The study was conducted to determine the difficulties that nurse instructors' experiences in clinical education.
This is a descriptive study. The sample of this study was comprised of 199 nurse academicians. A socio-demographic data collection form and a survey on the difficulties that nurse instructors' experiences in clinical education form was developed by researchers to be used for data collection in an electronic environment.
It was determined that the difficulties of nurse instructors' experiences included having a heavy workload (41.7%); providing clinical practice area (30.29%); having an excessive number of students (64.8%); being able to implement the nursing care plan (25.6%); a poor physical environment in clinics, and difficulties with health care team members (29.7%).
It was determined of nurse instructors' experiences that some difficulties in clinical education and they have the opinion that these difficulties have a negative effect on teaching.
Education, Nursing, Students, Challenge, Clinical nursing instructor, Clinical teaching
The general objective of nursing education is to help students gain professional nursing qualities and to prepare them for their future professional life. One of the targeted terminal behaviors in nursing education is "professional nurse" behavior  and nursing education is fundamentally a process that serves to raise students' awareness about nursing. This process involves two main areas that are integrated and complementary with one another, namely, Organizational/Theoretical Education and Clinical/Applied Education [2,3].
Clinical education serves as one of the primary educational experiences for nursing students and as such, has been an indivisible part of the educational process in all phases of nursing education history [2,4]. Clinical education gives students the opportunity to learn in real-life conditions. Nursing students must be fully prepared by both "knowing" the issues required for nursing functions and "performing" these functions. It is therefore important that students be prepared for their actual professional roles in the clinical area. In other words, clinical education and learning are a primary educational experience that helps students gain nursing skills [5-8]. Clinical education gives students opportunities to prepare for their future roles. These opportunities include participation in teamwork, decision-making, assessments, problem solving, critical thinking, coping with actual patients and their problems, and applying theoretical knowledge in actual practice [9-11].
Nursing instructors are responsible for creating an environment that can help students reach their educational goals. Learning outcomes are aimed at achieving high cognitive, affective and psycho-motor skill levels in the classroom, laboratory and clinical area . While it may differ from country to country, clinical teaching in nursing education tends to be done by instructors on the faculty of universities or schools, by clinical educators working in hospitals, by clinical nurse educators, and by nurses working in hospitals . However, it should be kept in mind that the most important factor determining the quality of education is the adequacy of nurses' educators. The World Health Organization emphasizes the need to address the quality of nursing education in order to train competent nurses equipped with the knowledge, attitudes and skills necessary to provide quality care services, and has defined 8 core competencies that nurse educators should have .
Clinical environments have a multi-dimensional and quite sophisticated social structure, wherein the low and difficult control of conditions characterizing the structure has an effect on learning [2,15]. The factors constituting this social structure include the conditions of the clinical environment, the characteristics of the students and educators, and the instructor-student interaction. It is highly important that students be able to derive benefits from these factors and conditions .
Clinical teaching can pose various problems and difficulties for both students and educators. A systematic research study investigated the strategies students applied to address the difficulties they experienced in advanced practices of nursing education . In this study, the difficulties affecting clinical education were examined and then labeled as either internal or external problems . Problems like excessive student demands, increase in faculty workload and the shortage of more nursing educators were identified as internal problems, while problems like limited number of clinical areas and preceptor programs and decline in educational programs in urban areas were identified as external problems. Facilitating cooperation between educational institutions and hospitals, developing patient-oriented research and increasing the use of simulation are recommended as solutions to these problems.
A qualitative study where they defined the difficulties that instructors and clinical educators experienced in the clinical teaching of nursing students conducted in Japan. The difficulties experienced were classified under four categories: Difficulties involving efforts to directly change opinions; inconsistency in school curricula content and clinical education content; difficulties in teaching skills to insufficiently educated students, and human and time constraints in education .
In Turkey, the nursing programme resemble some similarities to the nursing education programmes worldwide . The Turkish nursing education programme lasts 4 years and leads to a bachelor's degree in nursing. These programs provide 4600 hours of theoretical and clinical education, thus meeting the European Union (EU) requirement for the number of hours of nursing education .
