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Introduction

Clinical internship courses is vitally important information of professional identity of students, so that is considered as heart of professional education [1-3], and definitely the clinical environment in which students learn to integrate theory with practice, is a necessary and unparallel source to prepare students to implement their professional role [4, 5]. However, more than 50% of educational courses in nursing and midwifery is allocated to clinical educations [6]. Unfortunately, some studies showed that graduates in these fields have not practical skills and required efficacy in real occupational environments, and face problems in implementing their occupational tasks [7].

Outcome of inefficient educational programs in Iran is cases that include defect in practical knowledge in coping with real cases of patients in clinical practice, ambiguities of students in scholar education, inconsistency of educational and clinical staff and lack of observation of real face by client and community since these cases show necessity of more investing on resolving these challenges and changing educational system [8].

Since the first step is to resolve their cognition problems, educational staff should identify and introduce factors effective on the quality and quantity of clinical education as well as negative inhibiting factors of clinical education. In addition, improvement of clinical education quality requires continuous evaluation of present status, identification of strength and resolving limitations, which in regard to this; opinion and ideas of students can point future programs as an educational element. Students are the best source to identify clinical education problems as recipients of educational services since they have direct and non-mediated interaction and presence in this process [2].

The presence of each problem in clinical education faces the efficiency and efficacy of this part of education with problems [4] which one of them was students' stress. Most scientists agree that stress makes individual to take steps to change or adjust to their position. The adjustment, which can be effective or not [5]. In case of poor programming, deep gap between classical educational trend of nursing-midwifery and clinical care practice do not provide required ability for attaining competency and clinical skill to student, and new graduates in nursing and midwifery, despite well theoretical basis have not sufficient skill and talent in clinical practice and are poor in problem resolving [9].

In the studies performed abroad, factors include lack of value for clinical education, lack of access to sufficient clinical educators, lack of consistency between clinical educations of faculty, facilities, and practice in hospital and also factors such as lack of permanent access to educator to provide their educational needs, and lack applying required appreciates for student are presented as clinical education problems from the viewpoint of students, in addition in our country, various studies report undesirable status of clinical education [10].

Despite performing similar research in Iran, due to diversity of educators, students and educational system in each university unit and also due to lack of such studies in Sari despite the precedence of midwifery, this study aimed to determine clinical education status from the viewpoint of nursing and midwifery students of Mazandaran University of Medical Sciences.

Materials and Methods

The current study was a descriptive cross-sectional study performed through census in the school of nursing-midwifery at Mazandaran University of Medical Sciences. Sampling was done through census method for all the students at the final two semesters of Bachelor of Science degree in nursing and midwifery which passed at least two months of their internship.

Valid and reliable questionnaire (1) was fulfilled in three parts include demographic information, questions related to clinical education problems with Likert scale and one open question in regard to opinions of students in regard to clinical education problems.

Clinical education status was assessed in 4 contexts of questions include “educating teachers”, “communicate with student”, “educational environment”, and “supervision and assessment” as “always”, “often”, “sometimes”, and “rarely”, “never”.

Options of questionnaire in 4 mentioned contexts include following cases: Lack of adequate facilities and appropriate educational environment, lack of educational aid, inadequacy of facilities at educational centers, inadequate wellexperienced teachers to educate, not considering students’ opinions to plan internship program, indefinite students’ tasks, excess number of students in each group, inconsistency between theory and clinical practice, insufficient some cases, performing primary care by student, lack of support of students by teachers, lack of a constant clinical teacher in some locations of internship, inappropriate timing of internship in each ward, and inappropriate evaluation method.

Firstly, the aim of the study was completely explained for students, and after obtaining consent, questionnaires were provided to them and they fulfilled them through the self-report method. Students were free to participate or not, and data were analyzed by SPSS software through the Chi-square test and t-test.

Results

The age range of participants was 21-24 years and the mean age of the students in both fields was 23.04 years. All the students were Iranian. Out of 104 participants, 25 individuals were man and 79 individuals were women, which 49 individuals were studying midwifery and 55 individuals were studying nursing. All the students were in the third and fourth years of university .Out of this population, 80.8% were Bachelor of Science and the other were Associate degree.

Dissatisfaction factors presented by the students in both fields which were extracted from Descriptive questions were as follow: Professors (25%), authorities and lack of respect rights of students (11.5%), public and personnel culture (8.7%), facilities (7.7%), work hardness (6.7%), physician-centered and inconsistency of theory and practice (5.8%), and low-income (1%).

The satisfaction of clinical teachers according to "experience and interest in job", and "timely presence", and "appropriate communication with student" were assessed and the findings showed that 42.1% of nursing students and 16.7% of midwifery students were completely satisfied on their teachers.

In addition, nursing students were about 33.3% satisfied on way of respectful communication, which for midwifery students was only 7.4% (P-value< 0.005), and this difference was statistically significant between two fields. 39.4% of midwifery students were dissatisfied with the "status of objectives and educational programs", while 13.8% of nursing students were dissatisfied with this status.

About the context of"supervision and evaluation", 50.9% of nursing students and 57.1% of midwifery students reported status as “moderate”.

Given that nursing and midwifery are both clinical fields, but parturition experiences are allocated to midwifery, and hence, specialized experiences of each field were not compared. There was a significant difference in satisfaction rate on the "educational environment" between students of midwifery and nursing so that 38.9% of students of midwifery and 60.7% of nursing reported educational environment status as excellent (Table 2).

