Strategies to improve the performance of learners in a nursing college Part I : Issues pertaining to nursing education

The aim of this contextual, exploratory, descriptive and qualitative study was to describe strategies to improve the performance of learners in a nursing college. The article seeks to deal with factors relating to nursing education that contribute to the poor performance of learners and to outline related strategies to improve the situation. Three focus group interviews were conducted. One group was formed by seven tutors, and the other two groups were formed by fourth-year learners following a four-year comprehensive diploma course. All participants voluntarily took part in the study. Data was analyzed using the descriptive method of open coding by Tesch (in Creswell, 1994:154-156). Trustworthiness was ensured in accordance with Lincoln and Guba's (1985:290-326) principles of credibility, conformability, transferability and dependability. The findings were categorized into issues pertaining to nursing education as follows: curriculum overload; lack of theory and practice integration; teaching and assessment methods that do not promote critical thinking; tutors' lack of skills and experience; inadequate preparation of tutors for lectures; insufficient knowledge of tutors regarding outcomes-based education approach to teaching and learning; inadequate process of remedial teaching; discrepancies between tutors' marking; lack of clinical role-models and high expectations from the affiliated university as regards standards of nursing development programme by the staff development committee of the nursing college under study for implementation. Future research should focus on the effectiveness of the described strategies to improve the learners' performance. It is also recommended that similar studies be conducted or replicated in other nursing colleges to address the problem of poor performance of learners engaged in a four-year comprehensive diploma course.


Introduction
This research is part of the initiatives of a research sub-committee of the College Senate of a specific nursing college in Gauteng. The research was conducted for the purpose of identifying the reasons for the poor performance of learners from a broader perspective with the aim of describing strategies to im prove the situation.
The goal of any educational programme is to facilitate the learners' critical thinking skills and problem -solving abilities (South African Qualifications Authority Act, Act no 58 of 1995). When education in South Africa was placed under the spotlight on national to local levels, it became clear that many problems were directly related to the curriculum (Carl 2002:24). Becker, Viljoen, Botma and Bester (2003:57) maintain that the poor performance of nursing students is due to an overloaded curriculum, emphasis being placed on coverage of the content, frag m en ted and artific ia l learning, d u p licatio n am ong d iscip lin e s or subjects and the behavioural-objective m odel with its authoritarian stance. B ecker et al. (2 003:58) argue that although the scientific nursing process approach replaced the task-centred approach to a large extent, learning was still fragm ented, as subjects in the curricula were divided by traditional subject boundaries. This resulted in stu d en ts d em o n stratin g a lack of retention and integration of knowledge -in particular, basic sciences with the clinical context (Fichardt in Becker et al 2003:58). The educational changes in South Africa brought about the outcom es-based education (OBE) approach, which aimed to develop learners' critical thinking po w ers and th e ir p ro b lem -so lv in g abilities. The OBE learning approach re q u ires th at learn ers take g re ater responsibility for participating actively in the learning process and working hard, while facilitators take full responsibility for the careful planning and management of a conducive learning environment (Van der Horst & McDonald 1997:5). Becker et al. (2003:58) and Mtshali (2005:10) argue that for the education and training system in the country to m eet the o b jectiv es o f O BE, the use o f the in teg ra te d and p ro c ess-o rien te d curriculum model is advocated with the em p h asis on com m unity-based education and a philosophy of problembased learning.

Problem statement
D espite the collaborative efforts to im prove the cu rricu lu m and the in v o lv em en t o f the students in committees such as the senate and other related committees to address academic issues, for the past two years the nursing co lleg e u n d er study has been exp erien cin g poor perform ance by learn ers. A study conducted by Morolong and Chabeli (2005:44) revealed that newly qualified registered nurses from a nursing co lleg e w ere not competent in the application of clinical knowledge and skills to practice. Newly qualified registered nurses were defined as nurses who had recently completed final examination and had practised as registered nurses for six months prior to the time at which the data was collected. The fo llo w in g research questions emerged to give direction to the study. What are the issues that contribute to the poor performance of learners in a particular nursing college in Gauteng? W hat strategies can be em ployed to improve the situation?

Aim and objectives
The aim of the study was to describe strategies to improve the performance of learners in a specific nursing college in Gauteng. This aim was realized through the following objectives: • To explore and describe the perceptions of learners and tutors with regard to the factors that contribute to the poor performance of learners in a nursing college in Gauteng. • To re-contextualize the findings for the purpose of describing strategies to improve the situation.

Learners
Fourth-year learners studying towards a co m p reh en siv e diplom a (g en eral, psychiatric and community) and midwife registered with the South African Nursing Council constitute learners in this study.

Nursing Education
N ursing education is the process whereby learners are guided, assisted and provided with means which enable them to learn the art and science of nursing so that they can apply it to the nursing care of people who need such care (Mellish, Brink & Paton, 1998:7).

