student, tutor and staff nurse perceptions of the clinical learning environment
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Nurse Education in Practice 12 (2012) 192e197
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Nurse Education in Practice
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Student, tutor and staff nurse perceptions of the clinical learning environment
Ooi Loo Chuan a,1, Tony Barnett b,*a Lam Wah Ee Nursing College, Penang, MalaysiabDepartment of Rural Health, University of Tasmania, Australia
a r t i c l e i n f o
Article history:Accepted 3 January 2012
Keywords:Clinical learning environmentNursingStudentsEducation
* Corresponding author. Tel.: þ61 3 6324 4011.E-mail addresses: [email protected] (O.L. Chua
(T. Barnett).1 Tel.: þ60 4 6528874.
1471-5953/$ e see front matter � 2012 Elsevier Ltd.doi:10.1016/j.nepr.2012.01.003
a b s t r a c t
The aim of this exploratory study was to describe and compare student nurses (n¼ 142), staff nurses(n¼ 54) and nurse tutors (n¼ 8) perceptions of the clinical learning environment (CLE), and to identifyfactors that enhanced or inhibited student learning. The setting was a private hospital in Penang,Malaysia. Data were collected using a structured, self-administered questionnaire that consisted of sixa priori subscales. Principal component analysis supported a six factor solution and a reduction in thenumber of items from 44 to 34. Participants’ overall perception of the CLE was positive, though therewere significant differences in 5 of the 6 subscales between the three groups. For students and theirtutors, the most positive component of the CLE was ‘supervision by clinical instructors’. Staff nursesreported more favourably on the learner friendliness of the CLE than did students or tutors. Factors thatenhanced student learning included students’ and staff nurses’ attitude towards student learning, varietyof clinical opportunities, sufficient equipment, and adequate time to perform procedures. Factors thathindered student learning were: overload of students in the clinical unit, busy wards, and students beingtreated as workers.
� 2012 Elsevier Ltd. All rights reserved.
Introduction
Workforce shortages and changes in health care delivery haveencouraged a critical review of how nurses are prepared to meetcontemporary health care challenges. The development of clinicalskills and competencies through practical experience has beenemphasised as a corner stone of health professional education(Heath, 2002; Roxburgh et al., 2008). To encourage this, and insome jurisdictions, the amount or proportion of time studentnurses are required to spend in clinical areas during their course ismandated (Nursing Board of Malaysia, 2006).
Although learning in clinical settings has many benefits, it canbe challenging, unpredictable and stressful (Hosoda, 2006). Thestressors associated with this experience may have either positiveor negative effects that impact on learning (Gibbons et al., 2009). Asupportive clinical learning environment (CLE) is important for thedevelopment of nursing knowledge and skills, professional social-isation and in the development of students’ confidence, job satis-faction and preparedness for practice (Edwards et al., 2004). The
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CLE is an interactive network of forces influencing student learningoutcomes in the clinical setting. A positive CLE is perceived toproduce positive learning outcomes and a negative CLE producespoor learning outcomes (Dunn and Burnett, 1995; Penman andOliver, 2004).
A range of factors can influence the CLE including: the atmo-sphere of the ward, relationships with staff (Lewin, 2006), super-visors (Saarikoski and Leino-Kilpi, 2002) and mentors (Papastavrouet al., 2010). Understanding how major stakeholders (e.g. students,teachers and clinical staff) perceive the CLE, may enable strategiesto be developed to better support student learning (Hosada, 2006).With this aim, a review of the literature was undertaken for thispresent study and six characteristics of the CLE emerged asimportant: ward atmosphere, supervision of students by staffnurses and clinical instructors, theoryepractice gap, peer supportand student satisfaction.
Ward atmosphere is the intangible quality or characteristic ofthe ward such as the cooperation, attitude, morale and friendlinessof the staff (Edwards et al., 2004; Lewin, 2006; Papp et al., 2003) aswell as a product of the interpersonal relationships between staffand students. A ward with ‘good’ atmosphere can enhance studentlearning as theward staff are not only happyworking together, theyare also often willing to teach and guide students (Edwards et al.,2004; Papp et al., 2003). Students who experience difficult inter-personal relationships with the ward staff tend to have negative
O.L. Chuan, T. Barnett / Nurse Education in Practice 12 (2012) 192e197 193
perceptions of the CLE. Ward atmosphere directly influencesstudent learning as it determines whether students believe theirpresence is appreciated and influences their perception of whetherthey will be provided with a suitable range of learning opportuni-ties (Timmins and Kaliszer, 2002).
