The experience of educational quality in undergraduate nursing students

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School of Nursing, Catholic ... KEYWORDS: Educational quality, undergraduate education, nursing ..... stress and teaching load (Freeburn & Sinclair, 2009).
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The experience of educational quality in undergraduate nursing students: a phenomenological study L’esperienza della qualita’ formativa negli studenti di infermieristica: uno studio fenomenologico Loreana Macale1 Ercole Vellone2 Gennaro Scialò3 Mauro Iossa4 Elena Cristofori5

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RN, MSN, PhD, Nursing Science Degree Appointed Professor University of Rome "Tor Vergata" RN, MSN, PhD, Assistant Professor in Nursing Science, Department of Biomedicine and Prevention, School of Nursing, University of Rome "Tor Vergata" Italy RN, MSN, PhD, Nursing Science Degree Appointed Professor University of Rome "Tor Vergata" RN, MSN, Clinical nurse Catholic University, Rome, Italy RN, MSN, Appointed Professor School of Nursing, Catholic University, Rome, Italy RN, MSN, Associate Professor Department of Biomedicine and Prevention, School of Nursing University “Tor Vergata”, Rome Italy Contact person:

Loreana Macale, RN, MSN, PhD Nursing Science Degree Appointed Professor Faculty of Medicine, Department of Biomedicine and Prevention University of Rome "Tor Vergata", Office of Sora Loc. S. Marciano s.n.c - 03039, Sora, FR Italy Phone: +3907761938027 - Fax: +3907761938022 Mail: [email protected]

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Rosaria Alvaro6

ABSTRACT AIM. The evaluation of academic education has become crucial in the European Union since the Bologna Process encouraged all European universities to reach high quality standards in education. Although several studies have been conducted on the quality of undergraduate nursing education, few studies have explored this topic from the students’ perspective. The purpose of this study was to describe the experience of educational quality in undergraduate nursing students. METHODS. The phenomenological method was used to study 55 students (mean age 24 years; 73% female) pursuing a baccalaureate degree in nursing in three universities in central Italy. RESULTS. The following five themes emerged from the phenomenological analysis: 1) quality of faculties: teaching skills, preparation, sensitivity to students, self-discipline; 2) theory–practice integration and communication between teaching and clinical area; 3) general management and organization of the programme; 4) quality of infrastructures: libraries, classrooms, information technology, services, administration, and communication; and 5) clinical tutorship: humanity, relationships and ability of the clinical tutor to guide and support. CONCLUSION. This study’s novel finding was a deeper understanding of the educational quality’s meanings among undergraduate nursing students. Students thought educational quality consisted of the faculty members’ sensitivity towards their problems and the clinical tutors’ humanity, interpersonal skills, guidance and support. KEYWORDS: Educational quality, undergraduate education, nursing students, phenomenology.

RIASSUNTO SCOPO. La valutazione della formazione accademica è diventata fondamentale nell'Unione Europea da quando il Processo di Bologna ha incoraggiato tutte le università europee a raggiungere elevati standard di qualità nella formazione. Anche se diversi studi sono stati condotti sulla qualità della formazione negli studenti di infermieristica, pochi hanno esplorato questa tematica dalla prospettiva degli studenti. Lo scopo di questo studio è stato di descrivere l'esperienza della qualità formativa negli studenti del corso di laurea in infermieristica. METODO. E’ stato utilizzato il metodo fenomenologico per studiare 55 studenti (età media 24 anni; 73% donne) che frequentavano il corso di laurea in infermieristica in tre università del centro Italia. RISULTATI. Dall'analisi fenomenologica sono emersi i seguenti cinque temi: 1) Qualità dei docenti: capacità di insegnamento, preparazione, sensibilità per gli studenti, autodisciplina; 2) Integrazione teoria-pratica e comunicazione tra l'insegnamento e l'area clinica; 3) gestione generale e organizzazione del corso; 4) la qualità delle infrastrutture: biblioteche, aule, tecnologie dell'informazione, servizi, amministrazione, comunicazione; e 5) tutorato clinico: umanità, relazioni e capacità del tutor clinico di guidare e supportare lo studente. CONCLUSIONE. I risultati di questo studio forniscono una comprensione nuova e più approfondita sul significato della qualità della formazione negli studenti di infermieristica. Gli studenti ritenevano che la qualità della formazione consistesse nella sensibilità dei docenti verso i loro problemi e nell’umanità, capacità interpersonali, guida e supporto dei tutor clinici. Parole chiave: qualità formazione, studenti infermieristica, esperienza educativa, fenomenologia

