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   Table of Contents      
Year : 2020  |  Volume : 25  |  Issue : 1  |  Page : 76-83

The role of students with practical nursing diplomas in the process of undergraduate nursing education: A qualitative study

1 Department of Nursing, Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
2 School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
3 School of Nursing, Lorestan University of Medical Sciences, Khorramabad, Iran

Date of Submission10-Feb-2019
Date of Decision28-Aug-2019
Date of Acceptance14-Nov-2019
Date of Web Publication27-Dec-2019

Correspondence Address:
Shirin Hasanvand
Lorestan University of Medical Sciences, Anooshirvan Rezaei Square, Khorramabad
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnmr.IJNMR_38_19

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Background: Awareness of the experiences of students and educators in the educational process plays an important role in facilitating and improving this process. This study aimed to explain and investigate the experiences of nursing educators and students about the presence of students with practical nursing diplomas in the process of undergraduate education. Materials and Methods: In this qualitative study conducted from 2016 to 2018, which adopted a content analysis approach, 24 nursing students and educators of Lorestan University of Medical Sciences were selected using the purposive sampling method and were interviewed in depth. The data were manually recorded and analyzed using the Graneheim and Lundman method. Results: The three main themes of “from contrast to alignment with professional competence,” “peaceful coexistence in the educational process,” and “reflection of the perceived reality of the clinical environment,” along with six categories and 30 subcategories were extracted from the interviews. Conclusions: It seems that monitoring and managing undergraduate courses more thoroughly, as well as raising the awareness of educators about the positive and negative dimensions of the presence of nursing students with practical nursing diplomas in undergraduate nursing courses can make it possible to optimize and improve students' learning process.

Keywords: Education, Iran, nursing, qualitative research, students

How to cite this article:
Hosseinabadi R, Hasanvand S, Almasian M, Mirzayee-Sharifi S. The role of students with practical nursing diplomas in the process of undergraduate nursing education: A qualitative study. Iranian J Nursing Midwifery Res 2020;25:76-83

How to cite this URL:
Hosseinabadi R, Hasanvand S, Almasian M, Mirzayee-Sharifi S. The role of students with practical nursing diplomas in the process of undergraduate nursing education: A qualitative study. Iranian J Nursing Midwifery Res [serial online] 2020 [cited 2023 Apr 2];25:76-83. Available from: https://www.ijnmrjournal.net/text.asp?2020/25/1/76/274130

  Introduction Top

The development of the nursing profession requires paying attention to the quantity and quality of education and its challenges.[1] In this regard, awareness of the views of students and educators regarding factors related to theoretical and clinical nursing education is critical and can facilitate learning as the most important goal of education.[2] Students, as the clients of the educational process, interact with this process directly. Along with students, educators are also considered as the best source for judging and identifying the dimensions and challenges of nursing education due to their full experience in nursing education.[3],[4] Many factors in undergraduate education can affect the learning experiences of students. One of these factors is the interactions of learners with each other, which has been mentioned as a factor affecting student learning.[5] Learners share and reconsider their experiences during their studies. Such a process leads to a type of learning, which is referred to as vicarious learning.[6] Thus, students inevitably and informally learn from each other.[6],[7] Therefore, identifying the experiences of learners regarding the presence of each other is essential. During the 4 years of studying for a bachelor's degree in nursing, students constantly interact with each other, thereby learning and experiencing care behaviors from each other and developing their skills.[8]

Some of these students have Practical Nursing Diplomas (PNDs) and have undergone formal education in high school based on professional and ethical frameworks and are able to take care of clients under the supervision of nurses and on the basis of job descriptions.[9] Nursing students with PNDs often gain experience in providing many nursing services during high school and at work.[10] Given the informal learning that occurs through interaction among learners or peer learning, studying the effect of interactions between these two groups (i.e., students with PNDs and those without them) during undergraduate education can be of interest.[8],[11]

According to a study by Essa et al. (2018), the peer learning strategy is an effective approach that better improves and enhances knowledge, performance, personal and professional development, technical skill acquisition, and the cognitive skills of nursing students in comparison with traditional learning approaches.[12] Many of the advantages of peer learning originate from the informal relationships among students. Moreover, such an informal nonhierarchical environment reduces learners' performance anxiety. However, despite the clear benefits, peer learning involves challenges, too.

