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The chapter aims to discuss obstacles that affect the successful implementation of nursing training programs from learner nurses’ perspectives. The scope of the obstacles is limited to the clinical and classroom settings, where the nursing curriculum is implemented, and therefore the chapter will discuss obstacles to the nursing training program in hospitals/clinics and educational institutions. The chapter is a summary of a quantitative cross-sectional research study that collected data from all 190 learner nurses. Learner nurses were sampled with a stratified random sampling, which resulted in 129 samples of learner nurses. An electronic self-designed questionnaire written in English was sent to learner nurses via their university students’ email to complete it. Descriptive statistics were utilized to describe the frequency of learner nurses regarding the R425 program curriculum review. The source of information, in this chapter, is the research finding obtained from learner nurses, using a quantitative research approach and literature, which highlight that the success of health education could be observed when barriers to nursing program implementation have been eliminated. The chapter provides learning opportunities to program designers and leaders of the educational and healthcare facilities where the nursing training programs are implemented.
Department of Nursing Science, University of Limpopo, Polokwane, South Africa
Moila Dimakatso Ophilia
Department of Nursing Science, University of Limpopo, Polokwane, South Africa
Mamare Adelaide Bopape
Department of Nursing Science, University of Limpopo, Polokwane, South Africa
Livhuwani Muthelo
Department of Nursing Science, University of Limpopo, Polokwane, South Africa
*Address all correspondence to: masenyani.mbombi@ul.ac.za
1. Introduction
Nursing training programs play a significant role in the healthcare and educational sectors across the globe, especially since nurses continuously contribute significantly to the healthcare system [1]. At the moment, there are more than 20 nursing training programs (undergraduate and postgraduate) in existence with different significant roles in the healthcare and educational sectors. For instance, the bachelor of nursing and midwifery training program in South Africa train fundamental and general nursing care of individuals with different needs at hospitals, clinics, and occupational industries, while aiming to produce competent professional nurse and midwifery practitioner competent to function in a global context [2, 3, 4]. In contrast to this, a basic nursing program could be an intensive care nursing training program (post-basic course), which provides specialized nursing care based on the knowledge and skills of severely ill patients [5]. In South Africa, most matriculates aspire to study the bachelor of nursing and midwifery for employment purposes, while those who completed an undergraduate nursing program demonstrate intense ambitions to study post-basic courses (e.g., intensive nursing care, operating theater, trauma nursing care, and post-graduate qualifications—honors, masters, and PhD), which satisfies the career development desires [6]. However, these ambitions remain a dream for many candidates and professional nurses because of obstacles in the nursing training programs. This chapter focuses on perceived obstacles of learner nurses in the bachelor of nursing and midwifery (honors level).
To guide the process of identifying the obstacles in nursing training, we applied only 10 criteria by the council on higher education’s programme accreditation of South Africa [7], which Flott and Linden [8] mentioned two environmental settings that affect the learning outcomes of the training program (classroom and clinical learning). So far, we observed unclear goal settings by candidates for studying and selection criteria for access to nursing programs in higher educational institutions as dominant obstacles in the nursing training program [9]. The chapter discusses obstacles existing in the nursing training program following the perceptions of learner nurses regarding the curriculum of bachelor of nursing and midwifery at a selected higher education institution. Notably, there are diverse benefits inherited from the nursing training programs. For instance, having more competent nursing professionals that impact positively the healthcare services provision, increases nursing staff establishment and relief of staff workload [10], and reduces high mortality [11]. Carbajo et al. [12] noted that competent nursing professionals have a significant role in improving quality healthcare service delivery and also preventing and treating disease occurrence.
According to De Rosis et al. [13], user experiences in the training program are a key element for improving quality service delivery. The findings of the study assist in improving the designing curriculum of the nursing training programs, and its implementation within higher educational institutions and clinical healthcare facilities. We believe that failure to understand the obstacles in the nursing programs could have detrimental effects on higher education and healthcare facilities. For example, one notable effect could be defeating the plan of action for scaling up quality nursing and midwifery education and practice for the African region 2012–2022 [6]. Also, we believe that learner nurses’ perspective as recipients of the training programs provides an opportunity for nursing educators and institutions to monitor the quality and outcomes of the nursing training programs. Therefore, the chapter discusses the obstacles in the nursing training program—bachelor of nursing and midwifery from learner nurses’ perspective about the curriculum using a quantitative research approach at selected higher educational institutions in South Africa.
The study employed a quantitative research approach to collect numerical data from learner nurses on the selected criterion for program review [14]. The quantitative research approach assisted the authors in quantifying the perceptions of learner nurses regarding the criterion for the B. Nurs R425 curriculum program.
