The process of challenge formation in Iranian nursing education: A grounded theory study with model presentation

Abstract

BACKGROUND:

Nursing education faces many challenges that must be identified and removed to improve nursing education and promote the quality of nursing care. Identifying the challenges of nursing education helps to solve or correct the weaknesses and achieve educational goals, which ultimately help to train skilled professionals capable of providing higher quality care to patients. The present study was conducted with the aim of explaining the experiences of nursing tutors in regard to the process of challenge formation in nursing education in Iran.

MATERIALS AND METHODS:

This is a qualitative study with a grounded theory approach that was conducted in two stages. In the first stage, which took about 9 months, 18 experienced nursing tutors with managerial positions were selected by purposeful sampling from universities across the country. Data were collected through semi-structured interviews, field notes, observation, and memos. Data analysis was done by Corbin and Strauss method through MAXQDA software version 10. In the next step, using the method of Walker and Avant (2011), concepts and statements were gathered within a whole and a model was presented.

RESULTS:

Twelve male university tutors and six female tutors participated in this study. The mean age of the participants was 45.38 ± 2.1 years, and their mean work experience was 18.66 ± 3.8 years. The findings showed that the challenges of nursing education could be categorized into three categories (defective educational cycle, efforts to restore the educational structure, and learning is a member of educational family), and 12 subcategories. After analyzing the data, trying to provide a need-based education was determined to be the central theme of this study. The components of model developed in this study were presented in the three axes of improving the tutor’s teaching skills, managing the situation and educational facilities, and facilitating student’s participation in the education process and decision-making.

CONCLUSION:

Identifying barriers and facilitators of need-based education in health policy making can enable nurses to build a better future for their nursing position. To provide need-based education, it is necessary to create a suitable ground and platform for proper education. Such platform and ground are a necessity of educational, therapeutic, and community environments. To achieve this goal, it is recommended to improve the professional capabilities of tutors and support educational organizations.

Introduction

One of the most important missions of the higher education system in nursing schools is to empower students so that they accept the important roles of nursing profession.[1] The purpose of nursing education in nursing schools is to create critical and creative thinking, promote self-directed learning, improve psychomotor skills and time management ability, increase self-confidence, establish proper communication, and prevent students’ passivity.[2] In fact, nursing education is the infrastructure for providing efficient human resources to meet the needs of society.[3]

Given the rapid changes in healthcare environments, the more fruitful the education, the higher the students’ efficiency will be.[4] The academic system should train experienced nurses with acceptable scientific and practical abilities to provide quality care to patients.[5] Although significant progress has been made in the last decade in the field of medical science education, especially nursing, the problems of nursing education are still an obstacle to achieving great goals, and this issue needs to be investigated. Studies show that the output of nursing schools is not aligned with their goals in educating students.[6,7,8]

All factors that prevent an educational-therapeutic system from achieving its educational goals are considered challenges.[9] Nursing education faces many challenges that must be identified and removed to improve nursing education and promote the quality of nursing care.[10] Identifying the challenges of nursing education helps to solve or correct the weaknesses and achieve educational goals, which ultimately help to train skilled professionals capable of providing higher-quality care to patients. Improving the quality of education requires continuous review of status quo, recognition of strengths, and correction of weaknesses, and in this regard, the opinions and ideas of experts, as the main educational element, can pave the way for future programs.[4] Nursing education managers and faculty members are the main administrators of universities. They are also among the executive agents of strategic planning who have different beliefs, views and perceptions about the university and its functions, the atmosphere governing the university, and the acceptability and legitimacy of the university. Therefore, examining the experiences of faculty members in relation to the challenges of nursing education, and considering their beliefs and perceptions can help to identify challenges and provide practical solutions.

