Nurse Education Today 35 (2015) 733–739

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Attitudes toward clinical practice in undergraduate nursing students: A Q methodology study Eun-Ho Ha ⁎ Red Cross College of Nursing, Chung-Ang University, 84 Heukseok-Ro, Dongjak-Gu, Seoul 156-756, Republic of Korea

a r t i c l e

i n f o

Article history: Accepted 21 January 2015 Keywords: Nursing student Attitude Clinical practice Q metodology

s u m m a r y Background: Clinical practice (CP) provides an opportunity to directly apply nursing theories learned in class to practice, with the aim of improving nursing knowledge and skills. Nursing students' perspectives about CP can be diverse. Objective: To identify nursing students' attitudes toward CP. Design: Q-methodology, an integration of quantitative and qualitative methods, was used. Participants: A convenience P-sample consisting of 43 second-year undergraduate nursing students. Methods: Forty-three selected Q-statements from each of the 43 participants (P-sample) were classified into the shape of a normal distribution using a 9-point bipolar scale. The collected data were analyzed using the pcQUANL program. Results: Two discrete factors emerged. Factor I comprised a querulous attitude with a critical perspective. Factor II comprised an enthusiastic attitude with a future-oriented perspective. Conclusion: The subjective viewpoints of the two identified factors can be applied in planning effective CP for nursing students. © 2015 Elsevier Ltd. All rights reserved.

Introduction Clinical practice (CP) in the nursing curriculum is an essential prerequisite condition in the education and training of competent professional nurses (Bisholt et al., 2014; Papathanasiou et al., 2014). CP provides an opportunity to directly apply nursing theories learned in class to practice, with the aim of improving nursing knowledge and skills (Ironside et al., 2014; Sharif and Masoumi, 2005; Ulfvarson and Oxelmark, 2012). The most important learning outcome in CP is real-world experience of communicating with patients and other health care members (Levett-Jones and Lathlean, 2008). Through CP, nursing students are aided in establishing effective interpersonal relationships, which can help in their development of a professional identity (Brown et al., 2012). In addition, nursing students learn their role of nurses and the vital importance of nursing care in the clinical setting (Jonsén et al., 2013; Smedley and Morey, 2010). Positive experiences of CP improve the critical thinking and problem-solving ability of nursing students, promote a strong sense of belonging, inspire confidence, and enhance nursing professionalism and identity (Blomberg et al., in 2014; Levett-Jones and Lathlean, 2008; Mattila et al., 2010). In contrast, a negative experience with CP can lead to frustration, which detracts from the continuum between ⁎ Tel.: +82 2 820 5991; fax: +82 2 820 7961. E-mail address: [email protected].

http://dx.doi.org/10.1016/j.nedt.2015.01.013 0260-6917/© 2015 Elsevier Ltd. All rights reserved.

school-based and hospital-based nursing training (Brown et al., 2012), disappointment related to hands-on nursing performance, alienation, and debased self-esteem (Mattila et al., 2010). CP and its positive experiences/attitudes play significant roles in the future career choices of students including the choice of a workplace after graduation (McKenna et al., 2013). Conversely, negative CP experiences create feelings of being left out and decrease self-esteem (Mattila et al., 2010). Both positive and negative experiences and attitudes toward CP depend on close collaboration between school teachers and clinical staff who are especially responsible for the students' clinical education as a preceptor (Haugan et al., 2012; Jonsén et al., 2013; Löfmark et al., 2012). Therefore, developing high quality clinical environments and harmonious cooperation between the nursing school and hospital are cornerstones in optimizing clinical practice (Andrews et al., 2006; Bisholt et al., 2014; McKenna et al., 2013). Evaluating and reflecting nursing students' diverse experiences and attitudes, in particular, provide a helpful insight to facilitate development of effective clinical teaching strategies in nursing education (Sharif and Masoumi, 2005). Consequently, the experiences, attitudes, perspectives, feelings, and perceptions of each student toward CP must be investigated before and after clinical practice, and the results must be also respected and reflected to maximize clinical learning outcomes. Few studies have investigated the attitudes of nursing students toward CP. Careful contemplation and proper understanding of the attitudes of nursing students toward CP and reflection of these results

