Shourangiz Beiranvand  ( Department of Nursing, Tarbiat Modares University, Tehran, Iran. )
Sima Mohammad Khan Kermanshahi  ( Department of Nursing, Tarbiat Modares University, Tehran, Iran. )
Robabeh Memarian  ( Department of Nursing, Tarbiat Modares University, Tehran, Iran. )

Objective: To identify nursing instructors' clinical education competencies.

Methods: The integrative review comprised research articles published between 2008 and 2018 on Medline, Scopus, Web of Science and Education Information Resource Centre databases searched through relevant key words. All the short listed papers were reviewed and quality assessment was done. Data was analysed using content analysis method. Nursing instructors' clinical education competencies were extracted from the original texts in the form of initial codes which were categorised into subcategories and categories based on comparisons of their similarities and differences. Finally, themes were extracted as expression of content hidden in the data to generate new insights.

Results: Of the 17 studies selected, 6(35.3%) were quantitative, 4(23.5%) qualitative, 3(17.6%) review studies and 4(23.5%) were mixed-methods studies. Three overarching themes identified were clinical teaching process competencies, students' supervision competencies in clinical settings and nursing instructors' professional ethics.

Conclusion: The review provides insightful information on nursing instructors' clinical education competencies. Nursing educational institutions need to be encouraged to incorporate these concepts into educational curricula to empower nursing instructors and to enhance the quality of clinical education.

Keywords: Nursing education, Clinical competence, Scientific integrity review.

DOI: https://doi.org/10.47391/JPMA.089

 

Introduction

 

Constant changes in work and social life, rapid advances in medicine and nursing, aging population and the emergence of new diseases have created an urgent need for change of nursing education and clinical instructors' competencies.¹ Providing higher education of nursing, professional development and moving toward specialisation, establishing independent clinical job positions are some of the elements needed in the clinical education of nursing students, and this requires the presence of professional competencies in nursing clinical instructors. Therefore, nursing education is professionally developed and there is an emphasis on enriching nursing education.² Clinical education is an important part of professionalisation and socialisation for nursing students. Many goals of nursing education, such as critical thinking, communication skills, learning nursing cares, and applying ethical principles are achieved through clinical education.³ Clinical education is a relatively complex process, which is influenced by several factors. Competencies of nursing instructors' clinical education are undoubtedly among the most important factors affecting the quality of clinical education.⁴ Clinical educators play an important role in providing quality clinical education and applying abstract concepts in reallife situations.⁵ Qualified clinical educators need specialised skills in curriculum development, teaching strategies, evaluation methods and the ability to perform scientific and research activities in order to effectively help students achieve learning outcomes.⁶ Competency is defined as the specialised knowledge, skills, judgment and individual characteristics required for ethically and securely acting in specified roles and situations.⁷ The World Health Organisation (WHO) has consistently recommended improvement in the qualities of nursing educators so that they may provide quality education and train skilled and efficient nurses able to meet the healthcare needs of the community.⁸ The characteristics, competencies and behaviours of nursing clinical instructors have been investigated in a number of quantitative studies from the perspective of nursing students and clinical instructors. These studies have reported that the most important competencies of clinical instructors are communication skills, like respectful treatment of students, clients, and colleagues, clinical teaching abilities, nursing competency, ethical and behavioural role model, and personality characteristics.^1,4,5,9 Qualitative studies have been conducted with the approaches of grounded theory, phenomenology, content analysis and mixed methods in relation to the perception of clinical educators and nursing students of clinical education competence. These studies describe the competencies of clinical instructors in three areas of knowledge, skill and attitude. Clinical instructors' competencies in the field of knowledge include knowing different learning styles, preparing for the role and having specialised theoretical clinical knowledge. Clinical instructors' competencies in the field of skill include providing effective feedback, having interpersonal skills, evaluation, management and technology skills, being a role model and a source of support. Clinical instructors' competencies in the field of attitude include nursing instructors' personality traits, such as being patient, trustworthy, kind and having a positive professional attitude.^10-14 WHO and the National League of Nursing (NLN) have identified nurse educators' competencies. They have focussed on the normative standards of the role of nursing educators and their competencies were general concepts and not exclusive to clinical education competencies.^8,15 However, evidence suggests that nursing profession at present is also facing a growing global shortage of nursing educators, and a strategy in response to this shortage is the recruitment of nursing expert clinicians for clinical teaching in temporary employment positions.¹⁶ While these nurses are experts in practice, they are novice in the academic domain. Stakeholders in academia are concerned that the greatest challenge for clinical educators is inadequate preparation that has led to poor educational outcomes.¹⁷ Nursing instructors with clinical experience in some countries, such as the United Kingdom, should at least have 360 hours of teaching activities in order to qualify for the role of instructors.¹⁸ Nursing instructors should therefore be academically trained and they require an educational curriculum. Thus, clinical education quality should be improved through systematic curriculum development for nurses who wish to work as clinical instructors. The current review was planned to identify and integrate the clinical education competencies and indicators of nursing instructors.