Saarikoski and Leino-Kilpi (2002) reported that the mostimportant factor in students’ clinical learningwas their relationshipwith their supervisor.Whilst supervision is a key element in clinicallearning, staff nurses especially, may not always understand theirsupervisory role (Chapple and Aston, 2004). This has been attrib-uted to factors such as the lack of preparation, attitude towardsstudents and constraints associated with high clinical workloads(Maben et al., 2006). Where dedicated clinical teachers orinstructors are utilised within the CLE, these are often seen bystudents as critical to their clinical learning and help facilitate thetranslation of theory into practice (Lambert and Glecken, 2005).
The theoryepractice gap, a mismatch between what has beentaught and what is practised, is a common source of confusion,stress and anxiety for students. Students, as well as new graduates,are often caught in a dilemma of whether to practise what has beentaught in the classroom or what they observe is commonly prac-tised on the wards (Evans and Kelly, 2004). Investigation of thedifferent perceptions key stakeholders have of the CLE may there-fore provide insights to develop strategies that may assist in eval-uating and closing this gap.
Peers (other students) are a valuable resource in the CLE as theyare able to help, support and contribute to learning. When studentsnetwork, they are able to share and learn from each other’s expe-rience (Spouse, 2001). More junior students look up to and canappreciate the advice and ‘know how’ of those more senior who,whilst only having a year or two additional experience, relate moreeasily to them. The influence of peers on student learning has oftenbeen overlooked or underestimated and can be a key component ofthe CLE that impacts on a student’s experience (Roberts, 2008).
Students’ satisfaction with their preparation for practice isgreatly influenced by their experience of the CLE. Higher levels ofsatisfaction are reported when students are treated with respect,have effective mentors, receive constructive feedback on perfor-mance and are included as a part of the clinical team (Saarikoskiet al., 2005). Enthusiasm for learning and being provided withopportunities to demonstrate initiative also contribute to a positivelearning experience (Lewin, 2006).
A review of the literature informed the framework for thisexploratory study which aimed to describe and compare theperceptions of student nurses, staff nurses and nurse tutorstowards the CLE and to identify the key characteristics of CLE thatenhanced or inhibited students’ learning in a Malaysian hospital.
Setting
Malaysia is a multicultural country with both private and publicproviders of health services. Whilst nursing in the university sectoris becoming more prevalent, much basic education of nurse occursin colleges linked to major public and private hospitals. Rather thanbeing totally supernumerary, student nurses comprise an impor-tant part of the workforce in many hospitals where labour isgenerally organised within traditional hierarchical structures.Malaysia is experiencing a shortage of qualified nurses and thenation is committed to educating a greater number of locallytrained, clinically competent graduates (Barnett et al., 2010). As partof this initiative, a major review was undertaken of the guidelinesgoverning the national Diploma of Nursing curriculum, an outcomeof which was to increase the minimum amount of time studentsspend in clinical practice during their course (Nursing Board ofMalaysia, 2006).
The shortage of nurses and progressive changes to nurseeducation have contributed to theoryepractice gap tensions withfewer numbers of experienced nurses available to guide and shapethe behaviours of students and new graduates. Critical to thesuccessful recruitment and retention of students in nursing cour-ses, is their satisfaction with their preparation for and experiencesof the clinical environment. Negative experiences may lead to highattrition, failure to recruit and result in fewer new graduatesentering the workforce.
The study was conducted in a private hospital and nursingcollege in Penang, Malaysia. The hospital, a 700 bed tertiary facilitywith a wide range of medical and surgical specialties, had a regis-tered nursing staff complement of 466. Three medical and threesurgical wards were selected as these particular patient care areashad a high volume of students who were in regular contact withstaff nurses and clinical instructors. When the study was con-ducted; the college had 214 students enrolled in its 3 year (fulltime)Diploma of Nursing Course. Whilst on clinical placement in thewards, students were supervised by staff nurses and clinicalinstructors based on each ward. Staff nurses maintained a patientcase load when they supervised students, clinical instructors didnot.
