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 Table of Contents  
Year : 2018  |  Volume : 31  |  Issue : 1  |  Page : 32-38

The relationship between nursing instructors' clinical teaching behaviors and nursing students' learning in Tabriz University of Medical Sciences in 2016

1 Medical Education Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, USA
2 Student Research Committee, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
3 Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran

Date of Web Publication14-Aug-2018

Correspondence Address:
Fahimeh Alsadat Hosseini
Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Zand Street, Next of Namazy Hospital, Shiraz
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1357-6283.239044


Background: Clinical teaching is at the core of the nursing profession. However, clinical teaching may not empower students to gain clinical competency and skills. In this context, the performance of instructors is one of the main determinants of effective clinical teaching. Therefore, the present study aimed to determine the relationship between nursing instructors' clinical teaching behaviors and students' learning. Methods: This descriptive, correlational study was conducted with 267 nursing students selected through convenience sampling. The data were collected using the Nursing Clinical Teacher Effectiveness Inventory, developed by Knox and Morgan. The questionnaire included two parts: the extent to which nursing instructors used teaching behaviors and the effectiveness of these behaviors on students' learning. The data were entered into the SPSS statistical software, version 19, and were analyzed using descriptive and inferential statistics and the Pearson's correlation coefficient. Results: The results showed a significant positive relationship between the extent to which nursing instructors used teaching behaviors and the effectiveness of these behaviors on students' learning (P = 0.001). In terms of the utilization of teaching behaviors, the highest average rates were related to the dimensions of interpersonal relations and teaching abilities, while the lowest average rates were found for the evaluation dimension. With regard to the effectiveness of these teaching behaviors on learning, the dimensions of teaching ability and evaluation gained the highest and lowest average rates, respectively. Discussion: Instructors' capabilities have to be improved regarding the effective utilization of some behaviors related to evaluation, personal characteristics, and nursing competency. In this respect, the use of comprehensive teaching programs can be quite beneficial.

Keywords: Behaviors, clinical, instructors, learning, nursing students, teaching

How to cite this article:
Parvan K, Hosseini FA, Bagherian S. The relationship between nursing instructors' clinical teaching behaviors and nursing students' learning in Tabriz University of Medical Sciences in 2016. Educ Health 2018;31:32-8

How to cite this URL:
Parvan K, Hosseini FA, Bagherian S. The relationship between nursing instructors' clinical teaching behaviors and nursing students' learning in Tabriz University of Medical Sciences in 2016. Educ Health [serial online] 2018 [cited 2022 Jan 23];31:32-8. Available from:

  Background Top

Clinical teaching is at the core of the nursing profession with almost 50% of nursing educational programs devoted to this topic.[1],[2] At the clinical teaching stage, students gain the required experience by learning clinical skills and taking up opportunities to apply their theoretical knowledge to the mental, motor and social skills necessary for the delivery of patient care.[3] On the other hand, instructors' characteristics are directly related to learning and gaining skills.[4]

Instructors play a critical role in the clinical teaching of students. In fact, by having educational and practical skills and a sense of responsibility, instructors play a key role in the success of nursing students' clinical learning, as well as their ability to link theory and practice.[5],[6],[7] The effectiveness of clinical teaching and the characteristics of clinical instructors have attracted the attention of nursing and obstetrics researchers since 1990[7],[8],[9] and it has been stated that guiding students toward the intended goals requires the identification and application of effective behaviors in clinical teaching.[10],[11]