2.2 Research design
We adopted a cross-sectional descriptive design, which is observational and collects data from a group of learner nurses at one point in time [15]. A cross-sectional descriptive research design was used to examine the perceptions of learner nurses regarding the R425 curriculum program in the Department of nursing science.
2.3 Population and sampling
A total of 190 learner nurses from the second level to the fourth level studying for the bachelor of nursing science program (R425) in the academic year 2020 constituted the population of the study. The three levels of study were the last group for training the curriculum of the R425 program in the Department of Nursing Science. Since learner nurses were from different study levels, the stratified random sampling method was the best relevant method to sample 129 learner nurses according to the Slovin formula for calculating the sample size.
2.4 Data collection and analysis
An electronic self-designed questionnaire was used to collect data from the learner nurses. The literature and criterion of CHE guided the development of the questionnaire, which was pilot tested on five learner nurses who did not form part of the study in the same study setting. An english-written electronic questionnaire was chosen because of its ability to increase the rate of responses and the quality of responses. Learners took 10 to 20 minutes to complete the electronic questionnaire. Descriptive statistics on SPSS version 27 were used to analyze the perceptions of learner nurses about the nursing training program, and which statistician took a month to return the analysis results. Summary statistics of descriptive statistics was the perfect analysis method to compare the mean regarding perceptions of learner nurses on the selected criterion for program evaluation as listed by CHE.
The study had more female learner nurses (76%), who responded to the study than male learner nurses (24%)—see Figure 1. The gender profile of nursing professionals is consistently dominated by female professionals.
Figure 1.
Gender profile of learner nurses.
3.1.2 Level of study
The year 2020 had only three study levels for the R425 training program, hence we present the respondents according to their study levels. Based on Figure 2, most learner nurses who responded were in the 3rd level of study in 2020 making 59.7% of the study, learner nurses who were in their 4th level of study made 27.1%, and 13.2% learner nurses were in their second level of study.
Figure 2.
Study level of learner nurses.
3.2 Perceptions of learner nurses according to the selected criteria of the council on higher education’s programme accreditation
The following sections illustrate obstacles identified from selected criteria of the council on higher education’s programme accreditation, which was applied to describe learner nurses’ perspectives regarding the bachelor of nursing and midwifery curriculum. The obstacles were identified and quantified by 129 learner nurses of a selected higher educational institution with the use of a questionnaire. The quantitative data were analyzed using descriptive statistics as facilitated by SPSS version 27 software.
3.2.1 Lack of a clear study goal for the bachelor of nursing and midwifery
We investigated learner nurses’ perspectives, regarding a reason for studying bachelor of nursing and midwifery, which is not part of the accreditation criteria. Surprisingly, only 8.5% of learner nurses said they were studying a bachelor of nursing science because it is their calling, with the remaining 91.5% of learner nurses, indicating that they chose the training program for career purposes and lack a better choice for studying at a higher educational institution.
Figure 3 illustrates that most learner nurses chose to study bachelor of nursing science for a career purpose, which was expected considering the low employment rate among youth in South Africa. Based on these findings, we construe that the lack of a study goal that aligns with the nursing profession is an obstacle within the nursing training program. Raatikainen [16], in describing the nursing profession as a calling, noted that nurses who studied nursing, because it was a calling, were more devoted to their work, which translates to the provision of high-quality nursing care. Although many young people chose a study program because of employment opportunities [17], this study motive is perceived as an obstacle for the nursing profession that is described as a calling profession.
Figure 3.
Reasons for studying the R425 nursing program.
The results presented below are based on the selected Criterion for program review according to CHE. Table 1 below illustrates these selected criteria for program review.
D
N
A
2. Criterion 2: student recruitment, admission, and selection
2.1. The minimum requirements required by UL for students to qualify to study for the bachelor of nursing science program are fair.
46%
10%
54%
3. Criterion 3: staffing
3.1. There is enough staff to facilitate learning in both theory and practice within the nursing department at UL.
40%
14%
56%
4. Criterion 4: program coordination
4.1. Hours required by the nursing council (SANC) are prioritized over anything else.
10%
25.6%
63.4%)
4.2. Time allocation for clinical learning is adequate for us to learn the outcomes of the level of study.
80%)
6.3%
13.7%
5. Criterion 5: teaching and learning
5.1. Modules offered at UL from levels 1 to 4 of the bachelor of nursing science program all contribute to the production of competent registered nurses(RNs).