Methods
A descriptive design using a structured, self-administeredquestionnaire was used for the study. Participation was voluntaryand inclusion criteria set for the three participant groups. Studentnurses were required to have had at least two weeks of clinicalpractice on the ward. Staff nurses needed to have worked for atleast six months in clinical areas where students were regularlyplaced. All tutors from the nursing college not directly involvedwith the study were invited to participate.
Instrument
A questionnaire was developed for the study that requesteddemographic information from participants and a 44 item CLE scalethat represented the six characteristics of the CLE thought to beimportant locally: ward atmosphere, supervision by staff nursesand the clinical instructor, student satisfaction, the theoryepracticegap, and peer support. Each characteristic was represented by 6e9items. Items were drawn from examples of questions and itemsused in CLE instruments reported elsewhere in the literature (vide:Chan, 2002; Dunn and Burnett, 1995; Hosoda, 2006; Saarikoski andLeino-Kilpi, 2002; Sand-Jecklin, 2000). Given that no publishedstudy was located that reported on the CLE in the Malaysiancontext, a number of items were modified slightly to suit localinterpretations and common usage.
Items were scored using a 4-point Likert scale with responseoptions that ranged from 1¼ “Strongly Disagree” to 4¼ “StronglyAgree”. Some items were re-worded slightly for staff nurses andtutors to ensure they were student focussed. Negatively wordeditems were reverse scored and a higher cumulative score fora characteristic represented a more positive response. One open-ended question was included. This requested participants to listfactors that enhanced or detracted from student learning in the CLE.
The questionnaire was critically reviewed by one local and oneinternational expert for face and content validity. Items werearranged in random order and pre-tested with 15 students and 5staff nurses who were excluded from the study population. A reli-ability coefficient (Cronbach’s alpha) for the entire instrument wascalculated to be 0.89 and the coefficient for each (a priori) subscaleranged from 0.46 to 0.87. This demonstrated an internal consis-tency considered acceptable in questionnaires (Macnee, 2004).
O.L. Chuan, T. Barnett / Nurse Education in Practice 12 (2012) 192e197194
Procedure
The study was promoted by posters located in the college andthe wards. Explanatory statements, the questionnaire and anenvelope which could be sealed for the return of completed ques-tionnaires were available at each participating ward and thecollege. Participants were requested to complete the survey ata time convenient to them and to return the questionnaire withinfour weeks. Datawere then entered onto a spread sheet for analysisusing SPSS V.19 software.
The study was approved by the hospital and the relevant humanresearch ethics committee. Data were gathered and collated suchthat individual participants could not be identified.
Results
A total of 204 questionnaires were received; 142 from studentnurses (representing 74.7% of eligible participants), 54 staff nurses(55.1% of eligible participants) and 8 nurse tutors (100%). Principalcomponent analysis was applied to examine the relationshipbetween variables and to inform decisions about the removal ofitems. The KaisereMeyereOlkin measure of sampling adequacywas found to be good (0.823) and Bartlett’s test highly significant(c2 (203)¼ 2632, df 561, p< 0.001) which indicated that factor
Table 1Principal component analysis factor loadings (n¼ 203).
Item
23 Staff nurses regularly provide feedback to student nurses for the work that is15 Staff nurses are interested in supervising students.18 Staff nurses are good role models.8 Staff nurses are willing to spend time teaching student nurses.25 Staff nurses guide student nurses to perform new skills.12 Staff nurses show a positive attitude towards the supervision of student nurse16 The ward staff are easy to approach.11 The ward staff know the student nurses by their names.13 High quality care is provided to patients.6 Staff nurses regard the student nurse as a learner rather than a worker.19 The clinical instructor is a good role model.24 The clinical instructor provides prompt feedback to students for the work that17 The clinical instructor is easy to approach.26 The clinical instructor provides adequate guidance with new skills.5 The clinical instructor has good knowledge and skills.9 The clinical instructor devotes sufficient time to teaching students.33 The clinical instructor is readily available to assist learning.29 I enjoyed my time working on the ward.43 I am happy with the experience I have had on this ward.1 I look forward to clinical practice44 The experience on the ward makes me eager to become a staff nurse.40 Student nurses have difficulty finding help when needed.41 I feel stressed with the amount of work to be done on the ward.36 There is a conflict between procedures taught in the classroom and the real si
on the ward.34 Student nurses are given a lot of responsibility without adequate supervision.37 Student nurses compete with each other to practise skills.42 Theory learned in the classroom is reinforced on the ward.38 Student nurses are considered to be part of the ward team.39 Student nurses are taught to link theory to practice.27 What is learned in the classroom is being practised on the ward.31 Student nurses are encouraged to ask questions.21 Student nurses teach one another.22 Student nurses help one another to carry out allocated tasks.30 Senior students guide junior students.
