Abstract

Vocational students considered young workers who are usually injured at the worksite. Education and awareness are necessitated for them. Background: Clinical teaching is a very important mission of nursing education because the clinical experiences connect theory to practice. Where students who achieve good practice and safety technology in the available health facility and teaching atmosphere would establish nursing competencies through practicing partnerships [1]. Nursing education is the most viable study to continue the education process for practice [2]. Aim: This study aims to develop strategies to overcome the challenges facing nursing's clinical teaching. Method: Current investigation was conducted at Nursing faculty, Zagazig University on 3 studied groups: first; clinical instructors (77), second; faculty students (330) and third, jury (7). Tools: Three tools were utilized for data collection, including challenges assessment questionnaire and two experts' opinionnaires format. Results: The most frequent challenges facing nursing’s clinical teaching are: the clinical instructor was not concerned with the issues that students raised (92.2), the variance between faculty goals for students and clinical site goals (87), students didn't have the required clinical skills in the clinical setting (85.2), and, the clinical instructors enforce students for involvement in practice (82.1). Conclusion: The questionnaire of assessing nursing clinical teaching challenges is reliable, valid and usable. The strategies for overcoming nursing clinical teaching challenges was developed and validated.

1. Introduction

Nursing education is a blend of theoretical knowledge and clinical practice. Nursing students need more than conventional theoretical instruction in the classroom ³. Because nurses play a crucial role in health care services, they should obtain much-needed preparation in the clinical fields through adequate & efficient education. Clinical instruction is considering a professional nursing education center. Nursing experience for students and professional education are key proprietors of teaching methods and determinants that influence the model of clinical education ⁴. Practice experience is the key of nursing education ^{5, 6}.

Additionally, clinical teaching builds the familiarity with quiet wellbeing, proficient perspectives, regard for tolerant classification and solace, compassion advancement, data about clinical gear, and the significance of all-encompassing way to deal with persistent consideration, proper mentalities, and morals. The essential information on the understudies is reinforced by connecting the clinical information acquired from the patient with the fundamental sciences. Moreover, when clinical information is acquired, correspondence, critical thinking, dynamic and coordination of moral aptitudes are performed ^{7, 8}.

Clinical training fills in as one of the essential instructive encounters for nursing understudies and in that capacity has an unbreakable piece of instructive procedure in nursing instruction history times. Clinical instruction offers understudies the chance to learn. Nursing understudies must be completely arranged by both "knowing" the issues required for nursing capacities and "playing out" ⁹.

That is to say, 'clinical instruction and learning are crucial educational concepts that assist understudies with picking up nursing aptitudes. Clinical training gives the learners chances to get ready for their future jobs. It opens doors and support for cooperation, dynamic, evaluations and critical thinking. Also, it boosts basic deduction, adapting to genuine patients and their issues, and applying hypothetical information in real practice ¹⁰.

The clinical encouraging system incorporates (a) Before – how to set up your training and arrange your students, (b) During – how to support understudies and inhabitants gain from their cooperation with patients (c) After – thinking about your encounters as educators and helping your students to ponder their learning encounters, (d) Ongoing exercises – atmosphere setting, (e) Needs appraisal and relationship building and (f) Resources – connections to numerous valuable sites and articles for more data on a few points that may exceptional ¹.

The impact of the challenges experienced the structure of clinic, as educating of some nursing rehearses was not done, forestalled powerful educating and learning influenced, the inspiration of the learners in clinical showing diminished, clinical instructing didn't accomplish its objectives, clinical learning results were not accomplished, my inspiration as an instructor in clinical showing diminished, clinical showing got exhausting, and assessment of understudies got hard for me. These challenges adversely influence the training of some nursing rehearses, just as successful learning and instructing ⁹. The challenges can have negative impacts in creation learning openings and can lessen learning inspiration ¹¹.

The individuals who train understudies in clinical practice settings frequently are alluded to as "clinical medical caretaker teachers" ^{5, 6}. The instructing duties of clinical educators tend to incorporate & prepare a steady learning condition and overcoming a difficult one by safe learning conditions. ¹²

The connections among nurture instructors, nursing understudies, and staff inside the clinical region fluctuate. Whether or not a position is full-or low maintenance, as a rule, an attendant teacher who shows practice aptitudes is paid by one establishment to work in another, making them "guests" who do not have a feeling toward the work setting ¹³.

Clinical setting instruction is capricious/reliant on the accessibility of adequate clinical cases. These highlights more troubles for anticipating clinical instruction ¹⁴.

Clinical instruction has numerous difficulties considered potential issues and deficiencies which may go about as a hindrance toward accomplishing a decent situation for clinical educating. These boundaries can be separated into two sections; some are identified with the clinical educators while the others are identified with the understudies. ³ Likewise, ⁴ referenced that various issues in nursing instruction including issues identified with understudies, teachers, and clinical conditions. In clinical conditions, specialists and attendants demonstrate more regard for clinical understudies than different understudies of wellbeing sciences including nursing understudies and this prompts negative disposition of different understudies. ¹⁵ reported that the hindrances against clinical instruction of nursing were arranged into four gatherings: singular region (impediments related with understudies, teachers, and medical caretakers), the executives, offices, and others.

