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Views and perceptions of nursing students on their clinical learning environment: Teaching and learning
YNEDT-02448; No of Pages 4 Nurse Education Today xxx (2013) xxx–xxx
Contents lists available at SciVerse ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Views and perceptions of nursing students on their clinical learning environment: Teaching and learning Ioanna V. Papathanasiou a,⁎, Konstantinos Tsaras a, Pavlos Sarafis b a b
Clinical Professor of Nursing Department, Technological Educational Institute of Larissa, Greece Clinical Professor of Nursing Department, Technological Educational Institute of Lamia, Greece
a r t i c l e
i n f o
Article history: Accepted 11 February 2013 Available online xxxx Keywords: Nursing education Clinical learning environment CLEI Practice nursing Students' satisfaction
s u m m a r y Introduction: The clinical learning environment constitutes an initial area of professional practice for nurses and student opinion contributes to its improvement. Purpose: The assessment of students' views and perceptions of a Greek nursing school on their clinical learning environment. Material and Methods: The study was concurrent and included 196 students. We used the published questionnaire “Clinical Learning Environment Inventory (CLEI)” which is a tool for identifying and assessing Nursing students' perceptions of the psychosocial characteristics of their clinical learning environment. The questionnaire was anonymous and completed by the students themselves during their clinical training at the hospital. We conducted inductive and descriptive statistics. The level of statistical significance was set at pb 0.05. The statistical program SPSS 16.0 was used. Results: The highest mean score for the Actual Clinical Learning Environment was observed in the scales of “Personalization” (23.97) and “Task orientation” (23.31) while for the Preferred Clinical Learning Environment in the scales of “Personalization” (27.87), “Satisfaction” (26.82) and “Task orientation” (26.78). The lowest mean score for the Actual Clinical Learning Environment was found in the scales of “Innovation” (19.21) and “Individualization” (19.24) while for the Preferred Clinical Learning Environment in the scales of “Individualization” (22.72) and “Involvement” (24.31). Statistically significant positive correlation was found between “Satisfaction” and all other scales of the CLEI. Conclusions: There is a noticeable gap between the expectations and reality of the clinical learning environment for the students in nursing. Reorganization of the educational framework is needed with an emphasis on innovation and individualization. © 2013 Elsevier Ltd. All rights reserved.
Introduction Modern health care is provided within a dynamically evolving clinical environment, where new technologies and skills are applied. Clinical nurses are required to be well informed and committed to continuing education in order to incorporate all the latest scientific data into their practice. The learning environment plays a crucial role, especially during the clinical training of student nurses, as they come into contact with the realities of their function and form opinions on their professional careers and the clinical area prospects (Clarke et al., 2003; Egan and Jaye, 2009). It has been found that the students want to function in learning groups and maintain open lines of communication with their trainers (Clarke et al., 2003; Henderson et al., 2006a; Levett-Jones et al., 2007). Behaviors that facilitate learning and encourage reflection, and various initiatives promote innovation and individualization for future nurses. ⁎ Corresponding author. Tel.: +30 2410684446; fax: +30 2410613986. E-mail addresses: [email protected], [email protected] (I.V. Papathanasiou), [email protected] (K. Tsaras), psarafi[email protected], psarafi[email protected] (P. Sarafis).
If a clinical experience is acquired in this manner, we avoid the sterile repetition of practices proven to lead to an impasse and to be obsolete through an educational or clinical perspective (Newton and McKenna, 2007; Levett-Jones and Lathlean, 2009; Newton, 2011). The aim of modern education distances itself from the simple integration into existing clinical frameworks and fosters a more critical attitude. Thus, the depiction of students' views and their expectations from clinical training provides valuable information for the reorganization and improvement of their studies, with an obvious impact on future educational attainment and the establishment of nurses. The purpose of this study was to assess students' views and perceptions of a Greek nursing school on their clinical learning environment. Modern trends in professional education stress the importance of embodying the realities of working environments to academic training. Due to the current economic difficulties worldwide, this embodiment constitutes a necessity. To be sure, nursing education has always been closely linked with real working environments, and student nurses have always held a dual role, where learning was combined with active involvement and contribution to patient care (Allan et al., 2011); closely related is nursing's continuing goal of providing holistic care, which
0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.02.007
Please cite this article as: Papathanasiou, I.V., et al., Views and perceptions of nursing students on their clinical learning environment: Teaching and learning, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.02.007
2
I.V. Papathanasiou et al. / Nurse Education Today xxx (2013) xxx–xxx