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in planning and evaluating clinical practice are the linchpin to achieve clinical learning objectives. The main objective of this study was to identify subjectivity including attitudes of nursing students toward CP. Nursing Student CP in South Korea Nursing education in South Korea operates on two different tracks: three years at a college or four years at a university. Nursing curriculums in colleges and universities can be different or diverse, but nursing students' CP must exceed 1000 h during the two years before graduation (Park, 2012). The level of hospitals for CP varies (university hospital, advanced large hospital, and general or medium-sized hospital), which can produce diverse learning environments. Hence, the attitudes of nursing students toward CP can vary. Hands-on practice or observation-based practice depends on hospital policy. However, unit managers who are involved in CP must have a bachelor's degree, and be capable of evaluating nursing student's performance or attitudes. Methods

A Q methodological study involves several steps (Fig. 1). The first is the development of the concourse using diverse sources, such as literature review, interview, scientific papers, books, and newspapers (Akhtar-Danesh et al., 2008). The second is a production process of statements known as the Q-sample (or Q-set). The third is the selection of the sample of participants (P-sample or P-set). The fourth is a process of Q-sorting using a bipolar Q-sort table designed as a grid or data collection table. Individual subjectivity is deduced through the Qsorting procedure (Watts and Stenner, 2005). After these processes, the collected data are analyzed by varimax rotation for a by-person factor analysis. Several factors are eventually identified and labeled by a team of domain experts. The participants are asked to gather more information about the two most agreeable and disagreeable statements (Akhtar-Danesh et al., 2008; Dziopa and Ahern, 2011). These openended comments are a vital part of the Q methodological procedure for the interpretation of the emergent factors' viewpoints, communicating the shared viewpoints, and providing a source of further insights. In factor interpretation, a table commonly connotes the loadings of study participants Q sorting on extracted and rotated factors with zscores. The eigenvalues and the percentage of the study variance are illustrated by each factor (Watts and Stenner, 2005).

Q Methodology Research Procedure Q-methodology, first introduced by William Stephenson in 1935, is an integrated research approach that synthesizes quantitative and qualitative methods, which enables conversion of subjective human perspectives into an objective outcome (Akhtar-Danesh et al., 2008; Watts and Stenner, 2005). Q-methodology explores and clarifies individuals' consistent point of view about a phenomenon, interest, or concern (Dziopa and Ahern, 2011).

Concourse (Q Population) The concourse is representative of the universal point of views about a certain topic, and is central to the process of creating Q-sample (Akhtar-Danesh et al., 2008). In this study, the Q population consisted of statements generated from the following process (Fig. 2). The first

Concourse (a representative of the universe viewpoints) Literature review, interview, expert opinion, questionnaire

Development of the Q-Sample (Q-Set) from the concourse Clarifying statements (43)

P-Sample (P-Set) selection Group of study participants (43)

Q-Sorts Using a Q-sort table (arbitrary and forced distribution)

Factor Analysis By varimax rotation using pc-QUANL program

Factor extraction and interpretation The labeling of the two factors, and addition of comments Fig. 1. The practical steps in Q-methodology.

E.-H. Ha / Nurse Education Today 35 (2015) 733–739

Literature review Literature review related to CP

Written narratives Fill in the six-item questions by 207 nursing students

In-depth interviews

735

step was the review of prior studies related to CP by the researcher and two research assistants. The second step involved obtaining written narratives from 207 nursing students who were completing their second year semester. Each student was asked six questions formulated by the researcher based on a literature review: • • • • • •

What is CP? Why is CP needed? What is the relationship between CP and simulation-based learning? What did you learn through CP? What are the advantages and disadvantages of CP? What are the roles of a professor in CP?

