views and perceptions of nursing students on their clinical learning environment: teaching and...
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Nurse Education Today xxx (2013) xxx–xxx
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Nurse Education Today
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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 Clinical Professor of Nursing Department, Technological Educational Institute of Larissa, Greeceb Clinical Professor of Nursing Department, Technological Educational Institute of Lamia, Greece
⁎ Corresponding author. Tel.: +30 2410684446; fax:E-mail addresses: [email protected], papath
(I.V. Papathanasiou), [email protected] (K. Tsaras), psarafis@(P. Sarafis).
0260-6917/$ – see front matter © 2013 Elsevier Ltd. Allhttp://dx.doi.org/10.1016/j.nedt.2013.02.007
Please cite this article as: Papathanasiou, I.Vand learning, Nurse Education Today (2013)
s u m m a r y
a r t i c l e i n f oArticle history:
Accepted 11 February 2013Available online xxxxKeywords:Nursing educationClinical learning environmentCLEIPractice nursingStudents' satisfaction
Introduction: The clinical learning environment constitutes an initial area of professional practice for nurses andstudent opinion contributes to its improvement.Purpose: The assessment of students' views and perceptions of a Greek nursing school on their clinical learningenvironment.Material and Methods: The study was concurrent and included 196 students. We used the published ques-tionnaire “Clinical Learning Environment Inventory (CLEI)” which is a tool for identifying and assessingNursing students' perceptions of the psychosocial characteristics of their clinical learning environment. The ques-tionnaire 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 pb0.05. The
statistical program SPSS 16.0 was used.Results: The highest mean score for the Actual Clinical Learning Environment was observed in the scalesof “Personalization” (23.97) and “Task orientation” (23.31) while for the Preferred Clinical Learning Environ-ment in the scales of “Personalization” (27.87), “Satisfaction” (26.82) and “Task orientation” (26.78). The lowestmean 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 wasfound 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 forthe students in nursing. Reorganization of the educational framework is needed with an emphasis on innovationand individualization.© 2013 Elsevier Ltd. All rights reserved.
Introduction
Modernhealth care is providedwithin a dynamically evolving clinicalenvironment, where new technologies and skills are applied. Clinicalnurses are required to be well informed and committed to continuingeducation in order to incorporate all the latest scientific data into theirpractice. The learning environment plays a crucial role, especially duringthe clinical training of student nurses, as they come into contact with therealities of their function and form opinions on their professional careersand the clinical area prospects (Clarke et al., 2003; Egan and Jaye, 2009).
It has been found that the students want to function in learninggroups 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 variousinitiatives promote innovation and individualization for future nurses.
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If a clinical experience is acquired in this manner, we avoid the sterilerepetition of practices proven to lead to an impasse and to be obsoletethrough 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 inte-gration into existing clinical frameworks and fosters a more critical atti-tude. Thus, the depiction of students' views and their expectations fromclinical training provides valuable information for the reorganizationand improvement of their studies, with an obvious impact on futureeducational attainment and the establishment of nurses.
The purpose of this study was to assess students' views and percep-tions of a Greek nursing school on their clinical learning environment.
Modern trends in professional education stress the importance ofembodying the realities of working environments to academic training.Due to the current economic difficulties worldwide, this embodimentconstitutes a necessity. To be sure, nursing education has always beenclosely linked with real working environments, and student nurseshave always held a dual role, where learningwas combined with activeinvolvement and contribution to patient care (Allan et al., 2011); closelyrelated is nursing's continuing goal of providing holistic care, which
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presupposes a consistent co-existence of theoretical knowledge, valuesand principles together with practical applications and technical de-tails. However, recent economic developments pose a threat to holisticapproaches, as the elements of cost-effectiveness and cost-cutting pro-cedures tend to impose a new way of providing care, where savingresources is the ultimate goal. In light of these remarks, it is evidentthat, more than ever, student nurses need to be trained as effectivelyas possible in a real-time clinical environment, and gain theoreticaland practical knowledge in an interpersonal way, where the synergyof academic values and professional realities is anew fundamental.
