Seeking a progressive relationship for learning

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Japan Journal of Nursing Science (2014) 11, 65–77

doi:10.1111/jjns.12005

ORIGINAL ARTICLE

Seeking a progressive relationship for learning: A theoretical scheme about the continuity of the student–educator relationship in clinical nursing education Fariba YAGHOUBINIA,* Abbas HEYDARI and Robab LATIFNEJAD ROUDSARI School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Abstract Aim: The student–educator relationship is an educational tool in nursing education and has long-lasting influence on the professional development of nursing students. Currently, this relationship in clinical settings is different from that in the past due to a paradigm shift in nursing education and its emphasis on the centrality of the relationship. Methods: The purpose of this grounded theory study was to explore the continuity of the student–educator relationship in the Iranian context of clinical nursing education. Ten bachelor nursing students and 10 clinical educators at Mashhad University of Medical Sciences, Iran, were selected through purposive and theoretical sampling. The data were collected through semi-structured interviews and participant observation. Interviews were transcribed verbatim, and data analysis was done through open, axial, and selective coding, using MAXQDA ver. 2007 qualitative data analysis software. Results: The core category emerging from the data analysis was “seeking a progressive relationship for learning”. Other major categories linked to and embraced within this core category were: “creating emotional connection”, “trying to continue the relationship chain”, and “adapting the behaviors”. Conclusion: The findings indicated that in the Iranian sociocultural context, students and educators gain some action/interaction strategies for continuity of their relationship. It is obvious that the role of the nursing clinical educators and their relationship skills are critical in the relationship continuity of clinical settings. Key words: clinical education, grounded theory, student–educator relationship.

INTRODUCTION Nursing is a dynamic and applied profession, and nursing education is a set of theoretical sciences, practical activities, skills, creativity, and experience (Hosoda, 2006). Clinical education is the heart of nursing education and is essential for professional promotion of nursing students (Carlson, Wann-Hansson, & Pilhammar, 2009). Correspondence: Abbas Heydari, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Ebne-Sina Street, Mashhad 9137913199 Khorasan, Iran. Email: [email protected] *This author is also a faculty member of Zahedan University of Medical Sciences, Zahedan, Iran. Received 14 June 2012; accepted 23 October 2012.

Although clinical education is essential and valuable, it is not without problems and limitations (Levett-Jones & Lathlean, 2008; Tiwari et al., 2005). The number of students in training groups, long-term clinical experiences, and hard work may affect teaching and learning situations and their qualities. Among other influential factors are student and educator characteristics, ward environment, learning experience of theoretical courses, and relationship in clinical setting. Indeed, clinical education is a face-to-face education in which the quality of the relationship plays a key role in its promotion. The type and quality of this relationship is a key component of teaching and learning (Newberry, 2010). An appropriate student–educator relationship can lead to positive consequences such as an increase in learning

© 2013 The Authors Japan Journal of Nursing Science © 2013 Japan Academy of Nursing Science

F. Yaghoubinia et al.


motivation and self-confidence, as well as the promotion of students’ professional skills (Ghadami, Salehi, Sajadi, & Naaji, 2007; Yuen Loke & Chow, 2007), positive learning experiences, reduction of the possibility of educational failure, reduction in students’ fear and anxiety, and reception of more support during caregiving by the student (Allison Jones & Hirt, 2004; Andrews et al., 2006; Fraser & Walberg, 2005; Gillespie, 2002; Riley, 2009). Despite the importance of this relationship and the salient effects mentioned above, there are still problems with the relationship status. The findings of the study by Ghaneie Raad (2006) in Iran, on the role of student–teacher interactions in creating university social capital, showed that the relationship of students with their teachers is poor in various aspects (Ghaneie Raad, 2006). However, a similar study has never been conducted in the context of Iranian clinical nursing education. The findings of Savage and Favret’s (2006) study are indicative of students’ experiences of their educators insulting them in front of others. Furthermore, Webb and Shakespeare (2008) cited Bennett (2002) who found that students have potentially damaging experiences such as being ignored. In general, different research studies (Clark, 2009; Ghaneie Raad, 2006; Saberian, Haji Aaghajani, Ghafari & Ghorbaani, 2007; Savage & Favret, 2006; Webb & Shakespeare, 2008) have demonstrated that there are some difficulties in the student–teacher relationship in clinical education settings. One of the reasons for these difficulties in clinical education is that all aspects of the student– educator relationship are still unknown. Also, according to Lopez (2003), relatively little effort has been done to explore the nature of the student–educator relationship and its effects on students’ learning. Considering that the relationship is a complex human phenomenon, complete understanding of it requires a holistic approach. At present, there is a paradigm shift in nursing education from a behaviorist to humanistic approach. The limitations and disadvantages of the behaviorist approach to learning, as well as the wider philosophical changes within the field of psychology and the development of humanism, forced a paradigm shift in general education and thereafter in nursing education. In this paradigm, the educator becomes a facilitator of learning while the whole approach adopts a student-centered philosophy, with emphasis on the importance of holistic learning, the notion of personal growth for both participants, students, and the educators, and also represents

