https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article Challenges of Implementing Nurse Educator Core Competencies as Per- ceived by Clinical Instructors in Erbil City, Kurdistan Region, Iraq. ABSTRACT INTRODUCTION Clinical education is a vital component of nursing education [1]. The quality of nurs- ing education at the clinic is based solely on the clinical instructors’ (CIs) ability to provide and creating the most productive clinical environment possible. The terms clinical nurse instructor and clinical nurse educator are used interchangeably in the field of nursing education. CIs teach main- ly at clinical placements and support nurs- ing students in gaining theoretical knowledge, practical skills, and Background and objective: The quality of nursing education in the clinical setting in nurs- ing colleges, especially in the Middle East, is based solely on the clinical instructors’ ability to provide and creating the most productive clinical environment possible. The World Health Organization (WHO) identified eight domains as core competencies for clinical nurse educators. However, studies on contemporary clinical education and educators’ role indicate that clinical instructors continuously face challenges in adopting the competen- cies recognized by the WHO. Therefore, this study aimed to explore the challenges of im- plementing the nurse educator core competencies as perceived by the clinical instructors in Erbil in the Kurdistan Region of Iraq. Method: The interpretive phenomenological approach of the qualitative study and SWOT analysis was adopted to explore the clinical instructors’ experience of clinical education’s challenges. Result: The main challenges of the academic institutions were shortages of qualified clini- cal instructors, lack of confidence among instructors, and difficulty in achieving learning outcomes. Challenges reported among health institutions include inappropriate selection for managerial roles, poor recognition of clinical education, and poor teaching environ- ments. Conclusion: The study results highlighted challenges for clinical instructors to carry out their role in a safe and less stressful environment, including inadequate strategic plans for clinical teaching from academic institutions and stakeholder involvement in health institu- tions. Keywords: Clinical Instructors, Clinical Educators, Clinical Education, Challenges, Compe- tencies Newroz Ghazi Aziz; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: newroz.aziz@hmu.edu.krd) Vian Affan Naqshbandi; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Halmat Authman Rasheed; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 30 Erbil Journal of Nursing & Midwifery Received: 02/12/2021 Accepted: 01/02/2022 Published: 30/05/2022 mailto:newroz.aziz%20@hmu.edu.krd https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article understanding of the nursing roles and re- sponsibilities [2]. The World Health Organi- zation (WHO) identified eight domains as core competencies for clinical nurse educa- tors [3]: • Integrate contemporary teaching theories, principles, and models in teaching nursing adult learners • Design, implement, monitor, and manage nursing curriculum based on sound, contemporary educational models, principles, and best evidence • Teaching contemporary nursing prac- tice based on the best available evi- dence • Conduct research and utilize the find- ing to solve educational and practical problems • Communicate, collaborate, and part- ner with other health professionals • Develop policies, procedures and de- cision making based on the legal, eth- ical, and professional values • Utilize effective strategies to monitor and evaluate, nursing programs, cur- ricula, and students’ learning out- comes • Demonstrate the skills of system management and leadership to cre- ate, maintain, and shape the future of educational institutions The purpose of developing nurse educator core competencies was ‘to enable educa- tors to effectively contribute to the attain- ment of high-quality education, and the production of effective, efficient and skilled nurses who can respond to the health needs of the populations they serve’ (WHO, p.5) ³. The ability to master these domains enables CIs to utilize the most updated clinical teaching strategies to promote undergraduate nursing students’ competencies and help them to be lifelong learners [3]. Previous studies have revealed that supervised clinical practice by compe- tent CIs enhances the professional growth of the students, thereby ensuring patient safety and reducing medical errors. How- ever, studies on contemporary clinical edu- cation and educators’ role indicated that CIs continuously face challenges in adopting the competencies recognized by the WHO while teaching in clinical settings [4].Positive clinical teaching could be en- couraged by empowering CIs [5, 4]. Power is the ability to activate resources to achieve organizational goals. CIs could be empowered to face challenges when sup- port is received from health care institu- tions and academic institutions. Enhancing the practical environment by providing learning opportunities is a crucial role of health care institutions. It empowers CIs to utilize the most effective learning strate- gies. Additionally, the academic institu- tions could be better involved in clinical education by letting CIs access educational materials, organizational clinical guidance, providing access to continuous training courses, financial support, and rewards. On the contrary, less involvement of aca- demic and health