The experience of educational quality in undergraduate nursing students: a phenomenological study

INTRODUCTION The evaluation of academic education has become crucial in the European Union since the Bologna Process encouraged all European universities to reach high standards of quality in education and students’ satisfaction (Hensen, 2010). The Bologna Process has provided a framework for common efforts to reform and modernize the Europe’s higher education systems. Thus, from the beginning of the Bologna Process in 1999, there has always been a strong focus on quality. The Bologna Process aims to develop quality assurance systems, encourage students’ participation in higher education governance and consider students and faculty members as part of the same academic community (The European Higher Education Area, 2005). The core elements of the Bologna Process are as follows: a definition of the responsibilities of the bodies and institutions involved; evaluation of each institution’s programmes, including internal assessment, external review, participation of students and the publication of results; a system of accreditation, certification or comparable procedures; and international participation, cooperation and networking (European Association for Quality Assurance in Higher Education, 2009). Nursing education has also been involved in this process (Cameron et al., 2011; Rexwinkel et al., 2013), as several studies have shown that dissatisfaction in nursing education is associated with students dropping out (Dante et al., 2013; Dante et al., 2011; Eick et al., 2012). In a system that encourages competition among universities, quality improvement in academic education is a way to enrich students’ experiences and learning, to be competitive in the educational market and to maintain and improve prestige (Hughes, 2000a). In Italy, where this study was conducted, quality in nursing education is becoming increasingly more important, and specific laws require universities to evaluate their standards of education to evaluate student satisfaction and ensure the university offers efficient and effective courses. Failure to meet these requirements has an impact on the allocation of ministerial funds for the universities. Several authors have studied the quality of university education and have even developed measurement tools (Bernardi et al., 2007; Chen et al., 2012; Chou, 2004; El Ansari, 2002a; Macale et al., 2013; Scalorbi & Burrai, 2008; Vellone et al., 2007). However, these instruments have been primarily designed based on experts’ opinions, without considering students’ thoughts. In addition, the lived experience of educational quality and its meaning for undergraduate nursing students have never been studied. So far, very few studies have carried out in-depth research on the quality of university education from

students’ perspectives (Boylston & Jackson, 2008; Hughes, 2000b; Kantek & Kazanci, 2012). The aims of these studies were primarily to know students’ level of satisfaction in nursing education and to establish a sound base for better student satisfaction and thus improved perceptions of quality in education. Several authors have attempted to explore the concept of quality in nursing education (Melender et al., 2013a; Rexwinkela et al., 2013) and from several points of view. These studies emphasized the importance to monitor nursing education in the European Higher Education Area through the European Network for Quality Assurance in Higher Education (ENQA), which developed an important document of standards, guidelines and recommendations to follow (European Association for Quality Assurance in Higher Education, 2009). Therefore, the purpose of this study was to describe the experience of educational quality in undergraduate nursing students. This description would help to better understand students’ opinions regarding promoting a higher standard of education.

BACKGROUND Researchers who have studied quality in nursing education have mainly used quantitative methodologies measuring nursing students’ satisfaction with reference to their courses and have tried to identify variables influencing satisfaction (Melender et al., 2013b; Roberts, 1999). The literature suggests that the quality of nursing education has been studied based on different perspectives and several purposes. Some studies (El Ansari, 2002a, b), with the aim of identifying which variables influenced the perceived educational quality, were designed to assess student satisfaction with modular courses and may not apply to university courses conducted in other formats. Another study (Chou, 2004) developed tools to measure student satisfaction and identified the general quality of the courses, the faculty teaching skills, the connection between theory and practice and the clinical training’s quality as dimensions of educational quality. More recent studies on the quality of undergraduate nursing education have been carried out in Italy using quantitative methods in order to assess student satisfaction regarding the overall programme and the quality of clinical training. By developing a questionnaire to assess nursing education, Bernardi et al. (2007) identified the following quality dimensions in undergraduate nursing education: didactic, clinical training, mentoring, laboratory activities, and support services. In another study (Scalorbi & Burrai, 2008), the investigators evaluated the quality of clinical training in the baccalaureate degree in nursing and consi-

