Supportive relationship: Experiences of Iranian students and teachers concerning student-teacher relationship in clinical nursing education

Abstract

Background:

Student-teacher relationship is a salient issue in nursing education and has long-lasting implication in professional development of nursing students. Nowadays, this relationship in clinical settings is different from the past due to changing in nursing education paradigm. The purpose of this qualitative study was to explore the experiences of students and teachers about student-teacher relationship in the context of clinical nursing education in Iran.

Materials and Methods:

In this qualitative study that has been carried out adopting conventional qualitative content analysis approach, six bachelor nursing students and six clinical teachers in school of Nursing and Midwifery, were selected through purposive sampling. Semi-structured interview and participant observation were used for data collection. Interviews transcribed verbatim and analyzed using conventional content analysis through the process of data reduction and condensation, coding and also generating the categories and themes.

Results:

Results of the study showed the existence of a type of relationship in clinical education in which supportive actions of clinical teachers were prominent. These supportive actions appeared as three major categories including educational support, emotional support and social support which emerged from data.

Conclusion:

The results of this study explicit the ways that support could be provided for students in their relationship with clinical teachers. It also determines the teachers’ need to know more about the influence of their supportive relationship on students’ learning and the best possible outcomes of their education in clinical settings.

INTRODUCTION

There is evidence that the supportive relationship in education between student and teacher can be as a basis for student's health promotion. Also, this relationship is essential for maintaining of student's interest to profession.[1] Clinical education is the lifeblood of nursing education.[2] and it is essential for professional promotion of nursing students.[3]

In Iran, students can study nursing across all higher education levels from bachelor to doctoral.[4] The basic nursing programs offer a 4 year baccalaureate in nursing.[5] Nursing students start clinical training from the second semester and this is run concurrently with theoretical courses until the end of the 3^rd year. The 4^th year is allocated exclusively to clinical placement training. They learn in the clinical environment under the direct guidance and supervision of a male or female nurse teacher who had master degree in nursing for the first 3 years. In the final year they work under the guidance of staff nurses and alternate supervision of nurse teachers.[6]

Many factors such as the number of students in training groups, long time clinical experiences and hard work may affect teaching and learning situations and their quality. This may distinguish clinical situation from other educational situations. Among the other influential factors are student and teacher characteristics, learning experience of theoretical courses and relationship in clinical setting. Indeed, clinical education is a face-to-face education in which the quality of relationship plays a key role in its promotion.[7]

This relationship is valuable in clinical nursing education and should be facilitated in various ways. Considering the fact that teaching and learning are mutual interactive processes between students and teachers, these processes will be certainly facilitated via supportive approaches.[8] In fact, the type of relationships can help make a qualified clinical placement scenario.[9]

As much as the teachers have more support in their relationship with students, students are more convienent in the learning settings and they have more involvement in learning activities. Also, the students who experience supportive relationships from their teachers, exppress high quality of recieved education.[10]

Despite the importance of student-teacher relationship and its salient effects on self confidence, learning motivation and promotion of professional skills in students,[11,12] positive learning experiences, decrease in students’ fear and anxiety, reduction of the possibility of educational failure, promotion of professional identity and reception of more support during care provision by students,[9,13,14,15,16] there are still problems with relationship status. Webb and Shakespeare (2008) cited Bennett (2002) who found that students have potentially damaging experiences such as being ignored and unattended by clinical educators.[17] The findings of Savage's and Favret study (2006) are indicative of students’ experiences of their educators insulting them in front of others.[18]

In Iran the study by Ghadami et al. (2007) titled “Students’ points of view regarding effective factors in establishing communication between students and faculty members” was accomplished.[11] This study didn’t carry out specifically in clinical nursing education.

Now, student-teacher relationship with regard to the paradigm shift in nursing education and its emphasis on centrality of relationship has been changed from what it has been in the past. The exploration of this relationship and its dimensions in humanistic paradigm is inevitably necessary. Considering the dearth of studies about supportive relationship between student and teacher in clinical nursing education in Iran, as well as the different experiences and perceptions of nursing students and teachers according to the Iranian culture, this qualitative study was accomplished. The purpose of the study is to explore the experiences of nursing students and teachers about student-teacher relationship in clinical nursing education.

MATERIALS AND METHODS

This paper presents part of a larger study that served as the corresponding author's doctoral dissertation. The larger study focused on the process of student-teacher relationship in clinical nursing education in Iran.

