Iranian Journal of Medical Education

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Introduction: In recent years, professional development of teachers has become an important issue in educational system. The question of work has been the kind of supervision needed to save and secure teacher's successful performance in his/her teaching career. The present study aimed at answering this question. Methods: The study was preformed in two phase: At first a quasi-experiment on 372 randomly selected students was done. The exposed group's teachers were under clinical supervision. In the second phase, the clinical supervision method was evaluated based on opinions of 50 faculties and educational authorities. Results: In the exposed group, the rate of student's learning proved to be significantly higher (P<0.001). Those students evaluated their teacher's professional behaviors as more positive compared to teacher evaluations made by students in the control group (P<0.001). Full agreement and agreement to perform clinical supervision were expressed by 62.5 percent of respondents in the second phase study, whereas 91.7 percent of the same attitude was found toward self-evaluation (The latter was expressed as one of the best solutions for quality problems of teaching). The majority of respondents insisted on maintaining stable environment for teaching, a decrease in number of students and proper teacher selection methods as the other solutions. Conclusion: Applying clinical supervision method had a positive effect on students learning and teachers' performance. Thus this method should be considered as one of the basic ways to develop educational system in the field of medical sciences.

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With shorter periods of hospitalization, fewer in patient beds and more health care facilities in the society patients are now more acutely ill and highly dependent, causing less opportunities for medical students to practice and learn basic clinical skills. On the other hand, enhanced patient rights and other learning limitations require that professional education provide not only knowledge and practical skills, but also graduates with communication skills and attitude towards learning. Therefore, the Clinical Skills Learning Center (CLSC) has been developed in response to these issues in medical education and changing health care policies. It gives students the opportunity to practice a wide range of practical skills in a stress free and controlled environment, by using medical simulators, models, computers and other educational sources. Review of twenty CSLCs through internet and also review of related articles shows that CSLC can provide connection between theoretical subjects and practical skills, reduce student’s anxiety and teach communication skills more effectively. A successful skills center needs to be flexible in its design, integral to the curriculum and relevant to educational and training requirements. This requires a proper planning, organization and resources. This article attempts to present a general schema of CSLC and its application by investigating and comparing CSLC in different universities of the world.

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Background. Practice is where skills are developed and where theory must pass testing but there is a gap between classroom education and practice in nursing. The clinical supervision is a demonstration project of advanced practice and bridging the gap between theory and practice. Clinical supervision is a mechanism supporting both professional and personal development. The main purpose of this study is to evaluate the effects of clinical supervision on nursing students skills including interpersonal, professional and communication. Methods. This is a quasi-experimental study in which 100 nursing students under clinical training were selected by simple sampling method and were divided into two case and control groups. The data was collected by a questionnaire. For the case group, clinical supervision was applied by a staff member and an instructor for a two week period while that of the control group was a two week nursing practice conducted only by an instructor. Then the students’ viewpoints about interpersonal , professional and communication skills before and after the two week training were compared in both groups. Results. The findings showed that according to the students’ viewpoints the differences between the means of interpersonal, professional and communication skills and total skills in pre- and post-application of clinical supervision were statistically significant in the case group but in the control group they weren’t statistically significant before and after training. Conclusion. The results of this study indicate that designing teaching clinical courses based on clinical supervision model can promote interpersonal, professional and communication skills of the nursing students. Therefore, considering the problem of practice in nursing education and the effectiveness of clinical supervision followed in this study and other studies such as the ones conducted by Severinsson Sloan & Bishop , its vast application in teaching clinical courses in nursing is highly recommended.

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Background. The gap between what is theoretically taught and what is practically experienced has always been a remarkable issue in nursing. The present study was an attempt to explore the amount of coordination between learning activities and clinical nursing services. A comparison was made between them through comparing the means of ratings by nursing students, teaching staff and nursing employees. Also, factors causing the gap as viewed by subjects were studied. Methods. This research was carried out using triangulation quantitative and qualitative methods. In the first phase of the study through phenomenological method, the relationship between learning activities and clinical nursing services, and the variables affecting them were assessed by interviewing 10 nursing students, teaching staff and nursing employees and a questionnaire was finally designed. Analytic-Descriptive method was used in the second phase of the study during which the means of the scores earned from nursing students, teaching staff and nursing employees’ viewpoints about theoretical learning and clinical nursing services were statistically calculated. The areas covered were principles and techniques in nursing, medical and surgical nursing, community health nursing, mother and child health, pediatrics nursing, psychiatric nursing, client teaching, management in nursing, and nursing process. Using Likert’s scale, the items were ranked as completely coordinate, coordinate, partially coordinate, incoordinate, and completely incoordinate. Also for related variables using Likert’s scale, the items were ranked as completely effective, effective, partially effective, ineffective, and completely ineffective. Descriptive statistics were used to calculate and compare the means. Results. The findings indicate that according to the nursing students, teaching staff and nursing employees, learning activities and clinical nursing services do not have necessary coordination. Of the three groups studied, the teachers believed in less amount of coordination between the learning activities and clinical nursing services. Besides the null hypothesis regarding the differences between the viewpoints expressed by students, teachers and the nursing staff were confirmed. Discussion. Appreciation and recognition of the gap between the learning activities and clinical nursing services and the factors affecting it can result in bridging up the gap. A reappraisal of the nursing education curriculum with regard to the effective variables is recommended so that the theoretical and practical activities are better orchestrated.

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Abstract Introduction. This survey was performed to assess the competency level of last year medical students (Interns) in performing 20 selected basic clinical procedures as well as the effect of learning opportunities on their competency level. Methods. 200 randomly selected interns were asked to fill a questionnaire in order to self-assess their competency in performing 20 procedures and to record the ones they used in practice. These procedures were selected from current educational programs, according to expert opinion. They were also asked about the related learning opportunities they faced in clinical wards. The 20 selected procedures were divided into three groups by employing factor analysis with Varimax rotation (KMO=0.87). Results. The mean level of skills for the first group (general techniques) was 51.4%. Students assessed their level of skills "poor" for lumbar puncturing, airway intubation, splinting, chest tube insertion, and removal of superficial foreign bodies from the ear and the eye. They learnt most of the techniques through observation. Most of the students performed the procedures without direct supervision of teachers or residents. The majority of the students did not have the opportunity to use manikins for learning. Conclusion. The results suggested that competence of the students in performing most of the procedures was insufficient and most of them did the procedures without the needed training. It is recommended that using some educational facilities including skill labs and student assessment methods including OSCE (Objective Structured Clinical Evaluation) can play an important role in improving students’ level of skills in performing clinical procedures, especially before working as interns at clinical wards and in order to respect patients’ rights.