Strategy
A strategy refers to a broad plan of action with a view to achieving the aim. A strategy is really a plan of attack. It outlines the approach you intend to take in order to achieve the purpose ( Van der Horst & McDonald. 1997:124).

Poor performance
In this study, poor performance entails individual learner performance of less than 50%.

The research design and method
To get the best, informed results from this research, a qualitative, explorative, descriptive and contextual research design was employed in order to explore the perceptions of learners and tutors concerning the factors that contribute to the poor performance of learners in a nursing college in Gauteng (Mouton & Marais, 1992:45;Bums & Grove, 1997:67).

Data gathering
Three focus group interview s were conducted by an expert interviewer who has a doctorate in psychiatric nursing and is also an expert in qualitative re searc h . An ind ep en d en t person, purposively selected, collected the field notes during the interview to enrich the data collected. One group was formed by seven tutors and the other two groups w ere form ed by seven fo u rth -y ear learners in each group, undertaking a fo u r-y ear com prehensiv e diplom a course. All participants engaged in the research voluntarily.
The tutors who volunteered were all involved in the teaching and learning of learners studying towards a four-year comprehensive diploma course at the nursing college. A member of the research committee conducted a briefing session with the learners and the tutors on the purpose, objectives and benefits of the study. All the learners and tutors realized the need for the study to be conducted since every learner and tutor would inevitably benefit from the described strategies focusing on the improvement of the learners' performance. Participants w ere assured o f anonym ity and confidentiality during the process of the study and were also assured that the interview tapes would be destroyed upon completion of the study. Participants were further assured that there were no risks involved in their participation in the study and that they were under no obligation to participate in the study if they did not want to. They were also informed that they were allowed to withdraw their participation at any stage of the research process.

Data analysis
Focus group interviews were audio-taped and transcribed verbatim to ensure the accuracy of data collected. Field notes, which added value to the richness of the data, were also analyzed by way of the descriptive m ethod o f open coding (Tesch in Creswell, 1994:154-156). Two external coders, independent of each other and purposely selected because of their expertise in qualitative data analysis, were em ployed to analyze the data separately following the protocol as described by Tesch (in Creswell 1994: 154-156). T hereafter, a consensus discussion meeting was held between the independent coders with the aim of agreeing upon final categories and sub categories with regard to the factors that co n trib u te to poor perform ance o f learners in a nursing college (Lincoln & Guba, 1985:290-326). The identified categories and sub-categories were verified with the participants to determine the truth value of the findings. The findings were re-contextualized w ithin credible existing lite ratu re (Mouton 1998:109). Through deductive and inductive reasoning and inferencem aking, analysis, sy nthesis and derivation thinking processes, strategies to im prove the perform ance o f the learners were formulated.

Trustworthiness
The four p rin cip les to ensure trustworthiness of the study were used, th at is cred ib ility , tran sfera b ility , d ep en d ab ility and co n fo rm ab ility (Lincoln & Guba 1985:290-326).

Credibility
The following measures increased the credibility of the study: the guidance provided by a member of the research committee in possession of a doctorate w ith know ledge and experience in q u alitativ e research approach; the engagement of two experts in qualitative research who also hold doctoral qualifications in the collection and the analysis of data; the triangulation of credible primary and secondary sources to re-contextualize the findings for the purpose of describing the strategies to improve the performance of learners; the involvement of tutors who were at the time responsible for the teaching and learn in g o f learners (prolonged engagement); participants verifying the findings; the use of the tape recorder to o btain accurate in fo rm atio n and co n tex tu al v alid atio n ; and the maintenance of structural coherence by consistently asking about the factors that contribute to the poor performance of learners in a nursing college.

Transferability
Although the study is contextual in nature, the nature of the problem is of co n cern to all nurse ed u cato rs resp o n sib le for the fo u r-y ear comprehensive course in the country. The authors assume that the strategies described will be of assistance to nurse educators having a similar problem in improving the performance of learners undertaking this course. The dense description of the method used for the study will make replication of the study by other researchers possible.

Dependability and conformability
The study was consistent across the q u a lita tiv e m ethods o f research , co n g ru en t w ith and guided by the research question (dependability audit). The use of external independent coders to reach consensus agreement on the categories and sub-categories, the coderecode procedure and the triangulation of sources increased the dependability and conformability of the study.

Findings
The findings of the study, as well as the re la ted strateg ies to im prove the performance of learners will be described (Table 1). Recommendations will be made. The main category pertained to issues in nursing education, as indicated in Table  1. The related sub-categories were curriculum overload; lack of theory and p ra ctice in teg ratio n ; teach in g and assessment methods that do not facilitate critical thinking; tutors' lack of skills and experience; inadequate preparation of tu to rs for lectures; in su fficie n t know ledge o f tutors w ith regard to ou tco m es-b ased edu catio n ; inadequacies in the remedial teaching process; discrepancies betw een the marking by tutors; lack of clinical rolemodels and high expectations from the affiliated university regarding standards of nursing education in a nursing college.

