Ms. Berntsen is Assistant Professor, Faculty of Health and Social Studies, Telemark University College, Porsgrunn, and Ms. Bjørk is Associate Professor, Institute of Nursing and Health Sciences, University of Oslo, Oslo, Norway.
The authors thank Professor Darell Fisher, Curtin University, for his advice and encouragement during the planning phase of this study.
Address correspondence to Karin Berntsen, MNSc, RN, Assistant Professor, Faculty of Health and Social Studies, Telemark University College, Postbox 203, N-3901-Porsgrunn, Norway; e-mail: email@example.com.
The proportion of older adults in the population is growing on all continents, and at the same time older adults are living longer (United Nations, 2007). This trend increases the need for health care services and qualified personnel. Although RNs constitute the majority of health care professionals in the health care sector in Norway, a recent study has reported that the number of nurses employed in older adult care is inadequate (Hofseth & Norvoll, 2003). In addition, several studies have shown that working with older adults is the least preferred area of practice among nursing students in Norway (Bergland & Lærum, 2002; Kloster, Høie, & Skår, 2007), as well as in other countries (Happell, 2002; Stevens & Crouch, 1998). Clinical placement in nursing homes is obligatory for nursing students in Norway and is most often their first placement (Kunnskapsdepartmentet, 2008); however, it is a challenging place to learn due to patients’ complex care needs (Xiao, Paterson, Henderson, & Kelton, 2008). Several authors have underscored the importance of focusing on how the learning environment can affect students’ learning (Chan, 2001b; Ip & Chan, 2005; Henderson, Twentyman, Heel, & Lloyd, 2006; Xiao et al., 2008). Because positive experiences during clinical placement may influence later career choices, it is essential to pay attention to the learning climate for nursing students in nursing homes (Banning, Hill, & Rawlings, 2006; Robinson et al., 2008; Sheffler, 1998). Therefore, the current study aimed to assess how nursing students perceived the learning environment during their first clinical placement in nursing homes.
Learning in Clinical Studies
Practical knowledge and personal experience are cornerstones for integrating theoretical knowledge and developing nursing skills and are a major reason for clinical placements during nursing education (Midgley, 2006). Experiences in the clinical field support nursing students in bringing together cognitive, psychomotor, and affective skills in nursing activities with patients (Chan, 2001a). However, the overall focus in health care institutions is treatment (i.e., cure and care for patients), rather than teaching, learning, and professional growth (Bjørk, 1999; Karuhije, 1997). Similar to newly graduated nurses, nursing students find themselves in two different contexts that influence their learning: a context of learning and a context of performance. A context of learning is created when learning is acknowledged as a legitimate aspect of the nursing situation (e.g., when an experienced nurse accompanies the student either to observe or teach in the situation). However, usually, students are on their own and thus are forced into a context of performance where they have to do the best they can and know by repeating the most effective way of acting learned so far (Bjørk, 1999). When students are in clinical settings, they need to experience both contexts and enough opportunities for adequate guidance to connect performance and learning.
Most studies of clinical learning during nursing education have been performed in hospital settings. Supervision and mentoring were aspects with an effect on students’ learning outcomes (Hauge, 1999; Saarikoski, Leino-Kilpi, & Warne, 2002). A comparative study between Finnish and British nursing students showed that a better system for supervision by clinical teachers was interpreted to be a major reason for Finnish students’ higher satisfaction with their clinical studies (Saarikoski et al., 2002). Clinical placements provided students with opportunities to perform nursing care and practice specific nursing skills, as well as observe role models and reflect on a variety of clinical experiences (Chan, 2001b; Hauge, 1999). Clinical placements also afforded the students both planned and unplanned learning activities with patients in a complex social context (Chan, 2001b; Heggen, 1995). Earlier studies found that many students perceived clinical placements as anxiety provoking, which may have affected their learning process and learning outcomes (Campbell, Larrivee, Field, Day, & Reutter, 1994; Heggen, 1995). Being acknowledged, welcomed, guided, and provided with a comprehensive orientation from the beginning may reduce anxiety and pave the way for positive learning experiences (Hauge, 1999; Henderson, Twentyman, Heel, & Lloyd, 2006; Robinson et al., 2008; Rogan & Wyllie, 2003).