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Introduction. The significance of fostering critical thinking in students has been explicated by the increasing rate of knowledge and information. To assimilate knowledge and to assess the considerable amount of information, students need to develop their thinking skills. Considering reflection as a teaching strategy and one of the most effective ways for fostering thinking, this study was designed to determine the effect of reflection on thinking skills of nursing students at Tabriz faculty of nursing and midwifery. Methods. 40 senior nursing students participated in this study voluntarily. After receiving the necessary information regarding their participation they took California Critical Thinking Skill Test. Then they were divided into 2 equal case and control groups. Both groups had their routine clinical programs, but the interventional program was offered only to the case group. This interventional program consisted of 3 main parts: A 4 day workshop on reflection and 10 weeks reflection on their clinical experiences, concluding dialog journals and writing up logs. At the end of their clinical program, both groups took the same test as pretest. Data were analyzed by paired T-test and T-test. Results: Results of the study revealed that reflection has been effective on improving inductive reasoning and total scores of critical thinking skills of students. Conclusion: Improving general critical thinking skills due to a disciplinary specific strategy was a valuable outcome. Regarding this results, reflection is recommended to be infused in our educational program.

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Introduction. Encountering clinical environments as an inseparable part of studying medicine could bring about tension and anxiety for medical students. Early clinical exposure has been suggested in order to decrease these stresses and to motivate students for a better attitude and awareness. This study was performed to determine the effect of a short-term period of exposing to clinical environment on medical students' attitude toward medical education and their future career. Methods. In an interventional study performed as pre-test/post-test, 45 first and second year medical students were encountered clinical environments in rounds, operating rooms, emergency wards and out patient clinics, under the supervision of a mentor. They experienced one night in emergency ward. Students’ attitude was assessed by a questionnaire using Likert scale. Results. The score of attitude towards the effectiveness of medical education elevated (31%) at the end. While the score of attitude towards medical profession was 12% less than the first day. More positive change in attitude towards medical education was seen in women but this difference was not seen in attitude towards medical profession. 86% agreed or strongly agreed with necessity of this program for first year medical students96% thought that this course had motivated them to study more at school and the same rate said that this course made learning medicine more attractive and enjoyable. All of the students wanted to come to the hospital in the future, voluntarily. 65% mentioned that medical profession was more difficult than what they had thought. 35% agreed or strongly agreed that patients appeared different from what they had imagined before. Conclusion. This study clearly showed the effect of early exposure to clinical environment as a place for both education and patient care. Although the sample size and conditions of the study do not allow us to generalize the results to medical students’ population, the intervention influenced a positive change in medical students’ motivation for learning during their study years. It made them more aware of their future career.

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Introduction. One of the most important activities of leadership and management in educational organizations is supervising instructors’ performance. Supervision can be applied as administrative or clinical supervision. Administrative supervision is usually performed through official channels, and clinical supervision takes place using individuals’ relationship and is based on promoting instructors’ professional personality and improving the quality of students learning. This study was designed to compare faculty members' viewpoints regarding the effect of administrative and clinical supervision on teaching-learning process. Methods. 135 faculty members of medical universities including medical university of Hamedan, Tehran, Shahid Beheshti and Isfahan who were selected by cluster sampling method, filled a questionnaire. The data was analyzed by SPSS software, using descriptive statistics and Wilcoxon test. Results. The mean of the scores of participants’ viewpoints about the effects of clinical supervision on improving the quality of teaching-learning was more than the mean of the scores concerning administrative supervision. Also, the participants evaluated the application of clinical supervision with regard to the researcher’s suggestions very useful in improving the quality of teaching- learning. Conclusion. The application of clinical supervision can improve the quality of student’s learning by developing and promoting teaching skills of the instructors and as a result increases the efficiency of educational system.

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Introduction. Nursing instructors, in addition to having faculty members' responsibilities such as teaching and doing research, offer community services as well. These responsibilities often cause great amount of job stresses for them. The purpose of this study was to determine the stressors in clinical and theoretical nursing education on nursing instructors. Methods. This descriptive-analytical study was performed using a questionnaire as data collecting tool. The research sample included 96 faculty members from nursing and midwifery faculties in Tehran who were selected by simple stratified sampling method. Results. The results of this study showed lack of preparation and educational experience in theoretical teaching, and heavy workload caused by teaching theoretical and clinical courses, administrative responsibilities and inequality feeling, in clinical teaching were the most stressful factors. Also, in theoretical teaching, large class size, working with faculties having different habits and values and keeping professional knowledge according to new sciences and professional development caused a high degree of stress. Moreover, providing sufficient individual supervision for each student, unclear policy regarding substitute instructor in time of sick leave or vacation and lack of preparation and experience, in clinical teaching were other stressful factors.. Conclusion. Many factors in clinical and theoretical courses have been identified as stressors. It is recommended, theoretical nursing courses be taught as team teaching, and experienced instructors work with instructors with less experience. Also, educational programs should be planned in a way that nursing instructors with administrative responsibilities teach less theoretical and clinical courses.

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Introduction. The medical emergencies need not only clinical skills but also proper capabilities of the physicians. Meanwhile, researches show that young physicians are not properly trained to encounter the events threatening patients' lives. So, this study was designed to investigate the effect of an innovative emergencies course on clinical skills of medical students facing emergency patients. Methods. A semi-experimental interventional study was performed as pre-test/post-test in September 2002 in Ayatollah Kashany teaching hospital affiliated to Isfahan University of Medical Sciences. The duration of the designed course was one month and had two theoretical and practical sections. Fifteen students who had passed internal medicine and surgery courses were chosen and divided into five groups. The students' attitude towards their capabilities to encounter emergencies was asked at the beginning and at the end of the course by questionnaires. Also, at the end, the students filled an attitude questionnaire regarding the whole course. The data was analyzed with Wilcoxon test. The mean and standard deviation were calculated. Results. In most fields except ear, nose and throat section (E.N.T.), students assessed their capabilities at the end of the course higher than before. Conclusion. This course was designed mostly on trauma emergencies. The result showed the positive effect of emergency medicine education in improving the self confidence and capabilities of medical students and revealed the need to include this course as a part of medical education.

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Introduction: Clinical Education is the essential part of nursing education. Because the nursing teachers' clinical role is not clearly defined, this study was designed to understand the clinical role and its process in nursing teachers. Methods: This was a qualitative research (Grounded Theory) in which 15 nursing teachers of five nursing schools participated based on theoretical sampling. The data were collected using a semi-structured interview. The data constant comparison was used for analysis. Results: Categories including role clarity, professional identity, professional autonomy and fitting in were proposed as the means of describing how the respondents approached their clinical role. Conclusion: Due to perceived role ambiguity and professional dependence, the nursing teachers have problems in achieving their role of mastery. They try to avoid these problems by making a new professional identity and fitting in strategies. Unfortunately, these strategies banish them from educational real goals. Key words: Nursing Teachers, Clinical Role, Role Clarity, Nursing Education Address: Zamanzadeh V, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran Source: Iranian Journal of Medical Education 2002 6: 27-32.