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what is called democratization of the student–educator relationship, in which there is no place for authoritarian attitudes (Halarie, 2005) Therefore, the student–educator relationship with regard to the paradigm shift in nursing education has been different from what it has been in the past, and students have different expectations from their educators in relation to establishing a good relationship. Accordingly, it seems that understanding the nature and process of the student–educator relationship and its dimensions in the humanistic paradigm are inevitably essential. Regarding the unprecedented history of a similar study in Iran about the continuity of relationship between the student and educator in clinical nursing education, as well as the different experiences and perceptions of Iranian students and educators, which are influenced by the sociocultural context of Iran, the present study was accomplished to explore the continuity of the student–educator relationship in clinical nursing education.

NURSING EDUCATION IN IRAN In Iran, students can study nursing at all higher education levels from bachelor’s to doctorate. The bachelor’s nursing programs involve 4 years of education in nursing. Nursing students start clinical training from the second semester and this is run concurrently with the theoretical courses until the end of the third year. The fourth year is allocated exclusively to clinical placement training. For the first 3 years, they learn nursing practice in the clinical environment under the direct guidance and supervision of a nurse educator, who has a master’s degree in nursing. In the final year, they work under the guidance of staff nurses and alternate supervision of nurse educators (Peyrovi, Yadavar Nikravesh, Oskouie, & Bertero, 2005).

Methodology and method The grounded theory methodology developed by Strauss and Corbin was used in present study. The aim of the grounded theory approach is to discover behavioral patterns in a group of people in a specific situation and to understand the key psychosocial processes that occur in social situations (Curtise & White, 2005; McCreaddie & Payne, 2010; Wood & Haber, 2002). Because all aspects of the student–educator relationship are not fully known in educational settings, the



Seeking a progressive relationship

Table 1 Summary of participants’ profile Participants

Age

Gender

Job Experience

Participants

Educator Educator Educator Educator Educator Educator Educator Educator Educator Educator

34 37 37 38 42 53 49 50 50 53

Female Female Female Female Female Male Male Female Male Male

2 7 8 7 14 20 15 17 15 24

Medical Surgical Medical Surgical Medical Surgical Medical Surgical Medical Surgical Medical Surgical Medical Surgical Pediatric Medical Surgical Nursing management

1 2 3 4 5 6 7 8 9 10

grounded theory approach was used to explore the continuity of the student–educator relationship in clinical settings in Iran.

Participants Ten bachelor’s nursing students with apprenticeship experience and 10 educators with at least 1 year of experience in clinical education were selected through purposive and theoretical sampling (Table 1). Nursing apprenticeship in Iran is an integral part of professional nursing studies and includes a 40 week clinical placement, in which nursing students provide supervised care 7 h/day and 6 days/week under the supervision of an academic nursing educator (Cheraghi, Salsali, & Ahmadi, 2008). In clinical wards, the student–educator ratio ranges from 1:6 up to 1:12 (Peyrovi et al., 2005) Sample design ensured the inclusion of undergraduate students from each year. Both male and female students as well as male and female educators participated in the study. Contrary to some previous studies in which only educators or students were studied, the inclusion of both students and educators in this study was deemed as a strong point. The selection of participants was a function of developed categories for the purpose of theoretical sampling. Strauss and Corbin (2008) have described theoretical sampling as a method of data collection based on concepts or categories derived from the data. Sampling continued until data saturation.

Data collection Semi-structured interview and participant observation were used for data collection. Each student or educator was interviewed in a session which lasted approximately 45–90 min. Based on the participant’s choice, interviews were conducted either in classroom or educators’ office.