Get more information toward CP from 21 nursing students

Developed a total of 108 statements Correct redundant and unclear statements Fig. 2. The steps for construction of concourse.

Of the 207 students, 153 responded anonymously, and the responses were put into the researcher's mail box. The third step was in-depth interviews conducted during focus group discussions consisting of 21 nursing students who were willing to participate in further extraction of their responses concerning CP. A total of 155 statements as an initial Q population were extracted through these processes. After correcting for overlapping and unambiguous statements, 108 of 155 statements were generated as the second Q population. The procedures for

Table 1 Q statements. Q statement

1. It helps me to decide on my future course. 2. It can be applied to clinical practice by integrating the nursing theory that I have learned in class. 3. Nursing can be directly applied to real patients. 4. I feel nervous and burdensome because of a lack of nursing knowledge when I practice a subject that I didn't learn in class before. 5. It gives me an opportunity to build extensive knowledge through new and diverse experiences. 6. I become confident because I can learn about communication and coping skills, critical thinking, and interpersonal relationship. 7. It gives me the feeling of more interest in and importance of nursing. 8. It gives me an opportunity to grasp characteristics and the atmosphere of hospitals. 9. There is a need to allocate practice areas to consider the distance between home and hospital levels. 10. The hospital environment for nursing students such as changing rooms and lounges for student is not good enough. 11. Having a good sense, physical strength and quick steps are required to wear many hats in the play. 12. Because of running chores and small errands I feel like a substitute worker of the hospitals. 13. Clinical practice is an extension of schoolwork and authentic education. 14. It may reduce the gaps between clinical nurses and student nurses. 15. Actually, I can only give little nursing to the patients because there are a lot of limitations for nursing students in hospitals. 16. I am confused by the gap between nursing theory and practice. 17. Nurses must have equivalent knowledge and skills with doctors. 18. It gives me an opportunity to identify nursing knowledge and reflect weaknesses. 19. I like hospitals where I can study and search for data related to patients during clinical practice. 20. I feel like a doll because the practice is mainly proceeded with observation which makes me more tired and bored. 21. I feel like a real nurse and my senses of belonging and duties are formed in a medical team. 22. It remains in my memory longer than what I have learned in class. 23. It gives me an opportunity to emulate real nursing activities in a positive way. 24. How much experience I can get depends on my practice in hospitals and on the nurse instructors. 25. I feel uncomfortable when I ask questions because the nurses are too busy. 26. It gives me an opportunity to communicate with people from a variety of fields. 27. I feel like a machine that checks patient's vital signs. 28. The clinical adaptability can be facilitated since I can directly observe what nurses are doing. 29. Case studies and feedbacks are very helpful to organize clinical practice. 30. It gives me an opportunity to become close and to cooperate with peers. 31. I can observe the working relationship between doctors and nurses. 32. The psychological burden is greater because adapting to school after clinical practice is too hard. 33. The relationship between hospitals and schools has to be good for a smooth clinical practice. 34. Sometimes I think that I do clinical practice for case studies only. 35. The simulation helps me to calmly practice in a clinical setting. 36. I hope that hospital staffs understand that students' nursing theory and experience are not enough because students do not obtain a nursing license yet. 37. There is a person in charge needed who can observe and educate students' nursing activities. 38. A heartfelt advice based on the professor's abundant experiences and motivations is helpful for the clinical practice. 39. The place visit of the professor is helpful and a great comfort for my clinical education. 40. Each hospital's details are needed to share clinical experience and to exchange information. 41. A standardized nursing students' appellation is needed in hospitals and I hope nurses respect us. 42. Clinical practice should be done in three shifts to understand nursing activities generally. 43. Sometimes I wonder what the purpose of clinical experience is and it reminds me on my expensive tuition.