To achieve the aim of the study, conventional content analysis approach was used. Participants included six bachelor nursing students and six clinical educators in School of Nursing and Midwifery who were selected through purposive sampling in 2010-2011 [Table 1].

Table 1.

Summary of participants’ profile

Data were collected through semi-structured interviews and participant observation. Based on the participants’ choice, interviews were conducted either in classroom or teachers’ office. Each student or teacher participated in a semi-structured interview which lasted approximately 45-90 min. At first, some questions were asked about the experiences of student-teacher relationship as an introduction and then the interview process was guided through the participant's answer.

Interviews were conducted and recorded by the researcher and then transcribed verbatim. Subsequently, the transcribed interviews were reviewed and analyzed immediately. Data analysis was conducted concurrently through data collection. Data collection continued until data saturation was achieved.[19]

Unstructured observation (observer as participant) was carried out in the cardiac and surgery wards in Imam Reza (Al) hospital. Because the primary reason for using observational methods is to verify whether what people say is the same as what they actually do,[20] it is ideal that interviews and observations are conducted for the same people. Thus in this study, in some cases that it was possible, observation and interview were done as complementary data for the same participants and in other cases were carried out separately from each other. Observation was recorded through field notes. The role of the researcher was watching what participants did, listening to what they said and recording the way they acted. The behaviours of students and teachers and their relationship were observed for 3-4 h in each day.

The study was designed to minimize observer effect, as the researcher's presence could affect teachers’ and students’ behaviours. To minimize this effect, it was tried to give a general awareness of research aim to the participants, whereas they did not know exactly about the time of observation and the way that they were observed.

Collected data from observation of participants whom were both interviewed and observed were analysed as complementary for interviews’ data with regard to this point that do they confirm each other? However, in remained cases they were analysed as separated data. Conventional content analysis was done for data analysis. This approach is usually appropriate when existing theory or research literature on a phenomenon is limited. Researchers used inductive category development, i.e., Avoided using preconceived categories, instead allowed the categories flow from the data. Researchers also immersed themselves in the data to allow new insights to emerge.[21]

According to content analysis process, at first each interview or field note was read again and again carefully in order to gain a universal and primary understanding of the important under-lined statements. Then, meaning units about participants’ experiences of relationship existent in the interview text were determined. In the next phase, the meaning units were abstracted through condensation and were labelled as codes. Participants’ statements and implicit concepts were used for coding. Codes were compared for similarities and differences within the same interview and in different interviews and compared with field notes, and then categorization of codes was done accordingly.[22,23] In the next stage, categories and sub-categories were examined under supervision of expert supervisors who were experienced in qualitative analysis.

Credibility was established through prolonged engagement with participants, triangulation of methods and data sources, member checking, peer debriefing and review of data analysis with supervisors. For dependability, renewed coding of the interviews was carried out by colleagues who had experience in coding qualitative data. Moreover, the researchers documented research details in order to provide the possibility of external review.[19]

This research was carried out after getting ethical approval from research Ethics Committee, University of Medical Sciences and with the permission and consent of the Dean of Nursing and Midwifery School. Informed consent was obtained from all participants and they were ensured of their anonymity and were allowed to repudiate to answer any question or withdraw from the study at any time without prejudice to their clinical education.

RESULTS

Three major categories emerged based on data analysis. Those were including: (1) educational support, (2) emotional support, and (3) social support.

The first category: Educational support

Based on the participants’ experiences in this study, educational support was one of the most important aspects in the context of student-teacher relationship. They believed that the importance is such that the relationship in clinical education becomes meaningless without supporting the student. Educational support in this relationship was accessible through two methods including getting support for the accomplishment of clinical skills and also through creating learning situations.

Support for the accomplishment of clinical skills

Receiving support for doing clinical skills seemed very essential in relationship in clinical education from the experiences of both students and teachers, because they experienced that supporting students in doing clinical skills is a major factor in a successful clinical learning. Nursing students commented that they need to presence of clinical educator in a supportive atmosphere in clinical environments for better learning of skills. They experienced that if this support is available, the students will have enough self-confidence for skill accomplishment. At the same time, student's ability to carry out the skills correctly will be increased and clinical learning goals will be achieved. One of them commented:

“If we do an IV catheter insertion or some skills which we are not able to do alone, the teacher comes and helps us. For example, I appreciate it when Mrs. A accompanies me during the insertion of IV catheter or blood taking, because her speech and behaviour increases my self-confidence” (S1).

