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Hong Kong nursing students’ perception of the clinical environment: a questionnaire survey
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International Journal of Nursing Studies 42 (2005) 665–672 www.elsevier.com/locate/ijnurstu
Hong Kong nursing students’ perception of the clinical environment: a questionnaire survey Wan Yim IP, Dominic Shung Kit Chan The Nethersole School of Nursing, The Chinese University of Hong Kong, Room 826, Esther Lee Building, Shatin, N.T., Hong Kong Received 7 June 2004; received in revised form 18 September 2004; accepted 23 September 2004
Abstract Clinical practice is a vital component of the nursing curriculum yet it takes place in a complex social context. This survey examined Hong Kong nursing students’ perception of the social climate of the clinical learning environment. The targeted subjects were all Years 2–4 pre-registration nursing students at the school of nursing of a major University in Hong Kong. Participants were invited to complete the two versions, the actual and preferred forms, of the Clinical Learning Environment Inventory following the completion of their clinical field placement. Two hundred and eighty one actual forms and 243 preferred forms were returned. SPPS version 11 was employed to analyse the data using descriptive and inferential statistics. It was found that there were significant differences between students’ perceptions of the actual clinical learning environment and the ideal clinical learning environment they desired. The study highlights the need for a supportive clinical learning environment which is of paramount importance in securing the required teaching and learning process for students on clinical practice. r 2004 Elsevier Ltd. All rights reserved. Keywords: Nursing students; Clinical learning environment; Hong Kong
1. Introduction Nursing as a profession has evolved in response to society’s needs for well-prepared, caring practitioners during clients’ episodes of illness and promote health among all age groups. Originally taught at the bedside by skilled practitioners, the majority of nurses in Hong Kong received their training from hospital schools of nursing. As the government of the Special Administrative Region of Hong Kong has suspended all hospital schools of nursing in Hong Kong since 2003, nursing education within the region has been completely Corresponding author. Tel.: +852 26096229;
fax: +852 26035269. E-mail addresses: [email protected] (W.Y. IP), [email protected] (D.S.K. Chan).
transferred to tertiary institutions (Chan, 2002). However, nursing students continue to acquire the majority of their clinical experience in hospitals and health care institutions. Most importantly, the role of the student nurse has been reinstated from worker to learner. Clinical practice, which takes place in the clinical environment, is a vital component in the nursing curriculum and has been acknowledged as central to nursing education (Lee, 1996; Dunn and Hansford, 1997). The clinical environment encompasses all that surrounds the student nurse, including the clinical setting, the staff, the patient, the nurse mentor, and the nurse educator (Papp et al., 2003). In contrast to traditional classroom settings, clinical practice takes place in a complex social context. A few of these differences are: one has little control of environmental conditions; students must combine the use of cognitive,
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psychomotor, and affective skills to respond to individual client needs; client safety must be maintained while he or she is cared for by a novice practitioner; and nurse educators must monitor client needs as well as student needs (Chan, 2001). The purpose of this paper is to explore Hong Kong nursing students’ perceptions of the clinical learning environment in Hong Kong.
2. Background This section presents an overview of some literature relevant to the clinical environment and nursing students’ learning. Computer database searches of relevant literature was carried out using CINAHL (1984–2004) and ERIC (1984–2004). Key search words included: learning environment, student nurse, social climate, clinical education, clinical practice and student perception. Further searching through reference lists of identified papers was conducted to identify other related publications. Dunn and Burnett (1995) described the clinical learning environment as an interactive network of forces within the clinical setting that influence the students’ clinical learning outcomes. It is within this environment that students develop their attitudes, competence, interpersonal communication skills, critical thinking and clinical problem-solving abilities (Dunn and Hansford, 1997). Nursing students perceive the practice setting as the most influential context when it comes to acquiring nursing skills and knowledge (Chan, 2001). Thorell-Ekstrand and Bjorvell (1995) suggested that clinical placement provides the student with optimal opportunities to observe role models, to practice by oneself and to reflect upon what is seen, heard, sensed and done. This is in accordance with Benner’s (1984) description of how expertise develops. Benner emphasized that learning becomes integrated into personality to create a holistic way of seeing and relating. Most importantly, the professional socialization of nurse learners occurs largely in the practice setting (Lee and French, 1997). According to Moos (1987) the social climate or learning environment of a setting can have a strong influence on people in a particular setting. Rudolf Moos (1987, p. 2) asserted that ‘‘the social climate is the personality of a setting or environment, such as a family, an office, or a classroomy each setting has a unique personality that gives it unity and coherence. Environments, like people, also differ in how rigid and controlling they are. Like some people, some social environments are friendlier than others. Just as some people are very task oriented and competitive, some environments encourage achievement and competition.’’ Clinicians and researchers have evidence to show how social climate affects each person’s behaviour, feelings, and growth (Moos, 1987).
The concept of social climate also emphasizes the importance of the physical, human, interpersonal and organizational properties, mutual respect and trust among teachers and students (Knowles, 1990). In the process of teaching and learning, the learning environment has a dual function. From the teacher’s point of view, educational environments can be a powerful teaching instrument at the disposal of the teacher, from the student’s perspective, educational environments provide an important vehicle for learning. Hart and Rotem (1994) found that the culture of the workplace was essential in establishing the value of the learning experience for students. Students appreciated the opportunities to be provided with autonomy, increased responsibility and feedback from the ward staff. Students also valued recognition from staff for their contribution to patient care. In accordance with Hart and Rotem (1994), and Chan (2001) found that students welcomed and preferred hospital environments that recognized their individuality, provided them with adequate support and allowed them some degree of flexibility within sensible limits. In addition, students’ level of satisfaction was high when they were treated with respect especially when they were included as part of the working team. On the other hand, students expressed their disappointment when their work and efforts were not acknowledged. Hart and Rotem (1994) also noted that the roles of clinical supervisors were important and believed that improved communication between educational institutions and health care facilities would help to clarify the roles of both students and supervisors. In a descriptive study that examined nursing students’ perception of social support provided by faculty while on clinical practice, O’Reilly Knapp (1994) found that students desired more social support from the faculty than they have received, and that there was no difference between junior and senior students’ perception. Social support in this context referred to tangible assistance, nondirective support, directive guidance and positive social interaction. The concept of classroom learning environment studies has been well developed in the educational psychology discipline. Although there are numerous instruments available for assessing classroom learning environments at various levels, very few instruments have been designed specifically for measuring the hospital learning environment while nursing students are on clinical field placement. The Clinical Learning Environment Inventory, CLEI, developed and validated by Chan (2002a), based on the theoretical framework of learning environment studies, had been used to assess nursing students’ perceptions of the social climate of the clinical learning environment in Australia. In light of the recent total transfer of nurse training from hospital schools to the higher education sector in Hong Kong and the lack of local studies on clinical learning
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environment research, the research team saw the need to carry out the current study. The CLEI has been adopted as the instrument for data collection in the reported study. The empirical and theoretical basis of this survey instrument will be discussed later in this paper.
