Laying the groundwork for clinical teaching in Bachelor of Science Nursing programs: findings from a grounded Delphi study

¹Department of Nursing Science, University of Nairobi, Nairobi, Kenya

^&Corresponding author
Grace Wangechi Gachuiri, Department of Nursing Science, University of Nairobi, Nairobi, Kenya

Introduction    

The increasing concern over the clinical competence of newly graduated nurses [1-3], which is frequently associated with ineffective clinical placement (CP) [4-6], has cast doubts on the effectiveness of clinical rotations in equipping nursing students with the required practical competences [7-9]. Evidence shows that many Bachelors of Science Nursing (BScN) students attend their planned clinical placements unprepared, with poor procedural knowledge, vague role awareness, and poor confidence [1,10]. One study reported up to 40 percent of students were not prepared for clinical work exposure [11]. In another setting, students reported that their initial placements were emotionally overwhelming because of vague expectations and insufficient orientation [12].

CPs are supposed to harmonize theory and practice but the actual practice experiences reveal the gaps in preparation strategies [13,14]. Some of the gaps include variability in curricula, inconsistent application of simulation, and lack of smooth integration between academic teaching institutions and clinical teaching institutions [15,16]. Consequently, poorly prepared students risk jeopardizing not only patient and health worker safety [14,17-19], but also burden clinical teams [20,21], and miss critical learning opportunities [22-25]. Therefore, there is need for organized, standardized and supportive measure that prepare equip students to enter the real-life healthcare environment [26-28].

To fill the gaps, the literature offers three important processes that facilitate readiness [29-31] beginning with the cognitive priming strategy where theoretical training precedes practice. The second strategy is the development and dissemination of rotation-specific learning objectives [32] in order to promote purpose-directed learning. Last but not least, the skills lab-based training in the form of simulation-based practice and case presentations that provide secure settings of experiential preparedness [33].

Regulators like the Nursing Council of Kenya insist on CPs guided by exposure hours, but they do not directly mandate practices that promotes student readiness for CPs, since university have discretion in designing and implementing curricula [23]. Consequently, practices that support student readiness for CPs are not consistently applied in clinical settings [34,35]. Such discrepancy, evident not only in Kenya but also in other countries, may be aggravated by the limited co-ordination between academic institutions and clinical facilities, which operate independent of each other [21,36-38]. The central issue is not whether clinical placements are either necessary or available, but whether preparations are made to ensure that students are cognitively and procedurally prepared and whether there are structures that are deliberately put in place to facilitate the process.

Preparedness should not be a mere pedagogical addition to clinical placements but a systemic requirement [36,39] that should be established and not presumed. Clinical teaching continues to depend on unstructured exposure [40], and students are supposed to adapt to clinical exposure and not necessarily being intentionally primed for maximum learning and participation [32,34,36,41]. In other cases, students are sent for CPs with little to no instructions [39], vague expectations [12], and poor exposure to procedures [33], a problem that is exacerbated by overcrowded wards and undertrained preceptors [42]. Thus, the research examined preparedness as a foundational aspect of BScN clinical teaching to develop structured approaches that can be used to promote preparedness prior to placements. The article presents the research methods, the findings, the discussion, the conclusion and implications of the study.

Methods     

The grounded-Delphi methodology was applied in a 15-month study, which combined both qualitative and quantitative approaches to establish and formulate consensus on the CPs preparedness strategies.

Study setting and participants

The study targeted universities and teaching hospitals that are directly engaged in clinical education of undergraduate nursing students between May 2023 and August 2024. These were 22 accredited universities with BScN programs and their affiliated clinical placement teaching hospitals. There has been an increased interest in the quality of nursing education in Kenya, where governance of healthcare industry is decentralized amid rising number of diverse training institutions.

The participants comprised of people who had substantive roles in undergraduate nursing education and clinical supervision. These were university lecturers (BScN program), clinical nurses who supervised students on placements and final-year BScN students who had a minimum of three years of experience in placements. The selection aimed to attract those with informed views preparedness for CPs from both academic and practice settings.

