Nurse Education in Practice xxx (2013) 1e7
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Nursing students’ assessment of the learning environment in different clinical settings Birgitta Bisholt a, *, Ulla Ohlsson b, Agneta Kullén Engström c, Annelie Sundler Johansson d, Margareta Gustafsson b a
Department of Health Sciences, Karlstad University, S-651 88 Karlstad, Sweden School of Health and Medical Sciences, Örebro University, Örebro, Sweden School of Health, University of Borås, Borås, Sweden d School of Life Sciences, University of Skövde, Skövde, Sweden b c
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 27 November 2013
Introduction: Nursing students perform their clinical practice in different types of clinical settings. The clinical learning environment is important for students to be able to achieve desired learning outcomes. Knowledge is lacking about the learning environment in different clinical settings. Aim: The aim was to compare the learning environment in different clinical settings from the perspective of the nursing students. Design: A cross-sectional study with comparative design was conducted. Method: Data was collected from 185 nursing students at three universities by means of a questionnaire involving the Clinical Learning Environment, Supervision and Nurse Teacher (CLES þ T) evaluation scale. An open-ended question was added in order to ascertain reasons for dissatisfaction with the clinical placement. Results: The nursing students’ satisfaction with the placement did not differ between clinical settings. However, those with clinical placement in hospital departments agreed more strongly that sufficient meaningful learning situations occurred and that learning situations were multi-dimensional. Some students reported that the character of the clinical setting made it difficult to achieve the learning objectives. Conclusion: In the planning of the clinical placement, attention must be paid to whether the setting offers the student a meaningful learning situation where the appropriate learning outcome may be achieved. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Clinical learning environment Clinical placement Nursing education research Nursing students
Introduction Clinical education is a major and important part of the preregistration nursing education programmes and includes up to half of the nursing student training period (Furåker, 2001). The clinical learning environment is of particular importance for the achievement of the desired learning outcomes within the clinical placement (Salminen et al., 2010). According to Papp et al. (2003), the clinical environment encompasses all that surrounds the nursing student d clinical setting, staff, patients, nurse teacher etc. The fact that this environment varies in quality means that opportunities to achieving the learning outcomes vary. It is therefore difficult to plan an optimal clinical learning environment. The
* Corresponding author. Tel.: þ46 858 751 667. E-mail addresses: [email protected], [email protected] (B. Bisholt).
present study focuses on nursing students experience of the learning environment during their clinical placements. The study is part of a major project investigating various aspects of the organization of the clinical education on the nursing programmes. Background According to Papp et al. (2003), a good clinical learning environment is described by nursing student as a clinical setting where there is co-operation among staff and a good atmosphere where they feel appreciated and are given opportunities to study in order to achieve their objectives. The nursing student also state that a precondition for learning is that the learning opportunities are varied and that the demands correspond to the student’s personal level (ibid). Besides the pedagogical atmosphere in the clinical setting, the supervisory relationship, the leadership style of the ward manager and the quality of care are crucial for creating a good
1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.11.005
Please cite this article in press as: Bisholt, B., et al., Nursing students’ assessment of the learning environment in different clinical settings, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.005
2
B. Bisholt et al. / Nurse Education in Practice xxx (2013) 1e7
learning environment (Saarikoski and Leino-Kilpi, 2002; Papp et al., 2003). Moreover, it is important that there be co-operation between educational and health-care institutions about the clinical learning environment (Bisholt, 2009). Inadequate communication between such institutions can produce a tension and lead to less cooperation, thereby affecting students’ opportunities to learn during their placement. The nurse teacher has an important role to play in linking education and clinical practice (Carlson et al., 2009, 2010). Studies have shown that a good clinical learning environment is promoted through co-operation between the nurse teacher and the clinical staff (Papp et al., 2003; Johansson et al., 2010). The nurse teacher and the nurses are the ones primarily responsible for ensuring that the students have the opportunity to participate in as many learning situations as possible (Carlson et al., 2009). Few studies have considered the role of ward managers with regard to creating and maintaining a good learning environment even though this role is vital (Maben et al., 2006). The ward managers have strategic responsibility for learning at the ward level but their role has changed, reducing their direct involvement at the individual student level (O’Driscoll et al., 2010). The nursing students’ clinical placement can be in a variety of settings d for instance in a highly specialized hospital department, in a nursing home or within municipal home-based care of the elderly. The placement needs to be of such a nature as to support learning and provide opportunities for diverse clinical experiences (Edwards et al., 2004). Chan and Wan (2007) emphasize that the clinical learning environment is an irreplaceable part of the preparation for the profession of nursing. Research on clinical education within the nursing programmes during recent decades has mainly focused on the pedagogical atmosphere in the clinical setting, the supervisory role of the nursing staff and (more recently) the nursing students’ relationship with the