Undergraduate Nursing Students’ Perception on Clinical Learning Environment
Angelin EA1, Emily SD2, Amala R3, Grace R4
1Reader, College of Nursing, Christian Medical College (CMC), Vellore, India
2Professor, College of Nursing, Christian Medical College, India
3Professor and Head of Fundamentals of Nursing Department, College of Nursing, Christian Medical College, India
4Lecturer, Department of Bio-Statistics, Christian Medical College, India
*Corresponding Author E-mail: esthu80@gmail.com
ABSTRACT:
Clinical education is a fundamental part of nursing education and forms more than half of Nursing curriculum. The quality of Clinical Learning Environment (CLE) is a valid indicator to show the quality of nursing curriculum. Therefore, assessment of CLE is a duty of nursing education administrators. Purpose: The purpose of the study is to assess the undergraduate Nursing students perception of their clinical learning environment and to compare the perception of their clinical learning environment between I, II, III and IV year Nursing students in College of Nursing, Christian Medical College, Vellore to provide feedback on CLE in order to improve the quality of clinical experience. Material and Methods: The study used Clinical Learning Environment Scale (CLES) to examine 375 undergraduate nursing students’ perception of their CLE. It’s a 23 item, 5- point Likert scale that has 5 factors such as staff- student relationships, hierarchy and rituals, nurse manager commitment, patient relationship and student satisfaction. The questionnaire was administered to all Baccalaureate nursing students at the end of their 20 weeks of clinical placement. The statistical program SPSS v 22 was used. Frequency, mean and standard deviation were used to analyse the demographic variables. CLES questionnaire was analysed using factor analysis. One - Way ANOVA and Bonferroni Post hoc tests were used to assess the perception between the groups. Results: The statistical program SPSS v 22 was used that revealed 32.8% of the students perceived that their CLE was very good and 32.5% of them were highly satisfied with their clinical experience. To assess the difference of perception of their CLE between the groups One-Way ANOVA was used. It showed that there was statistically significant difference between the groups and to define further Bonferroni post hoc test was conducted that showed statically significant difference in the perception of CLE between the I year and other years (p >.05). Conclusion: Students value and accept a workplace where they have been acknowledged to be a part of health care team and their teachers are available to teach and meet their learning needs. Periodic evaluation of CLE provides feedback to teachers to organize a better clinical experience and to create a positive environment for students to complete their clinical requirements and to practice safely to become competent nurses.
KEYWORDS: Curriculum, Undergraduate, Nursing students, Perception, Clinical Learning Environment, Nursing education.
INTRODUCTION:
Curriculum is the blueprint of an educational programme and clinical education is an integral part of the nursing curriculum. The quality of clinical learning usually reflects the quality of the curriculum structure. Nursing education is strongly related to theoretical and clinical teaching. A clinical experience is an important element of the nursing profession. Clinical Learning Environment (CLE) is an important factor in nursing students’ clinical education. Learning experience is defined as deliberately planned experiences in selected situations where students actively participate interact and which results in desirable changes of behavior in the students. Learning experience should provide ample opportunities for the student to concentrate and relate the various activities in different areas of learning so that the required ability and skills are easily obtained (Sankaranarayanan B and Sindhu 2010)1. Clinical teaching is cornerstone of the nursing education to integrate theory into practice. In European countries to confirm theory into practice, efforts are taken to produce a high quality CLE by creating a pedagogical atmosphere. Organizing a quality clinical experience within a supportive and pedagogically adjusted environment is a significant concern for educational institutions. The assessment of these clinical settings as learning environment is a significant concern within the contemporary nursing education. Various studies have indicated that not all practice settings are able to provide a positive CLE for student nurses.
BACKGROUND AND PURPOSE:
The Clinical Learning Environment (CLE) is the interactive network of forces within the clinical setting that influences the student’s clinical learning outcomes (Dunn and Burnett 1995)2. The CLE is the place where the theoretical components of the curriculum can be integrated with the practical and transformed into professional skills and attitudes within an emotionally safe environment. Continuity, sequence and integration have to be followed while organizing the learning experience. The clinical experience should be efficient, cost effective and should ensure the best learning outcomes in an individual. Attainment of those educational outcomes of a clinical placement may be enhanced by modifying the CLE in ways that make it more congruent with the environment preferred by students” 3.