Snowballing was used in Round 1, where 13 experts were interviewed. The qualification criteria were post-basic education in nursing and at least five years of supervision experience. These experts were recruited through the faculty offices and nurse managers in the 22 universities and teaching hospitals. The first interaction was through phone calls and follow-up emails with study documents, including consent forms.

Round 2 involved a wider group which was purposely recruited using faculty office heads and nurse managers. The recruitment was directed at stakeholders who actively participated in clinical placements for BScN programs. A total of 103 respondents (lecturers, clinical nurses, and students) filled the online questionnaire. In round 3, only 75 responses were received (73% response rate), although stakeholder diversity was retained. The third round was used to provide validation of the previous findings (Table 1).

Methodology, method and study design

A constructivist qualitative methodology was applied to explore preparedness for clinical placements in undergraduate nursing education, which is an appropriate approach in creation of context-specific knowledge in dynamic learning environments [37,38]. The hybrid (Grounded-Delphi) design involved the combination of grounded theory and Delphi methods [39]. Round 1 involved an open-ended exploration using grounded theory, while Round 2 and Round 3 were surveys that used structured and iterative rounds guided by Delphi principles. This mixture allowed both in-depth exploration and consensus building, which is in line with the exploratory and practice-based objectives of the study.

Round 1 was a semi-structured interview with professionals, which were transcribed and thematically coded in order to determine student preparedness strategies. The second and third rounds used online Likert-scale questionnaires to evaluate the significance and feasibility of these strategies. Descriptive analysis of quantitative data was done and the comments emanating from open-ended questions provided complementary insights.

The grounded Delphi design was used to convert the expert views to practical recommendations. Round 1 created high-level strategies, round 2 helped to generalize them into survey items rated in terms of feasibility and significance while round 3 gave controlled feedback allowing participants to reconsider and reach consensus. The anonymity of participants was ensured to the end in order to decrease bias and promote independent judgment. The Delphi design principles of diversity and consensus saturation were used to determine sample size.

Data collection procedure

In round 1, in-depth interviews were held with 13 experts through face to face or online platforms depending on the availability of participants. The interview guide explored perceptions, challenges, and strategies related to student preparedness for CP. Interviews were recorded (with consent), transcribed word-for-word, and analysed concurrently with data collection until thematic saturation was achieved attained.

In round 2, round 1 result were summarized into 38 strategy statements, sorted by themes and measured on a 5-point Likert scale (1-strongly disagree to 5-strongly agree). Besides, opportunities for open-ended feedback was provided. The preparedness strategies were operationalized as those actions or mechanisms that were believed to enhance the students in their capacity to be effective in their clinical learning. They online survey was distributed to 126 individuals whereby 103 (82%) responded to it. Responses were shared through a private and secure system.

The results of Round 2 were summarized with median scores. Strategies that did not reach a consensus (=75%) were retained for a re-evaluation in the next round. During Round 3, participants were given feedback that included previous ratings and group statistics and re-rated each item. Out of 103 invited, 75 (73%) individuals completed the final round.

Data analysis

Analysis followed a sequential Grounded-Delphi approach, with qualitative findings guiding quantitative instrument design. Qualitative data were analyzed using constructivist grounded theory. Transcripts underwent initial, focused, axial, and theoretical coding to build a thematic framework. Coding was supported by Delve software, with two researchers coding independently and meeting regularly for consistency. Preparedness strategies were operationalized as actions or mechanisms perceived to improve students' ability to engage effectively in clinical learning, measured using a 5-point Likert scale (1-strongly disagree to 5-trongly agree). Final themes informed the Round 2 structured survey.

Quantitative data from Rounds 2 and 3 were analyzed in SPSS. Descriptive statistics (median, interquartile range, and percentage agreement) assessed consensus, predefined as =75% rating an item 4 or 5. Non-consensus items from Round 2 were re-rated in Round 3 after group feedback. All survey questions were mandatory, thus no missing data occurred. Participant attrition from 103 (Round 2) to 75 (Round 3) was attributed to competing professional obligations and reflected normal Delphi participation decline. Kruskal-Wallis tested differences across students, clinical nurses, and lecturers; p>0.05 indicated consistent ratings across groups. No sensitivity analysis was performed, as consensus levels were the primary endpoint.

