Because of the expanding practice expectations by employers for recently graduated RNs and the ever-increasing complexity of clinical environments, the nature and quality of student clinical learning experiences continue to increase in significance. However, not enough is known about the relationship between nursing students' clinical assignments and learning outcomes. 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's educational activities" (p. 16). Methods of structuring and organizing baccalaureate nursing clinical experiences are varied and are influenced by factors such as curriculum design and agency accessibility, as well as faculty and student preferences. Oregon Health Sciences University School of Nursing at Southern Oregon University faculty historically have used two major approaches to students' clinical assignments. Nursing students either have been placed on several units during the course of one term or have had a more consistent clinical placement. With the goal of providing optimal clinical education experiences, the faculty set out to evaluate the effects of consistent clinical assignments compared to multiple placements for nursing students.
The project had two specific aims:
* To evaluate the effects of a consistent clinical setting versus multiple placements on students' learning, satisfaction with the clinical experience, and selfesteem.
* To compare clinical agency staff's response to students with a consistent clinical experience on their unit versus multiple placements.
Both quantitative and qualitative data were collected for this study. Four instruments were used for quantitative data collection-the Rosenburg Self-Esteem Scale, (Rosenburg, 1965), as well as adaptations of the Learning Style Preference (adapted from Grobe, 1979), the Scale of Nursing Student Performance (adapted from Schwirian, 1979), and the Evaluation of Clinical Nursing Experience (adapted from Middlebrook, 1979). In addition, student scores on the National League of Nurses (NLN) Adult Health and Illness Achievement Test and the NCLEX Diagnostic Readiness Test were compared for the two groups. Interviews and openended questionnaires provided qualitative data from students, faculty, and clinical agency staff.
A class of 36 baccalaureate nursing students were assigned randomly to either multiple or consistent clinical placement during each of their two clinical courses with an adult health and illness focus. Students in the consistent placement group (n = 18) were assigned to a particular nursing unit for a 10- week term. Clinical units for these students varied from term to term but not within a term. The other half of the students were assigned to three or more units or specialty areas per term.
Students who chose to participate in the study agreed to respond to questionnaires that elicited feedback about them and their learning experiences. Thirtythree female nursing students originally entered the 2-year study. Four students withdrew from the study because of altered academic progressions. Participation in the study was entirely voluntary. The decision by a student of whether or not to participate in the study in no way affected their clinical placement, and clinical faculty were not advised which students were participating in the study.
Learning style preferences and selfesteem were assessed using self-report instruments (i.e., the Learning Style Preference and Rosenburg Self-Esteem Scale, respectively) completed by the students at the beginning and completion of each term. Students' perceptions of clinical competence (using the Scale of Nursing Student Performance) and satisfaction with the clinical experience (using the Evaluation of Clinical Experience) were assessed at the conclusion of each clinical quarter. It is estimated that completion of all of these tools by students took approximately 30 minutes per term. In addition, all students participated in standardized testing as a part of ongoing program evaluation. These measures included the NLN Adult Health and Illness Achievement Test and the NCLEX Diagnostic Readiness Test. Results from these tests were compared between the consistent and multiple placement groups, using independent sample t tests. All data were aggregated, without individual identifiers.
Data regarding clinical agency staff responses to students were collected at the end of the study using interviews. Faculty and students responded to open-ended questionnaires regarding their perceptions of the experience.
Results and Discussion
There were no significant differences between the two groups on the SelfEsteem, Learning Style Preference, or Nursing Student Performance scales. In addition, scores for the two groups on the NLN Adult Health and Illness Achievement Test and the NCLEX Diagnostic Readiness Test were not significantly different. The Evaluation of Clinical Nursing Experience Scale did yield significantly different (p < .05) responses between the two groups. Students in the multiple placement group rated their experience as more challenging (i.e., greater and variable stimuli in multiple environments) than students in the consistent placement group.
Consistent Placement Group
Qualitative data collected from students in both groups were mixed. Some students in the consistent placement group were concerned they had missed out on opportunities to experience a greater variety of clinical settings (e.g., intensive care unit, emergency room). One student remarked, "I believe we should all have the opportunity to be moved around. You don't really know if you are going to like an area until you have practiced in that area." Another student said, "Nursing school is the one time that you have a chance to explore all areas of nursing." Other students expressed a feeling of being supported by their consistent placement. Comparing her experience in the consistent adult health courses to that in a maternal-child course where she practiced on multiple unite in one quarter, one student wrote:
I was in the consistent placement group. It was difficult to compare my experience with multiple placements until I had M.C.H. [maternal-child health]. The multiple placement experience was stress inducing, jarring, and distracting. It was difficult to build proficiency and trusting relationships with staff. The consistent placement allowed me to build strong relationships with staff that was key to my success because they felt comfortable with calling me into tons of experiences and gave me a greater level of respect and independence that did wonders for my confidence.... I think consistency is vital.