care institutions in the clinical education program causes CIs to be confronted by various challenges, including relying on personal knowledge and clinical experience to plan clinical education pro- grams rather than on an institutional stra- tegic program [5]. In such cases, the clini- cal learning objectives are short and less dependable, compromising and hindering academic institutional goals and vision. The need to achieve a higher level of edu- cation and develop skills needed to meet the health organizations’ demands and di- versity of patient care made more students enroll in nursing colleges in recent years. The record number of enrollments calls for more competent nurse instructors clinical nursing education. The critical shortage of CIs causes various challenges to appear. Therefore, this qualitative study was con- ducted to explore the significant 31 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article based on the WHO competencies for nurse educators. The interview guide included questions related to challenges in meeting competencies. Due to the COVID-19 pan- demic and the participants' safety, the re- search team decided to interview using a digital program (ZOOM). Permission was obtained from the participants, and the informed consent was signed and sent back through email and Viber application. The interviews lasted between 60 to 80 minutes and were digitally recorded. The researcher reassured participants about the confidentiality of the interview records and the anonymity of participants’ names. Anonymity in qualitative research is the key to assisting participants in unveiling sensitive information [7, 8]. The partici- pants chose the Kurdish language in the interview to express themselves because they felt more comfortable and confident with their mother tongue. The quotations used in the study were translated to Eng- lish by an independent professional trans- lator. Ethical considerations Ethical approval was obtained from the Ethical Committee of the College of Nurs- ing of Hawler Medical University No. (4) on 29 January 2020. Before data collection, written informed consent was obtained digitally. The participants were informed about the study's purpose, benefits, and risks, and they were permitted to with- draw at any point if they felt insecure or uncomfortable. Data analysis This study used thematic analysis as the method of data analysis. Thematic analysis is widely used in a phenomenological study for com- patibility [9]. The SWOT analysis was written in English and did not need to be translated, only anonymized. The data analysis process was done manually after the digital records of the second phase in- terviews were anonymized and tran- scribed. Braun and Clarke's six phases of Thematic Analysis [ 10] was applied in the challenges in attempting to implement the core competencies developed by the WHO [3]. Study design: SWOT and the interpretive phenomenological approach were used. A SWOT analysis is a “methodology to identi- fy a department’s strengths, weaknesses, opportunities, and threats” [6].Time of the study: The study was conducted from Janu- ary to May 2020. The setting of the study: College of Nursing of Hawler Medical Uni- versity Sample size and data collection: The data were collected in two phases: The first phase was a workshop held 30 January 2020 on that focused mainly on clinical practice. Forty faculty clinical educators of the college were invited to a semi- structured focus group discussion to talk about their experiences and challenges at the clinics. The clinical educators were di- vided into several groups based on their specialty. After oral discussion, a group SWOT analysis was conducted to obtain reliable and written data. The second phase used the interpretive phenomeno- logical approach to explore the CIs’ experi- ence of clinical education challenges. A convenient sample of nine academic edu- cators at the college was recruited to par- ticipate in individual interviews. The partic- ipants have taught clinical practice at the college in different specialties, including adult nursing, pediatric nursing, and mater- nity care, for more than two years. The eli- gible criteria for recruitment of both gen- ders included two or more years of clinical teaching experience, completion of a Mas- ter’s or Ph.D. degree, and full-time employ- ment. With the help of the interview guide (see Table 1, Appendix 1), the in-depth semi-structured interviews were conduct- ed to obtain data from the participants over six weeks starting from March 2020. The original interview guide was developed 32 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article analysis process: 1- Listening and relistening to the recorded data for familiarization; the SWOT analysis were read several times by the researchers and one independent coder 2-Extracting initial codes by allocating in- teresting features relevant to the research question: “challenges of teaching under- graduate nursing students at teaching hos- pitals” 3-Generating initial themes by analyzing and combining potential codes; the codes were clustered and labelled based on their similarities and differences to generate main themes and sub-themes 4-Reviewing initial themes in relation to the research question 5-Naming and defining themes and sub- themes in a few sentences to explain what they are consisted of 6-Producing the final report with the final themes and subthemes written and pre- sented with dialogues extracted from the interviews and SWOT analysis Table 2 shows the demographic character- istics