Clinical education in undergraduate nursing in Ghana: A gap analysis

doi:10.21203/rs.3.rs-4960614/v1

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Clinical education in undergraduate nursing in Ghana: A gap analysis

https://doi.org/10.21203/rs.3.rs-4960614/v1

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Background: Nursing education comprises theory and practice as two complementary parts. In Ghana, the clinical education space is inundated with many challenges disrupting the intended purpose of clinical education. The challenges are multifactorial and include student issues, nurse and educator concerns, management and resource issues. To find solutions, there is a need for a critical analysis of the current clinical educational practices to inform the development of feasible and sustainable approaches for nursing education. This article, therefore, reports on a gap analysis of clinical education in Ghana.

Method: A qualitative descriptive design underpinned the study and was executed through key informant interviews, focus group discussions and document analysis. A total of seventy-three participants, drawn from four nursing education institutions and eight clinical sites, located in four administrative regions in Ghana, participated in the study. These participants comprised four principals, four heads of accounts, eight clinical coordinators, eight nurse educators, twelve preceptors, and thirty-seven final-year registered general nursing students. Data analysis was done deductively against the Global Pillars for Nursing Education thematically yielding three themes and eleven sub-themes.

Results: For Pillar 1, the study revealed a lack of a comprehensive competency-based assessment, ineffective interprofessional communication, and a non-stimulating clinical education climate. For Pillar 2, disregard for available admission standards and non-integration of interprofessional education into the Diploma in Nursing curriculum were found. In the case of Pillar 3, insufficient clinical experience of nurse educators was detected, financial resources to support clinical activities optimally were insufficient, and there was a lack of independence of nursing schools to support nursing education effectively.

Conclusion: This study brought to the fore the gaps in the nursing education system in terms of learning outcomes, the nursing education programme, and the educational institution in Ghana. This indicates that although clinical education occurs in the clinical setting, the challenges emanate from multiple facets of the nursing education system. To enhance clinical learning and teaching in undergraduate nursing education, strategies should target specific problems that may stem from any aspect of the nursing education system through a comprehensive framework that aims to enhance clinical learning and teaching.

Clinical Trial Number: Not applicable.

Clinical education

Critical thinking

Document analysis

Preceptors

Reports of unsafe and poor nursing care dominate media platforms and daily conversation (1, 2). Nursing education is expected to produce practice-ready nurses who are competent in rendering quality and safe nursing care (3). Incompetence of newly graduated nurses has been cited (3, 4) to have created problematic situations in the clinical settings (3). There has been a reported decline in the quality of nursing services, ineffective nursing practices, and job attrition attributable to the gap between theory and practice (5–7).

Nursing education has two complementary domains: theory and practice (8). Clinical education in nursing is focused on nursing education institutions (NEIs) adopting approaches to drive the development of clinical competency of nursing students to fulfil the professional standards and requirements established by nursing councils for qualification and registration as nurses (9). Clinical education allows students to integrate and transfer theoretical knowledge into direct patient care, develop problem-solving and decision-making skills (10), time-management skills, and collaboration with other healthcare providers, ultimately developing clinical competence (11–13). Clinical competence in nursing is the capability to integrate knowledge, experience, clinical reasoning, sound clinical judgement, skills, beliefs, values, and attitudes into the accomplishment of one’s professional role as a nurse in a given clinical situation (14, 15). A crucial connection exists between the quality of clinical nursing education experience and the development of clinical competence. Fundamentally, all nursing graduates must develop clinical competencies (16) in high-quality clinical learning environments.

Several factors have been cited to influence clinical learning and teaching outcomes directly. For instance, a well-resourced clinical environment (17, 18) and an adequate number of nurses in the clinical environment (19) have been identified as supportive factors in terms of clinical education. Conversely, multifaceted challenges have been reported to disrupt the intended outcome of clinical education. The curriculum, the administration of NEIs, students, clinical staff, a lack of resources, and the clinical learning environment (CLE) have been reported to compromise the quality of clinical education for undergraduate nursing students (19–21). Consequently, these challenges contribute to the theory–practice gap phenomenon (22–24), poor transfer of learning for undergraduate nursing students, and ultimately compromising competence development and attainment among nursing students. This is a concern for practitioners, educators and students (6, 24). Low-income settings have been reported to have compromised CLE, which eventually affects the quality of nursing graduates.

Like other settings, the clinical education of nursing students in Ghana is engulfed in many challenges emanating from a lack of resources and support of clinical nurses, ineffective clinical supervision, and insufficient classroom preparation of students (22, 25–27). Other drawbacks are poor student–clinical nurse relationships (26, 28), poor collaboration between NEIs and the clinical sites (29), theory–practice confusion among students (30), and the attitude of students toward clinical education (31). These reported challenges compromise the development of competence among nursing students in Ghana. Ghana battles with a complex disease burden (32), a shortage of health professionals (33), and limited opportunities for post-registration mentorship and induction for newly qualified nurses (34). To serve the communities effectively, Ghanaian nurses have to be competent at graduation.

Preceptors play instrumental roles in nursing students’ clinical learning (35–37). The preceptorship model (38) has been touted as one of the most useful models in clinical education, where preceptors support students in developing clinical competencies (38). Adoption of the preceptorship model to guide the clinical learning and teaching of nursing students at the placement sites in Ghana has not yet yielded the desired clinical learning and teaching outcomes (39).

The theory and practice components of nursing education can be likened to the two sides of the same coin; they are interconnected and inseparable. Although clinical education is known to occur mainly in the clinical placement site, it is crucial to acknowledge that activities within the clinical milieu are highly influenced by the curriculum content that guides the nursing programme and the NEI responsible for its implementation. Earlier studies conducted in Ghana on similar issues related to clinical education appear to have viewed clinical education as separate from nursing education; hence, losing sight of the complex, influential factors that have the propensity to optimise or disrupt clinical learning outcomes (40). As a result of those studies ignoring the complexity of clinical education as part of a bigger programme, recommendations from such work may not be useful and sustainable in addressing the root causes of challenges in the current clinical learning environment in Ghana. To improve the outcomes of clinical education, there is a need to view the clinical education of nursing students as an interconnected part of the broader nursing educational system.

The Global Alliance for Leadership in Nursing Education and Sciences (GANES) has developed global pillars for nursing education (41) in response to the World Health Organization’s (WHO) call on the international community to scale up, transform, and strengthen the capacity and quality of nursing education (42). The global framework outlines specified expectations for three interrelated pillars. The three pillars acknowledge the complexity of nursing education, reflecting an integration of learning, practice, and administrative standards related to undergraduate nursing education (see Fig. 1). The first pillar is learning outcomes, which comprise knowledge and practical skills, communication and collaboration, critical thinking, clinical reasoning, clinical judgement, professionalism, and leadership. The second pillar is that related to standards for nursing education programmes, which focus on the curriculum, admissions, and learning experiences. The third pillar reflects standards for educational institutions, which include faculty, instructors and preceptors, resources, leadership and administration, and outcomes (41).

