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Development and Validation of Clinical Nursing Teacher Self-efficacy Scale and Investigation of Self-efficacy among Clinical Nursing Teachers

Open AccessPublished:May 19, 2022DOI:https://doi.org/10.1016/j.anr.2022.05.001

      Summary

      Purpose

      The purpose of this study was to (1) add relevant contemporary items to develop an assessment instrument for the self-efficacy of clinical nursing teachers, to verify and evaluate the validity and reliability of the instrument, and (2) investigate the self-efficacy of clinical nursing teachers.

      Method

      A cross-sectional study was designed. A total of 205 clinical nursing teachers were recruited in Taiwan. Data were collected using the Clinical Nursing Teacher Self-efficacy Scale. An exploratory factor analysis was performed to examine the scale.

      Results

      The degree of self-efficacy of clinical nursing teachers was moderate to high. The 35-item scale showed great psychometric qualities. The Cronbach coefficient of the overall scale was 0.92; and 0.83, 0.91, 0.93, and 0.87 on the four subscales were acceptable. Four factors were extracted by exploratory factor analysis and explained 68.53% of the total variance. Four factors were (i) teachers' professional growth ability, (ii) teaching ability, (iii) clinical nursing competencies, and (iv) personality traits. The highest self-efficacy category evaluated by teachers was personality traits; the second was clinical nursing competencies; after that, teaching ability and teachers’ professional growth ability. The item with the lowest self-efficacy was foreign language ability (English).

      Conclusion

      Clinical nursing teachers have a moderate to high degree of self-efficacy. This scale with good reliability and validity can be used for the training and evaluation of the self-efficacy of clinical nursing teachers.

      Keywords

      Introduction

      Clinical nursing teachers (CNTs) are those who teach nursing students in a clinical setting. The term “clinical nursing teacher” is defined as someone who integrates theory into practice and creates an optimal learning environment [
      • Becker M.K.
      • Neuwirth J.M.
      Teaching strategy to maximize clinical experience with beginning nursing students.
      ]. In Taiwan, CNTs are typically experienced clinical nurses and registered nurses employed in university or college nursing schools to provide clinical instruction to nursing students in a variety of clinical settings [
      • Hall N.
      • Chichester M.
      How to succeed as an adjunct clinical nurse instructor.
      ] and are responsible for helping nursing students achieve learning outcomes. Taiwanese CNTs are full-time employees of nursing school; they were assigned to guide a group of six to seven students to perform clinical practice at clinical sites [
      • Yang C.I.
      • Chao S.Y.
      Clinical nursing instructors' perceived challenges in clinical teaching.
      ]. Since clinical practice is a compulsory and very important part of the nursing curriculum, CNTs are essential to promote students learning in clinical practice, improve students' professionalism, and improve their professional ability [
      • Tuomikoski A.M.
      • Kääriäinen M.
      Nurses' perceptions of their competence in mentoring nursing students in clinical practice: a systematic review protocol of qualitative evidence.
      ]. CNTs are considered to be able to guide differences between students and nurses; it means the difference from theory to practice; the gap between theory and practice is defined as the difference between knowledge and theory learned by student nurses in the classroom and their practical experience in clinical settings [
      • EL Hussein M.T.
      • Osuji J.
      Bridging the theory-practice dichotomy in nursing: the role of nurse educators.
      ]. CNTs must create a supportive learning environment to achieve learning integration, especially the learning environment related to differences in theory and practice in the clinical environment [
      • O'Rae A.
      • Langille J.
      • Li A.
      • Sealock K.
      • Rutherford G.
      The evolving role of a clinical instructor in an integrated undergraduate nursing curriculum.
      ].
      The significance and importance of self-efficacy of CNT are that when CNTs teach nursing students in clinical practice, it is necessary to help students achieve a balance between the theoretical knowledge obtained in the class and the application of the theory in the clinical setting [
      • O'Rae A.
      • Langille J.
      • Li A.
      • Sealock K.
      • Rutherford G.
      The evolving role of a clinical instructor in an integrated undergraduate nursing curriculum.
      ,
      • Ajani K.
      • Moez S.
      Gap between knowledge and practice in nursing.
      ]. Therefore, CNTs must be aware of effective self-efficacy and equipped with the necessary competencies [
      • Ghasemi H.S.E.
      • Rafii F.
      • Farahani M.A.
      • Mohammadi N.
      Being at peace as an important factor in acquiring teaching competency by Iranian nurse teachers: a qualitative study.
      ]. Nursing also emphasizes the need for a hands-on experience [
      • Ajani K.
      • Moez S.
      Gap between knowledge and practice in nursing.
      ,
      • Maginnis C.
      • Croxon L.
      Transfer of learning to the nursing clinical practice setting.
      ]; it is important to identify what kinds of behavior or characteristics of CNT are effective and modify clinical teaching methods to achieve learning effectiveness [
      • Soriano G.P.
      • Aquino M.G.B.
      Characteristics of a good clinical teacher as perceived by nursing students and faculty members in a Philippine university college of nursing.
      ]. Furthermore, to ensure the quality of clinical teaching, CNTs are required to apply classroom theory to concrete clinical situations; they need to demonstrate the clinical skills and abilities to create strategies that are conducive to clinical learning and help students combine theory with practice to improve clinical decision-making [
      • Soriano G.P.
      • Aquino M.G.B.
      Characteristics of a good clinical teacher as perceived by nursing students and faculty members in a Philippine university college of nursing.
      ,
      • Morgan J.
      • Knox J.E.
      Characteristics of “best” and “worst” clinical teachers as perceived by university nursing faculty and students.
      ]. CNTs must demonstrate good self-efficacy to facilitate the best clinical teaching, evaluate students' critical thinking, provide support, and establish good relationships with students to guide students toward achieving clinical learning goals and outcomes [
      • Heydari A.
      • Yaghoubinia F.
      • Roudsari R.L.
      The multidimensional nature of relationships: the perceptions of Iranian nursing students and educators of the student-educator relationship.
      ].
      The concept of self-efficacy was derived from Bandura's social cognitive theory of behavioral change [
      • Tschannen-Moran M.
      • Hoy A.W.
      Teacher efficacy: capturing an elusive construct.
      ,
      • Bandura A.
      Self-efficacy: toward a unifying theory of behavioral change.
      ]. Bandura describes self-efficacy as “a judgment of a person's ability to organize and execute a course of action to achieve a specified type of performance” [
      • Bandura A.
      Self-efficacy: toward a unifying theory of behavioral change.
      ]. Teacher efficacy is “a teacher's confidence in his or her ability to promote student learning” [
      • Barni D.
      • Danioni F.
      • Benevene P.
      Teachers' self-efficacy: the role of personal values and motivations for teaching.
      ,
      • Klassen R.M.
      • Tze V.M.C.
      Teachers' self-efficacy, personality, and teaching effectiveness: a meta-analysis.
      ]. According to Bandura (1997), teacher efficacy refers to teachers' beliefs about their ability to influence student achievement [
      • Bandura A.
      Self-efficacy: toward a unifying theory of behavioral change.
      ]. It refers to the belief of teachers that they have the ability to cope successfully with tasks, obligations, and challenges related to their professional activities, thus playing a key role [
      • Barni D.
      • Danioni F.
      • Benevene P.
      Teachers' self-efficacy: the role of personal values and motivations for teaching.
      ]. Teachers use their professional abilities, professional attitudes, and confidence to demonstrate their professional knowledge to help students learn effectively and achieve learning goals [
      • Collier A.D.
      Characteristics of an effective nursing clinical instructor: the state of the science.
      ]. It is important for its implications for teaching effectiveness, teaching practices, and student academic results (e.g., student achievement and motivation) [
      • Klassen R.M.
      • Tze V.M.C.
      Teachers' self-efficacy, personality, and teaching effectiveness: a meta-analysis.
      ]. Self-efficacy will be used throughout this paper to refer to teacher's efficacy (confidence) in their influence on students' achievement.
      Knox and Mogan (1985) [
      • Knox J.E.
      • Mogan J.
      Important clinical teacher behaviours as perceived by university nursing faculty, students and graduates.
      ] pointed out that the effectiveness of nursing clinical teachers is teaching ability, nursing competence, evaluation, interpersonal relationships, and personality traits. The effectiveness and competencies of clinical teaching are the key determinants of the quality of clinical learning; the most effective behavior was teaching ability/competence, which was reported to be 96% [
      • Okoronkwo I.L.
      • Onyia-Pat J.L.
      • Agbo M.A.
      • Okpala M.A.E.
      • Okpala P.U.
      Students' perception of effective clinical teaching and teacher behavior.
      ]. The definition of competence is the application of skills in all domains for the role of practice, focusing on specific outcomes, improving levels of competence, accountability of the learner, practice-based learning, self-assessment, and individualized learning experience [
      • Tilley D.D.S.
      Competency in nursing: a concept analysis.
      ]. The effective clinical teaching characteristics of CNT included nursing competencies, teaching ability, professional knowledge, interpersonal relationships, and positive personality traits [
      • Collier A.D.
      Characteristics of an effective nursing clinical instructor: the state of the science.
      ]. Several studies report that teaching ability and nursing competence were the highest rated evaluations, which were more important than evaluation skills, personality factors, and relationships with students [
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ,
      • Jowett R.
      • McMullan M.
      Learning in practice-practice educator role.
      ]; however, personality was the most favored teaching characteristics of students [
      • Soriano G.P.
      • Aquino M.G.B.
      Characteristics of a good clinical teacher as perceived by nursing students and faculty members in a Philippine university college of nursing.
      ]. Additionally, factors that affect teaching competence include knowledge expansion; Kelly (2007) [
      • Kelly C.
      Student's perceptions of effective clinical teaching revisited.
      ] found that teacher knowledge is the most important, become a knowledgeable teacher; followed by feedback and communication skills, create a positive learning environment, demonstrate professionalism and academic characteristics, and provide support [
      • Knox J.E.
      • Mogan J.
      Important clinical teacher behaviours as perceived by university nursing faculty, students and graduates.
      ,
      • Helminen K.
      • Johnson M.
      • Isoaho H.
      • Turunen H.
      • Tossavainen K.
      Final assessment of nursing students in clinical practice: perspectives of nursing teachers, students and mentors.
      ]. Teacher efficacy includes showing motivation to teach and being a good role model in a clinical setting. Collaboration between CNTs and nurses transforms the patient care unit into an environment that supports the learning of nursing students [
      • Okoronkwo I.L.
      • Onyia-Pat J.L.
      • Agbo M.A.
      • Okpala M.A.E.
      • Okpala P.U.
      Students' perception of effective clinical teaching and teacher behavior.
      ]. Furthermore, the internationalization of nurses continues to be a common phenomenon today. With the globalization and collaboration of educational programs, increased mobility requires nurses to have a foreign language ability and good language skills to communicate with patients and nurses from other countries [
      • Dos Santos L.M.
      Upgrading nursing students' foreign language and communication skills: a qualitative inquiry of the afterschool enhancement programmes.
      ].
      Overall, the characteristics of effective clinical educators and the most important competencies included teaching abilities, nursing competencies [
      • Tuomikoski A.M.
      • Kääriäinen M.
      Nurses' perceptions of their competence in mentoring nursing students in clinical practice: a systematic review protocol of qualitative evidence.
      ,
      • Morgan J.
      • Knox J.E.
      Characteristics of “best” and “worst” clinical teachers as perceived by university nursing faculty and students.
      ], clinical teaching skills, professional knowledge, clinical skills, interpersonal relationships [
      • Klassen R.M.
      • Tze V.M.C.
      Teachers' self-efficacy, personality, and teaching effectiveness: a meta-analysis.
      ,
      • Collier A.D.
      Characteristics of an effective nursing clinical instructor: the state of the science.
      ], personality traits [
      • Klassen R.M.
      • Tze V.M.C.
      Teachers' self-efficacy, personality, and teaching effectiveness: a meta-analysis.
      ], among which being a role model is important for nurse educators [
      • Knox J.E.
      • Mogan J.
      Important clinical teacher behaviours as perceived by university nursing faculty, students and graduates.
      ,
      • Okoronkwo I.L.
      • Onyia-Pat J.L.
      • Agbo M.A.
      • Okpala M.A.E.
      • Okpala P.U.
      Students' perception of effective clinical teaching and teacher behavior.
      ,
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ,
      • Glynn D.M.
      • McVey C.
      • Wendt J.
      • Russell B.
      Dedicated educational nursing unit: clinical instructors role perceptions and learning needs.
      ]. The conceptual framework of self-efficacy of CNTs is shown in Figure 1.
      Figure 1
      Figure 1The conceptual framework of self-efficacy of clinical nursing teachers.

