1. Introduction

As an effective approach, continuous quality improvement (CQI) has been widely used in many aspects of works in hospitals, especially in the nursing work. Zhang et al ^[1]. designed the quantitative evaluating indictors and exam methods to observe the effects of CQI in the shift-to-shift changes of the nurses, and found that the usage of CQI could significantly improve the timeliness, the completeness and realness of the nursing records. Meantime, the deficiency rate of writing decreased, too. So CQI could increase the quality of shift-to-shift change for nursing work. Xu et al ^[2]. studied on the application of CQI in the restricting nursing for the ICU patients and found that the acceptance degree of the patients, the satisfaction of the patients’ families and the nursing knowledge of the nurses were gotten notably increased. Therefore, they considered CQI could decrease the occurrence of adverse events, elevate the theories relate to restricting nursing and improve the relations between nurses and patients to some extent. Lee et al ^[3]. observed the medication incidents (MI) of the nurses of the emergency department, and found that the MI of the nurses who applied in their daily work was lower than those without application. This result indicated that the usage of CQI could reduce medication error and was beneficial for the nursing quality or safety. On a whole, many reports proved that CQI had used in different aspects of nursing work. With the usage, the nursing quality and service level got significantly improved.

In fact, except the work of patient care, the education of nursing trainees also is an important task that must not be ignored by the teaching hospital, especially the Universal hospital; and it is necessary to be improved with CQI approaches. However, to our knowledge, the studies relate to the improvement of nurse education mainly focus on the phrase of school ^{[4, 5, 6]}. A small and increasing literature revolves the application of CQI in nursing trainees in clinic. In this paper, we tried to apply CQI in the education the nursing trainees of our hospital, a universal hospital in Mainland China, and hoped to pose a references for improving the teaching quality in clinic.

2. Material and Methods

200 undergraduate students were recruited form Affiliated Hospital of Jining Medical Universtiy and taken as the objects of this study. They were randomly divided into the experiment and control groups; 100 persons per group.

The first three months since the undergraduate nurses began the clinical practice was designed as the adaptation period. In the period, all the nursing trainees were arranged to be familiar with the clinical environment; and meantime, they were taught by the clinical teachers according to the traditional methods in which no idea of CQI was involved.

Three months later, in order to understand the baseline of theory and practice and further exclude the effect of the grouping, all of 200 nursing trainees were tested with professionalism, communicative competence, nursing theory and operation. The former two test papers were designed according to Zheng’s report ^[7]. The test for nursing theory and operation were made out by our research team according to the Universal basic nursing textbook. The total exam scores set as one hundred, and finally judged with four degrees referred He’s study ^[8]: <60 was taken as D grade (equal to fail the exam); 60-79 as C grade; 80-89 as B grade; >89 as A grade (equal to excellent score). The exam excellent (failure) rate was equal to the percent of the persons with A (D) grade score.

According to the first exam results and the previous teaching experiences, a detail analysis was performed and the reasons were listed. According to each of the reasons, the strategies were respectively designed and were applied in the education of nursing trainees in the experiment groups. The nursing trainees in the control groups were still taught with the traditional method.

Six months later, the second test was carried out with the new contents, which still included professionalism, communicative competence, nursing theory and operation.

The software Statistical Package for the Social Sciences (SPSS), version 15.0 was used to analyze the data. The differences between the quantitative data were analyzed with Chi-square test, and the relativities were analyzed with Logistic regression analysis. α = 0.05 was taken as the test standard.

3. Results

As shown in Table 1, there was no difference between the exam results of the nursing trainee in experiment and control groups (P>0.05). The percentages of the nursing trainees who achieved excellent results were both less than 30% in the two groups, and there were always several students failed in one or more items (Table 2).

Table 1. The first exam results of the nursing trainees in the experiment and control groups

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View next table

Table 2. The respective rates for the excellence and failure results in the first exam

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

With brainstorming method, the reasons related to the low quality of clinical teaching were analyzed. In the analytic results, there were many factors related to nursing trainees, which revolved not only the nursing trainee themselves, the teachers, but also the nursing management. Aimed at the key factors, we made out the corresponding strategies and applied them in the clinical teaching of the nursing trainees in the experiment group (Table 3).