Undergraduate clinical nurse education in Ghana does not develop competent nurse graduates optimally. Current models adopted for clinical education do not seem to improve the quality of nursing education (39). Moreover, studies that have investigated clinical education in Ghana appear not to have engaged critically with the complex dynamics of nursing education, as they present clinical education as isolated from other facets of nursing education (30, 40, 43). This article reports on a gap analysis conducted in the southern zone of Ghana, which was aimed at understanding the gap between expected clinical and educational practice and the prevailing practice in Ghana from the lens of the Global Pillars for Nursing Education. In this article, we argue that clinical education is interconnected with theory and the entire nursing educational programme, and that it is vital to understand the contextual factors influencing gaps in clinical education practice. understanding the reasons behind the gap between practice and expectation would provide insight into the development of feasible and sustainable approaches to enhance clinical education in Ghana.

Aim of study

This study aimed to explore the clinical learning and teaching context in undergraduate nursing education in Ghana.

Design

The current study employed a descriptive qualitative design executed through key informant interviews (KIIs), focus group discussions (FGDs), and document analysis. The design allowed the researchers to explore the participants’ perspectives on clinical learning and teaching (44). In addition, document analysis as an additional qualitative methodological design made it possible to review, describe, interpret, and integrate text in relevant documents regarding a concept or phenomenon systematically (45). The current study used document analysis to complement the other data sources for a better understanding of the gap between current and expected education practices within clinical education for undergraduate nursing in Ghana.

Setting

The study was conducted in four public NEIs and at eight clinical sites drawn from four administrative regions in the southern zone of Ghana. The clinical sites included in the study are facilities available to all NEIs for clinical learning. These sites were conveniently chosen due to geographical accessibility and feasibility for the researcher, as they represented a typical clinical education site for nurses in Ghana. Table 1 shows the characteristics of the study sites.

Table 1

Characteristics of the study sites
Study site	Final-year student population	Educational programmes	Clinical placement sites (CPSs)	Type of health facility or hospital	Bed capacity	Number of preceptors
Site 1	135	RGN RCHN	CPS1 CPS2	Teaching Municipal	306 150	20 19
Site 2	228	RGN RM	CPS1 CPS2	Regional Teaching	470 531	25 10
Site 3	134	RGN RM	CPS1 CPS2	Municipal Polyclinic	96 50	13 3
Site 4	247	RGN RM	CPS1 CPS2	Regional Municipal	262 103	30 3
* CPS: clinical placement site RGN: Diploma in Nursing RM: Diploma in Midwifery Diploma in Community Health Nursing*

Population and sampling technique

The population for this study (N = 73) comprised principals (n = 4), heads of accounts (n = 4), nurse educators (n = 8), final-year diploma in nursing students (n = 37) from the four selected public NEIs, as well as preceptors (n = 12) and clinical coordinators (n = 8) from eight clinical placement sites of the selected NEIs. A purposive sampling technique was employed to select the 73 participants for this study.

Data collection and management

Data were collected between November 2023 and May 2024, using document analysis, KIIs, and FGDs. Relevant documents were procured from stakeholder institutions, such as the Nursing and Midwifery Council (NMC) of Ghana, the Ghana Tertiary Education Commission (GTEC), and the selected NEIs. The documents procured from the NMC were the Diploma in Nursing programme curriculum (46), a logbook for tutors and lecturers (47), training institution and clinical and field practice schedule for Diploma in Nursing students (48), and the procedure manual for the Diploma in Nursing programme. The document detailing the job description for the various cadres of tutors in public NEIs was procured from the selected NEIs. Furthermore, the standards for tertiary institution libraries in Ghana and the standards for physical facilities for tertiary institutions in Ghana were procured from the GTEC. The documents used for assessing students’ clinical performance were procured from the individual schools. Interviews with 36 key informants as well as four FGDs were conducted involving 37 students across the four study sites and the eight clinical sites. The KIIs and the FGDs were audiotaped, while informal non-verbal cues of participants were documented in the field notes. The venue, date and time for the interviews were scheduled at the convenience of the participants. All the interviews and FGDs were conducted in English by the first author. Interviews lasted 45 to 120 minutes, and probes were used to elicit detailed information. Signed informed consent forms were kept in a locked cabinet. Participants were assigned unique codes to ensure confidentiality and anonymity. The codes were formulated from the combination of site, population, and recruitment order. For instance, the codes for site 1 participants are as follows: S1Pr, S1ACC, S1NE1 and S1NE2, S1STN1 to S1STN9, S1CC1 and SICC2, S1P1 to S1P3 to represent the principal, accountant, nurse educators 1 and 2, student nurses 1–9, clinical coordinator, and preceptor respectively. The codes for the remaining three sites were formulated using the same approach.

Methodological integrity

Trustworthiness is the application of techniques to ensure the accuracy of findings in a qualitative study (49). The trustworthiness of the current study was guided by the criteria proposed by Lincoln and Guba (50). They are credibility, confirmability, dependability, and transferability.

These were ensured in the current study as follows:

Credibility

This was ensured through prolonged engagement with the participants at all the study sites. Participants were given the information sheet about the study, consent form, and guiding questions for the interview. This provided the participants with knowledge about the study. the guiding questions for the key informant interviews and the focus group discussions were pretested to refine any ambiguous questions before the main interviews and discussions.

Confirmability

The KIIs and the FGDs were audiotaped, and member checking was conducted. The author and one of the supervisors did the analysis by independently coding two transcripts and comparing codes to reach a consensus. The first author and all the study supervisors reviewed all the codes. Following this, the first author used the agreed codes to code all the transcripts.

Dependability

The researchers used demographic data collection forms, audio recordings, and field notes to ensure all necessary data were collected. An audit trail was maintained throughout the entire research process.

Transferability

Although all the data were included in the data analysis, the findings of this study may not be transferable due to the context specificity of the findings. Nevertheless, a comprehensive description of the study settings, methodology, and background of the participants was provided to determine the applicability of the findings in similar situations.

The documents analysed in this study were procured from authentic sources.

Data analysis

Deductive analysis was done in this study to determine the community needs. Two cycles of data analysis were completed, as suggested by Saldaña (51). The researcher transcribed all the informant interviews and focus group discussions verbatim. The first cycle involved multiple steps, where the initial step involved the researcher reading and re-reading the data to obtain a general picture of the participants’ views. This general impression was recorded on a separate data sheet. The transcripts were then exported to the ATLAS.ti version 24 software for coding. The next step comprised coding the data. Initial, open and in vivo coding were used to code the data generated from the transcripts. Initial and open coding were used to reveal the unique experiences of the participants, while in vivo coding supported the analysis by allowing for some poignant expressions to be captured throughout the data process. The initial and open coding yielded 1,168 codes, which were reduced to 298 after merging similar codes. The second cycle of data analysis was done using pattern coding (51) to code the data emerging from the first cycle, including comparisons with the findings of the document analysis. Eleven code groups were generated based on the Global Pillars for Nursing Education. Structural coding was used to group the data from the interview transcripts and the documents against the Global Pillars for Nursing Education. The merged codes and the information gathered from the document analysis were aligned with the code groups to identify the gaps in clinical learning and teaching in undergraduate nursing education in Ghana

The demographic characteristics of the participants are illustrated in Table 2 below. The outcome of the thematic analysis are subsequently presented.

