Globally, approximately 6 million children under age 5 died in 2015 (United Nations, 2015). According to the World Health Organization (WHO, 2012) and the United Nations (2015), of the 6 million children who died before their fifth birthday, in 2015 approximately 1 million died on the day they were born, 1 million died in the first week, and 2.8 million died during their first 28 days of life (the neonatal period). Sub-Saharan Africa carries half of the global burden of deaths under age 5—3 million in 2015. In Malawi, despite being one of the countries that met the Millennium Development Goal for child survival (United Nations, 2015), achieving 68 deaths per 1,000 live births in 2013 (You, Hug, Chen, Newby, & Wardlaw, 2014), the neonatal mortality rate remains high. You et al. (2014) estimated the neonatal mortality rate at 23 deaths per 1,000 live births in 2013, representing 33.8% of all deaths under age 5. Without intervention to further curb the neonatal deaths, the number of deaths under age 5 will continue to increase.
Limited access to well-trained and skilled health care providers in the area of neonatal care has been one of the contributing factors to higher neonatal mortality in developing countries (Sibley et al., 2014). On the other hand, Darmstadt et al. (2005) reported that countries with high rates of skilled birth attendance register lower rates of newborn deaths.
Addressing newborn survival rates is critical for further reduction of child mortality. This could be achieved through the provision of cost-effective interventions—for example, increased coverage and access to skilled birth attendance to address the needs of the women and their newborns across the continuum of care (United Nations, 2015). In Malawi, coverage and access to skilled birth attendance increased from 54% in 2008 to 71% in 2010 (National Statistical Office, 2011). Despite this increase, the country continues to face increased neonatal deaths. Save the Children (2014) stated that improving the rate of skilled birth attendance on its own may not reduce neonatal deaths. Rather, health systems need to provide in-depth training in newborn care to trainee health workers, as well as refreshers for qualified birth attendants, to improve the quality of neonatal health. However, the majority of neonatal health service providers in Malawi are middle-level health care providers, particularly nurse-midwife technicians (NMTs) who work as nursing or midwifery assistants in the clinical setting.
Training for NMTs
In Malawi, 15 training institutions offer preservice nursing and midwifery education with two active pathways: RN-midwife and NMT. Both pathways of training focus on general nursing and midwifery practice. The RN-midwife qualification is a 4-year program leading to professional state-registered nurses and midwives responsible for bedside patient care and supervision. The NMT pathway is a level-two integrated nursing and midwifery education offered through a 3-year college diploma program leading to NMT. NMTs are the major workforce in the delivery of health care services, contributing to more than 87% of the nursing and midwifery workforce in the public health service (Aukerman, 2006). NMTs enter into practice as nurse-midwife assistants, to provide basic nursing, as well as maternal and neonatal health services, albeit under the supervision of RN-midwives. However, in most settings, they often practice independently, with little or no supervision from professionals (WHO, 2008).
Clinical Teaching for NMTs
Given that students learning in the clinical setting is fundamental to the development of competent practitioners (Kaphagawani & Useh, 2014), the training for NMTs focuses on primary care, with an emphasis on practice-based learning. For example, during training, the NMT spends 60% of the time in practice-based learning (Nurses and Midwives Council of Malawi, 2012), to equip them with prerequisite knowledge and skills for entry-level and independent practice across clinical settings. The clinical-based learning environment exposes the student to professional socialization through interaction with other health care professionals, thereby preparing them for their future nursing roles. In addition, Msiska, Smith, and Fawcett (2014) observe that through clinical-based learning, the nursing students perfect the skills learned either in the classroom or during skills laboratory sessions. This gives them an opportunity to develop the competence and confidence to function within dynamic and complex settings (Courtney-Pratt, FitzGerald, Ford, Marsden, & Marlow, 2012; Killam & Heerschap, 2013). Furthermore, Thorell-Ekstrand and Bjorvell (1995) pointed out that during practice-based learning, students are provided with optimal time to observe role models, to practice the skills, and to reflect on their clinical experiences. Thus, the students learn through experience, as well as through interaction with other professionals, the patients, and the clinical environment, to develop their psychomotor skills (Gaberson & Oermann, 2010).