Trustworthiness

Trustworthiness followed Lincoln and Guba´s (1985) criteria: credibility, dependability, confirmability, and transferability. The Delphi iterative process was used to build credibility through ratings and feedback to polish the strategies into a context-relevant model. Reliability was facilitated by a uniform analytic scheme and thorough documentation. Confirmability was based on audit trails and memos of the analytic decisions. The transferability was also improved by providing descriptive information about the participants and study setting as it could help evaluate whether the model could be applied to other learning environments. Other than this, power influence was minimized by keeping anonymity in the rounds.

Ethical considerations

Ethical review and approval was obtained from The Kenyatta National Hospital-University of Nairobi Ethics and Research Committee through approval number KNH-ERC/A/233. A permit was also obtained from the National Commission of Science, Technology and Innovation (NACOSTI License No: NACOSTI/P/23/28224). The involved institutions provided administrative permission. All participants were informed and signed the informed consent. Data were coded and stored in a safe place.

Results     

The study aimed to develop and validate strategies for enhancing preparedness for CPs among BScN students in a three-round Delphi process. The results are presented in a chronological order of data collection rounds starting with findings from in-depth interviews that produced qualitative themes, then the stakeholder ratings and consensus outcomes of Round 2 and Round 3. The results reflect the breadth of expert views as well as the depth of congruence among participating stakeholder groups.

Identification of preliminary strategies (round 1)

Five themes emerged to describe strategies that could enhance preparedness as a means of enhancing the experience and learning of BSc Nursing students during clinical placement. First, is the need to align theory and practice through integrated curricula and harmonised instruction methods. Second, the need for structured orientation with early communication of objectives to all clinical teaching stakeholders. Third, structuring clinical learning via co-developed, placement-specific objectives. Fourth enhanced experiential readiness through skills laboratory practice, simulations, and return demonstrations to build confidence in students prior to patient encounter. Fifth, use of critical tools such as rotation plans, logbooks, and manuals that standardize supervision and ensure continuity between academic and clinical settings. Table 2 provides participant descriptions illustrating the themes and subthemes.

Refinement and prioritization of strategies (round 2)

Round 2 clarified round 1 strategy by translating them into structured survey items for stakeholder review. Responses showed strong agreement, with mean scores between 4.1 and 4.8. High ratings emphasized importance of clear communication and preparation, particularly orientation to the clinical area (mean = 4.8), discussion of objectives between the students, clinical nurses, with the lecturers (mean = 4.75), and supervisors identifying learning opportunities that relate to objectives to be met (mean = 4.63). Experiential methods also received strong endorsement, including peer learning (mean = 4.55) and task-based learning (mean = 4.54).

When asked to suggest additional preparation before placements, respondents highlighted psychological and practical readiness through theoretical exposure, skills-laboratory practice, and clear objectives. However, these views largely echoed Round 1 suggestion, rather than introducing new strategies. For example

“The course content that has already been covered. Learners should be placed in a clinical area where they have theoretical experience. The support tools, like charts, stationery, and applicable clinical tools, should be available. Preceptors should be prepared in advance with their work spelt out” (P39).

“Clearly stating the objectives to be met by the learner and how the lecturer is going to assist in meeting these expectations” (P42).

“The student nurses ought to be taught the various nursing skills in the skills lab prior to the placement so that they can get to actualized what they learnt in the lab” (P14).

The insights from round 2 led to a refined framework that outlined the major CP preparedness strategies. Based on those findings, round 3 was aimed at validating the framework through appraisal of stakeholder roles and responsibilities in the implementation of the proposed strategies. This last step enhanced the empirical validity and contextual relevance of the framework to the nursing education practice.

Final validation of strategies (round 3)

Round 3 validated the refined CP preparedness strategies by examining the stakeholder views on the application of the proposed measures. Faculty, clinical nurses and students were able to define their respective roles in preparedness for CP. The three validated strategies are presented.