Material and Methods
Study participants were students of the Nursing Department, TEIof Larissa. The sample consisted of 196 students during the springsemester of the academic year 2008–2009. Specifically, it involved 77 stu-dents on their fifth semester, 53 students on their seventh semester and66 students on their eighth semester. The eighth semester is the finalone,where there areno lectures in the class, and the students are requiredtowork at a hospital as trainees, based on the theoretical and clinical skillswhich they acquired during previous semesters. Students of the first foursemesters were excluded from the research because they have littlecontact with the clinical setting and therefore would provide inade-quate responses on their clinical experiences. The total number of thestudents of the Nursing Department was 851, fromwhich 300 studentswere in fifth, seventh and eighth semester (participation rate 65.3%).
The study was a cross-sectional, descriptive type research, and datawas collectedwith a questionnaire form. The questionnaire was anony-mous and completed by the students themselves during their clinicaltraining at the hospital.
In order to investigate the clinical learning environment, the “ClinicalLearning Environment Inventory (CLEI)” was used in the questionnaire.CLEI is a tool for identifying and assessing the perceptions of nursingstudents on the psychosocial characteristics of their clinical learningenvironment. CLEI has been used internationally, developed after a thor-ough retrospective study of the literature on the learning environmentof the classroom and the clinical learning environment, as well as discus-sions with experts in the field of nursing education and clinical nursing(Chan, 2001; Chan, 2003). A similar questionnaire has an importantrole in the creation of the CLEI, entitled “College andUniversity ClassroomEnvironment Inventory” (CUCEI), whichwas used in colleges and univer-sities, aswell as the theoretical background developed in accordancewiththe 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 characterizethe educational environment and that these dimensions should beincluded in all of the tools used to determine it (Moos, 1979). Thesethree dimensions are:
• Personal Development dimensions that determine maturity andself-esteem.
• The SystemMaintenance and SystemChange dimensions that includethe degree towhich the environment is orderly, clear in expectations,maintains control and responds to change.
• The Relationship dimensions that recognize the nature and intensityof personal relationships within the environment and the mutualsupport and mutual aid.
The CLEI consists of two types of questionnaire: the “Actual form”
which assesses students' understanding of the psychosocial characteris-tics of the real clinical learning environment, and the “Preferred form”
for the assessment of psychosocial characteristics of the desired clinicallearning environment. The twoquestions on the questionnaire forms arealmost 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 answeredwith one of the answers “Strongly Agree”, “Agree” “Disagree,” and
Please cite this article as: Papathanasiou, I.V., et al., Views and perceptionand learning, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.n
“Strongly Disagree” (Likert four-point scale), which score 5, 4, 2, and 1respectively, while there are questions which score in reverse, thatis 1, 2, 4, and 5. Incomplete or incorrect answers (multiple notes)score 3. The 6 CLEI scales reflecting the psychosocial characteristicsof the clinical learning environment and their correlation with thedimensions of Moos are:
• Individualization: assesses the degree to which students are allowedto make decisions and the extent to which they are treated accordingto their ability or the interest shown. This corresponds to the dimen-sion of the System Maintenance and System Change.
• Innovation: assesses towhat extent the teacher introduces interestingnew teaching techniques and learning activities, and whether he orshe provides a productive clinical experience. This corresponds tothe dimension of the System Maintenance and System Change.
• Involvement: assesses the extent towhich students participate activelyand consistently in activities in the clinical area. This corresponds to thedimension of the Relationship.
• Personalization: emphasizes the opportunities that the student hasto interact with the teacher. This corresponds to the dimension of theRelationship.
• Task orientation: assesses the extent towhich the activities in a clinicaldepartment are clear to the student and well organized. This corre-sponds to the dimension of Personal Development.
• Satisfaction: assesses the degree of satisfaction which students showfrom their training in a clinical setting. This corresponds to the dimen-sion of Personal Development.
In a Hong Kong study, scale reliability of the CLEI had been confirmedwith reported Cronbach alpha coefficients ranged from 0.50 to 0.80for 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 eachscale 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) foreach scale of the Preferred form of CLEI was 30.33 (3.04) for Personaliza-tion, 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 wasperformed using the software package SPSS 16.0 for Windows, withthe methods of descriptive and inferential statistics. To determine thedifference 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 becausemany research studies about the clinical learning environment recom-mend the use of this scale of CLEI as an outcome measure and becausea very strong relation was found between Satisfaction and the otherscales of CLEI (Chan, 2002; Perli and Brugnolli, 2009). Correlation coef-ficient of Pearson (r) and the model of multiple linear regression wereused to explore possible relations between students' Satisfaction andthe other scales of the CLEI. P valuesb0.05 were defined as reflectingthe 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 Pre-ferred Clinical Learning Environment (Preferred form) by 180 students.