During practice-based learning, clinical teachers are expected to facilitate and provide continuous support to enable the students to acquire the required clinical skills and competence. The clinical teaching and support for NMTs has followed the “one teacher” approach (Papastavrou, Lambrinou, Tsangari, Saarikoski, & LeinoKilpi, 2010, p. 177). For example, the nurse teacher has dual responsibility for classroom and clinical teaching, to resolve the theory–practice gap. However, reports indicate that NMTs lack the ability to transfer skills across clinical settings. There is no documented research on preregistration clinical teaching for these nurse-midwives, especially in neonatal nursing, despite being placed in such units on completion of training. This article reports on the challenges faced in pre-registration neonatal nursing clinical teaching and learning for NMTs in the Christian Health Association of Malawi nursing colleges.
This explorative, qualitative study was conducted to explore the challenges facing clinical teaching and learning in neonatal care, with respect to NMTs, by assessing approaches used in teaching neonatal nursing for NMTs in Malawi.
Study Setting and Sampling
The study was conducted in eight Christian Heath Association of Malawi (CHAM) Nursing Colleges that provide a NMT diploma program. Third-year students who were allocated to neonatal care and postnatal ward settings and clinical teachers involved in teaching neonatal nursing and midwifery were purposively recruited to participate in the study. These groups of participants were considered experienced and knowledgeable about the neonatal nursing clinical teaching under study (Streubert & Carpenter, 2011). Participants were recruited through convenience sampling, in that all third-year students and clinical teachers who met the eligibility criteria and were available at the time of data collection were contacted to participate. In total, 171 participants who volunteered to participate in the study were included, with a range of 17 to 23 participants per nursing college. The large sample was incorporated to attain data saturation.
Data were collected through focus group discussions with the participants to obtain narrative accounts pertaining to their clinical teaching and learning experiences. The focus group discussion method was adopted with the aim of building conversation among the participants, rather than conversation between the interviewer and individual participants (Millward, 2012), thereby ensuring the generation of a large volume of data and identifying a greater variety of views, opinions, and experiences on the subject matter from the participants (Hennink, 2007). Twenty-three focus group discussions were conducted in the eight nursing colleges, 16 focus group discussions conducted among students, comprising six to 12 students per focus group discussion, and seven focus group discussions among clinical teachers and tutors, comprising four to five clinical teachers and tutors per focus group discussion. In all, 23 focus group discussions were conducted in the eight nursing colleges. On average, conventional focus groups can comprise nine participants per session (Millward, 2012), with a range of five to eight participants (Hennink, 2007; Krueger & Casey, 2009). This enabled the researcher to control and limit each participant's opportunity to share insights and observations during the discussion.
Data collection and analysis were done concurrently with the aim of examining the information to identify new issues. The researcher used content analysis, systematic coding, and categorization to organize the data (Hennink, 2007). The data were transcribed verbatim by research assistants, and then the researcher repeatedly read through the transcribed data while listening to the audiorecordings to get a deeper and clear understanding of the content. Using Atlas.ti version 7.0.91 qualitative software, the researcher identified codes, themes, and families according to similarities, which were then categorized into six themes.
Trustworthiness for this study was achieved through the use of multiple informants and member checking. The researcher involved eight participants, one from each nursing college, to verify and check the authenticity of the results. In addition, peer checking was used to verify the credibility of the results. The researcher involved senior researchers and colleagues to independently identify the codes and themes from the data, which were later compared with the researcher's developed codes and themes. Differences were discussed and harmonization was reached through consensus.
Ethics clearance was granted by the University of the Western Cape's Senate Research and Ethics Committee and the National Health Sciences Research Committee for Malawi. Thereafter, permission was sought from, and was granted by, the CHAM nursing colleges. Each participant gave both verbal and written consent prior to participation in the focus group discussions. Participants' integrity, privacy, and confidentiality were maintained throughout using a series of measures, including the signing of the confidentiality binding agreement by the participants, during the process of data collection and reporting.