Table 2

Demographic characteristics of study participants
Variables	Principals (n = 4)	Accountants (n = 4)	Nurse educators (n = 8)	Clinical coordinators (n = 8)	Preceptors (n = 12)	Students (n = 37)
Gender
Male	1	3	2	2	1	15
Female	3	1	6	6	11	22
Age group (years)
21–25	–	–		–	–	28
26–30	–	–		–	–	9
31–35	–	–		–	–	–
36–40	–	1	2	5	3	–
41–45	–	1	3	3	7	–
46–50	–	2	2	–	2	–
51–55	2	–	1	–	–	–
56–60	2	–	–	–	–	–
Level of education
Bachelor’s	–	–	2	3	7	–
Master’s	4	4	6	5	5	–
PhD	–	–	–	–	–	–
Number of years in position
3–5	1	1	2	2	8	–
6–8	1	3	2	6	4	–
9–11	2	–	4	–	–	–

The results of this gap analysis are presented under the three global pillars for nursing education and their supporting sub-pillars.

Pillar 1: Learning outcomes

According to the GANES, learning outcomes focus on the competency expectations the nursing graduate should be able to implement after the programme in the specific areas of knowledge, skills, and attitudes. The first pillar describes the learning outcomes under four sub-pillars, namely knowledge and practice skills, communication and collaboration, critical thinking, clinical reasoning, and clinical judgement, and professionalism and leadership.

• Knowledge and practice skills

It is expected that the programme prepares the graduate to demonstrate essential competencies regarding knowledge and practice skills upon completion. The lack of a comprehensive competency-based assessment approach was however identified, where the current practice was sporadic and not aligned with best practices. Evidence showed that the assessment of clinical skills during students’ clinical placement was verbal. A preceptor from site 4 shared:

Before I sign the assessment form for a student … I ask the student if has achieved his objectives for the period. If the student says he or she can do vital signs … I’ll then ask the student … to tell me how to check BP [blood pressure] step by step … then I can assess him or her. [S4P1]

Although analysis of the Diploma in Nursing curriculum document showed courses to expose students theoretically to the care of varied individuals, it was gathered from the KIIs and FGDs that students lack practical skills in the care of individuals across the lifespan, families, communities, and citizens. The reason for this gap is students’ limited exposure to diverse clinical opportunities.

I don’t know if this is the fault of the facility or the school because since I started clinical placement in my first year, I’ve always been in a medical ward. I’ve never been to the surgical ward, so I don’t know what a surgical patient looks like. But I’ve been taught the pre-, intra and post-operative care in the classroom. But I don’t know how a surgical patient is cared for on the ward. [SISTN9]

Another gap was that students had limited support during clinical placement. This is because the ward nurses expect students to carry out procedures without support.

We are learning as students; the ward nurses should help us. During a clinical placement, I was asked to catheterise a male patient. I remember the theory, but the practical aspect was a challenge. The ward nurse said that because I was in my final year, I should be able to catheterise a patient. It was a difficult one for me. [S3STN7]

Additionally, it was identified that clinical placement opportunities were not aligned with clinical learning objectives.

Sometimes, when the students are overcrowded on the ward, I send some of the students to go to the other units, such as the laboratory, even though it is not part of their clinical objective. [S3P3]

Another gap identified was the weak educational outcomes on global perspectives on human rights, social justice, health equity, global awareness, and the interconnectedness of systems. Analysis of the Diploma in Nursing curriculum revealed that there is no content on these global perspectives.

• Communication and collaboration

The document analysis revealed that, in the Diploma in Nursing curriculum, courses, such as therapeutic communication and professional adjustment in nursing, prepare students for communication at the clinical site. Assessment strategies however did not assess students’ communicative skills during placement effectively.

On the assessment form of the students from some of the schools, there is a component on communication where we are to assess the communication abilities of the students in terms of verbal or written communicative skills during placement. It is a challenge. The fact is we don’t assess. I mostly write something there or tick for the student on the assessment form to represent something. That is all. [S4P2]

The analysis further revealed that students had documentation challenges at the clinical placement site. Some hospitals have integrated electronic documentation into their operations, and students are unfamiliar with the system. Due to the migration to an electronic platform, there is a lack of paper copies of the temperature, pulse, respiration, blood pressure charts and nurses’ notes for students to use for documentation.

Students have difficulties with documentation because this hospital has gone paperless [electronic] … The students do not have access to the system. Also, we don’t have paper copies of the nurses’ papers for them to document. Something must be done to support students during clinical placement. [S4CC2]

Another gap identified in the gap analysis is the non-alignment of clinical placement and assessment objectives on communication. The reason the clinical objectives do not include clear objectives on communication.

When you go through the clinical placement objectives, you will never find

a single objective stated to measure anything related to communication.

NEIs should include clinical objectives on communication. [S3P2]

Ineffective interprofessional communication was an additional gap identified. This is because nursing and other health professions education students mostly do not engage in interprofessional communication during clinical placement. The students do not deem it necessary to communicate among themselves during clinical placement.

Mostly, you don’t see nursing students communicating with medical or physician assistant students. The medical students see the nursing and physician assistant students as inferior. As a preceptor, I don’t see any communication between them. They [health professions education students] need to be sensitised. [S2P2]

• Critical thinking, clinical reasoning, and clinical judgement

Another gap identified was students’ ineffective application of the nursing process during clinical placement. Some of the reasons were that students did not understand the care plan from the classroom, and there were no opportunities to draw the care plan on the ward during placement.

There is a problem, the students do not understand the care plan. What they are taught in the classroom is abstract. It is when they come to the ward that they need to draw the care plan using real patients. They are supposed to identify the problems of a patient, think and select the best care strategies that need to be implemented for the patient to feel better. But it is not done. [S4CC1]

Another gap identified was a lack of self-direction among students in clinical learning. This was because some students were not interested but were forced into nursing, so they were not motivated. Some students reflected on being disappointed at the quality of responses they received to their questions from some of the staff during clinical placement. Others did not get answers to their questions at all. Yet more students were embarrassed by the nurses when they asked questions during placement.

In the first place, I was pushed into nursing so nothing motivates me to take the initiative to even learn in the school, skills laboratory or the clinical site. S3STN3

When you ask questions on the ward, [you] don’t receive answers. Sometimes, the nurses will embarrass you. So, I have decided not to ask any questions when I go to the ward. S1STN1

Also, nursing was seen as an apprentice-based approach. The reason is for students to learn ward routines.