Theme 1: sequencing of theory and clinical practice

The results of Round 3 indicated that all stakeholders highly supported a systematic, gradual process of transitioning classroom learning to clinical practice facilitated by system-level coordination. The participants noted that there should be a collective responsibility of the faculty, students, and nurses in ensuring that theory and practice are aligned. It was considered necessary to ensure that the prerequisite knowledge and professional behaviours were met prior to clinical placement (mean = 3.61). High level of agreement was achieved on the issue of strengthening the university-hospital collaboration by means of communication (4.1) and mentoring programs (mean = 3.73), better placement scheduling to minimize congestion (mean = 4.25) and professional development to improve supervision and appraisal capacity of clinical nurses (mean = 3.56).

It was also recommended that pre-placement preparation should involve peer learning by the use of role plays and returned demonstrations (mean = 3.73). On-site implementation was focused on coordinated involvement during the initial day of placement. Students should be accompanied by lecturer on their first day in a new placement (mean = 3.40), oriented (mean = 3.85) and assigned a nurse mentor (mean = 3.41). Faculty involvement in the ward orientation (mean = 3.59) and the presentation of the learning objectives to the ward staff by faculty (mean = 3.63) were also regarded as important issues to facilitate the transition and alignment of academic and clinical learning.

Theme 2: structuring clinical learning through objectives and work planning

This theme was organized according to the Triple S Approach (Setting, Synthesising, and Sharing Objectives) to provide systematisation that enables the alignment of learning goals with clinical opportunities. Faculty set behavioural and professional expectations (mean = 3.56), students are actively involved in setting objectives of the placements (mean = 3.33) and personal learning objectives (mean = 3.53). The engagement of faculty, students, and clinical nurses would encourage a sense of collective ownership and responsibility, whereby the goals are addressed to the needs of the institutions and each student individually.

In synthesising Objectives, students are expected to interpret objectives into competencies (mean = 3.56), develop work plans as learning roadmaps (mean = 3.67), and align them with personal goals (mean = 3.60). Clinical nurses review objectives (mean = 3.44), identify relevant learning opportunities (mean = 3.47), and guide students toward suitable activities (mean = 3.16). Faculty complement this by proposing structured activities (mean = 3.59), following instructional plans (mean = 3.45), and coordinating nurses´ supervision (mean = 3.25).

Sharing Objectives and Work Plans underscores collaboration to ensure a common understanding among all participants. Objectives are jointly discussed by students with lecturers (mean = 3.68), clinical nurses with lecturers (mean = 3.55), and students with nurses (mean = 3.55). Faculty reinforce this process by aligning clinical opportunities with learning goals (mean = 3.55) and facilitating communication across groups (mean = 3.63). Such collaboration enhances coherence in supervision and promotes consistent learning experiences throughout the clinical placement process.

Theme 3: building competence through mentorship and practice

This theme highlights the importance of simulation and experiential learning in preparing students for clinical placements. Stakeholders emphasized simulation in skills labs for observation, guided practice, and refinement (mean = 3.73). Mentorship, through faculty demonstrations (mean = 3.53) and continuous clinical supervision (mean = 3.41), was viewed as crucial for bridging theory and practice. They also recommended professional development for clinical nurses (mean = 3.56) and adequate resources to support simulation and clinical learning.

“Then another thing is that when you have a big population of students there is also the challenge of resources…. For example, if I can talk about a simple thing like gloves, you find the stocks are depleted very fast because the number of students is very high. And therefore because of the challenges of resources, some students may miss to practice certain procedure...” (P4).

“Preparing students for clinical placement is a bit tricky because, for instance, the issue about the procedures and the guidelines. The procedures touch on the resources. If you don´t have gloves, linen… (yeah), there are some things unless you have the resources you cannot do (practice) them the right way” (P2).

“Make sure that the things that the students would utilize in (clinical) learning in terms of procedures and learning skills are in place. Because there are many times, we send students to the wards and the units, the patients are there yes, but sometimes they may lack the necessary things that should be there for them to learn the skills. So, one ought to prepare the ground for them” (P4).