3. The study 3.1. Aim To explore nursing students’ perceptions of the clinical learning environment in Hong Kong. 3.2. Objectives 1. To assess Hong Kong nursing students’ perceptions of the social climate of hospital learning environments during clinical field placement. 2. To examine the differences between students’ perceptions of the actual clinical learning environment and their preferred clinical learning environment.
3.3. Design The study design was a cross-sectional, simple descriptive survey with data collected from the participants through completion of the survey instrument, the CLEI. 3.4. Sample Apart from the Year 1 nursing students, the target group consisted of all Bachelor of Nursing students of a major university school of nursing in Hong Kong. The bachelor of nursing award is a 4-year full time programme. Subjects were recruited from each year group following the completion of their clinical placement in the first term. The Year 1 students were excluded as they had minimal clinical contact at the time of the study to provide adequate feed back regarding their clinical experiences. 3.5. Questionnaire The CLEI developed by Chan (2002a) was used to assess students’ perception of the social climate of the clinical learning environment in the current study. The CLEI was developed following an in-depth literature review on classroom learning environments, clinical learning environments, and discussion with experts in the field of nurse education and clinical nursing. References were made to the College and University Classroom Environment Inventory, CUCE, I in the development of the CLEI. The CUCEI was originally
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developed in the early 1980s for use in small classes in college and universities (Fraser et al., 1986). Thus in the development of the CLEI, only relevant scales perceived to be salient for the clinical learning environment were adapted and modified from the CUCEI for use in clinical learning environment studies (Chan, 2002a). Underpinning many of the learning environment instruments developed over the past 30 years is the theoretical framework for human environments, which was originally proposed by Moos (1974). In his research on human environments in hospital wards, school classrooms, prisons, university residences and military establishments, Moos (1979) proposed that there were three dimensions that characterize learning environments and that these dimensions should be included in all instruments designed to assess learning environments. These three dimensions include: personal development dimensions which assess personal growth and self-enhancement; system maintenance and system change dimensions which involve the extent to which the environment is orderly, clear in expectations, maintains control, and is responsive to change; and relationship dimensions which identify the nature and intensity of personal relationships within the environment and support and help each other. Other than assessing students’ perceptions of the actual learning environment, an important feature of most recent learning environment instruments is that they have distinctive versions which also measure student perceptions of the learning environment ideally liked. The preferred or ideal forms are concerned with goals and value orientations and measure perceptions of the learning environment ideally liked or preferred. Although item wording is similar for the actual and preferred forms, instructions for answering them are different. By using a person–environment interaction framework, it is possible to investigate whether student outcomes depend, not only on the nature of the actual learning environment, but also on the match between students’ preferences and the actual environment (Wong and Watkins, 1996). The CLEI consists of the actual form which measures student perception of the psychosocial characteristics of the actual hospital learning environment, and the preferred form which assesses student perception of the hospital environment ideally liked or preferred. The instrument contains 42 items, with 7 items assessing each of six scales. Each item in the CLEI is responded to on a 4-point, Likert-type scale ranging from ‘Strongly Agree’ to ‘Strongly Disagree’. Positively worded items are scored 5, 4, 2 and 1, respectively, for the responses Strongly Agree, Agree, Disagree and Strongly Disagree. Negatively worded items are scored in the reverse manner. Omitted or invalid responses are scored 3. The six scales of the CLEI are made up of: individualization, which assesses the extent to which
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students are allowed to make decisions and are treated differentially according to ability or interest; Innovation, which assesses the extent to which clinical teacher/ clinician plans new, interesting and productive ward experiences, teaching techniques, learning activities and patient allocations; involvement, which assesses the extent to which students participate actively and attentively in ward activities; personalization, which assesses the opportunities for individual students to interact with clinical teacher and concern for student’s personal welfare; task orientation, which assesses the extents to which ward activities are clear and well organized; and student satisfaction, which assesses the extent of enjoyment of clinical field placement. Chan (2002b) recommended the use of the last subscale of the CLEI, student satisfaction as an outcome measure of the students’ perception of the social climate of the clinical placement. In an Australian study, the CLEI Cronbach alpha coefficients ranged from 0.73 to 0.84 for the actual form and 0.66–0.80 for the preferred form (Chan, 2003). Table 1 shows a summary of the descriptive information including Moos’s (1979) three categories of human dimension, along with sample items for each scale of the CLEI.
3.6. Procedure The ethics committee of the University granted ethical approval for the research team to conduct the study. Following the completion of students’ clinical field
placement, the researcher approached each year group towards the end of a lecture period. The actual and preferred forms of the CLEI were distributed to all students. The researcher informed the students about the purpose of the study and reassured the participants verbally and in writing that their participation in the study was an option and that their responses to the anonymous self-administered questionnaires would be used for further development and planning of hospital placements. A collection box was provided to collect the completed questionnaires before the researcher left the lecture theatre. Students spent approximately 20 min answering both versions of the questionnaire.
4. Results Of the 303 students enrolled on the bachelor of nursing programme, there were 43 (14%) male and 260 (86%) females among the group with an age range of 18–23 years. Two hundred and eighty one completed actual forms (response rate 92.7%) and 243 preferred forms (response rate 80.2%) were returned. The Cronbach alpha coefficients for each scale of the CLEI obtained from the study ranged from 0.50 to 0.80 for the actual form and 0.51 to 0.76 for the preferred form. The mean scores and standard deviations for all scales of the CLEI were examined. Of the six scales in the CLEI, personalization scored the highest mean in both actual and preferred versions of the instrument. On the
Table 1 Descriptive information for each scale in CLEI Scale name
Moos’ category
Scale description
Sample item
Individualization
S
Students are generally allowed to work at their own pace (+)
Innovation
S
Involvement
R
Personalization
R
Task orientation
P
Satisfaction
P
Extent to which students are allowed to make decisions and are treated differentially according to ability or interest. Extent to which clinical teacher/clinician plans new, interesting and productive ward experiences, teaching techniques, learning activities and patient allocations. Extent to which students participate actively and attentively in hospital ward activities. Emphasis on opportunities for individual student to interact with clinical teacher/ clinician and on concern for student’s personal welfare. Extent to which ward activities are clear and well organized. Extent of enjoyment of clinical field placement
New ideas are seldom tried out in this ward ()
There are opportunities for students to express opinions in this ward (+) The preceptor/clinician considers student’s feelings (+)
This is a disorganized clinical placement () Students look forward to coming to clinical placement (+)
Moss category: R—relationship dimension; P—personal development dimension; S—system maintenance and system change dimension. Items designated (+) are scored 5, 4, 2 and 1, respectively, for the responses strongly agree, agree, disagree and strongly disagree. Items () are scored in the reverse manner. Omitted or invalid responses are scored 3.