Issues experienced by clinical instructors incorporate the absence of clear destinations and desires or insufficient supervision of input. Understudies might low open door for conversation and having the absence of harmoniousness or progression with the educational program, the nature of supervision, input, and attributes of students or educators. Educating in the clinical condition has numerous difficulties e.g. time pressure which is everybody's foe ³.

The absence of appropriate inspiration (in mentors) stresses hypothetical viewpoints in instructive work ¹⁶. Also, it includes insufficient input to understudies, consigning overwhelming and troublesome undertakings to understudies, and not stressing pre-concentrate via coaches ¹⁷, as well as, nonattendance of experienced educator with a high scholastic level ¹⁸.

In this context, one can refer to the ineptitude of clinical instructors, the absence of direct showing clinical aptitudes, deficient dominance of clinical abilities, absence of input to understudies, and, terrible climate of the clinical condition ¹¹.

Another challenge in clinical educating, including those identified with having a substantial remaining task at hand, giving a satisfactory clinical practice territory, having an exorbitant number of understudies, actualizing nursing care plans, having a poor physical condition in facilities and picking up the help of human services colleagues ⁹.

Involve learners in important learning minutes, advance understudy learning in a genuine circumstance, deficient hardware is a gigantic hindrance to viable clinical educating and learning, futile assessment, understudies not engaged with assessment, absence of assessment, absence of organization/scholastic joint effort, conditions not helpful for instructing and learning, the requirement for good relational connections among understudies and staff medical caretakers for positive clinical encounters to happen, inadequate coordinated effort among scholarly and clinical settings, an absence of cooperation among schools and clinical settings, obliges successful correspondence and influences crucial segments of clinical instructing and learning, over the top travel time for clinical practice openings. Powerful clinical supervision and educating is required for tolerant security and to manufacture understudies' abilities comparable to a) high caliber and adequate hands-on training openings; b) psychomotor aptitudes; c) relational abilities; d) reconciliation of information into training; e) proof-based practice, and; f) open doors for differed clinical encounters ¹⁹. Besides the Absence of experienced teachers with a high scholastic level ¹⁵.

All together for the clinical preparation to be conveyed successfully, the clinical mentor must lead persistent explicit conversations with the understudy nurture and similarly separating time for every understudy ⁸. Issues about teachers making a domain encouraging getting the hang of, introducing training encounters fit learning results, accomplishing course objective, being a good example for understudies, helping out medical attendant group, helping out different individuals from human services group, remaining burden ⁹.

The difficulties of nursing understudies in managing the clinical learning condition, three fundamental topics rose: ineffectual correspondence as inappropriate treatment, separation, lacking availability, as lacking information, inadequate viable aptitudes, deficiently created relational abilities and enthusiastic responses as stress., feeling of inadequacy ²⁰.

Issues about student’s number of students, the inspiration of understudies, direction of understudies to the center, participation status of understudies, fundamental information and aptitudes of understudies, understudies' information and abilities explicit to rehearse zone, day by day observing of understudies, evaluation of understudies ⁹.

Dread to establish a test of clinical instruction in nursing as the dread of analysis by the clinical teacher, dread of the patient's family members, dread of doing an inappropriate method, and dread of scoring and assessment. In this regard, the following should be mentioned: a- deficient availability of understudy, blocking self-steam, c- the insufficient authority on intellectual segments of clinical aptitudes and d- insufficient dominance of clinical abilities in clinical abilities lab ⁴. Moreover, lacking correspondence among understudies and colleagues, rejection of understudies by and by territories, and negative biases about nursing that influence the understudies' inspiration were the most well-known issues that understudies experienced by and by zones ²⁰.

Difficulties related with nurses include not arranging instruction to the patient in the day by day assignment of medical caretakers as an obligation ²¹, the mismatch between the activity of staff and logical standards, not actualizing the procedure by the workforce ¹⁶, lack of physical and mental planning and deficient information and aptitude ¹⁸, improper treatment of the faculty ¹⁷, personnel uncooperativeness and fatigue ²², personnel uncooperativeness ¹⁵, and issues about the medical caretaker group, being tolerating of understudies, being steady of understudies, giving direction to understudies. ⁹

Difficulties going with health care team information; assessment trade with individuals from social insurance group; investment in dynamic systems about patient consideration and treatment; and making a situation encouraging learning with individuals from the medicinal services group ⁹.

Difficulties connected with the executives: a large number of understudies, the separation between nursing understudies and the understudies of other clinical sciences ¹⁶. The patient or their families grumbling about performing nursing issues by understudies ²² and unsatisfactory time ²³. Confound between the destinations of clinical instruction and desires for the medical clinic workforce ¹⁷. Not organizing instruction in the portrayal of obligations, not picking up the score for the medical attendant to prepare the patient, bungle between the number of patients and number of medical caretakers ²¹ and lack of time ¹⁵.