The study findings demonstrate the challenges faced in clinical teaching and learning of neonatal nursing for NMTs. The participants in this study perceived that clinical teaching and learning in neonatal nursing was neglected, compared with other nursing fields during training. Six themes were identified, namely Short Duration and Variation in Clinical Placement, Inadequate Resources and Student Congestion in the Clinical Area, Lack of Emphasis on Clinical Teaching, Lack of Clinical Supervision, and Lack of Skills Among Clinical Staff.
Short Duration and Variation in Clinical Placement Areas
Most of the participants, both clinical teachers and students, reported that the students spent 4 to 6 weeks for the postnatal clinical experience in the district hospitals. However, the duration was even shorter (2 to 3 weeks) for those students who were placed in neonatal care settings at a central hospital. Only a few students whose training institutions were close to the central hospitals had the opportunity to go through such neonatal nursing experiences. Yet, some students were given clinical objectives for neonatal nursing without going through the clinical experience, despite having a well-established neonatal care unit within the central hospital. This was revealed in the following statement from one student:
There is a good nursery ward [in that hospital]…. They could have allocated us there. They only [gave] us the objectives but did not allocate us for the [clinical] experience. We went there on our own to ask [to be placed on the nursery ward], but the in-charge [nurse] refused, requesting a letter from the school.
Given this, the students missed the opportunity to practice the skills in an ideal neonatal care unit.
In addition, most of the student participants reported that some of them were placed on the district hospitals' postnatal care wards, where no stand-alone neonatal nursing units exist; moreover, there were no very sick neonates, which made the placements not conducive for students' ideal learning experience. This was evidenced in this statement from one student participant:
Mostly, we are placed at a district hospital…maybe with one to two patients, but most of the time very premature, very sick neonates…are referred.... Only few students may have the opportunity to go to well-established neonatal nursing wards… in central hospitals.
Inadequate Resources for Learning
The participants, both students and clinical teachers, reported that the clinical setting where the students were allocated to, in the district hospitals, did not have adequate material resources to facilitate the students' learning experience. Notably, both groups of participants pointed out that the clinical settings lacked equipment for the provision of basic neonatal care to neonates who develop complications such as prematurity or jaundice. Therefore, students completed the clinical experience without meeting the expected skills, despite having met the conditions to learn. This was lamented by one clinical teacher in the following manner:
[In] some districts, the students are complaining that they haven't seen something like phototherapy. That means they'll finish their training without seeing one. So they say, “I think it's a problem; maybe we're going to find difficulties…after qualifying, when we go to the clinical sites.”
Similarly, the student participants reported having learned some skills in theory, yet they had no opportunity to practice them because the hospital in which they were placed for experience had no equipment to enable them meet the skills. One student commented:
Something like the incubators…there is a competency which we are supposed to acquire…caring of the neonate in the incubator. So you find that, at our setting there is no incubator there.… Sometimes, you go through the allocation without meeting a special case which you are supposed to acquire, like phototherapy. You find…no neonate with jaundice.
In some clinical settings, lack of adequate resources led to few students getting exposed to expected learning experiences, whereas the majority had no opportunity for a similar learning experience, thereby making it a challenge for them to acquire the required skills.
Sometimes resources become a challenge, in terms of trying to make students acquire some specific skills…in the specific hospital where resources are not able to support them, with few resources you find that maybe very few students are exposed to some kind of experience while others may not be able to because there were no resources there to assist them.
However, some clinical teacher participants observed that even some of the skills laboratories in the nursing colleges lacked resources to expose the NMTs to neonatal nursing skills prior to clinical placements. This makes it challenging for some clinical teachers to teach students the ideal way of performing the skills on the neonates. One clinical teacher noted:
We are talking about neonatal nursing.… Even in our skills lab, we do not have enough equipment for the students to learn.… Look at the…babies that we need to use there, or the resuscitation, some of these resources are not adequate in the skills lab. So it becomes difficult for us to teach the ideal [things] they are going to learn in neonatal care, because of inadequate resources.