      Aims

      To evaluate the self-efficacy of CNTs in complex clinical situations, this study aimed to (1) add contemporary applicable items to develop an assessment tool for the self-efficacy of CNTs (the Clinical Nursing Teachers Self-Efficacy Scale), validate psychometric properties and evaluate its validity and reliability; and (2) survey and describe the self-efficacy of CNTs.

      Methods

      Study design

      This was a descriptive cross-sectional study conducted in the nursing department of universities and colleges.

      Participants

      A convenience sample was used and CNTs were recruited from 43 universities and colleges [

      Ministry of Education [Internet]. School information [cited 2021 Nov 22]. Available from: https://ulist.moe.gov.tw/Query/AjaxQuery/Discipline/0913#.

      ]. The average number of CNT members in each nursing school is five to ten; therefore, the total sample size of CNT was estimated to be 215–430 in Taiwan. The inclusion criteria were (1) currently employed full-time CNTs by the department of nursing in colleges and universities, (2) more than 3 months of clinical nursing teaching experience; exclusion criteria were (1) within 3 months of probation period, (2) part-time employed, (3) according to the voluntariness principle, teachers who refused to participate were excluded. A previous exploratory factor analysis (EFA) study has shown acceptance of a small sample size [
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ]. The latest review of psychological research reports that a sample of 200 subjects or less is acceptable in 40–60% of studies [
      • McNeish D.
      Exploratory factor analysis with small samples and missing data.
      ]. A total of 35 items were included on the scale in this study, and considering the attrition rate, a sample size between 175 and 350 (n = 205 in our study) was estimated.

      Measurement

      Demographic questionnaire

      This questionnaire includes gender, age, education level, years of clinical nursing work, and years of clinical nursing teaching.