Table 3. The reasons analysis and the corresponding strategies

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

The exam scores of the nursing trainee in experiment group were significantly higher than those in control group (P<0.05) (Table 4). The percentage of the excellence scores in the experiment group was more than 50%, which was notably higher than that in the control group (P<0.05). There was no D grade of exam results in the experiment group but the control group (Table 5).

Table 4. The second exam results of the nursing trainees in the experiment and control groups

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

Table 5. The respective rates for the excellence and failure results in the second exam

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

Download as

• PPT
  PowerPoint Slide
• PNG
  Larger image(png format)

Veiw figureFigures index

•  NEW
  View larger figure in new window

View next figure

Figure 1. The comparison of the primary and second exam results in the experiment group

Download as

• PPT
  PowerPoint Slide
• PNG
  Larger image(png format)

Veiw figureFigures index

•  NEW
  View larger figure in new window
• PREV
  View previous figure

Figure 2. The comparison of the primary and second exam results in the control group

The second exam scores were significant higher than those of the first exam in the experiment group (P<0.05) (Figure 1). There was no difference between the two exam results in the control group (P>0.05) (Figure 2).

4. Discussion

Clinical training is the most important component of nursing education, even more than classroom learning ^[9].This is because that it enables students to achieve real experience with patients and practice the skills which they have learned in the classroom ^[10]. Therefore, as a more practical profession, the educational process of nursing should culture students the ability to perform professional activities in real-life situations rather than simple expressing understanding of principles ^[11]. However, most of the teaching hospitals do not take the clinical teaching of nursing trainees seriously in China. Accordingly, the present study on the nursing education could reflect the whole status in Mainland China to some extent. Aiming at this status, the present study focused on the improvement of clinical reaching of nursing trainees.

As shown in the results, the average scores of the four subjects in the first exam, including professionalism, communicative competence, nursing theory and operation, were on the low side, and the excellence rate were all less than 30%. There were some nursing trainees failed in the exam in both experiment and control groups. These results showed that there was no difference between the training effects for the nursing trainees in the two groups at the beginning of clinic training. According to such a status and companying with the past experience of clinical teaching, we carefully analyzed the causes and made out the corresponding strategies to improve the clinical education of nursing trainees. Firstly, the nursing trainees’ own reasons were the main factors which affected the training quality. The reasons mainly came from the basic nursing, including insufficient identification of nursing job, poor service consciousness, poor theory, low operation skills and so on. This opinion was different from that of Ding et al. ^[12], who thought the deficiency of acknowledgement of the excellent nursing was the decisive factor. In our opinions, excellent nursing should be a target only for the registered nurses; while basic nursing should be the primary task for the undergraduate nurses. Through enhancing the acknowledgement of the importance of clinical training, the nurses could be benefited from two points: (1) The theoretical and practical training provided in the classroom and laboratory in nursing school are reinforced with practical training performed in the clinical setting ^{[13, 14]}; (2) They will get the opportunity to repeatedly use the skill and gain feedback on performance ^[15]. Only based on such acknowledgements, the enthusiasm and initiative of learning in clinic setting will be really motivated, and there will be a good effect for the nursing trainees. Secondly, clinical teachers played an important role in the phrase of training for the nursing trainees. Yu et al ^[16]. considered that the key influential factors to the training quality laid on the correct and effective guidance of teachers. Under the incorrect instruction, the trainees could not get the learning of theory and the training of operation. In another studies, the researchers thought that the types of teaching had great effects on the training quality ^{[17, 18]}. To our understanding, the consciousness of clinical education was the key factor that affected the learning quality for the nursing trainees in the clinical setting. All the nursing teachers should indeed recognized that clinical teaching is an important part of nursing education, and take the clinical teaching as an essential part of the nursing work ^[19]. Besides, as a clinical teacher, he should continuously learn new knowledge relates to nursing on the basis of mastering the basic nursing theory, because most of nursing trainees are interested in different specialty area of nursing, and their experiences in clinical practice lead them to pursue areas of nursing with more interesting ^[20]. Lastly, nursing management is another important factor affect the quality of clinical training. As a manager who is in charge of the nursing trainees, she must cognizes that accurately understanding and treating the relative factors that influence the quality of clinical education is helpful for the culture of qualified nursing talents ^[21], and the nursing trainees without sufficient clinical skill competency will compromise patient care and safety ^[13]. Additionally, increasing the teaching quality of the clinical teachers and the learning effect of the trainees are the necessary duty for the teaching hospital, especially the Universal hospital ^[22]. From this view point of management, the rules that benefit clinical teaching should be created or improved.