Z-score (factor) I

II

0.28 −1.20 −1.41 0.05 −0.11 −0.47 −0.92 0.76 1.67 0.81 0.65 2.09 −0.49 −1.99 0.39 0.27 −0.72 0.02 0.48 1.40 −1.34 −0.03 −1.25 1.57 0.92 −1.59 1.83 −0.37 0.03 −0.29 −0.31 −1.00 −0.63 0.44 −0.71 0.79

1.25 −0.83 −0.17 −0.05 0.88 0.79 0.79 0.70 0.80 −0.36 1.11 −0.62 1.04 −1.55 −0.17 −0.40 0.92 1.91 0.45 −1.21 −0.29 0.68 −0.05 1.90 0.41 −1.62 −0.92 1.16 0.67 0.19 −0.15 −2.23 −0.17 −1.14 0.11 −0.16

0.09 0.16 1.04 −0.50 1.09 −2.03 0.52

0.21 0.18 0.74 −0.45 0.01 −1.70 −2.50

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Reliability and Validity

development of the Q population were devised by the study researcher and by domain experts involved in clinical nursing education.

Reliability of Q sorting was verified using a test–retest procedure. Repeated Q sorting was usually conducted at 1- and 2-week intervals (Brown, 1980). Validity of a Q study includes three purviews: content, face, and Q sorting validity. Content and face validity are generally appraised by domain experts including researchers. Q sorting validity is assessed by participants in a pilot study (Akhtar-Danesh et al., 2008). For content validity of statements in this study, statements were assessed by three professors of nursing and one methodologist as a team of domain experts. For face and Q sorting validity, the final panel of 43 Q samples extracted through content validity was evaluated by these domain experts, and tested by 10 volunteer students. The 10 students were retested 1 week later to clarify reliability. The correlation coefficients between respective Q-sorts were higher than .89.

Q Sample A list of 108 statements was edited to 65 by three professors of nursing and two methodologists to identify repetitious viewpoints and to eliminate duplication. After pilot testing the statements with 10 participants, the statements were further reduced to 48. This ensured expression of contrasting viewpoints, involved rewording and rewriting of statements, and eliminated further superfluous statements. Ultimately, 43 Q samples were created to represent the concourse surrounding CP (Table 1). Selection of Participants (P-sample)

Data Analysis

A predominant feature of Q methodology is not the number of participants but the representation of diverse viewpoints about the study theme (Akhtar-Danesh et al., 2008). Brown (1980) recommended that 40–60 participants are adequate. To recruit P-sample for Q sorting, second-year undergraduate nursing students enrolled at a college of nursing in Seoul, Korea were asked to participate in Q sorting. A convenience P-sample consisted of 43 students who had received CP for one year, and who had one more year to practice.

The pc-QUANL program was used to analyze the Q sorts (AkhtarDanesh et al., 2008). Factor analysis was established to reveal groupings or patterns in the data after each participant's score was entered into the database (Dziopa and Ahern, 2011). Relevant to the analysis of Q sorts were the following three points: eigenvalues of at least 1.0 for the final interpretation, conducting varimax rotation to maximize the variance between each type, and adopting z-score as a measure of standard deviation (statements with a z-score above + 1.0 as positive views and below − 1.0 as negative views) (Akhtar-Danesh et al., 2008).

Q Sorting Q sorting or the ranking procedure in Q methodology contains a distinctive characteristic, in which the P-sample attempts to force point of views to place a set of statements on fixed quasi-normal distribution, even if less than ideal. Consequently, Q sorting is composed of enthusiastic but reluctant configuration by P-sample (Watts and Stenner, 2005). Forty three study participants were asked to rank the order of Q samples using a quasi-normal distributed Q sort table. Each of the 43 Q sorters completed the 43 Q statements in the distribution provided ranging from + 4, through ‘zero’, to − 4 for items (Fig. 3). After each Q sort, each participant was requested to write open-ended comments to describe the reasons why they sorted the statements to which they strongly disagreed (−4) and strongly agreed (+4). These descriptions were used to interpret each factor classified.