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other hand, teaching innovation scored the lowest mean in both versions of the CLEI. The differences between students’ perceptions of actual and preferred clinical learning environment were examined by exploring the differences in each scale between the actual and preferred forms. The Bonferroni t-test was carried out for paired samples (n ¼ 243). The results indicated significant differences in all scales between the actual and preferred forms with po0:0083: The mean scores for all six scales of the preferred form were higher than the corresponding scales of the actual form, with the differences in scale means for each scale ranging from 5.23 to 8.36. See Table 2 for details. A one-way ANOVA was used to compare the scales of the actual form among the Years 2, 3 and 4 students. The results indicated that there were significant differences in the mean scores across the three groups in all scales. Follow-up univariate analyses of variance with post-hoc Tukey’s HSD revealed the following. The differences between the mean scores of Years 3 and 4 students were insignificant. Yet there were significant differences (po0:001) in all mean scores of the Year 2 students with the Years 3 and 4 students. The Year 2 students scored lower than the other two groups in all corresponding scales of the CLEI. These data are detailed in Table 3.
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As indicated earlier, Chan (2002b) recommended the use of the scale, student satisfaction as an outcome measure of the students’ perception of the social climate of their clinical placement. To examine the relationship between the outcome measure and each scale of the CLEI (actual form), the results of Pearson correlation (r) analysis indicated significant associations between Student Satisfaction and all five scales of the CLEI with the correlation coefficients ranging from 0.31 to 0.54, po0:001: To predict the relationship between the outcome measure, student satisfaction, and all other scales of the CLEI simultaneously, multiple regression analysis was carried out. Table 4 indicates that task orientation, student involvement, and personalization reached statistical significance (po0:001) in explaining 36% of the
Table 4 Predictors of satisfaction with clinical learning environment
Student involvement Personalization Task orientation
df
b
p
R2
F
5280
0.173 0.14 0.34
o0.001 o0.05 o0.001
0.36
30.58
Table 2 Differences in mean scores of each scale between the preferred and actual forms of the CLEI Scale name
Mean score (standard deviation)
Mean difference t-value 95% confidence interval of the difference
Actual, n ¼ 281 Preferred, n ¼ 243 Personalization Satisfaction Student involvement Individualization Task orientation Teaching innovation
24.17 23.07 22.19 21.35 19.90 15.23
(4.46) (4.50) (3.63) (3.90) (3.32) (3.50)
30.33 30.19 27.60 26.47 25.38 23.50
(3.04) (3.11) (3.12) (3.28) (2.57) (2.80)
18.56* 20.21* 18.65* 17.08* 22.09* 28.42*
6.25 7.27 5.34 5.23 5.56 8.36
Lower
Upper
5.59 6.56 4.78 4.63 5.06 7.78
6.92 7.98 5.91 5.84 6.05 8.94
po0:0083; Bonferroni t test.
Table 3 Analysis of differences in CLEI scores (actual form) in students at each year of study CLEI scale
Individualization Innovation Task orientation Satisfaction Involvement Personalization
Year 2 (n ¼ 72)
Year 3 (n ¼ 91)
Year 4 (n ¼ 80)
Mean
SD
Mean
SD
Mean
SD
19.26 14.26 18.46 22.06 20.11 22.50
4.18 3.10 3.73 5.50 3.20 4.94
22.45 15.96 20.19 23.46 23.20 24.75
3.08 3.74 3.28 4.58 3.43 4.51
21.63 14.98 20.65 23.08 23.13 24.73
3.68 3.31 2.97 4.89 3.39 3.64
po0:01; po0:001: Yr=Year.
F ratio
Tukey’s HSD (Po0:001)
12.26** 6.40** 6.63** 5.30* 14.28** 8.90**
Yr2o Yr2o Yr2o Yr2o Yr2o Yr2o
Yr3, Yr3, Yr3, Yr3, Yr3, Yr3,
Yr4 Yr4 Yr4 Yr4 Yr4 Yr4
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variance in the students’ perception of the social climate of their clinical placement.