      Clinical Nursing Teachers Self-efficacy Scale

      The Clinical Nursing Teacher Self-efficacy Scale (CNT-SES) was developed to comprehensively measure the self-efficacy of CNTs in guiding students' clinical practice. The CNT-SES survey tool developed by the authors determined the CNT-SES items through a literature review [
      • Soriano G.P.
      • Aquino M.G.B.
      Characteristics of a good clinical teacher as perceived by nursing students and faculty members in a Philippine university college of nursing.
      ,
      • Morgan J.
      • Knox J.E.
      Characteristics of “best” and “worst” clinical teachers as perceived by university nursing faculty and students.
      ,
      • Heydari A.
      • Yaghoubinia F.
      • Roudsari R.L.
      The multidimensional nature of relationships: the perceptions of Iranian nursing students and educators of the student-educator relationship.
      ,
      • Klassen R.M.
      • Tze V.M.C.
      Teachers' self-efficacy, personality, and teaching effectiveness: a meta-analysis.
      ,
      • Collier A.D.
      Characteristics of an effective nursing clinical instructor: the state of the science.
      ,
      • Knox J.E.
      • Mogan J.
      Important clinical teacher behaviours as perceived by university nursing faculty, students and graduates.
      ,
      • Okoronkwo I.L.
      • Onyia-Pat J.L.
      • Agbo M.A.
      • Okpala M.A.E.
      • Okpala P.U.
      Students' perception of effective clinical teaching and teacher behavior.
      ,
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ,
      • Jowett R.
      • McMullan M.
      Learning in practice-practice educator role.
      ,
      • Kelly C.
      Student's perceptions of effective clinical teaching revisited.
      ,
      • Helminen K.
      • Johnson M.
      • Isoaho H.
      • Turunen H.
      • Tossavainen K.
      Final assessment of nursing students in clinical practice: perspectives of nursing teachers, students and mentors.
      ,
      • Dos Santos L.M.
      Upgrading nursing students' foreign language and communication skills: a qualitative inquiry of the afterschool enhancement programmes.
      ,
      • Glynn D.M.
      • McVey C.
      • Wendt J.
      • Russell B.
      Dedicated educational nursing unit: clinical instructors role perceptions and learning needs.
      ,
      • Nehring V.
      Nursing Clinical Teacher Effectiveness Inventory: a replication study of the characteristics of ‘best’ and ‘worst’ clinical teachers as perceived by nursing faculty and students.
      ,
      • Hafeez M.
      Systematic review on modern learning approaches, critical thinking skills and students learning outcomes.
      ,
      • Stamps A.
      • Cockerell K.
      • Opton L.
      A modern take on facilitating transition into the academic nurse educator role.
      ,
      • Akbar S.
      • Lyell D.
      • Magrabi F.
      Automation in nursing decision support systems: a systematic review of effects on decision making, care delivery, and patient outcomes.
      ,
      • Kumah E.A.
      • Bettany-Saltikov J.
      • van Schaik P.
      • McSherry R.
      Evidence-based practice and evidence-informed practice competencies in undergraduate pre-registration nursing curricula: a document analysis at a university in England.
      ], expert consultation, and a preliminary small sample survey.
      Morgan and Knox (1987) [
      • Morgan J.
      • Knox J.E.
      Characteristics of “best” and “worst” clinical teachers as perceived by university nursing faculty and students.
      ] developed the Nursing Clinical Teacher Effectiveness Scale, which divided teacher characteristics into five categories: teaching ability, nursing competence, personality traits, interpersonal relationship, and evaluation. In addition, Hou et al. (2011) [
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ] developed a clinical nursing faculty competence inventory (CNFCI) that indicated the competencies of clinical nursing faculty, including leadership ability, problem-solving ability, educational intelligence, general teaching ability, and clinical nursing skills. The difference between our CNT-SES and these two inventories was that we have added contemporary applicable items, focus on the future development trends of the nursing profession; apply modern education technology and innovative teaching methods [
      • Hafeez M.
      Systematic review on modern learning approaches, critical thinking skills and students learning outcomes.
      ], pay attention to the development of nursing science, proficiency and ability in nursing research, participating in interdisciplinary research projects and interdisciplinary learning [
      • Stamps A.
      • Cockerell K.
      • Opton L.
      A modern take on facilitating transition into the academic nurse educator role.
      ], presentation at international conferences, international foreign language ability [
      • Dos Santos L.M.
      Upgrading nursing students' foreign language and communication skills: a qualitative inquiry of the afterschool enhancement programmes.
      ], decision-making [
      • Akbar S.
      • Lyell D.
      • Magrabi F.
      Automation in nursing decision support systems: a systematic review of effects on decision making, care delivery, and patient outcomes.
      ] and evidence-based nursing [
      • Kumah E.A.
      • Bettany-Saltikov J.
      • van Schaik P.
      • McSherry R.
      Evidence-based practice and evidence-informed practice competencies in undergraduate pre-registration nursing curricula: a document analysis at a university in England.
      ]. Finally, we develop the “CNT-SES” consisting of 35 items. There are four dimensions: (1) teachers' professional growth ability (1–8; 8 items), (2) teaching ability (9–19; 11 items), (3) clinical nursing competencies (20–24; 5 items) and (4) personality traits (25–35; 11 items). The scoring range for each item was 0–4; participants were instructed to rate all items on a 5-point Likert scale (4 = strongly agree, 3 = agree, 2 = neutral, 1 = disagree, 0 = strongly disagree); and the total score range was 0–140. The range of subscale scores was 0–32, 0-44, 0–20, and 0–44, respectively; the higher the score, the stronger the self-efficacy of the CNTs.

      Data collection

      The investigation of CNT self-efficacy was divided into three stages: (1) item generation and content validity; (2) preliminary survey; and (3) collect data in the descriptive and cross-sectional study.