 

Materials and Methods

 

The integrated review comprised research articles published between 2008 and 2018 on Medline, Scopus, Web of Science and Education Resources Information Centre (ERIC) databases searched through relevant key words. The integrated review method was chosen because it uses articles from different methodologies to fully understand the phenomenon under question. The first step comprised identification of the theme and selection of the integrative review's guiding objective. This was followed by the establishment of criteria for the inclusion and exclusion of studies; definition of the information to be extracted from the selected studies / categorisation of the studies; evaluation of the studies included in the integrative review; interpretation of results; and presentation of knowledge review.¹⁹ A broad search strategy was applied in which the four databases were explored with key search terms and related text words, like Nurse OR Nurses OR Nursing AND Educator OR Preceptor OR Teacher OR Faculty members OR Instructor AND Competence OR Clinical skill OR Characteristic OR Qualification OR Effective OR Behaviour. The articles included were published between 2008 and 2018, represented peer-reviewed research, were qualitative, quantitative, review and mixed-method studies, were in the English language, and in which the main focus was nursing clinical instructors' competencies. Those excluded were editorials, opinion pieces, nonresearch papers, conference abstracts, review papers, those published in non-English journals and articles focussing on nursing instructors' clinical education competency assessment tools. In addition, hand search was performed in specialized journals of nursing clinical education [Nurse Education in Practice' and 'Nurse Education Today] based on the assumption that relevant articles might have been missed, but no studies were found that met the inclusion criteria. All citations and abstracts were imported into EndNote version 8 and duplicate articles were removed. The abstracts were reviewed for specific relevance to nursing instructors' clinical education competencies. From the remaining articles, those that met the inclusion criteria were selected while following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.²⁰ Two researchers assessed the quality of the articles separately, and, in case of disagreement, the quality of the paper was discussed and mutually decided. Quantitative studies were assessed using the Bowling Comprehensive Checklist of 20 Evaluations Criterion.²¹ All quantitative studies included met a minimum 12-20 score on the checklist. Qualitative and mixed-method studies were examined using the Qualitative Assessment and Review Instrument (QARI) with 10 dichotomous criteria.²² Qualitative studies included scored 8-10 which represented medium to high quality. The quality of review articles was appraised using the Joanna Briggs Institute (JBI) quality assessment instrument with 11 evaluations criteria.²³ Data were analysed using conventional content analysis according to the techniques cited in literature.²⁴ The full texts of the selected articles were carefully studied. The nursing clinical instructors' competencies were extracted from the texts. The texts were divided into semantic units, and a summary of the units was extracted. The primary codes were then organised into subcategories which were then grouped according to similarities. Comparisons of similarities and differences across subcategories were done. Finally, the themes were extracted as expression of content hidden in the data.

 

Results

 

Of the 2860 articles initially identified, 17(0.6%) studies were selected. Of them, 6(35.3%) were quantitative, 4(23.5%) qualitative, 3(17.6%) review studies and 4(23.5%) were mixed-methods studies (Figure-1).

