University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA BALANCING ACADEMIA AND CLINICAL PROFICIENCY IN THE TRAINING OF NURSES AT UNIVERSITY DEGREE LEVEL IN GHANA BY BELINDA EMEFA ADZIMAH-YEBOAH (10508113) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL HEALTH SERVICES MANAGEMENT DEGREE University of Ghana http://ugspace.ug.edu.gh DECLARATION I do hereby declare that this study is the result of my own research and that no part of this work has been presented for another degree in the University of Ghana or elsewhere. All references have been duly acknowledged. …………………………………………… …………………………… BELINDA ADZIMAH-YEBOAH DATE (10508113) i    University of Ghana http://ugspace.ug.edu.gh CERTIFICATION I therefore certify that this thesis was supervised in accordance with the procedures laid down by the University of Ghana. ……………………………… ……………………………… Dr. Lily Yarney DATE ii    University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to the Almighty God, my family, friends and loved ones iii    University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I give thanks to all mighty God for giving me the wisdom, grace and strength to do this research successfully. My sincerest thanks go to Dr. Lily Yarney my supervisor who guided and supported me through the process. Next I want to say a big thank you to Dr. John Ernest Koku and Professor Prudence Mwini-Nyaledzigbor for their able support and guidance. I also thank Mr. Jonathan Armstrong for proofreading the work. I also say a big thank you to all the lecturers and students of the three universities where the research was conducted for their willingness to participate and their openness in contribute to the study. Finally, I thank my family and friends who all supported me to do the research successfully. God bless you all. iv    University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION……………………………………………………………………………………………i CERTIFICATION………………………………………………………………………………………….ii DEDICATION……………………………………………………………………………………………..iii ACKNOWLEDGEMENT…………………………………………………………………………………iv TABLE OFCONTENTS…………………………………………………………………………………..v List of Tables………………………………………………………………………………………………vi Abstract…………………………………………………………………………………………...………..ix 1.0. Introduction……………………...………………………………………………………………….1 1.1. Background………….………………………………………………………………………………1 1.2. Nursing education in Ghana………………………………………………………….…………….. 2 1.3. Problem Statement…………………………………………………………………………………..3 1.4. Significance of the study…………………………………………………………………………….5 1.5. Objectives of the study……………………………………………………………………………....5 1.6. Research questions………………………………………………………………………………….6 1.7 Conceptual Framework……………………………………………………………………………..6 CHAPTER ONE: RESEARCH OVERVIEW…………………………………………………………..1 1.0. Introduction…………………………………………….…………………………………………..1 1.1. Background………………………………………………………………………………………...1 1.2 Nursing Education in Ghana…………….…………………………………………………………2 1.3. Problem Statement…………………………………………………………………………………3 1.4. Significance and Relevance of the study…………………………………………………………..5 1.5. Objectives of the Study……………………………………………………..………………………5 v    University of Ghana http://ugspace.ug.edu.gh 1.6. Research Questions…........................................................................................................................6 1.7. Conceptual Framework……….………………………………………………………………….....6 CHAPTER TWO: LITERATURE REVIEW………………………………………………………….10 2.0. Introduction……………………………………………………………………………………….10 2.1. Legitimacy and Recognition of Nurse Educators as Experts in Academia and Also Experts in Academia and Clinical Practice…………………………………………………………………………...11 2.2. The role of the Nurse Educator as an Educator and a Clinical Practitioner……………………....14 2.3. Competency Requirement for Nurse Educators………………………………………………......15 2.4. Barriers and Enhancers to Balancing Education with Cynical Competency among Nurse Educators…………………………………………………………………………………………………..16 2.5. Models Available for Training Nurses……………………………………………………………......18 CHAPTER THREE: METHODOLOGY……………………………………………………………....22 3.0. Introduction……………………………………………………………………………………….22 3.1. Study Design……………………………………………………………………………..............22 3.2. The Study Area…………………………………………...............................................................22 3.3. Study Population…………………………………………………………………………….........23 3.4. Sampling Technique and Sample Size………………………………………………………........23 3.5. Data Collection Methods and Instruments…………………………………………………….......25 3.6. Ethical Considerations……………………………………………………………………….........28 3.7. Data Analysis...................................................................................................................................29 CHAPTER FOUR: PRESENTATION OF RESULTS AND DISCUSSION………………………...32 4.0. Introduction…………………………………………………………………………………………32 4.1. Presentation of Quantitative Results………………………………………………………………..32 4.2. Presentation of Qualitative Results…………………………………………………………………32 vi    University of Ghana http://ugspace.ug.edu.gh 4.3 Demographic Characteristics of Participants………………………………..……………………...33 4.4. Assessment of the level of experience of the lecturers as teachers and clinicians………………....34 4.5. The nurse educator’s obligation and expectation to teach both in theory and practice of nursing...38 4.6. The theory and practice gap in the training of nurses in the university……………………………45 4.7. University students and graduates ability to practice nursing with confidence……………….…...50 4.8. Difficulties Nurse Educators face in combining academia with clinical practice…………………53 4.9. Effects of clinical proficiency of a lecturer on the student nurse’s ability to learn clinical skills....59 4.10. Enquiries into requirement for nurse educator’s clinical practise………………...………………61 4.11. Models developed to aid nurse educators to balance teaching theory with clinical practice………63 4.12. Preference models………………………………………………...……………………………….64 CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS………………….66 5.0. Introduction………………………………………………………………………………………...66 5.1. Summary of the study………………………………………………………………………………66 5.2. Recommendations…………………………………………………………………………...……..67 5.2.1 Recommendations for policy makers…………………………………………………..………….67 5.2.2 Recommended models for training nurses at the university level………………………..………68 5.3 Recommendations for future Research……………………….………………………..…………71 5.4. Conclusions………………………………………………………………………………………..72 5.4.1. Lessons learnt from this Research………………………………………………………………..73 REFFERENCES…………………………………………………………………………………………74 APPENDICX A…………………………………………………………………………………………..76 1.0. Letter of introduction………………………………………………………………………………76 1.2. Questionnaire………………………………………………………………………………………77 2.0. Interview Guide…….………………………………………………………………………85 vii    University of Ghana http://ugspace.ug.edu.gh 2.1 Interview guide Questions for Deans and Heads of Department……………….…………………86 2.2. Interview Guide for Lecturers…………………………….……………………………………….88 2.3. Interview Guide for Student’s Focus Group Discussion…………..………………………………89 List of Tables Table 3.1. Evidence of saturation…………………………………………………………..……31 Table 3.2. Major themes and Sub-Themes from Interviews and Focus Group Discussions…….32 Table 4.1. Age distribution of lecturers……………………………………………………….…34 Table 4.2. Sex of respondents……………………………………..…………………...…….…..35 Table 4.3. Marital status of respondents……………………………………………………...….35 Table 4.4. Number of years employed by university….…….....………………………………...36 Table 4.5. Number of years of practice before teaching…………...…………………...………..38 Table 4.6. Lecturers/Students Responses on Obligation to Teach Both Theory and Practice…..40 Table 4.7. Perception of Nurse Educator’s Clinical Competency by Lecturers and Students…..44 Table 4.8: Lecturers and student’s responses to theory and practice gap in training University level nurses in Ghana…………..………………………………………………………………...47 Table 4.9: University Student Nurses and Graduate’s Ability to Practice with Confidence…….51 Table 4.10: Student’s rating of their clinical competency……………………………………….52 Table 4.11: Lecturers Having Difficulties in Balancing Theory and Professional Practice……..54 Table 4.12: Difficulties Lecturers have in Balancing Theory and Professional Practise………..55 Table 4.13: Lecturers coaching students on the wards…………………………………………..57 Table 4.14: Student’s preference of lecturers coaching them at the clinical site………….…..…58 Table 4.15: Effect of the Clinical Proficiency of a Lecturer on the Student Nurses Mastery of Clinical Skills………………………………………………………………………………...…..60 Table 4.16: NMC has a requirement for clinical competency for nurse educators……………..62 viii    University of Ghana http://ugspace.ug.edu.gh Table 4.17: Lecturers fulfillment of NMC Clinical Practice Requirement……………...………62 Table 4.18: Lecturer’s Knowledge of models used in training student nurses………..………...64 Table 4.19: Models for training nursing students………………………………………………..65 Appendix B Table 1.0: List of Lecturers obtained from selected Universities………..………………………91 Table 2.0: Guideline for sampling……………………………………………...………………..92 Table 3.0: Table of Random Digits………………………………………………………………92 Table 4.0: Numbers Selected 32 Lecturers…………………………………………...………….93 List of Figures Figure 1: The Graduate Nurse as a Practitioner, Scholar and Leader…………….…………….8 ix    University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Countries all over the world including African countries and Ghana are encouraging the transition of nursing education from hospital based training in colleges to a University based degree level. At the University degree level, the preparation of student nurses involves acquisition of theoretical knowledge and also clinical practice, which if well done can serve as a double edged tool for blending theory and practice. Objectives: The study investigated the ability of university nursing lecturers in Ghana to balance theory and practice in training student nurses at the university level. The objective of the study was to explore the role and experiences of nurse academics in balancing theory and practice in training nurses at the university degree level. Significance: This study seeks to contribute to the discourse on empirical knowledge that will inform policy on the development of strategies and models that could bridge the theory and practice gap in training nurses at the university, enhance the acquisition of innovative clinical skills to address the theory and practice gaps in the training of nurses and finally, address the complex challenges facing the nursing profession in the contemporary health care system in Ghana. Methodology: Using an exploratory research approach with a Methodical triangulation design, data was collected from university nursing lecturers and university student nurses using individual interviews and focused Group Discussions. Results: Clinical practice was seen as an important measure for enhancing theoretical preparation of nursing students to make them wholly qualified and proficient in the delivery of nursing care. While this is so, the study also discovered that majority of nursing lecturers in the university had a short duration of clinical exposure of two (2) to three (3) years before joining academia. Although the nursing lectureres themselves recognize the importance of clinical practice proficiency in training nurses at the university degree level, the university academic calendar does not favour the inclusion of clinical practice in their academic programmes, thus making balancing academic work with clinical practice difficult. Some of the findings of this research were congruent with other studies whilst dissimilarities were also established among the Ghanaian nurse educators on the part of their unwillingness to endevour to blend theory with practice. Conclusion: The study concluded that although both lecturers and students accept that nurse educators in academia are obliged to blend theory and practice in training nurses. A number of difficulties do not favour this situation. Recommendations: The theses provided recommendations for nursing education, policy makes and areas of future research identified. For nurse education, university curricula should be designed to place priority on clinical practice. Universities must give autonomy to the schools of nursing in designing the academic calendar. Nursing and Midwifery Council of Ghana should put monitoring mechanisms in place to ensure that university nursing lecturers acquire adequate clinical practice competencies. x    University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE RESEARCH OVERVIEW 1.0. Introduction This chapter discusses the trend in the training of nurses from hospital based training to a university degree and the problems associated with Nurse academic’s ability to play the dual role of training nurses both in theory and also to be proficient in nursing skills. The chapter also includes the background, problem statement, significance of the study, research question, objectives and the conceptual framework of the study. 1.1.Background Countries all over the world, including African countries and Ghana in particular, are encouraging the transition of nursing education from hospital based training (Registered Nurse (RN) to a University based degree nurse. At the University degree level, the preparation of student nurses involves acquisition of theoretical knowledge that should satisfy all the required university programme courses as well as the nursing professional theoretical courses and clinical practice requirements to imbibe practical skills on the neophyte student. This dual academic and professional proficiency require the nurse educator to impact both academic knowledge as well as professional skills to student nurses. In developed countries, the professor of nursing is a double edged sword, thus being able to deliver efficiently the theoretically required knowledge components within a university programme as well as skillfully blend clinical learning experiences in clinical placement areas. Thus, ensuring that the clinical credibility of a nurse educator is as important as the academic laureates of a dignified university lecturer. Thus, the nurse educator in the university should be one who must be able to apply theory to practice. And more importantly, nurses in academia are expected to impact knowledge in the discipline of nursing as well as adequately prepare student nurses to be clinically proficient in nursing practice. A study conducted in Ireland indicates that clinical practice is seen to be a problematic component of a nurse’s academic identity and disciplinary discourse, yet a focus on clinical practice is seen as central to the autonomy, integrity, and distinctiveness of nursing as an 1 University of Ghana http://ugspace.ug.edu.gh academic discipline (McNamara, 2009). Therefore, nurse educators therefore, wherever located and more importantly in Ghana are faced with the responsibility of balancing the demands of academia and professional practice as to adequately prepare student nurses to confidently acquire psychomotor skills for professional licensing and future practice. 1.2. Nursing Education in Ghana Nursing education in Ghana also evolved from hospital based skill training in the early 1960s (Akiwome 1995) and later included the University transition from the 1980s to date. Hence, for the past two decades nurse educators in University-based programmes are expected to adequately prepare students for professional practice whilst they maintain their own professional credentials in addition to fulfilling the demands of academia, doing research, publishing and other University responsibilities that account for promotions and self-development. The researcher, being a professional nurse with extreme passion for clinical practice as well as classroom teaching in academia, has observed with grave concerns over the adamant attitudes and laxity flare exhibited by fellow Ghanaian nurses in academia for no attention paid to acquisition of psychomotor skills towards clinical practice for student nurses, although this is what will enable them identify and acknowledge their discipline and legitimacy through clinical credibility and professional competency. According to McNamara (2009), the dual role of teaching and clinical practice seems attractive to faculty, and clinical staff, but requires significant amount of investment of time and money. Most nurse educators complain that playing the dual role, over a long period of time leads to burnout. Also, if nurse educators are not able to equip students with clinical skills the students feel incompetent and become scared of caring for patient and this defeats the main purpose of training the nurse. At the moment, there are about fifteen (15) which Universities who are training student nurses in Ghana, and the university based nursing programme is a four year degree programme consisting of both theory and practicum, Students are awarded a Bachelor’s degree in Nursing at the end of the programme and are and then are expected to write a professional licensure examination to obtain a certificate to practice as professional nurses. This research work therefore explored the obligations, expectations and experiences of nurse educators as teachers in universities and also as professional nursing experts shouldering the roles 2 University of Ghana http://ugspace.ug.edu.gh of training the university-based student nurse to be skillful and proficient in nursing practice in Ghana. 1.3. Problem Statement The advent of university degree nursing has been good news for the nursing profession and other disciplines in the health care sector, as it is generally assumed that nurses being prepared at the university level will contribute better to meeting the growing health care demands of today’s society. Whilst this assertion could be considered as a positive development, one critical issue that confronts nursing practice, both in the advance and developing countries is the issue of safe and quality patient care. Quality patient care and patient safety have always been a very important part of health care delivery, and it is obvious that unsafe patient care is one situation that is not tolerable in any society of the world. Research from advanced countries identified a number of factors in the nursing profession that result in unsafe patient care. Among these factors include; inadequate research on nursing practice; low level of competency in clinical skills; poor knowledge base and inability of nurse educators to balance theory and practice (McNamara 2009). Generally, it could be argued that the ability to address unsafe patient care depends largely on the extent to which the above mentioned factors are addressed. Studies have shown that the role of nursing services is critical in determining safety, quality and high performance in healthcare delivery. Dubois et al (2014) stated that: “Nurses form the largest professional group in the healthcare workforce, providing the most care at all levels of the care continuum around the clock. They account for a significant proportion of hospital’s operating costs”. In view of this, gaining an understanding of the impact of nursing care on patients is important in ensuring quality, safety and a patient-centered care. (Desborough et al, 2014). Larrabee et al (2004) also stated that nurses play an important role in patient care and their interaction with patients is the main determinant of patient satisfaction and recovery. Looking at the role of nursing in ensuring quality patient care and patient safety, it is important to ensure that nurses are adequately trained; hence the importance of emphasizing clinical practice in university nursing programmes. 3 University of Ghana http://ugspace.ug.edu.gh Based on anecdotal evidence, there has been a general complaint among nurses themselves on the theory and practice gap among the new generation of nurses in the 21st Century, especially University trained nurses. The question is; why is it so? Some people feel it is because nurses in Ghana are not adequately trained to give safe patient care, others also feel the nurses just don’t care about patients. It is also a common parlance in Ghana that nurses who are trained at the university level are not clinically competent and possesses inadequate nursing skills, as they usually lack confidence and become scared to touch patients let alone to care for them. However, experience has shown that the above factors apply to Ghana and several African countries. In addition, strategies for integrating theory and clinical practice in the training of nurses have not been adequately researched into. The paucity of data and subsequent lack of information on the subject has manifested in the inability of university student nurses to acquire enough professional knowledge and skills to enable them link theory to clinical practice and be able to deliver safe patient care. Furthermore, research into bridging the theory and practice gap has also received very little attention in Ghana, and yet it is a fact that failure to address the theory and practice gap could lead to unsafe patient care arising from the interplay of the above named factors, which ultimately could lead to high mortality resulting from complications of diseases that nurses have no knowledge about their care or prevention. This could have been better managed in a health care system where innovative practices have been promoted through research. Such practices could progressively be developed where the link between theory and clinical practice is fostered and integrated into the training of nurses. There is a dearth of literature in this area in Ghana, hence the need to investigate the training and preparation of nurses for the nursing profession in Ghana at the University level. This study therefore seeks to explore the responsibilities and experiences of University nursing lecturers in balancing teaching and clinical practice in their training of student nurses to become proficient professionals. 