Understanding the experiences of doctoral students regarding courses and comprehensive examinations is crucial to enhance the quality of doctoral programs. Scarce information is available on the experiences of nursing doctoral students on the courses and comprehensive examinations in China. The purpose of this study was to understand the nursing doctoral students’ experiences on courses and comprehensive examinations of the doctoral program at Xiangya School of Nursing, Central South University, and propose improvements.
Design
A convergent parallel mixed methods design adhering to EQUATOR guidelines for Good Reporting of a Mixed Methods Study.
Methods
A total of 20 doctoral students were recruited through purposive sampling in September 2022 from the Xiangya School of Nursing, Central South University. They completed the self-designed questionnaire on demographic data, course, and comprehensive examination evaluations and participated in focus groups. Quantitative data were analyzed using descriptive statistics. Qualitative data were recorded and transcribed for content analysis.
Results
Regarding course experience, doctoral students preferred in-person lectures (80%) and group discussions (60%) for specialized compulsory courses. They were satisfied with the course novelty (85%), difficulty (75%), and practicality (85%), and half of the students found the credit allocation reasonable. The qualitative findings revealed their preference for appropriate and blended teaching methods, needs for additional interdisciplinary courses, statistics, and inter-school collaborative courses, accessible Nursing Philosophy and Theory courses, and high proportion of compulsory course credits. Regarding comprehensive examination experience, only 20% considered it necessary, and qualitative data revealed that they prefer more distinctive and effective contents; moreover, students were confused about the purpose of comprehensive examinations. The triangulation of quantitative and qualitative data demonstrated relative convergence.
Conclusions
These findings illustrated nursing doctoral students' experiences on courses and comprehensive examinations and provide suggestions on improving the courses and comprehensive examinations in China and possibly in the world. This study contributes to improving the quality of nursing doctoral programs in China and can serve as valuable guidance for nursing doctoral programs with similar educational environment around the world that are undergoing course and comprehensive examination reform.
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What does this paper contribute to the wider global community?
This paper is the first to investigate the experiences of nursing doctoral students on courses and comprehensive examinations in China using a mixed method. It provides new knowledge about Chinese nursing doctoral education for the global nursing doctoral education community, including the evaluation of teaching methods, course content and credit allocation, as well as the understanding of the purpose and content of the comprehensive examinations.
This paper may facilitate comparisons with similar programs in other regions or continents of the world, providing a reference for nursing doctoral education programs that are undergoing initial reform.
Introduction
A high-quality nursing doctoral program serves as the foundation for training exceptional nursing doctoral students [1]. Continuous evaluation of doctoral programs is crucial for maintaining and improving quality [2]. However, to our best knowledge, research on the quality assessment of nursing doctoral programs in Asia is limited, with the majority of studies concentrating on South Korea and Japan, and even fewer focusing on mainland China [3, 4]. This limitation underscores the necessity for a dedicated quality evaluation study of nursing doctoral programs in China. Evaluating doctoral programs begins with assessing the quality of courses and comprehensive exams (CEs), because they are prerequisites for engaging in formal scientific research and writing a dissertation in most doctoral programs, especially in North America programs [5, 6].
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Currently, the doctoral nursing curriculum in China are not well-established. Most nursing schools face challenges such as a limited number of courses and a lack of specialized nursing courses, while CEs has only been piloted at a few prestigious nursing schools in China. Nevertheless, Xiangya School of Nursing at Central South University has developed a relatively rich doctoral courses and is one of the pioneers in implementing CEs. As one of the first schools in China to establish a doctoral program in nursing [7], its courses cover diverse areas including political thought, foundational theories, research methodologies, research directions, emerging trends, and scientific writing, all built upon a foundation of long-standing educational experience. Therefore, it is essential to evaluate the courses and CE at Xiangya School of Nursing.
Previous research emphasizes the significance of regularly evaluating courses and CEs of doctoral programs. Such evaluations can provide insights into current shortcomings and facilitate ongoing improvement of the programs to aligns with needs of the students [8, 9]. During the evaluation process, students are recognized as the primary recipients and ultimate beneficiaries of the program. Because the direct experiences of students can play an important role in enhancing the quality of courses and CEs [10], exploring their experiences of courses and CEs is essential.