patients (Salminen et al., 2010). There are few studies focussing on the nursing students’ opportunities to learn the profession in different clinical settings. Against this background, the aim of the present study was to compare the learning environment in different clinical settings from the perspective of the nursing students. Methods Design A cross-sectional study with comparative design was conducted at three Swedish universities during spring 2011. Data was collected from nursing students at the universities by means of questionnaires. A mixed method approach was used (Sandelowski, 2000) in that complementary data was collected by means of an open-ended question added to the questionnaire. Sampling and settings The study population consisted of third-year nursing student who were doing a course involving clinical practice in the final term of the nursing programme. They were enrolled through convenience sampling. Those who met the study criteria were asked, one week after completion of the course, whether they would give their informed consent to participate. Of the 208 who were eligible, 185 gave such consent. Thus the response rate was 89%, being 80%, 93% and 93% respectively at the three universities. The universities, where the nursing student were recruited, followed Swedish regulations for nursing education including academic requirements such as independence, responsibility, critical thinking, capability to use research and decision-making (SFS, 1992:1434, SFS, 1993:100). The programmes were all of three years’ duration (180 ECTS credits) and led to a Bachelor’s degree.
Courses including clinical practice accounted for approximately half of the time and credits. The program in Sweden can be organized in such a way that students spend two days to six or seven weeks clinical practice to gain experience. Students often have clinical placement in each term. Students’ total hours of the clinical placement are approximately 32 h per week. In Sweden, the number of weeks and hours, as well as clinical areas and clinical practice varies each term. This varies in other countries as well, depending on the nurse education and health care structure and curriculum (Zabalegui and Cabrera, 2009; Levett-Jones et al., 2009). In the study, students who were undergoing their last course in clinical placement had four to six weeks of clinical placement. The nursing student could choose clinical setting for their practice. They could perform their practice in a hospital or a nursing home, or within home-based care, primary health care or psychiatric care. Hospital placements were in a variety of departments d medicine, general surgery, orthopaedic surgery, thoracic surgery, urology, geriatrics, infectious diseases, paediatrics, neurology, oncology and emergency. During the clinical practice, the students received supervision from staff nurses within the departments. The supervisors’ role was to teach practical skills, serve as a role model and assess the nursing students’ professional development. The organization of the supervision was decided by the staff themselves and could differ between the clinical settings. There was also a nurse teacher employed by the university, who served as a link between the university and the clinical setting and was responsible for seminars with the integration of theory and practice during the clinical placement. The nurse teacher also participated in the final assessment and grading of the individual student together with the supervisor. Instead of a nurse teacher, some students met a clinician who had a post with affiliation to the university and had the same role and responsibility as a nurse teacher towards the student (Budgen and Gamroth, 2008). Data collection Data was collected from the nursing student by means of a questionnaire answered about a week after they had finished their clinical practice. The questionnaire contained items concerning demographic characteristics, organization of supervision and type of clinical setting. The instrument used for investigating the students’ perception of the learning environment in the clinical setting was the Clinical Learning Environment, Supervision and Nurse Teacher (CLES þ T) evaluation scale (Saarikoski and Leino Kilpi, 2002; Saarikoski et al., 2008). The CLES þ T has 34 items classified as “Pedagogical atmosphere on the ward” (9 items), “Leadership style of the ward manager” (4 items), “Premises of nursing on the ward” (4 items), “Supervisory relationship” (8 items) and “Role of the nurse teacher in clinical practice” (9 items). The term nurse teacher is defined as a nurse teacher employed by an educational institution teaching both theoretical and clinical knowledge (Saarikoski et al., 2008). The students respond to statements in the scale on a 5-point Likert-type scale: fully disagree (1), disagree to some extent (2), neither agree nor disagree (3), agree to some extent (4) or fully agree (5). The original version of the CLES þ T has proved to be a reliable and valid instrument and to have construct validity in the case of nursing students of different nationalities (Saarikoski et al., 2008; Warne et al., 2010). Psychometric tests of the Swedish version of the scale have shown that it has satisfactory psychometric properties also when used among Swedish nursing students with clinical placement in a hospital (Johansson et al., 2010) and in primary health care settings (Bos et al., 2012). The internal consistency of the scale was tested in the present study by means of Cronbach’s alpha. The alpha value was 0.95 for the total scale, and ranged from
Please cite this article in press as: Bisholt, B., et al., Nursing students’ assessment of the learning environment in different clinical settings, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.005
B. Bisholt et al. / Nurse Education in Practice xxx (2013) 1e7