1.4. Significance and Relevance of the study 4 University of Ghana http://ugspace.ug.edu.gh This study seeks to contribute to the discourse on empirical knowledge that will inform policy towards the development of strategies and models that could bridge the theory and practice gap in training nurses at the University level, enhance the acquisition of innovative clinical skills to address the theory and practice gap in the training of nurses and finally, address the complex challenges facing the nursing profession in the contemporary healthcare system in Ghana. 1.5.Objectives of the Study The main objective of the study was to explore the role and experiences of nurse academics as experts in the discipline of nursing that is; an expert teacher, and also an expert clinical practitioner. 1.5.1. Specific objectives of the research were to: 1. Determine the obligation and expectation of nurse educators as teachers and at the same 2. Assess the level of role of the lecturers as teachers and clinicians time as professional practitioners in clinical practice and education concurrently. 3. Identify the difficulties Nurse educators face in combining academia with clinical practice 4. Identify the factors that influence the nurse educator in Ghana to balancing their teaching with professional practice 5. Analyse the effect of the clinical competence of the nurse educator on the student nurse’s learning and mastery of clinical skills. 1.6. Research Questions The main questions this research sought to address are as follows: 5 University of Ghana http://ugspace.ug.edu.gh 1. Do nurses in academia have an obligation to be clinically competent? 2. What is the role of the nurse educator in training student nurses and assessing them in clinical practice? 3. What are the difficulties nurses in academia face in playing the dual role as teachers and practitioners? 4. What are the barriers to enhancers for the nurse educator’s ability to balance teaching with clinical practice. 5. What are the effect of the clinical competency of the lecturer on the student nurse’s learning and mastery of clinical skills? 1.7. Conceptual Framework Several theories have been put forward to enhance the understanding of the role of the nurse educator as a teacher, a practitioner, and trainer of health care practitioners. The theory that fits the purpose of this study is the Problem Based Learning (PBL). PBL is defined by Hmelo-Silver & Cindy (2004) as a student-centered pedagogy in which students learn about a subject through the experience of solving an open-ended problem. The theory was developed at the McMaster University Medical School in Canada in the 1960s and has since spread around the world. The goals of PBL are to help students develop flexible knowledge, effective problem solving skills, self- directed learning, effective collaboration skills and intrinsic motivation. Wilkerson and Gijselaers (1996) claim that PBL is characterized by a student-centered approach, with teachers as facilitators rather than disseminators,” With this in view, it is clear that the best approach to train student nurses is the PBL approach where open-ended problems could serve as the initial stimulus and framework for learning. Several medical schools have incorporated problem-based learning into their curricula following the lead of McMaster University Medical School, using real patient cases to teach students how to think like a clinician. In addition to emphasizing learning by “doing,” PBL requires students to be metacognitively aware (Gijselaers, 1996). That is, students must learn to be conscious of what information they already know about the problem, what information they need to know to solve the problem and the strategies to use to solve the problem. In nursing practice, this is called critical thinking, an 6 University of Ghana http://ugspace.ug.edu.gh approach that is used to solve client’s problems. In the training of nurses, being able to articulate such thoughts helps students to become more effective problem-solvers and self-directed learners. Initially, at the entry point of training, many students are not capable of critical thinking on their own, and for this reason, the instructor or lecturer must become a tutor or “cognitive coach” who models for the student to emulate. PBL theory is especially very effective in facilitating student problem solving and self-directed learning skills. (Dochy et al. 2003). The assumption of the PBL theory is that, “all life is problem solving and all life presents an opportunity for learning, because as we solve problems, we learn” (Karl Poper, 1994). Nursing is a lifelong act of solving problems, and so the skill can only be learnt through real life solving of patient’s problems and PBL is the most appropriate way for nursing students to learn nursing skills on patients. The conceptual framework on which the study is based is derived from the objectives of the study that is; university nursing programme as a legitimate academic discipline must produce nurses who will learn nursing to become scholars, practice nursing to become practitioners who will become leaders in the discipline of nursing, and will take the lead to deliver quality and safe patient care. As illustrated in Figure 1, these three qualities of a graduate nurse are what the nurse educator is expected to produce. Therefore it is imperative that a nursing lecturer possesses a dual competence as a nurse educator and as a clinical practitioner. This is because, everything involved in the training of nurses ends at the bedside of the patient or at the community. As stated by Souza et.al (2013), “the nurse educator’s vast experience in guiding or teaching nursing students in a clinical setting will provide a foundation for further studies in the area, and will definitely contribute to the existing source of knowledge in the field”. 7 University of Ghana http://ugspace.ug.edu.gh Figure 1: The Graduate Nurse as a Practitioner, Scholar and Leader. Source: Author’s construct, 2015 The framework shows that all nurses who graduate from the university must be prepared to be competent practitioners, knowledgeable professionals and seasoned researchers. This indicates that the nursing training programme at the university must prepare them to play these specified roles. 1.5.1. Training a student nurse to be a Practitioner In order to be a competent practitioner, the university student nurse must be trained to put clinical practise in the centre of his or her preparation to become a nurse. As stated by McNamara (2009), nurse academics who proclaim nursing as an academic discipline must be able to prepare student nurses to make clinical practice the focus of their training. At all levels of nursing education, the student nurse must be prepared to play the role of a practitioner who must deliver competent, holistic and contextually appropriate patient, family, and population centred nursing care, utilize advanced knowledge and skills related to health promotion, diagnosis and treatment of human responses to illness, and also assess, analyze and evaluate complex caring environments (Rush University, 2003-2004). Every output made by the nurse ends 8 University of Ghana http://ugspace.ug.edu.gh with client care; therefore, the university student nurse must be trained using problem based learning techniques to be a practioner who possesses the nursing skills that will provide quality client care. 1.5.2. Training a nurse to be a scholar To be prepared as a scholar, the university student nurse must gain knowledge and understanding in the art and science of nursing through study, instruction research and experience. The student nurse will also be prepared to be able to synthesize knowledge, scientific evidence and innovative technology to guide nursing practice, and must also be able to apply a variety of theories from nursing and related fields to nursing practice. Nursing students must also utilize evidence-based findings to manage direct and evaluate nursing care, and also collaborate with researchers and support research activities in a clinical setting (Rush University, 2003-2004). These qualities can only be acquired if open-ended problems could serve as the initial stimulus and framework for learning, as directed by the PBL theory 1.5.3. Training the Nurse to be a Leader The university student nurse must also be prepared to become a leader, who must influence and guide the direction of actions, opinions and attitudes of others, manage the structure and process of the care environment, participate in the formulation of health care policy, develop and implement professional standards and use leadership skills to influence health policy for diverse client populations (Rush University, 2003-2004) The graduate nurse must therefore, be able to lead in providing quality client care both in a facility and in the community at large. To achieve all the above, nurse educators must be equipped with all the above mentioned skills to train the calibre of nurses needed to give quality client care, and also legitimize the nursing profession as an academic discipline in a university environment. CHAPTER TWO LITERATURE REVIEW 9 University of Ghana http://ugspace.ug.edu.gh 2.0. Introduction This chapter reviews literature on the field of nursing as an academic discipline, and also as a profession. It also reviews the dual role of nursing lecturers as teachers and clinical practitioners. Experience has shown that for any meaningful functioning healthcare system in any part of the world to gain legitimacy, there is the need for mutual respect for each member of the health care team and their distinctive professional responsibilities and nursing is no different. For nursing to gain recognition, and legitimacy, the profession has to be respected by the other health care professionals in the health care industry. A search for literature on balancing academia and clinical practice among nurse educators was undertaken using data bases like PubMed, EBSCOhost, Science direct and Cochrane review using the key words: academia, clinical practice, nursing theories, nurse training models and nursing training. Before embarking on the review of literature on this topic, it was important to understand the meaning of clinical practice and academic nursing. Clinical practice is defined by Malcolm &, Natalie (2008) as a nurse actively engaging in direct patient care. This may include patients in a hospital or any other health care agency such as in the community and community based health centres. The concepts of clinical credibility or clinical competence also need to be clarified, because a variety of definitions exist and these terms are often used interchangeably. Fisher (2005) stated that when these terms are used with regard to nurse academics, they almost always refer to engaging in patient care. This means the simple act of providing nursing care to a patient somehow guarantees or ensures competency. Aston et al. (1992) provided an alternate definition by stating that clinical competence is simply having expert knowledge of a particular field. In their discussion of the clinical nurse tutor debate, these authors defined credibility as the quality of being worthy of belief or trust. These inferences that exposure to the clinical environment implies a greater level of trustworthiness with regards to the information being delivered in a classroom. Thus the clinical credibility of a nurse lecturer determines his or her trustworthiness in the teaching of the nursing skills. The literature review was based on the following five main issues: 10 University of Ghana http://ugspace.ug.edu.gh a. The legitimacy and recognition of nursing as an academic discipline in a university community b. The role of the nurse educator as experienced academic and also an experienced clinical practioner will also be discussed. c. The professional practice competency requirement for nurse educators and balancing the dual competence. d. Barriers and enhancers to balancing and sustaining education and clinical competency among nurse educators will be looked at, and e. Models that are available for training nursing students to be competent professionals will also be explored. 2.1. Legitimacy and Recognition of Nurse Educators as Teachers in Academia and Clinical Practioners McNamara (2010), reflecting on the Legitimization of Senior Nursing Academics and National leaders in Ireland, investigated the extent to which distinctive disciplinary identities are embedded in them. He noted, among other things, that “clinical practice features as a problematic component of Irish Nursing’s academic identity and disciplinary discourse. And yet, a focus on clinical practice is seen as central to the autonomy, integrity and distinctiveness of nursing as an academic discipline as well as to the legitimacy and credibility of those who claim to profess it. McNamara (2010), stated that the overall consensus on the state of academic nursing in Ireland is that of a field characterized by low autonomy, high density, weak specialization and disciplinary immaturity This observation is not different from the Ghanaian context. Experience has shown that the nursing profession in Ghana is still struggling to establish its identity as an academic discipline whilst maintain their professional integrity. Three issues stood out in McNamara’s study and relate to the Ghanaian context, low autonomy, weak specialization and disciplinary immaturity. 2.1.1 Low Autonomy An academic discipline’s autonomy is defined as the discipline’s external relations and its degree of insulation from external control and value system (Marton 2005). As reported by McNamara (2010), Irish nurses complained that, their vulnerability is that they have not been able to find nursing knowledge and discipline; they are still a part of a medical world that considers nursing as 11 University of Ghana http://ugspace.ug.edu.gh an afterthought, always coming behind, and this is not different in Ghana. On the issue of low autonomy, one problem which affects or undermines recognition and legitimacy of academic nursing in Ghana relates to the inability of nurses in academia to find nursing knowledge. Nursing is not autonomous in the medical world in Ghana. Just as stated by the Irish nurses, the university communities always regard nursing as dependent on other disciplines. The universities still insist that other disciplines like biomedical sciences are the ones qualified to teach the basic sciences not nurses themselves. Other disciplines like Medicine always want to control nursing when it comes to curriculum development for training of nurses. In some universities in Ghana, the Deans of nursing schools are medical doctors not nurses. Nurse academics have not yet been able to climb the academic ladder to become professors. At the moment there are less than five Nursing Professors in Ghana. All the above indicate that nursing has still not established its own autonomy as an academic discipline in Ghanaian universities. 2.1.2 Weak Specialization McNamara (2010) defines specialization as the way academics and their discourses are constructed as specialized and distinctive. Specialization emphasizes who you are and what you know (McNamara, 2009). As stated by Gee (2005) pulling of being in academia involves putting language, action, interaction, values, beliefs, symbols, objects, tools and places together in such a way that others will recognize you”. For Ghanaian nurse academics to be identified and attain academic legitimacy, they must have specialized knowledge as it is in the advanced countries, and this specialized knowledge has to be recognized by the community. Nurses in academia and professional nurses therefore need to address the following questions that have also been asked by McNamara (2010) in order to determine whether they have been able to build specialized knowledge:  “On what specific knowledge grounds do nursing’s professional and academic leaders base their own nursing’s claims to academic legitimacy”?  “In light of the level, form and substance of their nursing and academic qualification and the focus, depth and currency of their clinical experience, what is the distinctive nursing knowledge and practice base of the nurse educator’s new identity as a nurse academic? 12 University of Ghana http://ugspace.ug.edu.gh Just as stated by the Irish nurses in McNamara (2010), the Ghanaian nurse academics seem to have a weak academic infrastructure with insufficient specialized knowledge and a poor accumulated body of knowledge based on handed down tradition. Another enhancer of specialized knowledge is building up a body of knowledge through research, and clinical practice and which has been accepted by all as central to the building up of this body of knowledge. One of the respondents of McNamara’s (2009) research states; “clinical practice is the core activity of the nursing discipline, because the base of growing a theory of nursing has got to come out of clinical practice”. This is also another area where Ghanaian nurse academics are found wanting. There is the need to build their body of specialized knowledge based on research drawn from clinical practice. It is therefore clear that if nurses in academia are not involved in clinical practice, it will be almost impossible to build the body of specialized knowledge required for attaining autonomy and be recognized as an academic discipline. 2.1.3. Disciplinary Immaturity Meleis (2007) has proposed five indicators of scholarly disciplinary maturity for nursing. The First is continuity; that is whether fundamental questions in nursing are addressed with theoretical nursing frameworks that refine and sharpen concepts over time. The second is concatenation, demonstrated through nursing theories that evolved from practice and are used in education. Thirdly, a national body to coordinate research programmes. Forth cumulative work through research and theory on the central concepts in nursing. The next is the presence of centres of research where a critical mass of nurse scholars will focus on particular knowledge development areas of nursing like care of the elderly, symptom management, home care nursing, maternal and child care, adolescent care, etc. Nurse academics in Ghana are yet to address any of the above propositions and so has a long way to attaining disciplinary maturity. 2.2. The role of the Nurse Educator as an Educator and a Clinical Practitioner (Maureen & Milliken 2007) quoted Fawcett & McQueen (1994) that, because nursing is a practice- based profession, there has been a widespread assumption that nursing educators are also competent clinical practitioners, and nursing students worldwide, also identify clinical competency as being 13 University of Ghana http://ugspace.ug.edu.gh an important quality of effective educators. In view of this, before an educator can be effective, students have to see her/him as a model, meaning the teacher must be able to practise what is he/she preaches. Due to this fact, the nurse educator, especially in the universities worldwide, is expected to be both a teacher and a practitioner. (Maureen & Milliken 2007) also coated Patricia Benner 2003, who defines experienced practitioner as competent in the following manner: The competent practitioner has 2-3 years of experience in the same or similar setting; engages in conscious and deliberate planning; and consistently uses an analytic framework to practice. The expert on the other hand has practised for 6 or more years in the same or similar setting and does not rely on maxims, rules, or analytic frameworks to practise. For a nurse to be effective in academia, he or she must be an expert; that means practising nursing in a particular field for six years or more in the same or similar setting, and must not rely on analytic frameworks to practise. Experience has shown that, most nurses in academia in Ghana have not practised nursing on the field up to six years, and have not specialized in any field of nursing. This indicates that Ghanaian nurse academics cannot be regarded as experts in clinical practice to enable them to train student nurses to be competent in clinical practice. In Africa, including Ghana, not much study has been done on this subject matter. However, in the Ghanaian context students expect their lecturers to be models, that is, to impact clinical skills in them just as they impact theoretical knowledge in them. If the lecturers are not experts in clinical practice, this expectation cannot be feasible. Most nurse academics when confronted with the realities of teaching novice students that require accurate direction and modeling to apply their theoretical learning to practise, face serious professional and ethical challenges. These nurse educators have a problem with enlivening the discussion of theoretical concepts by illustrating them with real stories of patients and situations that reflect current clinical experience in reality. However, this is what can change what students may interpret as ideology into lasting impressions (Duffy-Durnin, 2004; Kubecka, 2004). The Ghanaian context is not different. Most nurse educators do not have enough practical experience to back their theory with real stories from the field. There is therefore the need for nurses in academia both in Ghana and elsewhere to understand that one major problem that is undermining their ability to be experts in both theory and the practice of nursing is their reluctance to integrate 14 University of Ghana http://ugspace.ug.edu.gh clinical practice with their core academic work, and until this is achieved, university graduate students will continue to have difficulty in attaining competent clinical skills. 