Ethical Considerations Prior to conducting this study, ethical approval was obtained from the Institutional Review Board at the College of Medicine, Chung-Ang University. Informed consent was provided by all participants with the knowledge that the data would never be used for any other purpose other than for this research. All participants were also informed that they could refuse to participate or withdraw from the study without penalty, and participation or refusal would not affect the participants' course grade. All information gathered was treated confidentially and anonymously.

13 16 3

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31

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40

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39

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41

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Raw Scores

-4

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-1

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No. of Card

(2)

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(7)

(9)

(7)

(5)

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Transformed Score

(Strongly Disagree)

(Neutral)

Fig. 3. Sample of completed Q-sort table.

(Strongly Agree)

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“It is so exciting to practice in hospitals. There are so many things happening. I have no time to get bored.”

Results Of the 43 participants in this study, 37 were females and 6 were males. Twenty four of the 43 were classified into Factor I and 19 were classified into Factor II. Ages ranged from 22 to 41 years. The two factors occupied 39.9% of all variance and included Factor I (27.1%) and Factor II (12.8%). Eigenvalues of each factor were 11.66 and 5.52, respectively (Table 2).

“I am confident of critical thinking, nursing theories, and communicating with patients. I often go over issues regarding my deficient nursing knowledge and skills through clinical observation. How much I can learn depends on my eagerness to learn.”

Factor I: Querulous Attitude (Critical Perspective) Twenty-four nursing students and 15 statements (seven items for +, eight items for −) were loaded significantly onto Factor I, which was labeled ‘a querulous attitude’. The students thought that hospital members treated students as supernumerary workers who only checked patient vital signs, and regarded students as roster staff. This group mostly agreed with Q statements 9, 12, 20, 24, 27, 39, and 41 as a positive view. The students did not agree with Q statements 2, 3, 14, 21, 23, 26, 32, and 42 as a negative view (Table 1). The student's responses were reluctant or dissatisfactory to CP. Illustrative openended comments of this factor were as follows: “I spent all day checking patients' vital signs, and running little errands for nurses without food. I had a feeling of being a water boy. It made me stressed and frustrated.”

“I realized that nurses should be knowledgeable to equally stand with doctors. It motivated me to study hard.”

Consensus Statements Between Two Factors There were several statements that the two factors equally either agreed or disagreed with (Table 3). The two factors all strongly agreed with statements 9 and 24. On the other hand, the two factors all strongly disagreed with statements 2, 14, 26, and 42. These responses reflected the views that nursing students' quality and quantity of learning through CP depend on the level of hospitals, and nurses' passion about teaching students. Discussion

“Nurses and even doctors treat us like extra workers. They see us as someone beneath them. It makes me frustrated.”

“Nurses' roles are not much more, and look more exhausted than I expected. I have to rethink about whether nursing is what I want or not.”

“The gaps between nurses and myself became more serious during CP. Nurses were not interested in teaching students and building relationships with us.”

Factor II: An Enthusiastic Attitude (Future-oriented Perspective) Nineteen of the 43 nursing students were loaded onto Factor II (‘an enthusiastic attitude’) on the basis of 13 statements. This group strongly agreed with Q statements 1, 11, 13, 18, 24, and 28. On the contrary, they did not agree with Q statements 14, 20, 26, 32, 34, 42, and 43 (Table 1). These responses reflected the views that CP helps students to decide on their career, have an opportunity to confirm nursing knowledge, and accelerate their clinical adaptation skills. Illustrative open-ended comments of this factor were as follows:

Factor 1 Factor I subjects (a querulous attitude: critical perspective) generally professed uncomfortable feelings for CP. The main issues concerning CP in this group were being treated as extra workers, patronizing attitude and actions of hospital staff, and observation-oriented practice with no practical duties assigned. Saarikoski et al. (2007) reported that nursing students are learners, not workers. Students deserve to be respected as learners, and should be educated and supervised on a one-to-one basis when they perform nursing activities learned in class. Levett-Jones and Lathlean (2008) interviewed 18 nursing students; some students mentioned that they sacrificed their practice hours for miscellaneous work, and some students remarked that they felt like nurses' assistants. Some of the interviewees in the study conducted by Jonsén et al. (2013) opined that some nurses ignored them and made them feel foolish and disrespected. A supportive clinical learning environment is vital to maximize the learning outcomes of nursing students; the attitude and behavior of nursing staffs and the ward culture are essential to this goal (IP and Kit Chan, 2005; Smedley and Morey, 2010). In this scenario, the primary role of nurses is to foster an atmosphere conducive to learning for nursing students. Ward managers, in particular, are the most key figures for nursing students to create an educational atmosphere in the clinical setting (Bisholt et al., 2014). The findings of Andrews et al. (2006)

“I could accumulate diverse nursing knowledge and experiences, and face various diseases and testing through CP.” Table 3 Consensus statements between two factors. Q statement Table 2 Eigenvalues, variance, and characteristics of the 43 participants. Variable

Factor I (n = 24)

Factor II (n = 19)

Eigenvalues (Variance, %) Sex Male Female Age in years (range)

11.66 (27.1%)

5.52 (12.8%)

5 19 22–30

1 18 22–41

24. How much experience I can get depends on my practice hospitals and on the nurse instructors. 9. There is a need to allocate practice areas to consider the distance between home and hospital levels. 2. It can be applied to clinical practice by integrating the nursing theory that I have learned in class. 26. It gives me an opportunity to communicate with people from a variety of fields. 14. It may reduce the gaps between clinical nurses and student nurses. 42. Clinical practice should be done in three shifts to understand nursing activities generally.

Z-score 1.79 1.24 −1.02 −1.61 −1.77 −1.86

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support the notion that development of a constructive learning environment for nursing students entirely relies on the ward manager's leadership styles and attitudes. Such a pedagogical environment results in invaluable experiences for nursing students and leads to a successful CP (Smedley and Morey, 2010). A nurturing clinical environment is not just the domain of nursing staff including ward managers. Professors are important in establishing cooperation between their schools and hospitals, and acting as a learning catalyst by coordinating relationships between students and nursing staff (Brown et al., 2012; Löfmark et al., 2012). The present group of students emphasized the importance of professor visitation to the CP location (statement 39). Brown et al. (2005) reported that students can feel abandoned when they move into the CP site. In contrast, students experience a feeling of security and a sense of membership when their professor visits their CP site. These feelings can be especially pronounced in the first day of CP placement because of a lack of confidence and limited information about the CP site (Sharif and Masoumi, 2005). An impertinent treatment of students by the professor can aggravate the negative feelings of students (Lasiter et al., 2012). Therefore, professors who are involved in the CP placement of nursing students should help the students to adapt to the clinical setting in a supportive manner, and endeavor to produce a studentfriendly clinical setting by adopting a cooperative demeanor with nursing staff (Al-Zayyat and Al-Gamal, 2014; Haugan et al., 2012; Jonsén et al., 2013). Prior experience in CP placement through simulationbased learning (Handley and Dodge, 2013) and provision of pertinent information about facilities, staff members, daily routines, and patients through an orientation session (Mattila et al., 2010) can benefit students. Development of strong relationships between schools and health care institutions can be also helpful to derive the intended learning outcomes and increase the confidence of students in their CP placement (Bisholt et al., 2014; Saarikoski et al., 2007). Factor I subjects as a group denied statements 14 and 21. These subjects vehemently felt a separation between clinical nurses and students, and never perceived a sense of belonging and duty as a nursing member during CP. A sense of belonging affects learning outcomes and influences decisions about a future career after graduation (McKenna et al., 2013). Levett-Jones and Lathlean (2008) reported that a strong sense of belonging promotes feelings of safety and empowerment and, as a consequence of self-directed learning, selfmotivation to learn and self-efficacy can be reinforced. On the other hand, a poor sense of belonging can result in diminished attention to engagement in CP, and increased apprehension and anxiety. These negative feelings can produce increased mental and physical stress in students (Lee and Jun, 2012). Stress in nursing students can give rise to a sense of powerlessness, and can hinder relationships between students and patients. These factors may cause psychological morbidity, and a shortage of nurses entering the nursing profession (Al-Zayyat and Al-Gamal, 2014; Blomberg et al., 2014; Watson et al., 2008). Teaching and learning strategies for Factor I individuals, development of standardized manuals for clinical practice, and constructive exchange between schools and medical institutions to build an effective learning environment are empowering strategies to overcome certain difficulties for Factor I.