 

 

The studies were conducted in the United States, Finland, Malaysia, Taiwan, Australia, Thailand, Ethiopia, Iran, Croatia and Norway, with the US and Iran contributing the highest number of articles on the subject (Table-1).

 

 

Data collection methods of qualitative studies used focus group discussions (FGDs) or interviews to explore nursing instructors' or nursing students' experiences of clinical education competencies. The participants in all studies were nursing students and nursing clinical instructors in various clinical settings. On the basis of the review, three main themes were generated: competencies of the clinical teaching process, nursing students' supervisory competencies in clinical settings, and professional ethics of clinical nursing instructors (Table-2).

 

 

Theme 1: Competencies of the clinical teaching process

 

Nursing clinical instructor's competencies in the role of teacher: Under the first theme, it was found that all the studies discussed the competencies of clinical teaching process as well as issues related to clinical teaching and learning methods for nursing students. The most important competencies of nursing instructors were their ability in clinical education. Studies emphasised the preparation of nursing instructors to teach clinical practice and develop educational skills.^5,11,25,26 Competencies in the clinical teaching process included familiarity with organised teaching styles, careful planning of clinical teaching based on students' needs, designing and evaluating students learning programmes, providing feedback and assessing students' clinical outcomes.²⁵ Empirical evidence suggested that the outcomes of the clinical teaching process are establishing a creative learning environment to facilitate students' learning and achievement of clinical teaching outcomes.¹ Due to the shortage of nursing educators, it was noted that educational institutions tend to hire nursing staff in temporary teaching positions without paying much attention to the standard procedures and requirements for nursing instructors. Novice clinical instructors possess sufficient skills in clinical practice, but they lack the clinical education competencies. They also need to be prepared for clinical education, orientation programmes, support and for clarifying the role.¹⁷

Clinical instructors 'competencies in evaluating students' clinical performance: Clinical instructors play an effective role in the fair evaluation of students in the process of clinical teaching. Clinical instructors used a variety of methods for nursing students' clinical performance evaluation.²⁷ They must fairly and objectively evaluate students' knowledge, attitude, and skills, also, the ability to provide effective to facilitate students' learning and their ability to achieve the clinical teaching outcome.²⁵ Studies reported that they expected fair and equitable evaluation of their clinical performance by clinical instructors. But from the perspective of nursing students, clinical instructors had the lowest scores in their evaluation skills.^1,11

Professional communication of nursing clinical instructors: Again, from the perspective of nursing students, the most effective instructional strategy for clinical instructors was respecting their students and colleagues.⁴ Respectful, mutual and effective communication among clinical instructors, nursing students, clients, colleagues, and healthcare team members was based on professional values of clinical teaching process competencies.^1,14,28 Effective communication between clinical instructor and students provides an ideal clinical learning environment, having positive impact on clinical learning experiences, increasing motivation and acquiring technical, psychological, and interpersonal skills.^{1,4,9,14,25,29}. Researchers reported that there are high levels of clinical instructors' competencies in the ability to communicate well with patients, which led to providing safe care to patients.²⁵ According to the current review, the most important indices of nursing instructors in clinical education process include students' critical thinking and clinical decisionmaking skills, ability to analyse the learning needs of nursing students, showing enthusiasm for teaching, expertise in communication skills, providing effective feedback and having expertise in evaluation of clinical learning outcomes of the students.

 

Theme 2: Students’ supervisory competencies in clinical settings

 

Organizing internships: Nursing clinical instructors reported a high level of knowledge and confidence in their ability to guide and supervise nursing students in clinical environments. They need to support and encourage educational institutions to play their roles.²⁸ Clinical instructors are involved in different levels of management hierarchy and are involved in planning, organising, coordinating, leading and controlling activities as well as directly implementing programmes to achieve specific goals in clinical education.² The supervisory competencies of nursing clinical instructors from the perspective of clinical professors and nursing students include accepting responsibilities, performing duties, attending in various educational meeting, recognising nursing principles and standards, following professional guidelines and facilitating professional communication.¹²

