Experience of Nurses with Educator Role in Selected Hospitals of Indonesia: Phenomenological Study

Introduction

The role of nurses in addition to being providers of nursing care also plays an important role in supporting the quality of service in hospitals through their roles as managers, researchers and educators. The importance of nurses as providers of care to achieve more optimal patient health, nurses can provide education to clients to learn self-care skills.¹ The role of the nurse as a manager is responsible for managing nursing services and care.² Nurse researchers bring essential skills and knowledge to the development of research in clinical settings.^3,4 Nurses also have a role as educators to improve the knowledge of nurses and students.⁵ This shows that health service activities cannot be separated from the role of nurses in hospitals.

Nurse educators are nurses who work in hospitals and play a role educator for nurses and students to maintain and improve their competence. The role of nurse educators remains a topic of significant discussion. There exists a disparity in the terminology used to describe nurse educators across different regions. In Singapore, they are known as clinical liaisons, clinical preceptors, clinical instructors, and clinical supervisors.⁶ Meanwhile, in Australia, the role is primarily defined as educating nurses and nursing students.⁷ This variation in terminology extends to Indonesia as well, with terms such as preceptor, CI (Clinical Instructor), mentor and preceptor being used interchangeably.^8,9

Nurse educators are pivotal in supporting both nurses and students within the healthcare sector. They play a key role in enhancing the knowledge and skills of these individuals, enabling them to achieve competent and proficient levels.¹⁰ Furthermore, nurse educators are instrumental in ensuring nursing staff maintain their competencies to deliver high-quality care.^5,11 For students, they facilitate an understanding of the intellectual culture within nursing.^5,12 The suboptimal competence of nurse educators has an impact on the job satisfaction of nurse educators. Nurse educators feel dissatisfied because they receive inadequate salaries and do not get teaching career development.¹³ It is imperative for nurse educators to possess the appropriate competencies.

However, nurses involved as educators still feel unprepared in carrying out their role. Many nurses complain about the conditions of education implementation in hospital services. Nurse educators do not have sufficient provisions to teach, determine appropriate and easy-to-deliver information. Nurse educators feel unprepared to act as teachers and do not have much time for nursing staff development.^11,14 Nurses feel that their additional roles and competencies as educators are less considered.¹⁵ This condition makes the role of nurses as educators not run optimally.

In nursing there are vocational education, bachelor of nursing and master of specialist nursing, and also differences in clinical nurse competencies from one to five. Differences in student levels can be a consideration for assessing the importance of competency levels between nurse educators. Nurses who have been given the opportunity to become educators in the hospital have not been optimally utilized, because there is no proper system for utilizing nurses as educators.

In Indonesia, the role of nurse educators has not been thoroughly examined. A significant issue is the lack of specific policies related to nurse educators; although Ministerial Regulation No. 40 of 2017 outlines a career path for nurse educators, it serves more as a framework than a concrete policy. In addition, there is no appropriate system for utilizing nurse educators. The impact is that nurses experience role confusion when nurses are assigned to educate nurses and students. Therefore, The purpose of this study was to obtain a comprehensive understanding of the experiences of nurse educators in implementing clinical educator competencies in the hospital setting.

Materials and Methods

Design

This study uses a qualitative method of phenomenological study approach. This research has been verified using the COREQ Checklist. The researchers actively engaged in exploring, analyzing, and articulating the phenomena under investigation, offering insightful interpretations. This research was conducted in two hospitals, the University of Indonesia Hospital (RSUI) and the Central Persahabatan General Hospital (RSUPP). The study was carried out in two hospitals selected for their ability to provide participants who met the inclusion criteria, specifically tailored to the phenomenon under investigation.¹⁶ RSUI was selected as a State Higher Education Hospital, with type B in Depok City. RSUI’s vision supports research, namely “To become a world-class teaching hospital by 2030”. RSUPP was chosen as a State Teaching Hospital, with type A in the city of Jakarta. RSUPP’s mission to support research is “Implementing Education, Research, and Training in the Field of Medicine and Health”.