After being interfered with CQI in this study, the training effects for the nursing trainees in the experiment group got notable improvement. The average exam scores of the trainee in the experiment were significantly higher than those in the control group, and the excellence rates of the former group were also obviously higher than those of the later one. There was no trainee failed in all the exams in the experiment group but in the control group. These results indicated that the training quality of nursing undergraduates achieved significant increase on the four subjects which including professionalism, communicative competence, nursing theory and operation, and these harvests can not be gained through classroom learning alone ^[23]. These results were consist with those of other two studies which reported that the improvement of teaching approaches and nursing management could increase the effects of clinical education ^{[24, 25]}. Based on the results, we consider that the training quality could be significantly raised by CQI method, and it is necessary to apply CQI in practice teaching during the period of clinical training for nurses.

In conclusion, the study shows that the application of CQI could raise the training quality for the nursing trainees, including the levels of professionalism, communicative competence, nursing theory and operation. The present results suggested that CQI approach should be used in practice teaching during the period of clinical training for nurses. Although such information has been transferred from the paper, the clinical education of nursing trainees is a systematic project and affected by lots of factor ^[26]. In the next step of study, we will further deeply analyze these factors and accordingly design more detail measures to rise the training quality for nursing trainees.

Funding

The article is supported by the Provincial Science and Technology Development Project (Grant 18054), the Provincial Nature Science Foundation (Grant ZR2012HL29), the High School Science and Technology Plan Project (Grant J11LF18), the Population and Family Planning Commission (Grant [2011]13), and the Development Plan Project of Jining Science and Technology Bureau of Shandong Province (Grant [2011] 57, 2014jnjc12 and 2014jnyx14), the Youth Foundation of Jining Medical College (Grant [2011]58), and the Miaopu Program of Affiliated Hospital of Jining Medical University (Grant JYFY-MP-2013-(2)-9).