One major aspect of supportive relationship was accompanying students in clinical setting to perform the skills until the procedure is completed. This issue was one of the main requests of students in establishing relationship with clinical teachers. Nursing students expected their teachers to be supportive and in occurrence of a problem in clinical setting, they attend and support students and don’t leave them alone. They pointed out if the teacher does not accompany them in doing clinical skill, they will receive assistance and support from their peers and/or ward staff. One of them commented:

“In the apprenticeship that we had the previous semester, we didn’t know how to do the uterine massage. So on the 1^st day, I asked my teacher several times to train me in this relation, but I eventually had no chance to be trained by my teacher until the end of the clinical course. So, I asked the other students and staff to help me with that.” (S6).

Support through creating learning situations

Clinical teachers in this study experienced that educational support in their relationship with students can be provided through creating good learning and teaching situations in clinical setting as well as establishing supportive relationship with students through having suitable clinical planning with the aim of decreasing the theory-practice gap and maximizing the usage of educational situations for students’ learning. Spending time with students and helping them to use of optimal learning situations was salient aspect of these supportive actions that led to more trust to teacher in mutual relationship. One of the teachers commented:

“I try to select the best cases for my students in the ward, so that they’ll have the opportunity to see various types of disease in practice. In this way, they trust me, because they know that I do my best to support them, and they don’t miss the practical situations in the clinical settings” (T3).

Students were also aware of the support of their teachers for helping them to learn better and this caused a pleasant experience of their relationship in clinical education. One of them commented:

“When our teacher supports us in learning situations, we trust him/her in our relationship. For example one of our teachers in cardiac ward tried to teach us the procedures according to the text books and supported us not to practice just routinely; you know, so we experienced a good relationship with her based on these supporting behaviors” (S4).

The second category: Emotional support

This aspect of supportive relationship was carried out through various methods including calming down students, helping them to verbalize and correct the mistakes.

Support through calming down students

Teachers experienced that support of students in student-teacher relationship could be occurred by calming them down in stressful situations. They believed that giving confidence and calmness to the students and decreasing their stress during performing the skills can be considered as a kind of support. In the circumstances that students show low self-confidence and endure much stress while carrying out clinical skills, calming down and reassuring them seems to be a salient issue. According to the clinical teachers in these cases, they could provide suitable situations to increase students’ self-confidence which itself creates a sense of serenity and consequently improved performance. One of the educators commented:

“When one of the students with low self-confidence performs a skill, her hands tremble; I take her hand in my hands and tell her: “Now I take your hands, how do you feel?” Then my student says that: “I don’t feel that you are standing over my head and I am reassured now. I told the student to go to the patient's bedside with confidence so that you demonstrate yourself as a skilled nurse; I will give you hints and help you there. Now, the student says she feels calm and relaxed in this way” (T2).

Another participant stated: “In some cases that students are stressful or hesitant, I practice with them before starting the clinical work and ask them to do this work with my help, you know, I want to decrease their stress in patients’ bedside when they want to do the clinical skills” (T6).

Support through helping to verbalize and correct the mistakes

Clinical teachers emphasized on helping students to verbalize their mistakes as a kind of support. They experienced that teachers should accept that students may have committing error and mistake in doing clinical procedures. So providing a warm atmosphere for students help them not to show fear or panic to verbalize the errors, as timely expression of mistakes can protect the patient's safety. Additionally, the teacher can support students to truly verbalize their mistakes in the clinical settings through reassuring them about expression of mistake without any fear. Meanwhile, providing a ground for convenient and fearless expression of mistakes can cause a pleasant feeling in teacher. One of them commented:

“I say to my students that when you make a mistake I won’t punish you. You should tell me immediately, because if I know what you did wrong, I may be able to resolve it to prevent deterioration of the patient's conditions. I’m very glad when a student who has made a mistake tells it me without any fear” (T2).

According to data, providing emotional support through helping students to correct their mistakes was another issue that was highlighted by both groups of participants. They experienced that the teacher should preferably manage the student's mistakes so that there is neither a danger for patient nor the student to incur a lot of stress. When a problem occurs, the teacher not only should remind the student about the mistake but also should help him/her to solve that problem. A teacher in the clinical setting having observed a student's mistake said:

“I always tell my students that you should be careful, but as soon as you did something wrong you must tell me about it, I try to resolve the problem. I think in case I am too strict towards them, they may refrain from revealing their mistakes” (T2).

