Journal of Nursing Education

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The Relationship Between Clinical Education Format and Selected Student Learning Outcomes

Sandra V Dunn, RN, BScN, MN; Lynette Stockhausen, RN, MEdSt; Robert Thornton, RN, MPHEd; Alan Barnard, RN, BA, MA

Abstract

Introduction

The goal of an undergraduate nursing program is to develop "an autonomous, accountable practitioner who has not only the practical skills necessary to deliver high quality nursing care, but also the broad knowledge base and analytical ability to make informed decisions about care and its management soundly based on research, rather than merely custom and practice" (Jinks, 1991, p. 127). Clinical education prepares the students for their professional role; provides them with the opportunity to apply knowledge, skills, and concepts introduced in the classroom; and is generally accepted as the arena in which synthesis of classroom, laboratory, and other learning experiences occurs. According to Infante (1981), "clinical activities, the heart of nursing's professional program of study, have been the most widely discussed and yet the least understood of all nursing education activities" (p. 16).

Previous research by Stockhausen (1993) identified that the organization of clinical education in Australian Schools of Nursing was not based on researchsubstantiated educational outcomes. The present study was initiated in response to a perceived need for welldocumented research on which to base decisions regarding undergraduate nursing clinical education programs. Of particular interest was the relationship between format of the clinical education placement and the student learning outcomes.

The structure, timing, and organization of the clinical education experience, including the number of hours per day, the number of days per week, and the number of weeks per semester devoted to clinical practice, constitute the format arrangements of the clinical placement. Research which identifies the relative advantages of various formats is required in order to provide guidance for specific clinical education format arrangements which will afford optimum learning outcomes for the student while meeting the requirements of the school, clinical experience venue, and registering authorities. Identification of any differences in optimum format arrangements for various undergraduate specialty clinical experiences, for example, mental health or acute care medical-surgical settings, is also required. The human and economic resource demands of undergraduate nursing clinical education programs are enormous, but research to guide appropriate decision making, resource allocation, and effective learning is negligible. Current approaches tend to be driven by value assumptions, prior experience, and personal preference rather than by research-based knowledge of practice and educational outcomes (Barnard & Dunn, 1994).

Aims

The aims of this study were to:

1. Describe the relationships between clinical education format and student learning outcomes for the undergraduate nursing student.

2. Identify differences in the relationships between clinical education format and student learning outcomes for Biophysical and Mental Health undergraduate nursing students.

3. Suggest appropriate changes in nursing clinical education based on study findings.

Instruments

Both qualitative and quantitative data were collected to assess six major learning outcomes of the clinical education experience. The Clinical Performance Assessment Tool (CPAT), the Student Evaluation of Subject (SES), a demographic sheet, and a semantic differential scale (SD) measuring students' affective responses to their clinical placement (Cameron-Jones & O'Hara, 1989) were used in quantitative data collection. Interviews, open-ended questionnaires, and participant observation provided the qualitative data.

The Australasian Nurse Registration Authority Committee (ANRAC) Competencies (1990) formed the basis for the CPAT. The ANRAC Competencies must be met by any nurse applying for registration in Australia and are defined as those required for safe, competent practice as an entry-level registered nurse. The CPAT used Bond/s (1983) scale for evaluation of the clinical practice of undergraduate students to grade the student in the areas of Interpersonal Relationships (7 items), Professional Development (6 items), and Clinical Decision Making (11 items). Students' mean scores in each of the assessment areas were used to give quantitative data on clinical performance. The Bondy scale has…

Introduction

The goal of an undergraduate nursing program is to develop "an autonomous, accountable practitioner who has not only the practical skills necessary to deliver high quality nursing care, but also the broad knowledge base and analytical ability to make informed decisions about care and its management soundly based on research, rather than merely custom and practice" (Jinks, 1991, p. 127). Clinical education prepares the students for their professional role; provides them with the opportunity to apply knowledge, skills, and concepts introduced in the classroom; and is generally accepted as the arena in which synthesis of classroom, laboratory, and other learning experiences occurs. According to Infante (1981), "clinical activities, the heart of nursing's professional program of study, have been the most widely discussed and yet the least understood of all nursing education activities" (p. 16).

