Students’ Satisfaction of Nursing Education: A Qualitative Study

Because students are important elements and the main audience of higher education, their satisfaction with how nursing education can be provided can be considered an indicator of student satisfaction. In this regard, a study has been conducted on the satisfaction of undergraduate nursing students with how-to education. This study is a qualitative study conducted with the participation of ten nursing students (second to the fourth year). Data were collected using semi-structured interviews, and the contractual content analysis method was used to analyze the data. The findings of the study showed that the students were dissatisfied with how provided nursing education. The most important causes of student dissatisfaction are academics/educators and educational environments. According to the findings of the study, to reform and upgrade the educational system, the quality of educational environments and professors must be constantly reviewed and evaluated.


Background
Education and learning of medical sciences at different levels requires a well-codified educational program, experienced academics/educators, a suitable educational environment, and the required equipment and technical facilities.The above factors are influenced by each other and affect each other (Hakim et al., 2016).In this regard, nursing education has been part of the higher education system in recent decades the world is developing and expanding rapidly, which has caused concern about the quality of education in this field (Kim et al., 2010).As the researchers stated, nursing education worldwide also faces challenges such as graduate competence, quality of education, and nursing curricula (Salminen et al., 2010).
The results of a study also show that nursing education in Iran, although it has a positive growth and trend, faces challenges.These challenges increase the importance of paying attention to the requirements of evaluation (Khodaveisi et al., 2012).In this regard, improving the quality of nursing education requires continuous review of the current situation to correct weaknesses, and students as recipients of educational services are the best source for identifying educational problems (Kermansaravi et al., 2013).
The study by Espeland and Indrehus also showed that 70% of students expressed dissatisfaction with the quality of nursing education programs as a whole, however, they were satisfied with clinical activities.The researchers concluded that it is necessary, to assess student satisfaction (regarding all nursing education programs and clinical activities) should be done annually and use standard questionnaires in nursing schools (Espeland & Indrehus, 2003).
Cook states that all events are filtered through the student's life experiences and shape the student's perception of those events, so it's important that educators consciously focus on the messages conveyed by individuals, places, policies, and processes in the learning environment (Cook, 2005).In this regard, researchers say that a large part of people does not have a correct idea of the nursing profession.
The social perspective on nursing is influenced by various internal factors such as personal feelings, beliefs, and ideas as well as many external factors such as family, institutions, civic institutions, and the mass of people (Ravanipour et al., 2014).
Based on the results of the Milisen et al. study,40.3% of the participants believed that the community has a negative view of nursing and a misunderstanding of the nursing profession.Students also stated that they felt frustrated and confused by this view of society (Milisen et al., 2010).On the other hand, studies have shown that more than 90% of students are satisfied with their field of study and had a positive attitude toward their field study (Sanaei Nasab et al., 2010;Rejali et al., 2010).
The results of the study also indicate that most of the studied samples had low satisfaction with educational environment conditions, clinical environment conditions, educators, social status, and communication with colleagues.Also, the samples were dissatisfied with the area of nursing management (Hakim, 2014).due to the different results of the studies, it can be acknowledged that one of the most important factors that create interest and motivation in students in their field of study is the level of satisfaction with the title of the field of study and the related job, social status, income and the level of difficulty of that field and job (Borjian Borujeni et al., 2011).
It should be noted that researchers in this regard have pointed to factors such as the educational programs of universities and the role of colleges, educational groups, and professors in improving attitudes toward the field of study and satisfaction with the field of study (Behnampour et al., 2012).
The results of Valizadeh et al.'s study show that through interviews with students and their evaluation, knowledge about the challenges of the educational environment is provided and causes students' interest in education to continue (Valizadeh et al., 2008).In this regard, Lo¨fmark et al.State in their study that university educators and professors are valuable resources in preparing students for the reality of their professional roles (Lo¨fmark et al., 2012).
So by examining quantitative studies from the perspective of nursing students from the field of study, it was found that the provision of information in this category is vague and limited.Therefore, the researchers, based on their experiences with nursing students ''satisfaction with the field of study, decided to conduct a qualitative study with the aim of students'' satisfaction with nursing education.Because in the end, the implementation of this research will improve the quality of care and improve the level of health of people in the community, as well as the awareness of relevant officials about the shortcomings in the nursing education system.

Study Design
This research is a qualitative study with a conventional content analysis approach.Ten nursing students (second to fourth year) of the School of Nursing and Midwifery affiliated with Ahvaz Jundishapur University of Medical Sciences were included in the study based on the purpose and with the maximum variety of choices.The reason for choosing a qualitative method is that the method can provide researchers with a deep insight into the understanding and experiences of individuals (Thomas et al., 2015).Also, qualitative methods can reveal subtle details of phenomena that are difficult to present in a quantitative way (Strauss & Corbin, 2008).