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ارزیابی تصمیم‌گیری بالینی دانشجویان مامایی نفیسه‌السادات نکویی، مینو پاک گوهر، زهره خاکباران، محمود محمودی چکیده مقدمه: تصمیم‌گیری بالینی از سری تصمیم‌گیری مهارتی است که در ارتباط با وضعیت بیمار انجام می‌شود. ارزیابی کیفیت و نیز آموزش تصمیم‌گیری بالینی پرسنل بهداشتی می‌باشند. الگوی اداره مشکل بیمار PMP(Patient Management Prolem ) از جمله روش‌های ارزیابی تصمیم‌گیری بالینی است. این پژوهش با هدف ارزیابی تصمیم‌گیری بالینی دانشجویان مامایی با استفاده از PMP رایانه‌ای انجام گرفته است. روش‌ها: در یک مطالعه پیمایشی، کلیه دانشجویان سال آخر کارشناسی مامایی دانشگاه‌های علوم پزشکی تهران، ایران و شهید بهشتی که کلیه واحدهای خود را گذرانده‌اند به صورت سرشماری (40=N) مورد مطالعه قرار گرفتند. پرسشنامه PMP رایانه‌ای شامل 9 مورد بیمار فرضی در ارتباط با مراقبت قبل از بارداری طراحی شده در یک نرم‌افزار رایانه‌ای توسط دانشجویان تکمیل شد. نتایج حاصل از این داده‌ها با استفاده از آمار توصیفی و رگرسیون چندگانه با نرم‌افزار آماری SPSS آنالیز گردید. نتایج: به طور کلی میانگین نمره کسب شده توسط دانشجویان مورد پژوهش از 100 نمره کل، 01/7±62/35 بود و اکثریت واحدهای مورد پژوهش در سطح متوسط تصمیم‌گیری بالینی قرار داشتند. میانگین نمره کسب شده دانشجویان در ارزیابی خطر 14/9±17/40، آموزش و مشاوره 23/10±87/31 و نفیسه السادات نکوئی (مربی)، گروه مامایی دانشکده پرستاری و مامایی، دانشگاه علوم پزشکی و خدمات بهداشتی- درمانی استان اصفهان، اصفهان e-mail:nekuei@nm.mut.ac.ir و در مداخله 77/13±42/31 بود و اکثریت واحدها در این سه حیطه نیز در سطح متوسط تصمیم‌گیری بالینی قرار داشتند. بحث: از آنجا که تصمیم‌گیری بالینی عامل مهمی در ارائه بهتر خدمات توسط پرسنل بهداشتی (وهمچنین دانشجویان مامایی) می‌باشد که امکان آموزش و ارزیابی آن با استفاده از PMP میسر است، بنابراین، توجه به آموزش دقیقتر آن در برنامه‌های آموزشی ضروری به نظر می‌رسد. واژه‌های کلیدی: تصمیم‌گیری کلینیکی، دانشجویان مامایی، اداره مشکل بیمار، ارزشیابی. مقدمه تصمیم‌گیری بالینی یک جزو اصلی عملکرد بالینی است (1). و در واقع اساس کار برای بیمار و شاخصی برای قضاوت ماهرانه می‌باشد. این عملکرد یک مرحله شناختی برای حل مشکلات بالینی است. در واقع تصمیم‌گیری بالینی را می‌توان تصمیم‌گیری در مورد مداخلات و راه‌هایی دانست که به بیمار کمک می‌کند تا از شرایط فعلی به شرایط مطلوب نهایی انتقال یابد(2). با توجه به افزایش روز افزون هزینه مراقبت بهداشتی، امروز جوامع در کنار توجه به بیمار، به جنبه‌هایی اقتصادی توجه بیشتری می‌کنند. تصمیم‌گیری‌های درست می‌تواند به کاهش هزینه و پیشرفت بیشتر درمان کمک کند. باعث تسهیل و افزایش استفاده درست از منابع انسانی و مواد شده و بهبود کیفیت مراقبت را به همراه داشته باشد (3). محیط بالین دارای ویژگی‌های منحصر به فرد و از بسیاری جهان با سایر محیط‌ها تفاوت دارد. بنابراین، عملکرد کارکنان در این محیط از اهمیت ویژه‌ای برخوردار می‌باشد. در محیط بالین لازم است هر فردی تصمیم بالینی درستی اتخاذ نماید. این تصمیم درست در موارد خطرناک نقش و اهمیت خود را بیشتر نشان می‌دهد و در این حالت، عدم تصمیم‌گیری درست و به موقع می‌تواند مراحل درمان و مراقبت را طولانی و با مشکل مواجه سازد (4).یک متخصص بالینی باید تصمیم بگیرد که چه اطلاعاتی را جمع آوری کند؟ اطلاعات را چگونه تفسیر کرده و مداخله درست انجام دهد؟ و نهایتاً سرانجام کار را ارزیابی نماید (1). با توجه به مطالب ارائه شده پیرامون اهمیت تصمیم‌گیری بالینی، لزوم کیفیت آن در پرسنل بهداشتی برای ارائه بهتر خدمات بالینی توسط آنها احساس می‌شود. امروزه در سیستم ارزیابی از روش‌های مختلف استفاده می‌گردد. از جمله این روش‌ها الگوی اداره مشکل بیمار PMP(Patient Management Problem) است که به صورت‌های مختلف رایانه‌ای و کتبی ارائه می‌گردد. PMP از سال 1980 به عنوان روشی برای ارزیابی صلاحیت بالینی دانشجویان و فارغ التحصیلان به کار رفته است (5). PMP اولین بار در آمریکا برای امتحان بورد کالج پزشکان آمریکا استفاده شد. این امتحان یک روش قابل استفاده برای ارزیابی تصمیم‌گیری در موقعیت‌های مختلف پزشکی و بالینی می‌باشد و گاهی به عنوان یک الگوی شبیه سازی از آن استفاده می‌گردد که ابزار مناسبی در آموزش دانشجویان علوم پزشکی است. با استفاده از CPMP(Computerized PMP) بسیاری از اشکالات PMP برطرف شده است. CPMP برای آموزش و ارزیابی بالینی به راحتی استفاده می‌شود (6). یک PMP معمولاً با یک عبارت بالینی در ارتباط با مشکل موجود یک بیمار، همراه با خلاصه‌ای از شرح حال و اطلاعات مربوط به معاینه بیمار شروع می‌شود. بعد از آن چند مرحله در ادامه به صورت پی در پی مطرح می‌گردد و در هر مرحله از دانشجو خواسته می‌شود در مورد اداره و ارزیابی بیمار تصمیم بگیرد. وی باید تصمیمی را که به نظر او مناسب شرایط بیمار است، اخذ نماید. بعد از اینکه تصمیم گرفته شد، اطلاعات مخفی بیشتری مشخص می‌شود که نتیجه تصمیم گرفته شده را نشان می‌دهد. در مرحله بعد، دانشجو بر اساس اطلاعات به دست آمده، تصمیم‌ بعدی را خواهد گرفت. فرایند برنامه ریزی PMP به صورت زیر می‌باشد: - اطلاعات در باره بیمار و مشکل وی - تصمیم‌گیری در مورد مشکل توسط دانشجو - ارائه بازخورد به پاسخ ارائه شده - پایان مشکل این مراحل تصمیم‌گیری، ارائه بازخورد و اطلاعات بعدی تا چند مرحله تکرار خواهد شد(7). CPMP با توصیف یک مورد بالینی شامل: سن بیمار، شرایط قبلی وی، علائم و نتایج بالینی در قالب یک نرم افزار رایانه‌ای شروع می‌شود و یک سری نکات مهم برای اخذ تصمیم داوطلب، ارائه می‌دهد. پس از تصمیم‌گیری داوطلب بازخورد از طریق سیستم رایانه‌ای به وی داده می‌شود و به دنبال آن، داوطلب تصمیم‌گیری ‌های خود را در PMP ادامه می‌دهد. این مدل به صورت دقیقی مراحل تصمیم‌گیری را که در عملکرد بالینی لازم است در قالب یک برنامه رایانه‌ای به صورت تعامل بین کاربر و رایانه منعکس می‌کند (4،6،7). در یک تقسیم بندی PMP به دو نوع خطی و شاخه‌ای تقسیم می‌شود. در نوع خطی، سؤالی به فرد ارائه می‌شود که شامل چند قسمت است: در ابتدا اطلاعاتی در باره بیمار به وی ارائه می‌گردد و سؤالی پرسیده می‌شود. امتحان دهنده باید پاسخ سؤال را به صورت تشریحی و یا انتخاب گزینه بیان کند در مرحله بعد، به وی بازخورد ارائه می‌شود و قسمت بعد همین سؤال مطرح می‌گردد و تا چند مرحله این سیر ادامه می‌یابد. در هر مرحله، فرد باید تصمیم مناسب بگیرد. در نوع شاخه‌ای در هر مرحله بر حسب پاسخ فرد به سؤال، قسمت متفاوتی در مقابل وی گشوده می‌شود و مسیر جدیدی برای تصمیم‌گیری او مشخص می‌گردد (4،6،7). دانشجویان مامایی به عنوان نیروهایی که به زودی وارد سیستم ارائه خدمات بهداشتی- درمانی می‌شوند، لازم است از قدرت تصمیم‌گیری بالینی بالایی برخوردار باشند. ارزیابی قدرت تصمیم‌گیری آنها می‌تواند برنامه‌ریزی بهتر سیستم آموزش را به‌همراه داشته باشد. دراین مطالعه از میان مطالب مهم و قابل توجه درمامایی، مسأله مراقبت قبل از بارداری انتخاب‌ شده ووضعیت تصمیم‌گیری‌‌‌بالینی دانشجویان مامایی درارتباط با آن مورد بررسی قرارگرفته است. هدف از این مطالعه تعیین وضعیت تصمیم‌گیری بالینی دانشجویان مامایی با استفاده از CPMP است. منظور از مهارت تصمیم‌گیری بالینی در این پژوهش، انتخاب روش ارزیابی، آموزش و مشاوره و مداخله مناسب برای ارائه مراقبت‌های قبل از بارداری برای کلیه خانم‌های سن باروری می‌باشد که به وسیله پرسشنامه به روش CPMP رایانه‌ای بر اساس میزان پاسخ‌های صحیح و مقیاس خوب، متوسط و ضعیف اندازه‌گیری شده است. روش‌ها این پژوهش یک مطالعه پیمایشی- مقطعی، تک گروهی و یک مرحله‌ای بود که از مهر تا آذر ماه سال 1381 در دانشگاه‌های علوم پزشکی تهران، شهید بهشتی و ایران به صورت سرشماری انجام شده است (40=N). معیار ورود به مطالعه، دانشجویان سال آخر کارشناسی مامایی بود که واحدهای تئوری و کارآموزی اختصاصی خود را گذرانده بودند و معیار خروج از مطالعه، دانشجویان انتقالی یا مهمان از دانشگاه‌های دیگر، دارای سابقه کار دانشجویی مراقبت قبل از بارداری، دانشجویان کارشناسی ناپیوسته مامایی و دارای تجربه شخصی دوران بارداری بود است. ابزار گردآوری داده‌ها در این مطالعه، پرسشنامه CPMP خطی شامل 9 مورد (Case) بیمار فرضی بود. این موارد شامل ابتلا به بیماری قلبی، ابتلا به دیابت، سابقه صرع، ابتلا به آسم، ابتلا به فشار خون مزمن، ابتلا به عفونت ادراری، سابقه تولد نوزاد مبتلا به نقص لوله عصبی، سابقه تماس با فرد مبتلا به سرخچه و وجود سابقه ناسازگاری خونی بین مادر و نوزاد بود. بیماران فرضی به صورت مراجعه کننده برای مراقبت قبل از بارداری و شامل گروه‌های پرخطر حاملگی و نیازمند مراقبت ویژه بودند. هر مورد شامل ساقه و 4 زیر سؤال است که هر زیر سؤال دارای یک نمره بود. بنابراین، هر مورد کلاً 4 نمره پرسشنامه را به خود اختصاص می‌داد. در ساقه، هر مورد اطلاعاتی مربوط به شرح حال و معاینه فیزیکی مراجعه کننده ارائه شده بود. در هر سؤال، پرسش‌هایی در ارتباط با تصمیم‌گیری در مورد مراجعه کننده فوق مطرح می‌شد. این چهار زیر سؤال به یکدیگر مرتبط بودند. برای پاسخگویی باید دانشجو در کنار رایانه قرار می‌گرفت. پس از باز شدن برنامه، یک سری راهنمایی برای تکمیل پاسخ‌ها به دانشجو ارائه می‌شد و سپس اولین مورد قسمت اصلی پرسشنامه آغاز می‌گردید. مشخصه این سؤالات به گونه‌ای بود که در هر مورد بعد از اینکه کاربر یک زیر سؤال را پاسخ می‌داد، بازخوردی به وی ارائه می‌شد که شامل پاسخ ارائه شده توسط وی و پاسخ صحیح سؤال بود. بعد از ارائه این بازخورد، دیگر کاربر قادر به تغییر پاسخ داده شده خود نبود. بعد از این مرحله، زیر سؤال «ب» همین مورد بر روی صفحه نمایشگر ظاهر شده و تا زیر سؤال «د» و ارائه بازخورد برنامه، مورد بعدی شروع شده و به همین نحو 9 مورد با تعامل بین کاربر و رایانه ادامه می‌یافت. برای انجام نمونه‌گیری، دانشجویان هر یک در کنار یک رایانه شخصی قرار گرفتند و به آنها یک کد تعلق گرفت. با ارائه توضیحات و راهنمایی‌های لازم، هر یک از آنها وارد برنامه PMP شده و به تکمیل سؤالات پرداختند. بر اساس مطالعه مقدماتی، 60 دقیقه زمان برای تکمیل این پرسشنامه تعیین شد. در جریان تکمیل پرسشنامه در صورت نیاز راهنمایی‌های لازم توسط کارشناس رایانه حاضر در محل در جهت کار با نرم‌افزار مورد نظر ارائه شد. در نهایت، سؤالات پرسشنامه CPMP یک بار به صورت کلی و بار دیگر به صورت تقسیم‌بندی سؤالات در سه حیطه مربوط به مراقبت قبل از بارداری یعنی ارزیابی عوامل خطر، آموزش و مشاوره و مداخله مورد بررسی قرار گرفت. با توجه به اینکه هر مورد دارای 4 گزینه بود. از 36 گزینه کلی موجود، 17 مورد در حیطه ارزیابی عوامل خطر، 12 مورد آموزش و مشاوره و 7 مورد در مداخله قرار گرفتند. برای نمره‌گذاری این پرسشنامه از سیستم متداول در نمره‌گذاری PMP استفاده شد. به این صورت که به مواردی که بیان آنها مهم و ضروری است، 1+ مواردی که بیان آنها مهم و ضروری است، 1+ و به مواردی که مفید نبوده و ضروری نیز برای بیمار ندارد، صفر تعلق گرفته است. نمرات کمتر از تفاضل میانگین و انحراف معیار به عنوان ضعیف، نمرات در فاصله یک انحراف معیار از میانگین به عنوان متوسط و نمرات بیش از جمع میانگین و انحراف معیار به عنوان خوب در نظرگرفته شده‌اند. برای تأیید روایی پرسشنامه از روش اعتبار محتوی و اعتبار صوری و برای تأیید پایایی آن از روش آزمون مجدد (Test re test) و انجام یک مطالعه مقدماتی استفاده شد که ضریب همبستگی 8/92درصد برای پرسشنامه به‌دست آمد. آنالیز آماری اطلاعات با استفاده از روش‌های آمار و توصیفی و نیز رگرسیون چندگانه و نرم‌افزار آماری SPSS انجام شد. نتایج طیف سنی دانشجویان مورد مطالعه 24-21 سال بود و اکثریت آنها در سن 22 سال قرار داشتند (50درصد). از مجموع 40 نفر نمونه مطالعه، اکثریت آنها (70درصد) مجرد و به ترتیب از سه دانشگاه علوم پزشکی ایران، تهران و شهید بهشتی 45 درصد، 5/32 درصد و 5/22 درصد بودند. میانگین نمره کسب شده در هر سؤال تصمیم‌گری به صورت جداگانه مورد بررسی قرار گرفت. در کل سؤالات، بیشترین نمره کسب شده (66/1) از کل 4 نمره، مربوط به موضوع «تصمیم‌گیری در ارتباط با بیمار قلبی کلاس II با سابقه تعویض دریچه میترال که مایل به حاملگی است» و کمترین نمره کسب شده (16/1) از کل 4 نمره، مربوط به موضوعات «مشاوره قبل از بارداری برای خانم مبتلا به صرع» و «مراقبت قبل از بارداری برای خانم دارای فرزند مبتلا به نقص لوله عصبی» بود. سؤالات مربوط به مهارت تصمیم‌گیری بالینی بر اساس سه حیطه موجود در مراقبت قبل از بارداری (ارزیابی عوامل خطر، آموزش و مشاوره و مداخله) به سه دسته تقسیم شدند. میانگین نمره تصمیم‌گیری بالینی واحدهای مورد پژوهش در زمینه ارزیابی عوامل خطر 14/9±17/40 بود و اکثریت افراد در سطح متوسط تصمیم‌گیری قرار داشتند. نمره تصمیم‌گیری بالینی در حیطه آموزش و مشاوره 22/10±87/31 بود و اکثریت افراد در سطح متوسط تصمیم‌گیری قرار داشتند. در حیطه مداخله نمره تصمیم‌گیری 77/13±42/31 بود و اکثریت واحدها در این زمینه نیز در سطح متوسط تصمیم‌گیری قرار داشتند. نمره مهارت تصمیم‌گیری بالینی در کل مراقبت‌های قبل از بارداری 01/7±62/35 بود و به صورت کلی نیز اکثریت واحدها در سطح متوسط تصمیم‌گیری قرار داشتند. سطوح مهارت تصمیم‌گیری بالینی دانشجویان مامایی در جدول یک ارائه گردیده است. با توجه به اینکه نمرات در مقیاس 100 محاسبه شده است، نتایج نشان داد که میانگین به دست آمده در هر یک از سه حیطه و به صورت کلی از نظر تصمیم‌گیری بالینی کمتر از 50 درصد کل نمره است. جدول 1. مهارت تصمیم‌گیری بالینی در مراقبت قبل از بارداری سطح تصمیم‌گیری بالینی ارزیابی عوامل خطر آموزش و مشاوره مداخله کل مراقبت قبل از بارداری ضعیف 5/17% 20% 15% 5/17% متوسط 65% 70% 70% 5/67% خوب 5/17% 15% 15% 15% برای شناسایی سهم هر حیطه تصمیم‌گیری در مقدار کل تصمیم‌گیری، با استفاده از مدل رگرسیون، آزمودنی بین مهارت تصمیم‌گیری کلی و مهارت تصمیم‌گیری در سه حیطه ارزیابی عوامل خطر، آموزش ومشاوره و مداخله انجام شد. نتیجه این مدل به صورت زیر بود: در این معادله خط مهارت تصمیم‌گیری در ارزیابی عوامل خطر، x2 مهارت تصمیم‌گیری در آموزش و مشاوره و x3 مهارت تصمیم‌گیری در مداخله و y مهارت تصمیم‌گیری در کل مراقبت‌های قبل از بارداری است. طبق این معادله خطی تقریباً 41 درصد از کل تصمیم‌گیری به دست آمده مربوط به تصمیم‌گیری در ارزیابی عوامل خطر، 33درصد مربوط به آموزش و مشاوره و 25 درصد مربوط به مداخله است. بحث تصمیم‌گیری بالینی عامل مهمی در ارائه خدمات به بیمار می‌باشد و آن را می‌توان پایه‌ای برای نحوه استفاده یک متخصص از اطلاعات و تجربیات قبلی خود برای بررسی و نتیجه‌گیری در موارد جدید دانست. مواردی وجود دارد که تشخیص افتراقی مهم و مشکل است و در این حالت عدم تصمیم‌گیری درست و به موقع می‌تواند مراحل درمان و مراقبت را طولانی و با مشکل مواجه سازد (4). تصمیم‌گیری بالینی در مامایی نیز به عنوان یکی از شاخه‌های مهم علوم پزشکی قابل توجه است. نتایج این مطالعه نشان داد که نمره کسب شده توسط واحدهای مورد پژوهش در هر سؤال کمتر از 50 درصد کل نمره آن سؤال می‌باشد. (کل نمره 4 و حداکثر نمره کسب شده توسط واحدها 66/1 بوده است)، بنابراین، ضعف در پاسخ به کلیه سؤالات احساس می‌شود. البته این ضعف در موارد مربوط به مراقبت قبل از بارداری بیشتر بود. در تقسیم بندی واحدها به سه سطح خوب، متوسط و ضعیف در سه حیطه مربوط به موضوع مورد بررسی و نیز به صورت کلی، اکثریت واحدها در سطح متوسط قرار داشتند. در این زمینه در مطالعه‌ای که بر روی دستیاران داخلی و دستیاران خانواده در ارتباط با بررسی مهارت ارزیابی بالینی آنها در مراقبت قبل از بارداری انجام گرفته، به این نتیجه رسیده‌اند که از مقیاس کلی 14، میانگین نمره دستیاران داخلی 6 و دستیاران خانواده 7 بوده است. اطلاعات مطالعه آنها نشان داده که مقیاس مهارت ارزیابی بالینی هر دو گروه در ارتباط با موضوع فوق پایین بوده است (8). توجه به معادله خط رگرسیون تصمیم‌گیری نشان می‌دهد که سطح بیشتری از تصمیم‌گیری کلی مربوط به تصمیم‌گیری در آموزش و مشاوره و مداخله بود و بنابراین، برای تقویت مهارت تصمیم‌گیری در مراقبت قبل از بارداری در مرحله اول باید تصمیم‌گیری در ارزیابی عوامل خطر را افزایش دهیم و در مرحله بعد تصمیم‌گیری در آموزش و مشاوره و مداخله مد نظر قرار گیرد، وجود ضریب مثبت نشان دهنده ارتباط مثبت این سه حیطه با کل تصمیم‌گیری است. با توجه به اینکه در مطالعه حاضر دانشجویان مورد مطالعه در سال آخر دوره تحصیلی خود به سر برده و واحدهای تئوری و قسمت اعظم واحدهای عملی خود را گذرانده‌اند، انتظار می‌رفت که از قدرت تصمیم‌گیری بالایی برخوردار باشند در حالی که نتایج این مطالعه این مسأله را تأیید نمی‌کند. علی‌رغم اینکه درصد بالایی از واحدهای ارائه شده به دانشجویان علوم پزشکی به صورت عملی و بالینی است، اما به دلایل مختلف صرف ارائه این واحدها نمی‌تواند تصمیم‌گیری بالینی را در آنها افزایش دهد. در صورتی که آموزش کلاسیک عمدتاً بر پایه دروس نظری باشد و توجه لازم به آموخته‌های عملی دانشجویان نشود، می‌تواند باعث ضعف قدرت تصمیم‌گیری شود. ممکن است علت پایین بودن نمره تصمیم‌گیری بالینی واحدهای پژوهش ناتوانی در بکارگیری بالینی اطلاعات علمی باشد. از طرف دیگر، این احتمال وحود دارد که دانشجویان به دلیل اضطراب، عدم تمرکز و نگرانی از آسیب به بیمار در محیط بالین، قدرت تصمیم‌گیری درستی نسبت به مددجویان پیدا نکنند. از این جهت، استفاده از روش‌هایی همچون: OSCE(Objective Structured Clinical Exam)، PMP و شیبه سازی (Simulation) به دلیل اینکه عوامل مخدوش کننده فوق حذف می‌شوند، می‌تواند در افزایش مهارت تصمیم‌گیری بالینی و آمادگی دانشجویان در برخورد با مددجویان در محیط بالینی واقعی مؤثر باشد. با توجه به اینکه طبق نتایج این مطالعه میزان تصمیم‌گیری بالینی عده کمی از دانشجویان در سطح خوب قرار داشت، لازم است در ارتباط با ریشه‌یابی علل آن توجه بیشتری مبذول شود و برنامه‌ریزان آموزشی کشور با دقت بیشتر به ریشه‌یابی این مسأله بپردازند زیرا مهارت تصمیم‌گیری بالینی عامل مهمی در ارزیابی بیمار است و دانشجو به عنوان نیرویی که به زودی مسؤولیت اداره سیستم بهداشتی- درمانی را به عهده می‌گیرد، باید در دوران دانشجویی این قدرت ومهارت را در حد مناسب و خوب به دست آورد. پیشنهاد می‌شود مسؤولین آموزشی دانشگاه‌ها به آموزش موارد مختلف تصمیم‌گیر بالینی و موارد مشابه آن در آموزش بالینی دانشجویان توجه بیشتری نموده و با ارائه راه‌حل‌های مناسب و استفاده از شیوه‌های نوین آموزش و تکنولوژی جدید در جهت ارتقای سطح آموزش دانشجویان گروه پزشکی و در نتیجه ارتقای سطح ارائه خدمات بهداشتی- درمانی بکوشند. از طرف دیگر، دانشجویان نیز لازم است با دقت و تأمل بیشتری دروس را به صورت کاربردی آموخته و بیشتر به تقویت مهارت تصمیم‌گیری بالینی در خود و نیز کاربرد بیشتر رایانه در آموزش بپردازند. تصمیم‌گیری بالینی عامل مهمی در ارائه خدمات بهداشتی- درمانی می‌باشد، بنابراین، لازم است که آموزش آن در رأس برنامه‌های آموزش پزشکی قرار گیرد. و می‌توان PMP به عنوان یک روش مناسب برای آموزش و ارزیابی تصمیم‌گیری بالینی استفاده نمود و برای افزایش کاربرد آن در سیستم آموزش پزشکی توجه لازم مبذول کرد. قدردانی از معاونت پژوهشی دانشکده‌های پرستاری و مامایی دانشگاه‌های علوم پزشکی تهران، ایران و شهید بهشتی برای مجوز نمونه‌گیری، مسؤولین واحدهای رایانه دانشکده‌های پرستاری و مامایی تهران و شهید بهشتی و مسؤولین بیمارستان‌های وابسته به سه دانشگاه مورد مطالعه برای همکاری در نمونه‌گیری و نیز مسؤولین محترم مرکز مطالعات و توسعه آموزش پزشکی دانشگاه علوم پزشکی اصفهان برای همکاری در تهیه پرسشنامه صمیمانه تشکر و قدردانی می‌شود. منابع 1- Tracy K, Bucknall BN. Critical care nurses decision making activities in the natural clinical setting. J Clin Nurs 2000 9(1):25. 2- Huber D. Leadership and nursing care management. 2nd ed. Philadelphia: Sounders Co.2000:111. 3- Ellis JR, Hartley CL. Managing and coordinating nursing. 3rd ed. Philadelphia:Lippincott Co. 2000:2. 4- Robinson DL. Clinical decision making a case study approach. 2nd ed. Philadephia:Lippincott Co.2000:2. 5- Nufeld V, Norman GR. Assessing clinical competence. New York: Springer Co.1985:184. 6- Takabayashi K. Implementation and evaluation of computerized patient management problem. Med Info 19958(2):1218. 7- Afroza S. Use of a PMP manual as a teaching tool for accelerates pediatric teaching in Bangladesh. Medical Teacher 2000 22(4):366. 8- Conway T.Hu TC. Are primary care residents adequately prepaid to care for women of reproductive age. Family Perspective 199527(2):73-5. Evaluation of Midwifery Students' Clinical Decision Making Nekuei N, Pakgohar M, Khakbazan Z, Mahmudi M Abstract Introduction: Clinical decision making is one of the skilful decision makings which is made considering patients situation.Quality evaluation and clinical decision making education are two important elements in improving health personnel's decision-making process. PMP (Patient Management Problem) is one of the clinical decision making methods in -which some clinical conditions are taken from a disease and are put forward in the form of a multi- stage question. This study tried to use the computerized PMP to evaluate midwifery students' clinical decision making. Methods: In a cross- sectional census research, 40 Senior midwifery students from Tehran, Iran and Shahid Behshti Medical Universities were studied. A computerized PMP questionnaire, including 9 assumed clients referring for preconception care was designed as a software program and was given to the participants to fill in. The data were analyzed by descriptive statistics and multiple regression using SPSS software. Results: The mean score earned by the participants was 35.62±7.01 out of 100. Most of the subjects had an average clinical decision-making score. The acquired mean score of the subjects in risk assessment was 40.17 ±9.14, in education and counseling was 31.87±10.23 and in intervention was 31.42±13.77. Most of the subjects had average clinical decision making score in these three fields. Conclusion: Since clinical decision making as a major element in enhancement of health team services can be evaluated and taught by PMP and as most of the studied subjects regarding preconception care were not in an appropriate level, more precise education in this field seems necessary. Key words: Clinical Decision Making, Midwifery Students, Patient Management Problem, Evaluation Address: Nekuei N, School of Nursing and Midwifery, Isfahan University of Medicine and Health Services Source: Iranian Journal of Medical Education 2002, 6: 49-54.