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dered the dimensions of educational quality to include students’ orientation and involvement in clinical settings, clinical coaching by nurses, integration with the clinical team, evaluation of acquired training skills, and overall satisfaction. Finally, when developing an instrument to measure the perceived quality in undergraduate nursing education in Italy, Vellone et al. (2007) used exploratory factor analysis to identify the following ten dimensions of quality: faculties’ and clinical teachers’ characteristics, overall quality of the course, faculties’ teaching skills, quality of clinical training, supportive service and organization, clinical tutors’ skills, teaching quality, examination quality, educational materials, and overall coordination of the courses. In summary, these studies have placed little emphasis on the experiences of the students, and the literature shows that educational quality in undergraduate nursing education is related to the faculties’ qualities, quality of teaching, available services for the students, clinical tutorship, coordination and connection between theory and practice, and general organization of the courses. However, these studies have not shown how such quality is related to the students’ perspectives of their own lived experience. METHODS Research Design The phenomenological method utilized by Cohen et al. (2000) guided this study. This method is a combination of descriptive and interpretative phenomenology and has been used in other Italian studies (Vellone et al., 2012; Simeone et al., 2015). Phenomenology was used because it provides a deeper understanding of people’s lived experience and enables researchers to investigate the meaning people attribute to that experience. Cohen et al. (2000) wrote that understanding people’s experience may allow for an improvement of people’s understanding. In fact, when people (e.g., faculty members) understand the meaning that other people (e.g., students) give to an experience, this also helps people to understand the others’ needs and to best meet these needs. Study Participants and Interviews Students pursuing a baccalaureate degree in nursing from three universities in central Italy were involved in the study in autumn 2014. Two universities were public and one was private. We decided to involve students from two public universities and one private university in order to have a better description of students’ experiences, as both public and private universities offer a bachelor programme in nursing in Italy. The only inclusion criteria was that students had to be in the third

year of the bachelor programme, as this meant they were in their last academic year and would thus have had a richer and fuller experience of the undergraduate nursing education. No exclusion criteria were adopted. The students were purposively selected for the study. After ethical approval from the institutional review boards of the involved universities was obtained, the study was presented by researchers to students in the classroom and its aims and methodology were explained. Subsequently, the fourth author scheduled appointments for interviews with students who agreed to participate. Interviews were scheduled based on student convenience during a 3-month period after the study presentation. All of the interviews were conducted at the schools, but they were carried out privately in order to respect participants’ privacy and confidentiality. Before each interview, students were asked to sign the informed consent form. The interviews consisted of asking students to freely describe their experience of educational quality in the undergraduate nursing programme. Researchers asked students to report all their thoughts regarding the educational quality of the nursing programme and to give examples and experiences of good and bad educational quality. During the interviews, researchers had a welcoming attitude to facilitate the participants’ storytelling. Specifically, researchers expressed cordiality and reassurance, were serene and smiling and did not judge students during the interview. Data Collection and Analysis We used Cohen et al.’s (2000) method to analyse the data, which consists of the following seven phases: In the first phase, before data collection, all investigators performed critical reflection, which requires the researchers to write their own assumptions and beliefs about the phenomenon under investigation. This activity ensures “bracketing” of presuppositions. In the second phase, the fourth author interviewed all study participants with open-ended questions until reaching the point of data saturation; that is, the point at which redundancy of the themes is achieved. The investigator tape-recorded all interviews and took field notes to reconstruct the environment, context, body language, tone of voice and reflections. In the third phase, all interviews were transcribed verbatim and the accuracy of the transcriptions was checked. In the fourth phase, all investigators immersed themselves in the data by reading and rereading the transcripts and field notes. In the fifth phase, themes were extracted by all investigators. Following Cohen et al.’s (2000) methodology, each investigator read and reread each transcript several times to uncover the meaning of the experiences. In the sixth phase, theme trustworthiness was established and thus comparison and discussion of the