presupposes a consistent co-existence of theoretical knowledge, values and principles together with practical applications and technical details. However, recent economic developments pose a threat to holistic approaches, as the elements of cost-effectiveness and cost-cutting procedures tend to impose a new way of providing care, where saving resources is the ultimate goal. In light of these remarks, it is evident that, more than ever, student nurses need to be trained as effectively as possible in a real-time clinical environment, and gain theoretical and practical knowledge in an interpersonal way, where the synergy of academic values and professional realities is anew fundamental. Material and Methods Study participants were students of the Nursing Department, TEI of Larissa. The sample consisted of 196 students during the spring semester of the academic year 2008–2009. Specifically, it involved 77 students on their fifth semester, 53 students on their seventh semester and 66 students on their eighth semester. The eighth semester is the final one, where there are no lectures in the class, and the students are required to work at a hospital as trainees, based on the theoretical and clinical skills which they acquired during previous semesters. Students of the first four semesters were excluded from the research because they have little contact with the clinical setting and therefore would provide inadequate responses on their clinical experiences. The total number of the students of the Nursing Department was 851, from which 300 students were in fifth, seventh and eighth semester (participation rate 65.3%). The study was a cross-sectional, descriptive type research, and data was collected with a questionnaire form. The questionnaire was anonymous and completed by the students themselves during their clinical training at the hospital. In order to investigate the clinical learning environment, the “Clinical Learning Environment Inventory (CLEI)” was used in the questionnaire. CLEI is a tool for identifying and assessing the perceptions of nursing students on the psychosocial characteristics of their clinical learning environment. CLEI has been used internationally, developed after a thorough retrospective study of the literature on the learning environment of the classroom and the clinical learning environment, as well as discussions with experts in the field of nursing education and clinical nursing (Chan, 2001; Chan, 2003). A similar questionnaire has an important role in the creation of the CLEI, entitled “College and University Classroom Environment Inventory” (CUCEI), which was used in colleges and universities, as well as the theoretical background developed in accordance with the studies of Moos on the human environment in hospital departments, schools, universities, prisons and the military sector. Moos suggested that there are three dimensions that characterize the educational environment and that these dimensions should be included in all of the tools used to determine it (Moos, 1979). These three dimensions are: • Personal Development dimensions that determine maturity and self-esteem. • The System Maintenance and System Change dimensions that include the degree to which the environment is orderly, clear in expectations, maintains control and responds to change. • The Relationship dimensions that recognize the nature and intensity of personal relationships within the environment and the mutual support and mutual aid. The CLEI consists of two types of questionnaire: the “Actual form” which assesses students' understanding of the psychosocial characteristics of the real clinical learning environment, and the “Preferred form” for the assessment of psychosocial characteristics of the desired clinical learning environment. The two questions on the questionnaire forms are almost identical with minor wording differences. The questionnaire includes 42 questions from the resulting 6 scales, each scale consisting of 7 questions. Each question can be answered with one of the answers “Strongly Agree”, “Agree” “Disagree,” and
“Strongly Disagree” (Likert four-point scale), which score 5, 4, 2, and 1 respectively, while there are questions which score in reverse, that is 1, 2, 4, and 5. Incomplete or incorrect answers (multiple notes) score 3. The 6 CLEI scales reflecting the psychosocial characteristics of the clinical learning environment and their correlation with the dimensions of Moos are: • Individualization: assesses the degree to which students are allowed to make decisions and the extent to which they are treated according to their ability or the interest shown. This corresponds to the dimension of the System Maintenance and System Change. • Innovation: assesses to what extent the teacher introduces interesting new teaching techniques and learning activities, and whether he or she provides a productive clinical experience. This corresponds to the dimension of the System Maintenance and System Change. • Involvement: assesses the extent to which students participate actively and consistently in activities in the clinical area. This corresponds to the dimension of the Relationship. • Personalization: emphasizes the opportunities that the student has to interact with the teacher. This corresponds to the dimension of the Relationship. • Task orientation: assesses the extent to which the activities in a clinical department are clear to the student and well organized. This corresponds to the dimension of Personal Development. • Satisfaction: assesses the degree of satisfaction which students show from their training in a clinical setting. This corresponds to the dimension of Personal Development. In a Hong Kong study, scale reliability of the CLEI had been confirmed with reported Cronbach alpha coefficients ranged from 0.50 to 0.80 for the Actual form and 0.51–0.76 for the Preferred form (Chan and Ip, 2007). In the same study the mean score (standard deviation) for each scale of the Actual form of CLEI was 24.17 (4.46) for Personalization, 23.07 (4.50) for Satisfaction, 22.19 (3.63) for Involvement, 21.35 (3.90) for Individualization, 19.90 (3.32) for Task orientation and 15.23 (3.50) for Innovation. Additionally, the mean score (standard deviation) for each scale of the Preferred form of CLEI was 30.33 (3.04) for Personalization, 30.19 (3.11) for Satisfaction, 27.60 (3.12) for Involvement, 26.47 (3.28) for Individualization, 25.38 (2.57) for Task orientation and 23.50 (2.80) for Innovation (Chan and Ip, 2007). The processing and statistical analysis of empirical data was performed using the software package SPSS 16.0 for Windows, with the methods of descriptive and inferential statistics. To determine the difference between Actual and Preferred Clinical Learning Environment, the t-test was used in pairs (control means of two dependent samples). The scale of “Satisfaction” was used to measure the outcome because many research studies about the clinical learning environment recommend the use of this scale of CLEI as an outcome measure and because a very strong relation was found between Satisfaction and the other scales of CLEI (Chan, 2002; Perli and Brugnolli, 2009). Correlation coefficient of Pearson (r) and the model of multiple linear regression were used to explore possible relations between students' Satisfaction and the other scales of the CLEI. P values b 0.05 were defined as reflecting the acceptable level of statistical significance. Results The questionnaire on the Actual Clinical Learning Environment (Actual form) was completed by 196 students, and the one on the Preferred Clinical Learning Environment (Preferred form) by 180 students. The reliability of each CLEI scale factor was determined by assessing the Cronbach alpha (internal consistency evaluation of data). The Cronbach alpha coefficient for each CLEI scale ranged from 0.55 to 0.76 for the Actual Clinical Learning Environment, and from 0.58 to 0.77 for the Preferred Clinical Learning Environment. The highest mean score (Table 1) for the Actual Clinical Learning Environment was found for the scale of “Personalization” (23.97) and
