Challenges of Nursing Students in Relation to Academic Performance at the Faculty of Technical Medical Sciences

Nursing students face various challenges during their years of study, which may hinder their academic performance. The success of nursing students is particularly important given that they must provide quality care to patients, family members and the community. Academic performance in nursing programs includes advances in theoretical subjects and the acquisition of practical skills in the clinic. A series of studies have shown that during the years of study, nursing students face many difficulties that affect their learning skills and consequently their academic performance. This study aims to identify and describe the difficulties experienced by nursing students of the Faculty of Technical Medical Sciences of Tirana in relation to academic performance. This goal was achieved by using a qualitative research method, such as focus group discussion. Data were collected through discussion with 51 Bachelor students, 17 of whom in the first year, 15 in the second year and 19 participants in the third year. For each year of the study 2 semi-structured discussions were held and the data were analyzed through thematic analysis. The findings of this study found that nursing students face these difficulties: Low level of students engagement in clinical practice; Low number of nursing courses; Passive teaching methods; Unfair and non-transparent evaluation; Large number of exams per season; Insufficient time to prepare for the season; Employment and finances; Physical environment in the faculty and public transport. Heads of Departments and Faculty can use the findings of this study to provide the necessary support that nursing students seek in reducing the difficulties they face in order to enhance their academic performance.


Introduction
Nursing students face various challenges during their years of study, which may hinder their academic performance. The success of nursing students is particularly important given that they must provide quality care to patients, family members and the community (Ratanasiripong et al. 2021). Academic performance in nursing programs includes advances in theoretical subjects and the acquisition of practical skills in the clinic. A series of studies have shown that during the years of study nursing students face many difficulties that affect their learning skills and consequently, their academic performance. Dante et al. (2013) in a systematic review of the literature regarding academic performance indicators confirmed the complex nature of academic performance for nursing students, arguing that the influencing factors for one student may be very different for another. While Mthimunye & Daniels concluded that nursing students face difficulties such as: part-time employment, off-campus stay, curriculum structure, insufficient academic and clinical support, and unfavorable physical faculty environment (Mthimunye & Daniels 2020). Previous studies have shown that during the years of study, nursing students face many difficulties that affect their learning skills and consequently, their academic performance. By identifying and recognizing the difficulties encountered by students during their years of study, measures can be taken to reduce barriers and improve academic performance (Fooladi et al. 2022).
This study was based on the conceptual model of reducing the gap towards student success, by Perna & Thomas (2006). These challenges can be the result of the interaction of personal, family, school as well as social, economic, and political context (Perna & Thomas, 2006).
This study aims to explore and describe the challenges experienced by nursing students of the Faculty of Technical Medical Sciences (FTMS) of Tirana in relation to their academic performance.

Methodology
This study used a qualitative research approach, such as focus group discussion, to identify difficulties encountered by students in relation to their academic performance. The study was conducted at the Faculty of Technical Medical Sciences (University of Medicine of Tirana, Albania), which prepares nurses in accordance with the Bologna system, Bachelor 3 years and Professional Master one year and Master of Science two years. Qualitative research seeks to provide a detailed explanation of human attitudes, feelings, and perceptions (Tong et al., 2012). This method was useful in this study to explore the difficulties faced by nursing students.
The sample consisted of 51 Bachelor students, who were randomly selected using the name lists of each year of study. Participants were informed that the principle of confidentiality and anonymity would be respected and their involvement in the study was voluntary. During the selection of the sample not all students agreed to participate. 17 participants from the first year, 15 participants from the second year and 19 participants from the third year took part in the research.
Prior to data collection, a pre-test was performed with 4 students, to improve validity in qualitative data collection procedures and interpretation of findings (Brown, Lindenberger, & Bryant, 2008).
Two focus group discussions took place with each study year in the period January-March 2022, and each discussion lasted about 50 minutes. All six focus group discussions took place in a FTMS meeting room.
Focus group discussion is a technique where the researcher discusses with a group of individuals a specific issue, aiming to extract from the complex personal experiences, beliefs, perceptions, and attitudes of the participants through a moderate interaction (Hayward, Simpson, & Wood, 2004).
Data were collected with the help of study assistants. The lead researcher together with colleagues supervised the process and the quality of the collected data. The following questions were asked to obtain the required data on the difficulties faced by nursing students regarding academic performance: -Describe the difficulties that have affected your academic performance encountered in the faculty settings.
-Describe the difficulties that have affected your academic performance encountered in clinical settings.
-What efforts have you made to ensure satisfactory academic performance and achievement?
-What do you think needs to be improved regarding overcoming difficulties that affect your academic performance?
Other investigative questions were used during the discussions to further delve into the problems students encountered during their years of study. The discussion took place in Albanian language, and it was recorded with the permission of the participants by using a recorder. Study assistants kept brief notes about each participant's comments that answered the semi-structured and open-ended questions. Qualitative research and especially focus group interviews generate large amounts of data. Yin (1989) states that data analysis consists of a series of stages such as examination, categorization, and tabulation or recombination of evidence, to address the initial purpose of the study. Data analysis was based on transcribing focus groups, identifying key topics, organizing data, interpreting topics and ideas, and reporting.