Strengthening students' morale during internship: Competence nursing instructors will facilitate students' learning, motivation and interest in patient care. They will raise a positive professional attitude by creating a supportive care environment.⁴ They strengthen students' independence and confidence in doing clinical practice. This motivates students to think about possible answers to clinical questions, possible solutions to clients' clinical problems and to develop critical thinking in them.¹² Studies have reported that encouraging students, ignoring small mistakes, not unnecessarily blaming the students and striving to create a healthy and supportive learning environment help boost morale of students.^5,11,14

Supporting the students: Nursing instructors provide support resource for nursing students through a wide range of personal and interpersonal skills. Clinical educators increase motivation, reduce stress, and promote learning, independence, confidence and selfefficacy in the clinical setting.^4,13 Nursing educators resolve emotional problems by establishing empathetic and emotional relationships with nursing students.¹¹ The most important indicators of supervision competencies of clinical instructors in internships include student guidance and supervision, empathy for students, counselling, emotional support for students, motivation, confidence-building, and student's independence in patients care.

 

Theme 3: Professional ethics competencies of nursing clinical instructors

 

Maintaining the ethical values of nursing instructors: Clinical instructors play a major role in teaching ethical reasoning, clinical decision-making in patient care, respecting patients' privacy, keeping patients' secrets, and protecting patients' moral and legal rights.^11,27 Students clearly indicated that clinical instructors' ethical values, such as enjoyment of nursing and nursing education, interest in the profession, professional expertise, like having knowledge, skills and critical thinking, can enhance clinical education, improve students' motivation to provide care to patients, cultivate values and ethics, and facilitate their learning.^9,10,13,27

Nursing clinical instructors’ attitude: Attitude is a combination of personality characteristics and professional attitudes of nursing instructors. The personality characteristics of effective clinical instructors include displaying a sense of humour, acceptance of limitations and mistakes, showing enthusiasm for teaching, being patience, expertise in nursing and interpersonal skills to communicate with nursing students 1. Professional characteristics and skills of nursing clinical instructors, such as self-control, selfregulation, authority, high self-esteem and professional commitment to clinical education, were attitudinal indicators of evaluating ethical and professional behaviour of nursing clinical instructors. As professional and ethical role models, they have influence on students' clinical performance and raise a sense of independence, responsibility and accountability in nursing students.^4,12,27 The most important indices of professional ethics of nursing clinical instructors in the current review included ethical reasoning, respecting patients' confidentiality, promoting social justice, and respecting patients' rights. They needed to have authority and high self-esteem, sense of responsibility and accountability, respect for students, have positive attitude toward the profession, be an initiator of change, and to have professional commitment, patience, honesty, happiness and kindness.

 

Discussion

 