Difficulties associated with the facilities and structures, Deficit of offices and working conditions ¹⁸, Limited cases in the wards, the medical clinic being non-scholastic ¹⁶, lack of access to the gathering room ¹⁷, poor instructive arranging ²², the deficit of offices and working conditions, structures, and different regions were recognized ¹⁵.

Difficulties appended with a physical condition, such as the number of patients, case assorted variety, giving gathering rooms, giving changing rooms to understudies ⁹, the disagreeable climate of clinical condition, improper conduct by specialists and attendants with nursing instructor and understudy, overlooking educator and nursing understudy and double-dealing attendant with clinical and nursing understudies ¹¹.

Other challenges include not perceiving the role of nurses as educators for patients and the general public ²⁴, uncooperativeness of the patient and disregarding training ²¹.

Depending on the challenges found across different dimensions, effective plans and strategies should be developed and implemented with each of the barriers to improving the quality of clinical training ¹⁵.

Teaching strategies include preparing, questioning, illustrate, provide clear guidance, clarify, observe and provide input, and review the clinical activities with the learners ⁵. Also, ⁴ described strategies for enhancing nursing clinical education as follows: use of models and methods of nursing education including nursing processes, simulation, and peer learning, enhancement of the relationship between the staff and clinical community and involvement of clinical nurses in clinical education, Startup orientation, the participation of nurses in clinical education, delivery of lesson plans and content of clinical courses and assessment of the student's cognitive and affective area.

A significant factor for improving nursing education, practice, and research is the institutional clinical partnership. It helps nurses become well prepared to drive change and improve health. Despite increasing attempts to close the practice gap, in theory, the lack of formal academic-practical collaboration leads to disintegrated efforts to improve nursing education.

There is a hope for an improved system of nursing education if nursing educators and practitioners understand and appreciate academic clinical collaboration, its benefits, elements, and challenges ²⁵.

The studies conducted in this field indicate that most studies have examined the obstacles individually, and the most significant obstacles included time and financial constraints as well as lack of access to evidence-based literature i.e. ^{26, 27, 28}.

Given the crucial importance of the researcher's understanding of the challenges and quest, so far no study has been conducted as strategies to overcome the challenges facing nursing clinical training at Zagazig University in Egypt. Thus the present research was aimed at identifying the problems of nursing clinical teaching and designing methods for overcoming them.

Several challenges facing nursing education such as provide the experiential, emphasis on outcome-based, evidence education and curriculum, student competency and evidence-based education required to maintain accreditation, diversity, distance learning increases access. Students reported that there was a lack in the performance of clinical teaching skills among their clinical instructors; they need to professional clinical instructors. They were faced with many difficulties in clinical teaching. Clinical instructors are not aware of their professional roles or standards of clinical teaching skills ²⁹.

It seems that there are some problems hindering students in learning effectively because, in practice, they cannot do what they learned. Researchers, in their clinical experiences, have observed some cases in which the students, even with proper theoretical knowledge, are in trouble at the patient's bedside and they are not able to provide care and do the skills independently.

So the development of strategies to overcome challenges that are affecting clinical teaching is very important to train qualified nurses for providing quality healthcare services, promote staff satisfaction, provide student satisfaction, represent a step to faculty accreditation, to promote better preparation of new nurses. The clinical learning environment is favorable to equip nursing students with basic clinical skills and required to be continuously assessed the existing situations, to recognize the strengths, and improving weaknesses and learners who are autonomous and self-directed.

Educational needs are identified by learners and they are ready/motivated and go to set their aims, select educational content and participate in decisions. Clinical Teaching – a Framework Distinguished clinical teachers by ³⁰.

2. Subjects and Methods

Developing strategies for overcoming challenges facing nursing clinical teaching throughout

1- Developing a tool for assessing challenges facing nursing clinical teaching at Zagazig University

2- Validate tool.

3- Assessment of the challenges facing nursing clinical teaching at Zagazig University

4- Developing strategies to overcome the determined challenges

5- Validate the proposed strategies

1. What are the challenges facing nursing clinical teaching at Zagazig University from students' point of view

2. What are the challenges facing nursing clinical teaching at Zagazig University from clinical instructors' point of view

3. What are the strategies required to overcome the challenges facing nursing clinical teaching at Zagazig University?

Descriptive and methodological designs were used to achieve the objectives of the present study; it aimed at developing strategies to overcome challenges facing nursing clinical teaching at Zagazig University. This was achieved through a cross-sectional assessment of challenges.

I- A convenience sample including the clinical instructors (77) at the faculty of nursing at Zagazig University who agreed to participate in the study.

II- A stratified proportionate random sample (330)from different nursing student’s levels. The sample is estimated with a 20% precision and Confidence level 95%, Population size 1345, and Margin of error 5%.

The ideal sample size was 299. After adjusting to a dropout rate of 10 % the sample size required was 330. Randomly samples taken through a stratified proportionate based on the distribution of students’ level

Exclusion criteria include:

1- Clinical instructors who are on leave

2- Clinical instructors under one year of employment

3- First level students

III- Jury committee (7).