      Stage 1: Item generation and content validity

      The instrument development procedure was based on a theoretical and literature review [
      • Hall N.
      • Chichester M.
      How to succeed as an adjunct clinical nurse instructor.
      ,
      • Tuomikoski A.M.
      • Kääriäinen M.
      Nurses' perceptions of their competence in mentoring nursing students in clinical practice: a systematic review protocol of qualitative evidence.
      ,
      • O'Rae A.
      • Langille J.
      • Li A.
      • Sealock K.
      • Rutherford G.
      The evolving role of a clinical instructor in an integrated undergraduate nursing curriculum.
      ,
      • Ghasemi H.S.E.
      • Rafii F.
      • Farahani M.A.
      • Mohammadi N.
      Being at peace as an important factor in acquiring teaching competency by Iranian nurse teachers: a qualitative study.
      ,
      • Soriano G.P.
      • Aquino M.G.B.
      Characteristics of a good clinical teacher as perceived by nursing students and faculty members in a Philippine university college of nursing.
      ,
      • Morgan J.
      • Knox J.E.
      Characteristics of “best” and “worst” clinical teachers as perceived by university nursing faculty and students.
      ,
      • Heydari A.
      • Yaghoubinia F.
      • Roudsari R.L.
      The multidimensional nature of relationships: the perceptions of Iranian nursing students and educators of the student-educator relationship.
      ,
      • Tschannen-Moran M.
      • Hoy A.W.
      Teacher efficacy: capturing an elusive construct.
      ,
      • Klassen R.M.
      • Tze V.M.C.
      Teachers' self-efficacy, personality, and teaching effectiveness: a meta-analysis.
      ,
      • Collier A.D.
      Characteristics of an effective nursing clinical instructor: the state of the science.
      ,
      • Knox J.E.
      • Mogan J.
      Important clinical teacher behaviours as perceived by university nursing faculty, students and graduates.
      ,
      • Okoronkwo I.L.
      • Onyia-Pat J.L.
      • Agbo M.A.
      • Okpala M.A.E.
      • Okpala P.U.
      Students' perception of effective clinical teaching and teacher behavior.
      ,
      • Tilley D.D.S.
      Competency in nursing: a concept analysis.
      ,
      • Kelly C.
      Student's perceptions of effective clinical teaching revisited.
      ,
      • Helminen K.
      • Johnson M.
      • Isoaho H.
      • Turunen H.
      • Tossavainen K.
      Final assessment of nursing students in clinical practice: perspectives of nursing teachers, students and mentors.
      ,
      • McNeish D.
      Exploratory factor analysis with small samples and missing data.
      ,
      • Nehring V.
      Nursing Clinical Teacher Effectiveness Inventory: a replication study of the characteristics of ‘best’ and ‘worst’ clinical teachers as perceived by nursing faculty and students.
      ,
      • Hafeez M.
      Systematic review on modern learning approaches, critical thinking skills and students learning outcomes.
      ,
      • Stamps A.
      • Cockerell K.
      • Opton L.
      A modern take on facilitating transition into the academic nurse educator role.
      ,
      • Akbar S.
      • Lyell D.
      • Magrabi F.
      Automation in nursing decision support systems: a systematic review of effects on decision making, care delivery, and patient outcomes.
      ,
      • Kumah E.A.
      • Bettany-Saltikov J.
      • van Schaik P.
      • McSherry R.
      Evidence-based practice and evidence-informed practice competencies in undergraduate pre-registration nursing curricula: a document analysis at a university in England.
      ] and initially constructed a list of 60 items in six categories: (1) teachers' professional growth ability, (2) teaching ability, (3) clinical nursing competency, (4) personality traits, (5) fostering student learning ability, and (6) competencies of clinical nursing educators. Three experienced nursing education experts were invited to review the initial 60 items to examine the content validity of the generated items. The experts offered comments and suggestions and also rated the suitability of each item on a 5-point scale. According to experts’ suggestions, categories and some items were merged, the content validity index of these items ranged from 0.85 to 1 [
      • Moore G.C.
      • Benbasat I.
      Development of an instrument to measure the perceptions of adopting an information technology innovation.
      ], and the scale-level CVI calculated based on the experts' score was 0.95 [
      • Polit D.F.
      • Beck C.T.
      • Owen S.V.
      Is the CVI an acceptable indicator of content validity? Appraisal and recommendations.
      ]; therefore, the questionnaire was revised to 50 items in four categories.

      Stage 2: Preliminary survey

      At this stage, the procedure included recruiting 20 CNTs to assess the suitability of the 50 items. Twenty participants from a university in central Taiwan conducted a questionnaire survey of 50 items, hoping to find out whether the description of the items was clear, readable, unambiguous, equivocal, and accurately reflects the self-efficacy of CNTs. They reported that it takes approximately 10–15 minutes to complete the instrument. In the preliminary study, the 50 items were carefully modified to make them more specific and explicit. A preliminary survey showed that the mean age of 20 CNTs was 43.25 (±5.39) years; clinical nursing teaching experience was 9.50 (±4.56) years, and clinical nursing work experience was 9.35 (±4.58) years. Respondents said that these items were easy to understand; it takes an average of 10 to 15 minutes to complete the questionnaire.

      Stage 3: Collect data in the descriptive and cross-sectional study

      We collected descriptive and cross-sectional data from July 2019 to January 2020. Data were collected from nursing schools in northern, central, southern, and eastern Taiwan. We do our best to contact all potential participants to complete the questionnaire electronically by sending an email invitation with a link to the questionnaire to potential participants. All participants were informed of the purpose of the study, read informed consent, and the time required to complete the survey. 400 emails were sent and 205 questionnaires were returned, and the response rate was 51.25%. The questionnaire was distributed and returned at the appointed time. Since the design of the questionnaire required that all questions be answered, otherwise the questionnaire was invalid and the valid questionnaires were 100%. After collecting the data, 15 items that did not meet the statistical significance were eliminated by item discriminant analysis; the initial 35 items were retained. The flow chart of data collection and item generation is shown in Figure 2.

      Data analysis

      SPSS version 26.0 was used for data analysis. The statistical significance level was set at p < .05 (two-tailed). The descriptive statistics of the demographic data are the standard deviation (SD) and frequency (rate). Psychometric properties consider validity, reliability, and rigor. The content validity index was used to assess the content validity of the scale. Internal consistency was determined by the Cronbach α coefficient (>0.70). Item analysis is the process of examining the responses to individual items to assess the quality of the items; and identify the underperforming items; including the mean and standard deviation [
      • Moore G.C.
      • Benbasat I.
      Development of an instrument to measure the perceptions of adopting an information technology innovation.
      ,
      • Polit D.F.
      • Beck C.T.
      • Owen S.V.
      Is the CVI an acceptable indicator of content validity? Appraisal and recommendations.
      ,
      • Chen H.L.
      • Tzeng W.C.
      • Lu M.S.
      • Chou H.L.
      • Chen S.H.
      • Lin L.Y.
      Reliability and validity testing of the Taiwanese inpatient nursing care satisfaction scale: a pilot-study.
      ,
      • Wang Y.
      • Li H.
      Moral leadership and unethical pro-organizational behavior: a moderated mediation model.
      ]; the critical ratio (CR) is a test for item discrimination, and good item discrimination is statistical significance [
      • Moore G.C.
      • Benbasat I.
      Development of an instrument to measure the perceptions of adopting an information technology innovation.
      ,
      • Polit D.F.
      • Beck C.T.
      • Owen S.V.
      Is the CVI an acceptable indicator of content validity? Appraisal and recommendations.
      ,
      • Chen H.L.
      • Tzeng W.C.
      • Lu M.S.
      • Chou H.L.
      • Chen S.H.
      • Lin L.Y.
      Reliability and validity testing of the Taiwanese inpatient nursing care satisfaction scale: a pilot-study.
      ,
      • Wang Y.
      • Li H.
      Moral leadership and unethical pro-organizational behavior: a moderated mediation model.
      ]. Pearson correlation analysis is used to test the correlation between the items and the total score, and the significance level is 0.01 [
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ,
      • Moore G.C.
      • Benbasat I.
      Development of an instrument to measure the perceptions of adopting an information technology innovation.
      ,
      • Zijlmans E.A.
      • Tijmstra J.
      • Van der Ark L.A.
      • Sijtsma K.
      Item-score reliability as a selection tool in test construction.
      ]. EFA was used to determine the construct validity of the scale and used principal component analysis. To determine whether it is suitable for factor analysis, the Kaiser–Meyer–Olkin (KMO) value was used to measure the adequacy of the sampling. Bartlett's test of sphericity, factor loading, and measure of sampling adequacy were used to determine the suitability of items. Items with factor loading <.5 would be excluded; factors with an eigenvalue greater than 1.0 were retained as common factors. The factorization of the correlation matrix was determined by the KMO test >.70 was acceptable, and significant on the Bartlett's test of sphericity [
      • Fabrigar L.R.
      • Wegener D.T.
      • MacCallum R.C.
      • Strahan E.J.
      Evaluating the use of exploratory factor analysis in psychological research.
      ].

      Ethical considerations

      This study was approved by ethics committees; the approval came from an Institutional Review Board (No. CS2-19024). All participants gave their informed consent. Research data will be strictly protected and confidential. All participants were informed that they could withdraw from the study at any time without affecting their rights.