Whenever we went to the clinical placement site, we were made to follow the

nurses, observe and learn from them. When they [nurses] are performing the

procedures they tell you [the student] to watch closely so that you [the student]

can repeat the same steps. [S2STN6]

Additionally, a non-stimulating clinical education climate was identified as gap in the clinical learning and teaching of students. The reason could be that the ward environment is not deliberately created to support student learning.

In the school, the skills laboratory is not well equipped, which makes

teaching and learning difficult. In my view going to the ward does not

make any difference. As a nursing student, I expect that when I go for clinical

placement it should make a difference, but no, I just go empty and come back

empty. [S1STN9]

Besides, there was an absent culture on evidence-based practice (EBP) among nursing students. One reason for this gap is the poor collaboration between NEIs and the practice setting.

I am a clinical coordinator and I can say nursing students are not being prepared for evidence-based practice. They are taught research, so I think the system should be structured in a way that meet to talk about research for students to see. Such meetings should be organised to share and discuss research findings and even do research together. But there is nothing like that. How will students embrace evidence-based practice? [S1CC1]

Again, analysis of the Diploma in Nursing curriculum document revealed that there is a course called ‘First Aid, Emergency Preparedness and Disaster Management’. Findings from the KII however showed an absence of emergency and disaster-related opportunities for students, which may be due to a lack of simulation facilities and expertise.

Students are taught this first aid course in the classroom because it is in the Diploma in Nursing curriculum. However, the problem is that we cannot make students feel the practical part of the preparedness and disaster management aspects of the course. How are we going to do that if we don’t have the facilities and the expertise in such things? [S3NE1]

• Professionalism and leadership

Analysis of the Diploma in Nursing curriculum indicated that the professional adjustment course is designed to provide information on ethical codes and principles. A gap identified was that students had challenges transferring learning from classroom teaching on professionalism to clinical practice.

Students are taught professional adjustment, a course expected to expose the students to ethical issues, and acceptable professional nursing behaviour, such as avoidance of absenteeism, lateness, proper dressing … However, when they come for clinical placement, they do the contrary, and I don’t know why. [S1P3]

There was inadequate supervision of and cognitive support for students during placement. The reason could be the preceptors’ lack of knowledge of student supervision and support during clinical placement. This led to students performing some procedures without supervision and support from experienced staff:

I was asked to feed a patient which I have never done before. When I told the nurse to come and guide me, she asked me to feed the patient the way I feed my younger siblings at home. I fed the patient to the best of my ability and encouraged the patient to eat all the food. The next day … I was informed that the patient had passed on. Was it that I overfed him? [SISTN6]

As part of the professionalism and leadership sub-pillar, students are expected to be advocates for clients and their families to optimise health and well-being. On the other hand, students were reported to be deficient in advocacy competencies because of their difficulties in communication during placement.

The students cannot communicate well when they come for placement. Some can only do so in the local language, and not in English. As a nurse, if you cannot communicate with the patient and the family, then you cannot perform the advocacy role. [S2CC1]

Pillar 2: Nursing education programme standards

According to GANES, nursing education programmes are anticipated to meet some expected standards in the domains of the programme curriculum, admissions, and learning experiences. The gaps identified in the three areas are subsequently presented.

• Curriculum

The analysis of the total hours allotted for theory and practicum in the Diploma in Nursing curriculum document shows 1,568 and 1,632 hours, respectively, indicating a difference of 64 hours between the total hours allotted for theory and practicum for the Diploma in Nursing programme. A gap identified during KIIs and FGDs was insufficient clinical experience students.

I don’t understand how students will come and spend 1 week on the ward. They cannot learn anything, the clinical placement time is too short, and it is not enough at all. [S3P3]

Standards require that the curriculum development and review process include key stakeholders. Nevertheless, evidence from the 2021 Diploma in Nursing curriculum revealed that students and alumni have been excluded from the development and review process of the 2021 Diploma in Nursing curriculum, demonstrating a less consultative approach.

• Admissions

Analysis of the GTEC standards regarding physical facilities for tertiary institutions in Ghana, class sizes should be between 30 and 100. Contrary to these standards, high student intake is disproportionate to available educators in nursing schools. The reason could be a lack of collaborative planning between the MoH, HTIs secretariat, and the heads of NEIs to consider their nurse educator strength before admissions.

The ministry does not check with the principals about their teaching staff capacity before the admissions. That is something they have to be doing, but they don’t. Admissions will end, but the ministry will keep sending students to us. Currently, the first-year class is 300 and over, and the Tutors are suffering. [S1Pr]

Another gap identified was a disregard for available admission standards in nursing education has been identified as a gap. There are various factors that influence this process, including politics and leadership.

Every year, applicants are informed about the time to apply with entry requirements and all the necessary information. However, the fact remains that the admission standards for nursing education are not respected at all. As for nursing, the politicians do whatever they want with our admissions. [S3Pr]

• Learning experiences

As part of the learning experiences, students are supposed to be exposed to learning opportunities through simulation and placement in a variety of clinical settings and with diverse populations. An important gap identified in this study however was scheduling students to only one unit during their clinical placement without recourse to their clinical objectives. This situation could be attributable mainly to poor coordination in the clinical placement of students.

Each time that we come for clinical placement, I think our objectives are to be presented to the coordinators so that they place us in various units to learn the skills that we are supposed to learn. But … the coordinator will decide which unit you should go to. Meanwhile, we have to have a feel of everything on the ward. For instance, in our case, we [the entire group of students] have only been to the wards. We have never been to the public health unit, the maternity ward or the theatre, so we don’t know what is going on there. All we know is the male, female, and emergency wards. We pleaded that we should be able to have the experience at other units, but they tell us that is what is needed of us as general nurses … [S3STN7]

Another gap identified under this sub-pillar is the non-integration of interprofessional education into the curriculum of the Diploma in Nursing programme. It might be that stakeholders tasked with the development and review of the curriculum have not considered this subject matter. This gap was reiterated by several participants across the study sites:

Currently, interprofessional education is a topical issue and we cannot do away with it. It must have its place clearly in the curriculum, I had an opportunity to join a few interprofessional education sessions and I must confess that it was wonderful. The nursing curriculum must have something on interprofessional education. [S4Pr]

Pillar 3: Educational institution standards

The educational institution is supposed to meet important expectations. Gaps were identified, indicating that the standards were not met. These gaps are captured under four sub-pillars.

• Faculty, instructors and preceptors

The gap analysis of the clinical teaching and learning milieu revealed that educators were not up to date with EBP, with a possible cause being that there is no active continuous professional development (CPD) in terms of EBP or that educators are not motivated to engage in clinical-oriented CPD.