Previous research by Stockhausen (1993) identified that the organization of clinical education in Australian Schools of Nursing was not based on researchsubstantiated educational outcomes. The present study was initiated in response to a perceived need for welldocumented research on which to base decisions regarding undergraduate nursing clinical education programs. Of particular interest was the relationship between format of the clinical education placement and the student learning outcomes.

The structure, timing, and organization of the clinical education experience, including the number of hours per day, the number of days per week, and the number of weeks per semester devoted to clinical practice, constitute the format arrangements of the clinical placement. Research which identifies the relative advantages of various formats is required in order to provide guidance for specific clinical education format arrangements which will afford optimum learning outcomes for the student while meeting the requirements of the school, clinical experience venue, and registering authorities. Identification of any differences in optimum format arrangements for various undergraduate specialty clinical experiences, for example, mental health or acute care medical-surgical settings, is also required. The human and economic resource demands of undergraduate nursing clinical education programs are enormous, but research to guide appropriate decision making, resource allocation, and effective learning is negligible. Current approaches tend to be driven by value assumptions, prior experience, and personal preference rather than by research-based knowledge of practice and educational outcomes (Barnard & Dunn, 1994).

Aims

The aims of this study were to:

1. Describe the relationships between clinical education format and student learning outcomes for the undergraduate nursing student.

2. Identify differences in the relationships between clinical education format and student learning outcomes for Biophysical and Mental Health undergraduate nursing students.

3. Suggest appropriate changes in nursing clinical education based on study findings.

Instruments

Both qualitative and quantitative data were collected to assess six major learning outcomes of the clinical education experience. The Clinical Performance Assessment Tool (CPAT), the Student Evaluation of Subject (SES), a demographic sheet, and a semantic differential scale (SD) measuring students' affective responses to their clinical placement (Cameron-Jones & O'Hara, 1989) were used in quantitative data collection. Interviews, open-ended questionnaires, and participant observation provided the qualitative data.

The Australasian Nurse Registration Authority Committee (ANRAC) Competencies (1990) formed the basis for the CPAT. The ANRAC Competencies must be met by any nurse applying for registration in Australia and are defined as those required for safe, competent practice as an entry-level registered nurse. The CPAT used Bond/s (1983) scale for evaluation of the clinical practice of undergraduate students to grade the student in the areas of Interpersonal Relationships (7 items), Professional Development (6 items), and Clinical Decision Making (11 items). Students' mean scores in each of the assessment areas were used to give quantitative data on clinical performance. The Bondy scale has demonstrated discrimination and reliability in use with second and third year students, reporting mean scores of 4.0 and 3.95 (SD = .46 and .52) over 2 consecutive years for second year students (P=NS), and mean scores of 4.39 (SD = .44) and 4.36 (SD - .45) over 2 consecutive years of third year students (P = NS). Additionally, the differences between the means for the second and third year students were significant during each year (P<.001) (Hawley & Lee, 1991).

Table

TABLE 1Research Schedule

TABLE 1

Research Schedule

The SES asked students to provide an overall rating for the subject on a 1 to 7 Likert scale. This instrument is used across the University to provide student feedback on subject content and teaching. During the year in which this study was undertaken, the university-wide mean for overall rating of subject was 4.53 (SD not reported).

The final quantitative tool was a 13-item semantic differential scale eliciting students' affective responses to the clinical placement. Descriptor pairs included usefuluseless, vital-unnecessary and informative-uninformative (Cameron-Jones & OHara, 1989). The SD has been extensively used in studies exploring students' affective responses to their clinical experiences in a number of clinical educational settings, including nursing, pharmacology, physiotherapy, and teacher education (N = 1262) (Cameron-Jones & OTIara). Two subscales, the organization scale and the value scale, were entered into data analysis. The reliability coefficients for the full scale was .90 in the present study, with alpha coefficients of .91 for the value subscale and .46 for the organization subscale. The low alpha for the organization subscale may be related to the small number of items in the subscale and must be considered when interpreting the results.