of the participants in the second phase of data collection. Out of nine partic- ipants, most were male and from adult nursing specialty (n= 6). The highest age of the participant was 38 years, who also had the highest years of experience in clinical education. The demographic characteristics of the participants in the first phase were not collected since they were divided into subgroups for data collection. The analysis of the overall study data revealed the fol- lowing themes: academic institutional chal- lenge and health institutions. The three principal subthemes under academic insti- tutional challenge were the shortage of qualified CIs, CIs' lack of confidence, and lack of clarity in the learning outcomes. In- appropriate selection for managerial roles, poor recognition of clinical education importance, and poor teaching environ- ment were the subthemes under health institutions. Academic institutional chal- lenges a) Qualified CIs shortage The nursing profession is in demand in Er- bil City, the capital city of the Kurdistan Region of Iraq. In recent years the number of private government hospitals have dra- matically increased, positively affecting the recruitment of nurses holding baccalaure- ate degrees. The fast-growing number of nursing students has put a lot of pressure on the college, requiring CIs to fill all the gaps present in the clinical schedule. “Some of the time I have to cover two are- as, helping nearly 25 students with the sim- ple and short task without focusing on the actual learning objectives… I prefer to look after six students as a maximum number, otherwise, it is hard to set clear learning outcomes” (Participant #1). The study participants reported that their lack of ability to cover all of the clinical are- as caused the college to recruit some clini- cal educators that have no expertise in su- pervising nursing students. “It is common to hear from students com- plaining about wasting their time in the areas where they are supervised by unqual- ified clinical teachers” (Participant #2). B) CIs lack of confidence Assigning the CIs to a clinical placement without the appropriate training course or previous clinical experience in the area is stressful and puts CIs in a risky and unsafe environment. Some CIs disclosed their lack of expertise in the clinical area they are assigned to in terms of skills and finding learning opportunities. The interviews with participants revealed that CIs are more 33 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article procedures, and this affected learning out- comes” (Participant #4). Changing clinical areas in the middle of the semester is challenging and requires extra hard work as reported by participants. “When I arrive at the clinic, either I ask the staff for activities that can be done by the students or I search by myself to see what procedures are available. Finding learning opportunities by myself is difficult and I do not feel comfortable going to clinical place- ment without appropriate, previously planned activity” (Participant #5). Moreover, none of the students has a portfolio. Students’ learning progress is not documented or shared between CIs when the clinical area changes. Some procedures and skills might be repeated several times in one clinical area. Students never get the chance to practice some activities. Most practical activity is planned daily when the students arrive at the clinic which does not necessarily fulfil the desired learning out- comes. “When students’ group changes, I call their CIs to see what activities I should focus on, and what students are lacking in so time is not wasted on repeated procedures and skills” (Participant #3). Health institution challenges a. Inappropriate selection for manage- rial positions The first sub-theme identified under health institution challenges is the CI’s weak au- thority in clinical settings. Most of the CIs are holding a master’s degree, or higher, in nursing science, whereas the managerial and administrative positions in the health service are filled by doctors or by nurses holding diploma degrees or lower. Unfor- tunately, promoting staff to a higher 34 Erbil Journal of Nursing & Midwifery textbook oriented and avoid being clinical- ly oriented to stay safe and make fewer errors in the practice. “I was assigned to teach at the urology unit, which I never did before. I struggled a lot. I had to familiarize myself with the ar- ea while teaching undergraduate students. A lot of learning objectives could be achieved if I had previous experience at urology unit” (Participant #3). The college administrators announced the clinical schedule shortly before students started their clinical placements. Most CIs were relocated to a new clinical area they had never taught before.