Inadequate resources for neonatal nursing practice in the clinical settings for student learning made some clinical teachers acknowledge that the district hospitals were not worthy teaching hospitals because they contributed to students' poor performance on various neonatal nursing procedures and skills. One teacher commented:
If you look at these hospitals where we send our students, although we call them teaching hospitals…they are far behind to be called the teaching hospitals.... They are experiencing a lot of problems. So, that is actually reflecting on the…experience of our students in the district hospitals; they poorly perform on those procedures.
In support of that statement, some student participants also perceived that the lack of resources in the clinical setting contributed much to the lack of skills in clinical practice because they could not practice the required skills learned in class, as explained by one student participant:
Lack of resources contribute to [students]…not meeting the necessary [clinical] skills that we intend to get, because when… you are…in class, you are taught using the ideal resources that you think of finding at the clinical areas…but when you go to the clinical area, you find that most of the resources that were used…in the skills lab…are not found at the hospitals.
Students' Congestion in the Clinical Placement Areas
Another factor affecting the students' learning experience and acquisition of skills in neonatal nursing was the increased number of students that led to student congestion in the clinical placement areas. Both student and clinical teacher participants reported that the nursing colleges had increased the student intake over the past years, thereby affecting students' clinical learning experience, as more students than required are allocated to a placement area. This made student learning experience a challenge, and only those students who were interested and self-motivated acquired the expected skills in the clinical setting.
[Student] numbers is also a challenge. You may find…that maybe those who learn are the ones who are interested. Those who don't have the interest, they do not take self-initiative to learn, they cannot learn because of the numbers. Because students are not only from one institution,…they have…students from so many institutions at one district hospital.
This was also echoed by a student participant:
Another challenge is the increasing number of the students, they are times when you go there [the hospital]…you are allocated to the neonatal ward…. You [the students] may be 10 or five for example [on one ward]. Sometimes, you find that other groups [students from other schools] are there…on the same ward. So it's like maybe, we are 20 [students] on the same ward against three or four patients. This makes it difficult for you to acquire competencies.
Lack of Emphasis on Clinical Teaching in Neonatal Nursing Practice
The findings also revealed a lack of emphasis in preregistration neonatal nursing clinical teaching for the NMTs. This observation was made primarily by the student participants. For instance, most of the student participants reported that in the postnatal care wards, clinical teaching focused on the care of the mother, rather than the baby. A student noted:
I have also observed that…people only concentrate on the mother, for the baby it is hardly done, because when coming for supervision, they [ask] “What have you done to the mother with eclampsia?” [and] “What is [the blood pressure] reading?” They only concentrate on the mother, not the baby…. In postnatal, they want you to spend more time where…mothers are admitted, but I have never heard them ask what I am doing to the baby, so I am always surprised…. What about the baby? Our first priority in life is the mother and not the baby.
The students perceived that the lack of emphasis in neonatal nursing clinical teaching and experience made them put less effort into learning neonatal nursing in the clinical area and adopted the shortcut way of performing the skills; hence, they feared that this could, in turn, affect the acquisition of clinical skills. According to one student:
We don't have…[a] clinical teacher to assist us in neonatal care…. I feel like we can…face a challenge when we start working, and we are allocated to a neonatal department…to care for the neonate, because in our training, neonatal care was not much concentrated on.
The student participants wished that the clinical teachers paid neonatal nursing the same attention as maternal health issues in the clinical setting.
Lack of Clinical Supervision
Concurring with the students' observation, some clinical teachers admitted to not adequately supervising the students in these clinical settings. Despite having an increased number of students and acknowledging the increased workload faced by clinical staff, the training institutions relied on the clinical staff for teaching the students in the neonatal care clinical setting. This was evidenced in the following contribution from a clinical teacher:
Normally, we [college clinical teachers] go there maybe weekly, but not all the days of the week, and we leave the task behind the staff nurses. So sometimes, because maybe they are busy, because the number of students are so many, they cannot deal with the students as an individual, because maybe of overload with work in the ward, it's really a challenge.