Field Student Student Student Student Student Student Student Student Student Student

1 2 3 4 5 6 7 8 9 10

Age

Gender

Semester

21 21 22 22 20 21 20 21 24 22

Female Female Male Male Male Female Female Male Female Female

6 6 5 8 3 5 4 6 8 8

At first, based on an interview guide, some questions were asked about the experiences of the student– educator relationship and then the interview process was guided through the participant’s answers. For example, they were asked: “Please tell me your relationship experience of 1 day in clinical education”. Interviews were conducted and recorded by the first author who was a nurse educator and then were transcribed verbatim. Unstructured observation in the form of observer as participant was carried out in the cardiac and surgery wards in Imam Reza Hospital, Mashhad, Iran, and field notes were written to describe the observations. Because the primary reason for using observational methods is to check whether what people say they do is the same as what they actually do (Mulhall, 2003), it is ideal that interviews and observations are performed on the same people; thus, in this study, in the cases it was possible, observation was performed on participants who were interviewed as sources of complementary and confirmative data, and in other cases these two methods were carried out separately from each other. The role of the researcher was to observe the participants’ behaviors and their relationships with each other for 3–4 h every day. The study was designed to minimize the observer effect, as the researcher’s presence could affect the participant’s behavior. To minimize this effect, the researcher tried to give a general awareness of the research aim to the participants, but they did not know about the exact time of observation and the way that they were going to be observed. Also, a prolonged stay of the researcher in the wards as an observer minimized the effect of their presence.

Data analysis In a grounded theory study, data collection, coding, and analysis are simultaneous processes from the beginning


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of the study to its conclusion. The transcribed interviews and field notes as recorded observations were reviewed and analyzed immediately. Data analysis for interviews and observations was conducted by the constant comparative method developed by Strauss and Corbin through carrying out three levels of coding: open, axial, and selective. Collected data from the observation of participants who were both interviewed and observed were analyzed as complementary and confirmative sources of data regarding whether they confirmed each other or not. However, in the remaining cases, they were analyzed as separate data. In the initial stage of data analysis and open coding, collected data from students and educators were analyzed separately. Because the main purpose of the study was to explore the continuity of the student–educator relationship, and because this relationship is behaviorally mutual and interactive, in the next stages of analysis, the data from these two groups were analyzed in relation to each other. Open coding as the first stage is a process of breaking the data into separate parts with the aim of processing and categorizing concepts (Strauss & Corbin, 2008). In the present study, the primary codes from interview text and field notes were examined to identify their characteristics and were compared with other codes within the same interview or observation, and in different interviews or different observations to find the similarities and differences. Then, similar codes were grouped so that initial categories could emerge (Strauss & Corbin, 2008). By categorizing the initial codes, 12 categories emerged from the data. In the stage of categorizing, initials codes from students’ and educators’ interviews according to constant comparative analysis were categorized in common categories. For example, the category “creating emotional connection” consisted of similar codes from both students and educators. Then, axial coding was carried out to put the fractured data back together in new ways by making connections between a category and its subcategories. The 12 categories were abstracted into three major categories that revealed the stages of the continuity of the relationship. For each category, a paradigm model was developed which allowed a linkage to be made between the categories and their subcategories. The paradigm model consisted of different components including: (i) phenomenon, the central idea that the action/interaction strategies focused on; (ii) contextual, causal, and intervening conditions; (iii) action/interaction strategies made by the partici-

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pants for managing and controlling the phenomenon; and (iv) consequences, the outcome and results of action/interaction strategies (Strauss & Corbin, 1998). In the phase of selective coding, the category “seeking a progressive relationship for learning” was identified as the core category, because it occurred frequently in the data and was connected with other major categories. The software MAXqda 2007 was used for organizing the data and facilitating the management of a large volume of text and a large number of codes.

Rigor In this study, credibility was established through prolonged engagement with participants, triangulation of methods and data sources, member checking, peer debriefing, and review of data analysis with supervisors (Streubert Speziale & Carpenter, 2007). For dependability, coding of the interviews was carried out by other colleagues who were experienced in coding the qualitative data. Moreover, the researchers documented the research details in order to provide the possibility of external review. Also, informative description about participants and research situation was offered by the researchers.

Ethical considerations This research was carried out after obtaining ethical approval from the Research Ethics Committee, Mashhad University of Medical Sciences, Iran, and with the permission and consent of the Dean of the Nursing and Midwifery School. The ethical issues in this study involved the assurance of confidentiality and anonymity of the participants. Informed consent was sought from all participants and they were allowed to refuse to answer any question or withdraw from the study at any time without prejudice.

RESULTS Twelve categories were generated from the data and their relationships were identified using the paradigm model recommended by Strauss and Corbin (1998). The way in which each of the properties within the paradigm model interacts with each other, and, in turn, how each relates to the development of the core category are detailed in Figure 1, and discussed below.