Please cite this article as: Papathanasiou, I.V., et al., Views and perceptions of nursing students on their clinical learning environment: Teaching and learning, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.02.007
I.V. Papathanasiou et al. / Nurse Education Today xxx (2013) xxx–xxx
“Task orientation” (23.31); accordingly, for the Preferred Clinical Learning Environment it was found for the scale of “Personalization” (27.87), “Satisfaction” (26.82) and “Task orientation” (26.78). The lowest mean score (Table 1) for the Actual Clinical Learning Environment was found for the scale of “Innovation” (19.21) and “Individualization” (19.24); accordingly, for the Preferred Clinical Learning Environment it was found for the scale of “Individualization” (22.72) and “Involvement” (24.31). By checking with the t-test for pairs of means, we noticed a statistically significant difference between the Actual and Preferred Clinical Learning Environments. Especially for all the scales of the CLEI, the means of the Preferred were significantly higher than the corresponding value of the Actual Clinical Learning Environment (pb 0.001). The difference between the means for each CLEI scale ranged from 3.51 to 6.40. The smallest difference was found in “Task orientation” and “Individualization”, and the biggest difference in “Innovation” and “Satisfaction” (Table 1). The scale of “Satisfaction” was used as an outcome measure of the CLEI, and we investigated its relationship to psychosocial characteristics expressed by the other scales of the questionnaire, the Actual Clinical Learning Environment. Data analysis identified a positive correlation, statistically significant between the “Satisfaction” with all the other scales of the CLEI. The correlation coefficient of Pearson (r) ranged from 0.18 (p=0.014) for “Individualization” to 0.60 (p=0.000) for “Involvement” (Table 2). To provide the relationship between the “Satisfaction” (dependent variable) and other psychosocial characteristics of CLEI (independent variables) the model of multiple linear regression was used. Data analysis showed statistically significant positive relationship between “Satisfaction” with “Personalization” (β = 0.22, p = 0.002), “Involvement” (β = 0.50, p = 0.000) and “Task orientation” (β = 0.30, p = 0.000). The aforementioned independent variables retained in the model explain 46% of the variability of the dependent variable, namely the “Satisfaction” for the Actual Clinical Learning Environment (Table 3). Discussion A very interesting finding of the study is that there is a significant distance between the Preferred Clinical Learning Environment and the one which is actually established, according to the students' opinion. This suggests that students generally wish for a more positive environment than what they have experienced, especially when it comes to issues related to satisfaction, individualization and innovation. Given that the scale of individualization assesses the degree to which students were allowed to make decisions and the extent to which they are treated in accordance with their ability or the interest shown, and that innovation refers to productive clinical experiences, it seems that the students in the sample deem the existing conditions inadequate in terms of creativity and initiative. This is also shown by the scores of Individualization (19.24) and Innovation (19.21) for the Actual Clinical Learning Environment. The low score of Individualization is probably due to the fact that in the
Table 1 Differences in the mean scores between the Actual and Preferred Clinical Learning Environments of each scale of the CLEI. CLEI Scale
Personalization Satisfaction Involvement Individualization Task orientation Innovation
Mean±St. dev. Actual (n = 196)
Preferred (n = 180)
23.97 ± 4.66 21.81 ± 5.21 20.72 ± 3.84 19.24 ± 3.16 23.31 ± 4.35 19.21 ± 4.39
27.87 ± 4.58 26.82 ± 4.98 24.31 ± 3.97 22.72 ± 3.91 26.78 ± 4.42 25.57 ± 4.46
Mean difference (95% confidence interval)
t
p value
3.98 4.88 3.64 3.57 3.51 6.40
9.33 12.02 10.72 9.43 9.00 13.77
0.000 0.000 0.000 0.000 0.000 0.000
(3.14–4.83) (4.08–5.69) (2.97–4.32) (2.82–4.32) (2.74–4.28) (5.48–7.32)
3
Table 2 Correlation coefficient of Pearson (r) between the scale “Satisfaction” with the other scales of the CLEI for Actual Clinical Learning Environment. CLEI scale
Pearson's correlation coefficient (r)
p value
Personalization Involvement Individualization Task orientation Innovation
0.49 0.60 0.18 0.54 0.42
0.000 0.000 0.014 0.000 0.000
Greek Educational System, the clinical education of nursing students is conducted in real and not virtual conditions, always with the presence of a clinical instructor and it is strictly guided. Initiatives and self-motivation are virtues that can prove particularly useful in clinical settings that require a rapid and effective action, and these results rightfully raise questions as to whether this goal is achieved. It is however promising that the students evaluate positively the dimension of personalization, but as the score indicates in the preferred environment scale, they would prefer even more support. Students consider human relations as a top priority in the clinical learning environment. As noted by Campbell et al. (1994), students of nursing feel vulnerable during their internship and need the understanding and respect from all those involved in their education. The gap between the expectations and reality in the clinical learning environment for nursing students has been marked in many studies and constitutes an international phenomenon (Chan, 2004; Henderson et al., 2006b; Chan and Ip, 2007; Perli and Brugnolli, 2009; Brown et al., 2011). The dimension of personalization emerges