Discussion of findings and strategies to improve the learner's performance in a nursing college
A discussion of the findings will be undertaken in accordance with Table 1. Direct quotations will be rendered in italics.

Curriculum overload
Both tutors and learner participants  Van R ooyen (1993:97) argue that the inherent nature and subject-specific characteristics of the learning co ntent m ake didactic demands different from other subjects. The authors maintain that an important general feature of contemporary subject co n ten t is the rap id rate at w hich k n o w ledge in cre ases and new approaches to subject content emerge. Content expands and certain elements of know ledge and inform ation become o u td ated , w hich in turn req u ires continuous revision of the curriculum content by teachers. As a strategy to improve the situation, the participants suggested a curriculum revision to make the curriculum relevant, realistic, valid and reliable to the learner and the society it serves.
To reiterate the point, Carl (2002:93) is of the opinion that the curriculum must be comprehensive and take all the learners' needs into account. It must contribute to the realization of the broader educational objectives to prepare learners for a constructive and productive life. It should reflect the realities of life and be relevant to them, as the following citation from Carl's work clearly illustrates: "The learner is filled with facts and figures which only accidentally and infrequently have anything to do with the problems and conflicts of modem life or his own inner concerns". Yet the citation from the participants in this study states: Is it really necessary fo r learners to work out the IQ o f a mentally retarded person? I m ean ... Som e o f the co n ten t that lea rn ers have to m a ster do not necessarily make them better nurses, they are rea lly o ve rlo a d e d with unrealistic things. The content of the curriculum must be relevant with regard to the developmental level of the learners, the learn ers' interest, the degree of difficulty and the motivational aspects. The inter-disciplinary nature of the curriculum design must be acknowledged (Carl 2002:93).
According to Spady (in Van der Horst & McDonald, 1999:145) outcomes-based edu catio n is an approach that will overcome some of the curriculum-related problems in that one will develop the curriculum from the outcomes that one wishes learners to demonstrate, rather than write objectives for the curriculum one already has. Because it is the desire of all teachers that learners be successful, it becomes the prerogative of the teacher to determine what content is presented to the learners based on the formulated learn in g outcom es; w hat learning experiences are made available to them; how they are assessed; how long they will be engaged in learning the importance of participation to gain knowledge and skills; and, above all, what is valued in the educational process. The underlying concern is for the learners to learn through innovative and creative methods o f teaching and helping learners to achieve their goals (Van der Horst & McDonald, 1997:145).
If teachers can be aware of and focus their teaching on the significant and im portant aspects of the curriculum, problem s such as re p etitio n o f the content, which add to the overloading of the curriculum, could be overcome (Van der Horst & McDonald, 1997:145). In addition, with regard to the overloading o f the cu rricu lu m , S canlan and C hernom as (1997:1142) argue that nursing curricula are still 'm ired' in co n ten t: "are we still too content orientated?" The authors believe that incorporation of frequent reflection on the existing curriculum as a process in nursing education activities will address the issues of content-laden curricula. The participants also stated as one of the recommendations to solve the problem of curriculum overload the importance of curriculum revision in order to meet current challenges in the health care serv ices. S canlan and C hernom as (1997:1142) further assert that knowledge explosion has resulted in adding content to nursing curricula without any deletion since it is painful to take anything out of "nursing courses". Nurse educators do not realize that learners become bored with some of the routine -especially if it is repeated in other classes. Scanlan andChemomas (1997:1142) suggest that the reflection process be encouraged to enable us to move our teaching beyond content and to a more process-oriented approach.
Various curriculum authors such as W alters, H ills, and Steyn (in C arl, 2 0 0 2 :9 2 ,1 2 0 ) m ade the follow ing contributions in connection with the criteria for selection of the curriculum content to prepare the learner for the real working world: the selected content should serve the realization of aims such as the subject sciences, philosophy of life orientation, broad educational goals, particular didactic and subject didactic aims. The curriculum content should be relevant and realistic, m anageable, accessible and viable, stim ulate and motivate the learners, take the learners' existing know ledge and needs into account, offer opportunities for selfdiscovery. It should empower learners to develop their full potential and promote their cognitive thinking skills, their affective and psychom otor skills. It should be practically achievable, offer possibilities for learner input and choices, have a balance with regard to the extent and depth of the study, consider the needs o f the learner, school, local com m unity, country and the world, promote integration of contents within a specific subject with a view to forming a meaningful whole.