Despite the importance of the characteristics of efficient clinical instructors, significant flaws exist in instructors' performances.[12],[13],[14] A previous study has indicated that nursing instructors were confused about their clinical teaching role.[12] Such failure in the performance of instructors could lead to the unpreparedness of nursing graduates.[4] A large number of studies conducted in different parts of the world have demonstrated considerable weaknesses in clinical teaching, most of which have been associated with nursing instructors.[13],[14],[15],[16],[17] The issues identified include unspecified clinical teaching goals, lack of clarity regarding the roles of instructors, the limited number of experienced instructors in clinical teaching environments, a lack of teaching and learning supports, a weak relationship between the theoretical and practical courses, weak interpersonal communications and unrealistic evaluations.[13],[14],[15],[16],[17],[18] These issues are also associated with the inaccessibility of instructors to meet students' teaching needs, a lack of time for learning and a lack of necessary encouragements for students.[19],[20],[21] Studies conducted in Iran have also revealed various flaws in nursing clinical teaching.[22],[23],[24],[25],[26] For example, studies show the weakness of nursing students clinical education and evaluation and a lack of training in competent nursing students,[25] inappropriate instructors' clinical performance [24] or a lack of experienced instructors and suitable clinical settings in which to teach.[26] An undesirable quality of health-care services and an ineffective responsiveness to society's needs [27] might partly result from deficiencies in the service providers' curricula.[28] In this regard, the dominant role of clinical instructors should be taken into account.[29],[30] Educational planners have to provide the basis for the optimal utilization of the available resources, eventually leading students to gain the necessary knowledge and skills for their future profession.[31]

To date, little attention has been paid to the relationship between nursing instructors' teaching behaviors and clinical learning.[32] Any changes made to clinical education should be made in accordance with the characteristics of the country in which it takes place.[33] Identifying effective factors in students' clinical teaching and taking measures for the elimination of obstacles and for its modification or empowerment will undoubtedly result in the achievement of educational goals that lead to skillful individuals and the provision of high quality care.[34] Students have direct contact with this process and receiving accurate teaching has a considerable impact on resource efficiency. Students are stakeholders in the important process of teaching evaluations.[35] The present study, conducted in 2016, aims to determine the relationship between nursing instructors' clinical teaching behaviors and students' learning in Tabriz University of Medical Sciences.

  Methods Top


The research participants, selected through convenience sampling, included 267 nursing students in their 2nd–4th year of study. The study sample size was estimated based on a pilot study.[36] The inclusion criteria were a willingness to participate in the study, being a nursing student in the 2nd–4th year of study, being a student at Tabriz University of Medical Sciences and not being a guest or transfer student.


Participants' sociodemographic information was collected using seven closed-ended questions (age, gender, marital status, economic status of family, ethnicity, and formal and informal work experience in nursing). Due to the impact of sociodemographic status on people's attitudes, the report of the sociodemographic characteristics of the participants in this study can help to provide a clear description of the conditions of the participants under study, as well as a more accurate evaluation and analysis of the results of the study. The instructors' teaching was measured using the Nursing Clinical Teacher Effectiveness Inventory (NCTEI), developed by Knox and Morgan.[37] This questionnaire consisted of 47 components divided into five dimensions, namely, teaching ability, nursing efficiency, personal characteristics, interpersonal relationships, and evaluation. Each component was assessed according to two criteria: the extent to which clinical instructors used teaching behaviors and the effectiveness of these behaviors on students' learning.[37] In fact, the first part of the NCTEI questionnaire (assessing the frequencies of use of teaching behavior) used a modified version of Knox and Morgan's (1985) NCTEI questionnaire,[36],[37] while the second part (assessing how the frequency of the use of the clinical teaching behavior helped the students to learn) was a researcher-designed questionnaire.[36] It should be noted that the modification of the first part and the development of the second part were carried out by Kube.[36]

In the first part of the NCTEI, the participants were required to assess the instructors' utilization of clinical teaching behaviors using a seven-point Likert scale ranging from one (never) to seven (always). In order to determine the students' perception of the extent to which the clinical teaching behaviors facilitated their learning, they were required to respond to the items in the second part of the questionnaire using a five-point Likert scale ranging from one (not at all) to five (to a great extent). Overall, the items were classified into five teaching behaviors as follows: teaching ability (17 items), nursing efficiency (nine items), personal characteristics (seven items), interpersonal relationships (six items), and evaluation (eight items). The score for each category was computed by the sum of its items scores.[37]