However, the student participants complained that although the training institutions relied on the clinical staff to teach students in clinical neonatal nursing, most of the clinical staff did not show interest to assist the students practice the skills, even when the student requested support. In some situations, the clinical staff negatively responded to students' request for assistance by telling the student to read from the books, which contributed to a fear of seeking assistance. As a result, the students were performing the procedures on their own without assistance or supervision. This was revealed in the following contributions from some students:
- The people who are already qualified there, when you ask them about a certain task or may be a certain procedure… what they will tell you is [to] “consult books, what are your tutors teaching you?” Then we practice that…no one to guide, to tell you that this is a real thing that you need to do…[so] you end up having nothing that you have really achieved from this. (Student, college 4)
- It's sad, let's say you are working with the staff, you don't know anything, but maybe the person that is supposed to be helping you…. He doesn't show…a spirit of teaching somebody, you just do things on your own, without…guidance because maybe you will be afraid, that if I'll ask this one maybe, the response [will be] that…she…or he will say…bad things. (Student, college 5)
Lack of Skills Among Clinical Teachers and Staff
Some student participants reported that in some situations, the clinical staff did not demonstrate the right skills to the students. As such, the students practiced the wrong skills because that was what they were exposed to, which was perceived as a challenge to their learning. For instance, one student said:
The problem is the skills of the people training you…. When you ask the qualified nurse, who has gone through the training, they will tell you that they don't know or tell you to do something in the wrong way…so you find also conflicting issues…. I think that situation is risky for students.
Concurring with the students' perception, the clinical teacher participants observed that even some tutors or clinical teachers lacked the confidence to demonstrate the right skills to the student. Therefore, they ended up leaving some skills undemonstrated or inappropriately demonstrated to the students. This was revealed in the following statement:
Sometimes…the challenge…is…that the tutor is not competent herself and has no confidenceto demonstrate to the student. So it's a challenge because you [the tutor]…just leave the student to go to placements without demonstrating the skill, you are not competent.
These findings reveal that student preregistration clinical teaching in neonatal nursing practice is not being emphasized. Students are exposed to varying learning experiences because of the nature of the learning environment in which they are placed for practice. In addition, the lack of emphasis in clinical teaching in this setting is a concern, given that quality neonatal care outcomes depends on the practitioners' clinical competence in this setting.
The study findings showed various challenges faced in neonatal nursing clinical teaching and learning. Typical among them are short duration and variation in clinical placement, inadequate resources and student congestion in the clinical area, lack of emphasis on clinical teaching, lack of clinical supervision, and lack of skills among clinical staff.
It was reported that the nursing students' clinical placements were combined with postnatal care, in which more emphasis was given on the care of the mother than the neonate. In addition, students were left to practice in district hospitals that had inadequate resources for the provision of quality neonatal care, given the increased number of students, thereby affecting the students' acquisition of clinical competence. This finding is similar to other research findings that a poor clinical teaching and learning environment (Bvumbwe, Malema, & Chipeta, 2015), inadequate resources (Bvumbwe et al., 2015; Msiska, Munkhondya, & Chilemba, 2014; van Dijk et al., 2010), inadequate time and practitioners' attitudes (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014), and lack of competence among clinical teachers (Bvumbwe et al., 2015) are some of the barriers for effective student teaching in nurse practitioner curricula. The quality of clinical practice placements has been associated with the development of competent and confident nurse-midwife practitioners (Murphy, Rosser, Bevan, Warner, & Jordan, 2012). In the clinical placements, students expect to develop and practice the attributes of caring, clinical competence, and technical skills through experiencing nursing in the real world. Any deviation from these expectations affects the students' acquisition of clinical technical skills for entry-level practice because they lack opportunities to practice and acquire the prerequisite skills for neonatal nursing practice.
Furthermore, clinical teaching in this setting was not emphasized, as the clinical teachers did not supervise the students or concentrated on maternal health issues other than teaching newborn care. The lack of emphasis in neonatal nursing clinical teaching emerged as a prominent issue affecting the students' acquisition of clinical competence. It was reported that most clinical teachers did not put more emphasis on neonatal nursing practice, as compared with other clinical placement areas. This made the students perceive neonatal nursing practice as less important, leading to lack of confidence for independent practice in neonatal nursing settings on entry into practice. Although some researchers have reported a lack of interest among students to practice in some clinical settings (Murphy et al., 2012; Shen & Xiao, 2012), in this study, students' perception of lack of interest to practice in neonatal nursing came about due to inadequate support from clinical teachers during clinical learning experiences. This is similar to the observation of Löfmark, Thorkildsen, Råholm, and Natvig (2012) that lack of emphasis in clinical teaching for nursing students affects the fulfillment of learning outcomes because the students feel inadequately prepared to take responsibility for patient care, thereby compromising quality neonatal services.