Lack of theory and practice integration
The lack of the integration of theory and practice emerged as a major problem: One day you are a p sychiatric nurse in practice and the next day you walk into a midwifery or pharmacology class. There is a lot of curriculum fragmentation which renders co n fu sio n to learn ers and contributes to a high failure rate.
Nursing is a hands-on profession that draws its satisfaction from the clinical practice setting where specialized skills and the acceptance of a patient as an autonom ous being with his/her own inherent rights must be a norm (Reilly & O erm an, 1985:1). C linical nursing ed u catio n , acco rd ing to C habeli (2001:150), is a dynamic, multi-purpose environment in which the theoretical component is integrated into practice. It provides the learner with a meaningful, authentic and humane experience and therefore the teacher as a facilitator of learning should create the environment that will prom ote the integration of knowledge, skills, attitudes and values in ord er to ren d er a h o listic and comprehensive care to patients. Becker, Viljoen, Botma and Bester (2003:58) believe that a strategy such as problembased learning seems appropriate as it seem s to have overcom e student passivity, integrating basic sciences with clinical courses and promoting lifelong learning on the part of learners. Problembased learning stimulates critical thinking and causes discipline boundaries to dissolve. Learner participants were of the opinion that tutors must create a culture o f learning conducive to lifelo n g learning.
The integration of knowledge, skills, attitu d es and values in a specified co n tex t is one o f the co rnerstones advocated by the o u tco m es-b ased approach to teaching and learning. It is stated that teachers are charged with the responsibility of creating a learning environment and learning opportunities th at are in v itin g , ch a lle n g in g and m otivating, and that promote critical thinking and problem-solving skills. The environment should be characterized by the emphasis on active participation, and collaborative and cooperative learning with learners taking responsibility for, and ownership of, their own learning (Van der Horst & McDonald, 1997:7). Approaches such as problem -based learning, community-based education, experiential learn in g , reflectiv e learning and a constructivist approach to learning serve as the basis for education and training that is learner-friendly, learner-centred and result-oriented. It is important for teachers to realize that learners in nursing are adult learners and, according to K now les's theory, they possess the characteristics of self-concept with plenty of experience to connect new knowledge for meaningful understanding and in terp retatio n o f thoughts and feelings.
The learning approaches indicated are appropriate to facilitate learning and critical thinking. Carl (2002:122) asserts that it is, inter alia, through the integration of these contents that the learner gets the opportunity to understand reality and the w orld better. It becom es important that the tutors use a variety of the stated learn in g ap p ro ach es to improve the performance of the learners. The involvement of learners in planning their learning experiences is also of vital importance. Mellish et al. (1998:67) assert that the teaching-learning transaction should be a m utual re sp o n sib ility between the nurse educator and learners sin ce, acco rd in g to K n o w le s's andragogic theory (1980), adult learners need to know why they m ust learn something and how learning should take place. Mellish et al. (1998:75) further state th at teac h ers should use teach in g strategies that are congruent with the learners' needs and encourage learners to use their initiatives relevantly and appropriately, based on their previous conception. The South African Nursing Council advocates the use of learnercentred, problem -based learning and co m m u n ity -b ased ed u c atio n and p a rtn e rsh ip , com m unity o u treach research projects and recognition of the p rin c ip le s o f N Q F in the n u rsin g program m e (SANC, 1999:1-8). It is recom m ended that tu to rs receiv e c o n tin u o u s s ta ff dev elo p m en t programmes for capacity-building. Such programmes will update them on the use of the teaching and learning approaches that foster the integration of theory into practice as well as the contemporary legislation that influences quality in nursing education.