Method

All students in the University's Bachelor of Nursing program leading to registration undertake one year of a Mental Health nursing strand and another year of a Biophysical nursing strand. Each of these strands may be taken in either the second or third year of the undergraduate nursing program. The conventional format for clinical education in this University is 1 day per week for 14 weeks, followed by a 2-week block at the end of the semester. A convenience sample of 64 second and third year undergraduate nursing students in either the Biophysical or Mental Health strand of their program and all clinical facilitators involved in the students' clinical placements was used for this study.

In order to evaluate effects of formats on clinical educational experiences, year two and three students from each strand were assigned to one of two formats, 1 day per week or 2 consecutive days once every 2 weeks. Student assignment to groups was based on student preferences and availability; group assignment to format was random. The four study groups of 16 students each thus formed were: Group 1 - Mental health 2 days once every second week × 14 weeks (Part A) followed by a 2-week block at the end of the semester (Part B). Group 2 - Biophysical 2 days once every second week × 14 weeks (Part A) followed by a 2-week block at the end of the semester (Part B). Group 3 - Mental Health 1 day per week × 14 weeks (Part A) followed by a 2-week block at the end of the semester (Part B). Group 4 - Biophysical 1 day per week × 14 weeks (Part A) followed by a 2-week block at the end of the semester (Part B). During Part A of the clinical experience, the students were in either the 1 day per week format or the 2 day every second week format for 14 weeks, but in Part B, all students were in the 2- week block format. These formats were selected for study as they offered viable alternatives to the present clinical education arrangements, were feasible within the constraints imposed by the university system, and explored a reasonable range of different formats.

The simultaneous use of qualitative and quantitative methods allows the researcher to cross the empirical, interpretive, and clinical research paradigms. In this study, a combination of qualitative and quantitative methods was used to explore the relationship between clinical education formats and clinical learning outcomes, while providing a contextually rich portrait of the study setting. The methods were interactive, ultimately providing a more complete picture of the study than that which could be obtained using either method singularly.

The researchers collected qualitative data throughout the 16 weeks of the clinical experience. Within the first 2 days of the placement, students in Groups 1 and 2 were interviewed by a researcher to determine any differences they anticipated between the conventional 1 day a week placement which they had experienced for the previous three semesters, and the 2 days once every 2 weeks placement (Table 1). These interviews were informal and semi-structured, with the researcher encouraging discussion on the differences students anticipated during their clinical experience, but not otherwise directing the discussion. Groups 3 and 4, those undertaking the conventional 1 day per week clinical format, were not interviewed at the commencement of their placements as it was felt data on anticipated impact of the familiar format on learning outcomes would not be significantly different than the data which would be collected during the later interviews.

Participant observation took place during Part A of the clinical placements. Open-ended written questions and unstructured group interviews were conducted by the researcher following Part A. A second set of open-ended written questionnaires and group interviews occurred at the conclusion of Part B of the clinical experience. This set of interviews, although still only loosely structured, were directed by the ongoing data analysis, providing the opportunity to test emerging themes and further explore the relationships revealed. All interviews were transcribed verbatim, coded, and entered into data analysis.

In order for students to have had several weeks of clinical practice during the semester to become familiar with the wards on which they were placed, quantitative assessment tools were completed at the end of Part A and again at the end of the Part B of the clinical experience (Table 1). The demographic data sheet was completed at the time of the initial interviews with each group.