Despite the students being entrusted in the hands of clinical staff, this study found that most of the clinical staff did not show interest to teach students; therefore, the students were not supported adequately to acquire the required competencies. This made students perform clinical tasks and learn skills without any assistance; in most cases, they were not certain what to do, leading to fear among the students. Lack of support to students' clinical learning experience has been associated with students' increased anxiety (Scully, 2011), affecting the acquisition of skills. On the other hand, Croxon and Magginis (2009) asserted that student-friendly clinical staff members play a key role in the students' achievement of clinical learning outcomes, as they create a positive learning environment. Furthermore, the clinical staff act as role models to the nursing student–midwife student; therefore, it is important that they establish a rapport with the students, creating a supportive and positive learning environment (Burgess, Goulston, & Oates, 2015) that will contribute to the development of professional competence, values, and attitudes.
However, it was reported in this study that some clinical teachers and clinical staff were not confident and lacked the skills to teach the students in neonatal nursing. This could have contributed to the lack of interest to assist the students during the clinical learning experience because of fear of incompetent practice (van Dijk, Hooft, & Waard, 2010). Nevertheless, students need more opportunities and guidance to learn the real world of practice of nursing during their academic program (Seada & El Hanafy, 2012). As such, clinical teachers should provide a learning environment that aids in the transition to the professional role and prepares the students for competent entry into neonatal nursing practice (Hickey, 2010).
Clinical Implications and Recommendations
In Malawi, NMTs form the majority in the health care service. They are entrusted with the responsibility to provide primary health care services in all clinical settings including neonatal care services. Considering that the clinical learning environment is crucial to the development of competent and independent practitioners (Brown et al., 2011), the nursing programs must reexamine current neonatal nursing care clinical teaching practices, as well as initiate methods to maximize student learning opportunities in neonatal nursing practice. In addition, a need exists to create neonatal nursing care units and wards in the district hospitals used for student teaching and learning, to create learning opportunities that meet students' needs. Furthermore, clinical teachers must continuously work in collaboration with the clinical staff to ensure effective clinical teaching and supervision, thereby promoting skills acquisition among the nursing-midwifery students. As role models, clinical staff need to create a positive clinical learning environment to enable the students' professional socialization and development of competent practitioners. Periodic workshops should be organized for both clinical teaching staff and classroom teachers to improve their stills and create interest in neonatal nursing practice.
This study was conducted in CHAM nursing colleges, training mid-level nurse-midwives. All institutions training RNs and midwives were not included. As such, the findings may not necessarily be generalized to RN-midwifery students. However, given that all training institutions in Malawi use almost the same clinical placements areas for training of different cadres of nurse-midwife practitioners, a need exists to conduct a similar study among the RN and midwifery student training institutions. Furthermore, the study involved nurse-midwifery students and clinical teachers from the training institutions, leaving out the clinical staff who are key players in practice and may have made a significant contribution to this study. These factors will be considered in subsequent research.
The study findings reveal some gaps between theory and practice in preregistration neonatal nursing teaching and learning, in that clinical teaching in this setting is not emphasized to assist the nursing students to acquire the necessary skills. These gaps have been increased in the light of other challenges, which include inadequate clinical practice areas, short duration of placements, shortage of resources, and lack of clinical supervision. In turn, these challenges have led to students' perceiving neonatal nursing practice as less important, compromising the acquisition of skills and competence for entry-level practice further. However, WHO (2014) recommended that mid-level nurse-midwife practitioners in low-resource settings require sufficient training to equip them with adequate knowledge and skills for quality neonatal health outcomes. Considering that the NMTs are the majority of primary health care providers in Malawi, the study proposes that nursing programs should consider maximizing student learning opportunities in preregistration neonatal nursing by creating more practice-based learning opportunities that meet students' needs.
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