Setting
Inclusion criteria in the present study included studying in the second to fourth year and Voluntary participation in the study.Exclusion criteria included unwillingness to participate in the study or to take study leave at the time of the research.Data were collected using semistructured interviews.This type of interview is suitable for qualitative research due to its flexibility and depth (Polit & Beck, 2006).

Participants and Sampling
The sampling of this study was continued until the data reached saturation, so the researcher was saturated with eight interviews in this interview, but to be sure, she conducted two more interviews that the obtained data was a repetition of the previous data.

Ethical Consideration
The Interviews with nursing students were conducted at a location in the School of Nursing and Midwifery affiliated with the University of Medical Sciences.It should be noted that in this place all the basic conditions for a proper interview were considered.
At the beginning of the interviews, the purpose of the research and the voluntary participation in the study as well as the freedom to withdraw from the research were explained.In addition, written informed consent was obtained from students to participate in the study and recording of interviews.Also, they were assured that the obtained information would remain confidential.

Data Collection Procedure
During the recording of the interviews by the digital device, the behaviors and states of students during the interview and what was observed and experienced during the interviews were recorded as a note by the researcher (Speziale et al., 2011).
The duration of each interview varied from 45 to 80 min.After each interview, the participants' speeches were listened to carefully, and the transcripts were reviewed word by word, and due to the need for the qualitative researcher to be immersed in the data, the transcripts were reviewed several times by the researcher.
To analyze the data, the method of conventional content analysis was used, which was done simultaneously with data collection.Content analysis is more than just extracting objective content from textual data.However, in this method, hidden themes and patterns can be identified from the content of the data of the participants in the research (Mayring, 2000;Spannagel et al., 2005).
To analyze qualitative data with this method, five steps are stated as follows: 1. Write the whole interview immediately after each interview.2. Reading the whole text of the interview to get a general understanding of its content.3. Determining the units of meaning and primary codes.4. Classification of similar primary codes in more comprehensive categories. 5. Determining the hidden content in the data and extracting the main theme (Graneheim & Lundman, 2004).
Therefore, in this study, the manuscripts of the interviews were immediately read line by line and coded.Then the codes that had similar meanings were placed under the classes and the subclasses were placed within a more limited class based on similarity, compatibility, appropriateness, and relevance, and finally, the analysis process was completed by determining and specifying the patterns.

Trustworthiness
To ensure the reliability of the data, the researchers maintained constant mental engagement with the data.Experts also used the method of checking to validate the data.Then the results obtained from their opinions were taken from the interviews presented to the participants in the research and compared with each other.The member check method was also used so that the initial codes for approved.
It should be noted that in case of conflicting codes with their opinion, corrections were made.The researcher also used the method of continuous comparative data analysis to check the validity of the data and tried to obtain valid and reliable data.Transferability was also assessed by verifying information obtained from two non-research students who had similar conditions to those participating in the study.
Interviews and initial coding and themes were also reviewed by the researchers.The observer review method was used to control the information consistency.For this purpose, parts of the text of the interview along with the relevant codes and the obtained classes were sent to several observers to review the information analysis and express their opinions on their accuracy.

Results
In the present study, by analyzing students' interviews about their satisfaction with nursing education, the main theme includes indicators of student dissatisfaction.According to the results, it was found that students are dissatisfied with the method of nursing education, which was named inefficiency of education due to its subcategories.
Subcategories of the inefficiency of education include four subcategories: Improper educational performance of academics/educators, Ineffective planning and monitoring, Ineffective educational competence, and Unfavorable educational environments (Table 1).
In other words, education in nursing schools is conducted in a way that shows the experiences and perceptions of dissatisfaction in students.Student dissatisfaction includes five subcategories: lack of attention to the legal status of students, Students' concern about not being qualified, training students to do routine work in departments, students' confusion in solving educational problems, and prolonging education courses (Table 2).
If the causes of dissatisfaction are eliminated, we can expect the training to achieve effectiveness.

Lack of Attention to the Legal Status of Students
Students believe that they are not consulted on issues related to themselves and do not have the legal status to participate.One of the students says in this regard ''Why without the opinion of the student who is the main rule of the university and without her the university is equal to nothing, they do not ask for an opinion about replacing some professors.Is our task just a lesson?What is the use of these sheets?To what pain?''Student (No. 5second year).
They stated that they could not talk to people involved in the training about their issues.
A student Says, ''You cannot talk to anyone except the dear director of the nursing group.''Student (No. 8second year).

Students' Concern About Lack of Sufficient Competence
Since qualification is one of the most important missions of nursing education, students are hesitant to acquire it.