The process of challenge formation in nursing education is a multi-dimensional issue, which is affected by cultural and social factors. Therefore, a qualitative approach and an in-depth study of the lived experiences of people involved in nursing education can help to gain a deeper understanding of this issue. Qualitative research is a suitable method for discovering complex human issues and what lies behind them.[11] Since the importance of understanding these experiences is effective in better educational planning in nursing, the present study aims to explain the experiences of nursing tutors in regard to the process of challenge formation in Iranian nursing education using a qualitative method and a grounded theory approach and also present a practical model. This research is innovative in the sense that, in addition to examining the experiences of experts in a qualitative method; at the same time, it has used related articles in this field to synthesize a theory.

Materials and Methods

The study was conducted in two stages to answer the main research question: “What is the process of challenge formation in Iranian nursing education [Figure 1]. Since research question guides the choice of research method,[12] and also as the challenge, which is a phenomenon occurring in the educational process, is formed during the social interactions between university tutors, students, patients, and other members of the treatment team in the real environment, the grounded theory method was chosen in this study.[13]

Figure 1.

Research process flow chart

Symbolic interactionism was chosen as the theoretical framework of this study. This framework is used as a foundation in grounded theory studies[13] and is suitable for studying people’s behavior and experiences, using people’s definitions of reality.[14] Therefore, the challenge in this study was defined many times by nursing tutors during a dynamic interactive process. These personal definitions provided the researcher with assumptions to guide the study and analyze the phenomenon.

Participants and data collection

First stage of the study

In a 9-month period (March 2022 to November 2023), 18 nursing faculty members (four professors, six associate professors, and eight assistant professors) participated in this study. First, the purposeful sampling and then theoretical sampling was used to collect the samples. In the sampling process, we tried to consider the maximum diversity in terms of age, work experience, education, educational group, and organizational position. The criteria for entering the study included being a faculty member, and having managerial experience and history of teaching undergraduate students.

Data collection was done with an inductive approach through semi-structured interviews, observation notes, field notes, and memo writing. In this way, observation notes were used in official observations, field notes were used during interviews and formal conversations, and reminders were used during data analysis. In all stages, symbolic interactionism provided the researcher with the basic understanding of the development and nature of human interactions.

The interviews were conducted individually and in a calm environment at a suitable time and place where the participants felt comfortable. The interviews were face-to-face and each lasted about 45–60 minutes. In some cases, after the interviews and review of the manuscripts, additional interviews were conducted if further explanation and clarification were needed. The main criteria for determining the number of interviews were the use of key informants, the quality of data, emerging classes and theories, and reaching theoretical saturation.[15] Based on this, 32 interviews were conducted.

Analysis

After the end of each interview, in a minimum time interval, the interviews were typed verbatim. Data analysis was done after completing the first interview, using the method of Corbin and Strauss (2015). This method was carried out at the open coding level to identify and develop concepts, analyze data for context, enter the process into analysis, and integrate classes. After reading the text of each interview and understanding it, an appropriate code was given to a desired phrase or paragraph. All interviews were coded in this way by one person. Constant comparative analysis was done through question formulation, word analysis, intra- and extra-class comparisons (flip-flop), sudden flip technique (researcher’s sudden sense of the validity of data), and raising red flags. This method prevented bias in data analysis and increased the theoretical sensitivity of the study.[13] Management of the coded data was done by MAXQDA software version 2010.

Second stage of the study

In the second phase of study, after the formation of descriptive theory, the three-step theory synthesis method of Walker and Avant (2011)[16] was used. This method is the best way to generate a prescriptive model. Prescriptive models are capable of empirical criticism, and their abstractness is less than descriptive theory. These models can also be tested in different clinical, teaching, and research fields.[17]