Guidance by preceptors and clinical teachers had a positive influence on the learning outcome, if sound pedagogical principles guided student supervision (Henderson et al., 2006; Saarikoski et al., 2002; Thorell-Ekstrand & Bjorvell, 1995). Purposeful organization of learning situations with variation in care tasks was also considered a key factor in a good clinical learning environment (Chan, 2002; Saarikoski et al., 2002). Students considered it important that the clinical lecturer was a facilitator rather than an instructor (Hauge, 1999; Henderson et al., 2006; Robinson & Cubit, 2005). Innovative teaching methods have also been suggested to positively influence perceptions of the learning environment (Chan, 2002; Henderson et al., 2006; Robinson & Cubit, 2005). However, in several recent studies, students reported that innovative teaching was the least developed aspect of clinical learning environments (Chan, 2002; Ip & Chan, 2005; Midgley, 2006). In all three studies, students also reported that the best developed aspect of the learning environment was Personalization (i.e., opportunities for the student to interact with preceptor and members of the nursing team and to experience concern for the students’ personal welfare).
Clinical Studies in Nursing Homes
Patients in nursing homes need highly qualified nursing care. Due to this demand, nursing students considered clinical studies in nursing homes to be extremely challenging, particularly first-year students with limited training in meeting patients’ basic needs (Bergland & Lærum, 1999). There are few positions for nurses in nursing homes, compared with hospitals, which hindered maintenance and development of good nursing care and thereby compromised the students’ learning environment (Hauge, 1999; Kloster et al., 2007; Robinson et al., 2008; Xiao et al., 2008). A survey of 53 nursing schools in the United States confirmed that a lack of appropriate role models among nursing home staff was a major problem in their use for clinical learning (Chen, Brown, Groves, & Spezia, 2007). Nursing students’ negative attitude toward older adults has been a common finding across decades and countries and probably a major reason for the lack of interest in older adult care (Bergland & Lærum, 1999, 2002; Disch & Høie, 2005; Happell, 2002; Kloster et al., 2007; McCracken, Fitzwater, Lockwood, & Bjørk, 1995). Studies have reported positive changes in students’ attitudes during placement in older adult care settings due to positive faculty attitudes toward older adults (Bergland & Lærum, 1999; Sheffler, 1998). In addition, work among older adults during clinical placements and part-time jobs has also been reported to influence students’ attitudes both positively (Banning et al., 2006; Bergland & Lærum, 1999; Robinson & Cubit, 2005) and negatively (Happell, 2002).
Several factors in the hospital learning environment have been reported to influence student learning outcomes during clinical placements. Although nursing homes are considered important clinical placements for nursing students in many countries, few studies have explored the learning environment in older adult care facilities. Nursing homes are complex organizations with few positions for RNs, and a limited number of nursing students consider older adult care as a career choice in the future. Creating better learning environments in older adult care institutions may help to remedy this problem. Increasing our knowledge about the influence of different factors in the learning environment is therefore warranted.
In the current study, the following research questions were developed to explore nursing students’ perceptions of the clinical learning environment in nursing homes:
- What are nursing students’ perceptions of the clinical learning environment in nursing homes?
- Which factors in the clinical learning environment have the greatest effect on students’ overall satisfaction with their clinical placement?
The study used a cross-sectional survey design in which nursing students in clinical placements at eight nursing homes completed a questionnaire on one occasion.