Given the challenges and opportunities of peer learning, years of experience, the present researchers have had as educators pointed to the different viewpoints of nursing students toward their peers with PNDs, and the contradictory feedback of educators on the knowledge and performance of practical nurses, investigating the experiences of students is of importance. So far, this issue has received little attention in the Iranian educational system and the researchers were not able to find any previous research on this matter. Therefore, this study aimed to explore the experiences of educators and students about the presence of learners with PNDs during the course of undergraduate nursing education in Iran.

  Materials and Methods Top

This content analysis qualitative study was conducted in one of the nursing schools of the Lorestan University of Medical Sciences during 2016–2018. Qualitative methods are used to identify and understand human conditions in different settings.[14] Due to lack of adequate research literature on the concerned phenomenon, the conventional method was used. The purposive sampling method was used to select participants among nursing students at different educational levels, educators, and faculty members involved in education. Criteria for selecting the subjects were as follows: students who had had the experience of interacting with practical nurses in classrooms or clinical settings, or educators who had been involved in clinical or theoretical training for at least four semesters.

Data saturation was achieved after interviewing 15 nursing students and nine nursing educators. Data were collected using semi-structured in-depth individual interviews, lasting 30–50 min. With the agreement of the participants, interviews were conducted in the nursing school or in the educational departments of one of the educational and treatment centers in Khorramabad, Iran. Interviews began with the question: “What experiences have you had with practical nurses in your classes or clinical environment?” The data were recorded on a digital audio recorder. Analysis was based on the conceptual framework proposed by Graneheim and Lundman (2004).[15] The audio file of each interview was transcribed and the transcription was studied line by line and was reread several times to understand the general sense and gist of the text. Words, sentences, or paragraphs were considered as units of meaning. Codes were used to name units of meaning. Then, similar initial codes were grouped together to form the subcategories. Next, by comparing, similar subcategories were merged to extract categories and themes.

In order to increase the credibility of the findings, prolonged engagement of the researcher and member check were used.[13] The first two authors had long been involved with the subject and its dimensions. However, during research, plenty of time was spent to review and analyze the data. In addition, the findings were made available to the participants for confirmation. The dependability of the findings was validated by the similar results obtained by the two researchers involved in the study. To improve the comprehensibility and transferability, rich descriptions of the findings were offered.[14]

Ethical considerations

Prior to data collection, the participants received an explanation about the project, the use of voice recorders, and how the recorded conversations were to be used. Approval was obtained from the Lorestan University of Medical Sciences.

  Results Top

Participants included 15 nursing students from different semesters including nine female students and six male students with a mean (SD) age of 21.60 (3.10) years. Nine educators including six female educators with a mean (SD) age of 36 (4.60) participated too [Table 1]. Out of all the interviews, 422 initial codes, the three main themes of “from contrast to alignment with professional competence,” “peaceful coexistence in the educational process,” and “reflection of the perceived reality of the clinical environment,” six categories and 21 sub-categories were extracted [Table 2]. The findings are described in more detail below.
Table 1: Demographic characteristics of participants

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Table 2: Thems, categories, sub-categories, and meaning unites extracted from the analysis interviews

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From contrast to alignment with professional competence

: This theme includes the categories of “role models” and “agents of incivility behaviors.”

Role models

The participants' statements indicated that some students with PNDs acted as role models in providing basic nursing care, professional communication, and the ability to interact well with educators, peers, and clients. “They showed respect to the educators, the patients, and behaved well towards the patients and us. We expect the same from other students” (Educator8).

A boy who was 13 or 14 years old was in the emergency department. He had fallen off a motorcycle. He was rude and spoke improperly. We did not know how to behave toward this boy, so that he would not talk like this in such an environment. However, the way the nursing student with PND behaved toward him stopped him from using improper language,” said another participant about modeling the behaviors of a nursing student with PND.

Agents of incivility behaviors

All participants emphasized the incidence of anomalous behaviors by practical nurses such as tardiness or absenteeism in the clinical setting, non-compliance with educational regulations, leaving the hospital without taking leave of absence, sleeping in class, cheating on exams, insulting peers and educators, domineering behaviors such as lack of cooperation with the group, making decisions for others, and presenting peers with fait accompli, “i.e., they may wear uniforms, but do not wear matching pants and shoes, they may not wear name tags, do not care about their classes or, for example, some of them do not regularly attend classes” (Educator4).