Another student suggested that consistency was particularly beneficial earlier in the curriculum but less so as she progressed and gained confidence. She stated, "During AHI [adult health and illness] I found this helpful for building confidence, getting to know the floor, and for building rapport with the staff. However, during summer term, I found it to be more of a burden. I was more confident of my skills.... I didn't need the stability of a consistent placement."
Multiple Placement Group
Students in the multiple placement group also were split in their evaluations of the experience. The majority of comments were positive. One student said, "I loved not being consistent because I was able to find out who I was as a nurse and where I was most comfortable." Another remarked, "I loved the ability to be a floater, I would have gone nuts in the same place." However, some were concerned that their experiences, although varied, lacked depth. One student stated, "I had some fun experiences, but in retrospect would have learned more and would be more comfortable with my skills if Fd stayed on a med-eurg floor." Similarly, another student said, "...it was difficult to always be put in a setting not knowing how the floor worked, where things were, etc." Another student summed up by saying, "Moderation in all things is best. Lots of opportunities, but enough consistency to feel somewhat comfortable in your placement."
Both agency RNs and unit managers who were interviewed had remarkably similar responses. Themes that emerged in the interviews centered around the students' increased comfort on the unit and staff's vested interest in their success for students in the consistent placement group. One interviewee said, "The consistent students were more comfortable on the unit, not being shuffled as much. They learned unit routines, and got to know us." Another stated, "Consistent students 'got their timing,' the more you're here, the better you get at it." The phrases "accepted as part of the team" and "we developed relationships" were repeated often. A charge nurse observed that, "the ones that are here longer develop a rapport, they get more out of the nurses." Although they expressed a willingness to help all students in their learning, the staff's perception was that students with multiple placements required more time (e.g., orienting them to physical layout of the unit and the routines).
Faculty also noted the stronger relationships that formed between consistent placement students and nursing staff. In response to a questionnaire at the end of the study, one instructor commented, "Staff became protective and welcoming to consistent placement students. Positive relationships were formed." Some faculty also perceived increased confidence in students from the consistent placement group.
Other themes emerged from faculty feedback. Most faculty wanted to customize student assignments based on their individual performance, learning styles, and personality traits (e.g., anxiety level, adaptability) but felt they lacked the tools to accurately assess these factors early in the curriculum. One instructor noted that while consistent placement students were more likely than multiple placement students to manage multiple patient loads by the end of the quarter, multiple placement students more often described themselves in their final evaluations as "able to adapt to new environments."
Implications and Recommendations
Because of the small sample, caution must be used in interpreting the data from this pilot study. The quantitative tools used did not differentiate between the two groups' clinical learning outcomes. The study could be replicated using a larger sample and other measurement instruments that would capture clinical competency more directly. Further research could suggest methods for faculty to match student abilities and learning styles to preferred clinical experiences, which would maximize learning.
Because consistent clinical assignments were perceived more positively by agency staff and managers, there is the potential that using this approach will strengthen the working relationship between schools of nursing and the clinical agencies they use for student experiences. In addition, based on the results of this study and supported in the literature regarding precepting of nursing students (e.g., Yonge, & Trojan, 1992) and block clinical schedules (Dunn, Stockhausen, Thornton, & Barnard, 1995), faculty may predict that as students spend more time on a unit they would be more likely to be actively mentored by staff and have greater opportunities for socialization to unit culture.
This study suggests that some students highly value having opportunities to explore multiple nursing roles and settings. As an alternative to using clinical time, faculty could consider creating other mechanisms for students to be exposed to specialty areas. This could satisfy students' desires to explore the nursing role as expressed in different settings, without compromising the depth of student experience within their core clinical courses.
- Dunn, S., Stockhausen, L., Thornton, R., & Barnard, A. (1995). The relationship between clinical education format and selected student learning outcomes. Journal of Nursing Education, 34, 16-24.
- Grobe, S. (1979). Nurses self description scales. In M.J. Ward & M.E. Fetler (Eds.), Instruments for use in nursing education research (pp. 311-317). Boulder, CO: Western Interstate Commission for Higher Education.
- Infante, M.S. (1981). Toward effective and efficient use of the clinical laboratory. Nurse Educator, 6, 16-19.
- Middlebrook, M. (1979). Nursing curriculum content semantic differential. In M.J. Ward & M.E. Fetler (Eds.), Instruments for use in nursing education research (pp. 348-361). Boulder, CO: Western Interstate Commission for Higher Education.
- Rosenburg, M. (1965). Society and the adolescent self'image. Princeton, NJ: Princeton University Press.
- Schwirian, P. (1979). Six dimension scale of nursing performance. In M.J. Ward & M.E. Fetler (Eds.), Instruments for use in nursing education research (pp. 639-644). Boulder, CO: Western Interstate Commission for Higher Education.
- Yonge, O., & Trojan, L. (1992). The nursing performance of preceptored and non-preceptored baccalaureate nursing students. Canadian Journal of Nursing Research, 24(A), 61-75.