Vanaki and Hakim
A student talks about her concerns.''Why do professors refuse to give the necessary information?Our bachelor's degree in nursing equals complete illiteracy.''Student (No. 5 -second year).
Another says; ''I wish instead of such questions, the page was empty so that it could be a place for the words of knowledge seekers.Dear Professor or Professors, if the questions are supposed to be copies of our past years so what about the hassle of buying our expensive books?Is it right?Instead of a young student who is a seeker, does this increase his scientific load!!The contents of the books are updated every day, but alas, the professors still rely on a question that they have designed in the textbook from the very beginning.''Student (No. 8 -second year).Another states ''why when taking an exam, does the professor leave a copy of the previous year's questions in front of the student?That is, the content has no updates. .

Training Students to Do Routine Work in Departments
They have even stated in terms of clinical training that they are only encouraged to do routine work by educators.So one of them stated ''we are not going to an internship to study, we are going to learn a job.Who is responsible for nurses who do not know how to work at Bedside, and students who become instructors without knowing anything?''Student (No. 6 -second year).

Students' Confusion in Solving Educational Problems
The students stated that the educational system is such that they are confused about solving educational problems.They have found a way to teach the research method and do it.
One of them says: ''that the faculty research committee has no activity at all and no workshop is set up for the students and the students go to the medical faculty to do the research.''Student (No. 2 -third year).
In other states, ''our faculty do not encourage student research work I am a student who has been in this college for 2 years now and have never been in contact with this committee it makes me do research with other faculties, and this article goes to other faculties instead of being published under the name of the faculty of nursing.''Student (No. 1 -Third year).

Prolonging Training Courses
The way educational management and planning for students can be one of the indicators of education