Teaching strategies and assessment methods that do not promote critical thinking
Teaching strategies and assessm ent methods were discussed at length by learner participants as some of the factors contributing to the poor performance of learners: Sometimes there are tutors who ju s t com e and talk. They d o n 't give examples. They just read the book and don 't share any o f their own experiences . . . we would like to debate more and discuss situations we experience in practice to promote critical thinking.
Learner participants voiced a desperate need for a more exciting and dynamic classroom atmosphere to be able to share their experiences, thoughts and ideas: The context should be more conducive fo r interaction o f learners. We need to be involved and get more pra ctica l examples from experience, more relevant case studies and debates. This is a challenging situation for the teachers since in teractio n is the underlying dynamic in the facilitation of critical thinking and reflective learning (Chabeli, 2001:226). The notion of interaction is in keep in g w ith the co n stru c tiv ist ep istem o lo g y , w hich ch allen g es traditional pedagogy in that it does take into account individual learners' previous learning experience as the foundation upon which to modify, build and expand new know ledge. Im plicit within the co n stru c tiv ist fram ew ork is the development of metacognitive skills that are an important facet of active and self directed learning (Peters, 2000:166;B ereiter, 1994:7). M etaco g n itio n , according to Darry and Murphy (1986:1 -39), refers to the learners' awareness and k n ow ledge o f th e ir own learning processes as well as their abilities and tendencies to control those processes during learning. It refers to the active, self-managing, conscious act of thinking about thinking and learning. Slabbert (in Fraser et al, 1993:51) suggests that the method for facilitating meta cognitive and m eta-learning in the classroom is as follows: learners must become aware of their own existing ways of learning, and they should develop a deep ap p ro ach to learn in g , w hich depends on the intrinsic motivation of the learner to commit him-or herself to learning. Learners have to develop the skills to exploit their existing knowledge in order to solve the posed problems. All experience, with specific reference to the learning experience, must be contentrelated because it is im possible to develop any higher-order thinking skills (problem identification, problem-solving, a n aly sis, sy n th esis, ap p licatio n , integration, interpretation, classification, etc.) w ithout working with or being su b jected to su b ject content. C o operative learning should be encouraged to give learners the opportunity to reflect on their own learning and that of others. Learners will develop co-operative skills such as interpersonal and communication skills, conflict management, decision making, leadership, recognition, respect and trust-building. Co-operative learning has to teach learners how to engage in h elp in g , a ssistin g , su pporting and en co u rag in g each o th e r's efforts. L earn ers d ev elo p individual accountability, taking ownership of their learning, and they develop positive in terd ep en d en ce depending on the quality o f the co n tribution o f each member of the group.
With regard to the assessment, learner participants mentioned the inconsistency in marking by the teachers: You find that what you are taught by the ward sisters is not the same as what the tutor expects on evaluation and you end up failing your clinical work Participants further stated: The things you are taught here in the college you never fin d in the hospital and some tutors are marking very strictly and w on' t even give you a h a lf mark, while others will give you m arks. In co n sisten cy in m arking frustrates and discourages learners, and this has a negative im pact on their performance.
Assessment is said to be the lifeblood of all educational activities in that it is one of the teacher's most important activities in the OBE approach to teaching and learning (Van der Horst & McDonald, 1997:12). Inconsistency in marking, and incongruent teaching at colleges by tutors and teaching in the wards by professional nurses has been a long standing problem in nursing education. In some cases, learners undermine the ward professional nurses -as indicated in C hab eli's study (1998:42) where learners called a professional nurse a 'bar one' sister, referring to the fact that the p ro fessio n al nurse has only one qualification and thus lacks knowledge. This leads to professional nurses losing their confidence as clinical facilitators and developing a negative attitude to clinical nursing education. To improve the situation, it is suggested that the professional nurses should be involved in the planning of the criteria for the assessm en t and be m ade second evaluators in order to attain inter-rater reliability, where more than one person is inv o lv ed in assessin g the learner. Thereafter consensus has to be reached on the mark to be allocated to the learner (C habeli, 1998:41;Evan & W hite, 1984:216). It is important for the ward professional nurses to be trained as assessors and in the development and use of evaluation instruments (Ewan & White, 1984:217). According to Knowles (1980:44), nursing learners, as adult learners, and in keeping with their need to know and do things in terms of their real-life concerns, should be involved in the formation of criteria against which they will be assessed. This can be done during a pre-assessm ent conference (Ewan & White, 1984:217).
The use o f a ltern ativ e , authentic assessment methods is advocated since learners become active partners in the assessm en t process. A lthough the teacher serves as the expert partner in the assessment providing appropriate feedback, learners involved in alternative authentic assessment activities learn to judge their own work and adopt goals for self-improvement (Van der Horst & McDonald, 1997:188). Self-assessment is also advocated in OBE, especially when large classes are taught, as is the case with nursing colleges. Universal criteria for an effective assessment are provided by Van der H orst and M cD onald (1997:178); Mellish, Brink and Paton (1998:228) and Klopper (2000/01:122) as indicated. The assessment should be fair, valid, reliable, relevant, objective, balanced and propedious. Propedious means that the assessment must lead to the acquisition of new knowledge.

Tutors' lack of skills and experience
The learner participants raised concerns about the lack of skills and experience of some tutors, and suggested that this contributed to the poor performance of learners. They claim that some tutors are not specialized enough in their fields of knowledge, and that this results in a drop in learners' motivational levels: The quality of some tutors is equal to that of the ward sister who are not specialized in their field. On the other hand, tutor p a rtic ip a n ts voiced th eir need to specialize, but there was no support from management: We do not get any study leave or long leave and we cannot even attend course. No wonder we are not motivated. The tutors' apparent lack of expert knowledge and experience is the result of many factors such as the lack of motivation, and the shortage of staff, resulting in a rotation system where a tutor has to teach a subject on the basis of knowledge obtained during training in a comprehensive course, but never practised after completion of the course. This creates a problem since the teacher has to rely on book knowledge and adapt to the situation, which cannot take place in a short period. H ow ever, Doll (in C arl, 2002:258) endeavours to overcome this problem by advocating strategies such as effective support by subject sp ec ia lists and subject heads to help the teacher plan effectively; providing the necessary facilities and administrative help; and sufficient opportunities for teacher development. Carl (2002:9,13) adds the following suggestions to empower the teacher with curriculum development: management should show confidence in teachers; maintain a healthy working relationship among teachers; provide m anagerial support; and be patient and realistic. T eachers should build a base o f knowledge in the subject in order to be able to take inform ed decisions and develop their subject-related expertise. M anagem ent should develop good communication channels and provide a democratic climate where teachers will feel free to bring forth their thoughts and feelings without fear of intimidation.
Gore (in Carl, 2002:8,9,10) adds the follow ing suggestions: m anagem ent should empower teachers to develop greater professionalism, which goes with the granting of more authority over the subject, status and individual growth. They should encourage teamwork and team teaching as part o f this empowerment of the teacher in a specific subject. Oppression, inequalities and injustices should be rectified. Teachers should also be encouraged to reflect on their practice.
With regard to teachers reflecting on their p ractice, S canlan and C hernom as (1997:1141) are of the opinion that teachers should engage in personal reflective activities on a regular basis. Teachers can practise this by keeping reflective journals about their teaching, and review what has happened in a teaching situation in comparison with other teaching situations, and what this means. This exercise helps teachers to understand their approaches to teaching and improve their teaching skills. Scanlan andChernomas (1997:1142) warn that personal reflection alone is limited by o n e 's own u n d erstan d in g and knowledge. The authors maintain that by talking about our teaching experiences with others, we can benefit from their insights and perspectives. Inform al opportunities may arise in discussion during coffee and lunch. By talking to someone, we are forced to bring our teaching to consciousness as we need to describe the situation. By simply verbalizing our thinking, the other person may lead us to our own understanding of the issue.
In the same vein, Scanlan and Chernomas are of the opinion that research seminars, teaching seminars, forming a discussion group of interested teachers in a specific subject and meeting regularly to discuss their 'sto rie s' about th eir teaching experiences would be an acceptable approach to improve individual teaching performance. Through this interchange, new understandings of teaching would emerge since we have rich experiences as teachers that would be useful to share with others so that we can learn from one another. These strategies would be of great help in the empowerment of a tutor with little experience in the subject.