1- Nursing Student:

A nurse student who enrolled in a traditional B.SC-N program and who has completed at least one clinical course (from levels 2, level 3 and, level 4 and, they are receiving clinical teaching)

2- Clinical instructor.

A registered nurse, employed by the university who has a minimum of a Bachelor's of Science in nursing degree and teaches at least one clinical course per semester.

3) Challenges

Challenges refer to difficults to deal with or achieve, especially in a way that needs a great physical and mental effort to done successfully ³¹.

According to the current study’ aim, challenges were defined as a self-reported tool (challenges’ assessment questionnaire sheet) containing three dimensions: Challenges regarding nursing students, challenges regarding clinical instructors and general challenges

4) Strategies defined suggested document contains precise strategies designed to be used consistently as a guideline for overcoming nursing clinical.

5- Perception: An individual's awareness, understanding, opinion, or insight

6- In this study, the clinical learning environment (CLE)

refers to hospitals where student nurses are receiving their clinical training

First, challenges assessment questionnaire:

It was developed by the researchers, after a thorough review of related litrature to get challenges facing nursing clinical teaching at Zagazig University. It contains part 1: socio-demographic data of the subjects, part 2: 3 dimensions involving the items of challenges facing nursing clinical teaching. Using the scoring system agree and disagree

Second, Opinionnaires

I- The first sheet: was developed to assess content validity and face validity of the challenges assessment questionnaire sheet through expert's opinions as:

A- Opinions of experts for each item on 2 points as relevant, or not.

B- Overall opinions about form.

II-Second sheet: was developed to assess content validity and face validity of proposed strategies for nursing challenges through expert's opinions.

A- Opinions of experts for each item on 2 points as relevant, or not.

B- Overall opinions about the form.

1-Preparation.

Managerial arrangements, official permission was obtained from the dean of the faculty of nursing at Zagazig University to select the samples, to conduct the study and to collect the data, after full explanation of the study aim.

Regarding the preparation of the challenges assessment questionnaire tool, it required an extensive review of relevant literature. Then the researchers developed it and test the content validity and reliability of the tool.

Validity and reliability of the challenges assessment questionnaire tool followed the following steps:

Content validity:

A- The opinions of the experts for each item were recorded on a two-point scale: relevant, not relevant.

B- General or overall opinion about the form was estimated.

A pilot study was carried out on 33 students and 10 clinical instructors who were selected randomly to identify obstacles and problems that may be encountered during data collection, to test clarity, the feasibility of the tool and whether it was understandable, and to determine the time needed to fill the forms. The tool was provided to the participants to fill it and collected by the researchers. The time for the completion of the questionnaire sheet was ranged from 45-60 minutes. Then reliability of the tool was done.

Reliability Testing:

Three estimations were used as:

Average Item-Total Correlation

Split Half Reliability

Cronbach's Alpha (a)

This approach also uses the inter-item correlations. Additionally, we compute a total score for the items is computed and used that as a variable (Total) in the analysis, with an average of .867 in this sample analysis.

3. Split-Half Reliability

In split-half reliability, we randomly divide tools administered to the pilot sample into two sets. Scores of subcategories of the tool are correlated between the 2 halves. The split-half reliability estimate is the mean of the correlation between these two total scores .897-.882

4. Cronbach's Alpha (a)

Cronbach's alpha was .757 - .870 for all items and none of the items was proved to affect alpha level if removed. This phase was carried out in two months.

2-Implementation phase

A- Challenges assessment: The researchers copied 330 challenges assessment questionnaire sheets. Data collection took the period from April 2018 to May 2018. Some participants (10) refuse to participate in the study; the researchers took the next numbers in the list of names, systematically.

3- Designing or developmental phase:

Based on the results of challenges assessment and an extensive review of relevant literature, the researchers developed the proposed strategies for overcoming the identified challenges, and then, develop an opinionnaire sheet to assess its validity from expert's viewpoints.

The opinionnaire involved two parts:

A- The opinions of the experts for each item of the developed strategies were recorded on a two-point scale relevant, not relevant.

B- General or overall opinion about the form was identified.

Statistical analysis was done by SPSS 13.0, P <0.05.

Ethical approval:

Instructors and students were fully informed about the research aim and then, agreed to join the research process. All instructors and students voluntarily responded to the survey. The research was employed through the principles of the Declaration of Helsinki.

3. Results

The majority of study sample (59.7%) ages were less than 30 years, most of them (89.6%) were females, as well, (90.9%) of the participants have work experience less than 10 years.

The major challenges facing nursing clinical teaching at Zagazig University could be grouped into three categories: Challenges related to students, challenges regarding clinical instructors and general challenges.