supervision, and to work as a member of a team. Liou et al. (2013) reported that students' direct experience of nursing activities in the CP placement can boost professional nursing competency and cultivate technical proficiencies. Successful CP, therefore, depends on assertive involvement of nurses in teaching students as a preceptor, and the direct involvement of students in nursing care (Bisholt et al., 2014; Löfmark et al., 2012). Papathanasiou et al. (2014) and IP and Kit Chan (2005) surveyed predictors of satisfaction with CP; an important factor was student involvement. However, Ulfvarson and Oxelmark (2012) revealed that some nurses as preceptors were not confident of their nursing theories. They were often afraid that they lacked the knowledge to teach students. Andrews et al. (2006) reported that some preceptors were unsure of their roles in teaching students and had no idea of how to instruct students. A preceptor is the key person who, as a mentor, supports and supervises student nurses, and provides feedback on what was done right and wrong (Plakht et al., 2013; Saarikoski et al., 2007). Nursing students' positive self-reflection can be promoted through preceptors' constructive feedback (Mattila et al., 2010) and contributes to advancing professional nursing self-image of students (Milisen et al., 2010). Therefore, development of regular advanced learning process for preceptors and its implementation, and support provided by professors as a part of school agenda can be effective in improving preceptor confidence. Factor II students, in particular, sublimated the benefits of CP into their future career. Guidance and supervision by preceptor working in regular duty than three shifts, and development of mentorship between nursing students and preceptors (Blomberg et al., 2014; Saarikoski et al., 2007) are strategies to consolidate and reinforce positive attitude toward CP. The present findings support the view that contemporary CP has imperative issues to enhance intended learning outcomes. Professors who are typically involved in clinical education should consider the perspectives of their students to CP. This involves respecting these attitudes and reflecting their students' perspectives in the curriculum, with the goal of optimizing learning outcomes. As well, the educational environment of participating hospitals and the distance from home to the CP placement need to be taken into account when planning CP. Implications for Nursing Education CP provides an opportunity to directly apply nursing theories to practice and can help improve both nursing knowledge and skills. Hands-on practice is one of the outstanding advantages of CP. Notwithstanding the benefits of CP, students' attitude regarding CP is not identical. Two factors revealed in this study showed how CP is important, how CP affects nursing students' learning outcomes, and what professors, nurses, and health care institutions should be doing to create and ensure effective CP in the present and future of CP. Nursing professors particularly involved in CP should encourage and inspire students to be more engaged in CP. Nursing staff attention and consideration for CP, and eligible preceptors' cultivation should foster a student-friendly educational atmosphere, and help achieve the desirable learning outcomes. Strengths and Limitations

Factor II Factor II (an enthusiastic attitude; future-oriented perspective) subjects believed that CP either affords an opportunity to reflect (and learn from) their mistakes or confirms nursing knowledge. They also opined that CP is a part of class as an authentic education, and is helpful in deciding their future career. These students were unconcerned about observation-based clinical practice, regarding it as a part of learning. They never doubted the purpose of CP. Mattila et al. (2010) reported that nursing staff can empower students to perform or observe nursing care under individualized