Several studies have explored the course experiences of nursing doctoral students, often limited in scope to a range of study designs. Molassiotis et al., conducted a cross-sectional study of 88 students in East Asian countries, finding that 24.5% of nursing doctoral students were dissatisfied with their courses [11]. However, Molassiotis et al., did not provide a specific reason for the reported dissatisfaction among students, as they only used quantitative methods, which did not allow for a deeper exploration of students’ experiences and perspectives [11]. Another study summarized the characteristics of courses in South Korea by conducting focus group interviews with nursing doctoral students, which revealed concerns such as the excessive emphasis on theoretical development or analysis. It is noteworthy that this study lacked quantitative data to objectively explain students’ course evaluations [12]. In mainland China, five quantitative studies have investigated students’ evaluations on courses, including advanced qualitative course, nursing philosophy and theory course and status of the curriculum [13‐17]. For example, the study on nursing philosophy and theory course collected data from 102 students across eight nursing schools nationwide. More than 80% of these students considered the courses to be very necessary. Between 44.1% and 89.2% of the students have mostly or completely mastered the content, indicating that some students still face difficulties with certain topics, such as the main schools of Eastern and Western philosophy and their characteristics [16]. However, no interview has been conducted to gain an in-depth understanding of doctoral students’ course experiences. This might be attributed to two main reasons: 1) Research Objectives: These five studies aim to produce objective, empirical data on doctoral course in China, and quantitative research is more applicable to their purpose [18]; 2) Resource Limitations: In these five national studies, the participants were nursing students from various schools across mainland China. Due to geographical constraints, it was quite challenging for researchers to conduct qualitative research, as it requires more time and manpower [18].
CEs are common in the nursing doctoral programs of North America, although the literature on CEs is not as extensive as expected. The American Association of Colleges of Nursing (AACN) identified CEs as an important quality outcome measure in nursing research-focused doctoral programs [19]. Internationally, CE content varies by school, university, and discipline, with formats including oral and written examinations (open or closed) [20]. Presently, only three studies explored the experiences of nursing doctoral students with regard to CEs, including two qualitative studies and one quantitative study [5, 8, 20]. One of the qualitative studies explored the CE experiences of dual Doctor of Philosophy (PhD)-Doctor of Nursing in Practice (DNP) nursing students in the United States [5]. The other study focused on Canadian nursing doctoral students, revealing that they desired more information about CE. Specifically, they sought clarification of CE process, including its purposes and potential outcomes [8]. Both studies reported students’ anxiety regarding CEs, which became evident through in-depth interviews. Students believed that college administrators should offer stronger support to them, by informing them of CEs’ purposes and providing guidance from personalized consultants. The quantitative study also shed light on the prevailing trends in the process, timing, and methodology of CEs in the American nursing doctoral programs [20]. The three studies all offered valuable insights and potential strategies that can be implemented to cultivate a supportive environment for CEs [5, 8, 20]. In 2014, the Ministry of Education of the People’s Republic of China issued a statement suggesting that universities focus on strengthening CE development [21]. Currently, China does not have a unified national regulation for CE. There is no statistical evaluation to determine the number of institutions that have CEs. Furthermore, no studies have been conducted to assess the quality or effectiveness of CEs from the perspective of students. We conducted a review of training programs of various renowned nursing universities in China and found that few universities have made relevant information available to the public. For instance, the CE of the Xiangya School of Nursing includes both written (closed-book) and oral test. It primarily evaluates doctoral students' grasp of foundational theories and specialized knowledge, their awareness of the latest advancements in the field, language proficiency, and their capacity for independent analysis and problem-solving.
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To address these research gaps, reveal nursing doctoral students’ experiences of the courses and CEs in China, and provide suggestions for improving their educational quality, a mixed method study was conducted.
Methods
Study design
This was a convergent parallel mixed-method study. Both qualitative and quantitative data was collected simultaneously, and results of both types of data were combined then integrated to explore various facets of the single research question. This integration aimed to expand and strengthen the conclusions drawn from the study [22].
Setting and sample.
Purposive sampling was used to recruit doctoral nursing students from Xiangya School of Nursing, Central South University, one of the top doctoral nursing schools in China that has included CEs into the doctoral program. The eligibility criteria were for students were: (1) being full-time second year doctoral nursing students and (2) having completed all the first-year study courses and having participated in CEs.
All eligible students received a flyer informing them of the purpose of the study and providing them the email address of the research assistant, whom interested students could contact. The research assistant administered the questionnaire and conducted the focus group interviews at the participants’ convenience.