I think educators must try and be abreast with EBP issues to enrich their clinical knowledge base; it must be a personal drive. A few do, but the majority expect that they are nominated by the school before they go. We do nominate sometimes, but I think tutors must be hungry for EBP knowledge. [S4Pr]

Educators were found to have insufficient clinical experience, which was linked to reasons, such as the recruitment process of nurse educators, not focused on clinical experience and the non-enforcement of the tutor logbook initiative by NMC and HTI:

It appears the clinical experience as a requirement to be a tutor is no longer considered by HTI. This is because some of the tutors posted to the schools are theory-based tutors. The clinical skill knowledge is not there at all. One thing that may help such tutors enrich their practical skills base is when the logbook initiative by NMC is enforced. HTI should consider the logbook during promotion interviews for tutors, and it will help. [S2Pr]

Another gap revealed was the poorly implemented clinical-oriented CPD for nurse educators. This is attributable to the fact that NMC is not monitoring the tutor logbook.

I am a nurse educator, and what I can say is that when it is time to renew our PIN [personal identification number], [the] NMC does not check our CPD status again. I once asked, and I was told that because I am a tutor, it is presumed that I read new things every day, so I am current. I think NMC should be checking the logbook for tutors. It will motivate us to improve our CPD obligations. [S4NE2]

Again, the inadequate number of nurse preceptors was identified as a gap in the clinical education of nursing students. The reason for this is the failure of stakeholders to identify and train more preceptors.

The preceptor work is not easy; we are not many. In this hospital, there are only four or five preceptors. More preceptors need to be identified and trained. [S3P2]

Additional gaps found were the preceptors’ lack of clinical experience and expertise in clinical teaching and learning. The most probable reason is the absence of a clinical education programme for preceptors, and the lack of orientation or induction into preceptorship.

I am the clinical coordinator in this hospital, and I can say that some of the staff who are preceptors lack clinical experience in teaching students. It is not everybody who can be a preceptor; a lot goes into preceptorship. There should be a training programme to equip the preceptors with the needed knowledge in preceptorship. The NMC, MoH [Ministry of Health] and HTI need to come together and train preceptors. I heard there was a national preceptorship workshop; I hope this will see the light of day. [S2CC2]

The unclear job description of nurse preceptors is the next gap that was identified. This gap is attributable to the failure of stakeholders to appoint nurses officially as preceptors, as there is an appeal for the utilisation of the preceptorship model for clinical education of nurses in Ghana.

They said I am a preceptor, and I have been trying to do what a preceptor is supposed to do … I don’t really know what exactly I am to do and not to do. There is no document showing that I am a preceptor, we need to sign an agreement with the stakeholders so that in that agreement, I know what I am supposed to do and also know what the reward package is. [S2P3]

The next gap recognised was the demotivation of nurse preceptors in terms of teaching student nurses. The reason is the lack of incentives and recognition as a preceptor.

The preceptor’s job is not easy. As you perform the routine nursing duties, you need to manage and teach students alongside. The key issue here is that, as a preceptor, we are not motivated in any way; it can be monetary, recognition, citations and so on. [S1P1]

Furthermore, a fragmented clinical teaching approach as an added gap was identified. This was due to a lack of collaborative planning between the school and clinical practice.

We all know that nursing is both theory and practice. So, for us to succeed in the clinical education of nursing students, tutors, preceptors, and clinical coordinators must plan together. We need to collaborate in clinical teaching and supervision. As tutors, when we go for clinical supervision, we have to spend some time and perform procedures with students. [S4NE2]

The final gap under this sub-pillar is the poor clinical training outcomes attributable to large student numbers due to poor adherence to GTEC standards.

The number of students being admitted into nursing is too high. The wards always get crowded and choked when they come for placement. This affects their clinical skills acquisition. Let us always remember that this is a practice-based profession. With the large numbers, supervision and teaching become a challenge and most of them don’t learn anything in the clinical setting. They hide behind the huge numbers and absent themselves, loaf around and go back to the classroom after the placement. We are training quantity and not quality. [S2CC1]

• Resources

Concerning resources, inadequate library and internet facilities in schools were identified as the first gap. This is due to poor adherence to the library standards of GTEC.

The size of the school’s library is too small for the huge student population. I know students who have never stepped into the library since their admission into this school. The books too are old. Regarding the internet, the school does not provide internet services to the students or the tutors. We need the internet in the teaching–learning process. [SINE2]

The second gap related to resources is the inadequate resources at the school and clinical sites. The main reasons for this gap were cited as the high student enrolments combined with the lack of infrastructural support by government.

We don’t have enough resources in the school. Classroom and hostel accommodation is a problem for the large student numbers. At the hospitals, too, there are no care plans, vital signs charts, and equipment for performing procedures. [S3STN4]

The third resource-related gap identified was logistical and transportation challenges of the NEIs. This is partly due to the high student enrolment numbers exceeding the existing infrastructure, and the inability of government to provide schools with sizable vehicles.

The school does not have vehicles for our operations, such as student clinical supervision. The few we have are old and keep breaking down. The school bus is too small for the large student number. [S3Pr]

Inadequate teaching and learning resources are reflected in the fourthh gap. This is due to a lack of support from government.

We do not have enough teaching and learning resources. The entire school has one skeleton [model] for teaching. When you are teaching procedures, we need to show the equipment to students but we don’t have them. It makes teaching and learning difficult. Sometimes we try to download videos of procedures, but the problem is they don’t fit our context. [S3NE1)

Another gap found was the inadequacy of clinical skills and simulation laboratories. This is also an infrastructure constraint.

Our demonstration room is too small; the students are many. So, sometimes we have to move the beds or other equipment to the classroom for demonstrations. We have two old mannequins and just recently, we got another one with a tracheostomy. [S3NE2]

Besides, a lack of awareness among clinical nurses regarding the approved procedure manual on the NMC open-access mobile application has been identified as another gap. This is due to insufficient publicity among the nursing fraternity.

NMC needs to bring copies of the procedure manual to the ward … if there is a mobile application as you have just said, I have not heard or know about it. [S1P2]

Insufficient financial resources to support clinical activities optimally comprised the final resource-related gap. The reason for this gap is the unrealistic amount allocated for the clinical-related activities on the student itemised bill.

The students’ bills are determined by the government. Prior to the approval of the bill, there is a meeting between the principals and the MoH … the amount allocated for clinical-related activities on the bill is not adequate. For the right amount to be determined, they have to list the various clinical education-related activities … currently, the amount is woefully inadequate. [S2ACC]

• Leadership and administration

Regarding leadership and administration, the lack of independence of NEIs to support nursing education effectively has been identified as a gap. The NEIs are under the MoH; hence, the MoH has strong control over the NEIs and does not allow principals to make critical decisions.

The principals … should be granted some autonomy in managing the schools. The MoH determines when students should reopen and vacate, the bills of students, and even admissions. I am not saying the principals are not consulted. But if the MoH could grant the principals autonomy, a lot would change in the positive direction. [S1NE1]

Moreover, one of the gaps identified was the absence of a clear memorandum of understanding (MoU) between NEIs and clinical facilities as a GTEC accreditation requirement. The lack of an MoU between the clinical placement sites and the NEIs is attributable to leadership and administrative lapses.