Data Analysis

Qualitative and quantitative data analysis methods were used interactively, with the quantitative analysis helping to identify potential categories in the qualitative data, and the qualitative data assisting in a rich interpretation of the quantitative results. Format group was the independent variable and the five outcome measures (interpersonal relationships; clinical decision making; professional development - CPAT; value and organization - SD; and overall rating - SES) were the dependent variables. As there was no reason to believe that the assignment of students to formats through the process described earlier would result in any biasing of the formats on the basis of the outcome variables, and in order to remain within the time and funding resources available for the study, a post-test-only research design was adopted. The repeated measures MANOVA was used to examine differences across format groups and between Part A and Part B within each format group for each of the dependent variables. Analysis of variance was further defined with univariate analysis followed by post hoc Tukey test (Table 2).

A grounded theory approach to qualitative data analysis sought to discover thematic categories within the data and to identify relationships between these categories. These categories were defined by the data and emerged during the data collection. Qualitative reliability was established by having two researchers independently code sections of the data and compare the results. Any areas of divergence were discussed and reevaluated. This procedure was repeated until the coding was in accord in all areas (Miles & Huberman, 1984).

Results

Interpersonal relationships. Interpersonal relationships were a dependent variable measured by the CPAT. Interpersonal relationships also emerged as a primary theme of the qualitative data. These interpersonal relationships characterized the students' interactions with the clinical facilitator, clinical nurses, and clients. In the CPATs, clinical facilitator evaluations of interpersonal relationships for Groups 3 and 4 (1 day per week) were significantly better than those for Groups 1 and 2 (2 days every second week) (P<.05, Table 2). This was true for both Part A and Part B of the clinical experience. When these results were compared and integrated with the qualitative data, some understanding of the similarities and inconsistencies between the groups could be established.

Students in Groups 1 and 2 expressed frustration with the 2 day every second week format because they perceived the arrangements did not allow them the opportunity to form any predictable relationships with either the clinical nursing staff or the clients. Holidays and university breaks interrupted the predictability of the placement. The lack of an easily understood pattern of student presence on the ward meant that clinical nursing staff did not have the opportunity to know the students as individuals ("by the end, staff probably didn't even know our names"). The students perceived the clinical staff did not appreciate the objectives or capabilities of the students, and often did not even know from which school of nursing they came: "With the 2 days (every second week) [the staff] were not sure which year group you were or what you were up to." The clinical nursing staff often set the students on an unproductive round of menial tasks for the shift (making all the patient beds, doing all the hygiene care): "You're always getting people saying 'Hey student, come here!," ". . . end up frequently caught up in menial tasks due to staff seeing students as Qaborers)," and were understandably reluctant to relinquish control of the patients, for which they had responsibility, to a basically unknown student nurse.

Table

TABLE 2Quantitative ResultsPARTA

TABLE 2

Quantitative Results

PARTA

Of major concern to the students in all format groups was the development of a rapport or productive relationship with the clinical nurse, client, and clinical facilitator. Issues of trust, rapport, and acceptance were seen as fundamental in the establishment and maintenance of relationships with registered nurses. The students stated that it was difficult to form these relationships during Part A, and the lack of a well-established relationship with the clinical staff was a major hindrance in the student's attainment of the learning goals set for the semester. "[Clinical staff nurses] have to get used to you all over again (after the 2 week break). As well, they hover when you're only there for 2 days because they know you're only there for 2 days, and they want to make sure what you're doing is the right thing . . ." The clinical staff were pivotal to the student's experience: "Hospital staff acceptance of students [needs to be improved]. Staff can make placements very unhappy for . . . students."

While aspects of the issues of predictability, trust, rapport, acceptance, accountability, and involvement interlaced across the interpersonal relationships, the overarching factor that crossed all relationships was that of effective communication. Many of the barriers to communication, which the students perceived in Part A of the clinical experience, were overcome by the consistency of the block placements. In the 2-week block placement (Part B), there remained as with Part A, no significant coherence between the Mental Health and Biophysical strand 3 (P=NS, Table 2). Again, Groups 1 and 2 received lower scores than Groups 3 and 4 (P<.05). Overall, however, there was an increase in the facilitators' scoring of the students' interpersonal relationship development between Part A and Part B (P = NS).