2.3. Competency Requirement for Nurse Educators Nursing faculty, as members of a practice discipline within academic institutions, are expected to maintain a high level of expertise in their practice specialty. In addition, nursing faculty is expected to expand and contribute to the scholarship of nursing through research, teaching, practice and integration (Boyer, 1990). To meet these goals faculty must have opportunities to engage in meaningful practice and must have access to sufficient and appropriate clinical resources for practice and research. Maureen & Milliken (2007) found from examining a number of studies on the nurse educator’s role that studies done on the dual competencies of academia and clinical practice were mostly British or American in origin, and it is clear that, American nurse educators were found to be more committed to their clinical roles than the British and because of this America and Canada have especially developed competency requirements for nurses in academia to follow to enable them sustain their dual competencies In the UK also, the National Board for Nursing, Midwifery and Health Visiting mandated that nurse educators spend 20% of their time in practice (Aston et al. 2000). Africa, including Ghana is still in the infancy stage in establishing nursing as an academic discipline, and so very little study has been done on the practice requirement for nurses in academia, however because nursing is a practice-based profession, there has existed a widespread assumption that those who teach nursing are also competent clinical practitioners. The discourse focuses on why is it that the nurses trained by nurse educators are not able to apply the knowledge to the practice. Zungolo (2004) stated that there is an unsubstantiated assumption that if one is a professional, one will “naturally” be successful in transmitting that professional knowledge to novices. But many researchers found out that, clinical competence and teaching skills are consistently identified as two of the major characteristics of clinical teachers (Murphy, 2000; Nahas, Nour, & Al- Nobani, 1999). 15 University of Ghana http://ugspace.ug.edu.gh In a Norwegian study, nurse educators rated the importance of teaching and nursing competencies more highly than other aspects of teaching nursing such as evaluation skills, establishing teacher- student relationships, and the instructor’s personality (Johnsen, Aasgaard, Wahl, & Salminen, 2002). Worldwide, nursing students identify clinical competence as being an important quality of effective teachers (Tang, Chou, & Chiang, 2005). 2.4. Barriers and Enhancers to Balancing Education with Cynical Competency Among Nurse Educators. As stated by Boyer (1990), nursing faculty are members of a practice discipline within the university environment and are expected to maintain a high level of expertise in their practice, specialty and also contribute to the scholarship of nursing through research, teaching, practice and integration. To meet these goals, nurse educators must engage in meaningful practice and also have access to sufficient and appropriate clinical resources. Contrary to this, studies have shown that most nurse educators have difficulty balancing teaching with clinical practice, and so do not feel competent to engage students in the clinical area, and various reasons have been given for this deficiency. This is illustrated by Little &Milliken (2007) in their indicated which shows that Maltese nurse educators allot minimal time to their clinical role, and the main reasons cited included workload, perceived lack of control over the clinical area, and diminished clinical competence. Nurse educators who frequented the clinical settings who were either university or joint university and health service employees at the study took location perceived that employment inequities among the various categories of nurse educators played an important role in the amount of time dedicated by each group to their clinical roles, and the importance individuals in these groups assigned to that role. Nahas (2000) and Cave (2005) argued that to enhance their teaching, nurse academics need to be more aware than ever of the clinical realities that could and should affect the application of the theory they teach. In Britain, the main factor identified by the nurse educators was lack of time, because of being overburdened with educational and administrative work and the need to conduct research and to publish (Clifford 1995, Cahill 1997, Day et al. 1998). In American studies, 16 University of Ghana http://ugspace.ug.edu.gh educators reported that they lacked time for their clinical role due to family responsibilities, and being enrolled in doctoral programmes (Barger and Bridges 1987, Just et al. 1989). One of the most common fears expressed by a number of nurse educators was that they felt threatened by the near perfect performance expected of them by clinical staff and students, and by the fact that they were expected to know everything about the care of patients with multiple problems. A study identified the following factors as impacting on the clinical role of nurse educators and labeled them as espousing theory and practice’. The label for this factor is derived from what participants thought the ideal clinical role of the nurse educator should be. When asked what they perceived as the ideal role for a nurse educator in the clinical area, two categories emerged, one being the educator as a clinical teacher, and the other as a facilitator of the learning environment through various roles with staff in clinical areas, e.g. liaison, updating staff, leading research, etc. Decisions about nurses’ professional development needs that are made in isolation of an appreciation of the realities of practice can lead to excessive emphasis on performance, blame- seeking, insufficient attention to the complexity of practice, and a default to generic, technical education to fix problems (Nairn, 2009). Nurse educators everywhere struggle to maintain clinical credibility. It is accepted that teaching efforts and time commitment often limit clinical practice. There is therefore, a saying that time away from practice, causes skills to fade away. Nurse educators must therefore find a way to incorporate clinical practice in their teaching role. 2.5. Models Available for Training Nurses The tradition in the training of nurses has been that student nurses learn to perform nursing duties to acquire nursing skills, and learn to put the skills learnt into practice as professional nurses, is predicated on engaging in experiential learning with actual patients/clients. This is problem based learning, the theory that supports this study. This type of learning opportunity is referred to as a “clinical practicum or experimental learning, and represents a field experience. Experiential learning can be done through a number of ways, including computer and virtual reality simulations, 17 University of Ghana http://ugspace.ug.edu.gh case studies, interactive videos, and hands-on direct patient interactions or experiences. Each of these modalities is an appropriate and useful means of teaching (Rush University, 2003-2004). However, the most common model used in many countries is the hands-on direct patient care referred to as clinical site-based learning. Experiential learning necessary for baccalaureate educational preparation includes the supervised practice of skilled nursing care in a variety of direct practice sites such as hospitals, clinics, schools, churches, homes, or other community venues (Rush University, 2003-2004). Students are expected during this period to receive a variety of experiences across a health/illness continuum, graduating as novice practitioners for nursing practice (Rush University, 2003-2004). In recent years, most Bachelor and Graduate nursing programmes are situated in a variety of educational institutions with connections to health care delivery sites. Regardless of affiliation within academia, however, the challenges of providing relevant clinical practicals for students seeking a baccalaureate or higher degree in nursing are similar. Traditionally, hospitals have been a major source of clinical learning opportunities for most programmes. Research has shown that access by academic institutions to hospital practice sites has been through direct alignment with the hospitals affiliated with an educational institution or by contractual agreements with unaligned hospitals, and this also incorporates substantial clinical practice at community-based sites. Clinical arrangements at these community-based sites have been largely through contractual agreements; however, as integrated health systems evolve to provide a spectrum of services, these experiences also can be by direct alignment. The development of faculty practice sites owned and managed by academic nursing is the new trend that is evolving in recent years (Rush University, 2003-2004). Literature has shown that models are being utilized in training nurses in different countries and they have been successful in equipping nursing students to become competent practitioners. Some of these models are as follows:  Preceptor model  The facilitator model  Facilitator/Preceptor model  Clinical nurse leader model  The residency model 18 University of Ghana http://ugspace.ug.edu.gh 2.5.1. The Preceptor Model This is the most common 1:1 model used to help nursing students to develop their professional knowledge and skills that will prepare them for clinical practice (Altman 2006). Under this model, the training institutions use a preceptor; that is, practice site clinicians, in most cases registered nurses who act as clinical instructors, to mentor the student nurses in learning the clinical skills. The student works one on one with the preceptor who provides direct and indirect supervision and undertakes formative assumptive assessment (Billy &Myrrh 2008). (Callahen et al. 2009). The preceptors are taken through a specialized training to learn how to teach students and mentor them and awarded certificates that will qualify them to play such an important role. The faculty work closely with the preceptors and guide them through the process. In most cases the preceptors are paid some allowance by the training institutions to motivate them to perform the role well. This is the most common model of clinical teaching, particularly in hospitals and has proven to be very successful. 2.5.2. The Facilitator Model In this model, faculty from the educational institution who are not employed or aligned to the practise site, and who do not provide direct clinical services for the hospital is appointed as clinical facilitator. The facilitator must be a very experienced nurse who has practised enough to be familiar with all the skills of nursing practice. She/he works closely with lecturers to plan the clinical practice activities of the school. She supervises the students on the field and mentors them in acquiring their clinical skills. She also organizes demonstration sessions and assists the lecturers in demonstrating procedures to student nurses in the skills lab. Skilled clinicians might be employed by the training institution to assist the facilitator in carrying out her duties. The facilitator also undertakes both summative and formative assessment of the students. 2.5.3. Facilitator/Preceptor Model This is a combination of preceptor and facilitator model where a group of students are assigned to preceptors, usually about 1:6 or 1:8 or more. The preceptor gives the 1:1 training, and the facilitator 19 University of Ghana http://ugspace.ug.edu.gh supervises the preceptors. The training institution works with the facilitator to coordinate the practicum activities. 2.5.4. Clinical Nurse Leader Model This model was developed by the American Academy of Colleges of Nursing (AACN). Here, clinical nurses are specially trained to be clinical leaders whose responsibility is to provide clinical leadership that is needed to guide an interdisciplinary team in the delivery of care consistent with the needs of patients and families. They also work with the training institutions in training student nurses by coordinating their clinical practice, and supervising the preceptors who mentor the students. Here too, the preceptors who work under the Clinical Nurse Leader must go through specialized training to enable them mentor students. 2.5.5. The Residency Model This model was also developed by the AANC, the model is based on two facets, and they are:  Improve transition to practice  Increase student accountability. The features of the Model are:  Skills laboratory training  Field Experience  Work requirement The student spends the first three years learning the theoretical aspects of nursing, namely the basic sciences, the liberal arts, pathology, pharmacology basic and advance nursing skills. There are teaching assistants who help faculty to mentor them to learn the basic and advance nursing skills through tutorials, and practice in the skills lab. They then go to the hospital to practice their skills during vacation times. Students are made to dress fully in uniform during skills lab days and anytime they go to the field. In the fourth year, students are immersed in the clinical arena. Focusing mainly on practicing the skills they have learnt on life patients. The main focus of training at this point is to rotate them through all the specialty areas they have been taught, namely medical nursing, 20 University of Ghana http://ugspace.ug.edu.gh surgical nursing, theatre nursing, community nursing, maternal and child health nursing, psychiatry nursing gerontological nursing eye nursing, ear nose and throat nursing, Cardiothoracic nursing, etc. After completion and passing the licensure examination, the new graduate nurses go through a one year residency programme where they work like regular staff nurses, still under the supervision of the training institution, where they continue to be supervised by faculty and preceptors. At the moment in Ghana, it is not very clear what model the universities are using to train nursing students. This study seeks to find out if the universities have adopted any of the above mentioned models in any form, and also to determine what model will be suited for Ghanaian universities to enable them equip student nurses with the necessary skills they need to deliver quality client care. 21 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.0 . Introduction This chapter describes the research methodology, which includes research design, research setting, research population, sampling techniques and sample size, data collection instruments and method, data processing, mode of data analysis and ethical considerations 3.1 Study Design The study design was an exploratory research approach which is combined with methodical triangulation design, i.e. a combination of quantitative and qualitative approaches. As stated by Creswell (1994), by using a triangulation approach, “any bias inherent in the data source, investigator and method will be neutralized”, One major advantage of the triangulation design is that it allows for more confidence in the result (Jick (1983). For the quantitative phase, the method used was simple random cross-sectional survey, where questionnaires were used as a data collection instrument. The data were analyzed using the Statistical Package for Social Sciences (SPSS) computer software, and the results presented in tables, bar charts and pie charts, and inferences drawn from the charts were used to analyzed data The qualitative part used the Phenomenology design. The phenomenon under study here is the responsibilities and experiences of nursing lecturers in combining teaching theory with clinical practice in training student nurses. At the end of the study, the experiences studied were reduced to a central meaning that could help nurse educators to combine teaching with clinical practice in the training of nurses in the Ghanaian context. 3.2 The Study Areas The research areas were schools and departments of nursing in selected Ghanaian universities. These universities have all been involved in the training of nurses and they are easily accessible, cooperation from the respondents was easily achieved and information required could easily be obtained. A typical Ghanaian university with a nursing programme is either a school of Nursing, or 22 University of Ghana http://ugspace.ug.edu.gh a department of nursing under a faculty of health sciences or faculty of applied sciences. The three Ghanaian universities selected for the study were: University of Ghana School of Nursing, University of Health and Allied Sciences School of Nursing and Midwifery Ho, and Valley View University (VVU) Department of Nursing Oyibi, Accra. University of Ghana is the oldest university among the three Pioneer universities in Ghana. The university was the first to start a Bachelor’s Degree in nursing programme in Ghana in the late 1980s. The present population of lectureres is 25 and student population is 1500. The next is Valley View University. VVU was started in the 1990s and is presently having 10 lecturers with a student population of 250. University of Health and Allied Sciences is the youngest among the three. The University is only three years old and has a lecturer population of 22 with a student population of 1500. All the three universities run a nursing programme which is a four year programme, made up of theory sections and clinical practice sessions. As directed by the Ghana Nursing and Midwifery Council, the ratio of theory to practice in the training of the student nurse must be 1:2 (Curriculum for Registered General Nursing, 2015), meaning the clinical hours must be twice that of the theory hours. This is indicative of the importance of clinical practicum in the training of a student nurse to become a proficient graduate nurse. A typical school of Nursing and Department of Nursing in Ghana has about 20 -30 Nursing lecturers, and the lecturer to student ratio of a typical nursing department has been approximately 60 students to one lecturer. This indicates that there are large numbers of students in the hands of one lecturer at a particular time to train to become competent professional nurses. 3.3 Study Population The study population constituted of university nursing lecturers employed by the selected universities before and during the time the data were collected. The target population is nursing lecturers teaching in a university nursing programme. 3.4 Sampling Technique and Sample Size There are seven public universities and numerous private universities in Ghana. Among the public universities five have schools of nursing and many of the private university also have nursing programmes. For lack of resources and unavailability of time, two public universities and one 23 University of Ghana http://ugspace.ug.edu.gh private university that have nursing programmes were selected for the study. The key informants and gatekeepers were identified in order to gain access to the school or department. The Deans and Heads of Department were the useful key informants in this case. They are the superiors responsible for the lecturers in the school and have a close relationship with them in terms of academic work and clinical practice training. As a study of a whole population is difficult, in terms of cost, size and accessibility, a sample which is the subgroup of the population that meets the criteria of the study was selected. For the quantitative phase of the study, a simple random sampling technique was used to select the sample. Number of lecturers from every school in the three universities was obtained, arbitrary names were assigned to each lecturer and a number was assigned to each name, (Table 1.0. Appendix B). The total number collected was 50 lecturers. The Stoker (1995) Guideline for sampling table was utilized to select the sample size. (Table 2.0. appendix B) According to the suggested guide, a population of 50 can have a sample size of 30. Therefore, 30 lecturers were selected randomly from the table of random digits constructed from the list of lecturers. (Table 3.0) The names attached to each number were members of the sample selected for the study. Sample members are in Table 4.0. Table 5.0 has the names attached to the numbers, showing which lecturers were members of the sample size for the quantitative phase of the study. The same method was used to select 50 students from the selected universities. The inclusion criteria was level 400 students who have gone through the full cycle of a university nursing training programme and are being prepared for graduation and the licensure examination. For the qualitative phase of the study, purposive and convenience sampling, which is a nonprobability sampling technique, was employed. The choice of this sampling method is based on the fact that, the researcher being a nurse educator used her knowledge about the population to handpick the cases to be included in the sample (Pilot & Hungler, 1995). The respondents were purposively selected and participants who were judged to be typical of the population in question or particularly knowledgeable and experienced in the teaching and training of student nurses were selected. The inclusion criteria for the study were all lecturers of a nursing school or department in a university. These lecturers were selected based on their insight into balancing academic work and clinical practice in the training of student nurses in a typical Ghanaian university for at least one to 24 University of Ghana http://ugspace.ug.edu.gh three years, and were willing to take part in the study. The selection criteria was nursing lecturers who have been employed by the university for at least two (2) years and have been involved in the training of student nurses. Eight nursing lecturers were selected. The subdivisions of the lecturers include; 3 older lecturers with at least six years of work experience as a nurse educator and 2 younger lecturers with at least two years of work experience as a nurse educator. In addition, 20 nursing students comprising of level 400 nursing students were selected were selected because they have been in the programme for more than three years, and were through at least three clinical practicum periods. This makes a total of 28 participants for the qualitative phase of the study. The lecturers were interviewed using unstructured and partially structured interview techniques. Open-ended questions were employed and impromptu questions were welcomed. Topics were chosen, responses were recorded and some questions were formulated but the others were determined by the interviewer to enhance getting more insight into the problem under study. The students were divided into four (4) groups of five (student per a group) for Focus Group Discussion. 