The fact is that the Ghana Health Service promised to issue the MoU on behalf of all public health facilities. However, that has not been done. As part of the GTEC accreditation requirements, the schools are expected to have an MoU with the clinical sites. As a principal, I have done so to a few facilities where students from this institution visit for clinical learning, but not all. [S4Pr]

In addition, weak QA mechanisms related to clinical teaching and learning have been identified as comprising one of the gaps. This gap stems from the lack of commitment and collaboration of stakeholders in the clinical education of nursing students.

There are a number of things that should be done. I think the schools should share their academic calendar with the clinical sites for planning, NMC should strengthen its monitoring of NEIs in a timely delivery of students’ logbooks to students and guiding students on how to complete the logbook and early submission of clinical placement sites for planning. Also, NMC should ensure the different year groups in all schools have different clinical objectives on the assessment form. [S1CC1]

• Outcomes

Regarding the standards for educational institution outcomes, an ineffective implementation of programme evaluation by HTIs and the MoH was found as a gap. The reason for this gap is a perceived lack of commitment by the HTIs and the MoH regarding programme evaluation.

The MoH and HTI should do more regarding the monitoring of the NEIs. Since I resumed here as a principal, the HTI has never been here for monitoring. [S3Pr]

Poor implementation of ongoing evaluation and analysis of the evaluation data collected is an additional outcome-related gap. It has been established that, although some of the NEIs collect the evaluation data, analysis is not done. The reason for this gap is a lack of commitment on the part of the schools to implement the tutor and the course evaluation initiative of the HTI and MoH.

The MoH and HTI initiated the tutor and the course evaluation on a semester basis. In this institution, we do the evaluation but we do not analyse and use the report. We have all gone to sleep. [S2Pr]

Likewise, the lack of the use of evaluation data to improve nursing education was yet another gap identified in this study. The absence of commitment to the evaluation process may again be responsible for this gap.

Every semester we do an online evaluation of the tutors and the courses they taught. Every semester. It’s a good thing to evaluate our tutors and the way they teach and all that. But what I have seen is that they don’t use the evaluation report for anything. It is just a formality, that is all. [S2STN8]

The final gap identified was the inefficient use of student evaluation data from clinical placement sites by schools. Equally, the lack of commitment by the school to the clinical teaching–learning outcomes of nursing students is deemed responsible for this gap.

Due to the student numbers, we are not able to go through the assessment reports they bring from the clinical site. So, we are unable to make interventions for individual students. [S4NE1]

The quality of clinical nurse education for undergraduate students in Ghana should be improved. Sustainable strategies informed by insights from current practice need to be developed, implemented and sustained for enhanced quality clinical education. This article reports on one part of an overarching study aimed at developing a framework for enhancing clinical learning and teaching in undergraduate nursing education in Ghana. Reporting on a phase of the overarching study, we sought to explore and describe the clinical learning environment for undergraduate nursing education in Ghana. Data were analysed through the lens of the three Global Pillars for Nursing Education, which reflect an understanding of the interlinked elements of a nursing education programme.

In terms of the first pillar, it was evident that the practices related to programme design, classroom education, clinical education, and practice were not aligned with best education practices. Balancing a heavy workload and the lack of opportunities for CPD reflect the challenges nurse educators face in low-income settings towards aligning their praxis with evidence.

Accurate clinical nursing assessment of students’ knowledge, skills, and attitudes guides in identifying students who have developed competence (52) and those who may need remedial action. In the current study, the application of poor assessment methods during the clinical placement of nursing students was evident. Assessment of students’ clinical skills was mostly verbal, biased, and not performance-based. Some reasons for the sporadic assessment approaches could be workload and a lack of knowledge of best assessment strategies. Inadequate training of examiners and a lack of standardised assessment approaches have been reported to affect the effectiveness of clinical assessment in Ghana (53). In their study, Norcini et al. (54) concur with these reasons that the time constraints of clinical staff are a factor that undermines good assessment practices, and these researchers propose development, guidance and training of teaching staff in terms of effective assessment, feedback, and the criteria for good assessment. Nurse educators and the clinical facilitators involved in the clinical teaching of undergraduate nursing students should be trained in best assessment practices for more objective assessment outcomes.

Interprofessional communication and collaboration among healthcare workers ensure quality and safety in healthcare (55). Interprofessional learning would improve communication and collaboration between students and prepare them for interdisciplinary teamwork after graduation (56). In the current study, the nursing students however demonstrated ineffective interprofessional communication and collaboration with other health professions students at clinical placement sites. One could anticipate that students in the current Diploma in Nursing programme may graduate and demonstrate interprofessional communication and collaboration lapses in practice due to the lack of interprofessional education programmes in Ghana. Even though the current curriculum for the Diploma in Nursing has a main course on communication, there is no explicit content on interprofessional communication. It is, therefore, imperative to employ strategies to improve interprofessional communication and collaboration. Interprofessional education should be developed and implemented within the nursing education fraternity in Ghana to strengthen the development of interprofessional communication.

Nurses are expected to possess skills in terms of critical thinking, clinical reasoning, and clinical judgement in order to provide quality and safe health care to patients, as it has been reported that this is implemented through the nursing process (57–59). A significant finding from the current study was the ineffective application of the nursing process in clinical placement. Some reasons are that most nurse educators and clinicians have a challenge in teaching the care plan – part of the nursing process – in the classroom and the clinical setting, leading to students’ lack of understanding and application of the nursing process in individualised patient care planning. The nursing process has been cited as a model that supports critical thinking in nursing practice (60). Previous studies have reported difficulties in applying the nursing process in many African settings (61, 62). This prompts an interesting question regarding understanding the current nursing models being used in practice, their impact on the professional identity of nursing, and whether the actual expected evidence-based nursing science is being practised in healthcare settings. A collaborative initiative planning between the and the clinical staff is required to teach and apply the nursing process. Some participants in the current study suggested that a care plan should be a mandatory clinical placement assessment tool.

Per the current Diploma in Nursing curriculum, students are taught professionalism in nursing in the professional adjustment course. Nursing students participating in the current study however experienced challenges in transferring their learning of professionalism to clinical practice. The students improperly used phones at the clinical sites, absented themselves without permission, and reported late to the clinical site. The use of phones in the nursing education has been beneficial to students both at the school and at the clinical sites. Improper use could however be distracting to the student and affect learning. The reason could be that clinical educators at the clinical placement sites do not coach and model professionalism for students. Factors known to influence training transfer in nursing include trainee characteristics, training design, and the working environment (63). All members of the health profession are expected to be role models, and to teach and inculcate the required values, attitudes, and behaviours in students (64). Nurse clinicians should reinforce professional values in nursing students during clinical placement.