Stakeholder consensus and differences

Consensus was strong across stakeholder groups on sequencing theory with clinical practice, showing broad support for structured communication and system-level preparation of students. Learning objectives, work plans, checklists, and clear faculty-nurse roles were consistently rated essential for guiding and assessing learning (p = .068-.868). Agreement also emerged on simulation and experiential readiness, with mentoring programs (p = .351) and faculty demonstrations (p = 0.500) valued for improving preparedness. However, divergence arose regarding aligning work plans with individual student objectives (p = .002), as students and nurses favored flexibility while lecturers preferred standardization (Table 3).

Discussion     

This study used a grounded Delphi approach to examine BScN student preparedness for clinical placements. It identified three key strategies: sequencing theory with practice, structuring learning through objectives and work plans, and enhancing experiential readiness through simulation. Preparedness emerged as a co-produced process requiring collaboration among students, faculty, and clinical nurses. The participatory design strengthened credibility and consensus, providing a strong foundation for developing indicators of preparedness in BScN education.

The results support the existing evidence that underscores the significance of matching classroom and clinical training of reducing anxiety and improving cognitive preparedness [6,25]. They also support ‘clinical cognitive alignment’ [40] model, which underlines the importance of starting with theory, then practice. In concurrence with the other research conducted in Ghana [20], the study finds that accountability and improved performance of students can be achieved through structured learning goals and common work plans. In contrast to reports of educator resistance to objective-based approaches due to weak institutional communication [41], this study found convergence between academic and clinical perspectives, suggesting that dialogue and reflection can overcome resistance.

Differing opinions were observed among the stakeholder groups. Flexibility and focus on individual goals were more important to the students and nurses, and the faculty focused on standardisation, potentially because they were more accustomed to curriculum design [42]. This mismatch emphasizes the importance of negotiation and joint planning. Also, the differences in the perceptions of experiential readiness across institutions might be attributed to the variable familiarity with simulation pedagogy [32] and resource limitations.

The combined framework makes preparedness a system level construct that connects sequencing, structured learning and simulation along a continuum. It highlights the fact that preparedness is achieved through coordinated university-hospital collaborations as opposed to unilateral interventions. This view builds on previous research that viewed simulation as a skills acquisition tool [43], but places it in a context of a wider pedagogical system that aids in the development of professional identity. These strategies ought to be implemented through alignment of the curriculum, development of the faculty, and inter-organisational cooperation to provide uniform, competency-based education [44].

The findings should be interpreted cautiously due to self-reported data, contextual differences, and a focus on consensus rather than measurable outcomes. They may apply to BScN programs in sub-Saharan Africa with similar curricula and resources. Future research should examine how preparedness strategies influence competence, confidence, and patient safety through longitudinal and comparative studies to identify contextual factors affecting students´ transition to independent practice.

Limitations

The research relied on self-reported perceptions as opposed to direct observation and this could have created bias in responses. At the data collection period, only 22 universities were active in Kenya and this restricts the representativeness of all BScN programs currently. The Delphi design encouraged consensus but it might have been biased towards divergent opinions. These limit the generalizability, but the study provides useful, situation-specific information and a useful framework on how to enhance clinical preparedness plans within BScN programs.

Conclusion     

BScN programs embrace effective clinical placements through structured preparation to foster intentional learning, safe practice, and professional competence. The tested framework highlights three interrelated priorities, which include sequencing theory and practice, aligning learning with work plans, and enhancing simulation and experiential preparedness. Clear coordination among students, faculty, and clinical nurses bridges gaps that disrupt learning and patient safety. Structured, mentored approaches can transform unplanned exposure into consistent, competency-based experiences that build confidence and professional identity. The framework is suitable for curriculum development and academic-clinical partnerships, positioning intentional preparedness as an educational innovation and a strategic investment in producing capable, safe, and competent practitioners who contribute meaningfully to healthcare quality and system capacity.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Grace Wangechi Gachuiri conceptualized the study, conducted data collection and analysis, and led manuscript drafting. Professor Lucy Kivuti-Bitok and Professor Miriam Wagoro contributed to the study design, supervised the research process, and critically reviewed manuscript drafts. All authors read and approved the final version of the manuscript.

Tables     

Table 1: profile of Delphi participants across rounds 2 and 3

Table 2: themes, subthemes, and illustrative quotes from round 1

Table 3: stakeholder ratings of preparedness strategies across professional groups

References