Students and faculty should anticipate an exciting clinical rotation for practice. A good clinical practice should promote positive student outcomes, enhancing their socialization skills, refining critical thinking ability, and interpersonal communication skills. It should also improve self- confidence, reduce anxiety and stress during clinical experience.
Dunn and Hansford (1997) 4 found that that ward nurses, being the gatekeepers and guides to students' learning opportunities, were the most influential factor affecting the CLE perceptions of nursing students among Australian undergraduate nursing students'. They further identified that students' satisfaction was an important factor to their perceptions of CLEs and was both a cause and effect of a positive learning environment.
Many studies have been conducted in the past to evaluate students CLE. Dunn and Burnett (1995)2 developed an instrument to measure CLE in terms of five subscales: staff-relationships, nurse manager commitment, patient relationships, interpersonal relationships and student satisfaction. Similarly, Saarikoski and Leino-Kilpi (2002)5 also developed a CLE instrument, using ward atmosphere, leadership style of the ward manager, supervisory relationship, premises of nursing care and premises of learning on the ward as its main components called as Clinical Learning Environment, Supervision and Nurse Teacher (CLES+T).
A study conducted by Rahmani A., et al (2011) 6 among 133 Nursing students “Clinical Learning environment in viewpoint of nursing students” in Tabriz University of Medical Sciences revealed that 93.2% of students had a negative viewpoint about CLE. According to Farnia et al.7 nursing students anticipate a favorable learning environment and their perception of the clinical learning environment is different from their perception of the actual learning environment.
Pugnair, et al.8 also described that assessing students’ perception and satisfaction of clinical nursing experience would be essential for nursing faculty, since it gives feedback to students, faculty and school that leads to enhanced educational performance. Although the CLE has been investigated in various educational institutions, studies exploring the nursing students’ point of view about their CLE in Asian countries are very minimal.
Students view hospital practice areas as more meaningful and educative because they provide them with opportunities of clinical practice that linking the theoretical aspect of their studies. Students’ comments should be considered important as it evaluates the nursing schools and also helps to increase the quality of nursing education programs. This current study aims to assess undergraduate nursing students’ perception of CLE in hospital settings by using. Clinical Leaning Environment Scale by Dunn and Burnett 1995. This study will provide important feedback and recommendations for clinical education and potential curriculum revisions. Nursing students’ perceptions about clinical education has been assessed in different countries; however, Indian studies in this field are very rare.
OBJECTIVES:
To assess the undergraduate Nursing students perception of their clinical learning environment
To compare the perception of their clinical learning environment between I, II, III and IV year Nursing students
HYPOTHESIS:
Nursing students perceive that their clinical learning environment is good and satisfying
METHODS AND MATERIALS:
It’s a descriptive study conducted among I, II, III and IV year Undergraduate Nursing students, College Of Nursing, CMC, Vellore. All (I, II, III and IV year) Baccalaureate Nursing students of College Of Nursing, CMC, wereinvited to participate. Total enumeration sampling was used. The minimum sample size needed to detect underlying factors in a set of items for factor analysis is an item ratio of 10:1 respectively. ( Polit and Beck, Pett et al. 2003) 7, CLES has 23 items hence a sample size of 375 was opted.
To collect the data, list of nursing students were obtained from the Clinical master rotation from the Dean’s office. The students who met the inclusion and exclusion criteria and willing to participate in the study after obtaining the Informed consent was asked to fill the CLES by Dunn and Burnett 1995. Inclusion criteria were all 4 years of Baccalaureate Nursing students, who have had completed minimum of 20 weeks of clinical experience and students who are willing to participate in the study.
