Teaching methods in community health nursing clerkships: experiences of healthcare staff in Iran

Purpose: Healthcare staff educate nursing students during their clerkships at community health nursing programs. Their teaching methods play an important role in nursing students’ acquisition of competencies; however, these methods have not been studied thoroughly. Thus, this study aims to describe, interpret, and understand the experiences of healthcare staff’s teaching methods in clerkships at a community health nursing program. Methods: This study was conducted using purposeful sampling and semi-structured interviews with 13 members of the staff of three urban healthcare centers in Iran. The data were analyzed through qualitative content analysis and thematic analysis. Results: Multiplicity of teaching was identified as the main category of teaching method, and the five subcategories were teaching through lecture, demonstration, doing, visits and field trips, and readiness. The most common method used by the healthcare staff was lecturing. Conclusion: The healthcare staff used multiple methods to teach students in the nursing clerkship of the community health program, which was the strength of the course. However, they should be familiar with, and utilize additional methods, such as discussion rather than lecture.


INTRODUCTION
Healthcare systems are shifting nursing activities from hospitals to homes, schools, industries, and community healthcare clinics [1,2]. Community health nurses play many roles such as coordinator, manager, and educator [3]. The healthcare staff educates students to learn how to apply theoretical knowledge to nursing practice [4]. The staff's teaching methods are important for students' acquisition of nursing compe-tencies. Their activities to prepare students for clinical experiences and their willingness to accompany students on visits with clients, improve students' learning [5], if they establish a close relationship with the students [6]. Nursing students enroll for 4 credits of clerkship experiences in the community health nursing courses, in accordance with the nursing curriculum. They register for 1 academic credit in their 5th semester to complete a clinical rotatin in an urban healthcare center for 10 days, from 8 am to 1 pm. The students also obtain 3 academic credits in their 8th semester. They spend 3 weeks in urban centers and 2 weeks in rural centers to fulfill the course objectives. The community healthcare centers offer several services to clients, including vaccinations, maternalneonatal care, and environmental health. Therefore, it is im-possible for instructors to be in all sections simultaneously. Consequently, the healthcare staff has been delegated to be responsible for nursing students' education. There are some controversial issues about teaching methods in clinical and community-based centers. Most of the staff have not been educated formally to educate students; and perhaps, they are unfamiliar with teaching strategies and methods. The healthcare staff members often employ teacher-centered methods, and use teaching skills incompetently in pre and post-conferences [7][8][9]. However, some researchers have reported that staff utilizes a multiplicity of teaching methods [10], such as demonstrations and involving students in real and practical situations [11].
If staff members are not qualified, many problems may arise in the clerkship community healthcare courses. The students might consider the courses as a 'break' or time for 'fun, ' and be unproductive. They might feel that supervision is lacking, lose their motivation to actively participate, or be unable to deliver nursing services outside of the hospital. In addition, they may identify a gap between theory and practice, and feel pessimistic about the clerkship period [1,[12][13][14]. Therefore, it is necessary to gain in-depth information about how the healthcare staff teaches the students in the community healthcare fields through a qualitative research study. This study aims to describe and interpret the staff's experience with teaching methods in clerkship courses.

METHODS
This qualitative study used content analysis, which is the process of understanding, interpreting, and conceptualizing meanings in the qualitative data of the participants [15]. Content analysis is useful for the investigation of phenomena that have not been studied in-depth [16]. This study investigated the staff's experiences with teaching methods in clerkships of community health nursing courses in healthcare centers in 2011 to 2012.
The current study was conducted in urban healthcare centers in Mashhad, Torghabeh, and Shandiz, Iran. The inclusion criteria were at least 1 year of educational experience and a willingness to participate in the study. The participants were 13 healthcare staff working in vaccination, maternal-neonatal, midwifery, environmental health, and rural healthcare centers. They were married, aged 40 to 50 years (mean age, 43.6 years), with an average of 18.4 years working experience. The sampling method was purposive. A semi-structured interview was conducted for 45 to 60 minutes with each participant. The interview began with the general question: "How do you teach your students?" Subsequent questions focused on more specific issues, such as "How do you teach vaccinations?" The in-terviews were taped using a digital recorder in the participants' workplace and then they were transcribed. The participants were encouraged to express their experiences and feelings freely about teaching students. Probing questions were used to gain a deeper understanding of the information, and included questions such as, "Could you explain more on this issue?" or "What do you mean when you say___?" Sampling continued until data saturation was achieved. The data were analyzed using thematic analysis. The steps of the analysis were open coding, and developing classifications and abstractions. The interviews were read thoroughly several times, line by line, to extract the primary codes, which were then classified in the same group. Reviewing group codes led to forming initial categories, in which similarities, differences and main categories were identified. The categorization designates the meaning of phenomena to improve understanding and to produce knowledge. After data coding and categorization agreement were completed, each category was studied for saturation [16]. After a prolonged immersion in the data throu gh several readings, the participants (staff members) checked the extracted data to verify that it matched their experiences. Peer debriefings were used as a method to ensure the rigor and the trustworthiness of the findings.
The approval for this study was obtained from the School of Nursing and Midwifery. One of the study' s researchers described the study objectives to the participants before obtaining their written consent forms.

RESULTS
The data analysis revealed that multiplicity of teaching methods was the main category. The subcategories included lecture, demonstration, doing, visits and field trips, and readiness.