0.70 to 0.97 for the sub-dimensions of the scale. With the exception of the items concerning “Premises of nursing on the ward” (which had lower values), the values for the sub-dimensions were comparable to those reported in the test of the Swedish version of the scale (Johansson et al., 2010). At the end of the scale it is possible to add items in order to obtain information about students’ total satisfaction (Saarikoski et al., 2009). We choose to use one of the items, “I am satisfied with the clinical placement that has just ended”. The item had response choices with wording and scoring (from 1 to 5), the same as the response choices on the CLES þ T scale. Finally, there was an openended question added inviting students who were dissatisfied with the clinical placement to give their reasons for this dissatisfaction. Ethical considerations The nursing students received written information concerning the aim of the study before they started their clinical practice. One week after they had completed this practice and were back at the university, they received oral information about the study and were asked whether they were willing to give their written informed consent to participate. The questionnaires were answered anonymously in a classroom at the university and handed over to the researcher in sealed envelopes. The researcher had no connection with the teaching or grading of the students on the course in question. The study was ethically approved by the ethics committee in Uppsala (www.epn.se) (registration no. 2011/071). Data analysis Age had a skewed distribution in the study group. Therefore KruskaleWallis test was used for statistical analysis of differences in age between groups of nursing students with clinical placement in different settings. Chi-square test was used for testing of statistical differences between them regarding gender, assistant nurse education or work in health care before attending the nursing programme. Responses to the statements in the CLES þ T were described by means of mean values (m) and standard deviations (SDs) in order to permit comparison with previous studies. However, differences between clinical settings with regard to responses to the statements were analysed by means of the KruskaleWallis test. It is a non-parametric test for analysing differences between more than two independent groups taking into account that the responses are given on ordinal scales. The ManneWhitney U-test, which is used when there are two independent groups only, was used for analysing differences regarding “Role of the NT”. The level of significance was set to 0.05. The responses to the open-ended question were subjected to qualitative content analysis (Hsieh and Shannon, 2005). The text of the written answers was read through repeatedly in order to get an overall sense of the content, then read closely in order to identify meaning units that represented the students’ dissatisfaction with the clinical placement. The next step was to derive codes from the meaning units, these codes being labelled to represent key notions. Thereafter the codes were sorted into sub-categories based on their relation to one another, then the sub-categories were organized into categories. Results
3
attended the nursing programme. More than half of the students performed their clinical practice in hospital departments (n ¼ 124, 67%). Most common was clinical placement in departments of medicine (n ¼ 66). The other students performed their clinical practice in community-based care settings: nursing homes and home-based care (n ¼ 39, 21%), in primary health care (n ¼ 13, 7%) or psychiatric care (n ¼ 9, 5%). There were no significant differences between nursing students in different clinical settings regarding age (p 0.185), gender (p 0.291), work in health care (p 0.851) or having an assistant nurse education before attending the nursing programme (p 0.325). The duration of the clinical placement was 4e6 weeks, the mean duration being 5 (SD 0.8) weeks. Clinical placement in settings overcrowded with patients was reported by 83 students (45%), all but one of whom performed their practice in a hospital. The majority of the students (n ¼ 161, 87%) had a particular personal supervisor assigned. The others were responsible for a patient room and supervisors differed between shifts. Rather more than half of the students (n ¼ 105, 57%) were taught by a nurse teacher employed by the university during their clinical practice, the rest by a clinician occupying a post affiliated to the university. Nursing students’ assessment of the learning environment in different clinical settings There were significant differences in the nursing students’ experiences of the learning environment depending on whether they did their practice in hospital departments, in community-based care, in primary health care or in psychiatric care (Table 1). Students who had their clinical placement in hospitals agreed more strongly than did the other students with the statements that the ward could be regarded as a good learning environment, that sufficient meaningful learning situations occurred and that the content of these situations was multi-dimensional. Students with clinical placement in psychiatric care agreed least with these statements; on the other hand these students agreed more strongly with the statement that the staff got to know the students by name. There were also significant differences concerning the leadership style of the ward manager (Table 1). Students with clinical placement in psychiatric care agreed more strongly than any of the others that the ward manager was one of the team, gave useful feedback and regarded them as a key resource. Students with clinical placement in community-based care agreed least with these statements. In the sub-dimension “Premises of nursing”, students with clinical placement in primary health care agreed more strongly than any of the others that the nursing documentation was clear. There were no differences between clinical settings regarding the nursing students’ ratings of the “Supervisory relationship” and the “Role of the nurse teacher” (Table 1). Seventy students (56%) with clinical placement in hospital and 35 (90%) with placement in community-based care were taught by a nurse teacher employed by the university. The students with clinical placement in primary health care or in psychiatric care encountered a clinician with affiliate position to the university and teaching responsibility. Those students who were taught by a nurse teacher rated the role of the nurse teacher low when it came to the relation between the nurse teacher and the team in the clinical setting. Of all the statements on the entire scale the students agreed least with those concerning the nurse teacher’s being like a member of the team and contributing pedagogical expertise.