Discussion
This study aimed to explain the perceptions of nursing students about nursing education.In this regard, the results show that students are dissatisfied with the way of education.Because an active educational environment is the result of the efficiency of education and playing the role of the teacher in educational management to qualify students.
If the teacher can establish and maintain a personal and professional relationship with the student, they will be able to help them acquire their qualifications, otherwise, they will be dissatisfied (Vanaki & Hakim, 2019).
The results of the present study indicate that students are dissatisfied with the provision of quality educational services.So that students' concerns about incompetence, students confusion in solving educational problems, the extension of education courses, and training students to perform routine tasks.Lack of attention to the legal status of students was one of the issues that identified the problems of nursing education.
In fact, it can be concluded that the first group that is directly affected by the structure of educational management and the quality of inappropriate performance of educational managers of nursing schools is nursing students and their level of satisfaction.
Students believe that they are not asked for their opinions on issues related to them and they do not have this legal position to attract participation.
The findings of we do almost nothing in the clinical setting except blood sampling and Temperature, pulse, respiration (TPR).The results of another study on the non-application of practical principles in inpatient care and unscientific routines in the wards were also among the issues that students emphasized (Kermansaravi et al., 2013).In the research, Borhani et al. students also stated that most of their actions were in the area of performing routine tasks such as giving medication and adjusting serum droplets, which they did from the beginning of the first semester (Borhani et al., 2011).
In Hemmati's research, final-year students also stated that most of their actions in some hospitals are to do basic work (Hemmati Maslakpak & Khalilzadeh, 2012).In improving any educational system, the role of the teacher is considered very important.It is also necessary to pay more attention to active teaching methods such as group discussion and problem-solving.Researchers also say that by revising the curriculum to establish a link between theoretical and practical education, the time interval between what is learned and the internship is reduced to give students ample opportunity to combine theoretical with practical topics.
Lack of coordination between theory and clinical or the distance between theory and clinical is one of the topics that is always raised in nursing education (Kermansaravi et al., 2013).
According to students, the support of nursing staff for students in new situations increases their self-confidence (Poorghane & Hosseini, 2010).In fact, Students should apply what they have learned through theory, despite the appropriate equipment, in practice, so that they do not panic and stress in case of emergencies that require their proper and rapid performance.Also, when they graduate, to acquire the necessary competencies in this field (Channell, 2002).
Therefore, it is important to pay attention to the factors increasing students' satisfaction such as the quality of theoretical and clinical education and evaluation processes, interactions, and attention to social prestige that ultimately maintains the improvement of educational quality (Hakim, 2013).The results of the study confirm the lack of up-to-date information from professors and the inefficiency of clinical instructors, as students state, we do not go to internships to study, but to learn work.
The results of a study (according to students) indicate the lack of mastery and skills of a clinical instructor.Undoubtedly, one of the most important factors in effective clinical education is the performance of trainers.Because coaching is a bridge between theoretical and practical training.Implementing the training process through efficient instructors can help students to acquire maximum clinical skills (Kermansaravi et al., 2013).Studies on clinical training show that these pieces of training are not necessarily effective.For example, a study conducted on novice nurses indicates that they have experienced a kind of unpreparedness in the transition from a student role to a professional role (Heshmatinabavi et al., 2011).
The existence of repetitive issues in clinical practice, the inefficiency of the clinical instructor, and the lack of up-to-date information of some nurses were some of the unfavorable experiences of students in clinical learning that the research samples considered the inefficiency of the clinical instructor as one of the reasons for their unfavorable learning experiences (Pourghane, 2013).researchers have stated in this regard, that improper management of human resources and equipping it in nursing as one of the important organizational resources is one of the organizational factors that cause serious damage to improving the quality of care and nursing services and professional nursing (Ravanipour et al., 2014).
A qualitative study performed on 15 nursing instructors, showed that ambiguity in the role and dependence on the profession has caused nursing instructors to be unsuccessful in mastering the role (Mollahadi, 2010).The results of the study show that students are concerned about their lack of professional qualifications.
The presence of experienced and qualified instructors in the clinical field has a fundamental role in the clinical education and training of students.Participants considered the lack of skills and clinical experience of the training instructor as one of the main failures of the education system and considered it one of the most important obstacles to training efficient and competent nurses.Another important shortcoming of the education system was the training of low-skilled graduates, which in turn caused damage to the quality of nursing services and their professionalization (Ravanipour et al., 2014).Kajander-Unkuri et al. stated that graduate nursing students based on their reports, had the highest level of nursing care activities in helping patients to cope and providing personal and ethical care and they had the lowest level of care in practice from representation to accountability, and autonomy (Kajander-Unkuri et al., 2013).
Also according to the results of the study by Wangensteen et al. newly graduated nurses reported that they had minimal competence in evaluating outcomes and in activities to develop nursing care (Wangensteen et al., 2012).several factors affect the professionalization of nursing, among these factors, are the role of nursing educators that the responsibility of theoretical education, how to apply theoretical content in the clinical field, gaining clinical experience and professional development, as well as ensuring the quality of nursing care of the patient is important (Heshmatinabavi & Vanaki, 2009).
In this regard, the results of a study based on the experience of participants showed that one of the factors affecting the confidence of nurses and, consequently, improving the quality of nursing care, is the effectiveness of apprenticeship and internship courses during the student period.Also, the distance between clinical nurses and educational instructors was one of the issues that were repeatedly emphasized and it was mentioned as an important barrier in student education and the path to professionalism which leads to the non-cooperation of employees with students and educational instructors (Ravanipour et al., 2014).
The American National Nurses Association has also stated that based on the evidence, changes in healthcare delivery systems, market demand, as well as reforms in the training of professional nurses are essential (Hickey, 2010).Despite the lack of consensus on the concept of nurses' professional competence, general components such as problem-solving skills and critical thinking are commonly included.As these also seem to be suitable for the competence of nursing students (Kajander-Unkuri et al., 2013).
Students' confusion in solving educational problems is another finding of the study.The way educational management and planning for students can be one of the indicators of educational inefficiency.Improper planning leads to prolonged study and excessive stay, which students have also stated in their interviews.On the other hand, critique and evaluation of students' experiences, which are usually ignored, should be on the agenda of the relevant administrators and should not be simply ignored.Because the consequence of this negligence indirectly causes the inefficiency of education and treatment systems (Vanaki & Hakim, 2019).
Based on the results of this study, students know the importance of their active participation in learning and claim that they must acquire basic nursing knowledge to solve problems in the clinical environment.
The results of the above studies were consistent with the experiences expressed by the study participants.
On the other hand, one of the things that are very effective in eliminating the competency deficiencies of the newly graduated nursing professionals, both at the undergraduate and postgraduate levels, and promoting their competence, is the provision of relevant continuing education (organizational environment and outside the organization) (Vanaki & Hakim, 2019).
Given the students' perception based on a lack of professional competence, it is necessary to perform other studies in this regard in other educational systems widely in different levels of nursing.Of course, it can be acknowledged that with the identification of shortcomings and deficiencies in the presentation of educational programs and as a result of efforts to improve their optimal implementation by educational staff, we will be able to deliver graduates with the desired professional qualifications to the relevant medical institutions.

Conclusion
According to the findings of the study, to improve and upgrade the educational system, the quality of educational environments and professors should be constantly reviewed and evaluated.Because the impact of educational environments and academics/educators, on the performance of these students and future graduates, of course, significantly impacts improving and promoting health services.
Therefore, based on the findings of this study, it is necessary to draw the attention of nursing education managers to the following, including educating students with professional competence must make an effort, to improve learning environments and empower nursing professors to achieve this strategic goal, so that students in addition to gaining satisfaction with the education system the faculty will be able to play its scientific, practical and professional role and finally meet the needs of society segments in future.

Table 2 .
The Process of Forming Classes Related to the Theme of Dissatisfaction Indicators of Undergraduate Nursing Students.

Table 1 .
The Process of Forming the Inefficiency Class of Nursing Education.