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]