Findings
Data analysis generated 194 citations, which were categorized into 3 topics and 11 categories. The categorization of the data and the clarification of the topics was based on the model adapted by Perna and Thomas (2006).

Category 1 Low level of student engagement in clinical practice
Bachelor's nursing students admitted that they were not properly supported by the clinical supervisors employed by the faculty to oversee the students at the clinical premises. In the discussions that took place, most of the second-and third-year students stated that the difficulties they encountered in the clinical environment negatively affected their academic performance. The students admitted that the practice hours are insufficient for them, which affects their practical training. The students stated that: "We are large groups, and we cannot even learn the basics." (FGD 5, BN 3)

Category 2 Curriculum structure
This discussion highlights the challenges directly related to the curriculum experienced by students. They say they have a large number of subjects and exams, and some subjects (in their judgment) are unnecessary for the nursing branch. They declare: "I think we have many subjects and exams, different from other faculties; some of these subjects seem unnecessary to me." (FGD 3, BN 2) "Some subjects should not be included in curriculum, because they are not related to the nursing branch, and unimportant subjects should have less credits." (FGD 6, BN 3) "The curriculum has a big volume and a lot of subjects, there are also subjects with one credit." (FGD 5, BN 3) "The literature and program need to be clearer and more concrete at to what we need as nurses." (FGD 6, BN 3)

Category 3 Educational workload
The transition from high school to university confronts first-year students with the burden and volume of lectures that make it difficult for them to understand and learn.
First year students suggest that it is more effective for them to develop laboratory practice in smaller groups and that the large number of subjects is a barrier to learning. Some of the students' sayings are: "I had difficulties at the beginning of the academic year with the adjustment regarding the volume of material received to find the right method of study and to manage time." (FGD 5, BN 3) "The lectures seem very long to me compared to high school and it is difficult to learn." (FGD 2, BN 1) "Anatomy is very difficult, we should go in smaller groups to the laboratory to learn." (FGD 1, BN 1)

Category 4 Organizing the exam season and scheduling
Students state that the exam season is short and insufficient to prepare for a large number of subjects. They say: "We have a very large number of exams and the time between exams is very short, which we find impossible to cope with and very stressful." (FGD 3, BN 2)

Category 5 Teaching methods
Students say that some of the professors do not use interactive methods during the lessons, which leaves the student passive only by listening and does not help them in acquiring knowledge, resulting in loss of interest. Some of their statements are: "I lose interest when certain professors start reading the material on the laptop without giving concrete examples to make it more attractive, this is a matter of concern not only to me, but also to my friends." (FGD 1, BN 1) "Lecturers should develop the lesson more as a conversation… we listen to the lecturer for 2 or 3 hours. I think they should concretize the subject with concrete examples from real life. " (FGD 2, BN 1) "Some lecturers only read the slides and do not explain to concretize what they say." (FGD 5, BN 3)

Category 6 Student Assessment
Regarding the assessment of knowledge by lecturers, students say that they face many difficulties and lack of transparency, which has reduced their motivation. Some of them say that the evaluation is not based on the merit of everyone.
"When I complained about the grade because I rightly deserved more, the professor, pressuring me, said that he could lower my grade even more." (FGD 5, BN 3) "What has influenced me is the fact that you work, study, get tired and in the end, you are evaluated less than you deserve… because there is a prejudice that not all students in a class could get grade 9 or 10." (FGD 3, BN 2) "… Our answers in seminars and course assignments are not considered in the final evaluation." (FGD 4, BN 2 "We are evaluated unfairly in exams, and we are not given the opportunity to see the exam thesis." (FGD 6, BN 3)

Category 7 Physical facilities of the faculty
Another concern mentioned by the students were the conditions at the faculty. They say that they did not have the minimum conditions such as. heating, elevator etc.
"Conditions are not good in the faculty, during the winter we did not have heating… only the boiler was not enough, the toilets do not even have the minimum hygiene." (FGD 4, BN 2) "We are on the fifth floor, and we lack the elevator, heating, reel, etc." (FGD 6, BN 3)

Category 1 Economic situation
Some students said that they face financial difficulties that force them to work during their studies. They show that the school fee and the prices of rented houses are very expensive. According to students: "School fees are expensive compared to salaries in Albania." (FGD 4, BN 2) "Living is very expensive and I have to work… after school I have to go to work and come back in the evening… and I prepare only 1 or 2 days before the exam, which is not enough, but I am obliged." (FGD 2, BN 1)

Category 2 Transportation
Despite of reduced transportation fares for students, urban transportation remains a concern for them. According to students: "One of the most negative experiences for me has been transport, as I live in the area of Astir and it is far; I cannot reach the faculty to attend the first hour due to traffic." (FGD 3, BN 2) "For me, the distance from the family, the transport that costs and takes a long time due to traffic are obstacles for the results." (FGD 1, BN 1)

Category 1 Student Efforts
One of the basic factors of academic performance is the efforts of the students themselves. During the study period the priority of students is learning to successfully complete university. Students have given due importance to some of the factors such as time planning, systematic study, utilization of other resources to meet the needs of learning such as the Internet and health institutions. They claim that: "I have prepared regularly by learning every lesson despite the fact that it was not worth, because I got lower grades than the other students, who cheated at the exam".