3.5 Data Collection Methods and Instruments In order to address the research questions and find out facts and opinions, the data collection instrument employed for the quantitative phase of the study was questionnaire. The questionnaire contained many statements as questions, with the interest to determine the extent to which respondents hold a particular attitude or perspective toward balancing academic work with clinical practice in the training of student nurses (Babbie and Mouton 2001: 233). The main objective of the questionnaire was to obtain facts and opinions about balancing teaching with clinical practice from people who are informed on the particular issue; in this case, the lecturers who were training student nurses to be clinically competent and the students who are being trained by the lecturers. 25 University of Ghana http://ugspace.ug.edu.gh The questionnaires were delivered by hand for the respondents to complete them for collection later. A pilot test was conducted on lecturers at the universities to ensure clarity of the questions and also to make sure the questions really address the research questions, after which the questionnaires were used for data collection. The qualitative data were collected by interviews with lecturers and focus group discussions with student nurses. In interviewing the lecturers, in-depth interviews backed by an interview guide, were used. The interviews were the most powerful qualitative methods which took interviewer into the world of the participants and allows them to see the context and patterns of their experiences” (Morse, (2002) cited in Olife (2005) A pilot test was conducted on lecturers to ensure clarity of interview questions and to check face validity, reliability and test- retest reliability. The pilot test also helped to determine the length of time needed to complete an interview section. Each interview session lasted for about 20 -45 minutes. When necessary, probing questions were used to ensure in-depth knowledge on the experiences, barriers and enhancers of the nurse educator’s ability to balance theory with clinical practice. The interviewer listened to each participant to tell his/her story individually and privately. The interviews were semi-structured with open-ended questions. An interview guide was used (questions and probes that will encourage further elaboration) to ensure specific contents were addressed, and open-ended questions too were utilized to make sure participants give answers in their own words (See Appendix B). Probes were used during the interview for clarification and for further information. Flexibility to elicit information during the interview was also allowed in as much as consistency was maintained in questions asked and provided depth of details. The interviews were conducted with different lecturers until saturation is reached. A facilitator was engaged to conduct focus group discussions with four (4) groups of level 400 students with five students in each group. A group discussion guide was used to direct the discussions, and probes were allowed to arise during the discussion sections for clarification and 26 University of Ghana http://ugspace.ug.edu.gh for further information. Flexibility was allowed to elicit information during the discussion sections as much as consistency is maintained in questions asked and provide depth of details. Policy documents from the Nursing and Midwifery Council concerning requirements for clinical practice by nurse educators were also reviewed to supplement the information gathered from the questionnaires and interviews. 3.6 Ethical Considerations Ethical issues were addressed considering various precautionary approaches. An introductory letter of permission to obtain data and information was obtained from University of Ghana business school (Appendix A). The purpose and objectives of the study were well explained to the respondents. Participants were assured that they would never be connected with their responses, and that their identity would never be revealed. The confidentiality of the data was maintained by the use of code numbers on the transcripts with the participant’s identity only known to the researcher. Participants chosen for the interviews were asked to sign informed consent, to make sure that they were informed about the risks and benefits associated with the study. Each participant of the study was given the opportunity to ask questions, and also given the chance to opt out of the study anytime he /she becomes uncomfortable. They were assured that their involvement will not have anything to do with their job evaluation. No matter how carefully a data collection instrument is designed, there is always the certainty of possible error, and in order to protect the instrument, a pilot study was conducted, where the questionnaires and interview questions were pretested with a small number of lecturers, and any difficulty with the procedure or materials was found out and corrected before the actual data collection commenced. By this, the accuracy, reliability and appropriateness of the instruments were determined (Babbie: 2001). During the pretest, a small number of lecturers and students were interviewed, and space was provided for the interviewees to comment on the wording of the questions, sequence of questioning, possible redundant questions and missing and confusing questions. Interviewees were also allowed to criticize the questionnaires and interview process, and adjustments were made to ensure that the data collected was suitable for the study design. 27 University of Ghana http://ugspace.ug.edu.gh 3.6.1 Mythological Rigor The rigour of a qualitative study was evaluated in terms of the trustworthiness of the findings. Specific concepts employed to assess rigour included, transferability, confirmation and dependability. (Morse and Richards, 2002; Lincoln and Guba 1985) 3.6.2 Credibility The credibility of data refers to the process of making sure that insights into participant’s responses are accurately represented for the overall credibility of the stud. It questions the researcher’s ability to capture the insider (emic) perspective, and represent that perspective accurately (Ostomy, 2005) Credibility was assured in this research by ensuring the participants have the desired comfort, and that the interviews and discussions took place in a relaxed private environment. Examples were provided verbatim to support how a particular perspective was represented. Data was documented in extensive field notes, and participants were later asked if emerging themes and categories represent their expectations when they were giving their views on the subject matter. 3.6.3: Transferability Transferability means the degree to which the individuals studied are representative of the individual nursing lecturers and students in which results might be generalized (Henderson, 1999). In this study, transferability was not decided by the researcher but will be decided by the consumer of the research. If the findings of the study help to inform policy in the training of student nurses, it would be used. 3.6.4: Conformability Conformability refers to the objectivity and neutrality of the data such that two or more people will agree on the data’s relevance and meaning. The reliability of the data collected in this study was ensured by doing a pretest before the real data was collected. This made it possible that the characteristics of the data and the records of the research findings and notes made during that period can be used by any other person to attain an audit trail. 28 University of Ghana http://ugspace.ug.edu.gh 3.6.5: Dependability Dependability refers to the stability of the data over time and conditions (Polit et al., 2004) It is also thought of as the closeness of fit between the research data and what actually occurs in the setting (Henderson, 1991).To ensure dependability, field notes were used to document the research plan, especially the changes in the plan that occurred, the methods used and to gather other data interpretations. A colleague qualitative researcher who is not involved in the study helped to assessed the data’s dependability. 3.7: Data Analysis 3.7.1: Analysis of quantitative data Data analysis involved categorizing, ordering, manipulating and summarizing the data to obtain answers to the research questions (Kerlinger, 1986) as outlined in Chapter one. The Quantitative data was analyzed using, Statistical Package of Social Scientists Data analysis software. Based on this data, descriptive statistics such as tables bar charts, and pie charts were used to explain the results. 3.7.2: Quantitative Analysis Interviews and focus group discussions were conducted for the qualitative stage of the study. The interviews, likewise the focus group discussions were audio-taped, transcribed verbatim coded and categorized, observations made during the interviews were also captured as field notes and content analysis involved identification, coding and categorization of data which are central to qualitative analysis. The demographic characteristics of the participants were presented with detailed descriptions of the circumstances of each participant, and the presentation of the main results and interpretation were also reported. The study identified six (6) major themes from the coding and categorization of the transcribed interviews. A number of sub-teams also emerged and have been presented under the major themes as part of the findings. Pseudo names were used to report verbatim quotes from the respondents. 29 University of Ghana http://ugspace.ug.edu.gh 6(six) major themes were also identified from the student focus group discussion, and some sub- themes also were identified and presented under the major themes. 3.8: Data Saturation Saturation in this study began with the recruitment of the participants and the analysis of the data text by coding, categorizing and generating themes until no additional themes emerged from the data. That is, interviews were stopped because the data yielded redundant information. (See Table 3.1) Table 3.1: Evidence of Saturation INTERVIEWS EVIDENCE OF SATURATION Interviews conducted 8 Interviews with emerging themes 6 Focus group discussions conducted 4 Discussions with emerging themes 4 Table 3.2: Major themes and Sub-Themes from Interviews and Focus Group Discussions NUMBER CATEGORIES SUB-THEMES 1 Obligation for nurses in The lecturers who are not proficient must be academia to teach both theory obligated to update their skills. 30 University of Ghana http://ugspace.ug.edu.gh and coach students in clinical practice 2 Number of years of practice Clinical experience as a criteria for before joining academia recruiting nurses 3 Lack of policy/regulation on Enforcement of policy clinical practice of nurse educators 4 Large class numbers University academic calendar Time Factor 5 Nursing colleges within No clear module university system require Module not being used well Modules to train students No knowledge about module 6 Nursing programmes within Nursing departments or schools drawing universities require autonomy their own timetable 31 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS AND DISCUSSION 4.0 Introduction This chapter presents the results of the analysis of both the quantitative and qualitative data. The presentation is structured in line with the major objective of this study which sought to explore the role and experiences of nurse educators (academics) in balancing theory and practice in training nurses at the university degree level. 4.1. Presentation of Quantitative Results This chapter starts with a presentation of two (2) major categories of demographic data on the respondents, namely; number of years employed by the university and number of years of practice before lecturing. These data sets would help throw light on the lecturer’s level of experience as lecturers as well as their experience as clinicians, since these are relevant in assessing the professional development of a nurse educator. 4.2. Presentation of Qualitative Results Results of the qualitative data analysis describe the information on the background of the respondents, their demographic characteristics, obligation of lecturers to teach both theory and practice of nursing, theory and practice gap in the training of student nurses at the university level, difficulties faced by lecturers in balancing theory and practice and the modules used in the training of nurses at the university level in the study setting. 4.3. Demographic Characteristics of Participants In order to assess the level of competence and experience of the nurse educators at the university level, the research looked at the demographic characteristics of the respondents and in relation to their ability to balance teaching theory and practice in training nurses at the university level in Ghana. 32 University of Ghana http://ugspace.ug.edu.gh 4.3.1. Demographic Characteristics of Respondents. The respondents were nurse educators lecturing in the university school of nursing or department of nursing and involved in the training of student nurses at the university level. Table 4.1 shows age distribution of the participants. Table 4.1: Age distribution of lecturers Age of Frequenc Percent Valid Cumulative lecturer y Percent Percent 27 1 3.3 3.3 3.3 32 2 6.7 6.7 10.0 33 5 16.7 16.7 26.7 34 2 6.7 6.7 33.3 35 3 10.0 10.0 43.3 36 3 10.0 10.0 53.3 37 2 6.7 6.7 60.0 38 3 10.0 10.0 70.0 39 2 6.7 6.7 76.7 40 1 3.3 3.3 80.0 42 1 3.3 3.3 83.3 44 3 10.0 10.0 93.3 45 1 3.3 3.3 96.7 50 1 3.3 3.3 100.0 Total 30 100.0 100.0 The table indicates that majority of the lecturers are in the thirties (30s) to early forties (40s) This is good for the universities because they are young and will be on the job for a longer period of time to gain experience in training student nurses to become seasoned practitioners. 4.3.2. Sex Distribution of Respondents Table 4.2 shows that 20% (n=6) were males and 80% (n=24) were females. This is an indication that majority of the nursing lecturers were females. 33 University of Ghana http://ugspace.ug.edu.gh Table 4.2: Sex of Respondents Sex Frequency Percent Male 6 20% Female 24 80% Total 30 100% Table 4.3. Marital Status of Respondents Table 4.3 shows that 50% (n=25) of the lecturers were married and 25% were not married. Sex Frequency Percent Married 25 50% Unmarried 25 50% Total 30 100% 4.4. Assessment of the Level of Experience of the Lecturers as Teachers and Clinicians In order to assess the level of Competency and Experience of nurse educators at the university level, the research looked at the demographic characteristics of the respondents and its relation to their ability to balance teaching theory and practice in training nurses. The two characteristics examined were: Number of years employed by the university and number of Years of Practice before Lecturing 34 University of Ghana http://ugspace.ug.edu.gh 4.4.1: Number of Years Employed by the University It is generally assumed that the number of years employed in an organization increases the likelihood of gaining experience in the performance of one’s responsibility. Since training of nurses entails teaching both theory and practice, it is imperative that nurse educators would be able to blend both aspects to be able to make an impact on the student nurse. This has an advantage of making the student nurses competent professionals in the performance of their duties upon graduation from school. In light of the above, the study sought to assess the number of years of employment of a lecturer to determine their level of experience. Information for this assessment was derived from a sample of lecturers which constituted respondents for the study. The inclusion criteria for this sample of lecturers were those who have been employed by the University for a minimum of three years and a maximum of six years. It was assumed that these lecturers were instructing nursing students long enough and would have been in the position to know the problems associated with the job. Table 4.4 shows respondent’s number of years of employment by the university. Table 4.4: Number of years employed by the university Number of Frequency Percent years employed by the university 1 2 6.7 2 2 6.7 3 10 33.3 4 6 20.0 5 4 13.3 6 4 13.3 7 1 3.3 8 1 3.3 Total 30 100.0 35 University of Ghana http://ugspace.ug.edu.gh Results shown in Table 4.1a above indicate that 33% (n=10) of lecturers have been employed for 3 years, 20% (n=6) have been employed for 4years, whilst the remaining 13% (n= 4) have been employed for 5years and above. The result suggests that those who have worked for three (3) years constitute the majority. This revelation indicates that majority of the lecturers are in the beginning stages of their career as nursing lecturers, although they might have some experience they should not be the majority. The theory guiding this study is the problem based learning theory which emphasizes engaging students in finding answers to clinical questions through care of real life patients. This type of teaching takes experience to deliver and lecturers who are three years on the job might not have that kind of experience. These young lecturers need to be mentored to be able to do this kind of teaching. Failure to address this might have implications on the student’s learning abilities and would in turn produce incompetent nurses having inadequate nursing skills. This result is likely to present a clearer insight that could further deepen discussions on this issue if disaggregated on the basis of responses from the three institutions and cross tabulated. 4.4.2. Number of Years of Practice before Lecturing Maureen & Milliken (2007) quoted Patricia Benner (2003), who defines a competent practitioner as having 2-3 years of experience in the same or similar setting; engages in conscious and deliberate planning; and consistently uses an analytic framework. An experienced practitioner on the other hand has practised for 6 or more years in the same or similar setting and does not rely on maxims, rules, or analytic frameworks to practise. Guided by the framework suggested by Maureen & Milliken (ibid), the present study assessed the number of years of practice of the respondents to determine their level of competence or experience in the nursing practice. In line with Maureen & Milliken’s (2007), framework Table 4.5 indicates that out of the 30 respondents, 50% (n=15) worked for 2 years before becoming a lecturer, 20% (n=6) practiced for 4 years, 6.7% (n=2) worked for 5 years and 3.3% (n=1) worked for 6 years. This indicated that majority of the university nursing lecturer worked only for two to three years before becoming lecturers. 