EigenvalueVariance (%)Cumulative variance (%)Internal consistency (Cronbach’s alpha)Number of items
analysis was appropriate for these data (Field, 2005). The initialanalysis identified 12 factors with an eigenvalue of >1. Supportedby an examination of the pattern and structure matrix, theelbows on the scree plot and because the questionnaire wasconceptualised a priori (Rattray and Jones, 2007), a six factorsolution was forced using Oblimin rotation with KaiserNormalisation.
An iterative process was used to remove redundant items,commencing with a review of the items within each factor, andthen an elimination of those items with factor loadings of <0.3,<0.4, and then <0.5 such that a minimum of three items wereretained in each factor. The final solution contained 34 items andexplained a total variance of 54%. Each factor was interpreted withreference to the items it contained and the framework used toconstruct the questionnaire. For example, items conceptualiseda priori as related to “ward atmosphere” and “supervision by staffnurses” loaded onto factor 1 which was subsequently labelled“learner friendly CLE”. Factor 5 contained items that were originallythought to describe the “theoryepractice gap” though whenreviewed, was interpreted as “translating learning”. A new subscaleemerged from the analysis: factor 4, “learning tensions”. Internalreliability was assessed by Cronbach’s alpha. The coefficients foreach factor ranged from 0.658 to 0.875. An alpha value of 0.867 wasobtained for the scale overall (Table 1).
Factor
1 2 3 4 5 6
done. 0.7670.7370.7080.6830.670
s. 0.6560.6040.5910.5500.505
0.859is done. 0.805
0.7380.6950.6810.6790.649
�0.822�0.740�0.617�0.575
0.6580.635
tuation 0.609
0.5950.521
�0.727�0.621�0.592�0.535�0.507
0.7670.6390.500
6.84 4.83 2.14 1.76 1.50 1.3020.1 14.2 6.3 5.3 4.4 3.820.1 34.3 40.6 45.8 50.2 54.00.875 0.871 0.705 0.695 0.658 0.729
10 7 4 5 5 3
Table 2ANOVA results, CLE scores of student nurses, staff nurses and nurse tutors.
Factor df (withingroups)
F p
Learner friendly CLE 201 38.762 0.000*Supervision by clinical instructors 201 11.040 0.000*Student satisfaction 201 8.951 0.000*Learning tensions 201 23.131 0.000*Translating learning 201 1.630 0.198Peer support 201 18.805 0.000*
*p< 0.05
O.L. Chuan, T. Barnett / Nurse Education in Practice 12 (2012) 192e197 195
The mean score for the 34-item CLE component of the ques-tionnaire was similar for students (16.94), staff nurses (16.95), andtutors (17.41). However, with the exception of factor 5: “translatinglearning” an analysis of variance (ANOVA) demonstrated significantdifferences between groups for each factor (p< 0.05). Whilst themean subscale scores derived from the student group showeda similar pattern to that of the nurse tutor group, the mean scoresfrom staff nurses demonstrated the least variability. Students andtutors gave their highest score to factor 2: “supervision by clinicalinstructor”. Both students and staff nurses gave their lowest scoresto factor 4 “learning tensions”. Tutors scored factor 1, the learnerfriendliness of the CLE lowest (Fig. 1 and Table 2).
Participants were asked to identify factors in the CLE thatcontributed to or hindered student learning (Table 3). All the threegroups identified that students’ attitude towards learning wasimportant. Comments made by the staff nurses included thatstudents needed to “showmore initiative and be motivated” and be“willing to learn something that is new for them”. Nurse tutorscommented that some students were “not proactive, not bothered”and were of the opinion that exposure to a sufficient number ofpatients with a variety of problems or medical conditions as well asthe opportunity to undertake a range of clinical proceduresenhanced students’ learning.