The current review identified clinical education competencies and indices of nursing clinical instructors in three main dimensions: competencies of clinical teaching process, student supervisory competencies in clinical settings, and professional ethics of nursing clinical instructors. The first dimension of nursing instructor's competencies in this review is the competencies of the clinical teaching process. Nursing instructors play the role of teachers with specialised skills in teaching principles, to integrate theory into practice, to guide nursing students to learning clinical outcomes, teach clinical skills, evaluation the clinical performance of nursing students and enhance problem solving skills.6 Although many studies have been conducted on the clinical teaching competencies of nursing educators, significant weaknesses have been observed in each of its relevant dimensions. As per the clinical education process skills, studies show that 31% of nursing instructors are not prepared for clinical education. They acquire educational skills through conferences (57%), orientation programmes at educational institutions (53%) or after graduating from college (38%). Furthermore, 26% nursing instructors are not prepared to evaluate students in the clinical settings. Clinical evaluation is still a challenge and concern for nursing and other healthcare professionals, with some part of this problem reflecting the fact that clinical evaluation tools are abstract and may have little connection to actual specific clinical behaviours in the clinical setting.³⁰ Students' experiences of clinical evaluation also indicate that there is no systematic protocol for evaluating their performance in clinical settings.3 Most clinical instructors intuitively evaluate their clinical performance, without the use of formative evaluation, based on the characteristics and behaviours of the students.¹¹ Thus, educational institutions can improve comprehensive orientation programmes, professional development, and continuous mentoring to help nursing clinical instructors effectively manage the teaching process. The interpersonal and communication skills of nursing clinical instructors are as important as their competencies in promoting students' clinical practice learning. An appropriate student-educator relationship has improved problem-solving skills, better clinical performance, motivation for learning, and reduced anxiety in students. There are also concerns about the lack of the preparation of nursing clinical instructors regarding their communication skills with clinical staff and their lack of credibility in clinical settings.³¹ The second dimension of competencies of nursing clinical instructors is the supervision of students in clinical settings. Students' supervision increased the students' motivation, reinforced their professional identity and accelerated their socialisation process.³² The results of a qualitative study revealed that most students in clinical settings had difficulty in finding help when needed, especially in faced with clinical difficult situations. It had a negative impact on their clinical skill learning, motivation, and attitude.³³ The third dimension of nursing clinical instructors' competencies is professional ethics, which has a strong impact on shaping and growing students' moral values, ethical knowledge and ethical performance.¹² Nursing educators need to be aware of their strong influence on students as an ethical role model, because the personalities of the students are clearly shaped by the attitudinal and professional characteristics of clinical instructors.³⁴ According to the views of half of the nursing students in a study, nursing instructors were fully aware of ethics principles, fairness, equity and honesty, but in practice, nursing educators were not respected very much in terms of their treatment of students.³⁵ Although clinical education competencies and indices were identified in the current review, there have been challenges regarding their operationalisation in the context of clinical placements. The statement of National League of Nursing says: "Obtaining formal training before and immediately after the employment of a nursing instructor is necessary for educating nursing clinical instructors to achieve competences in educational institutions".¹⁵ As a starting point, two supportive strategies are suggested to institutionalise these competencies. The first strategy is for teaching institutions to appoint a clinical faculty member as a mentor in each teaching hospital to prepare instructors for clinical education competencies. The second strategy is to identify the competencies of clinical education for nursing instructors based on the instructors' social and cultural perspective. A curriculum shall then be designed for nursing instructors based on the competencies identified by reviewing the literature and the context. Finally, an instrument should be developed based on the determined indices and competencies. The goal of this instrument should be to evaluate the performance of nursing clinical instructors in developing and maintaining the quality of clinical education. The main strength of the current review is its rigour in searching for resources and evaluating the quality of articles. The accurate, systematic and critical review was done with the help of information technology (IT) experts and through a variety of resources. To increase the credibility of the content, the peers' opinions were also used. All the researchers specialised in nursing education. The criteria for selecting articles were determined by two reviewers. The review found that qualitative studies used interviews and focus group discussions (FGDs) for datacollection. The quantitative studies used a variety of effective clinical instructor instruments in the four domains of pedagogical skills, evaluation, personality factors and communication with students using a 5-point Likert scale ranging from 'very poor' to 'very good'. None of the reviewed articles used observation as a method of data-collection, but observational studies are more important than self-report data, such as surveys and interviews. Comparing the results of the studies was challenging due to the different research designs, settings and outcome measures. Therefore, a metaanalysis was not performed. Instead, an integrative summary was conducted for the heterogeneous nature of the studies. The current review only included empirical studies available and related to nursing instructors' competencies, published in English peer-reviewed journals between 2008 and 2018. The findings of the reviewed studies may not be generalisable to specific settings or populations. However, there appears to be a high level of potential transferability, and this review can enhance understanding needed for the development of competencies of nursing clinical instructors.

 

Conclusion

 

Nursing instructors' competencies is a multidimensional concept and qualified clinical instructors must have a holistic view of the competencies required for professional practice in specific contexts. Therefore, nursing teaching institutions must be encouraged to incorporate these concepts into their educational curriculums to empower nursing instructors and to enhance the quality of nursing students' clinical education.

 

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.

 

References

 

1. Salminen L, Minna S, Sanna K, Jouko K, Helena LK. The competence and the cooperation of nurse educators. Nurse Educ Today 2013;33:1376-81. doi: 10.1016/j.nedt.2012.09.008.