Characteristics of the study group and the clinical placement The study group consisted of 161 females (87%) and 24 males (13%). The age-range was 21e49 years, the median age being 25 years (q1 23, q3 28). Forty nursing students (22%) had an assistant nurse education and 101 (55%) had worked in health care before they
Nursing students’ satisfaction with the clinical placement and reasons for dissatisfaction Regarding the statement “I am satisfied with the clinical placement that has just ended”, 158 nursing students (185%) agreed
Please cite this article in press as: Bisholt, B., et al., Nursing students’ assessment of the learning environment in different clinical settings, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.005
4
B. Bisholt et al. / Nurse Education in Practice xxx (2013) 1e7
Table 1 The nursing students’ assessment of the learning environment in the clinical settings.
Pedagogical atmosphere The staffs were easy to approach I felt comfortable going to the ward at the start of my shift During staff meetings (e.g. before shifts) I felt comfortable taking part in the discussion There was a positive atmosphere on the ward The staffs were generally interested in student supervision The staff learned to know the students by their personal names There were sufficient meaningful learning situations on the ward The learning situations were multi-dimensional in terms of content The ward can be regarded as a good learning environment Leadership style of the ward manager (WM) The WM regarded the staff on her/his ward as a key resource The WM was a team member Feedback from the WM could easily be regarded as a learning situation The effort of individual employees was appreciated Premises of nursing The ward’s nursing philosophy was clearly defined Patients received individual nursing care There were no problems in the information flow related to patient’s care Documentation of nursing (nursing plans, daily recording of nursing procedures, etc) was clear Supervisory relationship My supervisor showed a positive attitude towards supervision I felt that I received individual supervision I continuously received feedback from my supervisor Overall I am satisfied with the supervision I received The supervision was based on a relationship of equality and promoted my learning There was a mutual interaction in the supervisory relationship Mutual respect and approval prevailed in the supervisory relationship The supervisory relationship was characterized by a sense of trust Role of the nurse teacher (NT)b In my opinion, the NT was capable to integrate theoretical knowledge and the everyday practice of nursing The NT was capable of operationalizing the learning goals of this clinical placement The NT helped me to reduce the theory-practice gap The NT was like a member of the nursing team The NT was able to transmit his or her pedagogical expertise to the clinical team The NT and the clinical team worked together supporting my learning The common meetings between myself, mentor and NT were comfortable experience Climate of the meetings was congenial Focus on the meetings was in my learning needs a b
p-valuea
Hospital care n ¼ 124 m (SD)
Community-based care n ¼ 39 m (SD)
Primary health care n ¼ 13 m (SD)
Psychiatric care n ¼ 9 m (SD)
4.1 4.4 4.2 3.6
(0.7) (0.7) (0.9) (1.1)
3.8 4.3 4.0 3.6
(0.9) (1.0) (1.1) (1.0)
4.1 4.6 4.4 3.9
(0.7) (0.9) (0.9) (1.0)
3.9 4.4 3.6 4.1
(0.8) (0.5) (1.6) (1.2)
0.452 0.346 0.449 0.483
4.2 3.7 4.0 4.3 4.1 4.4 3.7 4.3 3.6 3.3
(0.8) (0.9) (1.0) (0.8) (0.9) (0.8) (0.9) (0.8) (1.3) (1.1)
4.0 3.7 4.1 3.4 3.7 3.7 3.0 3.5 2.6 2.7
(0.9) (1.2) (1.3) (1.3) (1.0) (1.2) (0.9) (1.2) (1.1) (1.1)
4.2 4.1 4.5 3.6 3.7 4.1 3.9 4.5 3.6 3.4
(1.3) (1.0) (0.7) (0.9) (0.8) (1.0) (0.7) (0.7) (1.4) (1.2)
4.4 3.9 4.7 2.9 3.3 3.3 4.5 4.9 4.3 4.4
(1.0) (1.3) (0.5) (1.7) (0.9) (1.3) (0.5) (0.3) (0.7) (0.9)
0.192 0.533 0.039
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Nursing students’ assessment of the learning environment in different clinical settings Birgitta Bisholt a, *, Ulla Ohlsson b, Agneta Kullén Engström c, Annelie Sundler Johansson d, Margareta Gustafsson b a
Department of Health Sciences, Karlstad University, S-651 88 Karlstad, Sweden School of Health and Medical Sciences, Örebro University, Örebro, Sweden School of Health, University of Borås, Borås, Sweden d School of Life Sciences, University of Skövde, Skövde, Sweden b c
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 27 November 2013
Introduction: Nursing students perform their clinical practice in different types of clinical settings. The clinical learning environment is important for students to be able to achieve desired learning outcomes. Knowledge is lacking about the learning environment in different clinical settings. Aim: The aim was to compare the learning environment in different clinical settings from the perspective of the nursing students. Design: A cross-sectional study with comparative design was conducted. Method: Data was collected from 185 nursing students at three universities by means of a questionnaire involving the Clinical Learning Environment, Supervision and Nurse Teacher (CLES þ T) evaluation scale. An open-ended question was added in order to ascertain reasons for dissatisfaction with the clinical placement. Results: The nursing students’ satisfaction with the placement did not differ between clinical settings. However, those with clinical placement in hospital departments agreed more strongly that sufficient meaningful learning situations occurred and that learning situations were multi-dimensional. Some students reported that the character of the clinical setting made it difficult to achieve the learning objectives. Conclusion: In the planning of the clinical placement, attention must be paid to whether the setting offers the student a meaningful learning situation where the appropriate learning outcome may be achieved. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Clinical learning environment Clinical placement Nursing education research Nursing students
