Clinical Nursing Teaching in Saudi Arabia Challenges and Suggested Solutions

Aims: To discuss the recent barriers and challenges facing nursing clinical teaching in Saudi Arabia and suggest solutions to overcome them. Background: The issues affecting nursing education today are increasingly complex and dynamic. Clinical teaching is one of the most important academic and health professionals’ components and should be given utmost consideration to cope with the recent requirements of nursing education. Discussion: The clinical teaching lacks effectiveness which indicates a need for more active clinical setting to be able to make the theoretical components come alive in the practice and enthuse students. Clinical teaching in Saudi Arabia suffers from the lack of coherent theoretical base necessary to inform students. Also, the lack of substantial research in the area of clinical teaching suggests that the clinical nursing teaching has been neglected. Conclusion: The rapid increase of the nursing students’ admission cannot be met with the limited number of clinical preceptors. The lack of preparing nursing clinical preceptors will impact negatively on the teaching process. Potential challenges related to the clinical educator and nursing students might act as a obstacle toward achieving a good environment for clinical teaching. Implication for nursing practice: Nurses provide the majority of patient care therefore; they must be empowered with good preparation to improve care and service in order to maintain quality of patient care. *Corresponding author: Abbas Al Mutair, Mohammed Al Mana College for Health Sciences, Ministry of Education, Saudi Arabia, E-mail: abbas4080@hotmail.com Received September 14, 2015; Accepted November 09, 2015; Published November 17, 2015 Citation: Mutair AAl (2015) Clinical Nursing Teaching in Saudi Arabia Challenges and Suggested Solutions. J Nurs Care S1: 007. doi:10.4172/2167-1168.S1-007 Copyright: © 2015 Mutair AAl. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

1. The rapid increase of nursing students necessitates recruiting clinical nurse preceptors.
2. Nurse clinical preceptors have a critical role in developing the clinical knowledge, experience and skills of the nursing students.
3. Nurse clinical preceptors should be clinically competent, of high quality teaching skills and relationship with students.

Background
It has been more than 50 years since the establishment of the first nursing institute in 1959 in the Kingdom of Saudi Arabia. It was a two year training course which gave the graduates license to work as a nurse assistant. In 1992 the Ministry of Health had opened the first college of nursing in the Kingdom which was a three year course which licensed the graduate to work as a nursing assistant. Prior to that the Ministry of Higher Education had opened the first bachelor of nursing program in 1976. The course duration is five years and offered in three universities. Also, in 1987 the nursing faculty of King Saud University in Riyadh started to offer the Master of Nursing program. Then, King Abdulaziz University in Jeddah in 1994 cooperated with some British Universities to offer PHD program in nursing for the master holders.
The Saudi nursing curriculum is covered over 5-year period (10 semesters) for bachelor degree of which is allocated to classes, laboratory work and clinical practice. Clinical practice is conducted 2 to 3 days per week throughout the semester. The composition of the nursing curriculum is influenced by university, faculty and nursing requirements. University requirements may include courses such as English, Islamic Studies. Faculty requirements may include courses such as Biology, Chemistry, Physics, Nutrition and Pharmacology.
Nursing requirements include all courses related to preparing students for the nursing profession and licensure.
In Saudi Arabia, clinical placement starts only during the second year of the undergraduate nursing programs. Students are also required to complete a comprehensive clinical placement during the last two semesters of the 5-year program. During this time, students are rotated to the different specialties of clinical practice. The first year of the program concentrates on core courses required by the university. During this first year, students attend clinical laboratory sessions where they are taught basic nursing skills in preparation for clinical placements in their second year.
Clinical teaching is carried out by both male and female clinical teachers who liaise closely with the course coordinator. They are required to have completed the university undergraduate nursing degree program and at least 3 year of post-registration clinical experience. Nursing lecturers (those who teach the theoretical component of the course) may hold a master or doctoral degree in nursing and should have a good clinical experience. Students are assigned to different clinical teachers for each clinical placement throughout the semester.
Graduating clinically competent nursing students is probably the principal objective of curricula and clinical teachers [1]. Nursing education consists of theoretical knowledge combined with clinical practice [2]. Nursing students require more than the traditional theoretical classroom teaching as there is so much in the nursing field that is best learned by doing not just talking [3,4]. Clinical practice increases nursing students' knowledge, and their capacity to synthesize theoretical knowledge and nursing care according to Addis and Karadag in 2003. Also, the main factor in the development of nursing capabilities is close observation of clinical practice. In line with Florence Nightingales ideals, clinical teaching that is teaching and learning focused on, and usually directly involving patients and their problems lies at the heart of nursing education. Clinical teaching in nursing has been defined as the mode that provides students with the opportunity to translate theoretical knowledge into the learning of a variety of skills required to give patient-centered care [5]. The main aim of clinical education is to provide students with necessary competencies in both nursing and clinical skills.