Table 1 shows that the most frequent challenges related to the students and reported by them involved that they have no required clinical skills in the clinical setting (85.2), readiness for clinical training is not enough (79.7), availability of patients' files to collect required data for their training (79.4), felt free to ask questions in the clinical area (78.8), Procedure manuals were accessible to students (76.7) and are unaware of the clinical training plan. While the least frequent challenges included were allowed to provide patient care under supervision (59.7), disappointment with the period of clinical training (60.3). Challenges regarding clinical instructors rated by students, clinical instructors enforce students for involvement in practice (82.1), clinical instructors explain day's program to students (79.7), clinical instructors monitor and evaluate student development (78.2), and clinical instructors solve student problems in the clinical site (78.2). While the least frequent challenges incorporated deficient cooperation among clinical instructors and clinical settings (26.1), insignificant appraisal (37.0). General challenges that have been stated by students were: essential nursing performances executed at clinical site distinction from procedures performed in faculty (79.7), Surroundings not helpful for instructing and training (79.4), and, poor health policies (76.4).

Table 2 illustrates that the most frequent challenges related to the students as reported by clinical instructors involved: the clinical instructor was not concerned with the issues that students raised (92.2), readiness for clinical training is not enough (88.3), Deficit of students' self-confidence (88.3), may have lack of congruence or continuity with the curriculum (87), The clinical instructor behaves towards students with the unfriendly and inconsiderate way (87). While the least frequent challenges were: lack the chance to clinical practice (61), Time pressure for students in clinical training site (62.3). Challenges regarding clinical instructors were variance between faculty goals for students and clinical site goals (87), Clinical instructors solve student problems in the clinical site (85.7), Clinical instructors detect student interests and motivations (84.4). While the least frequent challenges were: clinical instructors' alteration (53.2), the absence of students' participation in planning care (57.1). General challenges stated by clinical instructors incorporated with poor health policies (84.4), Deficit of required resources, facilities, materials and equipment necessary for clinical training (83.1), Essential nursing performances executed at clinical site distinction from procedures performed in faculty (81.8). While the least frequent challenges were: Surroundings not helpful for instructing and training (63.6).

4. Discussion

Clinical education is the heart of professional education in nursing ^{11, 38} where nurses play an important role in public health by providing proper services in areas of disease prevention, health education, and healthcare. To play this role, they should acquire much-required preparation in the clinical areas through proper education without any obstacles. Therefore, the present study aimed to develop strategies for overcoming challenges facing nursing clinical teaching at Zagazig University. The results of this study revealed that many challenges are facing clinical teaching. This agrees with ³² who reported that teaching in the clinical setting having difficulties and challenges facing clinical teachers during their clinical teaching and supervision. The major challenges facing nursing clinical teaching at Zagazig University could be grouped and discussed under three categories: Challenges related to students, challenges regarding clinical instructors and general challenges. While, ⁴ categoried the challenges of clinical education in nursing into 2 main categories, 7 subcategories, and 19 sub‑sub categories. The participants' experiences indicate numerous problems in nursing education including problems related to students, educators, and clinical environments.

The most frequent challenges related to the students reported by students involved: do not have required clinical skills in the clinical setting (85.2), readiness for clinical training is not enough (79.7), can use patients' files to collect required data for their training (79.4), felt free to ask questions in the clinical area (78.8), Procedure manuals were accessible to students (76.7) and are unaware of the clinical training plan. Students did not prepared enough in laboratory' skills training. Laboratory skills in the nursing faculty needs updating. The difficulty of obtaining patient’s files because the busyness of the environment often meant that clinical duties took precedence over educational endeavors. Unavailability of procedure manuals in nursing stations, some of the clinical instructors did not provide clinical training plan to students, the context did not encourage students to ask questions in the clinical area are common revealed challenges. Consequently, student nurses need more time at the bedside to help them correlate their academic knowledge with clinical experience. Clinical instructors may be insufficiently equipped for their role. Some of them are not up to date with their knowledge and their ability to teach and role model skills may not sufficient. Other instructors maybe not well prepared and keep updated with current trends in nursing.

These findings consistent with many types of research as follows: ³³ who stated that students' preparation to enter the clinical setting is one of the important factors affecting the quality of clinical education. As well as ¹⁸ listed that lack of physical and psychological preparation of the students lead them lacked in basic knowledge and skill. There is less than average students' preparedness for clinical learning which is a result of lacking clinical teaching preparation. Besides, ¹¹ added that students have a feeling of inability to do the procedure. The students did not acquire the necessary skills to do the procedures in the clinical skills at the laboratory. Also, they do not have cognitive knowledge required for doing the procedure, insufficient readiness of the student, students' inadequate mastery of cognitive components of clinical skills; and inadequate mastery of clinical skills in the skill lab during the clinical education process. In this regard, ⁹ stated that basic students' knowledge and skills specific to the practice area is a big challenge for clinical teaching.

This is in line with ²⁰ who mentioned that inadequate readiness includes three subcategories of inadequate knowledge, deficient practical skills, and insufficiently developed communication skills. Moreover, ⁴ clarified that insufficient readiness of the student, inadequate self-steam, inadequate mastery of cognitive components of clinical skills, insufficient mastery of clinical skills in the clinical skills laboratory affect clinical teaching.