Setting Participant

There were sixteen participants and they were identified through maximum variation sampling from two hospitals, considering factors such as age, education, experience, and career level. Participants were selected using purposive sampling. The criteria for participant selection included: The criteria for participant selection included: 1) Nurses as clinical staff working in a hospital, nurses with at least 3 years of experience in roles such as preceptor, clinical instructor, clinical supervisor, mentor, or clinical educator lecturer; 2) possession of a minimum of a bachelor’s degree in nursing; 3) demonstrated ability to articulate their experiences effectively?. Nurse educators from various departments within the hospitals, including the Emergency Department, Operating Room, Intensive Care Unit, and Inpatient Wards (encompassing VVIP, VIP, first-class, second-class, and third-class wards), were considered.

Data Collection

Data were collected using qualitative method of phenomenological study approach via Focus Group Discussions (FGDs), a method recognized for its effectiveness in exploring the cognitive dimensions of specific topics collaboratively.¹⁷ FGD was conducted in two different hospitals, namely RSUI and RSUPP. FGD RSUPP was conducted on February 13, 2024, and FGD RSUI was conducted on February 26, 2024. The FGDs were conducted twice from two different hospitals. The two FGDs reached data saturation. Data gathering for the FGDs was structured around a set of predetermined questions. The discussion is guided by the principal researcher as the research instrument. During this phase, the researchers practiced bracketing by setting aside any preconceptions, biases, and prior knowledge concerning the role of nurse educators.¹⁸ Some questions for participants are as follows: 1) describe your experience as a nurse educator?, 2) how do you organize yourself as a clinical educator?, 3) what do you feel when carrying out your role as a nurse educator?. Researchers used audio and video recording devices. Stages of FGD implementation include: 1) Preparation Stage: Preparing logistics: voice recorder, field note sheets, attendance sheets, consent sheets and research explanations. 2) Implementation Stage: Participants were briefed extensively about the study’s key elements, including the purpose, benefits, duration, and the use of recording devices, before the data collection began.Implementation of the FGD contract lasts around 90–120 minutes. Interviews are conducted using two-way and active communication. 3) Termination Stage: The researcher carries out final termination for all participants after all data obtained is in accordance with participant validation. This preparatory measure aimed to bolster the credibility of the findings, enhance participant engagement, and highlight the nursing perspective.

Ethical Considerations

This research was conducted with a keen awareness of ethical considerations, prioritizing the rights and welfare of participants. This included respecting their dignity and status, ensuring their well-being, and guaranteeing fairness for all involved.^16,18

Participants were formally briefed about the research objectives and interview processes via an official invitation letter. This communication underscored their right to withdraw from the study at any point before the dissemination of findings. Participants have completed a consent form stating that they agree to participate in the study and are willing if the results of the study can be published with a guarantee of confidentiality. This study ensures that research data will be stored and kept confidential, and not disseminated, so researchers pay special attention to anonymous data and direct quotes related to published data. The significance of maintaining confidentiality within the Focus Group Discussions (FGD) was reinforced, as initially outlined in the invitation letter. Ethical clearance and manuscripts to be published have received approval from the ethics committee Faculty of Nursing, Universitas Indonesia (KET-045/UN2.F12.D1.2.1/PPM.00.02/2024).

Data Analysis

The data analysis process uses systematic thematic analysis. The researchers had undergone qualitative research training and had been tested on qualitative research skills before data collection was conducted. The stages in data analysis include: 1) making interview data transcripts. 2) Open Coding, which is the identification process by sorting data and organizing the resulting data by labeling/coding, The coding process facilitated concept formation, with constant comparison of data.¹⁹ In this study, 240 data codes were obtained. Each code was validated by discussion with the research team 3) Axial Coding, which describes the dimensions of categories and explores interrelated categories, in this research obtained 42 categories. 4) Selective Coding, which is the researcher validates the relationship between categories so that the study can produce the main category, this study found 18 sub-themes and 5 themes. Data analysis using Microsoft Excel software. The research adhered to the principles of data validity, specifically credibility, dependability, confirmability, and transferability. The culmination of this analysis was the construction of a final theme, depicted through thematic figures, and grounded in a thorough description of the analytical process.

Results

Characteristics of Respondents

This study’s participants were nurse educators boasting a minimum of three years of clinical teaching experience. The gender distribution included twelve females and four males, with ages spanning from 28 to 47 years. Educational backgrounds varied, encompassing Bachelor of Nursing degrees and Master/Specialist in Nursing qualifications. Participants hailed from diverse clinical settings, including the Emergency Department (ED), Operating Room, NICU/PICU, Intensive Care Unit (ICU), Inpatient Care, and VIP to level one, two, and three wards. Their tenure as educators ranged between 3 to 10 years. Career-wise, one participant was at the Clinical Nurse (CN) level 4, while the remaining fifteen were at CN level 3. A detailed breakdown of participant characteristics is provided in Table 1.