2. Zlatanovic T, Havnes A, Mausethagen S. A Research Review of Nurse Teachers’ Competencies. Vocat Learn 2017;10:201–33. Doi: 10.1007/s12186-016-9169-0

3. Aliafsari Mamaghani E, Rahmani A, Hassankhani H, Zamanzadeh V, Campbell S, Fast O, et al. Experiences of iranian nursing students regarding their clinical learning environment. Asian Nurs Res 2018;12:216-22. doi: 10.1016/j.anr.2018.08.005.

4. Valiee S, Moridi G, Khaledi S, Garibi F. Nursing students' perspectives on clinical instructors' effective teaching strategies: A descriptive study. Nurse Educ Pract 2016;16:258-62. doi: 10.1016/j.nepr.2015.09.009.

5. Bifftu BB, Dachew BA, Tiruneh BT, Ashenafie TD, Tegegne ET, Worku WZ. Effective clinical teaching behaviors views of nursing students and nurse educators at university of gondar, northwest ethiopia: cross-sectional institution based study. J Caring Sci 2018;7:119-23. doi: 10.15171/jcs.2018.019.

6. Wu XV, Chan YS, Tan KHS, Wang W. A systematic review of online learning programs for nurse preceptors. Nurse Educ Today 2018;60:11-22. doi: 10.1016/j.nedt.2017.09.010.

7. Kuivila HM, Mikkonen K, Sjogren T, Koivula M, Koskimaki M, Mannisto M, et al. Health science student teachers' perceptions of teacher competence: A qualitative study. Nurse Educ Today 2020;84:e104210. doi: 10.1016/j.nedt.2019.104210.

8. World Health Organization. Nurse educator core competencies. Geneva, Switzerland: WHO Press; 2016.

9. Ludin SM, Fathullah NM. Undergraduate nursing students' perceptions of the effectiveness of clinical teaching behaviours in Malaysia: A cross-sectional, correlational survey. Nurse Educ Today 2016;44:79-85. doi: 10.1016/j.nedt.2016.05.007.

10. Reising DL, James B, Morse B. Student perceptions of clinical instructor characteristics affecting clinical experiences. Nurs Educ Perspect 2018;39:4-9. doi: 10.1097/01.NEP.0000000000000241.

11. Mingpun R, Srisa-ard B, Jumpamool A, Strengthening preceptors’ competency in Thai clinical nursing. Educ Res Rev 2015;10:2653-60. doi: 10.5897/ERR2015.2468.

12. Jafari H, Mohammadi E, Ahmadi F, Kazemnejad A, Shorofi SA. The experience of nursing instructors and students on professional competency of nursing academic staff: a qualitative study. Glob J Health Sci 2014;6:128-35. doi: 10.5539/gjhs.v6n4p128.

13. Heshmati-Nabavi F, Vanaki Z. Professional approach: the key feature of effective clinical educator in Iran. Nurse Educ Today 2010;30:163-8. doi: 10.1016/j.nedt.2009.07.010.

14. Niederriter JE, Eyth D, Thoman J. Nursing students’ perceptions on characteristics of an effective clinical instructor. SAGE Open Nurs 2017;3:1-8. doi: 10.1177/2377960816685571.

15. National League for Nursing. Certified nurse educator (CNE): Candidate Handbook. [Online] 2019 [Cited 2020 March 21]. Available from URL: http://www.nln.org/docs/defaultsource/default-document-library/download-the-certified-nurseeducator-(cne-)-examination-candidate-handbook-(pdf).pdf?sfvrsn=0

16. McPherson S. Part-time clinical nursing faculty needs: An integrated review. J Nurs Educ 2019;58:201-6. doi: 10.3928/01484834-20190321-03.

17. Jetha F, Boschma G, Clauson M. Professional development needs of novice nursing clinical teachers: A rapid evidence assessment. Int J Nurs Educ Scholarsh 2016;13:e0031. doi: 10.1515/ijnes-2015-0031.