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Introduction. Despite growing evidence in the field of undergraduate medical education, there is not much data on resident training. Case presentation is a useful tool for scientific clinical education which along with evidence based medicine will become an interactive training method. So, the goal of this study was to compare traditional educational methods with hard talk and their role in learning process, based on residents' viewpoints. Methods. In a pre-experimental study, special monthly case discussion sessions (named "Hard talks on gastroenterology") were designed for internal medicine residents of Shaheed Beheshti University of Medical Sciences. Then the data were collected using an attitude measurement questionnaire. Each educational case was started with a title followed by history, physical examination data, as well as paraclinical lab results, respectively. The scenario ended with a definite clinical question about next needed test, diagnosis or treatment. After the sixth session, questionnaires were distributed non-randomly among 50 participants and 31 questionnaires were completed. The data were analyzed by SPSS 11 using frequency distribution and Kruskal Wallis. Results. Residents were more positive toward Hard talks. They evaluated the possibility of challenge with speakers 54.8%, learning the presented subject during the session 80.6%, the compatibility of the subject with residents' real needs 77.4%, the possibility of using the attending physician experiences 77.2%, volume of knowledge transfer in a session 67.7%. The participants considered the Hard talks better than traditional methods. Conclusion. In general, this study showed a relatively successful experience in resident training. Due to the lack of new methodologies in resident education this can be used as a guide for designing new interventions in the field.