Tabel 1 Characteristics of Respondents

Thematic Findings

The analysis revealed five overarching themes, visually encapsulated in thematic tree diagrams. This Thematic Tree Diagram (Figure 1) explains the themes and subthemes of the research results. Through thematic analysis, five themes were distilled, reflecting the meanings, perceptions, and experiences nurse educators associate with practicing their competencies. Five themes identified in this study consisted of: 1) Requirements for Becoming a Nurse Educator, 2) Specific Competencies for Nurse Educators, 3) The ambiguity of Nurse Educator Programs, 4) Perceptions of Nurse Educators on Professionalism and Managerial Support, 5) Expectations for Career Path Clarity for Nurse Educators.

Figure 1 Thematic Tree Diagram.

Requirements for Becoming a Nurse Educator

Theme one theme consists of three subthemes and seven categories. First subtheme is education and experience of nurse educators must be higher than students. The categories consist of two, namely higher education and experience, expressed by participants “...at least a Bachelor of Nursing...”. The second subtheme is the importance of looking at clinical career levels, and having a specialization in a particular field. The category consists of having a specialization and a particular career level, expressed by participants’ “...at least Clinical Nurse (CN) level 2...”, another participant said “...have certification competency...”. Third subtheme is nurse educators must be responsible for carrying out the demands of the hospital as educators. There are three categories, namely demands from the hospital, persistence and efforts of nurses in carrying out demands as educators. “...continue to improve the quality of themselves so as not to disappoint...”.

Specific Competencies for Nurse Educators

This theme consists of six subthemes and seventeen categories. First subtheme is educational capabilities are adjusted to the competency level of students and specific units. This subtheme consists of three categories, namely educational skills, differences in student levels, and differences in units in clinical learning. Participants stated “…of course it varies at each level of education that students are currently undergoing…” another participant said “...emergency installations are more complex in science…”. Second subtheme is ability to conduct research, consisting of one category, namely scientific ability “...then it would be better if we guide students to get involved in research so they can write articles...”. The third subtheme is knowledge of complex cases and specific nursing sciences. There are two categories, namely knowledge of complex cases and depth of knowledge. Participants stated “…about anatomy, physiology and everything until finally students can perform post-cardiac care...”. The fourth subtheme is supporting skills in the era of information technology development, consists of five categories, namely communication skills, critical thinking skills, foreign language skills, time management and use of technology. Data is reinforced by participant statements “...need to take advantage of technology when starting education…”, another participant said “...we have to be smart in managing our time...”. The fifth subtheme is skills in determining teaching strategies in implementing nursing care. There are two categories, namely teaching strategies and implementation of nursing care, the data is strengthened by the participant’s statement “...knowing the needs of students, when to be accompanied and when to be independent, especially in carrying out nursing care...”. The sixth subtheme is attitude as a role model and provider of positive feedback to students. There are four categories, namely discipline, as a role model, giving positive feedback and being able to determine a mentoring strategy. The participant’s statement “...we are their reflection, don’t show your shortcomings in front of them…”.

The Ambiguity of Nurse Educator Programs

This theme consists of two subthemes and three categories. The first subtheme is There is no common understanding of who nurse educators are and no clarity about the ratio between nurse educators and students. The first subtheme consists of two categories, namely different understandings of nurse educators, the lack of clarity about the ratio. Participants stated. “...nurse educators are commonly referred to as clinical instructors, or preceptors or mentors”. Another participant said “…the ratio of teaching nurses to students varies, there is no certainty…”. The second theme is there is no clear documentation regarding the performance of teaching nurses “…documentation can use logbooks, performance indicators, separate tools, there is no clarity in the documentation…”.

Perceptions of Nurse Educators on Professionalism and Managerial Support

The fourth theme consists of three subthemes and six categories. The first subtheme is nurse educators are considered less professional in educating. Consisting of two categories, namely less professional and less confident as educators, participants stated “…nurse educators are less valued than nurse managers or clinical nurses…”. The second subtheme is lack of support from management for nurse educators, consisting of 2 categories, namely lack of support for self-development and lack of rewards as an educator, participants stated “…being a nurse educator requires a lot of sincerity, I teach a lot but it is not appreciated…”. The third subtheme is nurse educators play dual roles as clinical nurses and nurse managers. Consisting of two categories, namely time constraints and the role as a manager makes clinical education less than optimal “...I can’t manage my time with nurses and students, because I have many roles, I have to focus on patients and I am also the head of the room…”.