The authors revealed the reliability and validity of the instrument.[36],[37] This questionnaire had not previously been used in Iran. The questionnaire was translated into Persian by the researcher and translated back into English by an individual with a Master of Science degree in the English language. The validity of the questionnaire was evaluated and modified by 10 faculty members and PhD candidates from the School of Nursing and Midwifery, Tabriz, Iran. Cronbach's alpha was calculated for the two scales: the reliability coefficient was 0.98 for the teaching behaviors scale and 0.97 for the perceived effectiveness scale. The reliability coefficients of different dimensions ranged from 0.82 ( evaluation) to 0.95 (teaching ability).

After gaining approval from the University's Research Council and Ethics Committee (IR.TBZMED.REC.1393.214), nursing students in their 2nd–4th year of study at Tabriz University of Medical Sciences were recruited for the study. The participants received explanations about the study and were assured of the confidentiality of their information and the voluntary nature of the study. After giving verbal and written consent, the students were asked to complete the study questionnaires. Data collection was carried out in October 2016.


The data were analyzed using SPSS 19, IBM Corp, Armonk, NY, United States of America.[38] To evaluate the teaching behaviors and the effectiveness of these behaviors on nursing students' clinical learning, descriptive statistics were calculated, i.e., the percentage responding, the number responding, the mean and the standard deviation (SD). Pearson's correlation coefficients were calculated to determine the relationships between the extent of teaching behaviors used and the nursing students' learning. Normality tests (Kolmogorov–Smirnov, Shapiro–Wilk) revealed a non-normal distribution of the data. A Mann–Whitney test was used to assess the relationship between some binary demographic variables (gender, marital status, and formal and informal work experience in nursing), the extent of the utilization of teaching behaviors by instructors and the effectiveness of these behaviors in nursing students' clinical learning. The relationship of other multi-level variables (economic status of family, ethnicity) with two parts of this questionnaire was assessed using the Kruskal–Wallis test. The relationship between the age of the student and the extent of utilization of teaching behaviors by instructors, as well as the effectiveness of these behaviors in nursing students' clinical learning, was also evaluated using the Pearson's correlation coefficient. P < 0.05 was considered to be statistically significant.

  Results Top

The mean age of the study participants was 22.53 ± 0.46 years. In addition, the majority of students were female (168, 62.9%), single (201, 75.3%), and Turkish (204, 77.3%). The students' demographic characteristics are summarized in [Table 1].
Table 1: Descriptive statistics for the demographic variables

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Overall, the correlations indicated a significant positive relationship between the extent to which students reported that instructors used teaching behaviors and their perception of the effectiveness of these behaviors on their learning (r = 0.38, P = 0.001). The extent of the use of teaching behaviors was positively correlated with students' learning in the five dimensions of clinical teaching [Table 2]. In addition, considering the extent of the use of teaching behaviors, interpersonal relationships (mean = 4.31; SD = 1.08) and teaching ability (mean = 4.31; SD = 1.00) had the highest average ratings, while evaluation had the lowest average (mean = 4.12; SD = 1.05).
Table 2: Correlations of frequencies of use of clinical teaching categories with influence of them on learning

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The highest and lowest average ratings of perceived effectiveness were related to teaching ability (mean = 3.44; SD = 0.70) and evaluation (mean = 3.24; SD = 0.73), respectively [Table 2].

With the exception of 15 items in the questionnaire, the results also revealed significant, positive relationships between the extent of use of teaching behaviors and the effectiveness of these behaviors in learning.

Based on the results, the teaching behaviors most reported by the students included “answers carefully” (mean = 4.74; SD = 1.28), “emphasizing what is important” (mean = 4.61; SD = 1,35), and “questions to elicit reasoning” (mean = 4.52; SD = 1.13). The least used teaching behaviors were “recognizing students' strengths and limitations” (mean = 3.91; SD = 1.40), “guiding students to useful nursing literature” (mean = 3.99; SD = 1.23), and “being organized” (mean = 3.99; SD = 1.48).