Measurements
The questionnaire was developed through literature reviews and expert panel discussions with senior nursing doctoral educators. Any disagreements regarding the content, theme, or wording of the questionnaire were resolved through joint discussions until a consensus was reached to ensure its validity. The questionnaires included demographic questions as well as evaluations of both courses and CEs (Appendix). The course evaluation section specifically assessed teaching methods (such as online lectures, in-person lectures, and group discussions), course content, and allocation of credits. The evaluation of CEs focused on its content and purpose. The questionnaire could be completed in approximately 15 min.
The semi-structured interview guide (Table 1) was developed based on a literature review and an expert discussion. Participants were encouraged to engage in interviews to share their experiences regarding the courses and CEs.
Table 1
Semi-structured interview guide
Course experience
1. What do you think about the current teaching methods for specialized (compulsory/elective) and general education course (Chinese Marxism)? Please provide some suggestions
2. What do you think about the current course content? Please provide some suggestions
3. What do you think about the current course credit allocation? Please provide some suggestions
CE experience
1. What do you think should be the purpose of the CEs?
2. What do you think about the content of the CEs (oral and written exams)?
3. What do you think needs to be adjusted in the CEs?
CE Comprehensive examination
Data collection
We collected quantitative and qualitative data in September 2022. Quantitative data were collected using the self-designed questionnaire. Each participant selected the appropriate option(s) based on the specific questions.
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Qualitative data were collected through focus group interviews, commonly used in nursing education research because of its ability to elicit spontaneous multiple perspectives and attitudes in an economical, rapid, and efficient manner [23]. Interviews were conducted by two nursing researchers (moderator and assistant) with experience in interviewing. The moderator fostered positive rapport with doctoral students and used standard interview techniques including pausing, further questioning, nodding, and generalizing. The assistant was tasked with arranging the interview venue and observing the group dynamics. Data collection ceased when data saturated was achieved.
Data analysis
Quantitative data were entered into an Excel spreadsheet by one researcher, and the accuracy was checked by two nursing students from the team. The data were then imported into SPSS (version 25.0) for analysis using descriptive statistics.
Qualitative data were analyzed by content analysis [24], which followed a multi-step process: (a) each transcript and field record was reread for a comprehensive understanding of the big picture; (b) the data were deconstructed and analyzed line by line to find significant statements; (c) recurring statements were encoded and classified to generate sub-themes; (d) sub-themes were then cross-checked based on similarity; (e) the themes were synthesized and conceptualized in the context of the researchers’ experience.
Triangulation is the final step in the analysis of a convergent parallel mixed methods, which includes specifically by comparing quantitative and qualitative data collected by different methods to determine convergence (similarity) or differences between datasets them (Fig. 1). For example, the objective data of course content collected by questionnaires are integrated and compared with and the subjective evaluation of course content obtained from student interviews. This integration and comparison aim to achieve a complementary understanding and provide a comprehensive explanation of the different aspects of students’ evaluation of course content.
Fig. 1
The triangulation process in mixed method study
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Ethical considerations
The study was approved by the Ethics Committee of Xiangya School of Nursing, Central South University (number E2023247). Students were informed about not only the research aims and procedure but also their unconditional right to withdraw from the research without facing any detriment or reprisal. The researchers guaranteed their anonymity and confidentiality, ensuring that no identifying factors or information about participants were disclosed throughout the study and publication process.
Rigor
This mixed methods research study was guided by the Good Reporting of Mixed-method Study guidelines (GRAMMS) [25]. The questionnaire was pilot tested by experts who are senior nursing doctoral educators in the United States and China to check validity, with feedback provided on the time taken to complete, survey content and comprehensibility. In addition, we aimed to enhance the trustworthiness of the qualitative study by using a carefully developed and reported interview guide by investigators and experts and presented original quotations to demonstrate the abstraction process [26].
Results
Participants’ characteristics
A total of 20 doctoral students participated in both the questionnaire survey and focus group interview. All 20 questionnaires that were distributed were completed and returned, resulting in a response rate of 100%. Two focus groups were organized, each lasting approximately an hour. Table 2 depicts the characteristics of the participants, who were mostly female (90%), ranging in age from 25 to 40.