Some students said that students with PNDs ridiculed educators in classes. Other uncivil behaviors that both groups pointed out included displays of disobedience that offended the educators, and which were due to false self-confidence and feelings of scientific and practical independence and self-sufficiency, and in some cases the difference between the ages of the educator and the practical nurse. One of the educators said: “This is because they are self-confident; anyhow, they feel that they are heads and shoulders above the rest. And if the educator is young like me, they feel they know even more than the educator” (Educator 1).

Peaceful coexistence in the educational process:

“unequal educational atmosphere” and “facilitating the learning–teaching process” are the classes of this theme.

Unequal educational atmosphere

The experiences of the learners indicated that the presence of students with PNDs in the educational process limits learning opportunities in some cases. Disruptions in the learning atmosphere, the creation of distractions, depriving students of the experience of performing procedures, etc., were among examples of depriving students of learning opportunities. Discrimination among students is one of the impressions that students had about the presence of students with PNDs. Unfair evaluation, unequal attention, and respect received in different settings, etc., were among the indicators of discrimination. “Because practical nurses are older, the instructors usually give them higher grades. If they fail at a course and ask the instructor just once, the instructor gives them a passing grade” (Student 5).

Some students were unhappy with the absenteeism and the unequal attendance of the practical nurses, despite their need to learn, and also with the way instructors cooperated with the practical nurses. What the students said, especially in clinical settings, indicated that practical nurses were negligent and indifferent to assignments and did not participate in activities, and both groups indicated that the educators were not blameless in this regard, either. What the students said about this issue was interesting; “Some of them just thought of ways to dodge the presentations they had to make … they never made presentations” (Student 7).

Other behaviors that contributed to the creation of a sense of inequality in favor of students with PNDs included establishing informal relationships with educators and the personnel. “In the emergency ward, they were absent from time to time without just cause, and. a staff member said that he/she would confirm that the student had been present “ (Student1).

Frequent absenteeism, infrequent attendance in classes, and the fact that the educators tolerated such behaviors indicated the violation of educational regulations that had become somehow the customary practice about practical nurses with the willing or unwilling consent of the educators.

The experiences of both groups indicate that practical nurses have the potential to act as assistants to educators and can mentor their peers and share their experiences with them. Along with the support they offered their peers, they were willingly or unwillingly able to create a sense of inequality and alter the educational atmosphere to their own advantage. Furthermore, in order to make the educators or nurses disregard the violation of educational regulations by them or to get better grades, practical nurses started informal friendships with them or put them under pressure.

Facilitating the teaching–learning process

Based on the experiences of the participants, the students' process of learning with and from each other occurs in a hidden and intangible way, and students make their experiences available to their peers. “The practical nurse with whom I was in the same group taught me some things about medical-surgical training that my own teacher didn't teach me.” (Student 11).

Another positive impact of the presence of practical nurses in undergraduate studies and especially in the early semesters was to create a secure learning environment by supporting their peers. The peers also experienced a feeling of comfort when they were accompanied by practical nurses. “In the emergency class that we had, we wanted to ask some questions, but we were too inhibited to ask them from the instructor, so we asked the practical nurses, and they answered us very well “ (Student 14).

The educators also confirmed this. “He (a practical nurse) had positive behaviors such as respecting, cooperating, and supporting his peers so that they said they wanted to be with him. They are supportive” (Educator3).

In addition to creating a safe learning environment, they played a role in reducing the stress levels of the other students. “Honestly, we are more comfortable with practical nurses” (Student 7).

Students, especially students who are about to graduate, have a lot of questions on their minds about working conditions that may be a source of concern to them. By providing the needed job information, students with PNDs expanded their peers' awareness regarding nursing jobs and professional hardships, and played an important role in teaching retention skills and preparedness for work. “They give students information about how to find a job, how to work, which ward is the best, etc., “ (Student 11).

A number of students agreed with the statement that the presence of practical nurses in clinical training sessions is to the benefit of the educators. Educators, too, welcome their presence in the training group and consider them a potentially useful force. Educators admit that students with PNDs have a positive impact on reducing their workload and enhancing their calmness. “I consider them as potential assistants. I often left the students under their supervision. I trusted them” (Educator 3).

The reflection of the perceived reality of the clinical environment

: “Belief in the theory-practice gap” and “neglecting the principle of learning” were the categories of this theme.

Belief in the theory-practice gap

Perfunctory care, avoiding rethinking, and weakness in knowledge-based practice are among the examples of this category. One of the students said in this regard: “In the orthopedics class, we were learning the details of orthopedic traction, for example, how much should the patient weigh, etc., and one of the practical nurses said that they were not important at all. Those details were not needed.....