In the first stage of model design, by identifying the key concepts for the construction and processing of theory foundations, a concept or a set of related concepts for the development of model was identified and determined. The title “providing a need-based education” taken from the descriptive theory was chosen as the central concept. Next, in addition to the central concept, other related concepts were defined as the conceptual framework, so the four meta-paradigmatic concepts of the model including human, nursing, environment, and health were selected as the conceptual framework of the model. In the second step, a literature review was conducted to determine the factors related to the main concepts and meta-paradigmatic concepts of the model. The purpose of this literature review was to obtain relevant information to complement the elements of the model or prescriptive theory. All Persian and English texts available regarding the central concept (need-based education model) with the keywords of nursing education, challenge, need-based education, and educational need from 1990 to 2021 were reviewed in a detailed and targeted manner in order to find out the relationships between them and the factors affecting them. In addition, the results of grounded theory were used as one of the referable texts at this stage. In the third stage, the concepts and statements were organized into a related whole and the studied phenomenon was revealed using the above findings.

Validity and trustworthiness of the data

In this study, the accuracy and validity of the data were examined by the seven criteria of Chiovitti and Piran (2003),[18] as recommended by Corbin and Strauss (2015). These criteria include items, such as giving permission to participant and guide the research process, continuously controlling the theoretical structure under construction against the participants’ definition of the phenomenon, using the real words of the participants in the theory, expressing the researchers’ personal point of view about the investigated phenomenon and specifying the criteria formed in the researcher’s mind, specifying how and why the participants have been chosen to enter the research, specify the scope of study and describe how the texts relate to each category obtained in this theory.

Ethical considerations

This study was carried out with the permission of the research ethics committee (code: IR.NASRME.REC.1400.095). All the participants signed an informed consent form after being informed about the objectives of the study. Maintaining the confidentiality of information, having the right to withdraw from the study at any desired time, and voluntary nature of participation in the study were among the principles observed in this study.

Results

Twelve male and six female nursing tutors participated in the study. The mean age of the participants was 45.38 ± 2.1 years, and their mean work experience was 18.66 ± 3.8 years. After the data analysis, 1013 primary codes were obtained. The findings were reported in three main categories (defective educational cycle, trying to restore the educational structure, learner is a member of educational family), and 12 subclasses. After analyzing the data, the central theme of “trying to provide a need-based education” was determined [Table 1].

Table 1.

The formation of central them; “trying to provide a need-based education”

Theme	Categories		Subcategories
Trying to provide a need-based education	Background	Defective educational cycle	Resistance to new teaching styles
			Lack of standard evaluation criteria
			Inconsistency between theoretical learning and practical work
			Conflict between educational goals and society’s expectations
			Discrimination in educational justice
	Process	Trying to restore the educational structure	Managing situation and educational facilities
			Improving the educational capability of tutors
			Trying to teach by a unified approach
			Creating a balance between the volume of content and the overall needs
	Outcome	Learner is a member of the educational family	Development of comprehensive personal skills
			Socialization
			Development of professional communication

Defective educational cycle

According to the findings, the factors related to the formation of challenge in nursing education could be categorized into the category of defective educational cycle. This category also had several subcategories, including resistance to new educational styles, lack of standard evaluation criteria, inconsistency between theoretical learning and practical work, conflict between educational goals and society’s expectations, and discrimination in educational justice.

Resistance to new teaching styles

Nursing students have different learning styles and teachers should pay attention to this factor and use different teaching methods. Many tutors follow their old teaching methods and show resistance to new teaching styles.

“You have to go with the flow of technology. You can’t stand against progress, otherwise it will show its negative effect on its own system” (P. 6).

Lack of standard evaluation criteria

Evaluation is the main part of almost all educational systems, because it provides techniques and methodologies to determine effectiveness and ways to improve educational interventions. According to the participants, not having standard and unified evaluation criteria to measure the performance of tutors and students is one of the challenges that needs to be addressed. In this context, one of the tutors shared his experience as follows:

“Everyone has their own evaluation method based on their taste, which is not written anywhere. It is better to have a public checklist in the hands of both the person doing the evaluation and the person who is evaluated to know the content of this checklist from the beginning “(P. 8).