Core category The core category represents the main theme of the research. It is the concept that all the other concepts will be related to (Strauss & Corbin, 2008). According to the




Causal Condition

Context

Necessity of offering clinical education

Personality Characteristics of students and teacher

Need to educator’s help for learning

Trust Respect

Phenomenon (Core Category) Seeking a progressive relationship for learning

Action/Interaction Strategies Creating emotional connection Attention and sensitivity to student Considering student’s problems and concerns Affective help to resolve problems

Intervening Conditions (Facilitator Conditions) Met expectations Giving importance to student Teacher’s clinical competency

Trying to continue the relationship chain

Inspiring self confidence in student

Accompaniment and cooperation

Understanding mutual expectations

Supervision & Guidance

Mutual awareness of preferences and desires

Question & Answer

(Hindering Conditions)

Information Exchange

Inattention

Assignment determination / Doing Assignment

Talking loudly Criticism in presence of others

Adapting the behaviors Trying to have suitable behaviors and encounters Meet mutual expectations

Poor level of educator knowledge Not accepting the question Talking with belittling tone

Correcting relationship problems

Consequences

Figure 1 Seeking a progressive relationship for learning: a theoretical scheme about the continuity of student–educator relationship in clinical nursing education.

Increase student’s motivation for learning Better clinical learning Decrease of student’s anxiety Improvement of Clinical performance

data, the category “seeking a progressive relationship for learning” emerged from participants’ apprehensive expression that high quality clinical learning would be achieved through the educational relationship, which was repeated in the data again and again and related to other major categories by which the participants expressed their wishes to create and progress effective student–educator relationships. This category is related to other categories which were identified as continuity of relationship. According to the paradigm model, the categories of “need for the educator’s help for learning during the

relationship” and “necessity of offering clinical education by the educator” were the causal conditions for the phenomenon that occurs in the context of personality characteristics and secure relationship atmosphere. Both groups of participants used some strategies for managing the phenomenon including three categories: “creating emotional connection”, “trying to continue the relationship chain”, and “adapting the behaviors”. These categories are the basic stages of the continuity of relationship. Based on participants’ experiences, when the student–educator relationship is destroyed, education and learning are affected broadly; therefore,


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the participants attempted to preserve their relationship for this reason. Finally, improvement of clinical performance and learning, successful training, tendency for further relationship, and increased motivation for learning were the consequences of the action/interaction strategies. Comments from both students and educators showed the importance of the continuity of relationship in clinical settings to achieve improvement in learning. One of the educators commented: When I was comfortable with my students and our relationship was very good, they learned more and better, but in a stressful atmosphere in which I couldn’t establish good relationship, their learning was reduced. (Educator 5)

Similarly, one student declared that: In the ward that we passed with Mrs B., I learned much more, because if I made a mistake, I could say it to my educator and she didn’t show inappropriate behavior, you know, our relationship was such that it gave me motivation to be more interested to learn. (Student 7) Another educator commented: Our relationship in clinical education must be strong, because we expect effectiveness from education. If this relationship is interrupted, the student will create a wall of defense around himself and this is a learning obstacle. (Educator 7)

Causal conditions Based on Strauss and Corbin’s coding procedure, the findings showed that there were reasons why the participants sought a progressive relationship in order to achieve learning. The main causal conditions that led to the emergence of the phenomenon was the need for an educator’s help for learning and the necessity of offering clinical education by the educator; therefore, an unsuccessful relationship could cause problems and concern about learning. Nursing students acknowledged that they became eager to have a continuous relationship with clinical educators because of the need for the educator’s help in clinical learning; educators similarly commented that when students felt that their educator wants to help them, they established and continued a good relationship with them: I require a leader in clinical settings; of course, the personality of the educator is important in this way, but the main cause that makes me want to have a relationship with my educator is the instruction that he/she gives me. (Student 8)

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When students realize that I want to help them, they themselves feel comfortable, establish and continue their relationship with me. (Educator 5)

Contextual conditions Contextual conditions, according to the paradigm model, are the specific sets (patterns) of conditions that intersect at this time and place to create a set of circumstances or problems in which people respond through action/interaction strategies (Strauss & Corbin, 1998). Based on the results, the personality characteristics of students and educators and a secure relationship atmosphere containing respect and trust were contextual conditions of the phenomenon. Personality characteristics are the unchangeable part of individuals in which the relationship occurs. The student–educator relationship is formed and continued in the context of this set of characteristics. Also, with regard to the secure relationship atmosphere containing respect and trust, some positive findings emerged such as the importance of ensuring the creation of the relationship that had a protective role. The following two statements illustrate these findings: In fact, the relationship occurs on the basis of personal characteristics. Some of the educators have features that don’t change, so some of them can establish a good relationship but some cannot. (Educator 3) A proper relationship is established in a safe psychological environment in which mutual respect is observed and mutual trust is salient. (Student 3)

Action/interaction strategies Action/interaction strategies are purposeful or deliberate acts which are taken to resolve a problem and shape the phenomenon in one way or another (Strauss & Corbin, 1998). In this study, three categories were generated to be the action/interaction strategies as components of the paradigm model.

