Nursing students' views of sociocultural factors in clinical learning: A qualitative content analysis
Soroor Parvizy, Tehran Nursing and Midwifery Faculty, Center for Educational Research in Medical Sciences (CERMS), Tehran University of Medical Sciences (TUMS), Eastern Nosrat Street, Tohid Square, Tehran 1419733171, Iran. Email: firstname.lastname@example.org
Aim: The aim of this study is description of nursing students' views of sociocultural factors in clinical learning.
Methods: A qualitative content analysis was conducted to describe nursing students' views of sociocultural factors in clinical learning. The participants consisted of 21 nursing students. Semi-structured and interactive interviews were used to collect data. All the interviews were recorded and transcribed, and then, they were analyzed using Qualitative Content Analysis and Max Qualitative Data Analysis 2010.1
Results: From the transcripts, a remarkable number of primary themes, main themes, and sub-themes emerged. The main themes consisted of elements related to “society and culture”, “family”, “staff”, and “classmates”. The themes encompassed a spectrum of facilitators of and impediments to clinical learning.
Conclusion: The findings showed that the administrators of nursing education should coordinate with faculty and staff by adopting interactive and participatory solutions, including the establishment of clinical learning teams and the transformation of hospitals into suitable sociocultural environments for education.
Clinical learning is one of the important areas that helps elucidate the importance of nursing students' performance in the clinical setting and its impact on the development of nursing as a profession (Peyravi, 2005). Clinical education takes place within a complex social context, wherein a teacher is responsible for monitoring the needs of clients, students, and clinicians (Cheraghi, Salasli, & Ahmadi, 2008). In teaching, there is a remarkable focus on the social nature of science, especially the role of performance and experience in learning clinical skills (Field, 2004). Learning through participation in work in society, involvement in community, and professional cooperation (e.g. with teachers, staff, classmates) takes shape progressively and gradually. A consideration of the social and economic interactions of the involved parties in higher education is growing (Andrew, Tolson, & Ferguson, 2008). Therefore, one of the fundamental components of learning for students is learning from members of the society and from nursing staff (White, 2010). A recent published work review has demonstrated that clinical learning is a dynamic process of interactions between students, teachers, and other components of the clinical environment (Cheraghi et al., 2008).
Using research to identify the role of sociocultural elements in clinical learning is crucial and leads to the formation of a new understanding with regard to the significance of science in the clinical setting. At present, research should be used to make decisions related to clinical education (Brady & Hyde, 2002). Studies evaluating the experiences of nursing students with respect to cultural differences have shown that coursework and ward-based learning needs to cover cultural topics, including the sociology of learning, the principles of sociology, and medical psychology (Tortumluoglu, Okanli, Ozyazicioglu, & Akyil, 2006). Studies conducted by White (2010) concerning sociocultural approaches to clinical learning have demonstrated that learning is a social process. The author emphasized that the definition of the concept of learning should be revised in nursing education programs because learning is a process that takes place through undertaking responsibilities and participating in a social framework; in addition, accurate learning occurs in the course of informal interactions and social situations in an actual context (White, 2010). Other studies have also highlighted the role of social factors in education. For instance, research has examined the social factors impacting the educational regression of students. One study showed that five social factors – the economic situation of the family, familial conflicts, negative approaches to education, inappropriate friends, and educational elements (in relation to the teacher and school) – are effective in the academic regression of the students (Karimi, 2010).
Some research has been conducted on the nursing students' perceptions of professional roles and communications in clinical placements. A study by Andrews et al. explored the experiences and perceptions of students relating to their clinical placements and, in particular, their views on professional structuring. Specifically, it addresses the roles of and communications between the key academics, clinical professionals, and institutions responsible for their organization. It further highlights the diverse experiences that students receive on clinical placements, and their suggestions for improvement. Student informed models of worst, minimum, current, and best practice as well as a cross-setting evaluation feedback model are then presented. These models highlight responsibilities and communications across health professionals and educational sites. The main emphasis in these models is on the roles of ward managers, mentors, link tutors and, more generally, on shared but clearly delineated institutional responsibility for quality assurance mechanisms. They offer the opportunity to improve educational practice in clinically-based education and, concurrently, to improve the students experiences and outcomes (Andrews et al., 2006).