Inconsistency between theoretical learning and practical work

The gap between education and practice, the shock of facing the real clinical environment, and the inconsistency between theoretical education and practical work are some of the common challenges of nursing education that the participants referred to:

“Theoretical training is based on the latest translations and references of books that are provided according to the standard of care in developed countries. However, care in our country is provided in hospitals that can hardly provide even the smallest equipment for the training of students. Well, the students go to a reality shock”(P. 11).

Conflict between educational goals and society’s expectations

The educational goal is to train nurses who are capable of caring for patients, while members of pubic believe that many duties of secretaries, porters, nursing assistants, and hospital attendants are also part of nurses’ duties. The conflict between educational goals and society’s expectations creates challenges for motivation, professional dignity, and nursing education. In this context, one of the nursing tutors stated that:

“We were at nursing station when a patient’s companion came to us and shouted at a nurse that why should the quality of food be so low, so what are you doing here. The students saw this scene and well, it was not very pleasant”(P. 3).

Discrimination in educational justice

Educational justice refers to interactions, behaviors, and performances that are based on fairness, treating people without bias, providing guidance according to the ability of students, observing justice in evaluating and presenting points, etc. However, any inconsistency in each of these cases leads to discrimination and ultimately creates challenges in educational environment.

“All students are the same, and it doesn’t matter which university they get a nursing degree from. As much as possible, educational justice should be implemented in all cases”(P. 14).

Trying to restore the educational structure

The strategies of tutors in trying to restore the educational structure and solve underlying problems included; trying to manage the educational situation and facilities; trying to improve the teaching ability of tutors; trying to teach by a unified approach; and trying to create a balance between the amount of content and the overall needs.

Trying to manage the situation and educational facilities

According to the participants’ experience, the more suitable the educational situation and the access to educational facilities (such as educational equipment, educational location, sufficient number of teachers, specialized educational departments, and inter-professional communication with other educational groups), the less challenges in nursing education would be.

“One of our biggest challenges is the lack of facilities for each student. This issue is more visible in cities, especially satellite cities”(P. 10).

Trying to improve the educational ability of tutors

Formal models of tutor empowerment include participation in workshops, seminars, short-term courses, fellowships, and one-on-one counseling. Alternative and informal models also include training by colleagues, formal training, electronic learning, and self-learning. Appropriate empowerment strategies and programs should create a link between organizational empowerment and empowerment of individuals based on the organizational and individual needs.

“Every once in a while, a needs assessment should be done and the tutors should pass the workshops and training courses based on that needs assessment”(P. 7).

Trying to teach by a unified approach

According to the participants, different educational methods, contents, and resources are being considered even in the teaching of the same course during different semesters, which creates a great challenge for the students’ educational follow-up. Trying to have a unified educational program and a standard curriculum that can be followed in all faculties is one of the ways of overcoming this challenge.

“We have a single curriculum, but whether everyone is bound to implement it needs to be assessed”(P. 5).

Creating a balance between the volume of content and the overall needs

Based on the experiences of participants, content design according to the needs of learners in today’s society is recommended to provide solutions for the past and future challenges of nursing. The expert review of the educational content should be prioritized in the future in view of the comprehensive need in nursing care.

“We should be able to train nurses. We should not introduce a large volume of material to student and forced them to memorize them. This will not be useful for them in the future”(P. 13).

Learner is a member of educational family

In trying to restore the educational structure, the clearest concept revealed in the data was considering the student as an important member of educational family, and the need for student participation in educational decisions. This category also had several subcategories, including development of comprehensive personal skills, socialization, and development of professional communication.

Development of comprehensive personal skills

Considering the student as an important member of educational family leads to comprehensive personal growth, such as recognizing one’s weaknesses and strengths, and improving actions, behaviors, and beliefs. In this comprehensive process, the student is able to improve his/her capabilities, maximize his/her performances, and become the best version of him/herself.

“It is by handing over responsibilities and proper supervision that the student can develop him/herself in the best way and learn to manage patient care independently”(P. 1).