“Creating emotional connection” “Creating emotional connection” was the first stage that both students and educators experienced during the continuity of the relationship in the context of clinical education. Emotional connection is characterized by sensitivity and attentiveness to each other. According to the results, it seems that the attentiveness and sensitivity of the clinical educator to students and their needs, concerns, and problems, as well as comprehensive attention being paid to them at the beginning of each day and during the clinical course, were the prerequisites of the students’ tendency for continuing the relationship in



clinical settings. Clinical educators, who were identified as commencers in the relationship process in this study, took different approaches of action/interaction to manage this phenomenon. These strategies included comprehensive attentiveness to students, sensitivity to students’ problems and concerns, supplying affective help to resolve problems and improve conditions. In this way, students gave satisfactory feedback to the educator and were willing to continue the relationship. After the initial formation of the relationship between student and educator, it was important for students that the clinical educators pay attention to their conditions, and seek the reasons for any discomfort. When this happened, they were much more keen to continue the relationship and gain from its educational effects. One of the students commented: Some of the educators may ask the students about the reason for their upset, but some of them don’t this. When he/she follows the student’s problem, this reveals the importance of the student to the educator, which itself causes the preservation of the relationship. (Student 8)

In some cases, clinical educators also noted all issues relating to the students before training them and starting the clinical work. Some educators mentioned that sensitivity was the first stage in commencing the relationship. One of the clinical educators commented: At first, I make sure of their fair conditions and whether they are ready to take care of a patient. Do they have the physical ability for clinical work and are they able to provide bedside care? You know, at first I try to be sure that they are OK and then we start our work. (Educator 3)

In cases of a student’s illness, they expect their educators to take into consideration their problems in clinical settings. The comment by Student 7 demonstrates this point: For example, if my blood pressure is low today and I am pale, my educator should consider this and show understanding. If I have a problem, he/she should let me sit down more.

The existence of such attention and meeting expectations can act as facilitators for continuity of the relationship: When the student feels that his/her needs and expectations are considered, this helps the formation of a relationship process. You know, a better relationship will be established and continue between us. (Educator 9)

One of the educators pointed to the hindering effect of some of the educators’ attributes such as inattention to students’ conditions:


If a student is depressed or not in a good mood one day, for example he/she is sick and has a severe cold, in such a condition, if I don’t pay attention to him/her and don’t ask about his or her condition, this lack of concentration disrupts the relationship. (Educator 1)

Also, one of the students highlighted the positive effect of respect and attention to the student by the educator: “If clinical educators give enough importance to students in various aspects in clinical education, this causes establishment of a good relationship between them” (Student 3).

“Trying to continue the relationship chain” After creating emotional connection and providing a satisfactory atmosphere, participants had a tendency to make efforts to continue the relationship. They used action/interaction strategies such as clinical planning, requests for accompaniment and cooperation in clinical work, supervision and guidance, question and answer, information exchange, determining and performing assignments, and asking for help. Some of these were performed by the students and some by the educators, and interactions between their behaviors formed this stage. Based on the results, it seems that in most cases clinical planning is the first action performed through determining the aims and objectives of the clinical course. Through an organized, structured, and selected learning experience, students developed the confidence in their abilities to establish the relationship and to learn. According to the students’ experiences, this action can decrease their stress to continue the relationship. One of them commented: This is very good that our educator gives us educational aims, so we know when we are entering the ward, what he/she wants from us and what we must learn. This decreases our stress to continue the relationship with our educator. (Student 4)

Also, clinical educators stated that this action was carried out after starting the relationship with students: “After getting to know and greeting each other, I gave them the course plan, expressed my training policy, and how to achieve goals” (Educator 7). The majority of clinical educators experienced students’ requests for accompaniment and cooperation and they responded to them through assisting and being accessible to the students in order to continue the relationship. This may increase students’ self-confidence for improved performance of the clinical tasks and enhances learning. Parts of the field notes recorded were based on observation and demonstrated this point:


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The female student who needed to perform a PPD test saw the educator in the corridor of the ward and asked the educator to accompany her to do the test. A few minutes later, the educator accompanied her in a friendly manner and stood near the student at the patient’s bedside. (Field note 7)