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Introduction. Learning clinical skills at the bedside is one of the best educational methods which mainly depends on clinical instructors’ characteristics. It seems that teaching by qualified and competent instructors can enable students to reach their maximum capability. This research was designed to study the effect of teaching on knowledge, attitude and practice of nursing and midwifery instructors concerning effective behaviors at clinical teaching. Methods. This was a quasi-experimental research which studied all nursing and midwifery instructors (N=25) at Tabriz University. The research was designed as one group and two stages which assessed knowledge, attitude and practice of instructors before and two months after running the educational program (two days workshop). The data collecting tool was a questionnaire including four sections. The scientific validity of the questionnaire was confirmed by content validity and its reliability was evaluation by split-half method. In addition to instructors, the forth section of the questionnaire concerning performance, was also completed by the students who were under the supervision of trained instructors before and two months after the workshop. The results were analyzed by SPSS 9 software and using paired t-test, relative frequency, mean and standard deviation. Results. According to the results, participation of instructors in educational workshops had a positive effect on increasing knowledge and improving their attitude toward clinical teaching behaviors. Moreover, according to the viewpoints of instructors and students, their performance scores increased after education. But, no significant difference between the mean of performance score of instructors before and after workshop was observed. Based on students' viewpoints, instructors' performance in assessing students showed a significant difference. Conclusion. Considering the positive effects of education on knowledge and attitude of the instructors, providing education and an appropriate background in clinical environment for employing effective behaviors seems necessary. The results of this research can be used in designing a valid evaluation tool for assessing the effectiveness of clinical education and the educational performance of clinical instructors