Inadequate preparation of tutors for lectures
Not only did the learners voice their concern about specialization, but they also com m ented on the inadequate preparation of some tutors for classes: To address the pro b lem o f poor preparation of the teacher for lectures, Van der Horst and McDonald (1997:149) argue that "no teacher can face a class for long w ithout hav in g ca refu lly thought out what the learners are to learn from the lesson and how they are to learn it." You need to know what the lesson's intended learning outcomes are, what the content is, what the procedure will be and how it will be executed. Van der Horst and McDonald argue that even the most experienced teachers must give careful thought to their lesson preparation if they are to be successful for long. Careful planning ensures familiarity with the content. It helps to give you confidence that come from knowing what you are doing, and it shows the learners that you are prepared. It giv es the lesson structure, organization and sequence, and it helps to ensure optimum time on task. Van der H orst and M cD onald (1997:149) state that no matter what approach you take to lesson preparation, the general principles of planning apply. Alcorn, Kinder and Schunert (in Fraser et al, 1993:79) assert that planning is the foundation of good teaching. Neither ingenuity nor experience can serve as a substitute for thorough planning.

Insufficient knowledge about the outcomes-based education (0BE) approach to teaching and learning
Learner participants voiced their opinion that tutors lack knowledge of OBE and that this results in their inability to facilitate the related principles: In most cases we are meant to believe that the college is teaching according to OBE, but we sit there and don' t really have a clear explanation on what the outcomesbased education is. This opinion has serious implications as the OBE approach to teaching and learning is a regulatory mandate to be implemented in the country to facilitate learners' critical thinking. H ow ever, problem s ex isted in the im plem entation, and this resulted in teachers' reluctance to use it. The South A frican N ursing C ouncil and the ed u c atio n -rela te d leg islatio n place emphasis on the implementation of the OBE approach on education and training in the country. Nurse educators have to consider the use of the OBE approach seriously to facilitate teaching and learning and to prepare learners for the real working world.
A c co rd in g to Van d er H orst and M cDonald (1997:7), outcom es-based education is a learner-centered, resultsoriented approach to learning, which is based on the follow ing und erly in g beliefs: All individual learners must be allowed to learn to their full potential. Success breeds further success, that is, every success a learner experiences builds his or her self-esteem and the motivation and willingness to strive for fu rth er success. Therefore, learners should be granted learning opportunities to reach their full potential. The learning environment is responsible for creating and controlling the conditions under which learners succeed. Teachers are ch arg ed w ith the re sp o n sib ility o f creating learning environments that are inviting, challenging, creative, analytical and m otiv atin g . T he classro o m atm osphere should be positive and thereby promote a culture of learning. Active learning should be a norm.
A ll the d iffe re n t stak eh o ld ers in education -such as the community, teac h ers, learn ers, parents and the service -share the responsibility for learning. Different stakeholders must be co-operating partners -in curriculum d ev elo p m en t, im p lem en tatio n and evaluation alike. The stakeholders must com m unicate regularly on problems, sp ecial needs, the progress o f the learners, etc. E ducational change is required to provide equity in terms of educational provision and to promote a m ore balanced view, by developing learners' critical thinking powers and their problem-solving abilities. Van der Horst and McDonald (1997:5,144) maintain that this is indeed the heart of OBE. Teaching can no longer be defined as the mere transm ission of knowledge. It is the process of helping learners to understand information and to transform it into their own personal knowledge. The question may be asked: "What does this mean to the teacher?" Carl (2002:266) is of the opinion that within the outcom e-based education context, teachers are now facilitators and not "the source of all knowledge". They m ust en co u rag e d iscu ssio n and participation in the classroom. They should create an atmosphere which will promote critical thinking, discovery of knowledge, debate and reflection. They should facilitate learning opportunities that meet the needs of the learners and encourage the development of problem solving and decision-making skills. Their teaching should link with the world of work and everyday life. It should not be restricted to the classroom. They should be able to focus on the portability of one learning experience to another. Previous knowledge and experience of learners should be taken into consideration and classroom management should facilitate collaborative and cooperative learning.
From the discussion of the OBE approach to teaching and learning, it is clear that the support o f the nursing college m anagem ent and other instructional leaders becomes important to teacher em pow erm ent. M anagem ent should provide continuous staff development p rogram m es w ith regard to the im plem entation o f the contemporary legislations that has an impact on the education and training of learners in this country. Similarly, this empowerment requires commitment, a receptive attitude, enthusiasm , dedication, passion for one's subject and the willingness to be a lifelong learner by the teacher (Carl, 2 0 02:268). T eachers m ust attend workshops conducted by experts in OBE. A ttending seminars, conferences, inservice ed u catio n and netw orks nationally and internationally with other nurse teacher colleagues through e-mails and the internet to gain more knowledge on the im plem entation o f the OBE approach to teaching and learning would empower teachers.