Table 2
Characteristics of the sample (N = 20)
Characteristics
n
%
Gender
Male
2
10
Female
18
90
Age (years)
25–30
11
55
30–35
7
35
35–40
2
10
Experience of the courses
Quantitative results: Evidence from the questionnaire survey
Doctoral students firmly believed in the necessity of implementing distinct teaching methods for each course. As shown in Table 3, they overwhelmingly favored in-person lectures (80%) and group discussions (60%) for specialized compulsory courses but preferred online lectures for specialized elective courses (55%) and general education courses (60%).
The majority of doctoral students expressed satisfaction with the novelty (85%), difficulty (75%), and practicality (85%) of the course content. They strongly desired more interdisciplinary (100%) and statistics (95%) courses and looked forward to participating in courses offered by their school in collaboration with various international (95%) and national (90%) schools.
Regarding their evaluation of the courses’ credit allocation, half of the doctoral students agreed that it was reasonable, one quarter disagreed, and the other quarter remained neutral (Table 3). The current credit allocation for each course is detailed in Table 4.
Table 3
Evaluation of courses
Question
n
%
Teaching methods
1. What do you think is an appropriate way to study a general education course (Chinese Marxism)?
In-person lecture
6
30
Online lecture
12
60
Group discussion
6
30
2. What do you think is an appropriate way to study specialized compulsory courses (e.g., Nursing Philosophy and Theory, Advanced Qualitative Research in Nursing)?
In-person lecture
16
80
Online lecture
3
15
Group discussion
12
60
3. What do you think is an appropriate way to study specialized elective courses (e.g., Academic Integrity and Writing, Research Methodology in Global Health)?
In-person lecture
5
25
Online lecture
11
55
Group discussion
7
35
Course content
4. How would you rate the overall difficulty of the courses?
Very difficult
0
0
Difficult
4
20
Neutral opinion
1
5
Easy
13
65
Very easy
2
10
5. How would you rate the overall practicability of the courses?
Very impractical
0
0
Impractical
2
10
Neutral opinion
1
5
Practical
14
70
Very practical
3
15
6. How would you rate the overall novelty of the courses?
Very outdated
0
0
Outdated
1
5
Neutral opinion
2
10
Novel
13
65
Very novel
4
20
7. If the doctoral program adds new courses, which courses would you prefer be added?
Interdisciplinary courses
20
100
Statistics courses
19
95
National inter-school collaborative courses
18
90
International inter-school collaborative courses
19
95
Others
0
0
Credit allocation
8. How satisfied are you with the current credit allocation?
Very satisfied
0
0
Satisfied
10
50
Neutral opinion
5
25
Dissatisfied
5
25
Very dissatisfied
0
0
Table 4
Course list and credit allocations for nursing doctoral program
Course category
Course name
Credits
General education course
Compulsory
Chinese Marxism
2
Compulsory
Nursing Philosophy and Theory
2
Compulsory
Advanced Qualitative Research in Nursing
2
Compulsory
Advanced Evidence-based Nursing
2
Specialized courses
Elective
Academic Integrity and Writing
2
Elective
Research Methodology in Global Health
2
Elective
English Editing and Writing of Papers
2
Elective
Advances in Nursing Science
2
Elective
Theory and Practice of Psychological Nursing
2
Elective
Randomized Controlled Trial
1
Qualitative results: Evidence from focus groups
We identified four themes from course experiences of nursing doctoral students (Fig. 2).
Theme 1. “Preference for appropriate and blended teaching methods”
Doctoral students agreed that in-person lectures would enhance the depth of the course and be more suitable for specialized compulsory courses, while online lectures would enhance the breadth of the course and be more suitable for specialized elective and general education courses. They also felt that group discussions should be included in both online and in-person lectures.
“I believe general education courses and specialized elective courses should not be delivered through in-person lectures. This method is better suited for specialized compulsory courses.” Group 1 (A).
“Online lectures offer the advantage of access to courses in other countries or regions, allowing us to expand our knowledge base, which may be appropriate for electives.” Group 1 (B).
“General education course is also suitable for online lectures, because we only need to master some basic knowledge.” Group 1 (C)
“In-person lectures are often fast paced, which can create a sense of tension for students. If every course adopts this method, it could become overwhelming and lead to increased stress levels for students.” Group 2(A).
“Personally, I believe a class should not solely rely on the teachers’ lectures. Integrating group discussions into online or in-person lectures can help motivate and engage students.” Group 2 (B).