The qualitative thematic areas remained the same for Part B as they had been for Part A, however, responses became more positive, such as "Interaction with staff and patients has improved as we can relate better being here every day"; "Staff interaction has improved, they know who we are and when we are going to be here"; "The staff trust you more when they see you each day"; "The staff and clients seem more accepting of you"; "Client interaction has improved." "You get to know your patients a bit more, so you get to be able to talk to them. By the end of the week . . . you walk in and it's just like a friend."

Clinical decision making. The learning outcome, "clinical decision making" (CDM), was a component of the CPAT. Scoring criteria was based on the AANRAC Competencies and nursing process, and included items such as "formulates accurate nursing diagnoses," "implements interventions/activities safely and accurately," "organizes and prioritizes daily activities," and "accurately records data relevant to the client's care." Following Part A of the clinical experience, the only significant difference was between Group 4 and Group 2, with the 1 day per week group graded significantly higher than the 2 days every second week group (P<.05, Table 2).

Students' comments revealed a great deal of frustration in the 14 week placement (Part A). They indicated a lack of real involvement in patient care, an inability to formulate or implement plans, or to observe patient outcomes. The influence or impact of student involvement with patient care and the evaluation of outcomes in developing clinical practice judgment was identified as crucial. This frustration and lack of involvement in patient care was apparent in all groups: "With 1 day, you go with them, see the procedure, and go home. What happened to them, did it work?"; "You don't know the client, you don't know what they need, you don't have the opportunity to follow through on what they need . . ."; and "When you are here 2 days (every second week), you feel you have to go along with what the nurses say . . ." There were occasional benefits to the widely spaced patient contacts: "... he changes from week to week . . . one week, he is manic and the other week, he's depressed ... it just allows you to see the differences in their conditions . . ."; however, "it's not something you can count on ... it doesn't help you, nor does it help them."

Students involved in biophysical clinical practice showed a tendency toward a mechanistic approach to clinical learning insofar as many stated they tended to focus on getting through as many clinical skills as possible. Students emphasized the strategy of going from "skill to skill" in an attempt to experience what for many had only previously been witnessed or simulated in a university laboratory. The limited time available to prepare for clinical experience and to engage in a relationship with a patient whom they were unlikely to see the next week encouraged students to focus less on a holistic perspective.

Following the 2-week B block (Part B), the scores for Groups 3 and 4 (1 day per week) were significantly higher than those for Groups 1 and 2 (2 days every second week) (P<.05, Table 2). In addition, the assigned scores for the students' CDM following Part B were significantly higher than the CDM scores after Part A for all groups (P=NS).

The student comments following the 2-week clinical placement were strongly indicative of the importance they attach to following through patient care. "This prac is more coherent - you can follow patients through"; "Continuity is being able to follow up care of patients over a longer period and thus be able to evaluate care more effectively"; "Able to arrange activities and follow through with clients"; and "Continuity is the main thing, because it enabled you to effectively evaluate your care and to follow up over a longer period of time, got a lot more value . . ."

The students particularly emphasized increasing personal confidence in clinical settings and the development of clinical skills in the 2-week block: "you can practice a lot more of your skills"; "continuous practice over the 2 weeks makes it easier to remember skills, medications, etc. because of being able to get a certain amount of repetition"; "gives you the opportunity to gain confidence and skills."

This continuity of experience gave the students confidence in their own ability to plan, implement, and evaluate effective patient care. "If you're here for 2 weeks, you feel more responsible for your patient . . . you feel more confident of even thinking about it, because they're your patients and you're working with them ... on a continual basis." and "I think a lot more . . . if it's your patient, you're responsible for them, you've got to learn how to chart everything properly and all the different operations . . . doing a lot more because you're responsible."