as the one with the highest score, while those of innovation and individualization are significantly lower (Chan, 2002; Henderson et al., 2006b). Some studies show that when supervision is consistent but gradual, students develop confidence and independence with regard to clinical skills. It has been suggested that when the education of student nurses involves different backgrounds and different clinical approaches, students expand their learning horizons and develop more easily their critical thinking (Papp et al., 2003; Henderson et al., 2005; Midgley, 2006; Henderson et al., 2010a). Regarding satisfaction, it was found to be positively associated with all the other dimensions of the questionnaire, highlighting the multifactorial nature of the student's satisfaction from the clinical environment. The results of correlation analyses reported in Table 2 indicate that the correlation coefficients (r) ranged from 0.18 to 0.60. In similar research studies the correlation coefficients (r) between satisfaction and the other scales of the CLEI, ranged from 0.31 to 0.54 (Wan Yim and Chan, 2005; Chan and Ip, 2007). The contribution of personalization, involvement and task orientation is particularly significant, as revealed by multiple linear regression models. The highest contribution is attributed to participation, which seems to be an important predictor of student satisfaction in the real clinical setting. Indeed, it has been found that effective student participation in working groups is a strong predictor of satisfaction within a professional environment. Also, the feeling of acceptance and “belonging” to a group is important for students who are looking to redefine their academic identity and seek professional guidance in the clinical environment (Smedley and Morey, 2009; Henderson et al., 2010b). Table 3 Multiple linear regression with dependent variable for the scale “Satisfaction” and independent variables for the other scales of CLEI for the Actual Clinical Learning Environment. Independent variables
Coefficient β (95% confidence interval)
p value
R2
F
Personalization Involvement Task orientation
0.22 (0.08–0.36) 0.50 (0.32–0.68) 0.30 (0.15–0.46)
0.002 0.000 0.000
0.46
53.58
Please cite this article as: Papathanasiou, I.V., et al., Views and perceptions of nursing students on their clinical learning environment: Teaching and learning, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.02.007
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The efforts of the state and educators should turn towards the reorganization of clinical education and provide more opportunities for innovation by students within a controlled educational context. Perhaps the reduction in the number of trainees assigned to the instructor and the specialization of the latter will facilitate learning and the acquisition of clinical skills. Greater emphasis should be given to the students' clinical education, and the unstable economic environment should by no means become an insurmountable barrier to the continuing effort towards quality clinical training. Given the constant development of new technologies in the health care area, great vigilance should be used with regard to the implementation of all new developments in modern clinical training. In addition, a change of the existing model of education, with the creation of clinical education units may help optimize the performance of students. It has been shown that such units can provide greater psycho-social support to students, which is also reflected in the dimensions of the CLEI questionnaire. This study has some limitations; first of all, it was conducted with the participation of students coming from one university and at a single hospital. The students completed a self-report questionnaire, which can lead them to answer questions in a socially desirable and socially acceptable way. Students on three different semesters and with differing clinical experience were involved, while the study sample was a convenience sample, with almost one third of the students refusing participation. Therefore, any generalization of these results should be treated with caution. However, the alignment of the findings with other international studies emphasizes the need for further improvement of the clinical learning environment. References Allan, T.H., Smith, P., O'Driscoll, M., 2011. Experiences of supernumerary status and the hidden curriculum in nursing: a new twist in the theory–practice gap? Journal of Clinical Nursing 20 (5–6), 847–855. Brown, T., Williams, B., McKenna, L., Palermo, C., McCall, L., Roller, L., Hewitt, L., Molloy, L., Baird, M., Aldabah, L., 2011. Practice education learning environments: the mismatch between perceived and preferred expectations of undergraduate health science students. Nurse Education Today 31 (8), 22–28. Campbell, I.E., Larrivee, L., Field, P.A., Day, R.A., Reutter, L., 1994. Learning to nurse in the clinical setting. Journal of Advanced Nursing 20 (6), 1125–1131. Chan, D.S.K., 2001. Development of an innovative tool to assess hospital/learning environments. Nurse Education Today 21, 624–631. Chan, D.S.K., 2002. Associations between student learning outcomes from their clinical placement and their perceptions of the social climate of the clinical learning environment. International Journal of Nursing Studies 39, 517–524.
Chan, D., 2003. Validation of the clinical learning environment inventory. Western Journal of Nursing Research 25 (5), 519–532. Chan, D., 2004. The relationship between student learning outcomes from their clinical placement and their perceptions of the social climate of the clinical learning environment. Contemporary Nurse 17, 149–158. Chan, D., Ip, W., 2007. Perception of hospital learning environment: a survey of Hong Kong nursing students. Nurse Education Today 27, 677–684. Clarke, C., Gibb, C., Ramprogus, V., 2003. Clinical learning environments: an evaluation of an innovative role to support pre-registration nursing placements. Learning in Health and Social Care 2 (2), 105–115. Egan, T., Jaye, C., 2009. Communities of clinical practice: the social organization of clinical learning. Health: An Interdisciplinary Journal for the Social Study of Health, Illness & Medicine 13 (1), 107–125. Henderson, A., Winch, S., Grugan, C., Henney, R., McCoy, R., 2005. ‘Working from the inside’: an infrastructure for the continuing development of nurses' professional clinical practice. Journal of Nursing Management 13, 106–110. Henderson, A., Winch, S., Heel, A., 