“Teaching in a new clinical setting is hard work. I would prefer to be informed early to familiarize myself with the staff, cases, and learning opportunities” (Participant # 1). Concerning the problems of clinical settings, participants who spent more than one year in the same clinical setting com- plained less. “If I compare my clinical ob- jectives now to the first time, I can say it is more productive and clinically oriented. Now, I am more familiar with the environ- ment, cases and staff” (Participant # 9). C) Difficulty achieving learning outcomes There are a limited number of teaching hospitals (government hospitals) in Erbil City where students can practice their clini- cal teaching. Furthermore, the inadequacy of the health service at public hospitals results in more patients using non- teaching private hospitals rather than pub- lic health care institutions. These barriers forced the clinical committee of the college to distribute students to teaching hospitals based on the availability of the patients rather than learning objectives causing, a huge gap in applying theory to practice. “The area I used to teach in, which was related to my specialty, no longer received patients. Therefore, I had to distribute stu- dents in the areas that had patients so that students could practice required https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article position in government organizations usu- ally happens based on staff loyalty to a po- litical party, not professional capability. As a result, a vacant position might be filled by staff that has no experience or qualification relevant to that position. This lack of pro- fessionalization causes a significant misun- derstanding regarding the importance of nursing education, which sometimes means that nursing students are seen as a future threat to the way authority is dis- tributed among health care staff. “Most clinical areas where I used to teach had a team leader with a very low qualification in nursing. It was difficult to explain the role and purpose of good quality clinical educa- tion” (Participant #5).According to the par- ticipants, lack of authority forces CIs to use the personal relationships with the staff to be allowed into the clinical placement and find learning opportunities. “I try to teach in the clinical settings where I used to work or have friends, so that I can have freedom in using clinical equipment and find the best learning opportunities for stu- dents” (Participant # 6).In addition, hospital staff distance themselves from academic faculty, staff, and students, by creating an environment where no students are wel- comed. “I always advise my students and myself to avoid any argument or criticism with the staff, in fear of losing permission to practice teaching nursing care” (Participant #4). B. Poor recognition of clinical education importance The participants reported that the health institutions do not see students as their future employees. The quality of clinical education is of least concern of teaching hospitals. They believe that the students will ultimately learn the role of nursing even in the absence of supervisors. “Lack of knowledge about nursing role and importance of having mentor, preceptor or supervisor forced us to look after students alone, which I am positive, they would the learn more if hospital staff were involved inclinical education” (Participant #5).Additionally, the teaching hospital staff perceive CIs and nursing students as a bur- den. They demand that the college should have it is own teaching hospitals. Some participants mentioned that teaching hos- pitals have no rules or regulations concern- ing teaching students, which is a sign that clinical education is not welcomed at the teaching hospitals as indicated at the be- ginning. “Last year in the first week, with my students we had to wait more than one hour outside of emergency department be- cause we were not allowed to enter the department that claimed that we did not have a permission” (Participant #7).“Not acknowledging the importance to practice clinical education at teaching hospitals was discussed with the director at the Ministry of Health, who claimed that the best solu- tion is to have a private hospital belong to the college of nursing” (Participant #8).CIs and nursing students, during clinical days, have, however, solved some of the prob- lems of nursing shortages by putting a lot of effort into looking after admitted pa- tients and their relatives. During the inter- views, only one participant said that she got a letter of appreciation from the hospi- tal while others are still in a continuous argument with the hospital administration and staff over clarifying their role in im- proving the health care services. “Hospital staff leave them alone to look after the pa- tients, while it is illegal, but students under our supervision carry out their duties pro- fessionally” (Participant # 9). C. Poor teaching environment: One of the main challenges that CIs face at the clinic is the lack of standardization. At the college, the most updated version of nursing books is used in the theory lec- tures and clinical simulation laboratory sessions. Students are familiar with various equipment and techniques used in nursing 35 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article procedures. On the contrary, clinical placements are not equipped with the necessary equipment. CIs must involve students in clinical skills with minimal or sometimes old versions of medical equipment. In this way, students get confused between what they studied and what they are experiencing in the clinical settings. CIs are the first people to be criticized and blamed for these differences. “So many times, we did not have waterproof pad or sheet to create a sterilized filed. I had to teach my stu- dents using gloves paper or gauze to put under the equipment during proce- dures” (Participant # 9).Procedures are a daily challenge for CIs. Some nursing cares are such as Foley catheter inser- tion, NG tube insertion, and dressing of wounds are no longer done by nurses, are being claimed as doctors’ jobs, and have been banned by the Ministry of Health to undertake. Of course, it is not the same in all areas and there are differences between hospitals. “One of the relatives did not permit my students to participate in the dressing of her mother’s wound. She said: ‘I prefer it to be done by a doctor like yester- day.’” (Participant #3). Other issues with the teaching environment are lack of li- braries, conference rooms, and most im- portantly locker rooms. Most of the clini- cal discussions, according to the study participants, are taking place in the corri- dors or empty patient rooms. “Some hospitals have conference room, but the priority is given to medical students, on one occasion we were even asked to leave the room because medical stu- dents’ lecture started” (Participant #2). 