The educator in this observation was interviewed too; the results of the interview and observations of this participant confirm and support each other. She stated in her interview: “Whenever my students need help, I accompany them and don’t leave them alone” (Educator 8). Indeed, this action is a way to continue their relationship. Also, in order to execute the clinical program, they need to accompany each other. One of the educators commented: “My clinical programming necessitates that my student see me every day and attend with me; hence, our relationship exists directly and face-to-face until the last day of training” (Educator 10). Students also expressed that the cooperation of the clinical educator is one of the activities for continuity of the relationship: “For example, if we have to perform an i.v. catheter insertion that we can’t do alone, the educator comes and assists us” (Student 6). Clinical competency of educators is as a facilitating condition. One of the educators commented: “In some courses that I was proficient and had great skill, my relationship with the students was better” (Educator 5). This factor can increase students’ trust and confidence in educator in the relationship process and creates a better relationship. One of the students commented: I was relying on my educator being able to perform skills well. If my educator was more skillful, he/she could establish a better relationship and helped me. (Student 7)

Supervision and guidance were carried out by the educators in the progression of the relationship and consequently in better learning. Continued supervision of the student’s performance was required for this reason. One of the students commented: For example, my educator said that when you want to write in a patient’s records, stand near me or when you write it, bring it to me in order to be checked. This causes improvement of our relationship. (Student 8)

Also, one educator commented: “In each day of our clinical course, I go to the patients’ bedsides and supervise my students during the accomplishment of their duties” (Educator 1). Of course, the degree of supervision was different for senior and junior students.

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Guiding students was another action carried out to manage the phenomenon. In one of the observations, the researcher realized that: “The educator, while helping the student to look for a suitable vein for catheter insertion, talked to the student quietly and guided her so that the patient couldn’t hear her and so didn’t lose her trust in the student” (Field note 7).

Talking loudly and criticizing the student in the presence of others acted as hindering conditions and reduced student’s self-confidence rather than the educator acting as a facilitator to the student in seeking guidance and maintaining the relationship through this accompaniment. One of the students commented: When I am doing a dressing and make a mistake, Mr A. tells me loudly in the patient’s room that I am doing it wrong. In such a situation, you know, I try to get as far away from the educator in the ward as possible. (Student 3)

Another student commented: I know that when I am with Mr B. at a patient’s bedside, he reprimands me in the presence of others. For this reason, I always go alone. I don’t ask my educator to come with me. (Student 7)

Also, another student stated that: “I like Mrs B. to accompany me during blood taking or i.v. catheter insertion, because she gives me self-confidence” (Student 6). Questioning, answering, and information exchange were some of the strategies used by the participants in continuity of educational relationship. Participants believed that asking questions stimulated learning, and encouraging questioning and answering the students clearly could help them to establish a good relationship. In one of the observations, the researchers noticed that: In cardiac ward, the clinical educator paid kind attention to the students and was ready to help. In these conditions, students asked the educator about drugs and ECG interpretation. The educator said that, if you have a question, please feel free to ask it. One of the students asked a question comfortably and the educator responded properly to the question with cheerfulness. (Field note 7).

The educator mentioned above was interviewed too and stated: “During the time in which students accomplish their clinical work, they ask me questions conveniently and without fear” (Educator 2). The clinical educators, therefore, believed that they should create a secure atmosphere where students can ask questions comfortably, allowing them to continue the relationship with their educator: “I try to create an



atmosphere of questioning for my students in many aspects, for them to ask whatever they want, so that they can ask me in a challenging situation conveniently” (Educator 8). One of the students also commented: “As soon as we didn’t know something, we asked our educator and so we continued our relationship in this manner and at the same time we learned” (Student 8). According to the results, a poor level of educator knowledge could act as a hindering factor. In this situation, students avoided asking their educator questions, and this negatively affected the relationship and learning. One of the students commented: “When I know that my educator doesn’t have enough information, I don’t trust him/her and I don’t ask my question” (Student 2). Another intervening condition was a sense of insecurity in the relationship that implies that the student’s question has not been accepted and therefore belittles him. This concept is depicted in this statement: If I have a question that I want to ask my educator, it is very important to me how he/she manages this encounter. It’s important that he/she doesn’t say that this question is not a suitable or important question or will explain it afterward. (Student 7)

In most cases, in order to achieve goals, the educators gave clinical assignments and project work to the students in order to continue their relationship. One of them commented: “One of the things that I do for continuity of the relationship and achieving the learning goals is giving tasks to the students and demanding completion of them” (Educator 8). Also, students needed to have relationship with educators to accomplish their duties and tasks. One of them commented: “When we go to the ward in the morning and our educator gives us the responsibility of caregiving, this is one of the factors that helps us to continue this relationship” (Student 7). Nursing students in a stressful clinical environment ask for help and guidance in order to maintain the educational relationship. In one of the observations the researcher observed: A female student who asked her educator: “Do you come with me to perform the ABG test?” the educator said kindly: “Ok, I’ll come with you. Have you ever done it before?” The student said: “No, I don’t know how to do that.” (Field note 7)