2006(a)a. Partner, learn, progress: a conceptual model for continuous clinical education. Nurse Education Today 26, 104–109. Henderson, A., Twentyman, M., Heel, A., Lloyd, B., 2006(b)b. Students' perception of the psycho-social clinical learning environment: an evaluation of placement models. Nurse Education Today 26 (7), 564–571. Henderson, A., Twentyman, M., Eaton, E., Creedy, D., Stapleton, P., Lloyd, B., 2010(a)a. Creating supportive clinical learning environments: an intervention study. Journal of Clinical Nursing 19 (1-2), 177–182. Henderson, A., Walker, R., Creedy, D.K., Boorman, R., Cooke, M., 2010(b)b. Development and psychometric testing of the Clinical Learning Organisational Culture Survey (CLOCS). Nurse Education Today 30 (7), 598–602. Levett-Jones, T., Lathlean, J., Maguire, J., McMillan, M., 2007. Belongingness: a critique of the concept and implications for nursing education. Nurse Education Today 27 (3), 210–218. Levett-Jones, T., Lathlean, J., 2009. ‘Don't rock the boat’: nursing students' experiences of conformity and compliance. Nurse Education Today 29 (3), 342–349. Moos, R.H., 1979. Education climates. In: Walberg, H.J. (Ed.), Educational Environments and Effects. McCutchan, USA, pp. 79–100. Midgley, K., 2006. Pre-registration student nurses perception of the hospital learning environment during clinical placements. Nurse Education Today 26, 338–345. Newton, J.M., McKenna, L., 2007. The transitional journey through the graduate year: a focus group study. International Journal of Nursing Studies 44 (7), 1231–1237. Newton, J.M., 2011. Reflective learning groups for student nurses. In: Billett, S., Henderson, A. (Eds.), Promoting Professional Learning: Integrating Experiences in University and Practice Settings. Springer, Dordrecht, The Netherlands. Papp, I., Markkanen, M., Von Bonsdorff, M., 2003. Clinical environment as a learning environment: student nurses' perceptions concerning clinical learning experiences. Nurse Education Today 23, 262–268. Perli, S., Brugnolli, A., 2009. Italian nursing students' perception of their clinical learning environment as measured with the CLEI tool. Nurse Education Today 29 (8), 886–890. Smedley, A., Morey, P., 2009. Improving learning in the clinical nursing environment: perceptions of senior Australian bachelor of nursing students. Journal of Research in Nursing 15, 75–88. Wan Yim, I.P., Chan, D., 2005. Hong Kong nursing students' perception of the clinical environment: a questionnaire survey. International Journal of Nursing Studies 42 (6), 665–672.
Please cite this article as: Papathanasiou, I.V., et al., Views and perceptions of nursing students on their clinical learning environment: Teaching and learning, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.02.007
Contents lists available at SciVerse ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Views and perceptions of nursing students on their clinical learning environment: Teaching and learning Ioanna V. Papathanasiou a,⁎, Konstantinos Tsaras a, Pavlos Sarafis b a b
Clinical Professor of Nursing Department, Technological Educational Institute of Larissa, Greece Clinical Professor of Nursing Department, Technological Educational Institute of Lamia, Greece
a r t i c l e
i n f o
Article history: Accepted 11 February 2013 Available online xxxx Keywords: Nursing education Clinical learning environment CLEI Practice nursing Students' satisfaction
s u m m a r y Introduction: The clinical learning environment constitutes an initial area of professional practice for nurses and student opinion contributes to its improvement. Purpose: The assessment of students' views and perceptions of a Greek nursing school on their clinical learning environment. Material and Methods: The study was concurrent and included 196 students. We used the published questionnaire “Clinical Learning Environment Inventory (CLEI)” which is a tool for identifying and assessing Nursing students' perceptions of the psychosocial characteristics of their clinical learning environment. The questionnaire was anonymous and completed by the students themselves during their clinical training at the hospital. We conducted inductive and descriptive statistics. The level of statistical significance was set at pb 0.05. The statistical program SPSS 16.0 was used. Results: The highest mean score for the Actual Clinical Learning Environment was observed in the scales of “Personalization” (23.97) and “Task orientation” (23.31) while for the Preferred Clinical Learning Environment in the scales of “Personalization” (27.87), “Satisfaction” (26.82) and “Task orientation” (26.78). The lowest mean score for the Actual Clinical Learning Environment was found in the scales of “Innovation” (19.21) and “Individualization” (19.24) while for the Preferred Clinical Learning Environment in the scales of “Individualization” (22.72) and “Involvement” (24.31). Statistically significant positive correlation was found between “Satisfaction” and all other scales of the CLEI. Conclusions: There is a noticeable gap between the expectations and reality of the clinical learning environment for the students in nursing. Reorganization of the educational framework is needed with an emphasis on innovation and individualization. © 2013 Elsevier Ltd. All rights reserved.
Introduction Modern health care is provided within a dynamically evolving clinical environment, where new technologies and skills are applied. Clinical nurses are required to be well informed and committed to continuing education in order to incorporate all the latest scientific data into their practice. The learning environment plays a crucial role, especially during the clinical training of student nurses, as they come into contact with the realities of their function and form opinions on their professional careers and the clinical area prospects (Clarke et al., 2003; Egan and Jaye, 2009). It has been found that the students want to function in learning groups and maintain open lines of communication with their trainers (Clarke et al., 2003; Henderson et al., 2006a; Levett-Jones et al., 2007). Behaviors that facilitate learning and encourage reflection, and various initiatives promote innovation and individualization for future nurses. ⁎ Corresponding author. Tel.: +30 2410684446; fax: +30 2410613986. E-mail addresses: [email protected], [email protected] (I.V. Papathanasiou), [email protected] (K. Tsaras), psarafi[email protected], psarafi[email protected] (P. Sarafis).