Professional development. Students' professional development was rated by the clinical facilitator on items concerning humanistic, moral, ethical, responsible, and reflective practice. Group 4 students were scored significantly higher in Professional Development during Part A of the clinical experience than were students in the other groups (P<.05, Table 2). During Part B, students in Group 1 scored significantly lower than the other groups (P<.05). There were no other significant differences between comparison groups. There was, however, significant differences at the level of P = NS in the facilitators' ratings of students' professional development between Part A and Part B of the clinical experience.

During interviews, students occasionally spoke of their own role in influencing personal learning outcomes: "It depends on the person and how much effort you are willing to put into it and how motivated you are. It's up to you to take your learning in your own hands and say okay, today I want to take on patients, today I want to go to theater, today I want to stay with someone and spend the day going around and helping." These comments were more common following Part B: "If you're only there for 2 days (every 2 weeks), you don't feel confident enough to choose your own patient. In the 2-week block . . . you'd have your own workload and your own responsibilities."

Of particular relevance to professional development was the students' awareness of the client as unique individuals with dignity and self-worth. The recurrent theme of human relationships again surfaced, indicating the students felt more in tune with the patients following the Part B block: "I know the individual patients and their needs and abilities"; "It makes you appreciate how much the patient appreciates what you are doing"; "You're not as task oriented because you're getting out of that and into the mode of treating that patient as a person." Students also noted their ability to influence the professional growth of others: "We seem to get things done - sparks things off . .. after 2 weeks, we really made a difference to those wards and (the staff) are all aware of it." Some discussion of the essential nature and purpose of clinical education also emerged: "The clinical practice is related to my whole concept of nursing. Everything that I'm learning . . . I'm putting everything into practice."

Value. On the value subscale of the semantic differential instrument, students were asked to rate their clinical placement on a set of adjective pairs including such words as useful/useless, satisfying/disappointing, worthless/ valuable, relevant/irrelevant, and uninspiring/stimulating. In Part A placements, there were no significant differences between formats, but the Biophysical placements were rated higher than the Mental Health placements for both of the format groups (P<.05, Table 2).

Student comments following both of the formats in Part A again reflected students' perceptions of a disjointed experience which interfered with the learning possibilities. "When we come here on our one day, you're treated like you're not there . . . they have no consideration that you are here to learn"; "really disjointed . . . where we don't get to know the patients"; "I think it's an introduction thing every time, every week, what can you do, what year are you in . . ."; "[On the one day] you're so busy because they've had you do all the menial things for them"; "Sort of going from skill to skill ... so you can't really plan." The learning value of the placement was also affected by the weekly routine of the unit: "The day I was on was the day they discharged patients, so I had nothing to do," or the exclusion of students from patient treatment sessions due to their inability to participate on a regular basis: "We didn't even have a chance to sit in on a group and see how they do it."

Following the 2-week block placement (Part B), there was no significant difference between Biophysical format groups or the 2 days every second week groups; however, Group 3 (1 day per week Mental Health) rated their experience as significantly less valuable than the other groups (P<.05, Table 2). All groups scored Part B as significantly more valuable than Part A (P= NS).

The value of the 2-week block for the students was captured in statements such as "I can put all my theory to practice so it reinforces everything I have learned"; "Also you can make plans . . . we've organized heaps of things"; "They know you're coming in everyday, so they're prepared for the fact that you'll have your own workload and your own responsibilities" and finally, "During the 2-week block, as opposed to the 2 days a week, I have learned heaps."

Organization. Regarding the organization of clinical practice, the quantitative data did not demonstrate a clear direction of student preferences for either the 1 day a week or the 2 days every 2 weeks format group (Table 2). However, for all groups, Part B was rated significantly higher in terms of organization than Part A (P = NS).