Students who were on sick or special leave were the exclusion criteria. CLES has 23 items with 5 factors such as staff- student relationships, hierarchy and rituals, nurse manager commitment, patient relationship and student satisfaction. It’s a 5 point Likert Scale rated as “strongly agree to strongly disagree” with a reliability coefficients ranging from 0.85 to 0.63.
The questionnaires were given to students by the faculty who was not directly involved with their clinical experience and students were asked about their viewpoints regarding quality of their CLE in that academic year after completion of 20 weeks of clinical experience. Each student was administered a CLES questionnaire in their classroom after their class hours to rate. Time required by the student to complete the questionnaire is 20-25 minutes.
Data analysis:
The data was analyzed using the SPSS version 22.0. Descriptive statistics such as frequencies, mean and standard deviation were used to describe the demographic data. The CLES was analyzed using factor analysis and the students’ perception of CLE and satisfaction between the groups were analyzed using One – Way ANOVA and Bonferroni Post hoc procedure. A level of significance of 0.05 was adopted for the analysis.
RESULTS AND DISCUSSION:
There were 375 participants in the study. Of these 25.9% (n=97) were 1st year, 23.5% (n=88), 26.1% (n=98), 24.5% (n=92%) were 2nd, 3rd and 4th year undergraduate Bachelor of Nursing degree students respectively. The participants were between the ages of 17 to 25, with a mean of 20 years and 2 months. These participants were posted in 8 different clinical areas at the time of data collection (Table.1). Out of them 90.7% (n=370) had more than 3 weeks of clinical posting in that clinical area.
Table 1: Type of clinical placements and the number of students
|
Clinical areas |
Frequency (n) |
Percentage |
|
Nursing Foundations |
97 |
25.9 |
|
Medical |
37 |
9.9 |
|
Surgical |
36 |
9.6 |
|
Medical surgical specialty |
35 |
9.3 |
|
Child health |
40 |
10.7 |
|
Mental health |
38 |
10.1 |
|
Community |
48 |
12.8 |
|
Midwifery |
44 |
11.7 |
|
Total |
375 |
100.0 |
Using SPSS v22, a Principal Component Analysis (PCA) was run on the CLES 23 item for the data reduction that measured the perception of CLE among 375 nursing students. The overall Kaiser – Meyer – Olkin (KMO) measure was 0.91 and Bartlett’s Test of Sphericity was statistically significant (p < 0.0005), indicating that the data was likely factorizable (Williams et al., 2010) 10
Dunn and Burnett’s CLES has 5 subscales or factors that measure the perception of CLE: Staff- student relationships, hierarchy and rituals, nurse manager commitment, patient relationship and student satisfaction. The results showed high internal consistency for the overall CLES (Cronbach’s alpha= 0.88). Reliability coefficients for each of the 5 subscales ranging from 0.88 (student satisfaction) to patient relationships and hierarchy and ritual (0.46).
Nursing students’ perception on Clinical Learning Environment:
Staff- Student relationship:
Nurse Manager Commitment:
Items and factor loadings in the NM commitment subscale of the CLES describes that the NM/ clinical supervisor commitment is vital in meeting the learning needs of the student. Following are the items that has high factor loadings among 4 items: “ The NM/ Tutor devotes lot of her time to teach nursing students” (0.75), “The NM / Tutor attaches great importance to the learning needs of nursing students” (0.74), “The NM / Tutor has a teaching programme for students on this ward” (0.64). These results supported earlier findings that NM plays a vital role in providing an ideal environment for the students to practice and conducive to learning. The supervisory relationship is an important factor in clinical learning. In our institution, Nurse Managers/Tutors are directly involved in clinical teaching or in the supervision of students. Due to technological advancement, students expect their supervisors to use variety of clinical teaching methods.