Remedial teaching process inadequate to meet the needs of poor learners
L earners experienced the rem edial teach in g pro v id ed by teach ers as inadequate. These remedial sessions are meant to improve the performance of learners who failed tests, but the learner participants are not satisfied because the sessions are arranged for times at which learners are either in class or doing practical work. Learners often only become aware of the remedial programme after they have failed the test or when they have lodged an appeal to the appeals committee for their cases to be considered: To com e to a rem edial programme is impossible because you are either working or you are in class.
According to Fraser et al. (1993:87), the learner as a totality should be involved in the planning of how remedial sessions should be conducted. Making use of willing and able or gifted learners in rem edial sessions to im prove the performance of weaker learners would be beneficial since, according to Fraser et al. (1993:86), with peer group tutoring there is a very close interaction between peers because they are always in very close contact with each other. This contact provides ideal opportunities for teaching and learning experiences for learners. Fraser et al. (1993:157) maintain that peer tutoring provides a relaxed atmosphere and is often helpful when learners use it as a form of revision.
Remedial sessions must be planned well and thoughtfully, and the process must be brought to the attention of learners in good time. Remedial action is a process taken by the teacher to im prove the performance of the learner. It is, according to Carl (2002:263), diagnosing learning errors, taking appropriate action, and g iving the n ecessary support and guidance to the learner.

Lack of clinical role-models
Both the learner and tutor participants felt unsupported from the clinical area in that there are no real role-models. Even those professional nurses that learners can look upon as role-models cannot cope with clinical nursing education: Wait fo r the tutor. I cannot answ er your question. I lack know ledge in that regard. This lack o f confidence in professional nurses results in tutors having to work in the clinical areas to provide guidance to learners, which sometimes becomes a heavy and almost impossible task. Role-modelling goes together with trust and confidence, which is a problem to learners because You fin d that the system o f education by the sisters in the wards is not the same as when the tutors teach and evaluate you and you end up failing your clinical work.
Clinical nursing education is a major com ponent of nursing education and provides learners with basic theoretical nursing knowledge and a variety of in te lle c tu a l problem -solving and psychomotor skills. Professional nurses are in a good position to be role-models because of the hands-on nature of their work. They provide direct complex patient care on a daily basis. They are in the forefront of implementing any change in clinical practice. They must strive to be role-m odels because learners imitate what they do in the ward, good or bad. H in ch liff (1997:61) m aintains that teaching by example can be one of the best ways of passing on skills provided that the examples are good. In a study conducted by Lopez (2003:54-56), u n d erg rad u a te nursing learners perceived clinical teachers as caring m others w ho support, neg o tiate, reinforce, transform and release learners throughout their clinical practice.