Levett-Jones and Lathlean indicated the importance of belongingness as a prerequisite for nursing students' clinical learning. Eighteen participants from Australia and the UK provided a range of perspectives on belongingness and how it influenced their placement experience. Central to this discussion was their strong belief that belongingness is a prerequisite for clinical learning. This theme dominated all of the interviews. Given that the primary purpose of clinical placements is for students to learn to nurse, it is necessary to have a clear understanding of the relationship between belongingness and learning. This research suggests that reconceptualizing nursing students' clinical learning experiences through a “lens of belongingness” provides a new perspective and reveals yet unexplored insights (Levett-Jones & Lathlean, 2008).
A study by Saarikoski and Leino-Kilpi, titled “The clinical learning environment and supervision by staff nurses” aimed to: (i) describe students' perceptions of the clinical learning environment and clinical supervision; and (ii) develop an evaluation scale by using the empirical results of this study. The results demonstrated that the method of supervision, the number of separate supervision sessions, and the psychological content of supervisory contact within a positive ward atmosphere are the most important variables in the students' clinical learning. The results also suggested that ward managers can create the conditions of a positive ward culture and a positive attitude towards students and their learning needs. The data analysis indicated that the most important factor in the students' clinical learning is the supervisory relationship. The two most important factors constituting a “good” clinical learning environment include the management style of the ward manager, high quality nursing care, spirit of caring and familiarization as well as communication relationships and solidarity between staff and students (Saarikoski & Leino-Kilpi, 2002).
Therefore, with regard to the above issues, it can be noticed that different clinical settings, real-time experience, interaction with different people in society, cultural and familial differences, and deficits in clinical education programs and curriculum underscore the importance of this research project. Social factors are not simply explained by quantitative words, and their real significance is in the production of science and the development of professional values (Andrew et al., 2008). Therefore, more qualitative studies are needed to enhance our understanding of the role of sociocultural factors in clinical learning. To examine the topics just mentioned, the researchers decided to carry out qualitative research using qualitative content analysis, with the aim of describing the role of sociocultural factors and elements in the clinical learning of undergraduate nursing students.
In Iran, nursing education programs bear some similarities to nursing education programs worldwide. The admission requirements in Iran are a certificate of general education (12 years), and students must also pass the National University Entrance Examination. The Iranian nursing education program lasts 4 years and leads to a bachelor's degree in nursing. Nursing students start their clinical training from the second semester, and this training is run concurrently with theoretical courses until the end of the third year. The fourth year is allocated exclusively to training within clinical placements. At present, the nursing curriculum throughout Iran is accredited by the High Council of Medical Education, Ministry of Health and Education (Salsali, 1999). Student nurses are trained at university hospitals. In the clinical setting, they are assigned to care for patients based on nursing process. They learn within the clinical environment under the direct guidance and supervision of a nurse educator for the first 3 years. In the final year, they work under the direct guidance of staff nurses, with the additional supervision of nurse educators (Peyravi, 2005).
This research was carried out using a qualitative approach, consisting of qualitative content analysis and semi-structured interviews. Qualitative content analysis is a method that accounts for the contradictory comments and unresolved issues concerning the meanings and application of concepts and procedures. Qualitative content analysis is used in a large number of fields, ranging from marketing and media studies to cultural studies, sociology, and cognitive science, as well as other fields of inquiry (Palmquist, 2010).
Process of sampling, collecting, and analyzing data
In the present research, 21 undergraduate nursing students at the second or higher semesters of study in the Department of Nursing and Midwifery at the Medical Universities of Tehran and Shahid Beheshti were selected through purposive sampling. Tehran and Shahid Beheshti Universities are the main universities of medical sciences in Tehran, the capital of Iran.
In the present study, first, the chief researcher selected the most informant and appropriate participant as the first participant and ran the research. Sampling went on until data saturation.
After signing informed consent, the 21 student nurses were asked to agree upon a convenient time and place for the interview. The principal interview questions were the following: “What comes to your mind when you hear the phrase ‘clinical learning’?”; “Which sociocultural factors affect your clinical learning?”; and “What are, in your opinion, the sociocultural facilitators and deterrents of clinical learning?” The interviewer probed participant responses by using questions/statements, such as “Could you say something more about that?”, “What did you think then?”, and “When you mention . . . what do you mean?” (Kvale, 1996).