In Turkey, clinical teaching in nursing education is generally performed by instructors in nursing schools , and clinical nurses working in hospitals. There are some difficulties in clinical education in Turkey. Clinical educators generally experience the following problems: increased numbers of students, students' lack of proper preparation for clinical education, inadequate time devoted to clinical education and time spent in the clinic, inadequate clinical field and an insufficient number of educators, inadequate collaboration between clinical staff and academia [17,21-25]. For these reasons, nursing students graduate with lack of clinical experience although they learned all skills during their education .
It is widely known that there are serious problems regarding instructor-student interaction in Turkey, particularly on account of the rapidly increasing number of students, especially in recent years. Some areas of clinical environments are unsatisfactory in terms of providing educational experiences that enable students to learn and adopt targeted behavior and skills. In a study analyzing stressful events commonly experienced by educators in clinical work practice, it was determined that inadequate physical conditions created an unfavorable environment for education . Based on these shortcomings, it is clear that reformatory measures for clinical teaching should be taken by performing an urgent review of the clinical teaching process and the learning environments. Determination and analysis of the difficulties instructors experience during clinical education are highly important for maintaining and developing quality-nursing education. The only way effective actions towards improving clinical teaching can be implemented is by sharing experiences and developing a comprehensive description of the extent of the problem.
This study was conducted to determine the difficulties that nurse instructors' experiences in clinical education. To achieve this, we sought to answer the following questions:
1. What are the difficulties that nurse instructors' experiences in clinical education?
2. What are the opinions of instructors about the effect of these difficulties on achieving the goals of clinical teachings?
This is a descriptive study.
The population of this study was comprised of nurse academicians on faculties and in vocational schools that provide nursing education in Turkey and in the Turkish Republic of Northern Cyprus. According to official data derived from OSYM(Student Selection and Placement Center) that were accessed prior to conducting the study, there were 1,208 instructors working in nursing educational institutions during the 2012-2013 academic year in Turkey. The study sample included 199 nursing instructors, who were selected from the e-mail addresses that were obtained (1,156) and had voluntarily responded to the survey.
The data for the study were acquired [2,5,16,17,26,27] using a survey form prepared after analyzing researchers' experiences and problems regarding clinical education, as reported in the literature. The survey was semi-structured. It was containing both open-ended (six questions) and (nineteen questions) closed ended questions. The survey form consisted of two different parts, with the first part involving questions about the characteristics of the instructors and the organizations wherein they worked, and the second part involving questions about the difficulties instructors experienced during clinical teaching. The second part also included six open ended questions inquiring into the instructors' opinions about the effects of these difficulties on clinical teaching. The difficulties experienced by the instructors during clinical teaching were listed under six categories: "Instructor", "Student", "Patient Care", "Physical Environment", "Nurse Team" and "Health Care Team". The possible responses to the statements organized under each category were: "I do not experience any difficulties", "There are some difficulties" and "There are quite serious difficulties".
The study data were collected in the electronic environment from February to March, 2014. E-mail addresses of the instructors were acquired from university websites, and from lists compiled by various organizations responsible for arranging congresses after being granted their permission. The lists of available congress participants were used, from which a record containing 1,156 e-mail addresses was drawn up. In some incidences, there was more than one e-mail address for the same person. Since researchers did not have the opportunity to determine the instructors' primary e-mail addresses, an invitation letter for the study and a link to the electronic data base allowing participants to respond were sent to all e-mail addresses listed. The authors sent reminder emails twice. Participants were respond to the questionnaire for two months. A total of 199 instructors, which translated as 17.2% of the email addresses listed, voluntarily responded to the survey.
The study data were assessed in an electronic environment using SPSS 20.0 software. Numbers and percentage calculation were used for data assessment.
All instructors were fully informed of the research aims, and agreed to instructors in the research process. All instructors were voluntarily responded to the survey. The research was undertaken the principles of the Declaration of Helsinki.