5. Discussion The range of Cronbach alpha scores in the current study were comparable to Chan’s (2003) findings except in the scale, student involvement with scores 0.50 and 0.51 in the actual and preferred forms, respectively, which were comparatively lower than that reported in Chan’s (2003) study. The scale, student involvement assesses the extent to which students participate actively and attentively in hospital ward activities. The different approaches in clinical teaching between the current project in Hong Kong and the Australian study (Chan, 2003) used for establishing reliability may explain the differences. Future studies to compare various clinical teaching approaches across cultures are recommended. Nevertheless, the unsatisfactory reliability of the subscale student involvement (Nunnally and Bernstein, 1994) indicates the necessity to further test the psychometric properties of the CLEI. Overall, it is interesting to note that the mean scores for each scale of the preferred form are comparatively higher than the corresponding scales of the actual form. These data suggested that, in comparison with the actual hospital learning environment experienced, students prefer a learning environment at higher levels as represented by all scales of the CLEI. In addition, mean scores for all scales of the actual form reported high standard deviations. This suggests a large variation in the social climate perceived by different students. It is apparent that some students perceived their clinical learning environment to be very good yet others found them bad; resulting in a U-curve rather than a normal distribution around the mean. The preferred form, however, showed far less deviation from the norm in all scales, indicating that the students have a fairly consistent idea of how they would like the clinical learning environment to be. Similar to Chan’s (2002b) findings in Australia, personalization and teaching innovation scored, respectively, the highest and lowest mean in both versions of the CLEI. This implies students perceived personalization as the top priority in the clinical learning environment. This scale belongs to the relationship dimensions, one of Moos’ (1974) three human environment categories, which identifies the nature and intensity of personal relationships within the environment and the extent to which people are involved in the environment and support and help each other. The scale assesses the opportunities for individual students to interact with their clinical teachers and on their concern for the student’s personal welfare. In essence, students see human relationship in the clinical learning environment
as their top priority while on clinical placement. During clinical placement, student nurses frequently felt vulnerable in the clinical environment (Campbell et al., 1994) and they certainly needed respect, support, and recognition. The highest mean score in personalization in the actual form reflected the support that the students already received. Even though the students felt supported, respected, and recognized in the clinical learning environment, they demanded more attention in this area, which is supported by the higher score in personalisation in the preferred form. The scale teaching innovation in the CLEI assesses the extent to which clinical teacher/mentor plans new, interesting and productive learning experiences with innovative teaching strategies and techniques. To have scored the lowest in the actual form, this implies that the students did not perceive that they have received adequate innovative teaching or interesting learning experiences during clinical practice. In essence, teaching innovation is an area that clinical teachers and mentors need to invest more time and attention in facilitating students’ learning in the clinical environment. On the other hand, the lowest score in the preferred form implies that the students did not see the importance of teaching innovation as a factor that influenced their learning in the clinical setting. One major assumption of learning environment studies is that better understanding and improvement in teaching and learning can emerge by examining the ways that the students interpret the learning environments since students ultimately respond to what they perceive as important. Based on a person–environment interaction framework, it is possible to investigate whether student outcomes depend not only on the nature of the actual clinical learning environment, but also on the match between students’ preferences and the actual environment (Fraser and Fisher, 1983; Wong and Watkins, 1996). The outcomes of clinical field placement may be improved through matching between students’ preferences and the actual environment (Fraser and Fisher, 1983; Wong and Watkins, 1996). In other words, one of the many objectives of clinical nurse education is to reduce the gap between students’ perception of the preferred and actual clinical learning environment. In terms of the differences in the actual CLEI scores between students at each year level of study, it was noted that the Year 2 students scored consistently lower than the Years 3 and 4 students in all 6 scales of the CLEI. This is in contrast to O’Reilly Knapp’s (1994) findings, which suggested that there was no difference between junior and senior students in their perception of social support required and obtained from faculty. As mentioned, the Year 1 students had been excluded from the study because they have very minimal clinical contact during the course of study in the first year. As the
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students progress to senior years, the portion of clinical component gradually increases. Year 2 sits in the transitional period when the students are required to spend a considerably larger amount of time in clinical practice than in Year 1. This transitional period may come as a culture shock for the Year 2 students as the literature suggested that many nursing students perceived clinical experience as anxiety-provoking and that they often felt vulnerable in the clinical environment (Ashworth and Morrison, 1989; Campbell et al., 1994). It is important for the clients, clinicians, clinical mentors, clinical teachers and faculties to recognize and appreciate nursing students’ vulnerability in the clinical learning environment. It is only fair to make the assumptions that there is a need to better prepare the students, especially in Year 2, for this transition as well as to provide them with the very much-needed support. By Years 3 and 4, charged with more in depth knowledge and skills in nursing practice, the senior students might have somewhat adjusted to the notion of clinical practice and better adapted to the clinical learning environment. This explains the higher CLEI scores reported by the senior students. The results of correlation analyses reported in Table 4 indicate that significant associations emerged between satisfaction and all five scales of the CLEI with the correlation coefficients (r), ranging from 0.31 to 0.54 (po0:001), all within the acceptable range of 0.3–0.7 (Nunnally and Bernstein, 1994). The beta weights (b) from multiple regression analysis in Table 4 provide an estimate of the influence of any specific environment variable on the outcome when the remaining four environment variables are held constant. In other words, those variables whose regression weights are significantly different from zero are those that account for a significant increment in the outcome variance over and above that attributable to the other four environment variables combines. This more conservative analysis predicts that task orientation, student involvement, and personalization reached statistical significance in explaining 36% variance in student satisfaction. Thus higher levels of student satisfaction are likely to occur when ward activities are well organized and when students experienced greater involvement in ward practice. Moreover, students’ relationship with the clinical staff is also a predictor to their level of satisfaction with the clinical learning environment. The relatively high value of the beta weight for task orientation (b ¼ 0:34; po0:001) indicates that there is a strong association between students’ perception of task orientation and the outcome measure, satisfaction, during clinical practice. However, it is also important to acknowledge that, 64% of the variance had not been explained by this model. Further studies to explore the factors that may affect students’ perceived outcome of clinical practice are recommended.
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Task orientation in the CLEI assesses the extent to which students perceive ward activities are clear and well organized. Many students perceive clinical experience as anxiety-provoking (Ashworth and Morrison, 1989; Campbell et al., 1994) and students often express the opinion that they become less nervous in the clinical environment soon after they are involved or occupied with ward activities (Chan, 2002b). In order to facilitate the novice students to actively involve with ward activities which might have direct impact on the welfare of the clients, the clinical staff should provide clear and detail instructions on safe practice. Papp et al. (2003) suggested that the clinical environment encompasses all that surrounds the student nurse, including the clinical settings, the staff, the patients, the nurse mentor, and the nurse educator. In other words, students see the support, respect, and recognition by all personnel in the clinical environment as their prime priority during clinical placement. Maintenance of open and direct communication between each person concerned would provide and enhance a supportive learning climate that is a critical element of human resource development. Collaboration between the higher education and health care agencies is essential if the clinical learning environment is to best meet the needs of undergraduate nursing students. A supportive clinical learning environment is of paramount importance in securing the required teaching and learning process. The practice setting should provide the students with an environment where they can receive learning opportunities. However, various studies have indicated that not all practice settings are able to provide student nurses with a positive learning environment (Windsor, 1987; Lofmark and Wilkblad, 2001; Chan, 2002b; Espeland, and Indrehus, 2003). As the time allocation for the clinical component of nurse education is limited, it is important that the scarce but valuable clinical time is utilized effectively.
6. Limitations Perhaps the greatest limitation of this study is that the subjects were nursing students from just one university nursing school in Hong Kong, and thus the findings may not be representative of nursing students in general with respect to their clinical placement. A second limitation is that the findings are limited to the students’ perspective. Inclusion of perceptions of the clinical learning environment from the perspective of clinicians, clinical teachers, as well as clients from the receiving end, will provide a broad spectrum to complete the picture. It would be interesting to conduct a longitudinal study to follow through the students in their subsequent years in order to explore the pattern of changes in their perception of the social climate of the clinical learning environment.
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7. Conclusion The findings of this project help to describe Hong Kong nursing students’ perception of the social climate of the clinical learning environment. It was found that there were significant differences between students’ perceptions of the actual clinical learning environment and the ideal clinical learning environment they desired. Clinical education is a vital component the nursing curriculum yet clinical practice takes place in a complex social context. A supportive clinical learning environment is of paramount importance in securing the required teaching and learning process.