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themes extracted by the researchers and a review of the critical reflection of the first phase were performed. The seventh phase consisted of the research team writing the scientific report. When respondents ended their narratives, researchers provided a summary of the themes both to help participants clarify what they had said and also to encourage them to share additional information. After that, if participants had nothing to add, the interviews ended and some socio-demographic data were collected (gender, age, average exam grades, residence, nationality and occupation). On average, interviews lasted between 30 minutes and 1 hour. Confidentiality was guaranteed with the anonymity of data collection, as the researchers only assigned a progressive numerical code to students. In this article, all initial are fictitious. All students from the three universities who were invited agreed to participate in the study. After interviewing 55 participants, the saturation of the data and the redundancy of the extracted themes were achieved.

RESULTS Fifty-five students participated in the study (27 from the private university and 28 from the public universities). Fifteen students were male (27%) and 40 were female (73%), with an average age of 24 years (SD 4.2; ranges 21–40 years). The average exam grade was 26/30 (SD 1.9; ranges 22–30). With regard to residence, 48 participants were living in Rome (87%), while the remaining 7 (13%) were living in smaller cities around Rome. In addition, 41 participants (75%) were not workers, while 14 (25%) were working. Except in one case, all participants were Italians. Five themes emerged from the phenomenological analysis related to the experience of educational quality in undergraduate nursing education. Many interconnections were observed among the extracted themes, the result of which was that researchers had some difficulties in establishing a clear demarcation. In addition, it was observed that some participants during the interviews reported more opinions than experiences regarding educational quality. This happened when some students believed that the quality of the nursing baccalaureate programme should have some characteristics which were lacking in their experience. The five extracted themes were as follows: 1. Quality of Faculty: Teaching Skills, Preparation, Sensitivity to Students, and Self-discipline; 2. Theory–Practice Integration and Communication between Teaching and Clinical Area; 3. General Management and Organization of the Programme 4. Quality of Infrastructures: Libraries, Classrooms,

Information Technology, Services, Administration, and Communication; 5. Clinical Tutorship: Humanity, Relationships and Ability of the Clinical Tutor to Guide and Support. 1.

Quality of Faculty: Teaching Skills, Preparation, Sensitivity to Students, Self-discipline. For more than half of the participants, quality in the baccalaureate nursing education meant quality of the faculty. Participants were not “general” in describing faculty, but instead referred to specific characteristics, such as teaching skills (clarity, ability to integrate theory with practice, ability to attract students’ interest and be sensitive to their needs), their preparation and sensitivity to students’ problems. For example, one student said, “For me, the quality of a baccalaureate course means having faculties who have the ability to teach, to present their lessons with clarity and to stimulate students’ interest”. Another said, “I think that a nursing course has quality if faculties have an excellent professional background, make connections with other disciplines and are able to integrate theory with practice”. A third student said, “One aspect that I believe is related to the quality of a degree course is when the professor is sensitive to the problems reported by students”. Another aspect that participants related to the quality of faculties was connected to their self-discipline, which for students meant punctuality regarding class schedules. In fact, many students complained about this problem which, in their opinion, affected the quality of teaching and, consequently, the quality of the degree course. A student stated that, “Quality is when the professor is regularly present in class, is punctual and adheres to the timetable”. 2.

Theory–Practice Integration and Communication between Teaching and Clinical Area The majority of students reported that their education was too theoretical and that it was sometimes detached from practice. Participants complained about a lack of integration between theory and practice, which they considered essential for the quality of their educational process. Students also stressed the problem regarding the lack of communication between the educational area (the school) and the clinical area (clinical department): they sometimes experienced that the former did not know what happened in the latter and vice versa. For example, M. said, “For me, quality is when the theoretical teaching and the practical experience are integrated, so that one can put theory into practice”. Another student reported, “For me, the quality of a degree course is when theoretical knowledge can be transferred to practice. In my opinion, this can

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only be achieved if there is good communication between the university and the clinical departments”. 3.