Regarding the descriptive characteristics of the participating instructors, 98% were female, and 24.1% ranged in age between 31-35 and 36-40. It was determined that 80.9% of the instructors had doctoral degrees and that 34.7% of them worked as assistant professors. Furthermore, the study found that 35.7% of the instructors had worked as academicians for between 11 and 15 years in total, and 54.8% of instructors had worked as clinical nurses for 5 years or less.
According to the data on the organizations in which the instructors worked, 71.3% offered master's level education as well as undergraduate education, 34.2% had more than 26 instructors, 81.9% had 201 or more undergraduate students, 59.1% had less than 5 graduate students and 52.2% had less than 5 doctoral students.
Analysis of the teaching process of the participating instructors showed that they mostly performed clinical teaching in public hospitals (68.8%) and university hospitals (67.8%). Regarding the instructor-student ratio, 32.7% of the participants stated that there were 11 students per instructor in clinics. In relation to this, 94.4% of the participants reported that the instructor was responsible for clinical teaching, 47.7% stated that they had responsibilities in 3 or more clinics, 29.6% stated that they set aside time for students as needed, and 22.1% stated that sparing time for each student was not possible.
In the instructors' general views of their clinical environment, 19.8% reported that the laboratory and clinic equipment were incompatible. In contrast, only 28.8% of the instructors stated that the clinic was suitable for clinical education in general, while 24.9% stated that the physical structure of the clinic was adequate (Table 1).
Table 1: Instructors' general viewpoints on the clinical environment (n = 199). View Table 1
The opinions of the instructors on the difficulties they experienced in the clinical environment were examined under 6 categories: Instructor-related difficulties, Student-related difficulties, Patient Care-related difficulties, Physical Environment-related difficulties, Nurse Team-related difficulties and Health Care Team-related difficulties.
Regarding the issues related to the clinical environment, it was found that 41.7%, 33.2%, and 30.2% of the instructors, experienced quite serious difficulties, respectively, concerning a) Having a heavy workload, b) Providing an adequate clinical practice area, and c) Presenting educational experiences suited to the educational goals of the course. It was also determined that 65.8%, 63.8% and 61.3% of the instructors experienced some difficulties, respectively, concerning achieving the course objective, creating an environment that facilitates learning, and achieving cooperation with other members of the health care team.
Analysis of the difficulties experienced regarding issues about students determined that 64.8% of instructors experience quite serious difficulties about the number of students. In terms of the difficulties experienced in patient care, 28.1% of the instructors experienced quite serious difficulties in nursing care planning practices. Considering the difficulties the instructors experienced regarding the physical environment, 57.8% of the instructors stated that they experienced quite serious difficulties, about providing a changing room for students. Concerning the difficulties about the nurse team, 25.6% of the instructors reported that the most difficult issue was providing enough guidance for students. Moreover, 21.1% and 15.6% of instructors stated that they experienced quite serious difficulties, respectively, about providing enough support and acceptance of students. To continue, it was determined that 29.7% of the instructors had quite serious difficulties about participation in decision-making mechanisms regarding patient care (Table 2).
Table 2: Opinions of instructors on difficulties experienced in the clinical environment (n = 199). View Table 2
Analysis of the individuals responsible for clinical teaching, in terms of the number of instructors in the organizations, found that 69.3% of the instructors worked in organizations where 26 or more instructors were responsible for clinical teaching (Table 3).
Table 3: Clinical educators by the number of instructors (n = 231*). View Table 3
According to the opinions the instructors had about the effects the difficulties they experienced in clinical practice had on teaching, 85.9% of the instructors stated that the teaching of certain nursing practices was not carried out (Table 4).
Table 4: The opinions of instructors about the effect of the difficulties experienced in clinical practice on teaching (n = 199). View Table 4
Clinical education pertains to the application part of nursing education and provides students the opportunity to learn under real conditions. However, the lack of control of the conditions constituting the clinical environments can affect learning. Identifying the challenges in clinical education in nursing is crucial . Various problems are known to exist in clinical education, including those related to the educators, the health care personnel, and the learning environment. Limited number of studies have been conducted in Turkey and throughout the world, on the difficulties instructors in particular experience in clinical education .