Students emphasised the importance of being given sufficienttime to complete procedures correctly with less time pressure fromstaff. They stated that “busy wards” and staff nurses’ “unfriendly”attitude also compromised their opportunity to acquire newknowledge and skills. Comments also reflected the frustration theyfelt when they were denied the opportunity to learn, such as whenrequired to run errands like sending specimens to the laboratory,collecting patients’ case notes from doctors’ clinics and other “non-nursing tasks” or when asked to concentrate on “mundane” or“routine tasks” they believed that they had already been mastered.In addition, frustrations were voiced at having to work alongsideassistant nurses and ward aides. Some participants claimed thatthere was no role demarcation between students, assistant nursesand ward aides and students were instructed by these staff to do“work” for them, particularly “dirty tasks” that they did not want todo themselves. When the ward aides delegated tasks to thestudents, students felt that they were at the bottom of the clinicalhierarchy and not accepted as part of the nursing team.
2.00
2.20
2.40
2.60
2.80
3.00
3.20
3.40
3.60
Learner Friendly CLE Supervision by CI Student SatisfactioClinical Learning
Mean
S
co
re
Students
Fig. 1. Comparison of CLE scores from stu
Discussion
The “friendliness” of staff can impact on student learning(Lewin, 2006). In this study and as found elsewhere (Hosada, 2006),students and tutors perceived the CLE to be less learner friendlythan did the staff nurses. This could be attributed to staff nurses’familiarity with their ward and (conversely) student’s lack offamiliarity as a consequence of frequent and relatively short clinicalrotations which required them to regularly adapt to and “fit in”with a new nursing team. These rotations may not have providedward staff with sufficient time to get to know individual studentsand to build a rapport with them.
All groups valued the supervisory role of clinical instructorsthough staff nurses were more muted in their declaration. Thiscould be due to divergent views between the clinical instructorsand staff nurses about supervision or how students should performtasks. As previously observed by Swain et al. (2003), staff nursesmay have preferred students to work “the hospital way” so thatdelays were minimised. Though highly regard by both tutor andstudent groups, a conflict of opinion may have therefore led toa less favourable perception by this group of the supervisory role ofclinical instructor.
Students reported a quite high level of satisfaction with theirclinical experience (factor 3), a view shared by their tutors. Staffnurses tended to view student as being less satisfied withtheir placement experience, possibly because of their closerproximity to and observation of students’ levels of anxiety (Evansand Kelly, 2004) and “learning tensions” whilst on the wards.Tensions such as difficulty in finding help when needed (item 40),
n Learning Tensions Translating Learning Peer Support Environment Scale
Staff Nurses Tutors
dents, staff nurses and nurse tutors.
Table 3Summary of comments made by the participants.
Factors that contributed to student learning in the CLEAdequate supervision by clinical instructors and staff nursesStudents demonstrate initiative and an interest in learningSufficient time is given to students to complete proceduresDiverse clinical learning experiencesEquipment e sufficient and in good condition
Factors that hindered student learning in the CLEThe wards too busy, students have insufficient time to learn new thingsStaff nurses’ unfriendly attitude towards studentsToo many students on the wards, competing to do proceduresStaff nurses’ unwillingness to teach studentsStudents are delegated too many menial tasks that are not sufficiently
challengingStudents have to do non-nursing duties and tasksAssistant nurses and ward aides always ask students to do ‘work’ for themStaff nurses prefer to perform procedures themselves
O.L. Chuan, T. Barnett / Nurse Education in Practice 12 (2012) 192e197196
theoryepractice gap conflicts (items 36 and 42) and competitionwith other students to perform skills (item 37) were also felt moreacutely by students than their tutors. These differences in factorscores indicate that more attention could be paid to recognisingthese as issues for students by tutors and developing strategies tomitigate some of their negative or distressful impacts whilstenhancing those more positive (eustress) performance and learnerenhancing effects (Gibbons et al., 2009). The relatively high scoresreported by students for “peer support” (factor 6) point to onepotential area that could be explored to help reduce or amelioratesome of these tensions. Students learning from each other is animportant characteristic of the CLE and, where appropriate, couldbe structured into a clinical education program (Pearcey and Elliot,2004). Such a strategy may also contribute to improving the“learner friendliness” of the ward if the peer support role of moresenior students was acknowledged and accepted by the clinicalstaff (Roberts, 2008).
