. Students in the study of Al Sebaee et al. (2017) perceived that short rotation of the clinical placement which ranged from two to three weeks in the clinical setting contribute to lack of support in professional growth. These findings are in similar directions as other studies (Levett-Jones et al. 2006) wherein too short clinical rotation does not allow students getting familiar with the unit and therefore obtain less learning advantages.
In the study of Hasanpour -Dehkordi and Shahani (2016), the students reported the supervision of the instructor as desirable but did not mention the ratio of students to instructor. Another study (Heidari & Nurouzadeh 2015) mentioned that the strength in clinical supervision lies in the "sufficient number of patients for learning." Significant issues to meet clinical educational requirements involve the consultants' lack of time and the heavy work load (Alavi & Abedi 2008).
Couper and Worley's study (2010) reported that students observed a mismatch between the educational goals and the expectations from the instructor and in some others, the curricula and instructor's method were assessed to be poor. On the other hand, Fakhr et al. in their study (2013) revealed that nursing students gave an above average score to their clinical instructors.
Results in the study of Reising (2018) revealed that students ranked as the most desirable characteristics of the instructors knowledge and support followed by "patience, creating challenges, enthusiasm, and organization." The instructor's ability to depict professionalism, convey knowledge, demonstrate caring and reflect enthusiasm significantly influences the clinical experience. Phuma-Ngaiyaye et al. (2017) in their study revealed that students perceived the support of clinical preceptors as vital in gaining confidence and competence, thereby improving their learning outcomes.
The study of Berntsen et al. (2017) reported that students with "higher education and with no experience working in health care settings" had higher perception of their involvement. Those with higher education may have developed study skills, such as planning self -learning process. For some students, the absence of former health care experience may produce heightened attentiveness and involvement in daily activities.
The limited resources and the high number of students in the clinical settings are viewed by the students as factors affecting learning negatively (Arkan 2018). Moreover, the students assume "observer roles" and miss learning opportunities with the high student/clinical teacher ratio (Asirifi 2017).
Data obtained in the study of Dag et al. (2019) confirmed that the following situations which nurse instructors experience contribute to negative learning: excessive number of students, heavy workload, inadequate clinical practice area, poor clinical environment, difficulties with health care team members and limitations in implementing the nursing care plan.

Conclusion
This study presented the perspectives of clinical education from two different groups -the students and the teachers, thereby presenting a relatively comprehensive viewpoint. There are basic similarities in their perspectives on the state of clinical education in Kuwait and the factors which may potentially create problem areas. Collaboration between clinical agencies and the educational institution, and collaboration between the clinical staff and the faculty members supervising the students emerge as significant issues to contend with. Both groups came out likewise with recommendations such as controlling the ratio of students to a teacher, coordination with the clinical placements and creation of a conducive atmosphere for learning. Results of the study therefore, could help develop standards of unified strategy for clinical education; hence, contribute to the enhancement and ultimate improvement of the quality of clinical education in Kuwait.

Limitation
The small study sample is a limitation to generalize the findings of the study.

Recommendations
It is recommended that similar studies on clinical education considering perspectives of both teachers and students be undertaken in a wider scale. Of urgent relevance would be studies on the educational changes in the global scenario prompted by the COVID 19 pandemic. Studies on the effect of technological thrusts on the modes of teaching, such as the online education, virtual simulation and others are deemed relevant. Nursing education, particularly the clinical education has been significantly affected by this worldwide situation. Different perspectives on the use of these methods on clinical education would prove timely and beneficial.

Conflict of Interest
The authors of the study declare no conflict of interests.