      Results

      Demographic characteristics

      A total of 205 participants came from 43 nursing schools in different regions of Taiwan. CNTs (400 in total) were invited to participate; 205 questionnaires were completed for data analysis, with a response rate of 51.25%. The age of the CNTs was between 26 and 57 years, with a mean age of 41.20 (±6.41) years; all were women (n = 205, 100%). Participants with a master's degree were 71.70% (n = 146) and with a bachelor's degree were 28.30% (n = 59). The mean clinical nursing work experience was 9.42 (±5.11) years, and the clinical nursing teaching experience was 8.38 (±5.76) years. Most of the clinical nursing experience was 11–15 years (n = 76, 37.07%), the clinical teaching experience was 1–5 years (n = 68, 33.17%) and 11−15 years (n = 66, 32.20%) accounted for the majority (Table 1).
      Table 1Demographic Data of CNTs (N = 205).
      Characteristicn (%)Mean (SD)
      Age (years)41.20 ± 6.41
      Gender
       Female205 (100)
      Education level
       Bachelor59 (28.30)
       Master146 (71.70)
      Years of clinical nursing work9.42 ± 5.11
       1−544 (21.46)
       6−1068 (33.17)
       11−1576 (37.07)
      1617 (8.29)
      Years of clinical nursing teaching8.38 ± 5.76
       1−568 (33.17)
       6−1055 (26.83)
       11−1566 (32.20)
      1616 (7.80)

      Overall status of the Clinical Nursing Teacher Self-efficacy Scale

      The CNTs demonstrated moderate to high self-efficacy (neutral to strongly agree); in this study, the most highly rated category was personality traits, which implies that the CNTs demonstrate confidence in their personality traits (3.04 ± 0.34); the second was clinical nursing competencies, that is, the CNTs recognize the importance of having clinical competencies (3.02 ± 0.45); after that was teaching ability (2.89 ± 0.43) and the teachers' professional growth ability (2.50 ± 0.65). Among the 35 items, the mean of each item ranges from 2.09 (±0.79) to 3.27 (±0.49), indicating that the respondents were neutral or strong agree on this scale. Twenty-four of these items had a mean score of 2.09 (±0.79)–2.99 (±0.47), indicating that the respondents were neutral or agree with the 24 items. There were 11 items with a mean score was higher than 3.0, which means that the CNTs in these 11 items showed agree or strong agree on self-efficacy (Table 2). However, the item with the lowest mean score of 2.09 (±0.79) was “Foreign language ability - English” (Table 2).
      Table 2The Item Discrimination and Pearson Correlation Coefficients of Clinical Nursing Teacher Self-efficacy Scale.
      NoItemsMean (SD)Critical ratio (CR)p valueCorrelation coefficient (R)p value
      A. Teachers' professional growth ability
      1Ability to read and study extensively in one's own professional field.2.73 (0.58)4.425<.01.467<.001
      2Ability to understand current or future development trends of the nursing profession.2.53 (0.62)8.035<.01.507<.001
      3Ability to learn and use modern and innovative teaching methods to assist in teaching.2.60 (0.58)8.857<.01.574.<.001
      4Ability to develop nursing science and apply evidence-based nursing (EBN).2.61 (0.61)8.849<.01525<.001
      5Ability to conduct independent nursing research.2.52 (0.65)6.972<.01.590<.001
      6Have the ability to read the nursing research literature.2.55 (0.59)5.199<.01.451<.001
      7Have self-improvement ability (such as participating in continuing education, academic conferences, presentation at international seminars, participating in teamwork, or interdisciplinary research projects).2.35 (0.77)5.054<.01.516<.001
      8International foreign language ability (English etc.)2.09 (0.79)3.899<.01.311<.001
      B. Teaching ability
      9Ability to assess students' knowledge and clinic skills.2.94 (0.36)2.768<.01.527<.001
      10Answer students' questions carefully and accurately.2.95 (0.38)1.714<.01.364<.001
      11Stimulate students' reasoning ability.2.87 (0.44)4.086<.01.603<.001
      12Ability to assess students' knowledge and clinic skills.2.89 (0.45)3.703<.01.661<.001
      13Stimulate students' interest in nursing.2.71 (0.57)6.304<.01.662<.001
      14Effectively organize and arrange clinical teaching plans.2.90 (0.44)2.230<.01.431<.001
      15Guide students to solve problems based on literature and evidence.2.89 (0.42)3.037<.01.623<.001
      16Establish a good learning environment.2.92 (0.43)3.921<.01.540<.001
      17Show students the clinical decision-making process.2.86 (0.43)3.935<.01.611<.001
      18When students encounter difficulties, provide individual help.2.97 (0.43)4.221<.01.546<.001
      19Quickly grasp the meaning of students' questions or students' words.2.87 (0.39)4.069<.01.598<.001
      C. Clinical nursing competency
      20Have good clinical nursing skills.3.06 (0.48)4.989<.01.546<.001
      21Have a good clinical problem assessment ability.3.01 (0.43)4.900<.01.621<.001
      22Have the ability to make judgments and analyses based on clinical data assessment.3.03 (0.43)3.524<.01.508<.001
      23Possess professional knowledge of the subject.3.02 (0.42)3.339<.01.548<.001
      24Ability to handle emergencies properly.2.99 (0.47)4.420<.01.589<.001
      D. Personal traits
      25Establish interpersonal relationships and a harmonious teamwork spirit.3.10 (0.43)2.269<.01.423<.001
      26Empathy3.08 (0.53)3.744<.01.493<.001
      27Effective self-management (such as emotional stability, punctuality, and compliance with rules).3.08 (0.49)3.558<.01.541<.001
      28Understand self-limitations.3.09 (0.46)3.460<.01.524<.001
      29Good communication skills.2.97 (0.43)3.979<.01.506<.001
      30Open-minded and not critical.2.96 (0.48)2.569<.01.418<.001
      31Enthusiastic and energetic.2.92 (0.60)3.960<.01.510<.001
      32Be responsible for your behavior.3.27 (0.49)2.838<.01.310<.001
      33Be a good role model for nursing students.3.09 (0.44)3.180<.01.429<.001
      34Master the level of student learning ability.2.90 (0.40)4.770<0.01.581<.001
      35Touch people's hearts (understand students to express their thoughts and feelings, so as to perceive and evaluate their own behavior).3.02 (0.46)4.358<0.01.656<.001