In this study, there was no significant difference in mean scoreson factor 5 “translating learning”. This suggests that all threegroups shared similar views on the value of clinical experience insupporting the learning that occurs elsewhere (items 42, 39, 27)and that teamwork (item 38) and enquiry (item 31) are importantcomponents of learning within the ward.
The comments made by participants on factors that did anddid not contribute to student learning highlighted the complexityof the CLE and some shared understanding of these. Commentsfrom participants in all three groups identified the benefit ofstudents having a positive attitude towards their own learningand, as also suggested by Papp et al. (2003), a willingness to bemore self-directed. This in an area that could be further assessedin a CLE scale and contribute to our understanding of clinicallearning.
Participants reported that the quality of the CLE was alsodependent on the availability of diverse clinical experiences and, asobserved elsewhere (Mnzava and Savage, 2005) sufficient equip-ment being available for student use. If the clinical placement didnot provide a variety of learning experiences, students may beconfined to mundane jobs and routine tasks (Edwards et al., 2004).Students reported that many learning opportunities were forfeitedwhen the wards were busy as the priority was to complete tasksrather than meet their learning needs. In such circumstances, staffnurses may prefer to perform certain procedures themselves ortake over procedures commenced by students to reduce the timetaken. As a consequence, students may learn to practise “short-cut”methods in order to complete their tasks quickly. Heavy clinicalworkloads can deny students learning opportunities as they can be
delegated work that requires little or no supervision rather thanbeing provided with learning opportunities that extend them orrequire more advanced skills (Elcock et al., 2007). A positive CLE isone where students’ clinical time is valued and is used effectivelyby all stakeholders.
Whilst these particular findings may highlight the dominanceof service needs over the learning needs of students in the clinicalenvironment at times, they also point a reality of the workplaceand the competing and often recursive concerns and priorities ofthe various stakeholders in the educative process (Heath, 2002).Given that the instrument used in this study was able todiscriminate between the responses of the three groups, itsapplication allows those involved in nurse education to identifyareas where differences in perception do exist that may impact onstudent learning. Strategies could then be developed to addressthese components in ways that improve the CLE. In the presentstudy, these could relate to those items that loaded onto factors 1,4 and 6 (learner friendliness, learning tensions and peer support).For example, students could be equipped with understandings andpractical strategies that allow them to better resolve or adjust tofactors described as “learning tensions” when they do arise in theward. The skills learnt, such as establishing effective mechanismsfor securing peer support, would be largely transferable and mayalso be applied to help mitigate the effects of reality shock orburnout on initial employment as an RN (Duchscher, 2009; Mabenet al., 2006).
Conclusion
The goal of nursing education is the preparation of studentswho are able to enter the workforce and function safely andcompetently as new graduates. The ability to fulfil this function isdependent on a CLE that is supportive of student learning. Manyfactors contribute to an effective CLE. It is helpful to identify thesefrom the perspective of each major stakeholder in order to shareunderstandings so that the experience of students can beimproved and their learning enhanced. In this study, a number ofdifferences were identified between students, their tutors andstaff nurses in their perceptions of the CLE. A greater awarenessand discussion of these during undergraduate preparation,and especially towards the latter stages of a course, may allowstrategies to be developed to ease some of the stress, disillusion-ment and sometimes burnout associated with transition to thegraduate role.
The similarity in scores for the factor interpreted as “translatinglearning” encourages a level of optimism and suggests that thethree groups identified with a common purpose of clinical educa-tion: that students apply what is learned in the classroom (theory)to patient care through teamwork and enquiry.
A supportive CLE can only be created with the collaboration ofeducation and service providers. Students, as learners, also need tohave a positive attitude towards their own learning in order tomake best use of the learning opportunities available to themwhilst on placement.
This study was undertaken in Malaysia using an instrument thatwas developed from the research literature though designed to beapplied in a particular multicultural context. In recognition of thislimitation, it is recommended further work be undertaken to assessthe psychometric properties of the instrument with an indepen-dent data set drawn from different settings and cultural contexts tofurther assess its utility and confirm the 6 factor structure of thescale.
Conflict of interestThe authors declare they have no conflict of interest.
O.L. Chuan, T. Barnett / Nurse Education in Practice 12 (2012) 192e197 197
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