“Yes, one course can have multiple teaching methods.” Group 2 (C)
Theme 2. “Needs for additional interdisciplinary courses, statistics, and inter-school collaborative courses”
Doctoral students expressed their belief that it would be beneficial to add some interdisciplinary courses (e.g., the integration of nursing and intelligent technology) and statistics courses (e.g., generalized linear models). Besides, they eagerly anticipated the addition of inter-school collaborative courses to broaden their perspectives and enhance their educational experience through school cooperation and exchange opportunities.
“We aspire to study pioneering courses such as nursing informatics, telemedicine, and other smart technologies in order to enhance our research innovation.” Group 2 (D)
“We would be extremely grateful if additional courses on statistics were offered, in particular, courses that cover advanced statistical methods such as generalized linear models. The statistical methods currently taught in nursing are inadequate and do not meet our needs.” Group 2 (E).
“I hope there will be more inter-school collaborative courses to learn about other schools’ cultures, teaching styles, student standards, etc.” Group 1 (D)
“Collaboration between international schools would be even better.” Group 2 (F)
Theme 3. “Preference for an accessible Nursing Philosophy and Theory course”
Some students felt that although the Nursing Philosophy and Theory course is of great importance, the current course content is overly philosophical and difficult to understand.
“While I understand the significance of nursing theory as a course, I find it overly philosophical and challenging to comprehend.” Group 1 (D)
“Upon encountering that abstruse theory, I felt apprehensive and lacked the motivation to delve into it.” Group 2 (B)
Nursing theory is vital for research, as it provides an indispensable framework to achieve meaningful results. Thus, this course holds utmost importance.” Group 2 (C)
Theme 4. “Needs for a high proportion of compulsory course credits”
Some students said the current proportion of compulsory courses is low The content of some elective courses is crucial for scientific research and should be included as compulsory courses. They have taken more elective courses than the basic requirement of their elective score.
“The current compulsory course credits are relatively low; we actually need to study multiple elective courses to obtain the total credits” Group 1 (F)
“Each of us has to choose almost all the elective courses, some of which are ostensibly optional but are actually required and should be established as compulsory courses.” Group 2 (G).
Triangulation of qualitative and quantitative results
The qualitative and quantitative results are complementary in students’ experience of courses. Regarding the evaluation of teaching methods and unreasonable credit allocation, quantitative results provide objective data, while qualitative results offer further insights into the underlying reasons. In relation to the course content, quantitative results are supplemented by qualitative results. In interviews, students expressed a need for adjustments in some courses, including interdisciplinary, statistics, Nursing Philosophy and Theory, and school-level collaborative courses. This demand was not reflected in the quantitative results.
Experience of CEs
Quantitative results: Evidence from the questionnaire survey
CEs were divided into two parts: an oral examination and a written examination. The evaluation of the former revealed that 40% of doctoral students considered it relatively easy, while 55% held a neutral opinion. Conversely, 55% of doctoral students found the latter difficult, with one student rating it as very difficult. As a result, it was evident that the written examination presented a greater level of difficulty than did the oral examination (Table 5).
Table 5 reports the findings on doctoral students’ understanding of CEs’ purpose. Only 20% viewed CEs as necessary. A large majority (90%) recognized that CEs were intended to monitor and evaluate their progress in learning from courses and research. Furthermore, a majority of students (75%) expressed strong opposition to the disqualification criteria based on a student’s performance in CEs. Approximately 35% of students suggested that disqualification should be considered during the thesis proposal phase, while another 35% recommended it at the thesis defense phase.
Table 5
Evaluation of CE content and purpose
Question
n
%
CE content
1. How would you rate the difficulty of the oral part of this CE?
Very difficult
0
0
Difficult
1
5
Neutral opinion
11
55
Easy
8
40
Very easy
0
0
2. How would you rate the difficulty of the written part of this CE?
Very difficult
1
5
Difficult
11
55
Neutral opinion
7
35
Easy
1
5
Very easy
0
0
CE purpose
3. How would you rate the necessity of CEs during the nursing doctoral program?
Totally unnecessary
3
15
Unnecessary
4
20
Neutral opinion
9
45
Necessary
4
20
Totally necessary
0
0
4. What do you think is the purpose of implementing CEs?
Supervising doctoral students’ learning and research progress
18
90
Improving the ability of doctoral students in all aspects
6
30
Weeding out unqualified doctoral students
2
10
Discovering the potential of outstanding doctoral students
1
5
Others
0
0
5. How would you rate the necessity to disqualify doctoral students based on CE performance?
Totally unnecessary
4
20
Unnecessary
11
55
Neutral opinion
1
5
Necessary
4
20
Totally necessary
0
0
6. In which phase of the doctoral program do you think it is most appropriate to disqualify students?
CE
5
25
Thesis proposal
7
35
Thesis defense
7
35
Thesis blind review
1
5
Others
0
0
CE Comprehensive examination
Qualitative results: Evidence from focus groups
We identified two themes from CE experiences of nursing doctoral students (Fig. 2).