General Management and the Organization of the Programme Many students commented on their need to have a more structured, organized and well-planned course in order to improve their learning. In the participants’ experiences, improved organization and management of their studies would have allowed professors and all members of the educational team to monitor student learning and the achievement of learning objectives, thereby facilitating the learning process. A student reported as follows: “Quality in my opinion means to have better organization and professors and clinical tutors who are well organized”. Another student said, “When a course is well planned, it is of high quality”. Many of the students reported the existence of too many disciplines in their course and the lack of time to study. They highlighted the excessive academic commitment to attending classes, clinical training and examinations. Despite these difficulties, the students thought the organization of studies was acceptable even with aspects that could be ameliorated. Some of the comments related to this theme included the following: “The quality of an academic course involves the way a course is organized and the ability to plan learning by means of objectives” and “Quality for me lies in the way teaching is organized, avoiding excessive concentration of disciplines and the lack of time for studying”. Quality of Infrastructures: Libraries, Classrooms, Information Technology, Services, Administration, Communication Study participants considered that infrastructures had a significant impact on the quality of the baccalaureate programme and on the learning process. In fact, students considered it crucial to have adequate spaces/classrooms for teaching and lessons, services, libraries, and simplified administrative procedures. This theme recurred frequently in the interviews with the group of students who were not based at the central site of the university. One student said, “For me, a degree course is of high quality if it has good facilities with services for students, such as Internet, libraries, interactive platforms etc.” Another aspect that students described as a characteristic of quality was the adoption of computerized innovations in teaching and administrative procedures. An example of this was as follows: “For me, the quality of a degree course is to have effective services for students and appropriate spaces for teaching. In addition, I think that there should also be an appropriate use of information technology innovations, which would facilitate administrative procedures, ensure communication, and improve the relationship

with the university”. 5. Clinical Tutorship: Humanity, Relationships and Ability of the Clinical Tutor to Guide and Support Clinical tutorship was experienced by participants as a crucial element in contributing to the educational quality in their baccalaureate degree. For almost all students, tutorship was considered important because it meant support when faced with academic difficulties and helped to solve doubts during clinical training. Participants considered the tutors’ human aspects and relationship skills to be important. In the students’ experiences, these aspects facilitated learning and successful integration into the nursing profession. It emerged very clearly during the interviews that students needed tutors to assist them in the clinical units in order to stimulate their learning abilities, to promote their practical skills, and to help them integrate gradually into the profession. For example, G. said, “Based on my 3-year experience in attending the nursing course, for me, quality means to be guided by clinical tutors who are available and are able to support you in difficulties and can answer questions or clarify doubts”. Another student said the following: “Quality of a nursing degree means having a clinical tutor as a reference and support for students. In my opinion, this is a professional who has humane characteristics. The tutor should be someone with whom we have a very close relationship.”

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DISCUSSION To our knowledge, this is one of the first studies that used a phenomenological methodology to understand the experience of educational quality perceived by undergraduate nursing students. From a macroscopic point of view, no new findings emerged from the study: the quality of teaching, the integration of theory with practice, the organization and management of the course, the quality of infrastructure and clinical tutorship have already been identified in the literature as dimensions of educational quality (Kantek & Kazanci, 2012; Rexwinkel et al., 2013; Melender et al., 2013). Compared to these previous studies, however, our study allowed a deeper understanding of the educational quality in undergraduate nursing education. Regarding the faculties’ quality, students described both their expertise in teaching and preparation as being important; however, they also described new aspects which have never been reported in the literature, such as sensitivity towards students’ problems and self-discipline. For students, self-discipline in faculties meant having faculties who respected their classes’ timetable