The situations in the clinical environment that are regarded as unfavorable by instructors stem from various factors, such as excessive numbers of students, insufficient patient capacities of hospitals, and limited number of diverse cases. There is also the problem of clinics/hospitals having poor infrastructure, insufficient clinical practice areas, inadequate infrastructure in laboratories, or conversely, having advanced laboratories but insufficient clinics. Being provided with conveniences and opportunities that facilitate learning, and having access to physical conditions that foster clinical learning are fundamental to developing clinical skills . Doğan, et al.  conducted a study to research the most common stressful situations instructors experience in clinical practice . They determined that the patient care systems applied in clinics were not in accord with the philosophies of education, that physical conditions were not sufficient, that there were communication problems, that instructors were unable to participate in decisions about patient care, and that treatment and physical conditions were inappropriate for education. Similar difficulties were also reported in the present study. In the participating instructors' general view of the clinical environment in clinical education, they identified the incompatibility between laboratory and clinical equipment, the insufficient capacity within the clinics to handle the number of patients, and the poor physical structure as the negative aspects of the clinical learning environment (Table 1).
In Turkey, it is the nursing instructors who are largely responsible for carrying out the clinical education, as well as the theoretical education, of the nursing education curriculum . This study found that the issue reported by the highest number of instructors to be difficult was the heavy workload. The heavy workload was attributed to such factors as excessive number of students, insufficient number of instructors in universities, being responsible for both undergraduate and graduate education, being responsible for management of laboratory skills, and the pressure of academic promotion. Moreover, because most of the participating instructors were responsible for supervising more than one clinic during clinical education, this also increased their workload. Strengthening the number of instructors, improving the quality of instructors, creating a system to guide clinical education nurses, and gaining the support of nurses working at hospitals may all be effective in reducing instructors' workloads.
In recent years, the number of nurses who attend universities has increased to meet the nursing needs in Turkey. While the student quota in the 1996-1997 academic year was 644, by the 2015-2016 academic year, this number had risen to 14,048. In other words, the nursing student quota had increased by 21.8 times in the last 20 years. On top of that, while the number of students per instructor had been 25, this number has increased to 30 as of present . The increase in the student-to-instructor ratio affected the findings of this study, as witnessed by the fact that the highest percentage of instructors reported the excessive number of students as being a difficulty that they had experienced. This same issue resulted in instructors experiencing serious difficulties in motivating students regarding clinical practice and in the daily monitoring of students (Table 2). Furthermore, the participants noted that the increase in the number of students also caused other quite serious problems, especially in carrying on education in schools with poor infrastructure and an insufficient number of instructors. These problems occurred in clinical education in particular. The lack of sufficient laboratory and clinical practice areas hampered the quality of education.
An increase in the number of students created problems with students' motivation and the placement of students in suitable clinical areas [5,21,22,32]. It is thought that regulations like decreasing student quotas, improving the physical conditions of schools, and increasing the number and improving the quality of instructors should be considered. In addition, continuing education activities, departmentalizing courses, and placing students in private hospitals, special functioning hospitals, and in general hospitals, like public and university hospitals, should also be considered for improving clinical education. Increasing the number of clinical rotation areas would also be beneficial in reducing or preventing problems that arise from the excessive number of students.
One of the difficulties that instructors experience is motivating students in clinical practice. Its importance in clinical education is fairly evident, as studies have clearly shown that the biggest obstacle in clinical education is student lack of motivation and interest [33-35].
Nasrin, et al.  conducted a qualitative study to research the difficulties involving nursing students' motivation in clinical education and found that the most important theme was "anxiety about being a nurse" . This theme was comprised of three categories: nurses' perspectives on the future, monitoring of clinical competencies and clinical education, and being a role model. Researchers have determined that the performances and professional attitudes of nurses have an important role in motivating students in clinical education. Furthermore, insufficient communication between students and team members, non-acceptance of students in practice areas, and negative prejudices about nursing that affect the students' motivation were the most common problems that students experienced in practice areas [24,36-38].