The reliability of each CLEI scale factor was determined by assessingthe Cronbach alpha (internal consistency evaluation of data). TheCronbach alpha coefficient for each CLEI scale ranged from 0.55 to0.76 for the Actual Clinical Learning Environment, and from 0.58 to0.77 for the Preferred Clinical Learning Environment.
The highest mean score (Table 1) for the Actual Clinical LearningEnvironment was found for the scale of “Personalization” (23.97) and
s of nursing students on their clinical learning environment: Teachingedt.2013.02.007
Table 2Correlation coefficient of Pearson (r) between the scale “Satisfaction” with the otherscales of the CLEI for Actual Clinical Learning Environment.
CLEI scale Pearson's correlation coefficient (r) p value
Personalization 0.49 0.000Involvement 0.60 0.000Individualization 0.18 0.014Task orientation 0.54 0.000Innovation 0.42 0.000
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“Task orientation” (23.31); accordingly, for the Preferred Clinical LearningEnvironment it was found for the scale of “Personalization” (27.87),“Satisfaction” (26.82) and “Task orientation” (26.78). The lowest meanscore (Table 1) for the Actual Clinical Learning Environment wasfound for the scale of “Innovation” (19.21) and “Individualization”(19.24); accordingly, for the Preferred Clinical Learning Environment itwas found for the scale of “Individualization” (22.72) and “Involvement”(24.31). By checking with the t-test for pairs of means, we noticeda statistically significant difference between the Actual and PreferredClinical Learning Environments. Especially for all the scales of the CLEI,the means of the Preferred were significantly higher than the corre-sponding value of the Actual Clinical Learning Environment (pb0.001).The difference between the means for each CLEI scale ranged from3.51 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 theCLEI, andwe investigated its relationship to psychosocial characteristicsexpressed by the other scales of the questionnaire, the Actual ClinicalLearning Environment. Data analysis identified a positive correlation,statistically significant between the “Satisfaction”with all the other scalesof 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” (depen-dent variable) and other psychosocial characteristics of CLEI (inde-pendent variables) the model of multiple linear regression wasused. Data analysis showed statistically significant positive relation-ship 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 variablesretained in the model explain 46% of the variability of the dependentvariable, namely the “Satisfaction” for the Actual Clinical LearningEnvironment (Table 3).
Discussion
A very interesting finding of the study is that there is a significantdistance between the Preferred Clinical Learning Environment and theone which is actually established, according to the students' opinion.This suggests that students generally wish for a more positive environ-ment than what they have experienced, especially when it comes toissues related to satisfaction, individualization and innovation. Giventhat the scale of individualization assesses the degree towhich studentswere allowed to make decisions and the extent to which they are treat-ed in accordance with their ability or the interest shown, and that inno-vation refers to productive clinical experiences, it seems that the studentsin the sample deem the existing conditions inadequate in terms of crea-tivity and initiative.
This is also shown by the scores of Individualization (19.24) andInnovation (19.21) for the Actual Clinical Learning Environment. Thelow score of Individualization is probably due to the fact that in the
Table 1Differences in the mean scores between the Actual and Preferred Clinical LearningEnvironments of each scale of the CLEI.
CLEI Scale Mean±St. dev. Mean difference(95% confidenceinterval)
t p value
Actual(n=196)
Preferred(n=180)
Personalization 23.97±4.66 27.87±4.58 3.98 (3.14–4.83) 9.33 0.000Satisfaction 21.81±5.21 26.82±4.98 4.88 (4.08–5.69) 12.02 0.000Involvement 20.72±3.84 24.31±3.97 3.64 (2.97–4.32) 10.72 0.000Individualization 19.24±3.16 22.72±3.91 3.57 (2.82–4.32) 9.43 0.000Task orientation 23.31±4.35 26.78±4.42 3.51 (2.74–4.28) 9.00 0.000Innovation 19.21±4.39 25.57±4.46 6.40 (5.48–7.32) 13.77 0.000
Please cite this article as: Papathanasiou, I.V., et al., Views and perceptionsand learning, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.n
Greek Educational System, the clinical education of nursing studentsis conducted in real and not virtual conditions, always with the pres-ence of a clinical instructor and it is strictly guided. Initiatives andself-motivation are virtues that can prove particularly useful in clinicalsettings that require a rapid and effective action, and these results right-fully raise questions as to whether this goal is achieved. It is howeverpromising that the students evaluate positively the dimension of per-sonalization, but as the score indicates in the preferred environmentscale, they would prefer even more support. Students consider humanrelations as a top priority in the clinical learning environment. As notedby Campbell et al. (1994), students of nursing feel vulnerable duringtheir internship and need the understanding and respect from all thoseinvolved in their education.