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International Journal of Nursing Studies 42 (2005) 665–672 www.elsevier.com/locate/ijnurstu
Hong Kong nursing students’ perception of the clinical environment: a questionnaire survey Wan Yim IP, Dominic Shung Kit Chan The Nethersole School of Nursing, The Chinese University of Hong Kong, Room 826, Esther Lee Building, Shatin, N.T., Hong Kong Received 7 June 2004; received in revised form 18 September 2004; accepted 23 September 2004
Abstract Clinical practice is a vital component of the nursing curriculum yet it takes place in a complex social context. This survey examined Hong Kong nursing students’ perception of the social climate of the clinical learning environment. The targeted subjects were all Years 2–4 pre-registration nursing students at the school of nursing of a major University in Hong Kong. Participants were invited to complete the two versions, the actual and preferred forms, of the Clinical Learning Environment Inventory following the completion of their clinical field placement. Two hundred and eighty one actual forms and 243 preferred forms were returned. SPPS version 11 was employed to analyse the data using descriptive and inferential statistics. It was found that there were significant differences between students’ perceptions of the actual clinical learning environment and the ideal clinical learning environment they desired. The study highlights the need for a supportive clinical learning environment which is of paramount importance in securing the required teaching and learning process for students on clinical practice. r 2004 Elsevier Ltd. All rights reserved. Keywords: Nursing students; Clinical learning environment; Hong Kong
1. Introduction Nursing as a profession has evolved in response to society’s needs for well-prepared, caring practitioners during clients’ episodes of illness and promote health among all age groups. Originally taught at the bedside by skilled practitioners, the majority of nurses in Hong Kong received their training from hospital schools of nursing. As the government of the Special Administrative Region of Hong Kong has suspended all hospital schools of nursing in Hong Kong since 2003, nursing education within the region has been completely Corresponding author. Tel.: +852 26096229;
fax: +852 26035269. E-mail addresses: [email protected] (W.Y. IP), [email protected] (D.S.K. Chan).
transferred to tertiary institutions (Chan, 2002). However, nursing students continue to acquire the majority of their clinical experience in hospitals and health care institutions. Most importantly, the role of the student nurse has been reinstated from worker to learner. Clinical practice, which takes place in the clinical environment, is a vital component in the nursing curriculum and has been acknowledged as central to nursing education (Lee, 1996; Dunn and Hansford, 1997). The clinical environment encompasses all that surrounds the student nurse, including the clinical setting, the staff, the patient, the nurse mentor, and the nurse educator (Papp et al., 2003). In contrast to traditional classroom settings, clinical practice takes place in a complex social context. A few of these differences are: one has little control of environmental conditions; students must combine the use of cognitive,
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psychomotor, and affective skills to respond to individual client needs; client safety must be maintained while he or she is cared for by a novice practitioner; and nurse educators must monitor client needs as well as student needs (Chan, 2001). The purpose of this paper is to explore Hong Kong nursing students’ perceptions of the clinical learning environment in Hong Kong.
2. Background This section presents an overview of some literature relevant to the clinical environment and nursing students’ learning. Computer database searches of relevant literature was carried out using CINAHL (1984–2004) and ERIC (1984–2004). Key search words included: learning environment, student nurse, social climate, clinical education, clinical practice and student perception. Further searching through reference lists of identified papers was conducted to identify other related publications. Dunn and Burnett (1995) described the clinical learning environment as an interactive network of forces within the clinical setting that influence the students’ clinical learning outcomes. It is within this environment that students develop their attitudes, competence, interpersonal communication skills, critical thinking and clinical problem-solving abilities (Dunn and Hansford, 1997). Nursing students perceive the practice setting as the most influential context when it comes to acquiring nursing skills and knowledge (Chan, 2001). Thorell-Ekstrand and Bjorvell (1995) suggested that clinical placement provides the student with optimal opportunities to observe role models, to practice by oneself and to reflect upon what is seen, heard, sensed and done. This is in accordance with Benner’s (1984) description of how expertise develops. Benner emphasized that learning becomes integrated into personality to create a holistic way of seeing and relating. Most importantly, the professional socialization of nurse learners occurs largely in the practice setting (Lee and French, 1997). According to Moos (1987) the social climate or learning environment of a setting can have a strong influence on people in a particular setting. Rudolf Moos (1987, p. 2) asserted that ‘‘the social climate is the personality of a setting or environment, such as a family, an office, or a classroomy each setting has a unique personality that gives it unity and coherence. Environments, like people, also differ in how rigid and controlling they are. Like some people, some social environments are friendlier than others. Just as some people are very task oriented and competitive, some environments encourage achievement and competition.’’ Clinicians and researchers have evidence to show how social climate affects each person’s behaviour, feelings, and growth (Moos, 1987).
The concept of social climate also emphasizes the importance of the physical, human, interpersonal and organizational properties, mutual respect and trust among teachers and students (Knowles, 1990). In the process of teaching and learning, the learning environment has a dual function. From the teacher’s point of view, educational environments can be a powerful teaching instrument at the disposal of the teacher, from the student’s perspective, educational environments provide an important vehicle for learning. Hart and Rotem (1994) found that the culture of the workplace was essential in establishing the value of the learning experience for students. Students appreciated the opportunities to be provided with autonomy, increased responsibility and feedback from the ward staff. Students also valued recognition from staff for their contribution to patient care. In accordance with Hart and Rotem (1994), and Chan (2001) found that students welcomed and preferred hospital environments that recognized their individuality, provided them with adequate support and allowed them some degree of flexibility within sensible limits. In addition, students’ level of satisfaction was high when they were treated with respect especially when they were included as part of the working team. On the other hand, students expressed their disappointment when their work and efforts were not acknowledged. Hart and Rotem (1994) also noted that the roles of clinical supervisors were important and believed that improved communication between educational institutions and health care facilities would help to clarify the roles of both students and supervisors. In a descriptive study that examined nursing students’ perception of social support provided by faculty while on clinical practice, O’Reilly Knapp (1994) found that students desired more social support from the faculty than they have received, and that there was no difference between junior and senior students’ perception. Social support in this context referred to tangible assistance, nondirective support, directive guidance and positive social interaction. The concept of classroom learning environment studies has been well developed in the educational psychology discipline. Although there are numerous instruments available for assessing classroom learning environments at various levels, very few instruments have been designed specifically for measuring the hospital learning environment while nursing students are on clinical field placement. The Clinical Learning Environment Inventory, CLEI, developed and validated by Chan (2002a), based on the theoretical framework of learning environment studies, had been used to assess nursing students’ perceptions of the social climate of the clinical learning environment in Australia. In light of the recent total transfer of nurse training from hospital schools to the higher education sector in Hong Kong and the lack of local studies on clinical learning
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environment research, the research team saw the need to carry out the current study. The CLEI has been adopted as the instrument for data collection in the reported study. The empirical and theoretical basis of this survey instrument will be discussed later in this paper.