“Educational and occupational motivation” was not significantly different between two fields of nursing and midwifery and between two genders in nursing. in nursing field, 58.2% of educational motivation was positive and 25.5% of educational motivation was negative and 16.3% of nursing population did not respond to this question, and in midwifery, 85.7% of students did not respond to this question, which 59.2% of responses were positive and 26.5% of educational motivation was negative. About the“occupational motivation”, 65.5% of nursing students and 67.3% of midwifery students had positive viewpoints, and 18.2% of nursing students and 20.4% of midwifery students had not occupational motivation.

Discussion

This study showed that most of the students, particularly midwifery students, evaluated clinical education status as undesirable, which among the most important dissatisfaction factors can point to a deficiency of facilities in public hospitals.

In this regard, similar research such as the study by Dehghani in Yazd, Abedini in Hormozgan, Omidvar in Babol, Rahimi in Tehran, Hosseini in Yasuj, and Talasaz in Gonabad, reported clinical education status as undesirable [1, 9-13]. However, findings of the study in Ahvaz [14], and Sabzevar [15] were not in line with our findings.

This inconsistency might be due to different designs in the evaluation of clinical education status and discrepancy in students' opinion, personnel and clinical teachers in responding to these questions. A study by Moridi reported most stress rates in midwifery students and the most stressful context related to undesirable feelings [16]. Review in Isfahan explains the most important challenges of nursing education as follow: there are no basic concepts of nursing in the schedule of Bachelor of Science in nursing and leading students toward being physician assistant. The professional attitude of Iranian teachers of nursing is considerably different from the ideal situation and scholar image presented by professors of nursing is not consistent with the clinical image of nursing. Nursing students have not an appropriate attitude on their occupation. The academic environment is not the only developer of critical thinking but also in some cases is also presented as a suppressive factor [8].

Statistical results indicate that there is significant difference between nursing and midwifery in satisfaction rate on clinical educators, which evaluation of satisfaction was performed based on clinical history, patience, and endurance of educators and lack of occupational stress in students and full support of student, and the findings of current study was in line with the findings of studies by Gholi vahidi, Omidvar and Abedini [1, 7, 12]. The most important clinical education problems from the viewpoint of students in these studies were insufficient facilities and educational aids and experienced educators. The study by Salehi et al showed that students' earning in case of clinical supervision by teachers was significantly better than usual supervision, and they estimate the professional behavior of teachers more positive [17]. While other studies did not confirm this finding [6, 9-11], this difference in findings can be the result of the difference in educational facilities of universities. According to the opinion of students, the ideal professor is a knowledgeable professor who is an individual with significant ethical characteristics and properties, is a manager who supports the students properly, is committed to society and country and adhere profession properly [18]. The study by Heydarzade et al introduces effective educator as a person with managerial traits, educational skills, emotional and ethical properties, physical characteristics, and supportive role [19].

Despite findings of the current study on educational objectives and programs and adoption of theoretical courses with practical ones, the study by Del Aram reported viewpoint of students of nursing and midwifery as positive (6) so that strengths of clinical education according to that study were as follow:Appropriate communication of educator with student, timely presence of educator and student in the ward, compliance of prerequisites of lessons of internship and compliance of clinical education steps, complete support of educator for student and sufficient supervision on clinical education process, while, other studies reported similar findings with the current study [5, 7, 10, 12]. The study by Yousefi in Tabriz also estimated the rate of compliance of clinical courses of nursing with occupational tasks of nurses as “very high” and “high” [20].

The study by Imani pours introduced clinical evaluation satisfied by professors and students by objective, providing feedback, specialty, and full coverage of learning objectives [21]. In the study by Mirzaei et al in Kerman, the lowest satisfaction of nursing students was in the field of personnel support and most satisfaction was for supervision relationship [22].On the other hand, clinical survey in various levels can be different, so that study by Ahmadi et al showed a significant difference among viewpoint of professors and students, in this study according to opinion of professors, status of clinical supervision was at high level, and from the viewpoint of students were moderate [23]. A review study showed that the viewpoint of educators and students on the status of providing feedback was not the same in clinical education, and it is recommended that the status of feedback providing in clinical education is widely assessed by using the viewpoint of all the beneficiaries [24]. A combination study on nursing students also showed that they are skilled in performing routine activities, but some activities are not experienced even once by the student. In addition, there were problems on the nature of the internship, educator, and internship environment, which affect achieving the educational aims of the educator [25].

In regard with the improvement of status of facilities, it is recommended that upgrading medical facilities, standardization, making clinical education practical, and more attention to facilities such as educational room specialized to students of nursing and midwifery and educators in hospitals and providing appropriate place for rest especially for night shifts for students to be considered. Since clinical educators have considerable effects in increase of clinical education quality according to belief of experts and can make clinical experiences peasant for student, therefore, it is desirable that in the field of clinical problem solving, by actively investigating factors effective in promoting students’ motivation and active presence in therapeutic-educational fields, faculty members and clinical teachers rely on their invaluable experiences in clinical educating.

Problems in clinical education are generally evaluated in the level of educational committees and professors, while evaluating these problems from the viewpoint of students could be closer to reality, therefore the current study takes a step toward better clarifying clinical fields for future programming through exclusive investigation of viewpoints of students.

One of the limitations of the current study was the lack of dividing clinical problems as specialized fields. We recommend evaluating the needs of society, students, and clinical professors, and revision, and updating educational programs and bring objectives close to global standards to promote the quality of educational programs.

Acknowledgment

Thanks very much to the Honorable Research Assistant of Mazandaran University of Medical Sciences and to all Nursing and Midwifery students who contributed to this study.