The gap between the expectations and reality in the clinical learningenvironment for nursing students has been marked in many studiesand constitutes an international phenomenon (Chan, 2004; Hendersonet al., 2006b; Chan and Ip, 2007; Perli and Brugnolli, 2009; Brown et al.,2011). The dimension of personalization emerges as the one with thehighest score, while those of innovation and individualization are sig-nificantly lower (Chan, 2002; Henderson et al., 2006b). Some studiesshow that when supervision is consistent but gradual, students developconfidence and independence with regard to clinical skills. It has beensuggested that when the education of student nurses involves differentbackgrounds and different clinical approaches, students expand theirlearning horizons and develop more easily their critical thinking (Pappet al., 2003; Henderson et al., 2005; Midgley, 2006; Henderson et al.,2010a).
Regarding satisfaction, it was found to be positively associated withall the other dimensions of the questionnaire, highlighting themultifac-torial nature of the student's satisfaction from the clinical environment.The results of correlation analyses reported in Table 2 indicate that thecorrelation coefficients (r) ranged from 0.18 to 0.60. In similar researchstudies the correlation coefficients (r) between satisfaction and theother scales of the CLEI, ranged from 0.31 to 0.54 (Wan Yim and Chan,2005; Chan and Ip, 2007). The contribution of personalization, involve-ment and task orientation is particularly significant, as revealed bymul-tiple linear regression models. The highest contribution is attributedto participation, which seems to be an important predictor of studentsatisfaction in the real clinical setting. Indeed, it has been found thateffective student participation in working groups is a strong predictorof satisfaction within a professional environment. Also, the feeling ofacceptance and “belonging” to a group is important for students whoare looking to redefine their academic identity and seek professionalguidance in the clinical environment (Smedley and Morey, 2009;Henderson et al., 2010b).
Table 3Multiple linear regression with dependent variable for the scale “Satisfaction” andindependent variables for the other scales of CLEI for the Actual Clinical LearningEnvironment.
Independent variables Coefficient β(95% confidence interval)
p value R2 F
Personalization 0.22 (0.08–0.36) 0.002 0.46 53.58Involvement 0.50 (0.32–0.68) 0.000Task orientation 0.30 (0.15–0.46) 0.000
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The efforts of the state and educators should turn towards thereorganization of clinical education and provide more opportunitiesfor innovation by students within a controlled educational context.Perhaps the reduction in the number of trainees assigned to the instruc-tor and the specialization of the latter will facilitate learning and theacquisition of clinical skills. Greater emphasis should be given to thestudents' clinical education, and the unstable economic environmentshould by nomeans become an insurmountable barrier to the continu-ing effort towards quality clinical training. Given the constant develop-ment of new technologies in the health care area, great vigilance shouldbe used with regard to the implementation of all new developments inmodern clinical training. In addition, a change of the existing model ofeducation, with the creation of clinical education units may help opti-mize the performance of students. It has been shown that such unitscan provide greater psycho-social support to students, which is alsoreflected in the dimensions of the CLEI questionnaire.
This study has some limitations; first of all, it was conducted withthe participation of students coming from one university and at a singlehospital. The students completed a self-report questionnaire, whichcan lead them to answer questions in a socially desirable and sociallyacceptable way. Students on three different semesters and with dif-fering clinical experience were involved, while the study sample wasa convenience sample, with almost one third of the students refusingparticipation. Therefore, any generalization of these results should betreated with caution. However, the alignment of the findings with otherinternational studies emphasizes the need for further improvement ofthe clinical learning environment.
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