36 Erbil Journal of Nursing & Midwifery Table 1: Please describe any challenges in implementing the core compe- tencies developed by WHO (3)by answering the following questions: Interview questions How many years of clinical experience do you have? In how many clinical areas you have taught so far? Were they related to your specialty? Please explain the challenges of teaching in a new clinical setting. Please explain any challenges that would prevent you from adapting theoretical nursing expertise to clinical teaching practice. Please explain any challenges you may face in de- fining teaching objectives and integrating them for teaching students. Please explain any challenges you may face in teaching nursing practice to nursing students. Please explain any challenges you may face when undertaking research and applying results in the field of clinical teaching. Please explain any challenges you may face in in- cluding health care providers in the process of teaching. Please explain any legal and ethical challenges that may prohibit you from delivering professional nursing education. Please explain any challenges you may face when assessing students’ performance and the effective- ness of the curricula. Do you assist in developing policies and protocols for nursing students at your institution? If yes, please explain any challenges in developing them. https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article novice instructors requires an extensive orientation program. The importance of training CIs before assigning them to clini- cal placement is paramount [15]. CIs play a crucial role in developing students’ compe- tency and shaping the future of the health care system. Clinical practice skills and knowledge are the two most important components of CIs’ role, and they have a strong effect on the confidence level. In addition, conducting research, improving curriculum based on contemporary educa- tional models and theories, monitoring and evaluating students’ learning out- comes, demonstrating effective communi- cation skills with other health care profes- sionals, and professionally enhancing nurs- ing education policies, procedures, and decision- making as requested by WHO [3] are other components that every CIs must- have. Although competency is developed by practice, novice CIs should go through a relevant and recognized training program to acquire basic information on how to master the role of qualified CI. Nonethe- less, the clinical environment is complex and each practical situation requires a unique learning experience [4]. Although the unavailability of dependable resources is a major challenge in adopting core com- petencies mentioned by many WHO ex- perts [16], many strategic methods could The findings of the present study re- vealed that CIs face various challenges in implementing core competencies for nurse educators identified by WHO [3]. The challenges related to the academic institutions were the first theme identi- fied by the study participants and includ- ed three sub-themes: the shortage of CIs, CIs’ lack of confidence, and difficulty achieving learning outcomes. Interviews with the participants revealed that the college had been running clinical educa- tion with a short-term plan instead of having a long-term plan that can tackle minor and major issues more efficiently. The fast-growing population and devel- oping nursing services have made a larg- er number of students pursue nursing as a career. However, the College of Nursing/ HMU still works according to the plan that has been in situ since 2001. Many full-time and part-time CIs have been recruited and given the role of CI without previous preparation. The only requirement was holding a bachelor’s degree in nursing science and at least one year of clinical experience. The shortage of CIs is universal [11,12]. Many studies document the urgent need of nurse educators [13, 14]. Filling the shortage gap in the teaching faculty staff is challenging and transitioning nurses to 37 Erbil Journal of Nursing & Midwifery Table 2: Demographic characteristic of the study participants (second phase) No Sex Age Educational level Speciality Work experience/years 1 Male 38 Master degree Adult nursing 11 2 Female 36 Master degree Pediatric nursing 10 3 Male 35 Master degree Adult nursing 7 4 Male 32 Master degree Adult nursing 9 5 Male 32 Master degree Pediatric nursing 9 6 Male 32 Master degree Adult nursing 8 7 Female 32 Master degree Adult nursing 7 8 Female 30 Master degree Maternity nursing 5 9 Male 29 Master student Adult nursing 4 DISCUSSION https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article edgement and poor teaching environ- mentThe role of the manager in hospital settings in most countries is practiced by registered nurses who hold a BSc or higher degree in nursing science. Contrary to this, in Erbil City’s teaching hospitals, this role is practiced by nurses who often have a low- er degree and are loyal to a particular po- litical party. Due to the lower number of