One of the students commented

“If we do wrong in a procedure, some of the teachers do not tell us in presence of patient and don’t impair our personality, you know, they try to remind and advise us in another place regarding our wrong doing. They say: Look; now I’m going to do it again and you try to learn it.” (S5).

The third category: Social support

Another category in this study was social support in which the teacher tried to support the students in presence of patients or staff in essential cases.

Support in presence of staff

Clinical teachers experienced that to support the students socially they should not leave the students alone in difficult clinical situations. Students were also willing themselves to get more support in presence of patients or staff and assume that this is their right. They experienced that through granting this support, proper learning situations are provided for them. The reality is that in the majority of cases, nursing students and teachers were considered as foreign members of clinical wards, the existence of such support will create a sense of belonging to clinical environments and a feeling of having a supporter for students.

One of the teachers commented

“What the students mostly expect from the clinical teachers is their support in the clinical settings …, because when we go to the clinical wards, we and our students are like foreign members or stranger, so I feel that I need to provide a situation in which my students can work with the staff; for example if a problem occurs, I don’t give the priority to the staff and also don’t leave the students alone” (T5).

Above participant commented

“Most often, the staffs are trying to find faults with the students’ efforts. Students are the only ones who are usually blamed for any problem which occurs in the ward. What the students care mostly about is that their teacher stands beside them and defends them in sticky situations. Of course I believe that the defence should be fair. There have been cases when such problems have occurred, and I have reprimanded the staff for that.” (T5).

Moreover, the teacher's powerful support in the presence of staff is also important from the viewpoint of students. Students must be able to lean on the teacher as a strong supporter in clinical setting.

One of the students commented:

“This is very effective in establishing the relationship that the student can rely on the teacher.” (S2).

Support in the presence of patient

According to experiences of students, another type of support which can be provided by the clinical teachers is supporting them in the presence of patients. They experienced that this support has a vital role in the prospective relationship between student and teacher and also the quality and depth of their relationship.

One student stated

“The degree of support in presence of patient or staff influence on the establishment of our relationship with the teacher, but when we observe that our teacher may despise a student in front of a patient in the clinical setting at any time, we try to avoid relationship with that teacher” (S3).

DISCUSSION

Based on the study purpose that was to explore the experience of student-teacher relationship in clinical education in this study, findings revealed that participants experienced and described a kind of relationship in which the teachers were support providers and students were who received the support. The most important finding in this study was the necessity of establishing supportive relationship through various routes in clinical nursing education. In some cases similar findings have been reported in previous studies but we found some other findings which are more specific to Iranian socio-cultural context of clinical settings.

Three major categories that emerged from the data analysis in this study included: Educational, emotional and social support.

In aspect of educational support, the findings of current study demonstrated the potential benefits that the supportive relationship can provide to achieve goals in clinical settings, increasing student's self-confidence and existence more trust in their relationship. These findings showed that in Iranian socio-cultural context, educational support in relationship between student and teacher is a valuable and helpful issue in clinical settings.

With respect to support for the accomplishment of clinical skills, according to quantitative study by Craige (1991), students stated that they learn better and more in a supportive environment and they will have more confidence in their ability to do the clinical practice.[24] Crick and McCombs (2004) stated that: “If supportive relationship is established with learners, they will learn more and better”.[25]

In Craige study, when students receive no support from teachers, they have to depend on each other for support that the finding of current study is congruent with this study.[22] Although Campbell et al. (1994) found that peer support facilitate learning through the sharing of knowledge and experience and support in the completion of tasks,[26] but the request of help from teacher can strengthen the relationship between them.

Also, in Croxon's and Maginnis study (2008), the most important aspect of students’ experiences was receiving support from teachers in relationship with them. In Mc Laughlin study, Students stated that their support has been associated with enhancement of their self-confidence,[27,28] which is consistent with the findings of the current study. Therefore dependence on the clinical teacher for support is a necessity and teachers should have a moral responsibility for supporting students.[8]

Teaching and learning are dynamic and mutually interactive processes between student and teacher. Ideally, these processes will foster student learning by a facilitative, supportive and humanistic approach rather than the traditional, autocratic, teacher-oriented, and one-way approach to teaching.[8]