      Items discrimination analysis and homogeneity test

      Add all items in each subscale to get the total score. In the item discriminant analysis, the high-score group was in the top 27% and the low-score group was in the bottom 27%. Item analysis focuses on item and test quality and explores difficulty index (p-values; p-values converted to percentages) and discrimination index. The observed proportions in the two extreme groups into measures of item difficulty and item discrimination. Item discrimination helps to detect the ability of items to discriminate between low-achieving group and high-achieving score group [
      • Garrido C.C.
      • González D.N.
      • Lorenzo-Seva U.
      • Ferrando Piera P.J.
      Multidimensional or essentially unidimensional? A multi-faceted factor-analytic approach for assessing the dimensionality of tests and items.
      ,
      • Fan C.T.
      Note on construction of an item analysis table for the high-low-27-per-cent group method.
      ]. Item analysis constructs a high-low-27% group method. Generally, the top 27% are regarded as the high-achieving group, and the last 27% (73%) are regarded as the low-achieving group [
      • Garrido C.C.
      • González D.N.
      • Lorenzo-Seva U.
      • Ferrando Piera P.J.
      Multidimensional or essentially unidimensional? A multi-faceted factor-analytic approach for assessing the dimensionality of tests and items.
      ,
      • Fan C.T.
      Note on construction of an item analysis table for the high-low-27-per-cent group method.
      ]. In this study, item analysis was performed showing the discrimination indices, as well as the percentage of people in the upper and lower 27% who responded to each alternative. To examine the significant differences between the high-score group and the low-score group, an independent t-test was used; there was a significant difference between two groups (t = −10.634, p < .001) [
      • Moore G.C.
      • Benbasat I.
      Development of an instrument to measure the perceptions of adopting an information technology innovation.
      ,
      • Polit D.F.
      • Beck C.T.
      • Owen S.V.
      Is the CVI an acceptable indicator of content validity? Appraisal and recommendations.
      ,
      • Chen H.L.
      • Tzeng W.C.
      • Lu M.S.
      • Chou H.L.
      • Chen S.H.
      • Lin L.Y.
      Reliability and validity testing of the Taiwanese inpatient nursing care satisfaction scale: a pilot-study.
      ,
      • Wang Y.
      • Li H.
      Moral leadership and unethical pro-organizational behavior: a moderated mediation model.
      ]. A total of 15 items that did not meet the significant difference were eliminated; the remaining items showed statistically significant in CR values (Table 2).

      Internal consistency

      The overall scale reliability of the Cronbach α coefficient (>0.7 was acceptable) was 0.92, and 0.83, 0.91, 0.93, and 0.87 for the four subscales were acceptable [
      • Quaigrain K.
      • Arhin A.K.
      Using reliability and item analysis to evaluate a teacher-developed test in educational measurement and evaluation.
      ]. Regarding the correlation of each item with the total score, the results of Pearson correlation analysis between the items and the total scale score ranged from 0.310 to 0.662 (p < .001) (Table 2), which means that the 35 items correlated well with the scale, showing satisfactory reliability.

      Exploratory factor analysis

      EFA was conducted to examine the psychometric properties of the developed scale, in this study, EFA extracted four factors: (1) the teachers' professional growth ability; (2) teaching ability; (3) clinical nursing competencies; and (4) personality traits. Our result showed that the KMO value was 0.949, and Bartlett's test of sphericity was significant (χ2 = 6457.117, df = 595, p < .001). The results showed that 35 items were acceptable for factor analysis. Four factors explained 68.53% of the total variance (Table 3), and the variance explained for each factor (21.523, 19.633, 15.348, and 12.021) was presented in Table 3. The final version of the CNT-SES consists of four factors and 35 items.
      Table 3Factor Loading for Clinical Nursing Teacher Self-efficacy Scale.
      ItemComponents
      A. Teachers' professional growth ability
      1Ability to read and study extensively in one's own professional field..182.163.698.195
      2Ability to understand current or future development trends of the nursing profession..204.267.768.128
      3Ability to learn and use modern and innovative teaching methods to assist in teaching..284.216.720.147
      4Ability to conduct independent nursing research..121.177.692.209
      5Ability to develop nursing science and apply evidence-based nursing (EBN)..126.201.722.311
      6Have the ability to read the nursing research literature..183.117.738.135
      7Have self-improvement ability (such as participating in continuing education, academic conferences, presentation at international seminars, participating in teamwork, or interdisciplinary research projects)..002.202.679.197
      8International foreign language ability (English etc.).148.188.560.235
      B. Teaching ability
      9Ability to guide students to organize patients' problems..296.675.212.430
      10Answer students' questions carefully and accurately..369.701.182.231
      11Stimulate students' reasoning ability..291.676.332.200
      12Ability to assess students' knowledge and clinic skills..304.723.308.308
      13Stimulate students' interest in nursing..329.658.240.104
      14Effectively organize and arrange clinical teaching plans..261.700.235.360
      15Guide students to solve problems based on literature and evidence..322.750.286.249
      16Establish a good learning environment..462.635.265.177
      17Show students the clinical decision-making process..421.668.294.223
      18When students encounter difficulties, provide individual help..453.668.260.134
      19Quickly grasp the meaning of students' questions or students' words..414.599.284.234
      C. Clinical nursing competency
      20Have good clinical nursing skills..314.274.269.745
      21Have a good clinical problem assessment ability..339.354.288.726
      22Have the ability to make judgments and analyses based on clinical data assessment..333.325.250.767
      23Possess professional knowledge of the subject..341.299.263.742
      24Ability to handle emergencies properly..398.241.244.725
      D. Personal traits
      25Establish interpersonal relationships and a harmonious teamwork spirit..744.230.116.258
      26Empathy..731.245.134.212
      27Effective self-management (such as emotional stability, punctuality, and compliance with rules)..694.285.158.174
      28Understand self-limitations..715.252.141.174
      29Good communication skills..759.244.197.172
      30Open-minded and not critical..687.315.199.171
      31Enthusiastic and energetic..695.237.169.186
      32Be responsible for your behavior..690.239.118.247
      33Be a good role model for nursing students..679.307.106.289
      34Master the level of student learning ability..614.455.202.195
      35Touch people's hearts (understand students to express their thoughts and feelings, so as to perceive and evaluate their own behavior)..578.464.281.148
      The percentage (%) of variance by factors (Rotation sums of squared loading)
      Factor 1Factor 2Factor 3Factor 4
      21.52519.63315.34812.021
      Total percentage of the factor model 68.53%

      Discussion

      Demographic characteristics

      In this study, the majority of teachers have a master’ degree (71.70%), with clinical teaching experience 6–10 years (26.83%) and 11–15 years (32.20%) accounting for the majority, which means that more than half of the CNTs are experienced (59.03%). The result of this study showed the self-efficacy of CNT, with 33 of the 35 items were agreed or strongly agreed (mean ≥ 2.5). This study was consistent with Cayır and Ulupınar (2021) who found that perceptions of general self-efficacy and performance levels increased with age, occupational experience, and academic experience [
      • Cayır A.
      • Ulupınar S.
      The relationship among educational skills, general self-efficacy perceptions and performance in nursing instructors.
      ]. Although the individual items on the scale range from strongly disagree to strongly agree, the participants conducted a highly consistent assessment of these 33 items.