Fig. 2
Categories describing the course and CE experiences of nursing doctoral students
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Theme 1. “Preference for more distinctive and effective examinations.”
Currently, the content of the oral examinations includes a literature review report. Doctoral students believe that the oral examination is similar to the oral defense of a thesis proposal in the doctoral program. They expressed their desire for the CE oral examination to be designed in a way that distinguishes it from other phases of oral presentation in the doctoral program. Additionally, they also believed that written examinations were more difficult than were oral examinations, as they emphasized rote memorization, which did not effectively reflect students' ability to apply knowledge.
“The oral examination entailed a report on a literature review, and I am unsure of how it distinguishes from an oral report on thesis proposal.” Group 1 (G)
“Yes, I want to make the CE oral exam special so that it can be more meaningful.” Group 1 (H)
“The written exam is a bit more difficult than the oral exam, because I hate cramming. I prefer the written test to evaluate my practical research skills rather than my proficiency in reciting theoretical knowledge.” Group 2 (E).
Theme 2. “Confusion about CEs’ purpose”
Doctoral students were confused about the purpose of CEs, concurring that CEs adapted from the American nursing doctoral programs is not appropriate for the Chinese doctoral education system. They believed that the current CEs failed to select outstanding students or measure their scientific research abilities. Moreover, they strongly disagreed with the notion of disqualifying students based solely on the performance in CEs.
“We don’t understand the purpose of CEs.” Group 1 (F)
“I believe that the doctoral education system in China is different from that in the United States, so when we try to adopt certain aspects of American education programs, they may not match or be compatible.” Group 1 (G).
“I don't agree with using the CE score as the sole basis for disqualification, as it does not accurately assess our abilities.” Group 2 (F)
Triangulation of qualitative and quantitative methods
Relatively similar results were found when quantitative and qualitative data about CEs were triangulated. Specifically, the quantitative results illustrated that the written test was more difficult than the oral test. The reasons and the suggestions for this were elaborated through qualitative interviews. Likewise, quantitative and qualitative results also complemented each other with regard to CEs’ purpose evaluation, highlighting the need to clarify the purpose of CEs.
Discussion
This study provided an opportunity for nursing doctoral students with experience in both courses and CEs at Xiangya School of Nursing, Central South University, to voice their perspectives about the doctoral program. A convergent parallel mixed-methods design was employed to obtain students’ views on teaching methods, course content, and credits for the course, as well as on the purpose and content of CEs.
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This study identified several specific experiences with regard to course curricula from nursing doctoral students, including teaching methods, course content, and credit allocation. Students believed that different teaching methods have their own advantages, and faculty should select appropriate teaching methods according to the different categories of courses. Consistent with previous studies of doctoral nursing students in China, students generally acknowledged that online lectures overcame the constraints of time and space, while in-person lectures enhanced students’ attention and participation in the course [15, 16]. The integration of multiple teaching methods and flexible switching was the best way to improve students’ learning efficiency [27]. Thus, further strengthening the development of blended teaching in nursing doctoral programs is of great significance in inspiring students’ learning initiative and enhancing the quality of education.
Some of the course content did not meet the expectations of the students. Some recommendations included, first, adding interdisciplinary courses. Nursing is an integrated discipline that draws knowledge from various disciplines, including biomedicine, sociology, and humanities [28]. This integrated nature of nursing requires interdisciplinary nursing talents who possess a diverse skill set to solve intricate problems [29]. In the United States, a report by the Institute of Medicine (IOM) on the Future of Nursing emphasized the importance of interdisciplinary collaboration and recommended expanding research opportunities for nurses [30]. American nursing doctoral programs have long included interdisciplinary courses covering multiple disciplines, such as natural and social sciences, economics, and culture [31]. In contrast, interdisciplinary nursing education in China lags behind [32], and it is urgent to set up interdisciplinary courses provided by nursing doctoral programs to train interdisciplinary nursing talents.