There are other many challenges affect clinical teaching such as avoid sharing students or announcing them about the educational objectives. ³⁴ highlighted that being unfamiliar with educational methods or objectives is forbidden, particularly in clinical teaching. harmoniously, with this view, ²³ mentioned that unfamiliarity in the clinical setting is provoking an uneasiness learning atmosphere. ³⁵ Further, ³⁶ discussed that poor educational planning is a big obstacle in clinical education. As well as, unawareness of acquired learning/clinical practice goals was a challenge. Moreover, ²² to hide the educational objectives among the students and ignore assessing the student’s activities based on the objectives as trainers, are major hinders in clinical teaching. ³⁴.

While the least frequent challenges perceived by students included: allowing them to provide patient care under supervision (59.7), and disappointment with the period of clinical training (60.3). That could be due to the availability of the instructor's supervision and they perceive that the training period is mandatory and required for achieving and success. Therefore, this thought is congruent with ³² who stated that there are difficulties such as lack of clinical supervision, dissatisfaction with the duration of students' placement. Also, ³⁷ reported that students dissatisfied with their clinical experiences.

According to the present study, It was found that the clinical instructor was not concerned with the issues that students raised (92.2), readiness for clinical training is not enough (88.3), Deficit of students' self-confidence (88.3), may have lack of congruence or continuity with the curriculum (87), the clinical instructor behaves towards students with the unfriendly and inconsiderate way (87) were further listed by clinical instructors as challenges faced them during clinical teaching. It could be due to that the clinical instructors may be insufficiently equipped for their roles, some of them are rough and not prepared adequately psychologically as well as, they were loaded by work requirements and their post-graduate studies besides, family role. Lack of knowledge in some areas of nursing science and lack of clinical supervision and, limited time for clinical teaching were also other problems.

In this regard, these findings were consistent with many types of research as follows: ³² stated that clinical nurse educators reported that they lack knowledge in certain areas of nursing and they were often challenged by some students, lack of clinical supervision, teachers not being prepared for clinical teaching. Effective clinical educators need to be well prepared and keep updated with current trends in nursing. As well, they need to possess effective communication and professional teaching skills. ³⁷ reported that the clinical facilitator was not interested in the issues that students raised and dealing with un friendly and unkind manner towards them. ³⁵ added that clinical instructors face challenges such as: have the feeling of unable to satisfy the demands of students, teaching inadequately to prepare students to interact with the patient or the teacher and other health care providers. The changing nature of patient conditions; a lack of knowledge and skill to practice care to patients; and working with difficult patient's conditions are further challenges in between nursing instructors.

³ concluded that teaching in the clinical environment has many challenges such as time pressure, lack of congruence or continuity with the curriculum. Students have reported that the teacher is a source of stress for them. These findings highlighted the need for faculty members to develop supportive and trusting relationships with students in the clinical setting ³⁵. Furthermore, ²⁰ stated that many students verbalized that the instructor’s way of dealing with the student affects student's exposure to the clinical learning environment and the instructor did not treat them well.

Also, ¹¹ added that students have not adequate self-confidence to do clinical procedures. The unpleasant atmosphere of the clinical environment, dual and discriminatory behaviors of doctors and nurses with a nursing student in the clinical environment compared to medical students have caused feelings of frustration and loss of confidence among nursing students. In this regard, ³⁸ added that professional interactions are integral components of the clinical environment which has an essential role in increasing self-confidence and the learning motivation of nursing students.

Concerning, the current study, the least frequent challenges were lack the chance to clinical practice (61), Time pressure for students in clinical training site (62.3). From the researcher’s view, this might be due to the busy clinical days and the unpredictability of the clinical workplace

This is antagonized with many types of researches as follows: ¹⁹ stated that an opportunity for varied clinical experiences is a huge barrier to effective clinical teaching and learning. Matching to this point, ³⁹ concluded that clinical education allows students to use and improve the professional knowledge and skills specific to nursing, to make the right decisions, to increase self-understanding, and to prepare themselves for professional roles. In this context, ⁴ mentioned that clinical educators didn't instruct students on how to do and practice. Fitting to such inspections, ¹⁵ who reported that the most important obstacles against clinical education according to students was the lack of access to direct nursing experience. As well, there are several challenges around clinical teaching were exposed students to stress which relating to limited time for clinical teaching ^{18, 32, 38}.

Amongst the challenges regarding clinical instructors which are rated by students: clinical instructors enforce students for involvement in practice (82.1) was the most frequently described followed by, clinical instructors explain day's program to students (79.7), then, Clinical instructors monitor and evaluate student development (78.2), and Clinical instructors solve student problems in the clinical site (78.2). This may be due to some students did not take clinical learning seriously. Other students were irregular attend the clinical sessions, lacked respect for staff, and they are not willing to learn. It was found that students expected their clinical teachers to be knowledgeable and skilled in the field of nursing education. Furthermore and further challenges: student did not receive adequate preparation for performing practice, afraid of some peers, have minimal self-confidence, some instructors did not explain the day's program to their students, some instructors did not explain about the student's monitoring and evaluation process, lack of objective evaluation tools for clinical evaluations, some instructors are not qualified in conducting students evaluation, some instructors did not solve clinical problems or have the required communication skills for such process.