Introduction Clinical education is a major and important part of the preregistration nursing education programmes and includes up to half of the nursing student training period (Furåker, 2001). The clinical learning environment is of particular importance for the achievement of the desired learning outcomes within the clinical placement (Salminen et al., 2010). According to Papp et al. (2003), the clinical environment encompasses all that surrounds the nursing student d clinical setting, staff, patients, nurse teacher etc. The fact that this environment varies in quality means that opportunities to achieving the learning outcomes vary. It is therefore difficult to plan an optimal clinical learning environment. The
* Corresponding author. Tel.: þ46 858 751 667. E-mail addresses: [email protected], [email protected] (B. Bisholt).
present study focuses on nursing students experience of the learning environment during their clinical placements. The study is part of a major project investigating various aspects of the organization of the clinical education on the nursing programmes. Background According to Papp et al. (2003), a good clinical learning environment is described by nursing student as a clinical setting where there is co-operation among staff and a good atmosphere where they feel appreciated and are given opportunities to study in order to achieve their objectives. The nursing student also state that a precondition for learning is that the learning opportunities are varied and that the demands correspond to the student’s personal level (ibid). Besides the pedagogical atmosphere in the clinical setting, the supervisory relationship, the leadership style of the ward manager and the quality of care are crucial for creating a good
1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.11.005
Please cite this article in press as: Bisholt, B., et al., Nursing students’ assessment of the learning environment in different clinical settings, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.005
2
B. Bisholt et al. / Nurse Education in Practice xxx (2013) 1e7
learning environment (Saarikoski and Leino-Kilpi, 2002; Papp et al., 2003). Moreover, it is important that there be co-operation between educational and health-care institutions about the clinical learning environment (Bisholt, 2009). Inadequate communication between such institutions can produce a tension and lead to less cooperation, thereby affecting students’ opportunities to learn during their placement. The nurse teacher has an important role to play in linking education and clinical practice (Carlson et al., 2009, 2010). Studies have shown that a good clinical learning environment is promoted through co-operation between the nurse teacher and the clinical staff (Papp et al., 2003; Johansson et al., 2010). The nurse teacher and the nurses are the ones primarily responsible for ensuring that the students have the opportunity to participate in as many learning situations as possible (Carlson et al., 2009). Few studies have considered the role of ward managers with regard to creating and maintaining a good learning environment even though this role is vital (Maben et al., 2006). The ward managers have strategic responsibility for learning at the ward level but their role has changed, reducing their direct involvement at the individual student level (O’Driscoll et al., 2010). The nursing students’ clinical placement can be in a variety of settings d for instance in a highly specialized hospital department, in a nursing home or within municipal home-based care of the elderly. The placement needs to be of such a nature as to support learning and provide opportunities for diverse clinical experiences (Edwards et al., 2004). Chan and Wan (2007) emphasize that the clinical learning environment is an irreplaceable part of the preparation for the profession of nursing. Research on clinical education within the nursing programmes during recent decades has mainly focused on the pedagogical atmosphere in the clinical setting, the supervisory role of the nursing staff and (more recently) the nursing students’ relationship with the patients (Salminen et al., 2010). There are few studies focussing on the nursing students’ opportunities to learn the profession in different clinical settings. Against this background, the aim of the present study was to compare the learning environment in different clinical settings from the perspective of the nursing students. Methods Design A cross-sectional study with comparative design was conducted at three Swedish universities during spring 2011. Data was collected from nursing students at the universities by means of questionnaires. A mixed method approach was used (Sandelowski, 2000) in that complementary data was collected by means of an open-ended question added to the questionnaire. Sampling and settings The study population consisted of third-year nursing student who were doing a course involving clinical practice in the final term of the nursing programme. They were enrolled through convenience sampling. Those who met the study criteria were asked, one week after completion of the course, whether they would give their informed consent to participate. Of the 208 who were eligible, 185 gave such consent. Thus the response rate was 89%, being 80%, 93% and 93% respectively at the three universities. The universities, where the nursing student were recruited, followed Swedish regulations for nursing education including academic requirements such as independence, responsibility, critical thinking, capability to use research and decision-making (SFS, 1992:1434, SFS, 1993:100). The programmes were all of three years’ duration (180 ECTS credits) and led to a Bachelor’s degree.