Multiplicity of teaching methods
Multiplicity of teaching methods was the main category of educational methods used in the clerkships. The staff used different methods, including lecture, demonstration, doing, visits and field trips, and readiness, based on the facilities, services, and their own capabilities.

Lecture
The lecture was the most common method of teaching in the healthcare centers. The staff usually lectured when students first entered the healthcare center to introduce them to the center's potential for learning experiences during the delivery of services to the clients: We teach students that what we do is environmental health. Our work process and the tasks of each person who works in this field are taught in detail. All of them are described to the http://jeehp.org students. Indeed, I try to talk about diseases, because students are interested in them. When I teach a mother how to take pills in the presence of the students, I am more descriptive because the students learn more.

Demonstration
The staff used demonstrations to explain and show procedures in a step-by-step and gradual manner, before permitting the students to perform the procedures, such as vaccinations and measuring the heights and weights of children. Demonstration was the teaching method that was used most often for vaccinations and procedures in the midwifery sections: If the day's work assignment is allocated to child monitoring, we should measure height, head circumference, and the weight of the child in the presence of the students. The skills are demonstrated practically in the midwifery section. The student watchesand sees how we work.

Doing
The staff assisted the students in providing services to the clients from the different units. They taught skills and shared their experiences with the students. The staff delegated tasks based on the students' capabilities. For example, the students independently performed school health activities. However, they were prepared before doing any task independently in the vaccination unit: We try to share with students, information about preparing and completing files and managing clients. Every student goes to class and teaches clients about personal health and does dental, skin, and hair examinations. They go to the stores to check for expired goods and to see whether the shopkeeper has discarded them or not. When we are sure that students can vaccinate, this task is delegated.

Visits and field trips
The staff along with students, visited factories, stores, schools, and homes to understand the real atmosphere, events, and activities of the people. They also explained practical issues during the visits: Students visited water sources, carpentry workshops, and grocery stores. We visited important places, such as confectioneries, diary stores, and major restaurants that serve large volumes of food. Then, based on regulations, we taught the students about the personal health of workers; then the students explained environmental health and sanitation practices to the workers. We went to school with the students. We also visited diabetic and hypertensive families, and ion other days, we also visited families who had small children, for the family planning program.

Readiness
The staff performed different activities to prepare for the students' education, including student orientation, primary education, encouragement, control, and supervision: One of the strategies is to orient students. I explain the different sections of the healthcare center to them so that they are familiar with the section's tasks and routines. I explain their routines. I tell them about the prevention disease section and its responsibilities. In primary education, the staff attempted to do tasks first to prepare students. They vaccinated clients during the first days of the clerkship until the students were ready to do them: When students enter, there usually are one or two of them. I explain the registries to them, and then the procedures are taught. First, we do several injections. The staff tries to encourage the students in the clerkships of community health nursing. We try to discover what' s happening in students' minds; we encourage them based on their interests in the work. The participants continuously supervised and controlled the students' activities to correct or prevent possible problems: We should supervise students for vaccine storage conditions, based on maintaining the cold chain inside the refrigerator, outside the refrigerator, and during the injection. This knowledge reflects our supervision.

DISCUSSION
The staff used multiple teaching methods in the healthcare centers based on the nature of community health nursing education and the characteristics of available facilities. The results are in line with Hossein et al. [10]'s study. In clerkships for community health nursing, three domains of learning, including cognitive, affective, and psychomotor are considered simultaneously. Thus, each domain needs an appropriate method or more methods. In fact, learning objectives determine teaching methods for the most part.
The lecture was the dominant method for teaching. The staff lectured students on theoretical issues when they were free and not engaged in doing clinical activities on the units. The results support the findings of the studies by Mtshali [7] and Darvish Ghadimi and Roudbari [11]. The lecture is a teacher-centered method and does not facilitate comprehensive learning in students who are often passive and do not acquire the necessary competencies. However, the other methods, including demonstration, doing, and visits and field trips, directly involved students in the practical issues of the client.
In the student-centered approaches, learners actively participate in the process to acquire critical thinking, self-directed learning, communication, and teamwork skills [7,11,17]. Nursing students prefer and are satisfied with teaching methods that involve them actively in the learning tasks [18]. The staff attempted to prepare students in an educational atmosphere through primary education, orientation, encouragement, control, and supervision. These interventions provide an improved and low-stress educational atmosphere, and they increase the students' satisfaction with time management, understanding of professional responsibilities, learning of clinical skills, and quality of education. The findings are in agreement with Molabashi et al. [8]'s and Hossein et al. [10]'s studies. However, the results contradicted the study by Molabashi et al. [8], in which the majority of teachers had no direct supervision of the students [19]. The contradictory findings could be due to the personal characteristics of the staff, such as their responsibilities and different motivations.
In conclusion, the staff educated students using a mixedteaching method. The teacher-student-centered approaches could be considered as the strength of the clerkships for community health nursing education. It seems that demonstration along with a review of the theoretical subject areas is an effective method of education. The field trips and visiting programs increased the efficiency of staff in teaching and changing students' attitudes about providing services to the community. The findings revealed data not only for staff and instructors, but also for the education authorities to provide an atmosphere for staff and students to acquire as many competencies as possible. It is recommended that future studies investigate the experiences of both teachers and students.