These findings were matched with many types of research as follows: ¹¹ who mentioned that the participants stated that the clinical educator should perform the orientation at the beginning of the clinical education so that the students will know the objectives and contents of the clinical education course and evaluation method. Additionally, current findings were congruent with many types of evidence such as: ¹⁹mentioned that limited engaging students in meaningful learning moments, little promotion of student learning in a real-life situation, ineffective clinical supervision, ignore student's involvement in the evaluation were obstacles for clinical teaching. As well as, students reported that "Sometimes their clinical performances were evaluated by nurses with whom they had not worked". They were not involved in their performance evaluation. Furthermore, ¹⁵ clarified that the absence of experiences professors who should with a high academic level is another obstacle for clinical teaching.

Additionally, ³⁸ added that assessment is one of the most important and challenging issues in clinical training which is considered the most important duty of the instructor. Deficiencies of evaluation methods and limited capability of instructors to use it, push the instructors to be not currently capable to enough prepare student nurses to provide a comprehensive care program. This is in line with, ⁹ mentioned that daily monitoring of students and assessment of them was a challenge in the clinical setting. ³² detailed that lack of orientation before clinical placement and lack of knowledge in some areas of nursing training were provoking many problems in clinical teaching. Moreover, ⁴ mentioned that many times, students don't know what they will learn and do and how they will be evaluated. If the lesson plan is provided at the beginning and the training course continues according to it, repetition and overlapping will be overcome. The students believed that the clinical educator should introduce the lesson plan, the contents of the training course, and the evaluation method during the orientation stage at the beginning of the clinical education. So, the students will know the contents of the course. According to the present study, it was found that the least frequent challenges incorporated: deficient cooperation among clinical instructors and clinical settings (26.1), insignificant appraisal (37.0). This result was inconsistent with many types of research as follows: ⁴⁰ described that successful clinical practice can be achieved through the close cooperation and coordination between the nursing school and the hospital. Likewise, ¹⁹ stated that insufficient collaboration between academic and clinical settings is a huge barrier to effective clinical teaching and learning. Incidentally ²² mentioned that one of the difficulties and obstacles relates to individual obstacles, is the cooperation barriers in clinical teaching. Additionally ⁹ added that cooperation between schools and hospitals is a key role to give solutions to problems of the instructor's experience.

The present results indicated that clinical instructors are facing many challenges in the clinical settings as Variance between faculty goals for students and clinical site goals (87), Clinical instructors solve student problems in the clinical site (85.7), Clinical instructors detect student interests and motivations (84.4). That might be due to: the environment is often meant that clinical duties took precedence over educational endeavors, the conflict between students' learning requirements, clinical site goals, patients refusing students in some cases, clinical educators need to possess effective communication and professional teaching skills, some clinical instructors cannot make a balance between their teaching and their professional (clinical) responsibilities, managing the unpredictable nature of the workplace, there are limited opportunities for practical experience, the capabilities of individual learners, clinical instructors may encounter difficulties with students such as personality conflicts and lack of interest on the part of the students. This implies that the clinical educators may not be sufficiently motivated to teach, and had limited time to reflect on their teaching. These findings were supported by much evidence as follows: ¹⁷ stated that mismatch between the objectives of clinical education and expectations of the hospital personnel is one of the problems of clinical teaching. Also, and in line with ²² who mentioned that variance between school-required teaching content and clinical teaching content is one of the difficulties of clinical teaching. Furthermore, ³⁸ added that limited conformity of the clinical environment with professional standards is one of the difficulties of clinical teaching. Also, ⁹ mentioned that instructors experienced quite serious difficulties in presenting educational experiences suited to the educational goals of the clinical course.

¹¹ who mentioned that inadequate skill of clinical educator in doing nursing procedures and in teaching were other problems noted by the participants. The clinical educator needs theoretical knowledge and practical skills to teach the nursing procedures. The biggest obstacle in clinical education is students' lack of motivation and interest. ^{15, 41, 42} clarified that the increase in the number of students created problems with students' motivation and the placement of students in suitable clinical areas. Moreover, ⁹ identified that instructors experiencing serious difficulties in motivating students regarding clinical practice and daily monitoring.

However, the least frequent challenges facing clinical instructors were: clinical instructors' alteration (53.2), Absence of students' participation in care planning (57.1). That might be due to their perception that they have to do the same responsibilities regardless of differences in student groups, they have no authority to conduct the planning care in the clinical area and depend on performing what the clinical site and patients permit to perform.

This result was antagonized with ⁴³ who specified that the difficulties of clinical education include students' lack of autonomy in care planning. This point is in line with ⁹ who identified that another difficulty in clinical teaching that instructors experience pertains to the preparation and application of nursing care plans by students. Moreover, ⁴⁴ found that student's support, discussing the careless plan and facilitating effective plans and applications of care will contribute to solving many clinical teaching problems.