If a clinical experience is acquired in this manner, we avoid the sterile repetition of practices proven to lead to an impasse and to be obsolete through an educational or clinical perspective (Newton and McKenna, 2007; Levett-Jones and Lathlean, 2009; Newton, 2011). The aim of modern education distances itself from the simple integration into existing clinical frameworks and fosters a more critical attitude. Thus, the depiction of students' views and their expectations from clinical training provides valuable information for the reorganization and improvement of their studies, with an obvious impact on future educational attainment and the establishment of nurses. The purpose of this study was to assess students' views and perceptions of a Greek nursing school on their clinical learning environment. Modern trends in professional education stress the importance of embodying the realities of working environments to academic training. Due to the current economic difficulties worldwide, this embodiment constitutes a necessity. To be sure, nursing education has always been closely linked with real working environments, and student nurses have always held a dual role, where learning was combined with active involvement and contribution to patient care (Allan et al., 2011); closely related is nursing's continuing goal of providing holistic care, which
0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.02.007
Please cite this article as: Papathanasiou, I.V., et al., Views and perceptions of nursing students on their clinical learning environment: Teaching and learning, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.02.007
2
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presupposes a consistent co-existence of theoretical knowledge, values and principles together with practical applications and technical details. However, recent economic developments pose a threat to holistic approaches, as the elements of cost-effectiveness and cost-cutting procedures tend to impose a new way of providing care, where saving resources is the ultimate goal. In light of these remarks, it is evident that, more than ever, student nurses need to be trained as effectively as possible in a real-time clinical environment, and gain theoretical and practical knowledge in an interpersonal way, where the synergy of academic values and professional realities is anew fundamental. Material and Methods Study participants were students of the Nursing Department, TEI of Larissa. The sample consisted of 196 students during the spring semester of the academic year 2008–2009. Specifically, it involved 77 students on their fifth semester, 53 students on their seventh semester and 66 students on their eighth semester. The eighth semester is the final one, where there are no lectures in the class, and the students are required to work at a hospital as trainees, based on the theoretical and clinical skills which they acquired during previous semesters. Students of the first four semesters were excluded from the research because they have little contact with the clinical setting and therefore would provide inadequate responses on their clinical experiences. The total number of the students of the Nursing Department was 851, from which 300 students were in fifth, seventh and eighth semester (participation rate 65.3%). The study was a cross-sectional, descriptive type research, and data was collected with a questionnaire form. The questionnaire was anonymous and completed by the students themselves during their clinical training at the hospital. In order to investigate the clinical learning environment, the “Clinical Learning Environment Inventory (CLEI)” was used in the questionnaire. CLEI is a tool for identifying and assessing the perceptions of nursing students on the psychosocial characteristics of their clinical learning environment. CLEI has been used internationally, developed after a thorough retrospective study of the literature on the learning environment of the classroom and the clinical learning environment, as well as discussions with experts in the field of nursing education and clinical nursing (Chan, 2001; Chan, 2003). A similar questionnaire has an important role in the creation of the CLEI, entitled “College and University Classroom Environment Inventory” (CUCEI), which was used in colleges and universities, as well as the theoretical background developed in accordance with the studies of Moos on the human environment in hospital departments, schools, universities, prisons and the military sector. Moos suggested that there are three dimensions that characterize the educational environment and that these dimensions should be included in all of the tools used to determine it (Moos, 1979). These three dimensions are: • Personal Development dimensions that determine maturity and self-esteem. • The System Maintenance and System Change dimensions that include the degree to which the environment is orderly, clear in expectations, maintains control and responds to change. • The Relationship dimensions that recognize the nature and intensity of personal relationships within the environment and the mutual support and mutual aid. The CLEI consists of two types of questionnaire: the “Actual form” which assesses students' understanding of the psychosocial characteristics of the real clinical learning environment, and the “Preferred form” for the assessment of psychosocial characteristics of the desired clinical learning environment. The two questions on the questionnaire forms are almost identical with minor wording differences. The questionnaire includes 42 questions from the resulting 6 scales, each scale consisting of 7 questions. Each question can be answered with one of the answers “Strongly Agree”, “Agree” “Disagree,” and
“Strongly Disagree” (Likert four-point scale), which score 5, 4, 2, and 1 respectively, while there are questions which score in reverse, that is 1, 2, 4, and 5. Incomplete or incorrect answers (multiple notes) score 3. The 6 CLEI scales reflecting the psychosocial characteristics of the clinical learning environment and their correlation with the dimensions of Moos are: • Individualization: assesses the degree to which students are allowed to make decisions and the extent to which they are treated according to their ability or the interest shown. This corresponds to the dimension of the System Maintenance and System Change. • Innovation: assesses to what extent the teacher introduces interesting new teaching techniques and learning activities, and whether he or she provides a productive clinical experience. This corresponds to the dimension of the System Maintenance and System Change. • Involvement: assesses the extent to which students participate actively and consistently in activities in the clinical area. This corresponds to the dimension of the Relationship. • Personalization: emphasizes the opportunities that the student has to interact with the teacher. This corresponds to the dimension of the Relationship. • Task orientation: assesses the extent to which the