graduated nurses who hold a BSc this problem has not been resolved yet. The presence of a nurse manager is most im- portant for preparing hospitals to receive nursing students [19]. CIs find that dealing with someone who understands the pur- pose of the clinical practice is much easier [2] and that learning opportunities and learning outcomes could be designed more effectively through stronger collaboration between CIs and nurse managers [18]. Planning clinical teaching in public sector academic health institutions across all of Erbil City is authorized by the government, namely the Ministry of Health, under spe- cific rules and regulations. Nursing stu- dents like other medical students should be given the chance to experience practice in the most supportive environment. How- ever, not valuing the importance of clinical nursing training by health staff is a huge challenge as experienced by the study par- ticipants. The exact role of nurses or what nurses can and should do at the hospital is still vague. Presently nurses are not in- volved in providing holistic care, and the services they provide are simple and can be learned within a couple of weeks. This mentality leads the hospital staff to think that the students do not need extensive clinical practice or supervision. There is no doubt that the success of clinical training in nursing education depends largely on strong, structured, collaboration and rela- tionships between health care services and academic institutions [12, 20]. Not having this strong bond forces CIs to practice the be applied to achieve this task. An inno- vative approach implemented by nurse educators in Canada is through a project using Open Education Resources (OERs), where all necessary materials are made freely accessible online for novice nurse educators and the progress of learning monitored and supported by volunteered educators. The developers of the OERs are confident that faculty members and higher education institutes that lack or- ganizational and financial support would benefit from such a program [17]. Lack of clarity regarding the learning out- comes was another challenge identified by the participants. Continuous political conflicts and economic crises negatively influence education systems worldwide. Unfortunately, the Kurdistan Region of Iraq has seen various conflicts, which have not given the region the chance to build a well-organized structure in the education system and learning process across all levels. Participants disclosed their concern with the lack of viable edu- cational clinical settings and lack of learn- ing opportunities. Inability to fulfil health staff demand by the government result- ed in providing low-quality service in the teaching hospitals. In the search to find better services, patients use private hos- pitals if possible. Simply expressed, no patients mean no learning opportunities. Well clarified and articulated learning objectives are the key to achieving learn- ing outcomes [18]. However, even con- sistent learning objectives cannot be ac- complished when the clinical setting con- tinuously changes based on the availabil- ity of patients. This issue challenges the CIs to choose learning outcomes that are realistic and achievable. The second theme identified by this study was con- cerned with the challenges related to the health institutions included three sub- themes: weak authority, lack of acknowl. 38 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article still not ready or able to provide the learn- ing environment requested by the aca- demic institutions. The perceived challenges of clinical instruc- tors while teaching undergraduate nursing students have been scrutinized in the cur- rent study. The shortage of qualified CIs, CIs’ lack of confidence and lack of clarity in the learning outcomes are the three princi- pal issues under the main theme of the academic institutional challenge. Inappro- priate selection for managerial roles, poor recognition of clinical education im- portance and poor teaching environments were recognized as the most difficult chal- lenges under the theme of the health insti- tutions as perceived by the study partici- pants. The outcome of the study reassert- ed and supported the premise that inade- quate strategic plans for clinical teaching from the academic institution and the lack of more positive involvement of the health institutions in the clinical study made it much more difficult for CIs to carry out their role in a safe and less stressful envi- ronment. RELEVANCE TO CLINICAL PRACTICE: The findings of this study can be used to reform clinical education and to empower CIs based on the core competencies devel- oped by WHO [3] for nurse educators to achieve a more productive clinical teaching and learning. The study also recommends the following points: 1-Reforming the policy and mechanism of supervising students at the clinic, most im- portantly involving health staff as mentors or preceptors in the process of education. 2-Addressing CIs challenges and empower- ing CIs with basic needs and opportunities to practice the role more productively. 