Courses including clinical practice accounted for approximately half of the time and credits. The program in Sweden can be organized in such a way that students spend two days to six or seven weeks clinical practice to gain experience. Students often have clinical placement in each term. Students’ total hours of the clinical placement are approximately 32 h per week. In Sweden, the number of weeks and hours, as well as clinical areas and clinical practice varies each term. This varies in other countries as well, depending on the nurse education and health care structure and curriculum (Zabalegui and Cabrera, 2009; Levett-Jones et al., 2009). In the study, students who were undergoing their last course in clinical placement had four to six weeks of clinical placement. The nursing student could choose clinical setting for their practice. They could perform their practice in a hospital or a nursing home, or within home-based care, primary health care or psychiatric care. Hospital placements were in a variety of departments d medicine, general surgery, orthopaedic surgery, thoracic surgery, urology, geriatrics, infectious diseases, paediatrics, neurology, oncology and emergency. During the clinical practice, the students received supervision from staff nurses within the departments. The supervisors’ role was to teach practical skills, serve as a role model and assess the nursing students’ professional development. The organization of the supervision was decided by the staff themselves and could differ between the clinical settings. There was also a nurse teacher employed by the university, who served as a link between the university and the clinical setting and was responsible for seminars with the integration of theory and practice during the clinical placement. The nurse teacher also participated in the final assessment and grading of the individual student together with the supervisor. Instead of a nurse teacher, some students met a clinician who had a post with affiliation to the university and had the same role and responsibility as a nurse teacher towards the student (Budgen and Gamroth, 2008). Data collection Data was collected from the nursing student by means of a questionnaire answered about a week after they had finished their clinical practice. The questionnaire contained items concerning demographic characteristics, organization of supervision and type of clinical setting. The instrument used for investigating the students’ perception of the learning environment in the clinical setting was the Clinical Learning Environment, Supervision and Nurse Teacher (CLES þ T) evaluation scale (Saarikoski and Leino Kilpi, 2002; Saarikoski et al., 2008). The CLES þ T has 34 items classified as “Pedagogical atmosphere on the ward” (9 items), “Leadership style of the ward manager” (4 items), “Premises of nursing on the ward” (4 items), “Supervisory relationship” (8 items) and “Role of the nurse teacher in clinical practice” (9 items). The term nurse teacher is defined as a nurse teacher employed by an educational institution teaching both theoretical and clinical knowledge (Saarikoski et al., 2008). The students respond to statements in the scale on a 5-point Likert-type scale: fully disagree (1), disagree to some extent (2), neither agree nor disagree (3), agree to some extent (4) or fully agree (5). The original version of the CLES þ T has proved to be a reliable and valid instrument and to have construct validity in the case of nursing students of different nationalities (Saarikoski et al., 2008; Warne et al., 2010). Psychometric tests of the Swedish version of the scale have shown that it has satisfactory psychometric properties also when used among Swedish nursing students with clinical placement in a hospital (Johansson et al., 2010) and in primary health care settings (Bos et al., 2012). The internal consistency of the scale was tested in the present study by means of Cronbach’s alpha. The alpha value was 0.95 for the total scale, and ranged from
Please cite this article in press as: Bisholt, B., et al., Nursing students’ assessment of the learning environment in different clinical settings, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.005
B. Bisholt et al. / Nurse Education in Practice xxx (2013) 1e7
0.70 to 0.97 for the sub-dimensions of the scale. With the exception of the items concerning “Premises of nursing on the ward” (which had lower values), the values for the sub-dimensions were comparable to those reported in the test of the Swedish version of the scale (Johansson et al., 2010). At the end of the scale it is possible to add items in order to obtain information about students’ total satisfaction (Saarikoski et al., 2009). We choose to use one of the items, “I am satisfied with the clinical placement that has just ended”. The item had response choices with wording and scoring (from 1 to 5), the same as the response choices on the CLES þ T scale. Finally, there was an openended question added inviting students who were dissatisfied with the clinical placement to give their reasons for this dissatisfaction. Ethical considerations The nursing students received written information concerning the aim of the study before they started their clinical practice. One week after they had completed this practice and were back at the university, they received oral information about the study and were asked whether they were willing to give their written informed consent to participate. The questionnaires were answered anonymously in a classroom at the university and handed over to