3. The study 3.1. Aim To explore nursing students’ perceptions of the clinical learning environment in Hong Kong. 3.2. Objectives 1. To assess Hong Kong nursing students’ perceptions of the social climate of hospital learning environments during clinical field placement. 2. To examine the differences between students’ perceptions of the actual clinical learning environment and their preferred clinical learning environment.
3.3. Design The study design was a cross-sectional, simple descriptive survey with data collected from the participants through completion of the survey instrument, the CLEI. 3.4. Sample Apart from the Year 1 nursing students, the target group consisted of all Bachelor of Nursing students of a major university school of nursing in Hong Kong. The bachelor of nursing award is a 4-year full time programme. Subjects were recruited from each year group following the completion of their clinical placement in the first term. The Year 1 students were excluded as they had minimal clinical contact at the time of the study to provide adequate feed back regarding their clinical experiences. 3.5. Questionnaire The CLEI developed by Chan (2002a) was used to assess students’ perception of the social climate of the clinical learning environment in the current study. The CLEI was developed following an in-depth literature review on classroom learning environments, clinical learning environments, and discussion with experts in the field of nurse education and clinical nursing. References were made to the College and University Classroom Environment Inventory, CUCE, I in the development of the CLEI. The CUCEI was originally
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developed in the early 1980s for use in small classes in college and universities (Fraser et al., 1986). Thus in the development of the CLEI, only relevant scales perceived to be salient for the clinical learning environment were adapted and modified from the CUCEI for use in clinical learning environment studies (Chan, 2002a). Underpinning many of the learning environment instruments developed over the past 30 years is the theoretical framework for human environments, which was originally proposed by Moos (1974). In his research on human environments in hospital wards, school classrooms, prisons, university residences and military establishments, Moos (1979) proposed that there were three dimensions that characterize learning environments and that these dimensions should be included in all instruments designed to assess learning environments. These three dimensions include: personal development dimensions which assess personal growth and self-enhancement; system maintenance and system change dimensions which involve the extent to which the environment is orderly, clear in expectations, maintains control, and is responsive to change; and relationship dimensions which identify the nature and intensity of personal relationships within the environment and support and help each other. Other than assessing students’ perceptions of the actual learning environment, an important feature of most recent learning environment instruments is that they have distinctive versions which also measure student perceptions of the learning environment ideally liked. The preferred or ideal forms are concerned with goals and value orientations and measure perceptions of the learning environment ideally liked or preferred. Although item wording is similar for the actual and preferred forms, instructions for answering them are different. By using a person–environment interaction framework, it is possible to investigate whether student outcomes depend, not only on the nature of the actual learning environment, but also on the match between students’ preferences and the actual environment (Wong and Watkins, 1996). The CLEI consists of the actual form which measures student perception of the psychosocial characteristics of the actual hospital learning environment, and the preferred form which assesses student perception of the hospital environment ideally liked or preferred. The instrument contains 42 items, with 7 items assessing each of six scales. Each item in the CLEI is responded to on a 4-point, Likert-type scale ranging from ‘Strongly Agree’ to ‘Strongly Disagree’. Positively worded items are scored 5, 4, 2 and 1, respectively, for the responses Strongly Agree, Agree, Disagree and Strongly Disagree. Negatively worded items are scored in the reverse manner. Omitted or invalid responses are scored 3. The six scales of the CLEI are made up of: individualization, which assesses the extent to which
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students are allowed to make decisions and are treated differentially according to ability or interest; Innovation, which assesses the extent to which clinical teacher/ clinician plans new, interesting and productive ward experiences, teaching techniques, learning activities and patient allocations; involvement, which assesses the extent to which students participate actively and attentively in ward activities; personalization, which assesses the opportunities for individual students to interact with clinical teacher and concern for student’s personal welfare; task orientation, which assesses the extents to which ward activities are clear and well organized; and student satisfaction, which assesses the extent of enjoyment of clinical field placement. Chan (2002b) recommended the use of the last subscale of the CLEI, student satisfaction as an outcome measure of the students’ perception of the social climate of the clinical placement. In an Australian study, the CLEI Cronbach alpha coefficients ranged from 0.73 to 0.84 for the actual form and 0.66–0.80 for the preferred form (Chan, 2003). Table 1 shows a summary of the descriptive information including Moos’s (1979) three categories of human dimension, along with sample items for each scale of the CLEI.
3.6. Procedure The ethics committee of the University granted ethical approval for the research team to conduct the study. Following the completion of students’ clinical field
placement, the researcher approached each year group towards the end of a lecture period. The actual and preferred forms of the CLEI were distributed to all students. The researcher informed the students about the purpose of the study and reassured the participants verbally and in writing that their participation in the study was an option and that their responses to the anonymous self-administered questionnaires would be used for further development and planning of hospital placements. A collection box was provided to collect the completed questionnaires before the researcher left the lecture theatre. Students spent approximately 20 min answering both versions of the questionnaire.
4. Results Of the 303 students enrolled on the bachelor of nursing programme, there were 43 (14%) male and 260 (86%) females among the group with an age range of 18–23 years. Two hundred and eighty one completed actual forms (response rate 92.7%) and 243 preferred forms (response rate 80.2%) were returned. The Cronbach alpha coefficients for each scale of the CLEI obtained from the study ranged from 0.50 to 0.80 for the actual form and 0.51 to 0.76 for the preferred form. The mean scores and standard deviations for all scales of the CLEI were examined. Of the six scales in the CLEI, personalization scored the highest mean in both actual and preferred versions of the instrument. On the
Table 1 Descriptive information for each scale in CLEI Scale name
Moos’ category
Scale description
Sample item
Individualization
S
Students are generally allowed to work at their own pace (+)
Innovation
S
Involvement
R
Personalization
R
Task orientation
P
Satisfaction
P
Extent to which students are allowed to make decisions and are treated differentially according to ability or interest. Extent to which clinical teacher/clinician plans new, interesting and productive ward experiences, teaching techniques, learning activities and patient allocations. Extent to which students participate actively and attentively in hospital ward activities. Emphasis on opportunities for individual student to interact with clinical teacher/ clinician and on concern for student’s personal welfare. Extent to which ward activities are clear and well organized. Extent of enjoyment of clinical field placement
New ideas are seldom tried out in this ward ()
There are opportunities for students to express opinions in this ward (+) The preceptor/clinician considers student’s feelings (+)
This is a disorganized clinical placement () Students look forward to coming to clinical placement (+)
Moss category: R—relationship dimension; P—personal development dimension; S—system maintenance and system change dimension. Items designated (+) are scored 5, 4, 2 and 1, respectively, for the responses strongly agree, agree, disagree and strongly disagree. Items () are scored in the reverse manner. Omitted or invalid responses are scored 3.