Expectations for Career Path Clarity for Nurse Educators

The fifth theme consists of four subthemes and nine categories. The first subtheme is expectations for career path clarity among nurse educators, consisting of two categories, namely the hope for clarity of rewards and career levels. “…we hope that there will be clarity regarding salaries that are adjusted to career level or competency level…”. The second subtheme is Hope for guidelines for nurse educators. Consists of two categories, namely the hope for guidelines and coordinators for nurse educators “…currently there are no clear guidelines, so we are confused in carrying out our role as nurse educators…” The third subtheme is conduct comparative studies with other hospitals to determine the development of nurse educators. Consists of three categories, namely, it is better for managers to conduct comparative studies, see other professions, namely doctors, and see the development of nurse educators. “…hospital leaders should conduct comparative studies with other hospitals…” The fourth sub theme is hope to get recognition from the Ministry of Education and Culture, as well as the Ministry of Health. Consists of two categories, namely the hope of recognition and involvement in the university “…we hope that our role can be appreciated as befits lecturers in universities regulated by the Ministry of Education and Culture…”.

Discussion

Requirements for Becoming a Nurse Educator

One of the requirements to become a nurse educator is to have higher education and experience than students. This is in line with research in Australia, nurse educators are nurses who educate nurses and do not need to undergo a credentialing process, only need to have a higher degree to educate nurses at a lower level.²⁰ Nurse educators act as coordinators in teaching and as advisors to students, helping to maintain consistency of knowledge, so that they have more knowledge than students.²¹ Other studies state that In Ethiopia, nurse educators are called nurse educators who educate students, have a high level of education.²² To become a nurse educator, you need to consider education and experience so that the competencies provided are appropriate. Higher education of educators than students can improve student competency and improve teaching efficacy.

The importance of looking at the clinical career level, and having a specialization is also an important consideration. This is in line with government regulations that to become a nurse educator must have at least a level 3 clinical nurse or level 2 nurse manager.²³ Research states that preceptors are nurses who have more clinical experience, so they have a formal one-on-one relationship with nurses.²⁴ Choosing a nurse educator can take into account the clinical career level or the nursing manager career level. Nurse educators must be responsible for carrying out the demands of the hospital as educators. This is in line with research that Teaching efficacy is one of the parts that is considered to be able to form the competence of nurses as good educators. Teaching efficacy is very important to achieve effective learning goals.²⁵ Other studies state that Nurses with good teaching efficacy are more open to new ideas, create conducive classes, and are more persistent in teaching.²⁶ Becoming a nurse educator is a hospital demand and can be carried out with full responsibility and teaching efficacy. Career ladder is an external motivation for nurses, nursing managers should pay attention to the career ladder of nurse educators in order to improve the competence of nurse educators.

Specific Competencies for Nurse Educators

The second theme articulates the specific competencies required of nurse educators. These professionals are expected to possess specialized knowledge, skills, and attitudes in determining coaching strategies. One aspect of competency is the nurse educator’s knowledge, which includes a requirement to be well-versed in research. Nurse educators play a crucial role by applying essential knowledge to integrate evidence-based practice.²⁷ They are also required to have a broad understanding of complex cases in nursing education materials. Research supports the necessity for nurse educators to have comprehensive knowledge with a holistic approach to nursing care.²⁸ Furthermore, nurse educators are expected to have supporting skills such as public speaking, critical thinking, foreign languages, time management, and the use of the latest technological advancements. Clinical educators utilize professional communication skills to transfer knowledge.²⁹ Effective communication can help nurse educators achieve clinical learning goals. Critical thinking ability is especially vital for nurse educators in coaching.³⁰ Critical thinking needs to be continuously optimized by reading a lot, studying and keeping up with the times. Effective time management is essential for balancing patient care and mentoring responsibilities.³¹ Nurse educators should create a clinical learning schedule so that it does not overlap with their role as clinical nurses. The advancement of technology demands that nurse educators are adept at leveraging the latest technological tools.³² Currently, educators must follow technological developments in supporting clinical learning, clinical learning can be carried out online, using media and technology that facilitate learning. Nurse educators must also understand the use of either a pedagogical or andragogical strategic approach. Andragogy, suitable for adult students such as working nurses, fosters competence by applying skills in real-world conditions. Research indicates that andragogical students show a greater interest in the immediate implementation of acquired knowledge, hence preferring a problem-centered approach. In contrast, pedagogy enlightens students about the necessary knowledge and skills. This aligns with research stating that clinical educators need to coach according to the students’ conditions, whether pedagogical or andragogical.^33,34 The importance of skills in determining teaching strategies in implementing nursing care that is tailored to the needs of students. As a nurse educator, the attitude of being a role model and providing positive feedback to students needs to be considered.