Clinical Nursing Challenges
Clinical teaching internationally is seen internationally as an important part of nursing education.. The literature suggests that clinical learning is affected by many factors, including the quality of supervision and feedback, and characteristics of learners and teachers [6]. Nursing education receives surprisingly little attention from the nurse educators in Saudi Arabia (SA). It suffers from the lack of coherent theoretical base necessary to inform participants. There is also lack of substantial research in the area of clinical teaching which is the 'heart' of students' professional nursing education [7]. The clinical teaching in SA lacks effectiveness which indicates a need for more active clinical setting to be able to make the theoretical components come alive in the practice and enthuse students.
Teaching in the clinical environment in SA has many challenges such as time pressure which is everyone's enemy. Also, there are potential problems and deficits which might act as a barrier toward achieving a good environment for clinical teaching. These barriers can be divided into two parts; some are related to the clinical teachers while the others are related to the students. Problems encountered by clinical teachers include lack of clear objectives and expectations and inadequate supervision and provision of feedback. Students may have little opportunity for reflection and discussion and lack of congruence or continuity with the curriculum.
A further problem is that the number of clinical teachers in the clinical areas is less than required compared to the number of students. As shown in the Figure 1, the rapid increase of admission of nursing students of one of the nursing schools in SA which cannot be met with a limited number of clinical preceptors.
Furthermore, Most of the clinical preceptors lack the competence to employ effective learning strategies by being able to employ teaching methods, display solid communication skills, and have the ability to motivate students which have impacted negatively in the teaching process. The lack of adequate preparation of clinical instructors before they embark on teaching impacts greatly on the teaching learning process. Clinical educators must know what kinds of experiences facilitate or hinder the learning process [8,5]. The educator's selection of learning theories and structure of the learning experience become important in this realm. To be effective, educators must have knowledge of materials to be learned, the learner, the social context, and educational psychology [8] (Figure 2).  With respect to learning, learners' readiness has direct effect on the teaching process. This can inhabit students' enthusiasm to participate actively in the learning process. Readiness to learn can be defined as 'the time when the learner demonstrates an interest in learning the type or degree of information necessary to become more skilful in job' [9]. Therefore, the lack of the nursing students' enthusiasm prevents them from the participation in the teaching process. Moreover, clinical area is a place of multiple languages. With English as the language of communication, Saudi students find it hard to communicate using English language in open and busy areas like hospitals. Despite the fact that the entirely nursing curriculum program is instructed by English language students find it difficult to communicate in English. Students prior to college enrollment do not have sufficient exposure to the English language and English is not taught intensively to enable them to use it in sophisticated manner later in workplace [10]. Accordingly, the process of transferring, understanding and receiving information among students and other hospital workers is being affected due to the English language proficiency of many nursing students.

Role of Clinical Nurse Preceptor
The clinical preceptor has a crucial and essential role in developing the clinical knowledge and skills of the nursing students, as a large part of their education involves clinical practice. Clinical preceptors have a dual function care of patients and care of learners. Moreover, growth in applying the theoretical knowledge and skills in the clinical setting is a major task for clinical nurse teacher. In addition, the clinical instructor plays an important role in providing appropriate information which is suitable for the clinical part. Also, he or she gives feedback to the student and provides follow up support. The clinical instructor evaluates the student abilities and reinforces learning and the performance skills. They also can play an important part in the developing and enhancing student's self-confidence and learning outcomes. According to Reilly and Obermann in 1992 clinical teaching is a form of interpersonal communication between two people a teacher and a learner. Hence a clinical teacher may reduce the student's anxiety and promote the student's ability to apply energy creatively and to achieve learning goals.
Clinical teachers were described as caring mothers in their caring roles in guiding, supporting, informing, translating, sustaining, negotiating, reinforcing, transforming and releasing nursing students through their clinical practice [11]. The role of the clinical teacher is very important in facilitating nursing students' learning, especially in the clinical settings where uncertainty abounds. The "caring mother" role of the clinical teacher enable students to become actively responsible for making learning a formative, stimulating experience [11].
The roles of clinical teaching members could be summarized as to be skilled, experienced nurse to maintain and improve standards of patient care [4]. The clinical instructor should be concerned to help learners develop their potential as nurses [4]. This could be achieved through building good relationships, counseling supporting and advising. They must demonstrate expertise in caring for patients because patient's life or certainly his well-being could be at risk according to [4]. They also must show skills in teaching create a positive climate for learning and be alert to the learning opportunities in the ward [12].

Strategies to promote positive learning environment in the clinical setting in SA
Effective clinical nursing teaching requires good personal characteristics by educators to promote teaching-learning process as well as nursing competence, knowledge, clinical expertise and personality. Accordingly, Clinical teachers should be as role models while supervising students and show that they are prepared for teaching. They must also set an example in the clinical fields. It is important to remember that the quality of student learning is dependent not only on the type of clinical experience but also on the characteristics and skills of the teacher who facilitates that learning [13]. In order to correlate theory with practice students need to gain self-confidence and selfesteem [14]. Hence, to accomplish an effective learning environment in Saudi Arabia, three strategies could be followed. These strategies include knowledge and clinical competence, teaching skills and relationship with students.