Several difficulties were enumerated as being general challenges facing nursing students in the clinical areas are ranged: from essential nursing performances which executed at clinical site distinction from procedures performed in faculty (79.7), surroundings are not helpful for instruction and training (79.4), and poor health policies (76.4). This might be due to the shortage of resources and facilities, limited qualifications of the clinical instructors and they have no authority in the clinical setting, plus the unpleasant atmosphere of the clinical environment. These findings were fit with many types of research as follows: ¹⁹ stated that environments may not be conducive to clinical teaching and learning. Also, with ⁴ who mentioned that the unpleasant atmosphere of the clinical environment, inappropriate behavior by doctors and nurses with the nursing teacher and student, ignoring the teacher and nursing student and double-dealing nurse with medical and nursing students are other challenges. In the clinical environment, doctors and nurses show more attention to medical students than other students of healthcare sciences including nursing students that leads to a negative attitude toward the other students. Therefore, there is an unsuitable atmosphere in the clinical environment for nursing students than other students, especially medical students. This can have negative effects on creative learning opportunities and also can reduce a student's learning motivation. ⁹ instructors experienced quite serious difficulties as poor physical environment, lack of patient conditions which appropriate for education, providing an adequate clinical practice area, achieving cooperation with another team. The present results reported that clinical instructors facing general challenges, such as Poor health policies (84.4), Deficit of required resources, facilities, materials and equipment necessary for clinical training (83.1), Essential nursing performances executed at clinical site distinction from procedures performed in faculty (81.8). That might be due to inadequate resources and facilities and the nature of unpredictability of the clinical area. This is in line with ³² who stated that poor health policies, lack of financial resources, Lack of working materials were challenges related inherent to the clinical educators. Also with ³⁵ who illustrated some points about agency policies as challenges, as well as, ^{17, 18} who stated that deficit of facilities and working conditions considered challenges facing clinical teaching. ¹⁹ reported that inadequate equipment is a huge barrier to effective clinical teaching and learning. Furthermore, ⁴ added that insufficient teaching and learning resources are barriers to successful clinical teaching

Moreover, ³⁸ clarified that poor educational facilities are barriers to helpful clinical teaching. Whereas, surroundings not helpful for instructing and training (63.6) was listed as the least frequent challenges they faced. That might be due to their perception that they have no authority to make adjustments or control for these environments as well as, there are no other locations for training. This result is incompatible with ¹⁹ who clarified that environment not conducive to teaching and learning

5. Conclusion

The questionnaire of assessing nursing clinical teaching challenges is reliable, valid, and usable. The strategies for overcoming nursing clinical teaching challenges was developed and validated. Based upon the findings of the study about the major challenges facing nursing clinical teaching at Zagazig University which were grouped into three categories: (1) Challenges related to students, (2) Challenges regarding clinical instructors and (3) General challenges. Nursing students experienced many challenges as they do not have required clinical skills in the clinical setting, clinical instructors enforce them for involvement in practice, and essential nursing performances executed at clinical site distinction from procedures that performed in faculty. The clinical instructor was not concerned with the issues that students raised, Variance between faculty goals for students and clinical site goals, Poor health policies.

6. Recommendations and further studies

● The suggested strategies for overcoming nursing clinical teaching challenges should be used at the Faculty of Nursing, Zagazig University.

● The proposed strategies for overcoming nursing clinical teaching challenges should be disseminated by the faculty administration to all clinical instructors

● The proposed strategies for overcoming nursing clinical teaching challenges should be reviewed, revised and updated periodically annually as appropriate and as necessary to reflect continuing improvements.

● Faculty of Nursing, Zagazig University should constitute a committee for revision follow up of the application of these mentioned strategies

● Faculty of Nursing, Zagazig University should determine and allocate the needed and required resources for application of the recommended strategies for overcoming nursing clinical teaching challenges

● Faculty of nursing, Zagazig University should design and implement training programs about the recommended strategies for overcoming nursing clinical teaching challenges

● Rewards should be given for clinical instructors who apply the recommended strategies for overcoming nursing clinical teaching challenges

● Further researches using the developed tool to investigate definite clinical teaching challenges and develop each particular strategies in other settings

7. Implications

For nursing practice: Nurse managers have a goal to provide a high quality of patient care, therefore; they must be empowered with qualified nurses who received good preparation, have adequate knowledge and skills, and become mature enough to participate with nurse managers in the decision-making process. So graduating highly competent nursing students will positively and effectively reflect on all rendered services and consequently facilitate the work of nurse managers. For nursing education: Applying the developed tool and strategies with different sites for improving undergraduate clinical teaching. For nursing research: Replicate the study using the developed tool for assessing challenges facing nursing clinical teaching at other sites

Acknowledgments

The authors wish to thank all of the clinical educators and students for their cooperation and everyone had been participate in the conduction of this study

References