The lack of interest in the nursing profession was identified as a gap in the current study. Such students lack motivation for clinical learning and do not participate in learning activities at the school and/or at the placement site. Nachinab and Armstrong (65) support the claim that negative student attitudes could hinder clinical learning and teaching.

The second global pillar focuses on standards for nursing education programmes. Nursing education is expected to meet specific expectations in the areas of curriculum, admissions, and learning experiences. A curriculum is the heart of every educational enterprise (66). In Ghana, the NMC is responsible for developing and revising the curricular used in training the different cadre of nurses. The curricula for all the nursing programmes are reviewed every five years to ensure the curricula are responsive to the needs of the society at the time. Immediate alumni and current students are among the key stakeholders in designing and revising the curriculum for a programme. Although the NMC has been consistent with a consultative curriculum review process, an analysis of the current Diploma in Nursing curriculum indicates an exclusion of alumni and students currently in the programme. Interprofessional collaboration is crucial to optimal healthcare delivery. Evidence exists that healthcare delivered by a team of well-functioning multi-professionals yields desirable care outcomes (67). An educational model where students of health professions programmes would learn about, from, and with each other while in training may result in interprofessional collaboration in practice. Although the Diploma in Nursing curriculum in its current state has relevant courses, it may also be seen as unresponsive to current trends, as there is no module on interprofessional education. The NMC could consider the inclusion of interprofessional education as a standalone course or as part of another course in the next curriculum review. In addition, provision should be made in the curriculum for interprofessional clinical placement of health professions students.

High student intake disproportionate to the number of educators has become common at the NEIs in Ghana. Regulatory bodies in Ghana set standards and entry requirements for the admission of students (68, 69). In a GTEC report, most NEIs have been cited as not having properly constituted admission committees. Admissions into the schools are expected to align with existing physical and human resources of the schools. The opposite is however the case. For instance, the GTEC specifies that classes should accommodate between 30 and 100 students. Furthermore, the WHO (70) set educator–student ratios at the following minimum levels: theory 1:25, tutorial 1:10, skills laboratory 1:15, and clinical 1:8. All the NEIs involved in the current study however had large student numbers causing overcrowding in classrooms and skill laboratories, and at clinical placement sites. Other studies also reported overcrowding at the clinical placement sites (65, 71) but did not mention the classroom, which is an indication of them viewing the clinical education as an isolated entity from the entire nursing education. Although an inadequate health workforce has been identified as a basic hindrance to the achievement of the Sustainable Development Goals (56) and, hence, the necessity to train more nursing professionals, the quality of nursing education programmes cannot be overlooked. Nursing is a practice-based profession, and its graduates are expected to gain the necessary theoretical knowledge in the classroom, and the expected practical skills at the clinical setting to gain the necessary competence to render high-quality care. Admitting high student numbers without the supporting infrastructure, material, and human resources could however affect clinical learning and teaching in diverse ways; thus, defeating the intended purpose. It is, therefore, necessary for NEIs to adhere to admission standards to have a student population that can be adequately trained with existing human and material resources.

The third pillar, standards for educational institutions, is expected to be met by NEIs in the areas of faculty, instructors and preceptors, resources, leadership and administration, and outcomes. It was evident from the current study that nurse educators in NEIs lack sufficient clinical experience. One of the reasons responsible for this occurrence is poor enforcement of the tutor logbook initiative of the NMC, which is intended to keep the clinical skills of nurse educators updated. Another reason is the failure of HTIs to recruit nurse educators with the recommended five years of clinical experience into the NEIs. It was found that nurse educators were not familiar with EBP related to both educational and clinical practice. Student nurses in a related study mentioned the lack of supervisors’ knowledge of current practices as a challenge to a good clinical learning experience (72). Nurse educators are indispensable stakeholders in nursing students’ clinical learning and teaching; hence, they need to have enriched clinical skills to enable them to teach students. The NMC and the HTIs could make the tutor logbook and evidence of CPD as promotion prerequisites to encourage nurse educators to explore clinical-oriented CPD.

The participants in the current study mentioned inadequate numbers and a lack of training of preceptors as other gaps bedevilling clinical learning and teaching. Preceptors occupy a pivotal position in the clinical education of nursing students by serving as role models, tutors, coaches, mentors and supervisors (35–37). In Ghana, the preceptor role is mostly assumed by registered nurses. An inadequate number of registered nurses has however been reported (26), resulting in workload pressure on the few registered nurses. This could interfere with their support of students during clinical placement. Many recommendations on the preceptor–student ratios are available, such as 1:6 (73, 74), 1:15 (75)(68), and 1:15–20 (76). The Ghanaian government and the Ghana Health Service (GHS) may have to consider employing and posting newly qualified registered nurses to augment the workforce base at these facilities. Furthermore, stakeholders should consider a sustainable training programme for preceptors to improve their pedagogical skills.

The current study exposed the resource constraints both at NEIs and at clinical placement sites. As a result, there were no teaching aids to support teaching and learning at the schools. Furthermore, students do not have the opportunity to practice practical skills in the skills laboratory before visiting the clinical sites. Students and preceptors are therefore compelled to mimic reality by improvising. Additionally, there are no suitable venues at the clinical sites to conduct post-clinical conferences for students. Specifically, transportation challenges of the schools affect conveying students to and from distant clinical sites and student clinical supervision scheduled by teachers. The chain of challenges from the NEI level to the clinical placement sites could hamper the progress of clinical learning and teaching. Similarly, other studies in Iran (13), Malawi (19, 71), Angola (70), and Ghana (22, 26, 77) have cited resource challenges in the clinical education of nursing students. Some of these gaps could be due to infrastructural deficits, financial challenges, violation of the GTEC standards for physical facilities for tertiary institutions, and the library standards and guidelines for tertiary institutions in Ghana. Government should provide infrastructure and resource support to NEIs and clinical sites, and NEIs should adhere to GTEC standards. Stakeholders in the nursing education landscape may have to consider the application of technology to augment efforts in delivering clinical education in nursing.

The lack of independence of the nursing schools to manage their own affairs is yet another gap affecting clinical learning and teaching. For example, NEIs do not have the ability to make crucial independent decisions. Most activities at NEIs level are determined by the MoH. Similar observations were made by GTEC (78), which indicated that the MoH has strong control over the NEIs, leaving minimal space for innovations to meet important specific needs. For instance, the MoH play lead roles in admissions, recruitment of nurse educators, preparation of student bills, as well as determination of vacations and reopening dates of schools. A lack of autonomy of the nursing schools hinders their operations in essential areas, such as recruitment of critical staff, admission of students match with existing infrastructure and the teaching staff strength, and budgeting (78). There may be a need for broader stakeholder consultation to consider granting NEIs autonomy in the management of the institutions.