36 University of Ghana http://ugspace.ug.edu.gh Table 4.5: Number of years of practice before teaching Number of years of Frequency Percent practice before teaching 0 1 3.3 2 5 16.7 3 15 50.0 4 6 20.0 5 2 6.7 6 1 3.3 Total 30 100.0 This shows that, 50% of the respondents can be described as competent in the nursing practice and only 1 out of the 30 respondents can be regarded as experienced in the practice of nursing. Looking at the demands of being a nurse educator in the university, it needs experience in the practice of nursing to be able to train students to be competent and proficient nurses. In this regard, the results paint a rather gloomy picture of the ability of nursing lecturers to train student nurses to be proficient professionals. Moreover, considering the state of nursing care being delivered by nurses in Ghana, where there is so much dissatisfaction being expressed by the Ghanaian public, this observation is worrisome since incompetent nursing care is likely to compromise quality and safe patient care. Failure to address this has implications for the nursing profession and its role in care delivery as well as safe patient care as is discussed in the ensuing chapter. The amalgamation of nursing education from hospital based training to university based training has raised many questions about the clinical role of the nurse educator. Research from different parts of the world looked at what qualifies a nurse to become a nurse academic (Lecturer in a university) and what role they play in the clinical training of the student nurse. It is generally assumed that nurses who lecture in the university have obtained higher degrees in nursing and are also knowledgeable and competent in their field. In view of this, students expect their lecturers to be able to mentor them and to give quality and safe patient care. This was expressed by a student participant in this study as follows: 37 University of Ghana http://ugspace.ug.edu.gh “I think they (lecturers) are experienced nurses and should even know more than the nurses in the wards because they have gone further to get higher degrees in nursing”. The results have shown that majority of the lecturers are competent because they have worked in the field for at least two (2) to three (3) years, but only one has worked for six (6) years and can be regarded as experienced in the practice of nursing. The definition of experience by Maureen & Milliken (2007) is working in a similar specialty area for six years. This study has not looked at what area of nursing the lecturers have worked, and so cannot draw conclusions that the one who worked for six years is experienced in a particular field of nursing. The lack of clinical experience of a lecturer has serious implications for the student nurse and the nursing profession as a whole. The results paint a rather gloomy picture of the ability of participants to train student nurses to be proficient professionals. Moreover, considering the state of nursing care being delivered by nurses in Ghana, where there is so much dissatisfaction being expressed by the Ghanaian public about the low standard of nursing care that Ghanaian nurses are delivering, this observation is worrisome. As an incompetent nurse is a threat to a patient’s safety and life, an incompetent lecturer is a threat to the student nurse’s ability to learn clinical skills. Therefore, failure to address this has implications for the nursing profession and its role in care delivery as well as safety of patients. Whilst, Maureen & Milliken’s (2007) assertion may be generally true (especially in an advanced country), one needs to look beyond length of practice as a factor, and cover other relevant factors that may facilitate or hinder competence building in a developing country context (eg. Ghana), these may include enabling and supportive work environment positive attitude, mentoring, low level of hostility/competition and resources availability 4.5: The Nurse Educator’s Obligation and Expectation to Teach both in Theory and Practice of Nursing Studies have shown, as indicated by McNamara (2009), that the quest for professional proficiency in any academic training is pivoted on linking theory to practice, and in line with this, it is generally expected that university trained nurses would be more competent than those trained below university level. In the light of this, university nursing lecturers have the obligation to adequately 38 University of Ghana http://ugspace.ug.edu.gh train students to be proficient in both the theory and practice of nursing. On the contrary, with regards to the Ghanaian context, since nursing was moved from hospital-based training to university degree level, based on anecdotal evidence, there has been an assertion that nursing students from the universities were having difficulty applying the theories they learnt in classroom to the practice in the clinical environment. In the quest to explore what accounts for this problem, the role and experiences of nurse educators (academics) as teachers and as clinicians in the discipline of nursing, and their ability to balance the theory with practice of nursing in the training of student nurses. Asked whether a nursing lecturer has the obligation to link theory and practice in the training of a student nurse, 100 % (n= 30) of the lecturer participants answered in the affirmative whilst 92% (n=42) of students also agreed, 2% (n=1) of the students answered no with the remaining 6% (n=3) indicating they were not sure. (See Table 4.6). Table 4.6: Lecturers/Students Responses on Obligation to Teach Both Theory and Practice Responses On Nurse Yes No Not Sure Educator’s Obligation to link theory to Practice Freq. % Freq. % Freq. % Lecturers - - - - 30 100 Students 46 92 1 2 3 6 Quality and safety in health care is a global concern, and Ghana is no different, furthermore, quality and safe health care also relies on effective educational preparation of nurses (Henderson et al. 2011). In view of this, the nurse educator needs to be able to train the student nurse to attain both academic knowledge and clinical skills to become a proficient professional nurse who can give quality and safe care to patients. According to Fawcett & McQueen (1998) cited in Maureen &Milliken (2007), “Because nursing is a practice-based profession, there has been a widespread assumption that nursing educators are also competent and experienced clinical practitioners”. 39 University of Ghana http://ugspace.ug.edu.gh This is also demonstrated in the current study, where both lecturers and nursing students identify clinical competency as being an important quality of an effective nurse educator, therefore nursing lecturers are obliged to teach both theory and practice. This was stated clearly by one lecturer participant as follows: “I think being able to teach both theory and practice should be an obligation. I cannot comprehend how you will be teaching nursing and will not teach the practicals. If you can’t then you is not a nurse. You have to be able to teach both the practicals and the theory”. A student participant also remarked: “As a nursing lecturer you must have both skills I mean both theory and practicals. If you are teaching and you cannot site examples from the field, then how can you each well? We like lecturers who can relate the theory they are teaching us to their experiences on the field. For me it makes me understand things better”. The findings of the study as presented is insightful and underscores the need for nurse educators to blend theory with practice, with particular reference to integrating clinical practice with theoretical delivery in a university context. This observation blends with the claim by Fawcett & McQueen, (1998) cited in Maureen &Milliken, (2007), where the need for nurse educators to gain competency in clinical practice especially because nursing is a practice-based profession. It also becomes even more imperative in contemporary times where university student nurses have generally been criticized for not being able to deliver patient care adequately as described by D’Souza et al, (2013) stress this: “It is a challenge for many student nurses to imbibe the various roles of nursing in the clinical setting while learning new clinical concepts and most students describe the feeling as being thrown into a deep sea”. However, the discourse on teaching both theory and practice in the training of nurses at the university level in several advanced countries where the nursing profession has developed better relative to the Ghanaian context have been polarized. Griscti et al. (2004) have noted in their study of the role of nurse educators in the university that there are conflicting views about whether nurse educator’s priority should be in academia or in 40 University of Ghana http://ugspace.ug.edu.gh clinical practice. Thus, while some studies have argued against the need for nurse educator to be clinically competent, the theory can be taught in classroom context, leaving the practical aspects to be taught by professional nurses in a hospital context other researchers like Myrick and Younger, (2005) have held a contrary view and argue in support of the need for nurse educators to blend the two aspects of nursing (theory and practice). The argument of the former is pivoted on several considerations. For example, some have cited demands imposed on them by virtue of their position as nurse lecturers at the university level which adds further burdens on their works, especially when no further compensation is provided for the discharge of such extra responsibilities as supervising and mentoring students on clinicals (Griscti et al, (2004). The latter who have argued in support of the claim have underscored the need for this by claiming inter alia that nurse educators are equally professional nurses who practised before becoming lecturers. Thus, there is no reason why both aspects cannot be integrated to make a whole (Maureen &Milliken, 2007). Whiles none of the above two claims can be empirically confirmed in the Ghanaian context since no research has been carried out on this issue. Some respondents in a focus group discussion (FGD) conducted for students as an in-depth interview sessions held for lecturers expressed sentiments which confirm the latter. For example, on the issue of whether or not there is a need for nurse educators to balance teaching the theory and practice of nursing one lecturer respondent expressed the following: “I cannot comprehend how you will be teaching only theory in nursing and will not teach the practicals. If a lecturer cannot do this, then he or she is not a nurse. You have to be able to teach both the theoretical aspect of nursing and the practical aspect too”. In like manner, two other colleque lecturers who also think it is an obligation to teach both theory and practice as a nursing lecturer also said: “I think most nurse educators know that it is an obligation, but some did not work before entering the teaching field, so they do not have the practical experience. They want to justify their relevance by insisting that practical 41 University of Ghana http://ugspace.ug.edu.gh experience is not necessary for you to be a lecturer in nursing, but I think they know it is necessary”. To buttress this point another lecturer stated that: “How can you be teaching nursing if you are not proficient in the practice? We do not nurse the air, we nurse patients”. Embedded in these sentiments is the recognition of the need to blend the two aspects of nursing. Furthermore, insights provided by the students are more revealing. For example, while responses from the students have are generally the same as those of the lecturers, some two responses are quite critical and need attention. For example one student respondent noted that: “I think it will be better the lecturers teach us the practicals themselves. We were told we have preceptors to coach us on the clinical field, but most of the time we never saw the preceptor the whole time that we were there. They do not put the student in the same ward or even the same shift with the preceptors, how can any teaching take place? The ward nurses do not have any time for us. They are overwhelmed with workload on the ward, they are always busy.” Underpinning this statement is the critical issue of work load on nurses on the wards who supposedly should mentor the students. Another student, commenting on the issue also noted: “They (lecturers) are teaching us the theory, and they are the only people who can teach us the practice. I will actually prefer that, they know us well, they know our capabilities. Some of us are slow learners and some are fast learners, the ward nurses do not know how to handle us. They (lecturers) know us well and are the only ones who can mentor us well in the clinical environment. One major observation that has emerged from comments made by both lecturers and students on the issue under discussion was that both lecturers and students acknowledged the obligation of nurse educators to integrate clinical practice and teaching theory in training student nurses. This is a revelation that university authorities and policy makers need to pay attention to, and should not accept lecturers who keep insisting that they do not need clinical competency to lecture nursing students. 42 University of Ghana http://ugspace.ug.edu.gh 4.5.2: Perception of Nurse Educator’s Clinical Competency by Lecturers and Students Perception shapes the way people relate to each other, and in like manner, it also shapes their expectations from each other. Within the context of student nurse – nurse educator relationship, perception plays a key role in influencing the outcome of the relationship. Where the perceptions of two people meet each other, the outcome is usually positive. On the other hand, where the perceptions of two people are at variance with each other, the outcome is likely to yield negative results. The same applies to the student nurse- lecturer relationship. For example, when the perception of the lecturer’s clinical competency by the student is in doubt, it is likely to affect the student nurses ability to learn clinical skills. To further explore the obligation and expectation of nurse educators to teach theory and practice, the study assessed the perception of both lectures and student nurses of the clinical competency of nurse educators, by seeking the views of the two categories of respondents comprising thirty (30) lecturers and fifty (50) students on whether the lecturers were viewed as clinically competent. Results from the survey presents a paradox particularly when the two groups are supposed to work together towards a common goal (outcome) of producing competent nurses. Table 4.7: Perception of Nurse Educator’s Clinical Competency by Lecturers and Students Responses to whether Yes No Not Sure nurse educators in their school are clinically competent Freq. % Freq. % Freq. % Lecturers 17 56.7 2 6.7 11 36.7 Students 17 34 10 20 23 46 The result of the study as indicated in table 4.7 shows that 56.7% (n=17) out of the thirty (30) Lecturers stated “yes” meaning they were clinically proficient, and 6.7% (n=2 of them said “No”. The rest 36.7% (n=11) stated they were not sure. By contrast, when students were asked whether their lecturers were clinically proficient, only 34% (n=17) out of the 50 responded “yes” whilst 43 University of Ghana http://ugspace.ug.edu.gh 20% responded “no”. The final group constituting 46% (n =23) indicated they were not sure. This was further clarified by a student’s response during the focus group discussion: “Some of them (Lecturers) are proficient in in clinical practice, you can see from their style of teaching. They are able to cite examples from their experiences on the wards. This makes more sense to us as students, and when we get to the clinical environment we can easily relate what we were taught in the classroom with the realities on the wards. But I think some of them have not worked before; they just download PowerPoint from the net and read to us. They do not explain anything. Even if you ask questions, they cannot answer”. Another student stated: “You can tell those who are experienced in the practice and those who are not experienced. Those who know the job always site examples from the field. Their teaching is not abstract, we easily understand their teaching. Those who do not have the experience are always defensive and do not entertain questions. They do not site examples, and they are always reading to us not teaching”. All the above pointed to the fact that Ghanaian nurse educators are unable to identify practical components within theory topics that will enable them to plan clinical components of their lectures. Future research is suggested to investigate the ability of the Ghanaian nurse educator to identify practical components in theory and apply them in planning the practical component of their teaching. The implications of this paradox are grave. Although majority of the lecturers perceived themselves as clinically proficient, 34% of the students felt their lecturers were not clinically competent and 46% were not sure their lecturers were clinically competent or not. This shows that students do not perceive their lecturers as clinically competent or have doubts about the clinical proficiency of their lecturers. This will affect the outcome of their training as stated earlier perception shapes the way people relate to each other and the expectations from each; the result may produce varied outcomes. Within the context of this study, the perception of the lecturers of their clinical proficiency and the perception of the students of the clinical proficiency of the lecturers are at variance with each other, a situation that will yield negative results. This means that although the students acknowledged that their lecturers have the obligation to teach them both the theoretical aspect and clinical skills 44 University of Ghana http://ugspace.ug.edu.gh of nursing, they do not perceive most of their lectures as being able to do that. This is very disturbing, and future research may have to look at the reasons for the differences in their perceptions. 4.6: The theory and Practice Gap in the Training of Nurses in the University Level In examining the theory and practice gap in the training of nurses at the university level in Ghana, three major issues emerged, namely: University academic calendar, Autonomy of the nursing as an academic discipline and professional ranking of university nursing graduates As stated by Boshuizen (2010), Nursing is both an art and a science that is a profession based on scientific knowledge and clinical practice. The student nurse therefore needs to be prepared to play a dual role of using scientific knowledge to deliver a complete, holistic and appropriate patient family and population centred nursing care. Studies has also suggested that there is a gap between theory and practice in training university level student nurses, where students found out they were unable to integrate what they learnt in the classroom with real life patients. This was described by Boshuizen, (2010) that the shock of practice is a crisis moment experienced by most nursing students when they enter the clinical workplace. This is marked by a decrease in their ability to incorporate the basic biomedical science knowledge into their clinical reasoning. Although no empirical data exist about this problem in the Ghanaian context, anecdotal evidence has revealed that there has been a general complain from nurses and other healthcare workers that university student nurses have a theory and practice gap when it comes to clinical practice and the problems lingered on even after they graduate from school. Lecturers and students were asked about their views of both lecturers and students on the theory and practice gap in the training of nurses at the university level in Ghana. Table 4.8 shows that out of the 30 lecturers, (n=27); 90% off them agreed there is a theory and practice gap in the training of nurses at the university level in Ghana and only 10 % (n=3) disagreed. Out of the 50 students, 48% (n= 24) also agreed that there is a theory and practice gap in the training of students nurses at the university level, whilst, 32% (n=16) answered no and 20% (n=10) were not sure. 45 University of Ghana http://ugspace.ug.edu.gh Table 4.8: Lecturers and student’s responses to theory and practice gap in training University level nurses in Ghana Responses to Theory and Yes No Not Sure practice gap in the training of nurses at the university level in Ghana Freq. % Freq. % Freq. % Lecturers 27 90 3 10 - - Students 24 48 16 32 10 20 This result has serious consequences because the inability of a nurse to apply scientific knowledge to practice, compromises patient safety. This was further explored by assessing the student nurse’s ability to practice nursing skills with confidence. A final year student, just about to graduate who testified to not feeling confident in caring for patients lamented thus: ” With the few clinical experiences I had, I wouldn’t say that I am competent, I still have a lot to learn, we do not get to much practice much in school because the university curriculum is full of theory”. Some of the reasons given on the part of the lecturers for the theory and practice gap were; university academic calendar does not provide enough time for clinical practice, and they do not give the autonomy to nurse educators to plan clinical activities for student nurses either. In like manner, two other lecturers stated it clearly in their interviews, and one reported as follows: “If you look at the university academic calendar, no time is made available for clinical practice. It becomes very difficult to fit in practical periods into your class schedule. The university system does not understand that clinical practice is very essential in the training of nurses. If only the university will give us the autonomy to plan our own timetable, and also provide the resources needed, we will be able 46 University of Ghana http://ugspace.ug.edu.gh to plan their clinical practice well and give the students the chance to learn the nursing skills well”. One Dean of a nursing school stated: “I know the university system