Second, adapting statistics and Nursing Philosophy and Theory courses to the practical characteristics of the nursing discipline is essential for the identification and resolution of problems within the realm of nursing [33]. Statistics, as a fundamental element of nursing postgraduate courses, must be continuously enriched to accommodate the increasingly complex demands of nursing research on evidence-based practice. It is suggested that the focus of statistical competencies shift more towards skills in data analysis and visualization [31, 34‐36]. However, the majority of nursing postgraduate students in China, including those from Xiangya School of Nursing, are enrolled in statistics courses based on clinical medical cases rather than nursing cases [37]. This statistics courses often results in comprehension challenges for nursing students [38]. For the same reason, some doctoral students argued that the content of the Nursing Philosophy and Theory course is overly philosophical and does not sufficiently incorporate practical aspects of the nursing discipline, making it difficult to understand. Previous scholars have proposed that, in nursing research, philosophy is a valuable tool for revealing research hypotheses, thereby enhancing understanding and promoting nursing practice [39]. Therefore, it is essential for both statistics and Nursing Philosophy and Theory courses to be rooted in the practical aspects of nursing, explaining concrete knowledge using scientific studies and clinical cases to facilitate comprehension for nursing students.
Third, doctoral students need to participate in various courses organized by different national and international nursing schools. Collaboration, collegiality, and the sharing of resources is considered necessary to create diverse learning opportunities for doctoral students [40]. China has previous experience in domestic collaboration between schools. In 2014, with the financial support of the Chinese Medical Board (CMB), eight nursing schools across China, including Xiangya School of Nursing, took part in the construction project of the CMB's Chinese Nursing Network (CNN) Mixed-Mode Nursing Doctoral Core Curriculum to jointly establish a system for sharing course across institutions [41]. This system provides a platform for interaction between faculty and students from different schools, and successfully facilitates the collaborative construction and sharing of high-quality courses among these schools [17, 41]. However, Chinese international collaborative courses are currently focused on nursing undergraduates and graduate students pursuing master's degrees [42, 43]. Hence, in addition to establishing a resource-sharing system for nursing doctoral course in China, we recommend initiating international collaborative courses for doctoral programs. This initiative would foster the exchange of knowledge and experience sharing among nursing doctoral students globally.
Additionally, aligning with the findings of previous studies [13, 14] our finding indicated that Chinese students need a high percentage of credits for compulsory course. It is well known that compulsory courses usually cover the basic knowledge and core skills of the specialty. These courses are characterized by rich content, which can provide students with opportunities for profound learning experience. The assessment for compulsory courses tends to be quite stringent [44]. However, according to the 2021 course catalog of Xiangya School of Nursing (Table 4), there are only three compulsory courses related to the core knowledge of nursing. This number is notably insufficient to meet the learning needs of doctoral students. To make up for this shortcoming, students had to choose additional elective courses. But electives are courses students can select based their interests [44]. The content of elective courses is relatively more flexible, and the assessment criteria are typically less stringent. As a result, it often fails to ensure that students achieve a deep understanding of the course content [45]. Therefore, the nursing doctoral program should consider making appropriate adjustments to the credit allocation system. This could involve increasing the proportion of compulsory courses or reclassifying some elective courses into compulsory ones.
The findings of our study suggested that CEs’ content should be distinctive and focused on the application of knowledge. On the one hand, CEs’ content in doctoral programs is typically determined independently by the faculty at each school, lacking a standardized outline[20]. Consequently, there is potential for content conflict between CEs and other training phases in doctoral programs such as thesis proposal [46]. On the other hand, as mentioned above, nursing is a practical discipline [33], which highlights the significance of assessing doctoral students’ practical abilities when addressing scientific research challenges. Future efforts in CEs’ content design should prioritize the assessment of practical application abilities based on scientific research knowledge.
Clearly understanding the purpose of CEs is critical to further optimizing CEs’ content effectively. Results from our study revealed that students were confused about the purpose of current CEs. Actually, the confusion surrounding CEs’ purpose is a pressing global issue, because doctoral educators and students in various nursing schools have different understandings of and requirements from CEs [47, 48]. CEs were recently introduced as an exploratory training phase of Chinese nursing doctoral programs, where this confusion may be even more pronounced. Hence, it is imperative for both China and other countries to establish standardized criteria or guidelines for CEs to oversee and promote their effective development.