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and schedule. Several students complained that faculties were not on time for their classes or that they taught lessons without regularity. It is common knowledge that university faculties are very busy because they have several activities going on at the same time, such as research, teaching, and mentoring, along with bureaucratic and clinical activities; however, it is also true that teaching is a fundamental pillar of academia and therefore should not be overlooked. Theory and practice integration was another experience which participants considered as a dimension of quality in nursing education, an aspect which is also reported in the literature (Chou, 2004; Vellone et al., 2007). Nursing education has always included both theoretical and practical aspects, but sometimes the integration between the two areas could be improved. Several studies have documented that this issue causes anxiety and stress among nursing students (Andrew et al., 2011; Jahanpour et al., 2010). Positive experiences of integration between theory and practice were documented when adopting the educational contract model, in which students “negotiate” their training in terms of results to be achieved and learning time (Galletti et al., 2005). Other positive experiences for the integration of theory with practice were observed through the use of educational Internet sites; identifying clinical learning objectives for each year of the course; using clinical tutors; using diaries to report their training experiences and enabling students to perform nursing diagnosis, nursing intervention classification (NIC) and nursing outcomes classification (NOC) with real patients (Alvaro et al., 2009). Many students considered the general organization of the programme as an important aspect of quality. Commenting on this, they complained about the high workload involved in attending classes, clinical training and exams. There are several studies which have investigated stress in nursing education (Lou et al., 2010; Murdock et al., 2010; Ratanasiripong & Wang, 2011), but few have identified an association between students’ stress and teaching load (Freeburn & Sinclair, 2009). Rather, it seems that other factors contribute to stress, such as personality, coping styles and social support in nursing students (Chan et al., 2011; Watson et al., 2008). For students, quality also meant benefiting from the university’s infrastructures, such as libraries, adequate classrooms and opportunities to use information technologies. These aspects were reported both by students in the central sites and in the peripheral sites; however, the latter complained about the lack of infrastructures, reporting that they did not have sufficient libraries, classrooms and appropriate technologies. Nowadays, information technology can be an important source for peripheral sites of nursing education;

in fact, many universities, in addition to digital subscriptions to journals and books, allow students to access this material via the Internet through special software outside the university (Del Vecchio, 2009). Thus, information technology could be of considerable use in reducing the distance from the central sites of the university. Closely related to theory–practice integration was the theme related to clinical tutorship. Participants considered clinical tutors as a resource for providing students with support for dealing with difficulties and facilitating learning. Students also viewed the tutor as a role model with whom they could develop a very close relationship. Several studies have already shown the importance of the clinical tutor in contributing to the quality of nursing education (Hamshire et al., 2013; Quattrin et al., 2008; Walker et al., 2013); however, in this study, humanity, interpersonal skills, guidance and support emerged as quality characteristics of the tutor. These aspects of the quality in clinical tutorship have never been reported in the literature. In contrast to prior studies’ findings, in which sociocultural support in the university and integration among students were dimensions of educational quality (Baykal et al., 2005), these issues did not emerge in our study. It is important to note, however, that these studies involved students belonging to different cultures, while in our sample, only one student was foreign and she did not speak about integration. These experiences could have emerged if more foreign students had been interviewed.

IMPLICATIONS FOR FUTURE RESEARCH

PRACTICE

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This study allowed us to identify issues and factors relevant to a specific monitoring of the learning environments of nursing education, whose added value is that they have emerged from the students’ opinions. The identification of the factors which help to define the perceived quality based on the experiences of students allows trainers and academic institutions to study the critical points and control the processes that need to be developed and improved. Finally, this study adds new knowledge about promoting learning from the student’s point of view—an aspect considered relevant and in line with the statements made by the Nursing and Midwifery Council (Brown, 2008; Council, N. M., 2010), and which must be further developed in order to improve the output quality of training. However, further studies are needed to examine different educational contexts and realities, assuming significant similarities and differences of the issues raised in the various countries in order to engage

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in a constructive exchange of ideas in the scientific community that deals with the training of future nursing health professionals.