the researcher in sealed envelopes. The researcher had no connection with the teaching or grading of the students on the course in question. The study was ethically approved by the ethics committee in Uppsala (www.epn.se) (registration no. 2011/071). Data analysis Age had a skewed distribution in the study group. Therefore KruskaleWallis test was used for statistical analysis of differences in age between groups of nursing students with clinical placement in different settings. Chi-square test was used for testing of statistical differences between them regarding gender, assistant nurse education or work in health care before attending the nursing programme. Responses to the statements in the CLES þ T were described by means of mean values (m) and standard deviations (SDs) in order to permit comparison with previous studies. However, differences between clinical settings with regard to responses to the statements were analysed by means of the KruskaleWallis test. It is a non-parametric test for analysing differences between more than two independent groups taking into account that the responses are given on ordinal scales. The ManneWhitney U-test, which is used when there are two independent groups only, was used for analysing differences regarding “Role of the NT”. The level of significance was set to 0.05. The responses to the open-ended question were subjected to qualitative content analysis (Hsieh and Shannon, 2005). The text of the written answers was read through repeatedly in order to get an overall sense of the content, then read closely in order to identify meaning units that represented the students’ dissatisfaction with the clinical placement. The next step was to derive codes from the meaning units, these codes being labelled to represent key notions. Thereafter the codes were sorted into sub-categories based on their relation to one another, then the sub-categories were organized into categories. Results
3
attended the nursing programme. More than half of the students performed their clinical practice in hospital departments (n ¼ 124, 67%). Most common was clinical placement in departments of medicine (n ¼ 66). The other students performed their clinical practice in community-based care settings: nursing homes and home-based care (n ¼ 39, 21%), in primary health care (n ¼ 13, 7%) or psychiatric care (n ¼ 9, 5%). There were no significant differences between nursing students in different clinical settings regarding age (p 0.185), gender (p 0.291), work in health care (p 0.851) or having an assistant nurse education before attending the nursing programme (p 0.325). The duration of the clinical placement was 4e6 weeks, the mean duration being 5 (SD 0.8) weeks. Clinical placement in settings overcrowded with patients was reported by 83 students (45%), all but one of whom performed their practice in a hospital. The majority of the students (n ¼ 161, 87%) had a particular personal supervisor assigned. The others were responsible for a patient room and supervisors differed between shifts. Rather more than half of the students (n ¼ 105, 57%) were taught by a nurse teacher employed by the university during their clinical practice, the rest by a clinician occupying a post affiliated to the university. Nursing students’ assessment of the learning environment in different clinical settings There were significant differences in the nursing students’ experiences of the learning environment depending on whether they did their practice in hospital departments, in community-based care, in primary health care or in psychiatric care (Table 1). Students who had their clinical placement in hospitals agreed more strongly than did the other students with the statements that the ward could be regarded as a good learning environment, that sufficient meaningful learning situations occurred and that the content of these situations was multi-dimensional. Students with clinical placement in psychiatric care agreed least with these statements; on the other hand these students agreed more strongly with the statement that the staff got to know the students by name. There were also significant differences concerning the leadership style of the ward manager (Table 1). Students with clinical placement in psychiatric care agreed more strongly than any of the others that the ward manager was one of the team, gave useful feedback and regarded them as a key resource. Students with clinical placement in community-based care agreed least with these statements. In the sub-dimension “Premises of nursing”, students with clinical placement in primary health care agreed more strongly than any of the others that the nursing documentation was clear. There were no differences between clinical settings regarding the nursing students’ ratings of the “Supervisory relationship” and the “Role of the nurse teacher” (Table 1). Seventy students (56%) with clinical placement in hospital and 35 (90%) with placement in community-based care were taught by a nurse teacher employed by the university. The students with clinical placement in primary health care or in psychiatric care encountered a clinician with affiliate position to the university and teaching responsibility. Those students who were taught by a nurse teacher rated the role of the nurse teacher low when it came to the relation between the nurse teacher and the team in the clinical setting. Of all the statements on the entire scale the students agreed least with those concerning the nurse teacher’s being like a member of the team and contributing pedagogical expertise.