activities in a clinical department are clear to the student and well organized. This corresponds to the dimension of Personal Development. • Satisfaction: assesses the degree of satisfaction which students show from their training in a clinical setting. This corresponds to the dimension of Personal Development. In a Hong Kong study, scale reliability of the CLEI had been confirmed with reported Cronbach alpha coefficients ranged from 0.50 to 0.80 for the Actual form and 0.51–0.76 for the Preferred form (Chan and Ip, 2007). In the same study the mean score (standard deviation) for each scale of the Actual form of CLEI was 24.17 (4.46) for Personalization, 23.07 (4.50) for Satisfaction, 22.19 (3.63) for Involvement, 21.35 (3.90) for Individualization, 19.90 (3.32) for Task orientation and 15.23 (3.50) for Innovation. Additionally, the mean score (standard deviation) for each scale of the Preferred form of CLEI was 30.33 (3.04) for Personalization, 30.19 (3.11) for Satisfaction, 27.60 (3.12) for Involvement, 26.47 (3.28) for Individualization, 25.38 (2.57) for Task orientation and 23.50 (2.80) for Innovation (Chan and Ip, 2007). The processing and statistical analysis of empirical data was performed using the software package SPSS 16.0 for Windows, with the methods of descriptive and inferential statistics. To determine the difference between Actual and Preferred Clinical Learning Environment, the t-test was used in pairs (control means of two dependent samples). The scale of “Satisfaction” was used to measure the outcome because many research studies about the clinical learning environment recommend the use of this scale of CLEI as an outcome measure and because a very strong relation was found between Satisfaction and the other scales of CLEI (Chan, 2002; Perli and Brugnolli, 2009). Correlation coefficient of Pearson (r) and the model of multiple linear regression were used to explore possible relations between students' Satisfaction and the other scales of the CLEI. P values b 0.05 were defined as reflecting the acceptable level of statistical significance. Results The questionnaire on the Actual Clinical Learning Environment (Actual form) was completed by 196 students, and the one on the Preferred Clinical Learning Environment (Preferred form) by 180 students. The reliability of each CLEI scale factor was determined by assessing the Cronbach alpha (internal consistency evaluation of data). The Cronbach alpha coefficient for each CLEI scale ranged from 0.55 to 0.76 for the Actual Clinical Learning Environment, and from 0.58 to 0.77 for the Preferred Clinical Learning Environment. The highest mean score (Table 1) for the Actual Clinical Learning Environment was found for the scale of “Personalization” (23.97) and
Please cite this article as: Papathanasiou, I.V., et al., Views and perceptions of nursing students on their clinical learning environment: Teaching and learning, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.02.007
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“Task orientation” (23.31); accordingly, for the Preferred Clinical Learning Environment it was found for the scale of “Personalization” (27.87), “Satisfaction” (26.82) and “Task orientation” (26.78). The lowest mean score (Table 1) for the Actual Clinical Learning Environment was found for the scale of “Innovation” (19.21) and “Individualization” (19.24); accordingly, for the Preferred Clinical Learning Environment it was found for the scale of “Individualization” (22.72) and “Involvement” (24.31). By checking with the t-test for pairs of means, we noticed a statistically significant difference between the Actual and Preferred Clinical Learning Environments. Especially for all the scales of the CLEI, the means of the Preferred were significantly higher than the corresponding value of the Actual Clinical Learning Environment (pb 0.001). The difference between the means for each CLEI scale ranged from 3.51 to 6.40. The smallest difference was found in “Task orientation” and “Individualization”, and the biggest difference in “Innovation” and “Satisfaction” (Table 1). The scale of “Satisfaction” was used as an outcome measure of the CLEI, and we investigated its relationship to psychosocial characteristics expressed by the other scales of the questionnaire, the Actual Clinical Learning Environment. Data analysis identified a positive correlation, statistically significant between the “Satisfaction” with all the other scales of the CLEI. The correlation coefficient of Pearson (r) ranged from 0.18 (p=0.014) for “Individualization” to 0.60 (p=0.000) for “Involvement” (Table 2). To provide the relationship between the “Satisfaction” (dependent variable) and other psychosocial characteristics of CLEI (independent variables) the model of multiple linear regression was used. Data analysis showed statistically significant positive relationship between “Satisfaction” with “Personalization” (β = 0.22, p = 0.002), “Involvement” (β = 0.50, p = 0.000) and “Task orientation” (β = 0.30, p = 0.000). The aforementioned independent variables retained in the model explain 46% of the variability of the dependent variable, namely the “Satisfaction” for the Actual Clinical Learning Environment (Table 3). Discussion A very interesting finding of the study is that there is a significant distance between the Preferred Clinical Learning Environment and the one which is actually established, according to the students' opinion. This suggests that students generally wish for a more positive environment than what they have experienced, especially when it comes to issues related to satisfaction, individualization and innovation. Given that the scale of individualization assesses the degree to which students were allowed to make decisions and the extent to which they are treated in accordance with their ability or the interest shown, and that innovation refers to productive clinical experiences, it seems that the students in the sample deem the existing conditions inadequate in terms of creativity and initiative. This is also shown by the scores of Individualization (19.24) and Innovation (19.21) for the Actual Clinical Learning Environment. The low score of Individualization is probably due to the fact that in the
Table 1 Differences in the mean scores between the Actual and Preferred Clinical Learning Environments of each scale of the CLEI. CLEI Scale
Personalization Satisfaction Involvement Individualization Task orientation Innovation
Mean±St. dev. Actual (n = 196)
Preferred (n = 180)
23.97 ± 4.66 21.81 ± 5.21 20.72 ± 3.84 19.24 ± 3.16 23.31 ± 4.35 19.21 ± 4.39
27.87 ± 4.58 26.82 ± 4.98 24.31 ± 3.97 22.72 ± 3.91 26.78 ± 4.42 25.57 ± 4.46
Mean difference (95% confidence interval)
t
p value
3.98 4.88 3.64 3.57 3.51 6.40
9.33 12.02 10.72 9.43 9.00 13.77
0.000 0.000 0.000 0.000 0.000 0.000
(3.14–4.83) (4.08–5.69) (2.97–4.32) (2.82–4.32) (2.74–4.28) (5.48–7.32)
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Table 2 Correlation coefficient of Pearson (r) between the scale “Satisfaction” with the other scales of the CLEI for Actual Clinical Learning Environment. CLEI scale