has contributed in a way because it is difficult to get the university authorities to accept that we need time allocated for practicals. The nursing school has to follow the university wide time table, and try to fit in practicals time. It becomes very difficult. The students take other university wide courses and some other required courses that are taught by lecturers from other departments. Those lecturers complain if we decide to send the students to the wards on some days. I think for us to adequately train nurses, the universities have to give us the autonomy to have our own timetable separate from the university wide timetable, so we can plan our activities to suite the demands of our programme. These findings have revealed a serious vulnerability of nurse academics that needs attention. Clearly, nursing in Ghana has not yet attained autonomy as an academic discipline. According to McNamara (2010), clinical practice is seen as central to the autonomy, integrity and distinctiveness of nursing as an academic discipline as well as to the legitimacy and credibility of those who claim to profess it. The overall consensus on the state of academic nursing in Ireland is that of a field characterized by Low autonomy, high density, weak specialization and disciplinary immaturity. Three issues stood out in McNamara’s study, which relates to the Ghanaian context namely, low autonomy, weak specialization and disciplinary immaturity. Marton (2005) defined an academic discipline’s autonomy as the discipline’s external relations and its degree of insulation from external control and value system. As shown in the findings of this study, nursing in Ghana has not reached there at all. Just as stated by the Irish nurses in McNamara’s (2010) study, the university communities always regard nursing as dependent on other disciplines. They acknowledged that their vulnerability in academia when it comes to autonomy is their inability to find nursing knowledge and discipline that will grant them autonomy as a discipline. One Irish nurse stated thus: “We are still a part of a medical world that considers nursing as an afterthought, always coming behind. This is not different in the Ghanaian context. Although no empirical data exits on this issue in Ghana, experience has shown that Ghanaian University authorities continue to insist 47 University of Ghana http://ugspace.ug.edu.gh that other disciplines like biomedical sciences are the ones qualified to teach the basic sciences not nurses themselves. Other disciplines like Medicine always want to control nursing when it comes to curriculum development for training of nurses. Medical Doctors are appointed as Deans of nursing schools. All the above point to the fact that, nursing has still not established its own autonomy as an academic discipline in the Ghanaian university system. In the researcher’s opinion, one problem which affects or undermines recognition of nursing autonomy and its legitimacy in Ghana relates to the inability of nurses in academia to build nursing knowledge just like the Irish nurses. There is therefore the need for further research into building nursing knowledge in academia in Ghana. The Irish nurse academics also stated that specialized knowledge is built through research and handed down tradition, which can only be achieved through clinical practice. Just like the Irish nurses, the Ghanaian nurse academics seem to have a weak academic infrastructure due to insufficient specialized knowledge and a poor accumulated body of knowledge based on handed down tradition and research. Since this study has revealed that Ghanaian nurse academics do not have autonomy in the Ghanaian medical world, it means we also have not been able to build up nursing specialized body of knowledge. And since clinical practice is accepted to be central to the building up of specialized nursing knowledge, it is imperative that priority be placed on clinical practice in the training of Ghanaian nurses. The best way to achieve this is to have clinically competent and experienced nurse educators to train novice nurses. In addition to lack of autonomy, another issue revealed by the study was the ranking given to university graduate nurses upon graduation from school. In Ghana, the entry level ranking for a university graduate nurse is Nursing Officer, which is a senior position, where nurses play more supervisory role than engaging in direct patient care. This repels the new university graduate nurse from taking instruction from more experienced staff nurses who are much more competent in the clinical environment, and could have mentored them. As a result of this, the university graduate nurse never really got the chance to learn and master the nursing skills. These graduates were the ones who get the chance to do higher degrees in nursing and get employed by the universities as nursing lecturers. This might account for the inability of majority of nursing lecturers in Ghana to balance clinical practice with theory. This research has also revealed that the senior entry level for university graduate nurses is also a source of envy for staff nurses in the wards, and out of envy, 48 University of Ghana http://ugspace.ug.edu.gh the experienced nurses refuse to mentor the university student nurses alleging that, they will be their bosses when they graduate so they will not teach them the nursing skills. This was vividly expressed by a lecturer as follows: “The university trained nurses are made senior staff as soon as they qualify. Meanwhile in our hospitals, the senior staffs are not involved in most of the basic care giving; they supervise the staff nurses and auxiliary nurses. Here, the university graduates have just graduated from school where the focus is more on theory. They have not tried their hands of the practical things. How can they supervise the junior staff? The junior staff knows the practical work more than them”. In like manner, a student also described the situation as follows: “The hospital here has not been very good to us; the nurses are not willing to teach us the clinical skills. Some of them say we are going to be their bosses when we complete. We should not expect them to teach us? They will not teach us. Even the registered nurses who are now pursuing their degree here with us are never willing to teach us. They will teach the Nursing Training College (NTC) students but they will not teach us, they only send us on errands”. The three major revelations that emerged from this study are the following: Academic calendar of universities does not allow adequate time for clinical training of students, Nursing in Ghana has not reached the status of being recognized as an academic discipline and so does not have the autonomy to make its own timetable and allocate adequate time for clinical practice for lecturers and students. The ranking of university graduates nurse’s as nursing officers at the entry level to the profession does not enhance their learning of clinical skills. All these issues need to be looked at seriously and strategies need to be developed to address them. Since the graduate nurses enter the profession at the senior level, the training curriculum might have to be designed to allow enough practical components that will equip them to gain confidence in the clinical environment and become competent in clinical practice by the time they graduate from school. 49 University of Ghana http://ugspace.ug.edu.gh 4.7: University Student Nurses and Graduate’s Ability to Practice with Confidence In order to explore further the theory and practice gap in training university level nurses, the research also examined the university nursing student’s ability to confidently care for patients in the clinical environment. It has been observed that the best way to train a student to be a competent professional is by the use of PBL that is the theory that this study is built on. This approach helps students to acquire critical thinking skills; that is to become conscious of what information they already know about a patient’s problem, what information they need to know to solve the problem and the strategies to use to solve a patient’s problem. The ability of nursing lectureres to use the PBL approach to train student nurses is believed to enhance the student’s ability to care for patients with confidence. In view of this, the views of lecturers were sought as to whether university student nurses and graduates are able to engage in clinical practice with confidence: Table 4.9 shows that, 56% (n=17) out of the 30 lecturers answered “No” whilst 40% said “Yes” Student were also asked to rate their clinical competency at the time they are about to graduate; out of 50 respondents’ 6.0% (n=3) rated themselves excellent, 22% (n=11) rated themselves very good, majority (56% , n=29) rated themselves just good whilst 14% (n=7) rated themselves as average (See Table 4.10). Table 4.9: University student nurses’ ability to practice with confidence 50 University of Ghana http://ugspace.ug.edu.gh Variable Frequency Percentage Nursing Lecturer’s responses on students and graduates ability to practice nursing with confidence. 12 40% Yes 17 56% No 1 3.3% Not Sure 50 100% Total Table 4.10: Student’s Rating of Their Clinical Competency University Nursing Excellent Very good Good Average student’s rating their own clinical competency Freq. % Freq. % Freq. % Freq. % Students 3 6.0 11 22 29 58 7 14 This was again confirmed by students during the focus group discussion as follows: “I am not sure of myself. I still have challenges on the wards. I still feel afraid to care for patients, or let me say inadequate when it comes to bed side care, I am still facing challenges at the clinical environment. I cannot do most of the procedures with confidence. I believe I still have a lot to learn. The above results shows that lecturers acknowledged that student nurses are unable to practise nursing with confidence both in school and after graduation, and majority of student nurses are not able to rate themselves as excellent or very good practioner at the tail end of their training. This is alarming and confirms the alleged theory and practice gap in training nurses at the university level. 51 University of Ghana http://ugspace.ug.edu.gh The question was put to one of the lecturer participants as what should be done to bridge the gap between theory and practice gap in training student nurses at the university level, and responded thus: “It has been a while since this university nursing programme was started. I think it is time we review the programme and change certain things. If the leaders I mean the Deans and Head of Department can come together and collectively do a good evaluation of the university nursing programme, I think we can redesign it to include more Practicals”. Another participant also suggested: “May be we need to follow up on the graduates and assess their performance and progress in the profession. Or conduct a research like you are doing solely on the clinical proficiency of university graduate nurses, and let us see what the outcome will be. That might help us to device a more practical oriented programme”. Another participant made a following suggestion: “We might have to look elsewhere, especially those countries where they have successfully trained university level nurses to be clinically proficient. Examples are United States and Canada and also the United Kingdom. We can study their style and may be, adjust ours to suite our situation here that might help us”. In examining the above suggestions made by the participants, the researcher agrees with them that future research might have to look at the clinical proficiency of university graduate nurses, and also a study needs to be done on the various models used in training nurses at the university level in those countries where university graduate nurses are clinically proficient, and the one that fits into the Ghanaian context should be adopted. 4.8: The Difficulties Nurse Educators Face in Combining Academia with Clinical Practice 52 University of Ghana http://ugspace.ug.edu.gh Many countries researched into the difficulties of nurse educators in balancing teaching with clinical practice. One of such study was conducted in Malta by Little & Miliken in 2007 and the results revealed that nurse educators allotted minimal time to clinical practice, and the reasons given were; heavy workload, perceived lack of control over the clinical area, diminished clinical competence and employment inequalities. They felt those working in the wards earn more than them meanwhile they were expected to teach and also work on the wards. Another difficulty expressed by nurse educators in Malta was that they felt threatened by the near perfect performance expected of them by clinical staff and students, and by the fact that they were expected to know everything about the care of patients with multiple problems scares, them because they might not meet those expectations. Although no research was done in the Ghanaian context on the issue, this research so far has pointed to the fact that there are difficulties in balancing the theory aspect of nursing and the practice aspect in the training of nurses at the university level. The study therefore explored the difficulties Ghanaian nursing lecturers are facing in trying to play the dual role by asking the lecturers whether they have difficulties in balancing theory and practice in training nurses. . The results in Table 4.11 indicated that 96% of the lecturers, and 64% of students agreed that nurse educators have difficulties in balancing the teaching of theory with practice in training student nurses. Table 4.11: Lecturers Having Difficulties in Balancing Theory and Professional Practice Responses to Lecturers Yes No Not Sure Total having difficulty in balancing theory and practice in training Freq. % Freq. % Freq. % Freq. % student nurses Lecturers 30 100 29 96 1 3.3 0 0 Students 32 64 16 32 0 0 50 100 As to what the difficulties were, 67% (n=20) of lecturers stated they were too busy with university activities and 33% (n=11) stated lack of time as the reasons. 30% (n=15), of the students on the 53 University of Ghana http://ugspace.ug.edu.gh other hand stated the lecturers were too busy with university activities, whilst 70% (n=35) of students feel their lecturers do not have time (See Table 4.12). Table 4.12: Difficulties Lecturers have in Balancing Theory and Professional Practice Responses to What Too busy with Lack of time Other Total difficulties Lecturers university have in balancing activities theory and practice in Freq. % Freq. % Freq. % Freq. % training student nurses Lecturers 30 100 20 66.7 11 33.3 0 0 Students 15 30 35 70 0 0 50 100 These same reasons were stated during interviews of some colleque lecturers as follows: “With my experience, it is a very difficult situation. The academic calendar does not give us time to complete teaching the theory, let alone the practicals. I try to do my best, but it is almost impossible to accomplish anything. There is no time to really work with the students and coach them in the ward. The student numbers is also a problem. Right now, we have a class of 500 students. How do you coach them individually and oversee their practical work. It is impossible. You are responsible for over 100 students in a class. There is no time for anything”. It is clear from the findings that the nurse educators in Ghana do not have a clearly defined role in the university system to enable them to balance teaching theory with practice. This finding confirmed that of Griscti et al. (2004) in their study: Nurse Educator’s Clinical Role which pointed out that since nursing education began to be integrated into university education system, nurse educators began to have difficulty defining their clinical role because their role was not clearly defined at the time of the integration. 54 University of Ghana http://ugspace.ug.edu.gh Another issue that emerged in the in-depth interview of a colleague lecturer was large student numbers: “It is a daily struggle. We are overburdened with large number of students. Most of the universities both private and public take in large numbers of nursing student; meanwhile we the lecturers are few. It becomes very difficult to adequately pay attention to them individually. Nursing is like apprenticeship where each student needs individual attention to coach and mentor them adequately to acquire clinical skills. We will never be able to do that if we have such large numbers. In addition to these, we are expected to do research and publish, serve on university committees and many more university activates that keep us too busy already. And I also I think one big problem is the student numbers. We spend a lot of time marking because of the numbers and we never have time for anything else. We are not able to even follow them to the wards. I do not know what we can do to resolve this issue”. The findings of this study has indicated that Ghanaian nurse educators have stated some common problems with their counterpart nurse educators in other countries For example, lack of time and being too busy with university activities. In Britain, the main factor identified by the nurse educators’ as difficulties they face in playing the dual role also include lack of time, and being overburdened with educational and administrative work and also being expected to conduct research and publish. Ironically, in American studies, nurse educators reported that they lacked time for their clinical role due to family responsibilities, and being enrolled in doctoral programmes (Griscti et al. 2004). The common difficulties shared by all nurse educators including Ghana were; lack of time, work load (too buzy with university activities) and research and publishing. Unlike the Maltan nurse educators who acknowledged diminished clinical competence as a result of being away from the bedside for long, and inability to meet high expectations from students and ward nurses, Ghanaian nursing lecturers have not acknowledged either diminished clinical competency or too much expectation from them as their difficulties. The distinctive emerging difficulty peculiar to 55 University of Ghana http://ugspace.ug.edu.gh Ghana revealed by this research is large student numbers, a critical issue that will need more attention. Nursing authorities in academia need to find innovative ways to deal with the large number of candidates who apply to the universities to do nursing every year. It might not be a good thing to turn them away if they are qualified. Rather there is the need to device innovative ways to train them properly. Although the nursing lecturers are expressing the above difficulties, student nurses view their inability to balance teaching theory with practice as lack of time management, and still have a high expectation of them to be the ones to mentor them to become proficient professionals. A student in the FGD stated clearly: “I think they should be the ones coaching us not the ward nurses. They are also nurses and should even know more than the nurses on the wards because they have gone further to get higher degrees in nursing. I think they should coach us not nurses in the ward. I will actually prefer that. They should even be coaching the nurses in the wards too”. The students were further probed as whether their lecturers really coach them at the clinical sight? 68% (n=34) of the students said no and 16% (n=8) said yes, the rest 16% (n=8) answered not sure; (See Table 4.13) Table 4.13: Lecturers coaching students on the wards Student’s responses to Frequency Percent whether lecturers coach them on the field or ward Yes 8 16.0 No 34 68.0 Not sure 8 16.0 Total 50 100.0 This was further clarified by students in the FGD that: 56 University of Ghana http://ugspace.ug.edu.gh “I have never seen any of them (Lecturers) come to teach me in the wards. They expect the nurses in the wards to teach us; meanwhile the nurses do not show any interest in us. Most of them are very hostile to us”. Another student stated: “They do not coach us. If they come around they only check on us. They do not come to work with us or anything like that. The only time we see them stay in the wards is during exam time when they come to assess us on practical exams. If they are not teaching us the practicals what business do they have to examine us? For me, it frustrates me”. Students were further asked whether they prefer their lecturers coaching them at the clinical site. Table 4.14 indicated that 84% (n=42) answered yes whilst 8% (n=4) answered no. The rest 8% (n=4) said they were not sure. Table 4.14: Student’s preference of lecturers coaching them at the clinical site Student’s Frequency Percent response to whether they prefer lecturers coaching them at the clinical site? Yes 42 84.0 No 4 8.0 Not sure 4 8.0 Total 50 100.0 The students in the FGD stated the following: “I think that will be very good. They (lecturers) are teaching us the theory, and they are the only people who can teach us the practice. I will actually prefer that, they know us well, they know our capabilities. Some of us are slow learners and some are fast learners and they know us that way. The preceptors are not 57 University of Ghana http://ugspace.ug.edu.gh teachers; they are not patient with us’. Our lecturers are the ones who can mentor us better. The response of the students is in line with a study conducted by Sharif & Masouni (2005) where students mostly viewed their lecturer’s role as more of evaluation than teaching or mentoring, a situation they find disappointing. Nursing lecturers have to get more involved in the practical training of their students as expected by the students. This will actually enhance their mastery of nursing skills. 