3-Developing a strategic plan to tackle the issue of the fast-growing number of role alone and in an extremely unsup- portive environment. Worldwide, clinical education is a shared task. Mentors and preceptors who are experienced clini- cians and have skills take part in edu- cating nursing students [20]. However, clinicians in many studies reported that other challenges come with adopting these roles, mainly student’s assessment and the amount of time each student needs to achieve a specific task [18, 20]. Students need constant attention, which means that the supervisor should not be distracted with other duties in clinical settings [21]. On the other hand, faculty CIs can focus only on the students’ need, but has the least amount of clinical expe- rience, which ultimately affects the learn- ing opportunities they provide [22]. Therefore, achieving the best learning outcomes requires the involvement of both sides and all supervisor’s contribu- tions at the clinic should be acknowl- edged regardless of their background or position. The clinical environment is the real world where students finally get the chance to apply what they have learned at college to the real practice situation [23]. Students must find similarities be- tween textbooks, simulation laborato- ries, and clinical settings. Students expect to see role models and advanced tech- niques used in nursing care [19, 23]. Teaching in a poor environment that is far from students’ expectations, make CIs struggle to keep students motivated and not lose interest. When the differences are huge students feel doubt and accuse CIs of putting unnecessary pressure on them at the college to master the role of a qualified nurse. Study participants pointed out that teaching in a pedagogi- cal atmosphere would be more produc- tive. However, as has been mentioned, due to continuous political problems and economic crises, teaching hospitals are 39 Erbil Journal of Nursing & Midwifery CONCLUSION https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article No conflict of interest has been declared by the authors. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. [1] Creswell JW, Poth CN. Qualitative inquiry and research design: Choosing among five approaches. SAGE Publications, Social Sci- ence; 2016. 76 p. Availablefrom:https:// books.google.com/ bookshl=en&lr=&id=DLbBDQAAQBAJ&oi=fn d&pg=PP1&dq=Qualitative+Inquiry+26+Rese arch+Design:+Choosing+Among+the+Five+A pproaches&ots=- gw777HOPB&sig=UfSJdmi42WX4JK9SwscVa KM3DkE. Accessed [10-11-2019] [2] Younas A, Zeb H, Aziz SB, Sana S, Albert JS, Khan IU, et al. Perceived challenges of nurse educators while teaching undergraduate nursing students in Pakistan: An exploratory mixed-methods study. Nurse Education To- day. 2019;81(7):39–48. Available from: https://doi.org/10.1016/j.nedt.2019.07.002. Accessed [10-01-2020] [3] World Health Organization. Nurse Educator Core Competencies. WHO [Internet]. 2016;1 –36. Available from: http://apps.who.int/ iris/bitstream/ handle/10665/258713/9789241549622- eng.pdf;jsessionid=8DCAD822F36D10F1B82 9697B0637542D?sequence=1. Accessed [10- 11-2019] [4] van Wyngaarden A, Leech R, Coetzee I. Chal- lenges nurse educators experience with de- velopment of student nurses’ clinical reason- ing skills. Nurse Education in Practice [Internet]. 2019;40(October):102623. Availa- ble from: https://doi.org/10.1016/ j.nepr.2019.102623. Accessed [11-02-2020] [5] Thuss M, Babenko-Mould Y, Andrusyszyn MA, Laschinger HKS. Nursing Clinical Instruc- tor Experiences of Empowerment in Rwan- da: Applying Kanter’s and Spreitzer’s Theo- ries. International Journal of Nursing Educa- tion. 2016;13(1):1–9. Accessed [04-02-2020] nursing students’ enrollment. 4-Adopting a well-prepared program based on the core competencies³ recom- mended for transitioning expert nurses to expert educators. 5-Designing well-structured collabora- tions and partnerships with the health care institutions. LIMITATIONS The interviews with the participants dis- closed various issues related to clinical education, most of which have been dis- cussed in this paper. However, the chal- lenges of teaching nursing students in the Kurdistan region have not been high- lighted in the study. The teaching style in high schools when compared to the uni- versities is different, with universities having a more modern approach, which affects the academic ability of the new student cohorts. The researchers would like to undertake a research study focus- ing only on this subject. The participants did not adequately describe the challeng- es of conducting educational research itself. Therefore, further research is also needed in this arena. 1.1 Rigor The research question and the interview guide were discussed with multiple re- searchers who had expertise in qualita- tive research. To ensure dependability and transparency of the study results, the transcribed data from the video rec- ords and SWOT were analyzed, coded, and categorized by an independent re- viewer and the researchers separately. The researchers compared and verified their analysis with the reviewer’s conclu- sions. 40 Erbil Journal of Nursing & Midwifery Conflicts of interest Funding REFERENCES https://doi.org/10.15218/ejnm.2022.04 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article [13] Scammell J. The implications of nurse short- ages. British Journal of Nursing. 2019;28(3). Available from: https:// www.magonlinelibrary.com/doi/ full/10.12968/bjon.2019.28.3.208 Accessed [21-07-2020] [14] Berland A, Capone K, Etcher L, Ewing H, Keating S, Chickering M. Open education resources to support the WHO nurse educa- tor core competencies. International Nursing Review. 2020;67(2):282–7. Available from: https://onlinelibrary.wiley.com/doi/ abs/10.1111/inr.12583. Accessed [21-07- 2020] [15] Levett-Jones T, Fahy K, Parsons K, Mitchell A. Enhancing nursing students’ clinical place- ment experiences: a quality improvement project. Contemporary Nurse. 2006 Oct 1;23 (1):58-71. 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