Pearson's correlation coefficient (r)
p value
Personalization Involvement Individualization Task orientation Innovation
0.49 0.60 0.18 0.54 0.42
0.000 0.000 0.014 0.000 0.000
Greek Educational System, the clinical education of nursing students is conducted in real and not virtual conditions, always with the presence of a clinical instructor and it is strictly guided. Initiatives and self-motivation are virtues that can prove particularly useful in clinical settings that require a rapid and effective action, and these results rightfully raise questions as to whether this goal is achieved. It is however promising that the students evaluate positively the dimension of personalization, but as the score indicates in the preferred environment scale, they would prefer even more support. Students consider human relations as a top priority in the clinical learning environment. As noted by Campbell et al. (1994), students of nursing feel vulnerable during their internship and need the understanding and respect from all those involved in their education. The gap between the expectations and reality in the clinical learning environment for nursing students has been marked in many studies and constitutes an international phenomenon (Chan, 2004; Henderson et al., 2006b; Chan and Ip, 2007; Perli and Brugnolli, 2009; Brown et al., 2011). The dimension of personalization emerges as the one with the highest score, while those of innovation and individualization are significantly lower (Chan, 2002; Henderson et al., 2006b). Some studies show that when supervision is consistent but gradual, students develop confidence and independence with regard to clinical skills. It has been suggested that when the education of student nurses involves different backgrounds and different clinical approaches, students expand their learning horizons and develop more easily their critical thinking (Papp et al., 2003; Henderson et al., 2005; Midgley, 2006; Henderson et al., 2010a). Regarding satisfaction, it was found to be positively associated with all the other dimensions of the questionnaire, highlighting the multifactorial nature of the student's satisfaction from the clinical environment. The results of correlation analyses reported in Table 2 indicate that the correlation coefficients (r) ranged from 0.18 to 0.60. In similar research studies the correlation coefficients (r) between satisfaction and the other scales of the CLEI, ranged from 0.31 to 0.54 (Wan Yim and Chan, 2005; Chan and Ip, 2007). The contribution of personalization, involvement and task orientation is particularly significant, as revealed by multiple linear regression models. The highest contribution is attributed to participation, which seems to be an important predictor of student satisfaction in the real clinical setting. Indeed, it has been found that effective student participation in working groups is a strong predictor of satisfaction within a professional environment. Also, the feeling of acceptance and “belonging” to a group is important for students who are looking to redefine their academic identity and seek professional guidance in the clinical environment (Smedley and Morey, 2009; Henderson et al., 2010b). Table 3 Multiple linear regression with dependent variable for the scale “Satisfaction” and independent variables for the other scales of CLEI for the Actual Clinical Learning Environment. Independent variables
Coefficient β (95% confidence interval)
p value
R2
F
Personalization Involvement Task orientation
0.22 (0.08–0.36) 0.50 (0.32–0.68) 0.30 (0.15–0.46)
0.002 0.000 0.000
0.46
53.58
Please cite this article as: Papathanasiou, I.V., et al., Views and perceptions of nursing students on their clinical learning environment: Teaching and learning, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.02.007
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The efforts of the state and educators should turn towards the reorganization of clinical education and provide more opportunities for innovation by students within a controlled educational context. Perhaps the reduction in the number of trainees assigned to the instructor and the specialization of the latter will facilitate learning and the acquisition of clinical skills. Greater emphasis should be given to the students' clinical education, and the unstable economic environment should by no means become an insurmountable barrier to the continuing effort towards quality clinical training. Given the constant development of new technologies in the health care area, great vigilance should be used with regard to the implementation of all new developments in modern clinical training. In addition, a change of the existing model of education, with the creation of clinical education units may help optimize the performance of students. It has been shown that such units can provide greater psycho-social support to students, which is also reflected in the dimensions of the CLEI questionnaire. This study has some limitations; first of all, it was conducted with the participation of students coming from one university and at a single hospital. The students completed a self-report questionnaire, which can lead them to answer questions in a socially desirable and socially acceptable way. Students on three different semesters and with differing clinical experience were involved, while the study sample was a convenience sample, with almost one third of the students refusing participation. Therefore, any generalization of these results should be treated with caution. However, the alignment of the findings with other international studies emphasizes the need for further improvement of the clinical learning environment. References Allan, T.H., Smith, P., O'Driscoll, M., 2011. Experiences of supernumerary status and the hidden curriculum in nursing: a new twist in the theory–practice gap? Journal of Clinical Nursing 20 (5–6), 847–855. Brown, T., Williams, B., McKenna, L., Palermo, C., McCall, L., Roller, L., Hewitt, L., Molloy, L., Baird, M., Aldabah, L., 2011. Practice education learning environments: the mismatch between perceived and preferred expectations of undergraduate health science students. Nurse Education Today 31 (8), 22–28. Campbell, I.E., Larrivee, L., Field, P.A., Day, R.A., Reutter, L., 1994. Learning to nurse in the clinical setting. Journal of Advanced Nursing 20 (6), 1125–1131. Chan, D.S.K., 2001. Development of an innovative tool to assess hospital/learning environments. Nurse Education Today 21, 624–631. Chan, D.S.K., 2002. Associations between student learning outcomes from their clinical placement and their perceptions of the social climate of the clinical learning environment. International Journal of Nursing Studies 39, 517–524.
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Please cite this article as: Papathanasiou, I.V., et al., Views and perceptions of nursing students on their clinical learning environment: Teaching and learning, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.02.007