The interviews were recorded by digital voice recorder and were subsequently transcribed. All interviews were analyzed using the “MAXQDA 2010” software package (VERBI GmbH, Berlin, Germany). The process of qualitative content analysis often begins during the early stages of data collection. This early involvement in the analysis phase assists in moving back and forth between concept development and data collection, and may help direct subsequent data collection toward sources that are more useful for addressing the research questions (Zhang & Wildemuth, 2011). This process includes open coding, creating categories, and abstraction. Open coding means that notes and headings are written in the text while reading it. The written material is read through again, and as many headings as necessary are written down in the margins to describe all aspects of the content. The headings are collected from the margins onto coding sheets and categories are freely generated at this stage. After this open coding, the lists of categories are grouped under higher order headings. The aim of grouping data was to reduce the number of categories by collapsing those that are similar or dissimilar into broader higher order categories. When formulating categories by inductive content analysis, the researcher comes to a decision, through interpretation, as to which things to put in the same category. Abstraction means formulating a general description of the research topic through generating categories. Each category is named using content-characteristic words. Subcategories with similar events and incidents are grouped together as categories and categories are grouped as main categories. The abstraction process continues as far as is reasonable and possible (Elo & Kyngäs, 2008).
Credibility and consistency were confirmed through several methods. First, the evolving results were discussed continuously among the authors. A second review of the transcripts, codes and grouped codes, concepts, and designed relationships was carried out by a number of colleagues as a peer check and some of the participants as member check. Quotations were used to illustrate participants' key points. Finally, prolonged engagement with the participants enabled the investigator to gain the participants' trust and obtain deeper and more reliable data (Parvizy, Ahmadi, & Nikbakht Nasrabadi, 2008).
Ethical approval was obtained from the Research Committee of Nursing Faculty at Tehran University of Medical Sciences (Tehran, Iran).
To keep the autonomy of the participants, the following measures were taken:
First, with the help of each class representative, the researcher chose suitable students for the research and then took their email addresses and phone numbers. Before interviewing, she contacted them, introduced herself, and gave a brief description about the subject of her PhD dissertation. Then, by their consent and agreement, she arranged the location and time of interviews. In the formal meeting, first, she gave them a sheet consisting of the complete description of the research, objectives, methodology, voluntary participation in the research, and privacy of the participants' information. Upon reading the sheet, they were requested to ask any questions they might have about it. If the students showed interest in participating in the research, they were asked to sign an informed consent sheet. After gaining their oral and written agreement, the interviews were started in a very close and intimate atmosphere. At the end of each interview, the researcher gave each student a gift as a sign of gratitude. The participants were further informed that they had the autonomy to end their participation at any time they wished and receive their voice file and its transcription as well. Confidentiality was assured and this meant that only the researcher would be aware of the real identities with their respective tapes, report, or description (Holloway & Wheeler, 1995). For this purpose, a numeric code was allocated to each participant.
The mean age of the students was 21.6 ± 1.6 years, with a range of 19–25 years. Seventy-five percent of the participants were female, and 25% were male. Twenty-five percent of students were studying in the third semester, 41.7% were in the fifth semester, and 33.3% were in the eighth semester. Two of the students had clinical student work experience. All of the students were single.
According to the analysis of the 655 first-level codes extracted from the analysis of the interviews, four main themes with two dimensions were specified: factors related to society and culture, to family, to staff, and to classmates (Table 1).
Table 1. Main themes and their dimensions emerging from analysis of nursing students' views of sociocultural factors in clinical learning
|Society and culture factors||Supportive or suppressive||The positive public attitude toward the profession of nursing|
|Observing the prestige and esteem of the nursing students|
|The negative attitude of society concerning the profession of nursing|
|Ignoring the respect and esteem of the nurses|
|The negative public attitude towards male nurses|
|Discrimination between the fields of medical sciences|
|Family factors||Incentive or obstructive||The high level of awareness in the student's family|
|Encouraging the family of the student|
|Having similar cases of disease with clinical situations in the family|
|Backing up the profession by the student's family|
|Asking clinical questions of the student by the relatives|
|Educating the family of the patient|
|Being reprimanded by family members for selecting this discipline|
|Staff factors||Accompaniment or withdrawal||Cooperating with students|
|Guiding and directing the students|
|Respecting the students|
|Maltreatment of the students|
|Staff's lack of cooperation with the students|
|Preventing the students from taking charge of the affairs|
|Appointing the students to ease the work of the nurses on the ward|
|Classmate factors||Interaction or interference||The interaction of the students with each other|
|The students' exchange of questions and answers|
|The number of students on the ward|
|The conflicts between students|
|Embarrassment at making mistakes before each other|
Society and culture factors: supportive or suppressive
The positive public attitude toward the profession of nursing and the prestige and esteem afforded nursing students are among the secondary themes of factors related to society and culture. Participants believed that the positive public stance about the profession of nursing creates motivation for learning. One of the participants stated, “When we see that society has a positive attitude toward the profession of nursing and considers it as highly valuable, we'll be motivated more to learn clinically” (participant no. 8).