Sample and Setting
A cohort of first-year nursing students in a bachelor degree nursing program were invited to participate in the study (N = 92). The final sample comprised 74 students (80%). Forty-one students (55%) were younger than age 25, 16 students (22%) were between ages 25 and 35, and 17 students (23%) were older than age 35. Approximately half of the students (54%) had experience from working in nursing institutions before entering nursing studies, and 13 students (18%) confirmed former higher education. Clinical studies for the target group were organized in a 4-week module, with a 30-hour workload per week. During placement, students were supervised and guided by both teachers and nurses. Each student was allocated an RN as a preceptor. Both the preceptor and the teacher supervised each student twice during morning care. The teacher also organized and facilitated reflection in groups at each nursing home two times during placement.
Data Collection and Instrumentation
Data were collected using a questionnaire with two sections (i.e., demographic variables and the Clinical Learning Environment Inventory [CLEI]) (Chan, 2001a, 2001b, 2002). The CLEI was developed to include three dimensions that are relevant in all environments (i.e., relationship dimensions, personal development dimensions, and system maintenance and system change dimensions) (Fisher & Parkinson, 1998; Moos, 1974, as cited in Chan, 2001b). According to Chan (2001b), the CLEI originally consisted of 35 items evenly distributed in five subscales:
- Individualization—reflects the extent to which students are allowed to make decisions and are treated differentially according to ability or interest.
- Innovation—measures the extent to which the clinical teacher or clinician plans new, interesting, and productive learning experiences, teaching techniques, learning activities, and patient allocations.
- Involvement—assesses the extent to which students participate actively and attentively in hospital ward activities.
- Personalization—emphasizes opportunities for individual students to interact with the clinical teacher or clinician and concern for students’ personal welfare.
- Task orientation—assesses whether the instructions for hospital activities are clear and well organized.
These scales pertain to specific aspects of the environment. Chan (2002) also developed an additional seven-item scale to assess students’ overall satisfaction with their clinical placement. This subscale (i.e., Satisfaction) was later added to the final version of the CLEI (Chan & Ip, 2007). The CLEI comes in two versions: the Actual form, which measures the learning environment as perceived by the student, and the Preferred form, which measures ideally liked or preferred perceptions. Item wording is similar, but instructions differ. In the current study, only the Actual form was used. Development of the CLEI was based on an in-depth literature review on classroom and clinical learning environments and discussion with experts in the field of nursing education and clinical nursing. Internal consistency, estimated with Cronbach’s alpha, was reported in the range of 0.73 to 0.84 for the Actual form (Chan, 2001b). A later study reported Cronbach’s alpha on the subscales of the Actual form between 0.50 and 0.80 (Ip & Chan, 2005). The discriminant validity was assessed by calculating the mean correlation of one scale with the other scales. The values obtained for the mean correlation ranged between 0.39 and 0.47 for the Actual form and indicated that the CLEI measured distinct, although somewhat overlapping, aspects of the hospital learning environment (Chan, 2001b).
Responses to each item are marked on a 4-point Likert-type scale with response alternatives of 5 (strongly agree), 4 (agree), 2 (disagree), and 1 (strongly disagree). The 42 items are a mixture of positive and negative items with 7 items in each subscale. To calculate mean scores, the scores on negative items are reversed. In the current study, the CLEI was translated from English into Norwegian using translation procedures as described by Kim, Fisher, and Fraser (1999). Cronbach’s alpha varied between 0.43 and 0.86. The Satisfaction subscale was at the high end, with a value of 0.86, whereas both the Involvement and Personalization scales had comparatively low values at 0.43 and 0.56, respectively.
The first-year nursing students at one university college were given written information and invited to participate in the study. The questionnaires were administered in the classroom the week following completed clinical studies. The researcher was present to answer questions. Students were given 30 minutes to answer the questionnaire.