This study has several strengths. Some factors and common understanding of undergraduate nursing students' attitude toward CP were found. A differentiated intervention strategy designed to enhance students' positive attitude toward CP or suggested alternatives for modifying students' negative attitude based on these results were also benefits of this study. Despite its potential for nursing research, the greatest limitations in this study should be considered. Due to the small and typically convenience sample from only one nursing school, it may not be generalizable to groups with different experiences. Various levels of hospitals and nurses or preceptors who were involved

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in CP may affect nursing students' attitude. A poor nursing students' attitude cannot entirely exclude. Conclusions The predominant feature of this study was to extract subjectivity toward CP from undergraduate nursing students using Q methodology. Two factors and the consequential individual subjective perspective were manifested in some important issues regarding CP. The study findings highlight the supportive manner of professors involved in CP, development of standardized manuals for CP, constructive exchange between schools and health care institutions, and development of mentorship between nursing students and preceptors. This study also emphasizes that CP does not always positively influence the intended learning outcomes of the students. Based on findings in this study, professors should understand and respect students' attitude toward CP, and reflect their perspectives in evaluation before and after CP. Careful consideration in level of health care institutions, and strengthening relations between nurses and students can be key suggestions in this study for positively reinforcing students' attitude toward CP, and optimizing the potential of CP. References Akhtar-Danesh, N., Baumann, A., Cordingley, L., 2008. Q-methodology in nursing research: a promising method for the study of subjectivity. West. J. Nurs. Res. 30 (6), 759–773. http://dx.doi.org/10.1177/0193945907312979. Al-Zayyat, A.S., Al-Gamal, E., 2014. Perceived stress and coping strategies among Jordanian nursing students during clinical practice in psychiatric/mental health courses. Int. J. Ment. Health Nurs. 23 (4), 326–335. http://dx.doi.org/10.1111/inm. 12054. Andrews, G.J., Brodie, D.A., Andrews, J.P., Hillan, E., Gail Thomas, B., Wong, J., Rixon, L., 2006. Professional roles and communications in clinical placements: a qualitative study of nursing students' perceptions and some models for practice. Int. J. Nurs. Stud. 43 (7), 861–874. http://dx.doi.org/10.1016/j.ijnurstu.2005.11.008. Bisholt, B., Ohlsson, U., Engström, A.K., Johansson, A.S., Gustafsson, M., 2014. Nursing students' assessment of the learning environment in different clinical settings. Nurse Educ. Pract. 14 (3), 304–310. http://dx.doi.org/10.1016/j.nepr.2013.11.005. Blomberg, K., Bisholt, B., Kullén Engström, A., Ohlsson, U., Sundler Johansson, A., Gustafsson, M., 2014. Swedish nursing students' experience of stress during clinical practice in relation to clinical setting characteristics and the organisation of the clinical education. J. Clin. Nurs. 23 (15-16), 2264–2271. http://dx.doi.org/10.1111/ jocn.12506. Brown, S.R., 1980. Political Subjectivity: Application of Q Methodology in Political Science. Yale University Press, New Haven, CT. Brown, L., Herd, K., Humphries, G., Paton, M., 2005. The role of the lecturer in practice placements: what do students think. Nurse Educ. Pract. 5 (2), 84–90. http://dx.doi. org/10.1016/j.nepr.2004.03.006. Brown, J., Stevens, J., Kermode, S., 2012. Supporting student nurse professionalisation: the role of the clinical teacher. Nurse Educ. Today 32 (5), 606–610. http://dx.doi.org/10. 1016/j.nedt.2011.08.007. Dziopa, F., Ahern, K., 2011. A systematic literature review of the applications of Qtechnique and its methodology. Methodology 7 (2), 39–55. http://dx.doi.org/10. 1027/1614-2241/a000021. Handley, R., Dodge, N., 2013. Can simulated practice learning improve clinical competence? Br. J. Nurs. 22 (9), 529–535. Haugan, G., Sørensen, A.H., Hanssen, I., 2012. The importance of dialogue in student nurses' clinical education. Nurse Educ. Today 32 (4), 438–442. http://dx.doi.org/10. 1016/j.nedt.2011.03.011.

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