Another issue is the observation of the dignity and esteem of the nursing student: “Respecting dignity is very important. I believe that respect for a student by others has an effective role in building up his motivation for clinical learning”, one of the other participants said (participant no. 4).
Although society can have a supportive role in the process of clinical learning, it can have an equally suppressive role in learning as well. The negative societal attitudes concerning the profession of nursing, disrespect for nurses, a negative public attitude toward male nurses, and discrimination between the different medical science fields are among the secondary themes of the suppressive role of society and culture. One of the participants reported the following: “The dignity of the profession of nursing is disregarded in society. For example, people sometimes ask us which field we study. Once we tell them that we study nursing, they ask if nursing requires academic study at university” (participant no. 10).
Family factors: incentive or obstructive
The secondary themes in this category include the following: the high level of awareness in the student's family, encouragement by the family of the student, the presence of similar cases of diseases in the family as encountered in the clinical situation, the support of the profession by the student's family, the presence of clinical questions asked of the student by relatives, and the education of the family of the patient. Some of the participants believed that the level of education of the family is also important. One of the participants stated the following: “I'm used to speaking about my patients at home. My parents are educated; they ask me some questions which make me pay more attention to the status of my patient next time and this causes the information to remain in my mind for a longer period” (participant no. 8).
An example of having a similar case of illness in the family and its impact on clinical learning can be seen in the following quote: “I remember that my mother decided to change her wound dressing. Nobody had told me what to do in order to change a wound dressing. She asked me, and I didn't know how to do it. So, I asked my professor, and she told me what to do” (participant no. 12).
Another element highlighted was the endorsement of the profession by family members. One of the participants explained, “Since all of my family members substantiate my profession, I'm more inclined to learn in the clinical setting” (participant no. 2).
Another participant spoke about the impact of the questions posed by relatives and acquaintances on clinical learning: “One of my family members asked me how vitamins should be used. This caused me to pay more attention to these issues in the hospital and ask my professors about it” (participant no. 19).
The participants also pointed to the role of educating the families of patients: “When the family of the patient asks me about the condition of their patient, this causes me to pay more attention and pursue the case so as to avoid running short before them” (participant no. 11).
On the other hand, some of the participants alluded to the suppressive role of the family in the process of clinical learning. One of the participants said the following: “My family tells me that if I had studied better, I would not be forced to beworking in this painstaking discipline” (participant no. 21).
Another made a similar comment: “Selecting this discipline has even affected our marital status, because the majority of the men don't like to select for marriage the women who are not at home most of the time and keep watch at nights” (participant no. 13).
Staff factors: accompaniment or withdrawal
Cooperating with, guiding, and directing the students and respecting them are among the secondary themes of factors related to the staff. One of the participants said: “It will be good if the staff cooperate and assign duties to us. We will learn better this way” (participant no. 12).
Another participant, speaking about the guidance of the staff said, “Sometimes, the highly experienced staff can act as educational supervisors. They mention many things and tell the students what to do. This can serve as a good education for the students, and we can learn many things from them” (participant no. 8).
The participants have also underlined the effect of being respected by the staff on their learning: “My learning improves as I see the behavior of the staff and the respect they have for me” (participant no. 9).
Misbehavior, lack of staff cooperation with the students, the prevention of the students' assistance in caring for patients, and the use of the students to ease the work of the nurses in the ward are among the secondary themes of deterrent factors related to the staff. Some examples can be seen in the following quotes: “The behavior of the staff with the students is so unfair that they've lost their motive and don't like to work and learn anymore” (participant no. 4); “They do not have any appropriate cooperation with us. They don't hand the inventory over to us. They don't give us the dossiers to study” (Participant no. 6); and “They just assign a number of elementary works to us so as to alleviate their work” (participant no. 2).
Classmate factors: interaction or interference
One of the secondary themes of the factors related to classmates includes the interaction of the students with each other and their exchange of questions and answers. For example, one student commented: “In the break hour, we congregate in the ward and review each other's diagnosis to see if it's really a clinical diagnosis. This caused us to learn more effectively” (participant no. 2). They went on to say: “If classmates ask me whether this disease is, for example, an infectious disease, I should look for information and find the answer”.