As evidenced by statements made by participants, the understanding of practical nurses regarding the prevailing conditions of the clinical environment and the perceived reality shows that there is a gap between theory and practice in the clinical environment, and, therefore, they cannot develop an interest in the provision of evidence-based care. “They told us to do routine work, and that theoretical knowledge is useless. They believed that in the hospital, what is important is practice and what the educators and instructors say is not so useful “ (Student 7).

Neglecting the principle of learning

The participants' experiences about the performance of practical nurses pointed to their passivity and lack of interest and excitement as compared to their peers. Most practical nurses merely continued their studies to get a higher degree and promotion and had little motivation and interest in studying. “There is not much excitement and passion in them..... Their family and life conditions have led to some sort of stagnation, and they just bear and attend classes until they end and they get a degree, because acquiring new knowledge is not among their priorities “ (Educator 3).

In their interactions with their peers, they are very negative and this leads to lack of motivation and feelings of hopelessness among their peers toward their professional futures. “In some cases, practical nurses convey a negative attitude to you. …They say it is very unlikely that you will find a job “ (Student 10).

Of course, practical nurses are affected by role conflict due to conflicts between work, education, and family life, and appear to be weak in the role of students. They do not spend enough time on their assignments. The severity of these problems is so high that they sometimes put a lot of pressure on instructors to give them passing grades and to collaborate with them for less frequent attendance in classes and training sessions. Additionally, both groups' experiences highlighted the importance of the role of gender in many of the extracted categories. Violations of educational regulations and unconventional behaviors by male practical nurses in contrast to competitiveness, activeness, orderliness, compliance with educational regulations, science-based practice, good performance, etc., by female practical nurses studying for a nursing degree were what drew the attention of research participants. “They have a lot of information, are very experienced in clinical practice, study a lot, and are much more active than the rest of the students” (Student 10).

  Discussion Top

The findings indicated the relatively prominent role of practical nurses in undergraduate education. The impact of the presence of students with PNDs in the learning process is on a continuum. At one end, there are the positive effects, and at the other end, there are the negative effects of their attendance in the educational process affecting students, educators, and even the staff.

One of the themes was the impact of students with PNDs as role models. Students modeled them in their technical skills, professional behaviors, interactions, manners, and ethical views. Similar to the findings of the present study, Nelwati et al. (2018) have referred to the acquisition of technical skills, such as nursing procedures and patient education in the peer learning process.[15] Learners modeled others, especially clinical nurses, in performing clinical procedures. In this study, informal learning from students with PNDs occurred and, in some instances, it was observed that students with PNDs were even more influential than educators. In line with the present study, the results of a study by Saarikoski also showed that 59% of nursing students model clinical nurses, 27% model nurse teachers, and only 14% model their educators.[16] Modeling does not take place openly. Studies have shown that the nursing staff teach professional behaviors and this is referred to as the hidden curriculum in the literature.[17] A study by Barzegar et al. (2018) points to the significant effect of the hidden curriculum on student learning and the transfer of professional values.[18]

In addition to clinical practice, students with PNDs had a role in the teaching of the ethical dimensions of care to their peers. Educators should not disregard the stressful nature of clinical settings, especially when students face ethical dilemmas,[19] and should pay attention to the presence of practical nurses in order to enhance the ethical competence of learners. Another significant experience of the participants was norm violation and sometimes uncivil behaviors by students with PNDs, which might cause psychological or physiological problems, if these behaviors are ignored.[20]

Jahanpour et al. (2013) referred to the modest knowledge of nurses about professional regulations and the positive attitudes of only 1.5% of nurses toward professional regulations.[19] It seems that students with PNDs commit such behaviors because they either lack sufficient knowledge regarding the regulations and rules or for reasons such as occupational commitments, generation gap, transfer from the clinical environment to the academic environment, or other reasons. In any case, identifying and managing such behaviors is important, because these behaviors not only disrupt learning, but also have negative consequences for health and interpersonal interactions, and also lead to physical and emotional problems.[21],[22]

Another important finding was student's peaceful coexistence with practical nurses in the educational environment and especially in the clinical setting. On the one hand, students mentioned the inequality in the educational setting in favor of practical nurses. On the other hand, they talked of practical nurses as facilitators of learning. Students felt the inequality for many reasons. Even in some cases, according to them, practical nurses deprived them of opportunities to learn, for which the educators and staff were not blameless. In a study by Afrazandeh et al. (2016), the main concern of the students was the need for educators to pay equal attention to all students, which is consistent with the findings of the present study. Workplace discrimination is among job stressors that affects people's job satisfaction and health.[23] On the other hand, feelings of injustice provide grounds for inappropriate competition causing learners to do anything to ensure that the educator's views and expectations are met.[23] Therefore, educators' awareness of this issue is essential, especially in situ ations where they are involved unwantedly.