Student satisfaction:
The items in student satisfaction describe students’ attitude and interest in relation to their CLE. Items with the highest factor loadings were on this scale: “I am happy with the experience I have had on this ward”(0.87), “This was a good unit for my learning”(0.84), “This experience has made me more eager to become a Registered nurse”(0.80), “The work I did was mostly very interesting”(0.79). This subscale demonstrated highest reliability and factor loadings and showed statistically significant relationship related to all other subscales (p <0.001). The literature identifies that for various reasons many nursing students perceive that the clinical areas as laden with anxiety and stress (Timmins and Kaliszer, 2002) 12. The items in the CLES subscale ‘student satisfaction’ seem to indicate that student satisfaction is an outcome of the positive learning environment and partly to some extent students are responsible for the development of their own learning environment and outcomes4.
Patient relationships:
Items in this subscale of CLES portray the importance of individualized patient care and the therapeutic relationship prevails between the nurse and the patient. Factor loadings for the items were: “Nursing care is individualized for each patient on this ward” (0.80), “Patient allocation, rather than task allocation, is the practice on this ward”(-.80), “The patients' needs really are given first priority”(0.72), “Learning aids such as books/articles are available to nursing students on this ward”(.54). The item “Patient allocation, rather than task allocation, is the practice on this ward” had negative scoring. Students had felt they have been given too many patients or they have misunderstood the concept of patient and task allocation since they learn about patient assignments only in IV year. Students should be sensitized that their patients play a major role in their learning. It was similar to the findings identified in the same setting where students expressed dissatisfaction towards the demand from the staff nurses to do other work not related to their assigned patients (Sophiya V et al 2016)13.
Hierarchy and ritual:
Items in the CLES subscale of ‘Hierarchy and ritual’ contained elements relating to both the relationships between participants and the organizational culture of the CLE. These items and factor loadings included: “Nursing students are expected to obey Registered Nurses’ instructions without asking questions” (0.67), “Nursing students learn more from other students on the unit than from the nursing staff”(0.63), “There is too much ritual on this ward” (0.60), “The NM regards the nursing student as a worker rather than as a learner”(0.60). This subscale has produced the lowest readings of all the factors. There is some overlap of items in this subscale with the CLES subscale such as Nurse Manager Commitment as it portrays the characteristics of a clinical supervisor as unit hierarchy or ritual.
Out of 375 participants, 123 (32.8%) had scores in the top 33rd percentile; students had perceived that their Clinical Learning Environment is very good and 122 (32.5%) are highly satisfied with their CLE; had scores in the top 33rd percentile. (Figure 1). The CLES had 19 items for Perception of CLE and 4 items for student satisfaction of CLE.
Figure 1 Distribution of students according to their perception and satisfaction of CLE
Comparison of nursing students’ perception of CLE between groups:
The sum totals mean score for perception of CLE as measured by the CLES questionnaire was 81.89 (±14.18) and the overall mean score of students’ perception of CLE is 3.6 (±.62). The overall mean score of all the 4 years are discussed in the Table.2. Regarding the academic year, I year students has the highest mean score and the lowest mean score for III year students. I year students were highly satisfied with their CLE compared to other years. Papastavrou E et al (2016) 14 study also revealed that 1st year students were found to be more satisfied than the students in other years. The internal consistency (Cronbach’s Alpha) of II, III, and IV years are good except the first year (.45) indicates that I year’s are not consistent in their perception in regard to CLE due to new experience as a novice in the clinical area.(Table.3)
Table 2. Overall mean score of students’ perception of CLE
|
Year |
n |
Mean |
Std. Deviation |
Std. Error |
95% Confidence Interval for Mean |
Minimum |
Maximum |
|
|
Lower Bound Upper Bound |
||||||||
|
I year |
97 |
4.1452 |
.33572 |
.03409 |
4.0776 |
4.2129 |
3.17 |
4.96 |
|
II year |
88 |
3.3384 |
.50094 |
.05340 |
3.2323 |
3.4446 |
2.04 |
4.48 |
|
III year |
98 |
3.2533 |
.63170 |
.06381 |
3.1267 |
3.3800 |
1.61 |
4.70 |
|
IV year |
92 |
3.4825 |
.50880 |
.05305 |
3.3771 |
3.5879 |
2.09 |
4.61 |
|
Total |
375 |
3.5602 |
.61667 |
.03184 |
3.4976 |
3.6228 |
1.61 |
4.96 |
Table 3. Reliability assessment of students’ perception of CLE using CLES
|
Year of study |
Cronbach's Alpha |
|
I year |
.449 |
|
II year |
.721 |
|
III year |
.769 |
|
IV year |
.762 |
To test the mean difference of perception of CLE between the groups, One-Way ANOVA was used. It showed that there was statistically significant difference between the groups (p >.0005). In addition for multiple comparisons, Bonferroni post hoc test was conducted that showed statistically significant difference in the perception of CLE between I and II, III, IV year students. It also portrayed that there was significant difference between III and IV year students, regarding their perception of CLE (p >.05). There was no significant difference between the II and III years as the mean scores were so close.