On the other hand, some of the other participants pointed out an overlap of students' responsibilities in carrying out clinical work and said: “When there are a high number of students in the ward, the process of learning would not be fulfilled as it should be, because the responsibilities of the students overlap each other” (participant no. 6).
Some of the other students alluded to their embarrassment before their classmates while carrying out a procedure: “I once told one of the professors that I'm shy in front of my classmates and am fearful of making mistakes before the others” (participant no. 6).
Another situation mentioned by some participants was conflict with each other in the ward: “We are put in a group with the people who are fond of pinpointing our mistakes and ingratiating the professors. In my view, working with such students would not only preclude the process of learning but would demolish our motivation as well” (participant no. 14).
These results indicate that the sociocultural facilitators and deterrents are situated on two ends of the spectrum of learning. The more the facilitators are strengthened, the more the clinical learning improves. In the same way that the positive attitude of the public can have an effective role in the clinical learning of the students, the negative attitude of members of society toward the profession of nursing can be also a deterrent to learning. The negative attitudes of society toward nursing and the distorted images of this profession from the public can cause disappointment among nursing students and deterioration of their educational quality (Saberian, 1998).
One study in Jordan indicated that the low social prestige of nurses causes nursing students to detach from the profession (AbuAlRub, 2007). Therefore, the social stature of the nurses should be taken into consideration, and the public should be sufficiently educated about this profession. A study of nursing education has demonstrated the dissatisfaction of nursing students with the profession and its impact on their interest in learning (Davis, 1990). Another factor was the lack of respect for the nursing profession in society. Unfortunately, a number of countries still face challenges and problems in creating an appropriate social stature and respect for nurses and are grappling with the harmful culture of the inferiority of nurses in society (Oweis, 2005). The other deterring factor was the discrimination between different fields of medical sciences, which caused decreased interest in the nursing students and obstructed their effective learning in a clinical setting. Another study has also mentioned this factor (Julaie, Mehrdad, & Bohrani, 2006). The findings indicated that the sex factor and the consideration of nursing as a feminine profession in society are among the main deterrents of clinical learning in male students. Similar results were obtained in other studies, and despite the advances of the past decade, many countries still consider nursing to be a feminine profession (Oweis, 2005). Another study stated that, compared to other medical fields, men feel more dissatisfied in nursing than in the other fields (Conley, 1993). Research has shown that the impact of negative attitudes in society among nurses and health team staff is significant, especially for men (Lindop, 1989).
Some participants pointed out the impact of family on clinical learning. In the above studies, the facilitative and deterring roles of families have been emphasized as well. One of the cultural problems for nurses is the unacceptability of this profession for families because of the night shift work (AbuAlRub, 2007). This deterrent familial factor has resulted in the decline of students' interest and motivation for clinical learning because the participants in the research mentioned it several times as an obstruction to clinical learning.
Concerning the economic and social status of the family, one study on the educational barriers of nursing students showed that factors such as the occupation and education of parents impact students' learning (Alikhani, Markazi Moghadam, & Zand Begleh, 2006). The greater the social and cultural status of the family, the more they can comprehend the profession of nursing and its problems; therefore, they can better support students' learning and increase their sense of empowerment as nurses.
Another research finding was the role of illness within the family and its impact on clinical learning. When the student feels alone and unsupported at home, he/she feels more responsible and tries to be more watchful in taking care of family members in order to minimize error. If he/she encounters a question or finds a point to be ambiguous – because there are no trainers or supervisors at home – he/she actively sets out to find the answer, developing improved independent learning and a greater sense of responsibility. All of these factors make the process of learning more sustainable. In a similar way, questions asked of nursing students by their relatives or the relatives of patients encourage them to search for the answers independently and to pursue the process of learning more carefully while studying or taking care of patients.
Other factors mentioned included cooperation with staff, veneration of the students, and guidance of the students by the staff. From a professional perspective, according to the recommendations of the American Association of Colleges of Nursing, undergraduate nursing students should be prepared for the relationships and interactions with staff in order to care for their patients (Rich & Nugent, 2010). Students need to be able to learn from society and the nursing staff, a process that takes place through cooperation between the nursing services and the educational nursing wards (Rich & Nugent, 2010; White, 2010). Ongoing cooperation between nursing practitioners, clinical nurses, and nursing students is critical. These individuals should have constant, close relationships with each other (Chan, 2002).