At the other end of the continuum, some experiences of the participants indicated the facilitating role of students with PNDs for their peers and even the educators. They acted as assistants to the instructors and mentors for their peers. Nursing educators suffer extreme stress as a result of high workloads. Several strategies have been proposed to reduce the effect of these stressors and job burnout.[24] Given the experience of educators in this study, a non-strategic but useful solution is the presence of practical nurses alongside educators. Furthermore, practical nurses acted as mentors for their peers. Through mentoring, more experienced students provide support and training for lower-level students. The duties of these students as teachers are to guide and support other students and act as role models for younger students. It has been mentioned that it is the duty of peer educators as good mentors to be generous, competent, and self-confident. These characteristics were frequently mentioned in the experiences of the participants. It seems that students with PNDs often unofficially take up the responsibility for this role, and since they felt responsible to their peers, their peers were happy to be with them. Students also mentioned receiving support from students with PNDs and the creation of a safe and comfortable environment for learning. Based on the available evidence, peer learning helps students learn without feeling stressed and when they make mistakes, they have lower anxiety.[25] In addition, such peer support will improve their self-confidence and self-belief too.[25]

Other participants' experiences indicated reductions in the experience of tension in the clinical environment in the accompaniment of practical nurses. Numerous studies have shown that nursing students experience high levels of stress in clinical settings.[25] On the other hand, due to the high workload and special challenges educators face in their dual roles as nurses and educators,[25] the presence of reliable students with PNDs alongside their peers can be beneficial, especially during complex procedures. Another finding of this study was the central role of students as communication models. Role modeling is one of seven domains of professional socialization of nursing students and the clinician is an important role model.[17]

While in the peer learning process, individuals socialize by relying on friendly relationships, trust each other, and share their worries about their occupational prospects,[1] the results of the present study indicate that practical nurses show professional superficiality, transfer this attitude to their peers, and discourage their peers regarding their future careers. However, what peers expect from each other is supportiveness. Receiving negative attitudes toward the profession from peers leads to hopelessness and may even result in dropping out of university or changing the major.[26] Participants also mentioned routine and unprofessional care by students with PNDs and their passivity in the clinical setting. Given the consequences of routine care, including the waste of resources and time, and the slowdown in the recovery process,[27] the transfer of this negative attitude from students with PNDs to their peers is alarming and deserves attention.

In addition, in this study, students with PNDs emphasized the separation of theory and practice and the irrelevance of nursing knowledge. According to Hussein and Osuji (2017), clinical nurses prefer to make use of the knowledge of their colleagues and believe that such knowledge acts as a double-edged sword and can be incomplete.[28] However, in a study by Abusaleh et al. (2018), nursing students pointed out that clinical nurse colleagues should create coordination between clinical practice and nursing theory and help create a creative and innovative learning environment for educators and students.[29] Therefore, educators should be aware of this impact, and ensure the transfer of up-to-date and valid knowledge to learners, by monitoring students with PNDs, and help students link ideals and the reality.[28],[30] One of the limitations of the present study is that the results cannot be generalized to other nursing education settings. It is recommended that further studies be conducted on this issue.

  Conclusion Top

It seems that monitoring and managing undergraduate courses more thoroughly, as well as raising the awareness of educators about the positive and negative dimensions of the presence of nursing students with PNDs in undergraduate nursing courses can make it possible to optimize and improve the learning process of the students. Therefore, it is recommended that nursing educators put the skills and capabilities of students with PNDs to use and watch over aspects of their presence in the nursing education process.


We appreciate the sincere help of the Vice-Chancellorship for Research of the Lorestan University of Medical Sciences for supporting this study financially (N0 = LUMS.1154), and we express our gratitude to the nursing educators and students who participated in this research.

Financial support and sponsorship

Lorestan University of Medical Sciences

Conflicts of interest

Nothing to declare.

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