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Background. The dynamic and uncertain nature of health care environment requires nurses to be competent decision makers and to respond to the clients needs. Recently, the public and the government have criticized Iranian nurses because of a low quality patient care. However, the nurses’ views and experiences concern- ing the factors affecting their clinical practice and clinical decision making have rarely been investigated. Therefore, this research tried to study the viewpoints, perceptions and experiences of Iranian nurses concerning the factors affecting their clinical decision making. Methods. A qualitative research with Grounded theory methodology was used to study the participants’ lived experiences and their viewpoints regarding the factors affecting their clinical practice and clinical decision making. Un-structured interviews and participant observation methods were used to gather the data. Thirty eight participants were interviewed and twelve sessions of observation by taking field notes were carried out. Constant comparative analysis method was used to analyze the data. Results. Five main categories emerged from the data, indicating the participants’ points of view. “Being competent” and “feeling self-confident” were the most important internal factors, and “organizational culture”, “nursing education”, and “supporting structures” were considered as the most important external factors affecting their clinical decision -making. Conclusion. As participants in this research implied, although being competent and self-confident were important factors in nurses’ clinical decision making, organizational culture and structure were the core variables affecting other variables. Nurse managers and nurse educators are responsible for identifying barriers and enhancing factors within the organizational structure that facilitate nurses’ clinical decision-making.