Another important aspect of educational support in this study was supporting through improving learning situation. Clinical teachers are responsible for preparing the situation in order to provide optimal level of clinical learning for students. Johansson (2006) cites Ekerbergh (2001) — who indicates that: “Nursing students need support from their clinical teachers to integrate theory and practice”.[29] Also, the results of Lord's Study (2002) showed that clinical teachers in relationship with their students support them through determining their educational needs, better planning for learning and assessment and giving appropriate feedback.[30] Parsell and Bligh (2001) similarly stated: “Clinical teacher's responsibility is supporting students through providing opportunities for practical experiences.[31]

In current study, in some cases that supportive relationship was established, the pleasant experiences of clinical education and relationship were created for students. Also, the results of Andrew's study (2006) demonstrated that students will report positive clinical experiences if the clinical teachers support them through facilitating their teaching.[9] This finding is consistent with finding of the current study and introduces the necessity of clinical teachers’ attention to an appropriate educational planning for the maximum provision of learning situation in the clinical settings.

In current study, emotional support in relationship was done through several activities. Findings showed that this kind of supportive relationship lead to decrease stress of student, increase students’ self-confidence and sense of calm and consequently improve of clinical performance. Studies by Cooke (1996), Lopez (2003) and Hsu (2006) also corroborated the results of this study.[8,32,33] According to Lopez (2003) in Jordan, nursing students stated that supporting role of clinical teachers was very important in reducing their anxiety. Lopez (2003) cited Krichbaum (1994) that a sense of trust, competence, and mastery can come from a successful relationship thereby; developing a sense of confidence and adequacy in students.[8]

Also in the study by Cooke (1996), students described their teachers as supportive in their relationship. One aspect of this support was reduce anxiety and calming down students by preparing them before experience of clinical tasks.[32] that is consistent with findings of current study. In study by Lord (2002), the teachers also increased the students’ confidence in doing their tasks.[30] In study by MC Laughlin (1998), finding revealed that students appreciated that the emotional support led to an increase in their self-confidence.[28]

Also, in a study by Ling (2006), clinical teachers provided emotional support for students in stressful clinical conditions. One of these conditions was in relation to the student's learning difficulties.[33] Also, Parsell and Bligh (2001) stated that the responsibility of nursing clinical teachers is providing necessary explanations and being supportive in difficult clinical situations.[31]

Similar findings have been reported in research studies regarding to aspect of verbalize and correct the student's mistakes. Results of Mc Kee's study (2005) showed that when students encounter with any problem, clinical teachers should be available to support them.[34] Moreover, in a study by Kube (2010), one of the proper behaviours of teachers was correcting the students’ mistakes without belittling them.[2] Kleehammer et al. (1990) stated that: “Teachers, who are non-supportive in relationship with their students, have much negative effect on students’ learning, because of increasing their anxiety”.[35]

Social support was the third aspect of supportive relationship and in socio-cultural context of Iran was accessible through support of students in presence of others in clinical setting that seemed important and valuable. With applying supportive actions in this aspect, some outcomes were occurred such as create a sense of belongingness to clinical settings for students, more relying on teacher and tendency for future relationship with teacher.

The findings of Orelly-Kenapp (1994) similarly demonstrated that students are willing to receive social support in relationship with teachers in clinical settings.[36] Also, based on the findings of Lopez (2003) in Jordan, nursing students commented that clinical teachers support them in their relationship by advocating their performance or behaviours in presence of patients and personnel.[8]

In current study, junior students were willing to receive more support. This is noteworthy that novice students had more emphasis on positive relationship behaviours of teachers which led to their calmness and comfort in clinical environments.

Congruence of findings of current study with the findings of other studies is important, because it proved that clinical teachers should provide proper social support in relationship with students in clinical settings.

Although the researchers tried to recruit male teachers for the study, the most teachers were female, which may affect the results and act as a limitation. The reason was that the majority of nurse teachers in Iran are female. Also, with attention to this point that the results of current study are the portions of a large study, the results can be impressed and were richer if the current study was done inflectionally with concentration of supportive relationship.

CONCLUSION

The experiences of nursing teachers and students in Iran demonstrated the presence of supportive relationship in clinical nursing education. The results revealed that this type of relationship in clinical education is achieved through educational, emotional and social support. The value of support is evident in student-teacher relationship through the meaning that exists in their experiences of supportive relationship in clinical education. It is obvious that the role of clinical teachers is critical in facilitating such relationship and consequently improving the students’ clinical learning. Students’ positive experiences of supportive relationship are related to how their clinical teachers communicate with them.

The above findings demonstrate that teachers’ need to know more about the influence of their interpersonal relationship skills and also the comprehensive impact of supportive relationship on the student in clinical settings.