One of the major areas of interest in the qualitative analysis was the impact the organization of the clinical experience had on the students' social and work patterns. These included university study and assignments, parttime employment, family responsibilities, and social activity. When the students had more than one clinical day during the week, "It gets quite hectic when an assignment is due, and that was one of our worries, but as it turned out, it was quite okay"; "It was unusual having 2 days (every second week) . . . having to do two assessments and reflective journals for 2 days running took up a lot of time"; "It was very wearing coming 2 days a week (on evenings) . . . especially if you have a lecture the next day at 9 a.m."; but "[The 1 week offj was really good for study." The variable pattern of clinical days obliged students to modify work schedules: "different travel arrangements [because I] work on Thursday night, so that means [I] had to start here early and finish a little bit earlier . . ." Socially, "... [1 week] break was still good. You'd go to the coast for the day; you didn't have something on every single day."

Despite the ideal of theory-practice integration cherished in nursing education, students stated that the experience of clinical practice often bore little relationship to the theoretical content being addressed at the university. Students outlined their interest in topics which were never available in clinical practice or were out of sequence with the course: "We didn't learn personality disorders until week 10 and that was three quarters through our practice"; "You learn things in Uni and then you come out for the 1 day, you may not get to do it." They complained of not enough time spent in university laboratories or time which was of poor quality: "We enter the hospital with no hands-on, but a brief memory of watching someone perform a skill we are not familiar with once."

Students' approaches to clinical practice during 1- or 2-day experiences were influenced to a large extent by organization with respect to learning opportunities. The availability of only 8 hours for 1 or 2 days meant that if organization was lacking, then learning was severely limited because learning experiences were not taken up on the day: "When we're there just 1 day . . . half of it is spent working out what we're doing." Staff and patients were less prepared for the students' arrival in the clinical area and less able to quickly engage in a productive relationship.

Students indicated the 2-week block (Part B) presented better opportunities for them to organize their own learning in conjunction with their facilitator and the nursing staff "Everything was organized well with regard to staff being accepting and helpful." Learning opportunities were more plentiful: "You tend to get more because the staff tend to get to know you; the staff know that they can trust you to do it all, whereas with the (14-week placement), they don't give you as much"; and the students' time management skills had improved their personal organization: "You get to know where things are, you don't have to ask everyone every 5 minutes where everything is." This continuity of time in the clinical arena afforded the students an opportunity to develop thenconfidence, increase their skills, and move beyond the focus on the individual tasks at hand to see the overall picture of client care: "Less time was wasted because we could organize our patient load the day before and we could remember the specific needs of our patients as well as adapt to any additional needs."

Overall rating. The students were asked to rate their clinical experience overall on a seven-point scale from "very poor" to "excellent." Neither the 1 day per week nor the 2 days every second week was universally preferred by the students (Table 2). Students in mental health rated the 1 day a week as significantly better than the 2 days a week (P<.05), but students in biophysical rated the 2 days every 2 weeks as better than the 1 day a week. Both biophysical health groups were rated higher than either of the mental health groups (P<.05). Finally, Part B was rated significantly better than Part A (P= NS).

Discussion

Neither the 1 day a week or the 2 days every 2 weeks format demonstrated clear superiority across all outcome variables. The Biophysical strand students rated the 2 day every second week placement significantly better overall than the 1 day per week placement; however, the reverse was true for the Mental Health strand students (P<.05, Table 2). Other learning outcomes indicated an equivocal response without a strong preference for either format. Much of the qualitative data regarding the Part A clinical experience was negative, indicating the students had difficulty in meeting their learning goals and did not see the clinical placement as a rewarding or fulfilling experience. The positive student responses to 1- and 2-day clinical experiences occurred when students were willing to reflect on and take responsibility for their own learning, and the experience was well planned and relevant to student needs.

The students in both format groups showed significantly better learning outcomes in all measured variables during the 2-week block than during the initial 14 week portion of the clinical placements (P=NS, Table 2). Student overall evaluation of the placement and affective responses were also significantly better during the 2-week block for both format groups (P=NS). Three interrelated factors emerged:

1. Through enabling establishment of continuity of care, students established an improved rapport with the patients and the patients began to trust the students during the 2-week block. Staff tended, after an initial period, to accept students' presence and were more open to the students' need for freedom and responsibility within the clinical environment.