Talking with a belittling tone was a hindering condition in asking for help from the educator in a clinical setting. In such environments, there are many people and the type of encounter between the students and


educators in front of them is important, especially for students, and can act as a factor in increasing or decreasing their self-confidence and professional identity. One of the students commented: “When I knew that my educator would quarrel with me in front of others, especially the patient, and would belittle me during the accomplishment of clinical tasks, I didn’t ever ask her for help” (Student 6). Also, clinical competency of educators acted as a facilitating condition in asking for help because the students expected to observe practical skills in their educators. One of the educators commented: Students usually expect good practical work from their educators, expect that the educators are expert in the ward. When this expectation is met, students like to get help from them and benefit from their supervision. (Educator 9)

“Adapting the behaviors” Subsequently, regarding the areas in which some problems may occur in relationship encounters and behaviors between students and educators, the need to gain adaptability is very prominent. Sometimes, educators and students may behave and interact in ways that interrupt the relationship in clinical settings. In such cases, they try to apply some activities for adapting their behaviors with each other and to prevent the disconnection; therefore, this leads to maintaining their relationship. They use different actions/interactions to achieve suitable behaviors and encounters, to meet mutual expectations, and to correct the relationship problems. One of the educators who had behaved inappropriately behavior with a student said: After that encounter, I saw that her relationship with me was disrupted, she didn’t establish eye contact and didn’t have motivation to work. Then I tried to refine my dealing with her and resolved this problem. (Educator 1)

Understanding mutual expectations can act as a facilitating condition in this adaptation process. When the students and their educators are aware of each other’s expectations in various aspects of the relationship and educational work, they can adjust their behaviors to each other better and maintain the relationship. One of the educators commented: My relationship with students may be stricter than others, but my students adapt themselves to me, because I tell them my expectations and want them to tell me their expectations, too. So our relationship is maintained.” (Educator 4)

Mutual awareness of preferences and desires, especially about preferences and desires of clinical educators


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both in disciplinary actions and clinical tasks, was another facilitating condition. When students pay attention and keep to these issues, they can preserve their relationship more easily. Students commented: If it is important for my educator that I check drugs with him/her before injection, I am required to do this. Therefore, we will not have any problem with each other. (Student 7) If my educator doesn’t behave with me according to my expectations, I will change my behaviors in our relationship according to her/his expectations. (Student 9)

Consequences Consequences may be actual or implicit and may occur in the present or future (Strauss & Corbin, 1998). Action/interaction strategies taken by the participants in managing the phenomenon resulted in various consequences. Improving clinical learning and performance, increased motivation for learning, successful training, and tendency for further relationship were the predominant consequences of actions/interactions in this study. One of the students commented: Sometimes, when our relationship was very good, we would wish to continue this connection and we would say to our educator “is it possible that you guide us in conducting research?” So in this way our relationship becomes more stable. (Student 8)

Also, the type relationship created may lead to strengthening the students’ motivation for learning and following up the clinical tasks. One of the students commented: “The first thing that can help students having motivation in clinical settings is the relationship which the educator establishes with the students” (Student 5). Enhanced learning and performance are other consequences of a successful continuing relationship. Please pay attention to this comment: “I experienced that when I was comfortable with my students and we had a proper connection with each other, they learned better and their work was advanced” (Educator 5).

DISCUSSION This study explored the continuity of the student– educator relationship in clinical settings. The core category was “seeking a progressive relationship for learning”. In completing the first day of clinical education, participants tried to learn by achieving a constructive and progressive relationship. The core category manifested itself in some activities by the participants that could be affected by intervening conditions.