The Ambiguity of Nurse Educator Programs

The third theme highlights the ambiguity in the nurse educator program. Nurse educators report a lack of clarity in mentoring nurses, including a lack of uniformity, understanding, and ratio, as well as documentation ambiguity. The terminology used for mentoring nurses varies, leading to differences in competencies. In Indonesia, nurse educators are referred to as preceptors, CIs, or mentors.^8,9 Ambiguity in terminology can lead to role confusion. A preceptor program is an orientation program aimed at increasing student motivation and bridging competency gaps.³⁵ A mentor supports learning through a professional relationship between experienced nurses and those with less experience.³⁶ In Singapore, student mentorship is managed by a clinical liaison, who acts as a bridge between students and clinical staff.³⁷ Nurse educators feel that the workload is mismatched when undertaking additional roles as educators.³⁸ Managers need to pay attention to the nurse educator’s workload and adjust to the workload analysis. Clinical mentorship ratios can be 1:1, while facility mentorship models have ratios ranging from 1:6 to 1:8.³⁹ Ratios are a concern for hospitals in managing the implementation of clinical education. Research states that the implementation of nursing mentoring has not been documented.²¹ Other studies state that good mentoring in clinical learning must be documented.⁴⁰ The implementation of the education program is important to pay attention to the clarity of roles, ratios and documentation.

Perceptions of Nurse Educators on Professionalism and Managerial Support

Theme four examines nurse educators’ perceptions of professionalism and managerial support in relation to inadequate rewards, insufficient self-development support, and the dual role of nurse educators, which results in suboptimal mentoring time. Generally, managerial support for nurse educators appears deficient.¹¹ The role of nurse educators has not been fully recognized by management, and the facilities provided for nurse educators fall short of fully supporting their roles.^14,41 As a result, nurse educators are unable to perform optimally in their educational duties. Clinical nurse educators experience role ambiguity when teaching students,⁴² which complicates their ability to educate effectively and impacts their competency. The clarity of the rewards for the additional clinical duties undertaken by nurse educators is lacking, particularly in Indonesia. Furthermore, nurse educators are deprived of self-development opportunities, such as relevant training,³⁸ making them feel undervalued in their educational role. This leads to a lack of preparedness to teach and insufficient mentoring time.^14,41 Management support and rewards are significant factors that impact nurse educator competence.

Expectations for Career Path Clarity for Nurse Educators

Theme five highlights the expectation for clear career progression paths for nurse educators, as they continually seek to enhance their own skills. There is a desire among nurses for the Ministry of Education and Culture to recognize and clarify the career paths of nurse educators. The drive and aspirations of nurse educators are deemed essential. Such motivation can significantly boost the teaching efficacy of nurse educators, which in turn supports their competency.^30,41 Nurse educators with high teaching efficacy are more receptive to new ideas, capable of creating a conducive learning environment, and demonstrate greater perseverance in their teaching roles. Nurse educators strive to improve their self-quality as a personal reward, aiming to nurture a positive educational atmosphere.^43,44 Active and professional mentorship is expected of nurse educators, who also seek clear recognition and understanding from the Ministry of Education and Culture.⁴⁵

Conclusion

This study offers detailed insights into the experience of competencies by nurse educators in hospital settings. This study identified Five key themes, consists of requirements for becoming a nurse educator, specific competencies for nurse educators, ambiguity of nurse educator programs, nurse educators’ perceptions of professionalism and managerial support. Additionally, this research underlines nurse educators’ desire for clear career progression. These findings contribute to the advancement of clinical education, aligning it with contemporary needs, thereby enhancing the quality of nursing care and fostering the development of a professional nursing workforce.