2. Students indicated that the block experience assisted them to gain confidence and consider more holistically the care of the people they were nursing, which improved self-esteem and personal confidence. Students emphasized a need to give holistic care to familiar patients.

3. The 2-week experience provided the student with a broader understanding of the clinical environment by providing a wider range of learning experiences and facilitating improved communication with patients and staff

There are several sources of error which need to be considered when evaluating the quantitative data. Each of these format groups had a different clinical facilitator. In the Mental Health groups, there was a change in facilitator during the duration of the study for some of the students. Interrater reliability may have been a factor influencing the CPAT scores. The CPAT was used as a routine educational evaluation tool and stringent research standards were not maintained. Additionally, the individual facilitators may have influenced the students' perceptions of their clinical learning experience. The facilitator's effect on the clinical experience was both direct, acting as a teacher, role model, and assessor for the students; and indirect, influencing the clinical staff and their attitudes and actions toward the students.

While much of the American and Australian research to date focuses on the role of the clinical facilitator in establishing the learning environment for the student (Daggett, Cassie, & Collins, 1979; Dawson, 1986; Marriott, 1991; Morgan & Knox, 1987), our research to date seems to support the work of British researchers in emphasizing the importance of the clinical nurse as a primary mediator in the students' learning outcomes (Lewin & Leach, 1982; Ogier, 1981; Orton, 1981). It is the establishment of the human relationships with the clinical Registered Nurses which allows the students access to the patient, and the clinical facilitator appears to have a less significant role in establishing those patient contacts than in facilitating the staff-student relationship.

The 2- week block (Part B) was undertaken at the conclusion of the 14-week Part A clinical placement. The students had prior knowledge of the specific setting in which they continued their experience during Part B, and may have established staff contacts and acceptance, as well as developed the foundations in clinical decision making and professional development which enhanced their Part B experience. However, the qualitative data does not seem to support this interpretation of the results, indicating that students felt Part A had produced no important advances in any of the learning outcomes. The congruence of clinical facilitators' and students' perceptions on the relative merit of Part A and Part B as learning formats lends support to the research conclusions.

The settings in which the four groups were placed varied widely. The different formats in which the groups practiced their clinical education was but one of the factors which may have determined the students' learning outcomes and affective responses to the experience. As in most naturalistic studies, these confounding variables are virtually impossible to control. Instead, the researchers must seek confirmatory evidence to support the conclusions drawn from the study. In the present case, the triangulation of qualitative and quantitative methodologies provides the evidence that supports the conclusions of the researchers.

Conclusion

There has been a paucity of published research which explores the relationships between clinical education formats and student learning outcomes. The results of this study demonstrate no consistent differences in the student outcomes which clearly favored either the 1 day per week or the 2 days every second week format. Each format seemed to have advantages and for the most part, these advantages were not specific to either the Mental Health or the Biophysical strand students. There were, however, highly significant differences between the perceived benefits of a short and block experience. These differences were consistent in both the qualitative and quantitative data and indicated the student outcomes were far superior in the 2-week block.

The integration of the quantitative and qualitative data provided an intricate tapestry through which the twin themes of human relationships and student learning are inextricably interwoven. The data has produced some rather predictable outcomes, but also some surprising insights. As with much in teaching and learning, the results have raised a number of new questions and suggested fertile fields for further study. Further analysis of the data and further research in this area may help to clarify some of the questions remaining.

Integration of research findings into nursing practice is a complex process involving not only the perceived value and applicability of the findings to the practice setting, but the surmounting of obstacles to change. Feasibility of implementation entails consideration of financial, time, and human resources. Clinical experience is the heart of undergraduate nursing education, combining art and science and defining nursing as a practice profession. Whether changes in clinical education formats will result from research such as this study may depend as much on the willingness of the profession to reconsider opinions long held, and to undertake a potentially difficult and painful transition as it will on the findings themselves.

References

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TABLE 1

Research Schedule

TABLE 2

Quantitative Results

PARTA

10.3928/0148-4834-19950101-06

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