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Throughout the educational relationship, clinical educators tried to provide opportunities to meet students’ expectations from clinical learning through this connection in clinical settings, improvement of students’ learning, and supporting them. The students also made efforts toward better learning through maximum usage of opportunities that were provided during the relationship process. In the present study, participants’ experiences revealed some activities for continuity of the educational relationship. Regarding the fact that clinical educators should create a physical and emotional environment conducive to learning, to help students and to develop their clinical competency, their responsibility and obligation in the educational relationship is very important. Most participants commented that creating emotional connection was an important part of continuity of the relationship rather than just starting it. This action shows that educators’ attention and sensitivity to their students as individuals as regards physical, emotional, and social aspects is important. This leads to an enhanced sense of respect and motivation for learning in students through emotional connection, and can act as a factor in their tendency for developing such a relationship. Students also wished for clinical educators to consider their needs and conditions in this relationship in stressful clinical environments, and consequently to facilitate their learning through creation of a relaxed and safe relationship atmosphere. In the study by Craig (1991), 52% of students reported that their clinical educators are sensitive to their feelings and needs. Also, students stated that insensitivity to them reflects the lack of empathy of clinical educators (Craig, 1991). No other studies were found to report this attribute. This finding showed that clinical educators should not look at students just as learners, but – to strengthen the relationship – they should consider them as individuals with various aspects and needs. In the process of developing a relationship and in trying to continue the relationship chain, the clinical educators’ clinical competency plays a major role in preservation of the relationship with students because the existence or lack of it may cause them to recognize whether they can rely on their educators for skill development or not. Lack of confidence in clinical educators can also lead to the feeling that the educators do not have anything to teach them in clinical settings. In a study by Gillespie (2002), students emphasized the importance of clinical educators having recent clinical experience, indicating that their practical knowledge led



them to be more effective in helping students to learn and become a nurse in the real world (Gillespie, 2002). Being accessible to students and accompanying them were among the actions that led to continuity of the relationship. Spending time with students in clinical environments and being with them were considered requisites for prosperity of this connection, and provided opportunities for students to communicate and talk with their educator. The findings of Gillespie (2002) also revealed that students described connected educators as emotionally and physically available, where availability was identified as a characteristic in effective teaching. In another study (Lopez, 2003), students experienced that if they needed help from teachers, they could accompany them at the patient’s bedside and cooperate with them. In the present study, clinical educators were using supervision and guidance for developing the relationship and achieving the goals of clinical education. In the study by Lopez (2003), students reported that they required an educator who could guide and support them to perform well during clinical placement. In this respect, up-to-date theoretical knowledge of the educators was important in a successful relationship. The findings of Ghadami, Salehi, Sajadi, and Naaji (2007) showed that educator knowledge was important in establishing the relationship between the student and educator, because knowledge is accepted in nursing published work as an essential part of clinical educator competence (Chow, 1988; Gillespie, 2002; Nahas, Nour, & Al-Nobari, 1999; Tang, Chou, & Chiang, 2005). The findings of the current study add to this subject by highlighting the relationship between the educator’s knowledge and the successful relationship between student and educator. Another factor in this relationship was the expectations of students and educators of each other in clinical settings. The findings revealed that students enter the student–educator relationship with opinions and expectations of themselves and their educator. For example, they expect an educator who is competent and knowledgeable, who talks properly with them and does not belittle them; they believed that they are students and inexperienced, and may make mistakes. These beliefs and expectations had important influences on the continuity of the relationship. Throughout the relationship, students want to receive support from their educators by the educator’s response to their requests for help. In McKee’s (2005) study, during the faculty–student relationship progress, the


students seemed to need support and encouragement (McKee, 2005). Encouraging questions and supplying answers carefully and precisely were other important actions in the student–educator relationship. This activity increased students’ tendency for an ongoing relationship. In the current study, in some cases students were afraid of being belittled and demeaned during questioning, but if they were assured that their question would be accepted, they would ask comfortably. This finding is similar to those of Craig (1991). In adapting the behaviors, the participants tried to accommodate themselves to each other’s behavior. In most cases, students and educators reported successful adaptation to each other’s behavior and, in few cases, they reported unsuccessful adaptation.

CONCLUSION The experiences of nursing educators and students in Iran demonstrated that, in order to achieve goals in clinical education, they need to apply action/interaction strategies to maintain and develop the relationship. Consequently, in most cases, clinical educators advance clinical learning in their students via this educational relationship. It is obvious that the role of the nursing clinical educators and their relationship skills is critical to the continuity of the relationship. Because clinical educators are commencers of this process, they need to know more about the influence of their interpersonal behaviors on all aspects of training students, especially clinical learning and professional dimensions.

Implications for nursing education and research The results of this study bear important implications for clinical education, and clinical educators should pay attention to these findings in order to start, develop, and maintain their relationship with students. In nursing research, future studies can focus on the effect of contextual factors on relationships too.

ACKNOWLEDGMENTS This article is part of a large PhD research thesis approved and funded by the Vice Chancellor for Research, Mashhad University of Medical Sciences, Mashhad, Iran coded 89428. The authors gratefully acknowledge their assistance in supporting this study. The authors would like to thank the clinical educators and students involved in this study for their valuable


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contribution. The author also express their gratitude to the Dean and Vice Deans of Mashhad Nursing and Midwifery School and also the Director of Imam Reza Hospital.

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