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other hand, teaching innovation scored the lowest mean in both versions of the CLEI. The differences between students’ perceptions of actual and preferred clinical learning environment were examined by exploring the differences in each scale between the actual and preferred forms. The Bonferroni t-test was carried out for paired samples (n ¼ 243). The results indicated significant differences in all scales between the actual and preferred forms with po0:0083: The mean scores for all six scales of the preferred form were higher than the corresponding scales of the actual form, with the differences in scale means for each scale ranging from 5.23 to 8.36. See Table 2 for details. A one-way ANOVA was used to compare the scales of the actual form among the Years 2, 3 and 4 students. The results indicated that there were significant differences in the mean scores across the three groups in all scales. Follow-up univariate analyses of variance with post-hoc Tukey’s HSD revealed the following. The differences between the mean scores of Years 3 and 4 students were insignificant. Yet there were significant differences (po0:001) in all mean scores of the Year 2 students with the Years 3 and 4 students. The Year 2 students scored lower than the other two groups in all corresponding scales of the CLEI. These data are detailed in Table 3.
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As indicated earlier, Chan (2002b) recommended the use of the scale, student satisfaction as an outcome measure of the students’ perception of the social climate of their clinical placement. To examine the relationship between the outcome measure and each scale of the CLEI (actual form), the results of Pearson correlation (r) analysis indicated significant associations between Student Satisfaction and all five scales of the CLEI with the correlation coefficients ranging from 0.31 to 0.54, po0:001: To predict the relationship between the outcome measure, student satisfaction, and all other scales of the CLEI simultaneously, multiple regression analysis was carried out. Table 4 indicates that task orientation, student involvement, and personalization reached statistical significance (po0:001) in explaining 36% of the
Table 4 Predictors of satisfaction with clinical learning environment
Student involvement Personalization Task orientation
df
b
p
R2
F
5280
0.173 0.14 0.34
o0.001 o0.05 o0.001
0.36
30.58
Table 2 Differences in mean scores of each scale between the preferred and actual forms of the CLEI Scale name
Mean score (standard deviation)
Mean difference t-value 95% confidence interval of the difference
Actual, n ¼ 281 Preferred, n ¼ 243 Personalization Satisfaction Student involvement Individualization Task orientation Teaching innovation
24.17 23.07 22.19 21.35 19.90 15.23
(4.46) (4.50) (3.63) (3.90) (3.32) (3.50)
30.33 30.19 27.60 26.47 25.38 23.50
(3.04) (3.11) (3.12) (3.28) (2.57) (2.80)
18.56* 20.21* 18.65* 17.08* 22.09* 28.42*
6.25 7.27 5.34 5.23 5.56 8.36
Lower
Upper
5.59 6.56 4.78 4.63 5.06 7.78
6.92 7.98 5.91 5.84 6.05 8.94
po0:0083; Bonferroni t test.
Table 3 Analysis of differences in CLEI scores (actual form) in students at each year of study CLEI scale
Individualization Innovation Task orientation Satisfaction Involvement Personalization
Year 2 (n ¼ 72)
Year 3 (n ¼ 91)
Year 4 (n ¼ 80)
Mean
SD
Mean
SD
Mean
SD
19.26 14.26 18.46 22.06 20.11 22.50
4.18 3.10 3.73 5.50 3.20 4.94
22.45 15.96 20.19 23.46 23.20 24.75
3.08 3.74 3.28 4.58 3.43 4.51
21.63 14.98 20.65 23.08 23.13 24.73
3.68 3.31 2.97 4.89 3.39 3.64
po0:01; po0:001: Yr=Year.
F ratio
Tukey’s HSD (Po0:001)
12.26** 6.40** 6.63** 5.30* 14.28** 8.90**
Yr2o Yr2o Yr2o Yr2o Yr2o Yr2o
Yr3, Yr3, Yr3, Yr3, Yr3, Yr3,
Yr4 Yr4 Yr4 Yr4 Yr4 Yr4
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variance in the students’ perception of the social climate of their clinical placement.
5. Discussion The range of Cronbach alpha scores in the current study were comparable to Chan’s (2003) findings except in the scale, student involvement with scores 0.50 and 0.51 in the actual and preferred forms, respectively, which were comparatively lower than that reported in Chan’s (2003) study. The scale, student involvement assesses the extent to which students participate actively and attentively in hospital ward activities. The different approaches in clinical teaching between the current project in Hong Kong and the Australian study (Chan, 2003) used for establishing reliability may explain the differences. Future studies to compare various clinical teaching approaches across cultures are recommended. Nevertheless, the unsatisfactory reliability of the subscale student involvement (Nunnally and Bernstein, 1994) indicates the necessity to further test the psychometric properties of the CLEI. Overall, it is interesting to note that the mean scores for each scale of the preferred form are comparatively higher than the corresponding scales of the actual form. These data suggested that, in comparison with the actual hospital learning environment experienced, students prefer a learning environment at higher levels as represented by all scales of the CLEI. In addition, mean scores for all scales of the actual form reported high standard deviations. This suggests a large variation in the social climate perceived by different students. It is apparent that some students perceived their clinical learning environment to be very good yet others found them bad; resulting in a U-curve rather than a normal distribution around the mean. The preferred form, however, showed far less deviation from the norm in all scales, indicating that the students have a fairly consistent idea of how they would like the clinical learning environment to be. Similar to Chan’s (2002b) findings in Australia, personalization and teaching innovation scored, respectively, the highest and lowest mean in both versions of the CLEI. This implies students perceived personalization as the top priority in the clinical learning environment. This scale belongs to the relationship dimensions, one of Moos’ (1974) three human environment categories, which identifies the nature and intensity of personal relationships within the environment and the extent to which people are involved in the environment and support and help each other. The scale assesses the opportunities for individual students to interact with their clinical teachers and on their concern for the student’s personal welfare. In essence, students see human relationship in the clinical learning environment
as their top priority while on clinical placement. During clinical placement, student nurses frequently felt vulnerable in the clinical environment (Campbell et al., 1994) and they certainly needed respect, support, and recognition. The highest mean score in personalization in the actual form reflected the support that the students already received. Even though the students felt supported, respected, and recognized in the clinical learning environment, they demanded more attention in this area, which is supported by the higher score in personalisation in the preferred form. The scale teaching innovation in the CLEI assesses the extent to which clinical teacher/mentor plans new, interesting and productive learning experiences with innovative teaching strategies and techniques. To have scored the lowest in the actual form, this implies that the students did not perceive that they have received adequate innovative teaching or interesting learning experiences during clinical practice. In essence, teaching innovation is an area that clinical teachers and mentors need to invest more time and attention in facilitating students’ learning in the clinical environment. On the other hand, the lowest score in the preferred form implies that the students did not see the importance of teaching innovation as a factor that influenced their learning in the clinical setting. One major assumption of learning environment studies is that better understanding and improvement in