Characteristics of the study group and the clinical placement The study group consisted of 161 females (87%) and 24 males (13%). The age-range was 21e49 years, the median age being 25 years (q1 23, q3 28). Forty nursing students (22%) had an assistant nurse education and 101 (55%) had worked in health care before they
Nursing students’ satisfaction with the clinical placement and reasons for dissatisfaction Regarding the statement “I am satisfied with the clinical placement that has just ended”, 158 nursing students (185%) agreed
Please cite this article in press as: Bisholt, B., et al., Nursing students’ assessment of the learning environment in different clinical settings, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.005
4
B. Bisholt et al. / Nurse Education in Practice xxx (2013) 1e7
Table 1 The nursing students’ assessment of the learning environment in the clinical settings.
Pedagogical atmosphere The staffs were easy to approach I felt comfortable going to the ward at the start of my shift During staff meetings (e.g. before shifts) I felt comfortable taking part in the discussion There was a positive atmosphere on the ward The staffs were generally interested in student supervision The staff learned to know the students by their personal names There were sufficient meaningful learning situations on the ward The learning situations were multi-dimensional in terms of content The ward can be regarded as a good learning environment Leadership style of the ward manager (WM) The WM regarded the staff on her/his ward as a key resource The WM was a team member Feedback from the WM could easily be regarded as a learning situation The effort of individual employees was appreciated Premises of nursing The ward’s nursing philosophy was clearly defined Patients received individual nursing care There were no problems in the information flow related to patient’s care Documentation of nursing (nursing plans, daily recording of nursing procedures, etc) was clear Supervisory relationship My supervisor showed a positive attitude towards supervision I felt that I received individual supervision I continuously received feedback from my supervisor Overall I am satisfied with the supervision I received The supervision was based on a relationship of equality and promoted my learning There was a mutual interaction in the supervisory relationship Mutual respect and approval prevailed in the supervisory relationship The supervisory relationship was characterized by a sense of trust Role of the nurse teacher (NT)b In my opinion, the NT was capable to integrate theoretical knowledge and the everyday practice of nursing The NT was capable of operationalizing the learning goals of this clinical placement The NT helped me to reduce the theory-practice gap The NT was like a member of the nursing team The NT was able to transmit his or her pedagogical expertise to the clinical team The NT and the clinical team worked together supporting my learning The common meetings between myself, mentor and NT were comfortable experience Climate of the meetings was congenial Focus on the meetings was in my learning needs a b
p-valuea
Hospital care n ¼ 124 m (SD)
Community-based care n ¼ 39 m (SD)
Primary health care n ¼ 13 m (SD)
Psychiatric care n ¼ 9 m (SD)
4.1 4.4 4.2 3.6
(0.7) (0.7) (0.9) (1.1)
3.8 4.3 4.0 3.6
(0.9) (1.0) (1.1) (1.0)
4.1 4.6 4.4 3.9
(0.7) (0.9) (0.9) (1.0)
3.9 4.4 3.6 4.1
(0.8) (0.5) (1.6) (1.2)
0.452 0.346 0.449 0.483
4.2 3.7 4.0 4.3 4.1 4.4 3.7 4.3 3.6 3.3
(0.8) (0.9) (1.0) (0.8) (0.9) (0.8) (0.9) (0.8) (1.3) (1.1)
4.0 3.7 4.1 3.4 3.7 3.7 3.0 3.5 2.6 2.7
(0.9) (1.2) (1.3) (1.3) (1.0) (1.2) (0.9) (1.2) (1.1) (1.1)
4.2 4.1 4.5 3.6 3.7 4.1 3.9 4.5 3.6 3.4
(1.3) (1.0) (0.7) (0.9) (0.8) (1.0) (0.7) (0.7) (1.4) (1.2)
4.4 3.9 4.7 2.9 3.3 3.3 4.5 4.9 4.3 4.4
(1.0) (1.3) (0.5) (1.7) (0.9) (1.3) (0.5) (0.3) (0.7) (0.9)
0.192 0.533 0.039