References

[1]	Zhang JF, Gao LL. Application of continuous quality improvement in the management of nursing shift change. Chinese Rural Health Service Administration 2012, 32(6): 575-576.
	In article
[2]	Xu YH, Yang JQ, Fang H. Impact of applying continuous quality improvement in ICU patient restraint nursing. Hospital Nursing 2014, 18(11): 68-9.
	In article
[3]	Lee SB, Lee LL, Yeung RS, Chan JT. A continuous quality improvement project to reduce medication error in the emergency department. Word J Eerg Med 2013, 4(3): 179-182.
	In article		View Article  PubMed
[4]	Wolf ZR, Czekanski KE. Analyzing student complaints against nursing programs: taxonomies of complaints and outcomes. J Prof Nurs 2011, 27(5):283-91.
	In article		View Article  PubMed
[5]	Burgatti JC, Bracialli LA, Oliveira MA. Ethical problems experienced in a supervised curricular internship in nursing in an integrated curriculum. Rev Esc Enferm USP 2013, 47(4):937-942.
	In article		View Article  PubMed
[6]	Olson SE. Achievign success when returning to nursing education. Nursing 2015, 45(2): 22-24.
	In article		View Article  PubMed
[7]	Zheng J, Gao YZ, Wu Wj. Han LQ, Sang ML. Construction of the evaluation index system of nursing students and the teaching quality of clinical clerkship. Chinese Nursing Education 2008, 5(3): 99-102.
	In article
[8]	He MW. The application of nurse teaching management system in gynaecology department. China Higher Medical Education 2014, 2: 98.
	In article
[9]	Xu F, Di CH. The questions and strategy in the current clinical nurse teaching. Journal of Qilu Nursing 2008, 14(23): 96-98.
	In article
[10]	Chapman R, Orb A. Coping strategies in clinical practice: the nursing students' lived experience. Contemp Nurse 2001, 11(1): 95-102.
	In article		View Article  PubMed
[11]	Shuman LS. The signature pedagogies of the professions of law, medicine, engineering, and the clergy: potential lessons for the education of teachers. 2005, Availiable: https://hub.mspnet.org/index.cfm/11172.
	In article
[12]	Ding J, Xu X, Shi F, Yang Y, Wang XF, Zhang XN. The acknowledgement and analysis of nursing undergraduate trainees toward to excellent nursing service. Journal of Qilu Nursing 2014, 20(5): 26-27.
	In article
[13]	Bloomfiled J, Roberts J, While A. The effect of computer-assisted learning versus conventional teaching methods on the acquisition and retention of handwashing theory and skills in pre-qualification nursing students: a randomized controlled trial. Int J Nurs Stru 2010, 47: 287-294.
	In article		View Article  PubMed
[14]	Pitt V, Powis D, Levett-Jones T, Hunter S. Factors influencing nursing students’ academic and clinical performance and attrition: an integrative literature review. Nurse Education Today 2012, 32(8): 903-913.
	In article		View Article  PubMed
[15]	Quinn F, Hughes SJ. Quinn’s principles and practice of nurse education. 2007, Nelson Thornes Ltd, Cheltenham.
	In article
[16]	Yu CH, Xu H, Zhao SH. Comparison between nurse’s and nursing intern’s cognition of quality nursing care. Journal of Nursing Science 2011, 26(17): 16-18.
	In article
[17]	Struksnes S, Engelien RI, Bogsti WB, Moen ÖL, Nordhagen SS, Solvik E, Arvidsson B. Nurses’ conceptions of how an alternative supervision model influences their competence in assessment of nursing students in clinical practice. Nurse EEUC Pract 2012,12(2): 83-84.
	In article		View Article  PubMed
[18]	oskinen L, Mikkonen I, Jokinen P. Learning from the world of mental health care: nursing students’ narratives. J Psychiatr Ment Health Nurs 2011, (18): 622-628.
	In article		PubMed
[19]	Fakhr Movahedi A, Yousefpour M, Sadeghi S. Comparison of teaching behaviors of clinical nursing instructors from the perspective of nursing students of the public and private Universities of Semnan in 2012. Journal of Medical Education and Deveplpment 2013, 8(3): 81-95.
	In article
[20]	Steen JE, Gould EW, Raingruber B, Hill J. Effect of student nurse intern position on ease of transition from student nurse to registered nurse. J Nurses Staff Dev 2011, 27(4):181-186.
	In article		View Article  PubMed
[21]	Tavakoli M, Khazaei T, Tolyat M, Ghorbani S. The quality of clinical education from the viewpoints of students and instructors of paramedical and nursing obstetrics schools of Birjand University of Medical Science. Daneshvar 2014, 110: 1-9.
	In article
[22]	Walker K. Postmodern pedagogy and the nursing curriculum: collaborating for excellence. Collegian 2005, 12: 36-40.
	In article		View Article
[23]	Oermann MH, Kardong-Edgren SE, Odom-Maryon T. Effects of monthly practice on nursing students’ CPR psychomotor skill performance. Resuscitation 2011, 82(4): 447-453.
	In article		View Article  PubMed
[24]	Zhang XP. Comparison of different methods applying in clinical teaching for trainees. Health Vocation Education 2014, 32(1): 111-112.
	In article
[25]	Wang H, Dou HC, Xin CJ, Wang P. The application of nursing education management system in the clinical trainees. Chinese General Practice 2010, 13(5S): 100-101.
	In article
[26]	Nicholl TA, Lou K. A model for small-group problem-based learning in a large class facilitated by one instructor. Am J Pharm Educ 2012, 76(6): 117.
	In article		View Article  PubMed