70%
13%
17%
6. Criterion 6: learner assessment
6.1 I get feedback on our work and then do corrections with our facilitators.
52%
10%
38%
7. Criterion 7: infrastructure and resources
7.1. There are enough resources for me to practice the procedures demonstrated.
56%
10%
44%
7.2. Our skills lab is structured in a way that is convenient for me to practice the procedures demonstrated by our facilitators.
66%
0%
44%
7.3. The capacity of our skills lab is sufficient enough to accommodate all learners and makes learning easier.
56%
10%
44%
8. Criterion 8: coordination of experiential learning
8.1. My lecturers and registered nurses are always there for us at our practice area to help and support us to abide by our scope of practice.
51%
6%
43%
9. Criterion 9: learner retention, student throughput, and program impact
9.1. The program has high expertise within the department.
76%
2%
22%
9.2. The second level of nursing science is a the level where most students fail a subject and carry it to the next level.
2%
0%
98%
10. Criterion 10: program reviews
10.1. Nursing has not been able to prepare adequately prepared nurses to provide safe high-quality services.
58%
8%
34%
10.2. It can be beneficial to the nursing department, the university of Limpopo, SANC, and the health care system at large to review the bachelor of nursing science program.
45%
47%
8%
Table 1.
Perceptions of learner nurses based on criteria.
3.2.2 Criterion 2: student recruitment, admission, and selection
According to council on higher education accreditation criteria, criterion 2 focuses on “recruitment, access, and selection procedures are effected in line with the University’s policies and procedures. They are appropriate for the program’s academic requirements, within a framework of widened access and equity. The number of students selected takes into account the program’s intended learning outcomes and its capacity to offer good quality education.” Learner nurses (56%) perceived one of the minimum standards of criterion 2 (requirements for admission) as an obstacle to the nursing training program. For instance, A total of 89% of learner nurses confirmed that minimum requirements constituted by high levels in mathematics and physical science are an obstacle for many matriculates’ to pursue a bachelor of nursing and midwifery. The concern about minimum requirements for nursing qualifications has been discussed by several authors [9, 18, 19, 20]. The findings indicate continuous trends of concern regarding minimum entry requirements that require urgent attention.
3.2.3 Criterion 3: staffing
We acknowledged the role of staffing in ensuring good outcomes of the nursing curriculum by asking how learner nurses perceived staffing for support of their classroom and clinical learning for the bachelor of nursing and midwifery training program. A total of 54% perceived staffing as inadequate to support their clinical learning for the bachelor of nursing and midwifery training program. Furthermore, learner nurses perceived modules facilitated by one nurse educator as a barrier to their learning. Similarly, Mlaba and Emmamally [21], with other scholars [22, 23, 24], also reported inadequate clinical staff support and a lack of clinical educators for mentoring learner nurses’ clinical learning as an obstacle within the nursing training program.
3.2.4 Criterion 4: program coordination
Criterion 4 ensures that the program is effectively coordinated to facilitate the achievement of its intended purpose and outcomes. The majority of learner nurses (63.4%) reported a concern regarding one of the minimum standards—stating that the regulatory body (South African nursing council) requires lots of clinical hours, which is a challenge to accumulate due to various factors. Learner nurses (86.3%) also reported concern about the duration of clinical allocation, which is perceived as short to meet the required clinical hours. In contrast, the South African nursing Council (SANC) requires 4000 clinical hours in clinical learning experiences under supervision over four years for a bachelor of nursing and midwifery [2]. There are fewer or limited scholarly studies that aimed to challenge the requirement of SANC.
3.2.5 Criterion 5: teaching and learning
The majority of learner nurses (83%) reported that some of the modules offered from levels 1 to 4 for the bachelor of nursing and midwifery program seem to be not related to the nursing profession. For example, learner nurses struggle to understand why their training program requires them to study chemistry and sociology. Learner nurses expressed concerns as they fail these modules offered outside the nursing disciple than those under the nursing. Similarly, Lewis [25] deliberated on the implications of failing modules, which included emotional, social, and financial consequences as well as the impact on the student, institution, and nursing profession at large.
3.2.6 Criterion 6: learner assessment
Suganya [26] explained that feedback is one of the essential components of the nursing curriculum. For the feedback to be effective, it should be given in a regular manner and in a supportive environment. However, our findings demonstrate that 62% of learner nurses fail to receive assessment feedback, thus being an obstacle to the successful implementation of the nursing training program. Nursing educators and supervisors should ensure they provide feedback promptly and specific to the learner’s performance. Specific and high-quality feedback comments make feedback effective and valued by the learner nurses when compared to nonspecific evaluative feedback [27]. It provides an opportunity to self-assess their skills and capabilities and also it provides direction that increases motivation, confidence, self-esteem, cognitive skills, and behaviors. Effective feedback gives confidence and reassurance to the learner nurses. So, nursing professionals should give importance to feedback in their learning process and implement a mechanism by which the quantity and quality of the feedback are monitored [26].