Because the interactions between staff and students have a remarkable impact on learning, a poor relationship and an absence of mutual respect obstructs learning. One of the important impediments frequently mentioned and observed in nursing research was relationship conflicts between students and nurses and the disrespect for students by the nursing staff. It appears that excess work and low wages were also important factors contributing to the bad-temperedness and low motivation of the nurses.
This study revealed disrespect for the dignity of the students by the staff. Undergraduate nurses should not be considered mid-ranking employees; rather, they should be seen as students. There is a dire need to revise the view of students in nursing education and to view the interns as students rather than as novices, mid-ranking employees, or laborers (Nikbakht Nasrabadi & Movaghari, 1999). Being forced to take charge of the responsibilities of the ward staff is among the problems that students mentioned in the previous studies (Barimnejad, Azarkerdar, Hajamiri, & Rasooli, 2003; Dehghani, Dehghani, & Fallahzadeh, 2005). Taking into consideration the respect and esteem of the students brings them enhanced self-confidence and creates in them a sense of responsibility, which in turn contributes to their active participation in clinical tasks and, consequently, clinical learning.
Another study finding was the impact of classmates on learning. White (2010) believes that several factors, including learning from classmates, are key to clinical learning (White, 2010). Paying attention to the social and organizational context is more important than individual learning. Horizontal or lateral learning takes place through interactions with colleagues (Engestrom, 2001). Learners become involved in the society of learning through internships and they share their beliefs, skills, and mutual understandings within this society and learn from each other (Wenger, 1998). The results of a study by Campbell, Larrivee, Field, Day, and Reutter (1994) showed that learning from instructors and classmates are two main factors in the clinical learning of nursing students (Campbell et al., 1994).
On the other hand, some of the students complained of their overlapping and numerous responsibilities on the ward and cited these as impediments to clinical learning. Some of the participants also referred to rejection by classmates as a deterrent to effective learning. As we know, acceptance or rejection by classmates has an important influence on learning. It is necessary to identify the emotional and social problems of classmates (Zimmer-Gembeck, Waters, & Kindermann, 2010). Particularly in the clinical environment that demands interaction, active participation, and teamwork, this issue should be given special consideration. Emotional and social problems in the work environment are among the impediments that cause poor concentration, distractibility, anxiety, and disordered learning. Here, the role of clinical practitioners is immensely important; they should identify and solve the emotional and social problems of the students, guide them, and minimize these impediments to learning. Another deterrent was embarrassment related to the practice of procedures in front of peers; this problem can be solved to a great extent by educating the students, drawing the attention of the clinical practitioner to this issue, and avoiding the mistreatment and punishment of the students in front of their peers.
Future research should pursue the following aims: (i) to study the real-life experiences of the students engaged in clinical learning, concerning the facilitating and inhibiting sociocultural factors in clinical learning; (ii) to develop a model for clinical learning in different settings and different cultures in order to localize the nursing clinical learning curriculum; (iii) to study and promote nursing students' communication skills by action research method; and (iv) to develop an interdisciplinary approach regarding the sociocultural conditions prevailing in the clinical environment with the participation of students from different branches of the medical sciences.
Because this study is based on a small sample of student volunteers from the urban Tehran population, generalizability may be limited.
With regard to the recent technological advances in clinical learning spaces, revision of nursing students' clinical education curriculum seems essential. Nursing education programmers should consider the sociocultural factors related to the students' clinical learning and localize the clinical learning process with respect to their clinical learning environment. Also, administrators of nursing education need to make interactive and participatory decisions, including the establishment of clinical learning teams and the transformation of hospitals into appropriate educational environments. These changes will likely bring about coordination between the faculty and the hospital and help realize the goals of clinical nursing education more effectively. Administrators should also educate the public to excise the negative attitudes held by society about the nursing profession. Consequently, the public will become more familiar with the field of nursing, its responsibilities, and its social and moral role.
We gratefully acknowledge the very helpful participation of the nursing students. This article was written based on the first author's PhD dissertation at the faculty of Nursing and Midwifery, Tehran University of Medical Sciences; therefore, the financial support from the University is also acknowledged (No: 82/B).
MAX Qualitative Data Analysis 2010 is software for qualitative analysis of the data. Excerpt of the interviews with its codes and memos can be seen in this software. It also makes it possible for constant and comparative analysis of the interviews' data.