Socialization

Socialization is a vital aspect of development in nursing students, which begins with students entering nursing education and continues with the completion of nursing education and entry into the practice. This process helps students to become active members of nursing community. The most important aspects of socialization include acquiring a comprehensive professional identity, adapting to own role as a nurse, and creating professional and organizational commitment.

“Our whole goal is to create a nurse who has a professional identity and commitment. In other words, being able to create socialization in the student”(P. 8).

Development of professional communication

Nursing is a profession that requires teamwork and communication. Communication with other members of health team is an important part of a nurse’s work, which is necessary to facilitate the patient care process. Professional communication is formed in nursing students from start of their training. With the growth of effective professional communication, members of educational team have a common therapeutic goal, understand each other’s roles, respect each other, resolve conflicts effectively, have flexibility, and use transparent communication.

“When a student learns professional communication in the educational environment and this communication is properly established, it will continue and transfer down the line” (P. 5).

According to the analysis of connection between categories, a central concept was chosen as the mean theme of the study; “trying to provide a need-based education.” This descriptive theory helps learners to understand the actions and interactions in clinical settings and the real context of education and also specifies that the tutors are trying to provide education based on the needs. But this theory cannot answer the practical question of how nursing tutors can improve the challenges of nursing education by providing education based on the overall needs. The answer to this question is possible by designing a prescriptive model.[16]

Accordingly, in the second phase of the study, which is the synthesis of prescriptive model, the results of reviewing articles and concepts resulting from the grounded theory stage were explained as a whole. In the search phase, 1231 articles were initially obtained and after being reviewed by two researchers familiar with systematic review method and checking articles based on PRISMA, this number was reduced to 23 articles related to the central concept of this study. Next, by reviewing and considering the results of grounded theory, the concepts and axes of the need-based education model were defined.

In this model, human being as a biological, psychological, social, and spiritual being has different physical and spiritual needs and shows different behaviors to meet his/her needs in different conditions and situations. In this model, human being is a person who is somehow involved in providing need-based education. The nurse (tutor) in this model is an educated person with sufficient scientific knowledge and ability. He or she is a responsible and accountable person who provides education, decision, and intervention in order to improve the level of education by applying professional knowledge and skills, using communication skills and following professional regulations and standards. In the current prescriptive model, the environment is a set of elements and factors that surround the person (recipient and provider of education). The environment should be healthy and motivating so that the teacher can fulfill his or her duties. In this model, health is equivalent to the result of correct and effective training in challenging situations and correct performance at the right time and place. Establishing a need-based education is also an education, which include three axes of improving the tutor’s educational skills, managing the educational situation, and facilitating student’s participation in education [Figure 2].

Figure 2.

Components of the need-based education model

In managing educational situation, paying attention to the educational and welfare facilities, the number of students in internship groups and classes, the relations of educational group with other groups, and the use of visiting professors are very important. In addition, according to the findings of the present study, gaining the support of organization, improving professional and inter-professional cooperation in the organization, and getting help from student groups play a vital role in helping to balance the situation.

In improving the tutor’s teaching skills, it is important that the tutors first know their personal values and goals and at the same time respect the students’ personal values. It is important to pay attention to the individual attitudes and presentation skills of tutors in providing education to learners and also, how much of the material with what educational content through which teaching method in what time frame and at what time and place should be presented to learners. Also, managing individual capabilities and students’ feedback, using appropriate communication strategies and predicting possible inconsistencies in education are very important in this regard. Experience, sufficient study, and self-management are important factors in increasing the tutor’s self-confidence.

In facilitating student’s participation in the education process, paying attention to the rights of students and avoiding the adoption of paternalistic approach, as well as following inclusive educational principles are among factors that the participants referred to in this study. The educational team should pay attention to inclusive factors such as students’ acceptance of new roles and level of awareness, self-confidence, age, gender, economic level, ethnicity, culture, and goals.