Knowledge and Clinical Competence
Clinical teacher must have mastery knowledge of the subject matter. He/she should have surrounded broad knowledge which links between the various theoretical knowledge students have learned in the classroom and the practical milieu. For example, say the student has just collected a urine sample from a patient, He/she could be asked to explain the anatomy and physiology of the kidneys and common microbes found in urine. This transfer of learning and connection could be drawn from their Human Biology and Microbiology lectures [5]. Through this students will capture what it would have been like for them to conduct an intimate procedure. Though, the clinical teacher's theoretical and clinical knowledge if used in the practice of nursing and attitude toward the nursing profession will influence the teaching effectiveness.
Like knowledge, the effective clinical teaching requires competence in clinical nursing practice as well. The maintenance of clinical competence is essential in assisting students in development of knowledge and skills and providing expert supervision in clinical setting [15].

Teaching Skill
Clinical is the only setting in which the skills of history taking, physical examination, clinical reasoning, decision making, empathy, and professionalism can be taught and learnt as an integrated whole. Therefore, an effective teacher should present information in an organized manner, gives clear explanations and directions to students, answers questions clearly, and demonstrates procedures and other care practices effectively [15]. Good teachers also, clarify ideas, emphasize important points during teaching and motivate students through active participation throughout their teaching practices. Furthermore, in clinical setting teachers may need to assimilate knowledge starting from the specific towards the general. For example, when teaching about diabetic care, the teacher needs to focus on a specific care required by a diabetic patient such as how to actually administer the insulin injection rather than teaching about the general care of a diabetic patient [12].
In addition, clinical teachers need to identify individual student needs and learning styles and plan supervision accordingly. An example was given by Henderson in 1995, students with a predominately extroverted personality may in their zest to please the teacher state that they understand something being explained when in actual fact they do not understand. Teachers who do not pick up on this may fail to facilitate meaningful learning. One strategy that Henderson has mentioned with extroverted students is to get them to present to their peers what they have understood from the teacher's explanation. Similarly, introverted students may appear to be disinterested and being uninvolved because of their quiet and introspective manner. This is not usually the case and all the teacher needs to do is to gain their trust and give them more time to 'open up' and provide opportunities for them to share their knowledge with others adds Henderson in 1995.

Relationship with Students
Facilitating learning involves interacting between teacher and students and the ability of the teacher to interact with students is a very critical teacher's behaviour. A study by Kuo and Kao in 2006 aims to understand the current status of clinical nursing teachers' teaching effectiveness and in-service education needs in China and to explore the personal factors affecting and the relationship between these two aspects. The study results concluded that the most important factor with regard to the teaching effectiveness of clinical nursing teachers was "Harmonious interpersonal relationships" [16].
Clinical preceptor could enhance student learning by having an unconditional positive regard for them. Teachers also need to be sensitive to student's feelings and problems and convey confidence in the student's ability to learn [12]. Henderson in 1995 has given a good example of mutual respect of students in situations where teachers need to correct students. They need to clearly convey to students that it is their behaviour that the teacher is not happy with, rather than being unhappy with them as people. Students should not be made to feel that their personhood has been put on the line which could damage their self-esteem as highlighted by this comment.

Implications for Nursing Practice
The issues and trends affecting nursing care today are increasingly complex and dynamic. It is widely believed that nursing leads the whole quality movement in health care. Nurses provide the majority of patient care therefore; they must be empowered with good preparation to improve care and service in order to maintain quality of patient care. Graduating highly qualified nursing students will positively and effectively reflect on all rendered services. Based on that, the need to improve clinical nursing education should become a major concern.

Conclusion
The present paper has discussed the recent deficits and challenges which face clinical teachers in Saudi Arabia. It has discussed also the lack of preparing clinical preceptors before teaching which may impact negatively on the teaching process. Accordingly, it is recommended that they clinical preceptors engage in professional development programs as soon as they get involved in teaching and to be encouraged in continuous education. Moreover, the paper has addressed the potential problems which are related to the clinical instructors and nursing students. These might act as a barrier toward achieving a good environment for clinical teaching. Roles of clinical nurse educator were presented as well in the paper. Furthermore, strategies have been suggested to promote positive learning environment in the clinical setting in Saudi Arabia. The strategies included having good knowledge and clinical competence by the clinical preceptor as well as good teaching skill. Also, a good relationship with students would enhance the student's ability to learn. It is good to know that educating teachers to become more effective clinical instructors will result in highly qualified nursing staff which will improve the quality of patient care. Although the paper could contribute towards the clinical nursing education, there is a need for further exploration of the nursing students' clinical experience in Saudi Arabia using different research approaches, quantitative and qualitative methods.