58 University of Ghana http://ugspace.ug.edu.gh 4.9: Effect of the Clinical Proficiency of a Lecturer on the Student Nurse’s Ability to Learn Clinical Skills As student nurses enter the clinical environment, they face the challenge of imbibing the various nursing roles and also learning new clinical concepts and applications of the nursing practice. Students describe this feeling as being thrown into the deep end of a rough sea where they feel afraid and confused. In order to allay their fears and confusion, the nurse educator’s competence in clinical skills and being a role model for the student nurses will go a long way to influence the learning process of the student and help students to adjust to the clinical environment effectively. With this in mind, the study sought to explore the effect of the lecturer’s clinical proficiency on the student’s ability to master nursing clinical skills. Table 4.11 shows that majority of lecturers i.e. 70% (n= 23) agreed that their clinical proficiency has an effect on the student nurses’ mastery of clinical skills, and 23.3% (n=7) did not acknowledged it. Students were also asked if their lecturer’s clinical competency has an effect on their mastery of clinical skills, an overwhelming majority; 49 out of 50, 98% answered yes and only 2% (n=1) answered no. (See Table 4.15) Table 4.15: Effect of the Clinical Proficiency of a Lecturer on the Student Nurses Mastery of Clinical Skills Responses from Yes No Not Sure lecturers and students to the effect of their clinical competency on the Freq. % Freq. % Freq. % student’s mastery of clinical skills. Lecturers 23 70 1 3.3 0 0 Students 49 98 1 2.0 0 0 This was further stated by a participant of the FGD when asked whether the lecturer’s clinical competency has an effect on their learning and mastery of clinical skills: 59 University of Ghana http://ugspace.ug.edu.gh “It does have effect. If you are teaching me something, and I found out that you yourself you are not sure of what you are doing I will not have the confidence in you to learn from you. If lecturers are making mistakes, it is difficult for students to trust their teaching. On the other hand if I see lecturers confidently care for patients; it will encourage me too to do the same. Clearly, student nurses expert their lecturers to influence their ability to learn and master clinical skills and nurse educators have no choice but to fulfill this expectation. In order to further explore the student’s dependability on lecturers to be their mentors and coaches in the clinical environment, the study sought from student whether they prefer their own lecturers not preceptors to mentor them to acquire clinical skills. 84% (n=42) of students stated they would prefer their lecturers to coach them at clinical sites rather than preceptors (See Table 4.8b). A statement from a student in the FGD further supported the above result: A participant in the FGD stated: “If a lecturer is clinically competent we learn from him/her. If not, then why is the person a nursing lecturer”? Definitely the lecture’s clinical competence will determine the student’s clinical competence too”. This study has revealed that students expect lecturers to be their teachers in the theoretical aspect of nursing, and also their mentors and coaches in the clinical environment. As stated by Sharif & Masouni (2005), clinical experience prepares student nurses to do as well as knowing the clinical principles in the practice of nursing. It stimulates them to use critical thinking skills to solve patient’s problems. This is in line with the Problem based theory, the theoretical basis of this research. Nurse educators therefore need to make efforts to meet the student’s expectations by making sure they build up their own clinical competency and become more aware of clinical realities. To be able to play the dual role of teaching both theory and practice effectively, Nahas (2000) and Cave (2005) argued that nurse academics need to be more aware than ever of the clinical realities that could affect the application of the theory they teach, and this can only be possible if they are practising in the field. Inability to address these could result in training nurses who are not clinically competent and this will in turn compromise patient safety which is the backbone of health care delivery. 60 University of Ghana http://ugspace.ug.edu.gh 4.10: Enquiries into Requirement for Nurse Educator’s Clinical Practice In order to ensure that nurse educators maintain their clinical proficiency, different countries have policies that require them to engage in clinical practice that would enable them balance teaching theory and practice effectively. It is expected that Ghana should have the same policies in place. The study sought to enquire if the Nursing and Midwifery Council (NMC) of Ghana has a requirement for clinical practice for nurse educators. Table 4.16 shows that 100% (n=30) of the lecturers answered in the affirmative. As to whether they fulfilled the requirements, again 100% of the lecturers answered yes (See Table 4.17). Table 4.16: NMC has a requirement for clinical competency for nurse educators. Responses of Yes No lecturers on NMC Freq. % Freq. % requirement for clinical practice Lecturers 30 100 0 0 Table 4.17: Lecturers fulfillment of NMC Clinical Practice Requirement Responses of Yes No lecturers as to Freq. % Freq. % whether they fulfill the NMC requirement Lecturers 30 100 0 0 But a colleque lecturer pointed out in the in-depth interview that there is no monitoring as to whether the requirements are fulfilled: “Yes, there is a log book and we are required to record our practice times in it and use it to renew our PIN. But how many times has the NMC even asked 61 University of Ghana http://ugspace.ug.edu.gh about it? Nobody monitors to see whether you go and practice and fill the log book or not, nobody cares”. Just like the Ghanaian situation, research from the advanced countries has revealed that there are clinical practice requirement for nurse educators to update their clinical skills to remain at breast with the growing challenges of the nursing practice. Maureen &Milliken (2007) found that, American nurse educators were found to be more committed to their clinical roles than their British counterparts, and because of this America and Canada in particular especially have developed competency requirements for nurses in academia to follow and have put in place monitoring mechanisms to make sure they follow them. In Britain, the National Board for Nursing, Midwifery and Health Visiting mandated that nurse educators in the United Kingdom (UK) spend 20% of their time in practice (Aston et al, 2000) There is therefore the need for the NMC of Ghana to put monitory regulations in place to make sure nurse educators in Ghana update their clinical skills, and maintain their clinical proficiency. Future research looking into the policies put in place by NMC of Ghana to monitor clinical practice competence of nurse educator will benefit the Ghanaian nursing education system. 62 University of Ghana http://ugspace.ug.edu.gh 4.11: Models Developed to Aid Nurse Educators to Balance Teaching Theory with Clinical Practice The problem of nurse educators especially at the universities having difficulties in balancing theory with practice in the training of student nurses has been a long standing one since nursing education was extended to university based training. Different countries have developed different models to help nursing lecturers to play the dual role. Some of the models developed in the advance countries are; the preceptor model, the facilitator model and residency model just to mention a few. The study enquired from lecturers if they knew of any of the models and if their schools were using any model in training student nurses. 30 % (n=9) of them said they knew of some models whilst 63% (n=19) of them do not know of any model. The remaining 6.7% said they were not sure (See Table. 4.18). Table: 4.18: Lecturer’s Knowledge of models used in training student nurses Response to Frequency Percent Lecturers knowledge of models used in training nurses Yes 9 30.0 No 19 63.3 Don’t know 2 6.7 Total 30 100.0 It was inquired from students if they also knew of a model their schools were using to train them. 60% (n=30) did not know of any models their schools were using. 16% (n=8) stated they did not know whilst 24% (n=12) said they were not sure (See table 4.19) Table 4.19: Models for training nursing students 63 University of Ghana http://ugspace.ug.edu.gh Student’s response to Frequency Percent Valid Percent Cumulative knowledge of models their percent schools were using to train them Yes 4 8.0 16 16 No 15 30.0 60 76 Valid 6 12.0 24 100.0 Not sure 25 50.0 100.0 Total 25 50.0 Missing System 50 100 Total 4.12: Preference of Models The different models for training Nurses as described in the literature review (Pages 18 -21 ) was explained to students during the FGD and they were asked which one they think will be the best that will give them the opportunity to learn nursing skills. Most of the student respondents stated they would a combination of two preceptor model and or the facilitator model and residency mode: That is, the universities to recruit clinical instructors to be their coaches on the field. They also expressed preference for the Facilitator/Preceptor model and also the Residency Model. One participant opinioned thus: “I think the university employing clinical instructors will be the best thing. In addition to that we will need a facilitator; I will really like that so we will not have to deal with all the hostility we face on the wards. The nurses in the wards are very hostile to us. If our instructors are with us they will not be able to do of the things they do to us”. In addition the residency period after graduation is an excellent idea. Even the medical students do that. I 64 University of Ghana http://ugspace.ug.edu.gh think that is what they call horsemanship. If the Facilitator and the clinical instructors will be with us and coach us that will be the best”. One student participant also stated: “I really like the residency models that one will help students to be confident in the practice. We are always looking for the chance to practise what we are taught in the classroom with ease. If the schools will adopt that, it will be very good. Another student participant stated: The facilitator model and residency model will be the best. I will also like the lecturers to be involved. I find it very disappointing that there are some of the lecturers who will even join the nurses in the wards to insult and intimidate. How can we be encouraged to learn from them if they are insulting us? If the preceptors will be used at all, they need to be trained well because sometimes what they (preceptors) taught us in the wards was totally different from the classroom. They also teach us wrong things sometimes”. The study’s findings have clearly brought out the need to redesign the nursing curriculum in the university nursing training in Ghana. There is also the need to design a model that will make it possible for nurse educators in academia to balance their teaching and maintain their clinical proficiency. This will make it possible for them to train student nurses at the university degree level to become competent and proficient professional nurses who will provide quality and safe patient care to the Ghanaian public. 65 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE SUMMARY, CONCLUSION AND RECOMMENDATIONS 5.0: Introduction This chapter gives a summary of the study and its findings, and provides recommendations for balancing academia with clinical practice in the training of nursing students at the university level in Ghana. 5.1: Summary of the Study The advent of higher education in nursing has come both as a bane and a blessing to nursing education in developing countries such as Ghana. Looking at the role of nursing in ensuring quality patient care and patient safety it is important to ensure that nurses are adequately trained, hence the essence of emphasizing clinical practice in university nursing programmes can never be omitted. The study therefore set out to investigate the ability of nurse educators in Ghana to balance theory and practice in training university nursing students, with the aim of determining the obligations and expectations of nurse educators as teachers and also clinical practitioners, and also to identify the difficulties encounted in balancing and combining academia with clinical practice. Literature from the United States of America, United Kingdom, Ireland Malta, Australia and many more was reviewed using search engines as Pro-Med, Google Scholar to discover variances and similarities in the research area. A triangulated method of; quantitative and qualitative collected from interviews with nursing lecturers and Focus Group Discussions (FGD) with nursing students. The findings of the study revealed both lecturers and students affirmed that University lectures are obliged to teach both theory and practice in training student nurses. There is also a theory and practice gap in the training of nurses at the university level. Both students and lecturers agreed that lectures were having difficulties in balancing theory and practice in training student nurses at the university level. Students indicated that their lecturers do not have time to mentor and coach them in the clinical environment. In addition they will prefer lecturers to coach them rather than preceptors. Lecturers expressed the need for the Nursing and Midwifery Council of Ghana to 66 University of Ghana http://ugspace.ug.edu.gh monitor their maintenance of clinical proficiency. Both lectureres and students expressed the need to adopt a model that would enhance the lecturer’s ability to balance theory and practice in training student nurses at the university level. Student’s expressed preference for the facilitator and residency models to be adopted to train them to become competent nursing professionals. 5.2: Recommendations Throughout the trajectory of this study, recommendations were made for policy makers, nursing education, and future research. A model for training nurses at the university level to become competent professionals was also recommended. 5.2.1: Recommendations for policy makers  For nurse education; university curricula should be redesigned to place priority on clinical practice than theory in the ratio of 2:1 to enable the graduate nurse to assume the senior position with confidence.  Regarding policy, universities that seek to include nursing Schools and Departments of nursing in their setup need to give autonomy to the schools/departments to draw their own academic calendar, and to their independence.  It is important that, the Nursing and Midwifery Council of Ghana also put monitoring mechanisms in place to ensure the clinical practice competencies of university nursing lecturers.  It might be necessary for the universities to make clinical experience (number of years of practice) important criteria in recruiting nursing faculty, and also plan their nursing staff development to include specialization in different specialty areas of nursing.  Policy makers and university authorities therefore might have to find innovative ways of including enough practice periods in training student nurses to equip them to become proficient professionals.  Deans and Head of Departments can come together and collectively do a good evaluation of the university nursing programme; I think of innovative ways to redesign the university degree nursing programme to include more Practical periods. 67 University of Ghana http://ugspace.ug.edu.gh  Nursing leaders in academia therefore need to clearly define the role of the nurse educator in the university environment in order to give them some direction as to how to play the dual role. 5.2.2: Recommended Model for Training Nurses at the University level in Ghana The Recommended training model that has emerged from this study to be most effective in training nursing students in Ghana is a combination of the Facilitator/ Preceptor model and the Residency Model. 5.2.2a: The Preceptor Model This model is the most common model used to help nursing students to develop their professional knowledge and skills that will prepare them for clinical practice (Altman 2006). Under this model, the training institutions use practice site clinicians, in most cases registered nurses who act as clinical instructors, to mentor the student nurses in learning the clinical skills, and these field clinicians are called preceptors. The student works one on one with the preceptor who provides direct and indirect supervision and undertakes formative assumptive assessment (Billy &Myrrh 2008). (Callahen et al, 2009). The preceptors will have a specialized training to learn how to teach students and mentor them to master clinical skills and at the end of the training will be awarded certificates that will qualify them to play such an important role and will be paid some allowance by the training institutions to motivate them to perform their roles well. The faculty will work closely with the preceptors, and guide them through the process, and continue to partner and mentor them to be effective mentors to students. According to Billy &Myrrh (2008), this is the most common model of clinical teaching, particularly in hospitals and has proven to be very successful. 5.2.2b: The Facilitator Model For this model, faculty from the educational institutions who are not employed or physically aligned to the practice site, and who do not provide direct clinical services for the hospital are 68 University of Ghana http://ugspace.ug.edu.gh appointed as clinical facilitator. The facilitator must be a very experienced nurse who has practiced enough to be familiar with all the skills of nursing practice. She/he works closely with lecturers to plan the clinical practice activities of the school. She/he supervises the students on the field and mentors them in acquiring their clinical skills. She also organizes demonstration sessions and assists the lecturers in demonstrating procedures to student nurses in the skills lab. Skilled clinicians might be employed by the training institution to assist the facilitator in carrying out her duties. The facilitator also undertakes both summative and formative assessments of the students, in collaboration with the lecturers. 5.2.2c: Facilitator/Preceptor Model This is a combination of preceptor and facilitator model where a group of students are assigned to preceptors usually about 1:6 or 1:8 or more. The preceptor and clinical instructors give the one on one training, and the facilitator supervises the preceptors. The training institution works with the facilitator to coordinate the practicum activities. 5.2.2d: The Residency Model The model was also developed by the American Academy of Nursing Colleges (AANC) and is based on two facets: 1. Improve transition to practice 2. Increase student clinical proficiency and accountability. The model begins from the first year of entry into the university till the student nurse graduates. After graduation, the new nurse slowly transitions into the nursing practice through the one year residency programme. To improve transition to practice, the newly graduated nurse spends one year to engage in intensive practical experience, where he/she will be scheduled as a staff nurse but will still work under the supervision and mentorship of the school’s clinical facilitator and clinical instructors and a preceptor who will guide the new nurse to get comfortable with nursing activities. 