teaching and learning can emerge by examining the ways that the students interpret the learning environments since students ultimately respond to what they perceive as important. Based on a person–environment interaction framework, it is possible to investigate whether student outcomes depend not only on the nature of the actual clinical learning environment, but also on the match between students’ preferences and the actual environment (Fraser and Fisher, 1983; Wong and Watkins, 1996). The outcomes of clinical field placement may be improved through matching between students’ preferences and the actual environment (Fraser and Fisher, 1983; Wong and Watkins, 1996). In other words, one of the many objectives of clinical nurse education is to reduce the gap between students’ perception of the preferred and actual clinical learning environment. In terms of the differences in the actual CLEI scores between students at each year level of study, it was noted that the Year 2 students scored consistently lower than the Years 3 and 4 students in all 6 scales of the CLEI. This is in contrast to O’Reilly Knapp’s (1994) findings, which suggested that there was no difference between junior and senior students in their perception of social support required and obtained from faculty. As mentioned, the Year 1 students had been excluded from the study because they have very minimal clinical contact during the course of study in the first year. As the
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students progress to senior years, the portion of clinical component gradually increases. Year 2 sits in the transitional period when the students are required to spend a considerably larger amount of time in clinical practice than in Year 1. This transitional period may come as a culture shock for the Year 2 students as the literature suggested that many nursing students perceived clinical experience as anxiety-provoking and that they often felt vulnerable in the clinical environment (Ashworth and Morrison, 1989; Campbell et al., 1994). It is important for the clients, clinicians, clinical mentors, clinical teachers and faculties to recognize and appreciate nursing students’ vulnerability in the clinical learning environment. It is only fair to make the assumptions that there is a need to better prepare the students, especially in Year 2, for this transition as well as to provide them with the very much-needed support. By Years 3 and 4, charged with more in depth knowledge and skills in nursing practice, the senior students might have somewhat adjusted to the notion of clinical practice and better adapted to the clinical learning environment. This explains the higher CLEI scores reported by the senior students. The results of correlation analyses reported in Table 4 indicate that significant associations emerged between satisfaction and all five scales of the CLEI with the correlation coefficients (r), ranging from 0.31 to 0.54 (po0:001), all within the acceptable range of 0.3–0.7 (Nunnally and Bernstein, 1994). The beta weights (b) from multiple regression analysis in Table 4 provide an estimate of the influence of any specific environment variable on the outcome when the remaining four environment variables are held constant. In other words, those variables whose regression weights are significantly different from zero are those that account for a significant increment in the outcome variance over and above that attributable to the other four environment variables combines. This more conservative analysis predicts that task orientation, student involvement, and personalization reached statistical significance in explaining 36% variance in student satisfaction. Thus higher levels of student satisfaction are likely to occur when ward activities are well organized and when students experienced greater involvement in ward practice. Moreover, students’ relationship with the clinical staff is also a predictor to their level of satisfaction with the clinical learning environment. The relatively high value of the beta weight for task orientation (b ¼ 0:34; po0:001) indicates that there is a strong association between students’ perception of task orientation and the outcome measure, satisfaction, during clinical practice. However, it is also important to acknowledge that, 64% of the variance had not been explained by this model. Further studies to explore the factors that may affect students’ perceived outcome of clinical practice are recommended.
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Task orientation in the CLEI assesses the extent to which students perceive ward activities are clear and well organized. Many students perceive clinical experience as anxiety-provoking (Ashworth and Morrison, 1989; Campbell et al., 1994) and students often express the opinion that they become less nervous in the clinical environment soon after they are involved or occupied with ward activities (Chan, 2002b). In order to facilitate the novice students to actively involve with ward activities which might have direct impact on the welfare of the clients, the clinical staff should provide clear and detail instructions on safe practice. Papp et al. (2003) suggested that the clinical environment encompasses all that surrounds the student nurse, including the clinical settings, the staff, the patients, the nurse mentor, and the nurse educator. In other words, students see the support, respect, and recognition by all personnel in the clinical environment as their prime priority during clinical placement. Maintenance of open and direct communication between each person concerned would provide and enhance a supportive learning climate that is a critical element of human resource development. Collaboration between the higher education and health care agencies is essential if the clinical learning environment is to best meet the needs of undergraduate nursing students. A supportive clinical learning environment is of paramount importance in securing the required teaching and learning process. The practice setting should provide the students with an environment where they can receive learning opportunities. However, various studies have indicated that not all practice settings are able to provide student nurses with a positive learning environment (Windsor, 1987; Lofmark and Wilkblad, 2001; Chan, 2002b; Espeland, and Indrehus, 2003). As the time allocation for the clinical component of nurse education is limited, it is important that the scarce but valuable clinical time is utilized effectively.
6. Limitations Perhaps the greatest limitation of this study is that the subjects were nursing students from just one university nursing school in Hong Kong, and thus the findings may not be representative of nursing students in general with respect to their clinical placement. A second limitation is that the findings are limited to the students’ perspective. Inclusion of perceptions of the clinical learning environment from the perspective of clinicians, clinical teachers, as well as clients from the receiving end, will provide a broad spectrum to complete the picture. It would be interesting to conduct a longitudinal study to follow through the students in their subsequent years in order to explore the pattern of changes in their perception of the social climate of the clinical learning environment.
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7. Conclusion The findings of this project help to describe Hong Kong nursing students’ perception of the social climate of the clinical learning environment. It was found that there were significant differences between students’ perceptions of the actual clinical learning environment and the ideal clinical learning environment they desired. Clinical education is a vital component the nursing curriculum yet clinical practice takes place in a complex social context. A supportive clinical learning environment is of paramount importance in securing the required teaching and learning process.
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