      Construct validity and reliability of the CNT-SES

      The newly developed CNT-SES showed a satisfactory estimation of psychometric properties. In the original CNT-SES development process, an item analysis was performed to guarantee fitting items for EFA; the results of the item analysis showed that 15 items were excluded because they did not meet the statistically significant and these 15 items obviously showed caring for students. Additionally, previous studies emphasized problem-solving ability, general teaching ability, nursing competence, clinical nursing skills, interpersonal relationships, and personality traits [
      • Morgan J.
      • Knox J.E.
      Characteristics of “best” and “worst” clinical teachers as perceived by university nursing faculty and students.
      ,
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ]; in this study, the item analysis of these items was considered a high score. The item analysis identified the high-score group and the low-score group, and an independent sample t-test was required to test whether there was a significant difference in the total score between the high-score group and the low-score group. The CR was statistically significant, indicating that the total score of the high-score group and the low-score group had good discrimination [
      • Mosier C.I.
      • McQuitty J.V.
      Methods of item validation and abacs for item-test correlation and critical ratio of upper-lower difference.
      ]. Additionally, correlation analysis was used to test whether the scores of each item were correlated with the total scale score. The higher the correlation coefficient, the stronger the internal consistency between items. Pearson correlation coefficients were interpreted as weak (r = .10–.30), moderate (r = .40–.60), strong (r = .70–.90) or very strong (r = 1.00) [
      • Akoglu H.
      User's guide to correlation coefficients.
      ]. The correlation coefficient is reported weakly with an r of .30; and consider removing items with correlation coefficients below .30 [
      • Moore G.C.
      • Benbasat I.
      Development of an instrument to measure the perceptions of adopting an information technology innovation.
      ,
      • Chen H.L.
      • Tzeng W.C.
      • Lu M.S.
      • Chou H.L.
      • Chen S.H.
      • Lin L.Y.
      Reliability and validity testing of the Taiwanese inpatient nursing care satisfaction scale: a pilot-study.
      ,
      • Cayır A.
      • Ulupınar S.
      The relationship among educational skills, general self-efficacy perceptions and performance in nursing instructors.
      ]. Fortunately, in this study, the correlation coefficient for each item was >.30. In addition, the results of the Cronbach α coefficient reliability test for the overall scale and for the four subdimensions were acceptable, ranging from 0.83 to 0.90, showing that the higher the value of Cronbach α, the higher the internal consistency between items. Furthermore, factor analysis is the most effective method to test construct validity; from these factors, some structural elements of psychostatistical concepts can be identified to understand the valid measurement factors [
      • Fabrigar L.R.
      • Wegener D.T.
      • MacCallum R.C.
      • Strahan E.J.
      Evaluating the use of exploratory factor analysis in psychological research.
      ]. The four dimensions explained 68.53% of the total variance, which met the criteria for selecting factors.

      Self-efficacy of CNTs and the significance of each attribute of the scale in clinical practical implications

      This study surveyed the self-efficacy of CNTs in clinical teaching settings by developing a structured questionnaire; CNT-SES was divided into four factors with a total of 35 items.

      Teachers' professional growth ability

      Items 1–8 were professional growth, research ability, and innovative teaching methods to facilitate teaching; according to our results, the CNT showed that the lowest self-efficacy was the professional growth ability. Hou et al. (2011) [
      • Morgan J.
      • Knox J.E.
      Characteristics of “best” and “worst” clinical teachers as perceived by university nursing faculty and students.
      ] found that teaching ability and clinical practice ability were the top two competence characteristics of clinical faculty; which was the same as our study included teachers’ professional growth ability and proficiency in theoretical knowledge, teaching ability, clinical nursing competencies, and clinical skills proficiency. However, despite having the lowest score in the four categories, the CNTs still highly recognized by the professional growth ability. This result was consistent with the results of previous studies on teaching effectiveness and competencies among CNTs [
      • Morgan J.
      • Knox J.E.
      Characteristics of “best” and “worst” clinical teachers as perceived by university nursing faculty and students.
      ,
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ]. Professional growth can effectively improve the general professional ability and teaching ability of teachers, which is conducive to mastery of the clinical knowledge and operational practices of nursing students [
      • Ghasemi H.S.E.
      • Rafii F.
      • Farahani M.A.
      • Mohammadi N.
      Being at peace as an important factor in acquiring teaching competency by Iranian nurse teachers: a qualitative study.
      ]. In addition, especially in item 8 “International foreign language ability-such as English” (2.09 ± 0.79), indicating that CNTs lack the ability or confidence to speak a foreign language (English). This result showed that the lowest ability was the ability to speak a foreign language, which means that the confidence of CNTs in the ability to speak a foreign language was not as good as other items, which was consistent with the study [
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ]. Therefore, we suggest that teachers pay more attention to cultivating foreign language skills. Nursing professions face new challenges at any time, and these challenges are accompanied by the need for new technologies and skills development to ensure that clinical nursing continues to advance and educate its profession. Teachers are more confident when they have extensive experience and expertise in the field they teach, use advanced technology to aid learning, and serve as role models for their students [
      • Rahimaghaee F.
      • Nayeri N.D.
      • Mohammadi E.
      Managers' roles in the professional growth of Iranian clinical nurses.
      ]. The self-professional growth of nursing teachers enables them to achieve proficiency in clinical competencies [
      • Lovrić R.
      • Prlić N.
      • Milutinović D.
      • Marjanac I.
      • Žvanut B.
      Changes in nursing students' expectations of nursing clinical faculties' competences: a longitudinal, mixed methods study.
      ,
      • Zlatanovic T.
      • Havnes A.
      • Mausethagen S.
      A research review of nurse teachers' competencies.
      ], and implementing optimal teaching of nursing curriculum, support training programs, and provide nursing students with quality nursing education is critical. Therefore, the promotion of professional growth and development of CNTs is of great significance and administrators should consider investing in the professional growth and development of CNTs.

      Teaching ability

      In this study, the teaching ability score was 2.89 (±0.43). Good clinical teaching leads to good clinical learning [
      • Ghasemi H.S.E.
      • Rafii F.
      • Farahani M.A.
      • Mohammadi N.
      Being at peace as an important factor in acquiring teaching competency by Iranian nurse teachers: a qualitative study.
      ]. The focus of CNTs is clinical practice teaching; they must be able to instruct students while providing care to the patient, including helping students learn to care for patients, nursing technology and skills, planning assignments or evaluating students' learning outcomes, maintaining patient safety and fostering relationships with students, patients and nursing staff [
      • Yang C.I.
      • Chao S.Y.
      Clinical nursing instructors' perceived challenges in clinical teaching.
      ,
      • Collier A.D.
      Characteristics of an effective nursing clinical instructor: the state of the science.
      ,
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ,
      • Lovrić R.
      • Prlić N.
      • Milutinović D.
      • Marjanac I.
      • Žvanut B.
      Changes in nursing students' expectations of nursing clinical faculties' competences: a longitudinal, mixed methods study.
      ]. CNTs are responsible for cultivating students’ abilities in decision-making, critical thinking, and developing successful interpersonal relationships in clinical practice [
      • Yang C.I.
      • Chao S.Y.
      Clinical nursing instructors' perceived challenges in clinical teaching.
      ,
      • Hou X.
      • Zhu D.
      • Zheng M.
      Clinical nursing faculty competence inventory-development and psychometric testing.
      ]. They guide students to implement the correct nursing interventions to improve their skills and prepare them to be a good nurse [
      • O'Rae A.
      • Langille J.
      • Li A.
      • Sealock K.
      • Rutherford G.
      The evolving role of a clinical instructor in an integrated undergraduate nursing curriculum.
      ,
      • Omer T.A.
      • Suliman W.A.
      • Moola S.
      Roles and responsibilities of nurse preceptors: perception of preceptors and preceptees.
      ]. In addition, CNTs' assignments include classroom lecturing, research, or participation in seminars to improve their teaching ability.