Conflict of interest

LIMITATIONS OF THE STUDY

REFERENCES

As with other qualitative studies, one of the limitations of this study is that the results are not generalizable. However, it is interesting to note that the results of this study macroscopically confirm previous studies conducted with quantitative methods. A second limitation is that only students attending the third year were selected for the study, and thus these students may have different experiences compared with students attending the first and second year. However, the researchers’ aim was to describe a comprehensive experience regarding the educational quality in undergraduate nursing education and therefore third-year students were the most suitable for this purpose. Finally, another limitation was that this study was carried out only in one European country, which may further limit the generalizability of the results due to differences in the manner in which universities are organized across Europe. Sometimes complaints emerged during the interviews because students considered some aspects which were not present in their university to be aspects of quality. If this is true, we also have to consider that, as shown in previous studies (Baykal et al., 2005; Vellone et al., 2007), students in their last year of a nursing programme perceive the quality of education at a lower level than students in the first or second year. This aspect could have influenced the results of this study.

Alvaro, R., Vellone, E., Fierro, A., Faia, A., Petrone, F., Miliani, R., & Venturini, G. (2009). Tools and methods to improve clinical training of undergraduate nursing students: The experience of "Tor Vergata" University or Rome. Professioni Infermieristiche, 62, 32–40. Andrew, N., Robb, Y., Ferguson, D., & Brown, J. (2011). 'Show us you know us': Using the Senses Framework to support the professional development of undergraduate nursing students. Nurse Education in Practice, 11, 356–359. Baykal, U., Sokmen, S., Korkmaz, S., & Akgun, E. (2005). Determining student satisfaction in a nursing college. Nurse Education Today, 25, 255–262. Bernardi, M. G., Scalorbi, S., & Burrai, F. (2007). Planning and application of a valutation methodology in UNI EN ISO 9001:2000 quality system, for the analysis satisfaction level of third-year student University of Bologna, Bachelor of Nursing Course, CRI School of Nursing formative section. Professioni Infermieristiche, 60, 991–06. Boylston, M. T., & Jackson, C. (2008). Adult student satisfaction in an accelerated RN-to-BSN program: A follow-up study. Journal of Professional Nursing: Official Journal of the American Association of Colleges of Nursing, 24, 2852–95. Brown, J. F., & Marshall, B. L. (2008). Continuous quality improvement: An effective strategy for improvement of program outcomes in a higher education setting. Nursing Education Perspectives, 29(4), 2052–11. Cameron, J., Roxburgh, M., Taylor, J., & Lauder, W. (2011). An integrative literature review of student retention in programmes of nursing and midwifery education: Why do students stay? Journal of Clinical Nursing, 20, 1372–1382. Chan, M. F., Creedy, D. K., Chua, T. L., & Lim, C.C. (2011). Exploring the psychological health related profile of nursing students in Singapore: A cluster analysis. Journal of Clinical Nursing, 20, 3553–3560. Chen, H. C., Farmer, S., Barber, L., & Wayman, M. (2012). Development and psychometric testing of the nursing student satisfaction scale. Nursing Education Perspectives, 33, 369–373. Chou, S. M. (2004). Evaluating the service quality of undergraduate nursing education in Taiwan–using quality function deployment. Nurse Education Today, 24, 310–318. Cohen, M. Z., Kahn, D., & Steeves, R. (2000). Hermeneutic phenomenological research: A practical guide for nurse researchers. Sage: Thousand Oaks, CA. Council, N. M. (2010). Standards for pre-registration nursing education. NMC, London. Dante, A., Petrucci, C., & Lancia, L. (2013). European nursing students' academic success or failure: A postBologna Declaration systematic review. Nurse Education Today, 33, 46–52. Dante, A., Valoppi, G., Saiani, L., & Palese, A. (2011). Factors associated with nursing students' academic

CONCLUSION Based on the findings of the study, in order to improve quality in undergraduate nursing education, the following actions would be appropriate: to consider the importance of both didactic teaching and sensitivity when dealing with students’ problems; to carefully coordinate theory and practice and to have good communication between teaching and clinical settings; to improve the quality of infrastructure and the availability of adequate classrooms, libraries and information technologies which facilitate both learning and access to scientific literature; to improve the general organization of the entire programme, with good coordination regarding lesson times, clinical training and individual or group study; and to improve clinical tutorship, which has been proven to help students reduce anxiety and stress during their clinical experience.

None declared

Vol. 69, n.4, Ottobre - Dicembre 2016

The experience of educational quality in undergraduate nursing students: a phenomenological study

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