18. Summers JA. Developing competencies in the novice nurse educator: An integrative review. Teach Learn Nurs 2017;12:263-76. Doi: 10.1016/j.teln.2017.05.001

19. Toronto CE, Remington R. A step-by-step guide to conducting an integrative review, 1st ed. Cham, Switzerland: Springer; 2020.

20. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. [Online] 2009 [Cited 2019 November 06]. Available from URL: https://www.equator-network.org/reportingguidelines/prisma/.

21. Bowling A. Research methods in health: investigating health and health services, 4th ed. Maidenhead, UK: McGraw Hill; 2014.

22. Pearson A. Balancing the evidence: incorporating the synthesis of qualitative data into systematic reviews. JBI 2004;2:45-64. doi: 10.1111/j.1479-6988.2004.00008.x

23. Joanna Briggs Institute. Critical appraisal tools for use in JBI systematic reviews: Checklist for analytical cross sectional studies. [Online] 2017 [Cited 2019 October 13]. Available from URL: h t t p s : / / j b i . g l o b a l / s i t e s / d e f a u l t / f i l e s / 2 0 1 9 - 0 5 / J B I _ C r i t i c a l _ A p p r a i s a l - Checklist_for_Analytical_Cross_Sectional_Studies2017_0.pdf

24. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105-12. doi: 10.1016/j.nedt.2003.10.001.

25. Chen YL, Hsu LL, Hsieh SI. Clinical nurse preceptor teaching competencies: relationship to locus of control and self-directed learning. J Nurs Res 2012;20:142-51. doi: 10.1097/jnr.0b013e318254ea72.

26. Guy J, Taylor C, Roden J, Blundell J, Tolhurst G. Reframing the Australian nurse teacher competencies: do they reflect the 'REAL' world of nurse teacher practice? Nurse Educ Today 2011;31:231-7. doi: 10.1016/j.nedt.2010.10.025.

27. Borhani F, Alhani F, Mohammadi E, Abbaszadeh A. Professional ethical competence in nursing: The role of nursing instructors. J Med Ethics Hist Med 2010;3:3.

28. Dahlke S, O'Connor M, Hannesson T, Cheetham K. Understanding clinical nursing education: An exploratory study. Nurse Educ Pract 2016;17:145-52. doi: 10.1016/j.nepr.2015.12.004.

29. Collier AD. Characteristics of an effective nursing clinical instructor: The state of the science. J Clin Nurs 2018;27:363-74. doi: 10.1111/jocn.13931.

30. DeBrew JK, Lewallen LP. To pass or to fail? Understanding the factors considered by faculty in the clinical evaluation of nursing students. Nurse Educ Today 2014;34:631-6. doi: 10.1016/j.nedt.2013.05.014.

31. Roberts KK, Chrisman SK, Flowers C. The perceived needs of nurse clinicians as they move into an adjunct clinical faculty role. J Prof Nurs 2013;29:295-301. doi: 10.1016/j.profnurs.2012.10.012.

32. Joolaee S, Ashghali Farahani M, Jafarian Amiri SR, Varaei S. Support in clinical settings as perceived by nursing students in Iran: A qualitative study. Nurs Midwifery Stud 2016;5:e31292. doi: 10.17795/nmsjournal31292.

33. Kaphagawani NC, Useh U. Clinical supervision and support: Exploring pre-registration nursing students' clinical practice in Malawi.. Ann Glob Health 2018;84:100-9. doi: 10.29024/aogh.16.

34. Lovrić R, Prlić N, Milutinović D, Marjanac I, Žvanut B. Changes in nursing students' expectations of nursing clinical faculties' competences: A longitudinal, mixed methods study. Nurse Educ Today 2017;59:38-44. doi: 10.1016/j.nedt.2017.08.013.

35. Salminen L, Rinne J, Stolt M, Leino-Kilpi H. Fairness and respect in nurse educators' work- nursing students' perceptions. Nurse Educ Pract 2017;23:61-6. doi: 10.1016/j.nepr.2017.02.008.