Highly motivated students in clinical practice areas contribute to efficiently maintaining the education process. Therefore, when students are supported and accepted by their colleagues they will be able to gain greater satisfaction from educational activities [23,24,39-41]. In addition to this support and acceptance from the nurses, members of the health care team and instructors, the function of clinical nurses as role models and leaders can also increase motivation. Moreover, the effective use of a reward system to acknowledge the achievement of students, the arrangement of regular meetings to share experiences with colleagues, who in their function serve as role models, and the continual support of instructors are considered as important measures for increasing students' motivation.
Another difficulty in clinical teaching that instructors experience pertains to the preparation and application of nursing care plans by students. One of the primary concerns of nursing education is that students are not able to put knowledge into practice. When educators mostly focus on theoretical information, students do not learn to sufficiently comprehend how theoretical information is put into practice. There are differences between practicing nursing in the actual environment and learning theory. Lack of support from instructors and nurses, short patient care time in the clinic, and inappropriate practice areas can hinder learning goals. These are regarded as the main reasons for the difficulties students experience in transferring knowledge to the practice area; in other words, it is a shortcoming in the preparation and application of nursing care plans. One of the seven items defined in a systematic investigation carried out by Jokar and Haghani  to research the difficulties of clinical education was students' lack of autonomy in care planning . Providing as many case studies and examples as possible to students during theoretical education on nursing care planning will help to facilitate students' ability to put theoretical knowledge into practice. It is believed that being supportive of students, discussing the daily care plan and use of methods (concept map, etc.), and facilitating the learning of planning and application of care will contribute to the solution of the problem [42,43].
Clinical education gives students the opportunity to use and improve the professional knowledge and skills specific to nursing, to make the right decisions, to increase self-understanding, and to prepare themselves for professional roles [22,23,39]. However, clinical education can present a number of problems and difficulties for students, educators, nurses and other members of the patient care team. Successful clinical practice can be achieved through the close cooperation of the school and the hospital [22,24,36]. Studies researching student opinions about school and hospital cooperation have reported that close cooperation can help students adapt to the profession, increase motivation and self-confidence, and help put theoretical knowledge into practice [36,44]. Based on the results from this study, it is believed that cooperation between schools and hospitals plays a key role in providing solutions to the difficulties that instructors experience with nurses and health care teams in clinical education.
The difficulties that instructors experience in clinical education have negative effects on clinical education. Similar to the findings from this study, the results from the study by Eta, et al.  showed that the difficulties encountered in clinical education made teaching difficult, prevented effective learning and teaching and led to negative learning results . The difficulties experienced in clinical education are considered to be the most significant obstacles in achieving objectives.
The two limitations impacting the outcomes of this study were that data collection was performed in an electronic environment due to access problems, and that, according to the number of outgoing emails, there was a response rate of just 17.2%.
It was determined that instructors experience various difficulties, including those related to having a heavy workload, providing an adequate clinical practice area, having an excessive number of students, implementing nursing care plans, having a poor physical environment in clinics and gaining the support of health care team members. Instructors stated that these difficulties negatively affect the education of some nursing practices, as well as effective learning and teaching.
It is clear from these results that there should be careful planning regarding the number of students receiving clinical education. The physical and educational opportunities of organizations must be considered in order to increase the efficiency of clinical education. Clinical practice areas should be selected from institutions that have a suitable physical infrastructure to create positive learning environments. When laboratories in educational institutions are not adequate, clinical areas should be equipped with advanced technology simulators (e.g. realistic high-fidelity procedural simulators, and high-tech interactive human simulators). Effective communication and cooperation should be provided between clinical teams and instructors, and cooperation protocols should be signed between schools and clinical practice areas.
We would like to thank all the Instructors who participated in this study.
GSD, HFK and RSG was responsible for the study conception and design. GS and RSG performed the data analysis. GS, HFK and RSG was responsible for the drafting of the manuscript. GS, HFK and RSG made critical revisions to the paper for important intellectual content.