The behaviors that had the highest impact on students' learning were “showing enthusiasm” (mean = 3.66; SD = 0.95), “grasping what students ask” (mean = 3.62; SD = 0.95), and “providing practice opportunities” (mean = 3.59; SD = 1.01). On the other hand, the behaviors with the lowest impacts on students” learning included “criticizing students in front of others” (mean = 2.94; SD = 1.06), “guiding students to useful nursing literature” (mean = 3.16; SD = 1.03), and “having an open mind devoid of prejudice” (mean = 3.19; SD = 0.98).

Considering the relationship between the sociodemographic variables and the extent and effectiveness of instructors' use of teaching behaviors in clinical learning, the male students (U = 570.5, P = 0.012), the students with high economic status (χ2 = 11.88, df = 2, P = 0.003), and formal working experience (U = 245.5, P = 0.01) provided significantly higher mean scores compared to others. However, no significant relationships were found with respect to other items [Table 3].
Table 3: Comparison of the nursing clinical teacher effectiveness inventory mean scores by various characteristics

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  Discussion Top

This study aimed to assess the relationship between the extent of the nursing instructors use of clinical teaching behaviors and the effectiveness of these behaviors on students' learning at Tabriz University of Medical Sciences. The results indicated significant positive relationships between the extent to which nursing instructors used teaching behaviors and the effectiveness of these behaviors on students' learning. In light of the relationship between the two, university authorities have to find strategies to employ instructors that are efficient in using clinical teaching behaviors, and they should plan to empower their instructors in this field.[36]

In the current study, it was the extent of the use of teaching behaviors, interpersonal relationships and teaching ability that gained the highest average ratings, while evaluation had the lowest average ratings. Although previous research has reported conflicting results regarding evaluation, interpersonal skills and nursing efficiency,[39],[40],[41] perceived teaching ability has always been highly rated by students.[36],[39],[40] Moreover, some studies have shown that communication skills play a pivotal role in students' learning,[42],[43],[44] which is consistent with the findings of the present research. Furthermore, evaluation has a considerable impact on needs assessment and on the identification of students' status. Indeed, this is a prerequisite for effective teaching and a useful instrument for the assessment of students' learning. Therefore, clinical instructors need to become familiar with clinical evaluation methods and to use them to improve students' learning in clinical settings.

With regard to the effectiveness on learning, the highest and lowest average ratings in the current study were related to teaching ability and evaluation, respectively. The differences between these results and those of previous studies may be due to differences in the research design, the educational needs and facilities and the nursing education curricula, particularly the clinical teaching.[36]

In the present study, the students attributed a large proportion of their learning to their instructors' capabilities. Previous studies have reported that students attributed 60% of clinical teaching problems to incorrect evaluation.[45] However, in our study, students believed that behaviors related to the field of evaluation had the lowest impact on their learning. This might be due to the fact that instructors did not use evaluation as an instrument for learning.

The teaching behaviors rated most highly by students included “answers carefully” and “emphasizes what is important.” On the other hand, behaviors with the lowest student ratings were “recognizing students' strengths and limitations” and “guiding students to useful nursing literature.” These results contrast with those of studies conducted between 1987 and 2006 that focused on clinical instructors' most widely used teaching behaviors.[36],[37],[46],[47],[48],[49]

In the current study, the behaviors that had the greatest effects on student learning included “showing enthusiasm” and “grasping what students ask.” On the other hand, the least effective behaviors were “criticizing students in front of others” and “guiding students to useful nursing literature.” In general, the characteristics of an effective instructor included sufficient preparedness, clinical knowledge, and skills, creating motivation in students, building appropriate relationships with students and playing a supportive role.[50],[51] In our studies, some of the behaviors were shown to have low impacts on learning are of great importance in the management of clinical teaching. This might be because they are unfamiliar to students and probably also to clinical instructors. Hence, authorities and policymakers in nursing education have to consider the effective positive and negative factors in clinical teaching and to plan for improvement in the capabilities of clinical instructors.