Table. 4 ANOVA for students’ perception of CLE
|
Source of Variance |
Sum of Squares |
Df |
Mean Square |
F |
Sig. |
|
Between Groups |
47.310 |
3 |
15.770 |
61.641 |
.000 |
|
Within Groups |
94.917 |
371 |
.256 |
|
|
|
Total |
142.227 |
374 |
|
|
|
Many studies were conducted to assess Nursing students perception or view point of CLE. Mostly it reveals that the students are not satisfied with their CLE. Salmani and Amirian (2015) 15 had conducted a study that revealed that 77% of students believed that the quality of their CLE is moderate, but some studies in the west showed that nursing students had positive attitude towards CLE 4,16, 17. Students’ satisfaction is a complex and multifactorial issue. Studies reveal that factors such as the ward’s pedagogical atmosphere and leadership style, the sense of belonging, peer support and the motivation level (Dimitriadou M, et al 2015) 18.
A qualitative study was conducted in the same setting by Sophiya V et al 13 to assess the nursing students’ perception of clinical experience that showed that the nursing students were not completely satisfied with their clinical experience. They expressed anxiety and stress. They provided suggestions to improve their clinical learning.
Nurses continue to be in demand and the health care is also complex with its technology. Educational institutions are stake holders in the outcome of a successful clinical experience. It is the responsibility of the institution to organize an effective clinical experience for students which is ideal for the students to learn and to practice. Student nurses should be encouraged to prepare themselves clinically and with emotional intelligence. Now a day’s curriculum is student – centered, where the students are actively involved in learning activities eg., active learning through Group work and Problem Based Learning (Lynn and Barbara 2007)19. Hence the students should be aware of the fact that they are ultimately responsible for their learning.
LIMITATIONS:
This study is a snapshot only of students’ perception in relation to CLES scale. A qualitative component may add lot of weight age as it enables students to express their viewpoint. I year students can be excluded as they are new to the clinical area and they have limited knowledge towards ward routines and hierarchy and they also have very close supervision compared to other years. Further research may be considered to assess the perception of the clinical supervisors of students.
CONCLUSION:
Clinical Learning Environment’s are highly complex settings. CLE’s are integral to nursing students learning. Clinical Learning Environment Scale (CLES) is a useful means of capturing the variation in these settings. Nursing work places have become more intense, complex and demanding environments, which ultimately has an impact on student learning. In CLE, students learn how to apply nursing knowledge, nursing skills, patient communication, professionalization and it prepares them as competent registered nurses for practice in future workplaces.
SOURCE OF FUNDING:
The research was funded by the College of Nursing, Christian Medical College, Vellore.
CONFLICT OF INTEREST:
No conflict of interest reported
ETHICAL CONSIDERATIONS:
The study was approved by the College of Nursing research committee. The participation of students is entirely voluntary. They were allowed to withdraw from the study at any time and the data was kept confidential. There was no direct benefit nor any actual risk associated with their participation in the study.
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Received on 31.07.2017 Modified on 19.09.2017
Accepted on 28.10.2017 © A&V Publications all right reserved
Int. J. Nur. Edu. and Research. 2018; 6(2): 173-178.
DOI: 10.5958/2454-2660.2018.00041.8