Although students were generally confused about the purpose of CEs, they also had their own views about them. A significant majority of students believed that CEs were meant to supervise their acquisition of scientific knowledge, with only 10% believing its purpose was to disqualify underperforming students. One possible reason is that the number of nursing doctoral programs in China is relatively limited, and admissions are complex and rigorous, including both application and examination [49]. Presumably, the elimination of the doctoral qualification at CEs will exert great pressure on students and potentially lead to a reduction in the number of doctoral admissions. By contrast, In the United States, it is a common phenomenon to determine the qualification of doctoral students based on CE scores, and the average elimination rate is 10% to 25% [49]. The United States has a large number of doctoral programs and follows open application-based admissions, requiring strict CEs, which serve as an opportunity for doctoral students to further ascertain their qualification and interest in pursuing the profession [20, 50]. Consequently, CEs influencing disqualification is not particularly suitable for doctoral programs in China. We recommend that educators of nursing doctoral programs in China tailor CE to fit the specific context of the Chinese educational system. In light of this recommendation, the goal of CE in China should focus more about identifying students' shortcomings in research practice and offering targeted guidance to facilitate their growth rather than weeding out them.
This study has important implications for research, practice, and policy in the development of nursing doctoral courses and CEs. Regarding the courses, nursing educators should regularly collect feedback from doctoral students about their experiences of teaching methods, course content, and credit allocation and, subsequently, implement targeted improvements. Similarly, by exploring their experiences with CEs, we gained a clearer understanding of the introduction of CEs in Chinese nursing doctoral programs, emphasizing the clarity and optimization of their purpose and content. Additionally, we need to further develop and customize doctoral programs (especially the CEs), to fit the Chinese educational context. Specific recommendations could be as follows: in course design, we should consider student feedback and concurrently emphasize the conveyance of advanced knowledge to address the shortcomings in the development of nursing disciplines in China; and the CE component should be tailored to fit the admissions process of Chinese doctoral program to alleviate student pressure, with a focus on tracking the academic ability and research progress of doctoral students. These adaptations should be standardized by the Chinese government and supervised by the doctoral management committees at each nursing school. The seamless integration of CEs into Chinese nursing doctoral programs demands continuous investigation and research. Future research should consider gathering experiences and feedback from teachers, administrators, and students to explore opportunities for optimizing both the course and CE design. Finally, this study may facilitate comparisons with similar programs in other regions or continents, providing a reference for the nursing doctoral education programs that are undergoing initial reform.
Limitations and strengths
Some limitations of this study should be noted. Although steps were taken to establish the content validity of the questionnaire, external validity and reliability estimates were not determined. More effective standardized instruments are needed to evaluate students’ experiences in the future. With a mere representation of 2 males among the total of 20 participants, the inclusion of a male perspective was severely limited. Nonetheless, gender bias was unintentional because all students were volunteers. The sample size was small because this study was conducted in a single nursing school. Despite these limitations, the study has undeniable strengths. First, it represents the first exploration of Chinese nursing doctoral students’ experiences of their courses and CEs. Second, the convergent parallel mixed-methods design compensated for a lack of a qualitative or quantitative study design, providing valuable insights to enhance our overall understanding of the students’ experiences of courses and CEs [51]. Finally, our study focused on first-year doctoral students who had recently completed their coursework and CEs, thereby minimizing recall and response biases as much as possible.
Conclusions
This study underscores the importance of understanding the experiences of nursing doctoral students with regard to courses and CEs to offer target suggestions for improvement. Major areas that warrant special attention include strengthening the implementation of blended teaching methods, adapting the course content to the nursing discipline, rationally allocating credits, and designing clear and distinctive purposes and contents for CEs. The findings of this study contribute to improving the quality of nursing doctoral programs in China and can be utilized by nursing school faculty and administrators around the world to enhance the doctoral education they impart.
Acknowledgements
The authors would like to express their gratitude to all members of the Xiangya School of Nursing Doctoral Management Committee, including Prof. Maritta Välimäki, Prof. Lezhi Li, Prof. Xianhong Li, Prof. Jingping Zhang, Prof. Jia Guo, Prof. Shiping Yuan, and Mr. Jianglong Xiao.
Declarations
Ethical approval and consent to participate
The study was approved by the Ethics Committee of Xiangya School of Nursing, Central South University (number E2023247). We obtained participants’ informed consent before the survey and interview. All methods were performed in accordance with the relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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