Apart from an existing MoU between NEIs and clinical placement sites being a GTEC accreditation requirement, it spells out key issues regarding the clinical learning of students at a particular placement site and serves as evidence of a contractual agreement between NEIs and clinical learning settings. The results from the current study however revealed the absence of an MoU between the NEIs and their clinical sites confirming the existing administrative shortfalls within NEIs (78). Administrative pitfalls at NEI level have been identified to have caused delays in requesting and delivering field practice-scheduled books to students before the commencement of the clinical placements. Such administrative anomalies have also affected the timely delivery of intended clinical placement letters to clinical sites for planning.

Quality assurance (QA) in nursing education encompasses the management of the day-to-day practices in NEIs that are quality-oriented to ensure that the programme meets the standards specified by nursing authorities (79). In Ghana, NEIs have QA units headed by a QA officer to monitor and evaluate the learning -teaching process to ensure competent nurses are produced at graduation (68). An important observation made from the current study was the weak QA mechanisms related to clinical learning and teaching resulting from the failure of NEIs and regulatory bodies to monitor essential activities at schools and their affiliated clinical sites. Perhaps Ghana could learn a lesson from India. In India, the body responsible for regulating nursing and midwifery education ensures quality in the institutions through regular visits to the institutions, receiving feedback from students, consumers, hospitals and clinics and, in return, relaying feedback to schools and facilities (79). In a study to assess the internal QA practices in selected NEIs in Ghana, health tutors were unsatisfied with infrequent and ineffective inspection by regulatory bodies (68). NEIs may have to extend their QA efforts to the clinical placement sites to ensure the facilities and personnel are meeting the expectation of quality. Such a deliberate effort could guarantee competent nurses at graduation.

The outcomes, as a subsection of the standards for nursing institutions, focus mainly on an evaluation of the educational programme and programme outcomes, collection, analysis and use of evaluation results to improve the programme. The findings from the current study however indicated that, at the time, evaluation practices were not effective, although the HTI secretariat of the MoH initiated the tutor and course evaluation at the end of every semester in the NEIs. Formative and summative evaluation of a programme are essential (80). As part of formative evaluation in nursing programmes, data on student, teacher, and preceptor satisfaction could be collected with the aim of improving the system.

The importance of programme evaluation has been established. According to Lewallen (81), programme evaluation is crucial for NEIs in order to ensure that daily activities and practices are heading to desired outcomes. The same author (81) further argues that objective data can be examined through programme evaluation to guide decision-making and planning, provide the basis for changes, and improve programme outcomes. Evaluation data should be collected routinely, analysed, and reported. Key information regarding programme outcomes could be collected from students and graduates, employment data, pass rates in national or state examinations, and programme satisfaction data from graduates.

It is important for NEIs, the MoH, and other stakeholder institutions to evaluate the nursing programme both at school level and at clinical placement level constantly in order to identify and rectify challenges that may prevent the nursing institutions from meeting their core goals.

Strengths and limitations of the study

The current study was the first to conduct a gap analysis of the entire nursing educational system in Ghana. Involving multiple study sites provided a multidimensional perspective on clinical learning and teaching. Moreover, the employment of document analysis, KIIs, and FGDs (methodological triangulation) provided rich data; hence, a holistic picture of the gaps in the clinical education landscape.

The transferability of these findings may not be possible due to the contextual realities captured in this study. However, he procurement and use of approved documents, such as the curriculum for the Diploma in Nursing programme, the logbook for tutors and lecturers, and the field practice schedule for use by all public NEIs in Ghana, may make the findings transferable to other settings. The detailed description of the study sites and the characteristics of the participants could guide in determining the applicability of the findings to settings that may be similar.

The current gap analysis was part of an overarching study to develop a framework to enhance clinical learning and teaching in undergraduate nursing education in Ghana. The findings suggest that the challenges in terms of clinical learning and teaching of undergraduate nursing students are multifactorial and can be traced to the nursing education programme, the nursing institutions, and the learning outcomes. Stakeholders require that specific strategies be adopted to address the challenges identified. Based on the findings of this gap analysis, the researchers make the following recommendations:

Clinical education of nursing students should be embraced as part of the entire nursing educational system, not as an isolated entity.
Revisions of the Diploma in Nursing curriculum should consider a module on interprofessional education and interprofessional collaboration.
infrastructural and logistical support should be provided to NEIs and clinical learning sites.
Preceptors should be formally appointed and trained in preceptorship and pedagogical skills.
NMC, HTIs and the MoH should strengthen their monitoring evaluation functions of the schools and clinical sites.
Nursing institutions should adhere to accreditation standards set out by the GTEC.
The government should provide infrastructure and resource support to NEIs and clinical learning sites.
NEIs should adhere to admission standards.
The HTI and the MoH should make the logbook for tutors and lecturers a promotion prerequisites for nurse educators.

BP: Blood pressure

CLE: Clinical learning environment

CPD: continuous professional development

CPS clinical placement site

EBP: evidence-based practice

FGDs: focus group discussions

GANES: Global Alliance for Leadership in Nursing Education and Science

GHS: Ghana Health Service

GRNMA: Ghana Registered Nurses and Midwives Association

GTEC: Ghana Tertiary Education Commission

HTIs: Health Training Institution

KII key informant interview

MoH: Ministry of Health

MoU: Memorandum of understanding

NEI: nursing education institution

NMC: Nursing and Midwifery Council

QA Quality assurance

WHO: World Health Organization

Ethical approval and consent to participate

The study was executed with ethical approval from the Health Sciences Research Ethics Committee of the University of the Free State (UFS-HSD2023/0654/2811) and the Ghana Health Service Ethics Research Committee (GHS-ERC: 003/07/23). Gatekeeper permissions were sought from the selected NEIs, the NMC, the HTI, the GTEC, and the Ghana Registered Nurses and Midwives Association of Ghana (GRNMA).The researchers observed all ethical principles applicable to human participants, including verbal and written informed consent, confidentiality, privacy, anonymity and participants’ liberty to withdraw from the study at any stage without sanctions.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interest

The authors declare that they have no competing interests.

Funding

There was no external funding for this study.

Author contributions

KAH conceived the idea and discussed it with CNN, AOA, and FN, which led to a formal written proposal. KAH collected the data and analysed it with CNN, AOA, and FN. KAH drafted the manuscript, which was critically reviewed by CNN, AOA, and FN. The final manuscript was revised and approved by all authors.

Acknowledgements

The authors are grateful to all the key informants and students who participated in this study, and to Ms Jackie Viljoen for the language editing of this article.

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No competing interests reported.

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Clinical education in undergraduate nursing in Ghana: A gap analysis

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Abstract

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Background

Methods

Aim of study

Design

Setting

Population and sampling technique

Data collection and management

Methodological integrity

Data analysis

Results

Pillar 1: Learning outcomes

When you go through the clinical placement objectives, you will never find

Pillar 2: Nursing education programme standards

Pillar 3: Educational institution standards

Discussion

Strengths and limitations of the study

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1