In the present study, some behaviors were rated as occurring more often and consequently, were perceived as having a considerable effect on learning. However, the behaviors that were seen to be less frequent could also be effective in learning, even though students might be unaware of them. Kube stated that students might report more practical and objective behaviors as being effective in clinical learning and may consider other abstract behaviors or educational approaches to be less effective.[36] Thus, the evaluation of these behaviors should be undertaken by individuals who are more familiar with clinical teaching and with the importance of these behaviors. An alternative approach would be to ensure that learners are aware of the types of behavioral features that should be demonstrated by an efficient clinical instructor. This would then attract the assessors' attention to those behaviors and provide a more realistic perspective of their impact on students' clinical learning.

Considering the relationship between the demographic variables and the main variables of the current study, desirable economic status, and working experience were relevant to students' attitude toward effective behaviors and the performance of their clinical instructors. In addition, male students had more positive attitude toward the extent of the use of teaching behaviors of their clinical instructors.

Research limitations and suggestions

This study has only focused on student reports of the utilization of clinical teaching behaviors and their perceptions of the effectiveness for their clinical learning. However, many variables, such as students, clinical instructors, personal factors, and those related to the clinical environment, can also affect students' learning. Therefore, it is recommended that future studies identify and evaluate these factors.[52] A further limitation of the study was that the clinical instructors at Tabriz School of Nursing and Midwifery included faculty members, preceptors, MSc students and PhD candidates, which restricts the generalizability of the results to other settings with different structures of clinical education. Thus, it is suggested that similar research should be performed in other settings. One other limitation of this study is the possibility that the students may not have been willing to present their real information and to complete the questionnaire accurately due to concerns about the impact that their responses may have had on their instructors' evaluations. However, this was controlled to a great extent by providing the students with sufficient explanation, applying anonymity and excluding unreliable questionnaire responses. In addition, the students may have had the tendency to choose higher scores due to extreme responding, a form of response bias, which was also controlled by providing them with sufficient explanations. Furthermore, due to the fact that participants were selected through convenience sampling, differences may exist among students at various education levels, and some students may have been excluded due to inaccessibility. It is, therefore, suggested that future studies of this issue should use larger sample sizes. A further recommendation is the use of interventional plans that may be used to improve the extent and the effectiveness of instructors' teaching behaviors in students' clinical learning.

  Conclusions Top

The results of the present study indicate that students' ratings of teaching ability had a higher frequency, on average, compared to other dimensions of instructors' clinical behaviors. Indeed, the students' ratings suggest that instructors paid more attention to teaching behaviors that were directly associated with learning practical and professional skills. Instructors may have to be provided with additional support in the application of other behaviors related to evaluation, personal features and professional efficiency because these factors are effective in students' learning of personal and professional skills.

Despite the emphasis on expectations of the clinical instructors and the importance of teaching programs for instructors, no comprehensive programs are available in this regard in Iran. However, the evaluation of effective behaviors in clinical teaching and their effect on learning can provide appropriate feedback with regard to the strengths and weaknesses of clinical instructors' teaching behaviors.

Managers and instructors in schools of nursing and midwifery can use the findings of the present research. Accordingly, through the continuous assessment of clinical teaching behaviors and their impact on learning, clinical instructors can be professionally promoted in accordance with their clinical teaching needs. This, in turn, can improve nursing instructors' effective behaviors and enhance the quality of clinical teaching.


This article was extracted from the research proposal approved by Medical Education Research Center, Tabriz University of Medical Sciences. Hereby, the authors would like to thank the authorities of Tabriz University of Medical Sciences and School of Nursing and Midwifery, the participants, and all individuals who helped in performing the research.

Financial support and sponsorship

This study was supported by Medical Education Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]

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Mostafa Ghasempour,Reza Shabanloei,Azad Rahmani,Mohammad Asghari Jafarabadi,Fariba Abri,Mohammad Khajehgoodari
Journal of Cancer Education. 2019;
[Pubmed] | [DOI]


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