      Clinical nursing competencies

      Additionally, CNTs recognize the importance of having clinical competencies (3.02 ± 0.45). The clinical nursing competencies of CNTs are the most important factor that affects the clinical learning [
      • Lovrić R.
      • Prlić N.
      • Milutinović D.
      • Marjanac I.
      • Žvanut B.
      Changes in nursing students' expectations of nursing clinical faculties' competences: a longitudinal, mixed methods study.
      ,
      • Zlatanovic T.
      • Havnes A.
      • Mausethagen S.
      A research review of nurse teachers' competencies.
      ]. However, when teachers have insufficient clinical experience and lack the relevant skills to facilitate student learning, students cannot learn effectively in the clinical field, and the level of CNT skills may affect students' perception of the teacher's ability [
      • Zijlmans E.A.
      • Tijmstra J.
      • Van der Ark L.A.
      • Sijtsma K.
      Item-score reliability as a selection tool in test construction.
      ,
      • Akoglu H.
      User's guide to correlation coefficients.
      ,
      • Mukan S.M.W.
      • Kulai D.
      • Nor R.H.C.M.
      Nursing students' perceived effective clinical teachers' behaviors.
      ]. Professional competence has been proposed as a core element of nursing [
      • Fabrigar L.R.
      • Wegener D.T.
      • MacCallum R.C.
      • Strahan E.J.
      Evaluating the use of exploratory factor analysis in psychological research.
      ,
      • Omer T.A.
      • Suliman W.A.
      • Moola S.
      Roles and responsibilities of nurse preceptors: perception of preceptors and preceptees.
      ]. The development of professional competence, that is, the provision of nursing services according to professional standards, is crucial. In the past, the professional competence of nurses was defined as the combination of skills, knowledge, attitudes, values, and competencies that lead to effective or high performance in occupational and professional positions [
      • Epstein R.M.
      • Hundert E.M.
      Defining and assessing professional competence.
      ]. Similarly, the professional competence of nursing teachers is an essential requirement, and nursing teachers must be more competent and committed to their nursing or clinical teaching.

      Personality traits

      Items 25–35 are related to personality traits; they demonstrate self-efficacy in their personality traits. The literature indicated that the personality traits and characteristics of CNTs have a profound impact on the clinical experiences of students [
      • Collier A.D.
      Characteristics of an effective nursing clinical instructor: the state of the science.
      ,
      • Okoronkwo I.L.
      • Onyia-Pat J.L.
      • Agbo M.A.
      • Okpala M.A.E.
      • Okpala P.U.
      Students' perception of effective clinical teaching and teacher behavior.
      ]. In this category, teachers showed greater confidence in communication skills and interpersonal relationships, which was consistent with previous studies showing that the ability to develop interpersonal relationships is the most valued skill by clinical teachers [
      • Heydari A.
      • Yaghoubinia F.
      • Roudsari R.L.
      The multidimensional nature of relationships: the perceptions of Iranian nursing students and educators of the student-educator relationship.
      ,
      • Klassen R.M.
      • Tze V.M.C.
      Teachers' self-efficacy, personality, and teaching effectiveness: a meta-analysis.
      ,
      • Dos Santos L.M.
      Upgrading nursing students' foreign language and communication skills: a qualitative inquiry of the afterschool enhancement programmes.
      ]. Certain items such as empathy, open-mindedness and enthusiasm are also consistent with Collier (2018) who identified approachability as the most important personality trait of clinical teachers [
      • Barni D.
      • Danioni F.
      • Benevene P.
      Teachers' self-efficacy: the role of personal values and motivations for teaching.
      ]. Furthermore, being responsible for behavior, emotional stability, punctuality, obedience to rules, and understanding self-limitations, which means focusing on proactive behaviors, including aspirations and efforts to start changing yourself and/or the environment, as well as self-initiated (as opposed to passive) and change-oriented (as opposed to maintaining the status quo) and focus on the future (instead of focusing on the current situation) [
      • Hirschi A.
      • Koen J.
      Contemporary career orientations and career self-management: a review and integration.
      ].

      Looking toward the future

      In this study, the author suggested that the definition of self-efficacy of CNT was that the CNTs possessed four characteristics: professional growth ability, teaching ability, clinical nursing competencies, and positive personality traits. In recent years, with the rapid development of international health issues and international nursing education, several studies have appeared on teacher self-efficacy. However, the strengths of the tool we developed and compared to similar tools in the past were that this study highlights the potential and self-efficacy of CNT in the future nursing profession, modern education technology, innovative teaching methods, nursing science, international conferences, leadership, evidence-based nursing, research competence, and interdisciplinary learning; these issues have received more attention [
      • Ehrenberg A.
      • Gustavsson P.
      • Wallin L.
      • Boström A.M.
      • Rudman A.
      New graduate nurses' developmental trajectories for capability beliefs concerning core competencies for healthcare professionals: a national cohort study on patient-centered care, teamwork, and evidence-based practice.
      ]. To maintain the pace and progress in nursing practice and education, we may need to pay more attention to the application of EBN and independent research ability in clinical nursing practice rather than traditional concepts of competency [
      • Kjerholt M.
      • Hølge-Hazelton B.
      Cultivating a culture of research in nursing through a journal club for leaders: a pilot study.
      ].

      Study limitations

      The limitation of this study was that it was not easy to collect data while having direct face-to-face contact with all CNTs in Taiwan because the participants were teachers of nursing schools and assigned to various hospitals and scattered in various regions. Therefore, the sample was not expanded, which was our main limitation. Additionally, it was not easy to collect data directly and complete the questionnaire, which may limit sample sizes. Therefore, we sent email notifications and questionnaires to collect data, and the email was sent many times to all potential participant; however, the response rate was not as expected. Furthermore, more comprehensive studies are needed to explore the self-efficacy of CNTs in different cultures and contexts.

      Recommendations

      We encourage researchers to use the entire scale for future research or clinical practice. In future research, we suggest that this tool can be used to explore the perceptions of nursing students about CNT in nursing education. We suggested modifying the CNT-SES from the views of nursing students to measure students' perceptions of the effectiveness and competence of CNTs. This tool can serve as the basis for creating a self-efficacy assessment tool in the field of nursing education, which can be used to train and assess the self-efficacy of CNT. CNT-SES can also serve as an assessment tool for observational and intervention studies of teacher self-efficacy in future research. The significance of using this tool depended on the evaluation results of each attribute of the scale, to formulate strategies for CNTs to improve self-efficacy. Therefore, it is important to refer to the various items of the CNT-SES in clinical practice to develop teaching strategies to promote the self-efficacy of CNTs and further facilitate the clinical learning of students. Our suggested strategies include an appropriate continuing education course should be formulated for each attribute of the item, encouraging the setting of personal goals, sharing teaching experiences and participating in Nursing Teachers Associations, building self-confidence and empowerment to help teachers improve their self-efficacy.

      Conclusions

      The 35-item CNT-SES provides an available assessment tool with good reliability and validity. CNTs showed moderate to high self-efficacy. The study findings offered information on the characteristics of self-efficacy of CNT, including nursing professional growth, teaching ability, nursing competence, ability to develop interpersonal relationships, and certain personality traits. These efficacy characteristics are mainly reflected in the perception of self-efficacy of CNT, and their identification can guide clinical nursing teaching strategies.

      Funding

      This research was supported by the Ministry of Science and Technology of Taiwan [ 108-2314-B-040-002- ].

      Ethical approval

      The study protocol was reviewed and approved by the Ethics Committee of Chung Shan Medical University Hospital (No. CS2-19024). Date of approval: May 15, 2019.
      The author agrees to be responsible for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

      Conflict of interest

      The authors declare that they have no competing interests.

      Acknowledgments

      The authors would like to thank all clinical nursing teachers who participated in this study.

      Appendix A. Supplementary data

      The following are the supplementary data to this article:

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