Discussion

The findings of the present study show how challenges are formed in nursing education, and also present a prescriptive model. In the present study, resistance to new educational styles, lack of standard evaluation criteria, inconsistency between theoretical learning and practical work, conflict between educational goals and society’s expectations, and discrimination in educational justice were found to be the factors that create a defective educational cycle. In other researches, the main obstacles to improve the level of nursing education in developing countries have been found to include shortage of nursing tutors, lack of unified educational programs, and lack of new educational methods.[19] The existence of various problems, such as inconsistency between theoretical learning and clinical work, lack of clear clinical training goals, stressful hospital environment, low desire of experienced tutors to attend clinical environments, lack of real evaluations, and lack of educational facilities, are among obstacles to achieving the goals of nursing education.[20,21] On the other hand, from the students’ point of view, the quality of education is not favorable and factors such as dispersion of internships in clinical departments, forcing students to perform the duties of employees, large number of students, lack of proper evaluation by nursing tutors, lack of sufficient access to instructors, lack of proper coordination between theoretical and clinical education, lack of time needed to deal with various illnesses in order to practice the learned materials in the clinical environment, and stressful situations are among the challenges of nursing education.[22,23]

The inconsistency between theoretical learning and practical work was one of the most important educational challenges that were mentioned by the participants in this study. In other studies, the gap between theory and practice has also been mentioned as the most important challenge of nursing education, which refers to the inconsistency between what is learned in the classroom (theoretical knowledge) and what is experienced in the clinical environment (performance).[9]

In the category of trying to restore the educational structure in response to underlying problems, issues such as trying to manage the situation and educational facilities, trying to improve the educational abilities of tutors, trying to teach by a unified approach, and trying to create a balance between the volume of content and overall needs were mentioned by the participants as the influential factors. In other studies, factors such as teacher’s characteristics, environment, and training situation have been introduced as the most important components of education.[24] The selection of managers and faculty members should be based on scientific, general, and moral merits,[25] in order to achieve educational goal.

Considering the student as an important member of educational family and the necessity of student participation in decision-making by developing comprehensive individual skills, socialization and promotion of professional communication are the result of tutors’ efforts in nursing education. Other studies have also referred to the importance of paying attention to comprehensiveness in education process. Factors related to students, including fear of causing harm to patient, fear of ridicule, fear of criticism from the instructor, fear of the presence of patient’s companions at the bedside, emotional reactions of students, lack of scientific and communication skills, low self-confidence, inadequate mastery of cognitive components, and student’s lack of educational and care planning skills have also been proposed as the challenges of nursing education.[26,27]

In relation to the model presented in the present study, no similar model was found in nursing for comparison. It can be said that the current model is the first prescription model in this field.

Limitation and recommendation

Based on the findings of the qualitative and search phase, a need-based education model was designed. It should be taken into account that the need-based education model and other dominant models are dependent on culture and history. Therefore, these educational models should be considered as dynamic and dependent on the culture and educational conditions of each country. Thus, it can be concluded that these methods are not global models.

Conclusion

Identifying the obstacles and facilitators of education with the aim of removing the obstacles and increasing the motivation of learners has an important role in improving the quality of education. The educational challenges faced by all nursing tutors are similar, but the educational conditions and situations in each region can be effective in the occurrence of problems and challenges ahead, so knowing the dimensions of educational challenges in nursing profession require more investigation. This concept is dynamic and changes over time. In this context, it is necessary to teach new teaching skills to tutors, monitor their skills in practice, and hold periodic training workshops for them. Considering the preferences of students and the importance of empowering students, and paying attention to the opinions and values of patients and their families are among the important factors that have been considered in the present study. To provide a need-based education, it is necessary to create a suitable ground and platform for proper education. Providing such platform is a necessity in educational, therapeutic, and social environments. So, in future studies, effective solutions to solve the challenges of nursing education and clinical practice should be investigated.

Authors’ contribution

All authors met the standard writing criteria based on the recommendations of the International Committee of Medical Journal Publishers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.