High expectations from the affiliated university regarding standards
Learner participants were of the opinion that the affiliated university interferes with the autonomy of the tutors: The fact is that a lot o f our learners fa il the test and when we beg our tutors to do something about it or lift the marks, they will say no, because the university this ... and the university that. Tutors are unable to make their decisions regarding changes of marks without the moderator's permission to do so. On the other hand, tutor participants voiced their concern around the role of the university and mentioned that the moderators have very high expectations and do not understand the context of the college. They feel angry and frustrated: What the moderators expect from us and the learner is not always fair, because remember, these are diploma learners.... and they went on to say: They expect certain standards from us, putting a lot o f pressure on us ... they do not know! The decision of the National Health Policy Council, which was accepted by the M inister o f E ducation and the Advisory Committee of Universities, made it clear that nursing colleges offering training at diploma level may be linked to universities selected by the authority financing the college (Searle, 1983:6). The nature of an academ ic affiliation between a university and a nursing college was stipulated in the memorandum advocating a system of linking. In the memorandum, one of the requirements for the affiliation is that the contribution of the university with which a college is academically linked will be determined by an agreement between the university and the college. In broad outline, this includes the follow ing issues: the university shall maintain academic standards by means of further education of the college personnel, interlibrary facilities, assistance with research, and acting as external exam iners to college-based exam inations (Searle, 1983:7). To facilitate the academ ic process, the university w ould have representatives on college committees such as the college council, the college senate, and the curriculum , subject, examination and research committees. It is also ind icated as part o f the fundamental principles of the nature of affiliation that all the courses offered by the nursing college m ust m eet the academic requirements of the affiliated university as well as the m inim um requirements prescribed by the South African Nursing Council (Searle, 1983:7). It was emphasized that this is an academic link and each p artn e r rem ains autonomous and in control of its own budget, facilities and activities. Taba and Kane (in Carl, 2002:264-265) argue that many teachers do not have the necessary knowledge and skills to carry out effective research and that training institutions such as training colleges and universities have a role to play in this regard by way of in-service education. Carl (2002:264) argues that, as developers of the curriculum, teachers should be involved in research activities by starting with classroom research that deals with classroom issues such as handling slow learners or gifted learners, the effect of peer group teaching, the relevance o f co n ten ts, testin g the effectiveness of educational methods, etc. However, Tanner and Tanner (in Carl, 2002:264) warn that if this classroom research takes place in a haphazard m anner and is not accu rate and systematic, it is not of much value. It is therefore imperative that the affiliated university takes the initiative in guiding and building the capacity of the college personnel by co n ducting research projects on the college and utilizing the research findings to improve the situation in the college. Teacher quality and the nursing education quality offered to the learners is the prime responsibility of the affiliated university, which should use other developed countries to benchmark the nursing performance of our learners. Research will allow teachers and learners to evaluate both their academic strengths and weaknesses. Mok (2000:168) is of the opinion that other measures to assess teaching quality that can be adopted are peer review and learner evaluations. In addition, it is urged that the university must recruit highquality staff who are scientific and subject specialists that can act as rolem odels to the college teachers. It is important that tutors bring to the notice of learners the role of the affiliated university in m aintaining standards. Once learners understand that the role played by the university is to their advantage, they will appreciate the affiliation.

Recommendations
The recom m endations m ade by the p artic ip a n ts in d icated freq u en t curriculum revision to meet the current challenges of the health care delivery system . C urriculum should be resp o n siv e, flex ib le and relevant. Mentoring, capacity-building and tutor support through staff developm ent program m es on issues such as the implementation of the outcomes-based education approach to teaching and learning, adult learning principles and the use of learning approaches that promote interaction such as the constructivist approach, problem-based learning, co operative learning and community-based education should be used. Participants also recom m ended that the theory/ practice gap be closed, that tutors to be consistent in their marking, that adequate resources be provided to fa cilitate learning and that tutors be available for learners to consult when they encounter problem s. Since the fin d in g s o f a qualitative, contextual research cannot be generalized to other situations, it is recom m ended that studies related to nursing education be conducted by research committees of other nursing colleges to identify problems leading to poor perform ance of learners and to improve the level of nursing education in the country.

Conclusion
The study has attem pted to identify factors relating to nursing education that contribute to the poor performance of stu d en t nurses follow ing a basic comprehensive diploma leading to the registration with the South A frican Nursing Council as registered nurse (general, psychiatry, community nursing) and midwife. The factors identified were curriculum overload, lack of theory and p ra ctice in teg ra tio n , teach in g and assessment methods that do not facilitate critical thinking, tutors' lack of skills and experience, inadequate preparation of tutors for lectures, insufficient knowledge o f tu to rs w ith reg ard to the implementation of the outcomes-based education approach to teaching and learning, inadequate process of remedial teaching of poor learners, discrepancies between the marking of tutors, lack of c lin ic a l ro le-m o d els and the high expectations from the affiliated university regarding the assurance of standards in n ursing education. The recontextualization of these findings within relevant literature helped the authors to d escrib e strateg ies to im prove the situation and add value to nursing education. The described strategies will be im plem ented through staff developm ent organized by the staff developm ent committee in a nursing college.
The freedom to learn is a basic human right. By expanding this freedom to learn, we strengthen democracy, encourage prosperity and inspire new intellectual tho u g h t and inquiry. C o ntinued encouragement of teacher participation in research to improve nursing education should be m andatory. Teachers are regarded as change agents who can make a real co n trib u tio n to professional d ev elo p m en t. T his p ro fessio n al development can, however, take place only if opportunities for it are created and the teacher realizes that the process of em pow erm ent should eventually be stro n g ly c h a rac te rized by se lf empowerment and mental liberation. The success in the performance of learners is a joint venture of the teacher and the learner. Once again, the importance of support should be strongly emphasized.