3.2.7 Criterion 7: infrastructure and resources
The criterion requires that suitable and sufficient venues, IT infrastructure, and library resources be available for students and staff in the program. Efficient provision of infrastructure and resources is needed for the proper implementation of the nursing training program by creating well-established academic support centers [28] and keeping up with the demands of the healthcare system [6]. Leary et al. [29] also note that the provision of adequate infrastructure and resource allocation is a strategic way for enhancing the innovation of the nursing training program. Pesut and Greig [30] emphasized that the existence of proper resource allocation has fruitful results in the implementation of the nursing training program. However, most learner nurses (66%) perceived infrastructure design and allocations of resources (staff and materials) as not adequate to assist them with their learning needs. In contrast, Mothiba et al. [31] regarding the role of infrastructure in the nursing program noted a diverse positive impact of the newly established clinical skills laboratory on the clinical learning of learner nurses in the study setting. Therefore, inefficient provision of proper infrastructure and resource allocation hinders the successful implementation of the nursing training program. Subsequently, this deters the plan of action for scaling up quality nursing and midwifery education and practice for the African region 2012–2022, which requires adequate resource allocation. There is a continuous need for nursing regulators, institutions/schools, and educators to invest in proper infrastructure and adequate resource allocation to ensure effective implementation of the nursing training program.
3.2.8 Criterion 8: coordination of experimental learning
According to the council on higher education of South Africa, criterion 8 ensures that the coordination of work-based learning should be done effectively in all components of applicable programs. This includes an adequate infrastructure, effective communication, recording of progress made, monitoring, and mentoring. Learner nurses (51%) reflected a shortage of clinical nurse educators that impact negatively on clinical learning. During the clinical exposure, most learner nurses reported monitoring and mentoring for clinical learning. Clinical learning is a significant component of the nursing training program, as such, failure to achieve the component defeats the purpose of the whole nursing training program. Flott and Linden [8] reported similar concerns, regarding factors that influence clinical learning, including the physical space, psychosocial and interaction factors, the organizational culture, and teaching and learning components. Najafi Kalyani et al. [32] reported inadequacy of the educational environment faced by learner nurses that resulted in “confusion of professional identity.” The aforementioned authors emphasized improving the clinical environment by identifying professional models and increasing their influence on management, education, and clinical education.
3.2.9 Criterion 9: learner retention, student throughput, and program impact
The criterion indicates that the program should take steps to alleviate shortages of expertise in relevant nursing, in cases where these are the desired outcomes of the program. However, learner nurses (76%) reflected that this is not the case within the nursing training program, where expertise is sourced outside the department. For example, expertise in sociology, chemistry, physiology, anatomy, and psychology is offered by non-nursing professionals. Sourcing of expertise outside the department contributed to the slow throughput rate of the nursing program, with more learner nurses failing at the second level. Therefore, failure to alleviate shortages of expertise is an obstacle for the nursing training program. Similarly, Fawaz et al. [33] noted the desire for growing nursing experts that occurred from a shift in the age of the nursing workforce to ensure the successful implementation of the nursing training program.
3.2.10 Criterion 10: program review
Nursing programs aim to prepare nurses who can deliver safe and high-quality care and would be able to adapt to the evolving environments of practice. However, according to learner nurses (58%), nursing has not been able to prepare adequately prepared nurses to provide safe high-quality services due to various factors that impacted the implementation of the nursing program. A few of these various factors include an increased disease burden, an overloaded healthcare system, and a shortage of nurses in schools and clinical healthcare settings. Few of the learner nurses (8%) expressed the desire of having program evaluations annually to improve the implementation. To adapt to the rapidly varying and advancing healthcare settings; nurse educators must regularly assess and review education curricula, teaching-learning strategies, and programs [33].
To our best knowledge, this chapter presented a unique perspective of learner nurses based in a rural university regarding the implementation of the nursing training program using selected criteria by CHE in South Africa. Based on the selected criterion of the council on higher education, there are obstacles to the implementation of the nursing training program, which indicate the required support from different stakeholders involved in nursing education. We recommend that program designers and educational and healthcare managers consider these obstacles in the nursing training program as a baseline reference for a successful implementation of the program.
We would like to acknowledge the learner nurses who participated in the study. Also, to the faculty of health sciences at a selected university for granting permission to conduct the study.
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