Category 2 Student suggestions for improving the situation
Students think that curricula and educational load should be improved; more attention should be paid to clinical practice, students should be motivated, teaching should be improved. They identify and suggest: "The exams we take in the season (at the end of the semester) should be reduced because they are too many." (FGD 3, BN 2) "Lecturers need to evaluate fairly, and improve teaching." (FGD 4, BN 2) "Lecturers should be more transparent with the student and create opportunities to develop more regular practices." FGD 6, BN 3 "Reduce the number of not very important subjects, pay attention to practice, the explanation should be more complete." (FGD 5, BN 3)

Discussion
This study found that the difficulties faced by nursing students at FTMS of Tirana in relation to academic performance are as follows: low level of student engagement in clinical practice, large number of courses and exams, insufficient time to prepare for the season, low number of nursing courses, passive teaching methods, unfair and nontransparent assessment, employment and finances, faculty physical facilities and public transport.
Nursing students do not receive adequate clinical support at the facilities of University of Medicine from internship mentors. According to (Baraz et. al. 2015), the clinical learning experience is at the heart of nursing education and also in a study by (Papastavrou et al. 2016), the quality of nursing education depends largely on the quality of clinical experience. Students suggest that more needs to be done in regulating internships performed in hospitals, they seek a more supportive and hospitable learning environment. During clinical practice, students often face challenges, which make them feel vulnerable (Chan 2001); this requires the serious commitment of the faculty to facilitate the practice and create a supportive environment for students. Other studies have argued that instructor incompetence, negative attitudes, and poor student support can cause adverse effects on student academic performance. (Anthony 2011;Sharif 2005).
In the discussions that took place, the second-and third-year students stated that the difficulties they encountered in the clinical environment negatively affected their academic performance. Another learning challenge from the perspective of most of nursing students, who participated in this study, was the lack of reliability of clinical evaluation. This is because these assessments were not able to properly assess students' scientific knowledge, practical skills, and professional conduct. This result is consistent with the results of the study of Bourbonnais et al. (2008). The relationship between faculty and student is an important part of student success during clinical practice (Foreman et al. 2016). The environment where students study and practice include important aspects such as social climate, care activities, communication, and interpersonal relationships as well as reflection (Kamphinda & Chilemba, 2019).
According to the students, the lecturer-student communication and cooperation is not at the right level and that this leads to an increase in their distrust regarding the veracity of the professional evaluation and judgment. A considerable number of the students express their concern about the assessment, the transparency of the lecturer regarding the assessments and it often seems that the grade is a "strong weapon" in the hands of the lecturer.
In a study in Iran, Cheraghi came to the conclusion that during the learning process regarding the acquisition of knowledge, there was not much attention to students and aspects of learning (Cheragi et al. 2007).
Assessment methods can have their share of negative impact on quality student performance as they often result in a large amount of stress (Wang and Yeh, 2005).
Both Boulton and O'Connell (2017) noted that the amount and difficulty of learning material in the nursing program is a common stress for nursing students.
Jeffreys (2012) discussed study skills as an important factor influencing academic performance. He noted that reading skills, note-taking should also be accompanied by attitudes of accepting responsibility for study, activities such as self-direction, willingness to adapt and detailed plans.
The internal context of the students is related to the approaches, the student's behavior in relation to the chosen vocational education. They claim that they seek higher results, try to learn more by using all possible resources (internet, additional literature) to supplement their knowledge in the field of nursing. They have organized the day; they have chosen to attend classes regularly and some even admit that they learn in groups to improve academic performance.
Employment and finance have a major impact on students' academic experience, according to the UCE Center for Quality Research (CRQ). This study found that students are under pressure to afford living, the cost of renting housing, paying for public transportation, educational materials, and are forced to work part-time by not devoting enough time to lessons. In the National Student Engagement Survey (NSSE) in 2012, students were asked how finances affected their academic performance. The results showed that 60% of students said this interfered with their performance negatively. This proves that work and financial worries lead to fatigue and lack of concentration which endanger the performance of students in universities (Al-Muslimawi & Hamid 2019).

Conclusions and recommendations
The purpose of this study was to explore and describe the challenges experienced by nursing students of FTMS of Tirana in relation to academic performance. Low level of students engagement in clinical practice, large number of exams, insufficient time to prepare for the season, low number of nursing courses, passive teaching methods, unfair and non-transparent evaluation, employment and finances, physical facilities of the faculty and public transport are some of the difficulties encountered by FTMS nursing students in relation to academic performance. These findings indicate that measures should be taken to help students cope with difficulties that hinder their academic performance. Heads of Departments and Faculty can use the findings of this study to provide the necessary support that nursing students seek in reducing the difficulties they face to enhance their academic performance.