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ِIntroduction. Since the major part of professional nursing education takes place in clinics, clinical teaching is considered one of the most important parts of nursing education process. Accordingly, clinical teaching effectiveness and the characteristics of an effective teaching have overshadowed a good number of nursing and midwifery research studies. This study was performed to determine and compare the teachers' and students' perspectives regarding the characteristics of effective clinical teachers in Isfahan University of Medical Sciences in the year 2002. Methods. In a triangulation study using both qualitative and quantitative methods, 93 teachers and 475 students in the school of nursing and midwifery were investigated. During the first stage, the Delphi method was used and the teachers and students were interviewed regarding the characteristics of effective clinical teacher. Then a 56- item questionnaire was designed with the five domain of "professional", ''personal", ''communicative", ''teaching methods" and "evaluation" using 1 to 7 Likert scale. In the second stage, through survey method and using the designed questionnaire, the students and teachers' perspectives were determined. The data were analyzed by SPSS software using mean, standard deviation and t-test. Results. The mean of Students' and teachers' scores for effective clinical teachers characteristics were 6.15±0.98 and 6.19 ± 0.48, respectively which showed a statistically significant difference between them. Based on the viewpoints of students and teachers, the most important characteristic of effective clinical teachers was responsibility for one's own action and the lowest score belonged to educating clinical ward's staff. Conclusion. All the characteristics mentioned in the questionnaire were approved by the teachers and students. Moreover, the mean of the scores given by teachers was higher than the one given by the students. It is recommended that teacher evaluation be performed using these characteristics and teachers pay more attention to them.