5.2.2e: The features of the Residency Model a. Skilled lab training b. Clinical and field experience c. Work requirement 69 University of Ghana http://ugspace.ug.edu.gh d. Residency year a. Skilled Laboratory experience During the first year of training, the student will spend most of the time learning the theoretical aspects of nursing, namely the basic sciences, the liberal arts and humanities and basic nursing skills. The basic nursing skills are practiced in the skills laboratory using dummies and simulators. On the practical days in the skills laboratory, students are made to dress fully in uniform as if they are working in the wards. This will instill discipline and the right code of conduct in them before they enter the clinical environment. b. Clinical and Field Experience In the second year they will be learn Medical Nursing, Surgical Nursing, Pathology and Advance Nursing Skills. Teaching assistants will be engaged to help the clinical facilitator and faculty to mentor the students to learn the basic and advance nursing skills through tutorials, and practice in the skills laboratory. Students are made to dress fully in uniform during skills lab days and anytime they go to the field. From the skills laboratory, student nurses will be slowly introduced to the clinical environment through Intrasemester practicum periods where they will be made to practise what they have been learning in the classroom on real life patients using the problem based learning approach. From this time on, there will also be vacation practicum periods where student nurses go to work in a clinical environment under the mentorship of faculty, clinical facilitator, clinical instructors, and preceptors. c. Work requirement In the third and fourth years, students are immersed in the clinical arena with the main focus on rotating through specialty areas like Psychiatric Nursing, Gerontology and Home based nursing, Orthopedic Nursing Obstetric and Gynecological Nursing, Eye, Ear Nose and Throat Nursing, Theater Nursing, Critical and Emergency Care Nursing, Urology and Dialysis Nursing, Pediatric Nursing, Public Health Nursing and Cardiothoracic Nursing etc. After the rotation they will spend six months to prepare to write the licensure examination. d. The Residency Year After completing and passing the licensure examination, the new graduate nurses will go through a one year residency programme where they work like regular staff nurses, but still under the 70 University of Ghana http://ugspace.ug.edu.gh supervision of the training institution, where they continue to be supervised by the clinical facilitator and clinical instructors and preceptors. This one year residency will help the new university nurse graduate to transition slowly into the work environment and gain confidence in performing the nursing activities. This model is believed to prepare the university graduate nurse to face the challenge of being a senior nurse who can also mentor younger nurses. The researcher believes that by the time the student nurse goes through the above schedule. He or she will be ready to enter the professional world of nursing and will be competent and confident enough to deliver quality and safe nursing care to patients and effectively supervise junior nurses to give quality and safe care to patients. 5.3: Recommendations for future research  Future research may be done to assess the mode of teaching of young nursing lecturers in the university and its effect on student nurses’ learning and mastery of clinical skills.  Research may also be done to explore the effect of number of years’ of clinical experience of a lecturer on the student nurses’ acquisition of clinical skills.  Future research is also suggested to investigate the ability of the Ghanaian nurse educator to identify practical components within theory topics that will enable them plan clinical elements of their lectures.  Future research may also be done on the effect of large student numbers on the ability of nurse educators in academia to balance teaching theory with clinical practice.  There is the need for future research to investigate the policies put in place by NMC of Ghana in monitoring clinical practice competency of university nurse educators.  It might be important for future research to explore the effect of recruitment practices for nursing faculty on the training of nurses in Ghanaian universities. 5.4: Conclusion 71 University of Ghana http://ugspace.ug.edu.gh The study discovered that most of the nursing lecturers had a short duration of clinical exposure for two (2) to three (3) years before joining academia. Although the nursing lecturers recognize the importance of clinical practice in the training of nurses, they cited several difficulties including being too buzy with university activities, lack of time and the university academic calendar not being favourable for teaching and practice. They also complained of large student numbers as a critical issue that needed to be addressed. The findings of the study were discussed to identify the congruences and incongruences with existing literature on the topic and recommendations for future research provided. 72 University of Ghana http://ugspace.ug.edu.gh 5.4.1: Lessons learnt from this Research  As a professional nurse with strong passion for nursing excellence and also a nurse educator, this research has aroused a great interest to emphasize clinical practice in the training of students.  It has also given me the impetus to build more knowledge in nursing clinical practice to enable lectureres guide students to be become competent clinical practitioners.  Finally, the study has made me develop empathy for university nursing students who are struggling to gain clinical competence when exposed to the clinical environment and the struggle to blend academia with clinical practice.  At the end of it all, the patient is the sufferer as an incompetent nurse is a threat to the lie of a patient. there is therefore a need to develop a training model that will guide nurse educators to successfully blend theory and practice in training nurses to become competent professionals and provide quality nursing care. 73 University of Ghana http://ugspace.ug.edu.gh REFFERENCES 1. Aston, L., Mallik M., Day, C. & Fraser F (2000). An exploration into the role of the teacher/lecturer in practice: findings from a case study in adult nursing. Nurse Education Today 20, 178–188. 2. Barger, S.E. and Bridges W.C (1987) Nursing Faculty Practice: Institutional and Individual Facilitators and Inhibitors. Journal of Professional Nursing Nov-Dec, 338–345.7 3. Boshuizen, H.P.A. (2010). The Shock of practice: Effects on Clinical Reasoning. Annual Meeting of the American Educational Research Association. New York, 8 -14 April 1996. 14 4. Cave, I. (2005). Nurse teachers in higher education – without clinical competence, do they have a future? Nurse Education Today 14 (5) 394–399. 5. Desborough, J., Banfield, M., Parker, R (2014). Australian Journal of Primary Health, Vol. 20, Issue 214487527. 6. Dochy, F. Segers, M., van den Bosche, P., and Gijbels, D (2003). Effects of problem based learning: a meta-analysis. Learn. Instruct 13,533-568 7. D’Souza M.S., Venkatesaperrumal R., Radhakrisnan J., & Balachandran S Engagement in Clinical learning environment among nursing students: Role of nurse Educators. Nursing and Health Vol. 27 No. 4, pp. 254-68. 8. Dubois et al, (2014). Conceptualizing performance of nursing care as a prerequisite for better measurement: a systematic and interpretive review. BMC Nursing 12:7; http://www.biomedcentral.com/1472-6955/12/7 9. Duffy-Durnin, K. (2004). Letters: From baccalaureate to the doctorate. American Journal of Nursing 104(2), 15. 10. Fisher, M., (2005). Exploring how nurse lecturers maintain clinical credibility. Nurse Education in Practice 5 (1), 21–29. 11. Griscti O., Jacono B & Jacono J (2004): The Nurse Educator’s Clinical Role. Journal of Advanced Nursing 50 (11) 84-92 12. Ghana News Agency: 23rd Apr, 2013. www.ghanaweb.gh 13. Henderson A., Briggs J., Schoonbeek S. & Paterson K (2011). A Framework to develop a clinical learning culture in health facilities: Ideas and Literature. International Nursing Review, 58, 196-202. 74 University of Ghana http://ugspace.ug.edu.gh 14. Larrabee, J.H., Ostrow, C.L., Withrow, M.L., Janney, M.A., Hobbs, G.R. Jr and Burant, C. (2004). Predictors of patient satisfaction with inpatient hospital nursing care, Research 15. Little J & Jane Milliken P. (2007). Practicing What We Preach: Balancing Teaching and Clinical Practice Competencies. International Journal of Nursing Education Scholarship Volume 4, Issue Article 6 16. Meleis A, (2007). Theoretical nursing development and progress. Lippincott Williams and Wilkins, Philadelphia. 17. Myrick & Yonge (2005). Nursing preceptorship: Connecting practice and education. Philadelpihia: Lippincott Williams &Wilkin. 18. Murphy, F. A (2000). Collaborating with practitioners in teaching and research: A model for developing the role of the nurse lecturer in practice areas. Journal of Advanced Nursing, 31, 704-714. 19. Nahas, V., (2000). Maintaining clinical credibility as a nurse teacher in a postgraduate tertiary specialization program. Clinical Nurse Specialist 14 (4), 184–188 20. Popper. (1994). Alles leben inst problemlosen. Munic, Germany: Piper Verlag 21. Rush University Bulletin (2003-2004). Chicago, IL 22. Sharif F & Masouni M. (2005), A Qualitative study of nursing student’s experiences of clinical practice: BMC Nursing. November 2005 1166/1472-6955, 4-6. 23. Webber, P.B (2002). A curriculum framework for nursing. Journal of Nursing education 41 (1), 15-34 24. Zungolo, E. (2004). Faculty preparation: Is clinical specialization a benefit or a deterrent to quality nursing education? The Journal of Continuing Nursing Education 35(1), 19-23. 75 University of Ghana http://ugspace.ug.edu.gh APPENDICX A 1.0: Letter of Introduction BALANCING ACADEMIA AND CLINICAL PROFICIENCY IN THE TRAINING OF NURSES AT UNIVERSITY DEGREE LEVEL IN GHANA My name is Belinda Adzimah-Yeboah; I am a student of the University of Ghana Business School pursuing a Master of philosophy in Health Services Management. I am conducting a research into Balancing of academic work and professional practice among university nursing lecturers. I wish to seek your consent to obtain information from you about your views concerning the professional proficiency of university nursing lecturers and their ability to balance academic work with professional practice. You have been chosen as one of the respondents. I would be most grateful for your support and cooperation with the assurance that your anonymity will be preserved and any information you provide will be treated confidentially. 76 University of Ghana http://ugspace.ug.edu.gh 1.2 Questionnaire This questionnaire is aimed at determining your knowledge and attitude with regards to the obligation and responsibility to balance teaching students with practicing as a professional nurse, and also mentoring students to become proficient professional nurses. It will take you approximately 10 minutes to answer the questions. You are assured of your anonymity being protected and your identity being preserved. All information obtained from you will be held confidential. Case Number………….. Date…………………….. 1. Age: 20 - 29 30 - 39 40 - 49 50 + 2. Gender: Male Female 3. Number of years employed as a lecturer 1 year 2years 3years 4years 5years 77 University of Ghana http://ugspace.ug.edu.gh 6years Over 6 years 4. Number of Years of practice before becoming a lecturer 1 year 2years 3years 4years 5years 6years Over 6 years A. Obligation to teach theory and also Practice a nurse educator 1. Are nurses in academia required to be experienced in clinical practice? Yes No Not Sure 1 2 3 78 University of Ghana http://ugspace.ug.edu.gh 2. How proficient should a nurse educator be in professional practice? Very Proficient 1 Proficient 2 Moderately proficient 3 Does not need to be proficient 4 2. How do you rate your clinical competency? Excellent 1 Very Good 2 Good 3 Average 4 Poor 5 Very poor 6 79 University of Ghana http://ugspace.ug.edu.gh B. Theory and Practice Gap 1. Is there a theory and practice gap in the training of nurses at university level in Ghana? Yes No Not sure 1 2 3 2. Is there a theory and practice gap among university graduate nurses in Ghana? Yes No Not sure 1 2 3 3. If yes how wide do you think the gap is? Very wide 1 Moderately 2 wide Slightly 3 wide Wide 4 Not Wide 5 80 University of Ghana http://ugspace.ug.edu.gh 4. Are university graduate nurses able to practice with confidence? Yes No Not sure 1 2 3 5. If yes, how does the gap affect the graduate nurse’s clinical competency? Severely 1 Badly 2 Moderately 3 Slightly 4 Does not affect it 5 C. Nursing and Midwives Council of Ghana’s (NMC) Nurse Educators Practice Requirement 81 University of Ghana http://ugspace.ug.edu.gh 1. Does the NMC have a clinical competency requirement? Yes No Don’t know 1 2 3 2. If yes, have you been able to fulfill the requirement? Yes No 1 2 3. If no, state why not? …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… Barriers to teaching with Clinical Practice 1. Do you have difficulties in balancing your teaching and professional practice. Yes No 1 2 2. If yes, what are the difficulties? 82 University of Ghana http://ugspace.ug.edu.gh Lack of time 1 Too busy with university 2 obligations Not a requirement 3 Requirement not clearly defined 4 Personal issues 5 D. Effect of a nurse educator’s Clinical Competency on the student nurses acquisition of clinical skills 1. Does your clinical competency have an effect on the student nurses you train? Yes No Not sure 1 2 3 2. If yes how does it influence it? ………………………………………………………………………………… ………………………………………………………………………………… E. Models for training student nurses 83 University of Ghana http://ugspace.ug.edu.gh 1. Do you know of models used in training student nurses to be proficient in professional practice? Yes No Don’t know 1 2 3 2. If yes, please name those you know? ……………………………………………………………………………… ……………………………………………………………………………… 3. Is your school using a training model to train your student nurses? Yes No Not Sure 1 2 3 4. If yes, what model is your school using? ………………………………………………………………... ………………………………………………………………… 84 University of Ghana http://ugspace.ug.edu.gh 2.0: Interview Guide Permission I am a student of the University of Ghana Business School pursuing a Master of philosophy in Health Services Management. I am conducting a research about Balancing of academic work and professional practice among university nursing lecturers. I wish to seek your consent to obtain information from you about your views concerning the professional proficiency of university nursing lecturers and their ability to balance academic work with professional practice. Thank you. This interview is aimed at determining your knowledge and attitude with regards to the obligation and responsibility to balance teaching students with practicing as a professional nurse. The interview is expected to last for about 45 -90 minutes, and I hope it is ok with you. Thank you for your cooperation. You are assured of your anonymity being protected and your identity being preserved. All information obtained from you will be held confidential. 85 University of Ghana http://ugspace.ug.edu.gh 2.1: Interview guide Questions for Deans and Heads of Department Permission Dear participant, thank you for accepting to spend time with me to have a conversation about the ability of nurse educators to balance their teaching with clinical practice. This conversation is aimed at determining your knowledge and attitude with regards to the obligation and responsibilities of nurse educators especially those in academia to balance teaching students with practicing as professional nurses. The ability of your lecturers to balance the demands of academic work with clinical practice, the clinical competency of your lecturers and its effects on their ability to train students, to become proficient in their professional practice. The interview will take about 45 -90 minutes. I hope you are ok with it. Thank you for your cooperation. You are assured of your anonymity being preserved and your identity being protected. You are also assured of protection of your right to privacy. Thank you. Questions: 1. What is your view on the allegation that university trained nurses and midwives are not proficient in clinical practice, and that they are afraid to touch patients? 2. May you please tell me whether you believe your students and even graduates nurses really have this problem, and what do you think the cause is? 3. Please tell me your feelings about how the nursing theory and practice gap exist. 4. What do you think is the source of the nursing theory and practice gap problem in Ghana? 5. Do you think your lecturers have difficulty balancing their teaching of theory with training student on the field to acquire clinical skills? 6. Please Tell me whether you have a model to guide the nurse educators (lecturers) to balance teaching and clinical practice in training student nurses at your institutional level 7. Please tell me in your opinion whether clinical competence is a necessary requirement to qualify a nurse to become a lecturer. 86 University of Ghana http://ugspace.ug.edu.gh 8. In your opinion, does you faculty also think it is a necessary requirement to become a lecturer? 9. May you please tell me if you consider number of years in clinical practice as a criteria in the recruitment of nursing and midwifery lecturers to your school or department. Probes: If yes, why? If no why not? 10. Please tell me whether there is room for improvement in the training and preparation of nurses to be professionally proficient and competent 11. Tell me any suggestions you will make as to what needs to be done to train university graduate nurses to be clinically competent? 12. Please tell if you have any practical experience requirement in recruiting nursing lecturers 87 University of Ghana http://ugspace.ug.edu.gh 2.2: Interview Guide for Lecturers Permission Dear participant, thank you for accepting to spend time with me to have a conversation about the ability of nurse educators to balance their teaching with clinical practice. This conversation is aimed at determining your knowledge and attitude with regards to the obligation and responsibilities of nurse educators especially those in academia to balance teaching students with practicing as professional nurses. Your ability as a lecturer to balance the demands of academic work with clinical practice. The effects of your clinical competency on your ability to train students to become proficient in their professional practice. The interview will take about 45 -90 minutes. I hope you are ok with it. Thank you for your cooperation. You are assured of your anonymity being preserved and your identity being protected. You are also assured of protection of your right to privacy. Thank you. Questions: 1. What is your view on the allegation that university trained nurses and midwives are not proficient in clinical practice, and that they are afraid to touch patients? 2. May you please tell me whether you believe your students and even graduates nurses really have this problem, and what do you think the cause is? 3. Please tell me your feelings about how the nursing theory and practice gap exist. 4. What do you think is the source of the nursing theory and practice gap problem in Ghana? 5. As a lecturer 88 University of Ghana http://ugspace.ug.edu.gh 2.3. Interview Guide for Student’s Focus Group Discussion Permission: I am a student of the University of Ghana Business School pursuing a Master of philosophy in Health Services Management. I am conducting a research in Balancing of academic work and professional practice. I wish to seek your consent to converse with you about your views concerning your clinical proficiency as university student nurses and balancing of academic work with clinical practice. We will also talk about you views on how the clinical proficiency of your lecturer affect their ability to teach you well and also train you to be proficient in clinical practice. Thank you. Participants; Levels 200, 300 and 400 Student nurses and midwives from a university based training programme. Questions 1. Theory and practice gap. There is a general believe that there is a theory and practice gap among university student nurses , some also say university graduate nurses are not clinically competent. Do you think there is theory and practice gap especially among university student nurses? You are now in training; do you feel you are having difficulty applying what you learn in the classroom to practice? Can you explain your experiences in trying to apply theory to practice? 2. Clinical competency of lecturers and its effect on the training of student nurses a. Do you think it is necessary that your lecturers be clinically competent? b. If yes, how do you know if a lecturer is clinically competent or not? c. How do you think the clinical competency of a lecturer affects his or her teaching? d. Does the clinical competency of your lecturer affect your own acquisition of clinical skills? e. Are your lecturers presently mentoring you to learn nursing skills? 89 University of Ghana http://ugspace.ug.edu.gh f. Do you think it is better the lecturer mentor you in clinical practice rather than preceptors? g. If yes why? 90 University of Ghana http://ugspace.ug.edu.gh APPENDIX B Random Sampling Methodology Table 1.0: List of Lecturers obtained from selected Universities 01 ADJOA 27 KOBINA 02 MARY 28 WORLADEM 03 KWAME 29 SETOR 04 KODJO 30 SEDINAM 05 PEARL 31 SETSOAFIA 06 SELORM 32 FELICIA 07 ELALI 33 BEATRICE 08 ETORNAM 34 JUSTINE 09 MAWULI 35 BRIDGET 10 ABENA 36 CATHERINE 11 AKOS 37 CECILIA 12 EMEFA 38 REGINA 13 GLADYS 39 AGNES 14 LINDA 40 GENEIVE 15 KOKUA 41 JANE 16 ERIC 42 GEORGINA 17 FELIX 43 MAGDALENE 18 JOHN 44 LUCY 19 MAWUNYO 45 BENJAMIN 20 MAWUENA 46 JUSTICE 21 YAA 47 PAUL 22 KWESI 48 MATHIAS 23 SUSAN 49 EMMA 24 DELANYO 50 MANUEL 25 SEDEM 26 SEYRAM 91 University of Ghana http://ugspace.ug.edu.gh TABLE 2.0: Guideline for sampling POPULATION PERCENTAGE NUMBER OF RESPONDENTS SUGGESTED 20 100% 20 30 80% 24 50 64% 32 100 45% 45 200 32% 64 500 20% 100 1000 14% 140 10000 4.5% 450 100000 2% 2000 200000 1% 2000 Source: Stoker (1995) Table 3.0: Table of Random Digits 01 15 22 11 31 47 02 24 12 29 20 23 03 35 40 17 28 14 04 42 49 39 37 53 05 46 51 48 45 06 16 44 52 26 07 32 36 55 34 08 43 27 25 41 09 56 18 30 12 10 33 21 54 38 92 University of Ghana http://ugspace.ug.edu.gh Table 4.0: numbers selected 32 lecturers 22 31 15 47 12 20 24 23 40 28 35 49 37 42 51 45 46 44 26 16 36 34 32 27 41 43 18 12 56 21 38 33 Table 5.0: Table of Sample Members NUMBER NAME NUMBE NAME NUMBER NAME R 22 KWESI 18 JOHN 39 AGNES 14 LINDA 12 EMEFA 21 YAA 48 MATHIAS 53 SELASE 40 GENEIVE 31 SETSOAFIA 52 ERNEST 46 JUSTICE 49 EMMA 20 MAWUENA 34 JUSTINE 16 ERIC 51 MENSAH 28 WORLADEM 41 JANE 32 FELICIA 44 LUCY 37 CECILIA 12 EMEFA 43 MAGDAL ENE 36 CATHERINE 45 BENJAMIN 38 REGINA 56 DANIEL 27 KOBINA 26 SEYRAM 23 SUSAN 33 BEATRIC E 93