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Introduction. Transition from the student’s role to the professional role, as an important stage in the nursing career, is of considerable importance. Lack of readiness in new graduate nurses for transition to their professional roles and joining the clinical setting brings about unfavorable physical and psychological reactions that act as a barrier for adaptation to their new position. This study has been conducted to make an understanding of the new graduate nurses’ experiences about their own readiness to start their new roles as a professional nurse. Methods. This was a qualitative, phenomenological research, carried out with the participation of 9 new graduate nurses. Data collection was done through in-depth unstructured interview Dieklemann method was used for data analysis. Results. Four themes emerged during data analysis: professional competency, self-esteem, colleagues’ expectation and emotional distress. Conclusion. The findings of this study, which were the lived experiences of the participants, indicated that most of them had experienced some degrees of lack of readiness for entering the new settings. It is suggested to revise the nursing curriculum and provide appropriate educational programs to help graduate nurses in getting ready for their new roles.

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Introduction. Clinical skills training program provides an opportunity for medical students to improve their clinical skills in a simulated setting which is designed and equipped for learning a number of key skills by practicing on manikins and related equipments. The aim of this study was to determine the effect of clinical skills training program on clinical competencies of medical students in the management of vaginal delivery in Tabriz Medical University. Methods. In this quasi-experimental research with one group, pre- and post-test design, 50 medical students were selected randomly and assessed using a valid and reliable questionnaire asking about their clinical competencies in the management of different stages of vaginal delivery and also about their suturing skill. Likert scale was used for determining the level of competency based on self-assessment approach. Data analysis was done by SPSS software using descriptive analysis, paired t-test, ANOVA and Pearson correlation coefficient. Results. A significant increase was observed in the mean score of skills related to pre-delivery stage (from 14±13.65 to 89±10.72), skills needed during performing the delivery (from 18.17±13.3 to 88.95±9.26), and skills needed during the post-delivery stage such as suturing and dressing (from 31.07±16.57 to 85.17±12.78). There was a significant difference between the mean score related to the skills needed before, during and after delivery, before and after education. Conclusion. Practicing in Clinical Skills Center considerably increased perceived self-efficacy of medical students for doing the skills needed for the management of a safe vaginal delivery which in turn could lead to increasing their skills in confronting patients.

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Introduction. Different problems could lead to reducing the efficiency of field training for nursing students. Identifying and solving these problems is necessary to reinforce some effective educational methods. The aim of this study was to determine the problems in clinical field training for nursing students from the viewpoints of nursing teachers and nursing students in Shahid Sadoughi University of Medical Sciences. Methods. In this descriptive study 22 nursing instructors and 36 last year nursing students were selected by census method. The data gathering tool was a valid and reliable researcher made questionnaire. The data was analyzed by SPSS software using frequency distribution, mean and standard deviation and t-test. Results. The majority of nursing students and teachers (over 50%), evaluated this programme as relatively weak to weak, in attaining "holistic view and community-oriented nursing", and acquiring "skills in nursing process and patient education". They stated some problems in clinical training such as "inadequate access to educational and welfare facilities", "lack of health care team cooperation", and "scattered training in clinical wards". They believed that some changes are necessary in field training. There was no significant difference between the mean scores of nursing students' and instructors' view points. Conclusion. Although field training is appropriate for promoting skills and students' independency for providing community-oriented services in different fields of nursing and the total view towards this program is positive, there are numerous problems in the process of field training that have to be addressed by nursing educational leaders.

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Introduction. Continuous evaluation is necessary for improving and promoting the quality of clinical education. The purpose of this study was to determine the views of nursing and midwifery students of Gonabad University of Medical Science about the condition of clinical education. Methods. This was a cross-sectional survey in which 140 nursing and midwifery students registered as day or night students were selected by census sampling method. They were studied using a questionnaire consisted of 4 sections about instructor’s performance, cooperation of staff, patients and students, facilities and equipments of clinical environment and clinical evaluation system. Data was analyzed by SPSS software using descriptive statistics, t-test, Mann Whitney and Pearson correlation coefficient. Results. Most of the students evaluated the instructor’s performance, good with the mean and standard deviation of 62.3±15.7, cooperation of staff, patients and students, at a borderline level(between good and intermediate) with the mean and standard deviation of 51.4±22.4, facilities and equipments, at an intermediate level with the mean and standard deviation of 30.64±19.2 and clinical evaluation system at an intermediate level with the mean and standard deviation of 37.6±27.7. There was no significant difference between nursing and midwifery students' viewpoints about different aspects of clinical education. Conclusion. In order to improve the situation of clinical education in nursing, it is recommended to provide facilities and equipments for clinical environments and revise the tools and process of clinical evaluation. These points have been confirmed by other studies as well. Improving instructors' performance and encouraging professional cooperation could lead to the improvement of clinical education.