There was no ethics committee at the university college, but the dean of the nursing department had the authority to review and make decisions on research protocols. There was no need for identifiable questionnaires in this study. Guarantees of confidentiality and the freedom to refuse participation or to withdraw at any time during the study were ensured. Informed consent to participate was indicated by the return of the questionnaire. The respondents’ right to privacy was protected during the data collection phase. The main researcher (K.B.) was a teacher in the baccalaureate nursing program at the university college but did not participate in grading, testing, or clinical supervision in the year of the study.
The questionnaires were coded by hand and data were entered into SPSS version 12 software. Data were analyzed with descriptive statistics, t tests, and multiple regression.
The possible range of scores in the CLEI Actual form was 42 to 210. True scores in the present sample varied between 75 and 184 (mean = 141.59, SD = 22.16) (Table 1). The mean score was the highest on the Personalization subscale and was the lowest on the Innovation subscale. Standard deviation on the subscales Personalization and Involvement revealed highest student consensus on these aspects of the learning environment (Table 1).
Table 1: Total and Subscale Scores on Clinical Learning Environment Inventory Among All Students (N = 74)
The highest mean scores were noted on four items concerning the role of the clinical teacher and attitudes toward fellow students, whereas only two items received comparatively low mean scores (Table 2).
Table 2: Clinical Learning Environment Inventory Items with High and Low Mean Scores
T tests showed no significant differences in either total score or subscale scores related to age (older than or younger than 35 years) or work experience (with or without work experience in health care settings). However, students with no prior college-level or university-level education had significantly higher mean scores on the Innovation subscale, compared with students with prior college-level or university-level education (20.61 versus 17.92, p = 0.047).
To examine the relationships between the outcome measure Satisfaction and the other subscales of the CLEI, simple bivariate correlations (r) were used to measure each linear relationship. The results of this analysis showed that there were significant associations between Satisfaction and all other five scales of the CLEI (Table 3). The values of the simple correlation coefficients ranged from 0.373 to 0.516. These values suggest there are moderate to moderately strong associations between nursing students’ perceptions of all specific scales of the CLEI and their overall satisfaction with their clinical placement. Multiple regression was used to gauge the associations between Satisfaction and all five learning environment scales combined (Table 3). A multiple correlation of r at 0.68 suggests that associations between students’ perceptions of the clinical learning environment and their level of satisfaction are strong. To find out how any of the specific environment variables influenced the outcome measure Satisfaction when the remaining four subscales or variables were held constant, beta weights were measured. The beta weights suggest that scores on the subscale Satisfaction were significantly greater in students who highly valued Innovation, Involvement, and especially Personalization.
Table 3: Correlation Between Satisfaction and Other Subscales of Clinical Learning Environment Inventory
The students’ total mean score on the CLEI instrument indicated that students perceived their learning environment in nursing homes as moderately positive. One reason for this may be the supervisory system that included supervision and guidance from both nurses and clinical teachers. The supervisory system may emphasize the ward as a context for both learning and performance (Bjørk, 1999; Robinson et al., 2008). This interpretation is supported by the study by Saarikoski et al. (2002) in which Finnish students’ positive evaluation of the learning environment was partly explained by good supervision. We also find similar support for the use of reflection groups and preceptors in supervision in recent studies (Henderson et al., 2006; Robinson & Cubit, 2005). If wards are perceived as contexts of learning, the students adapt to their role as learners with greater ease and move forward from a peripheral to a legitimate position on the wards (Heggen, 1995; Lave & Wenger, 1991).
Students in the current study had lower means on all subscales of the CLEI compared with Chan’s (2002) original study with this instrument. This could be explained by negative attitudes toward older adults and also by the lack of interest in future work in this area of practice. However, two similar and more recent studies from hospital settings (Ip & Chan, 2005; Midgley, 2006) show much lower mean scores than those reported by Chan (2002). Of note, they are similar to the mean scores in the current study, indicating small differences in learning environments across different care settings. The difference in subscale means in the current study indicates that students were most satisfied with the aspect of Personalization in their clinical learning environment, whereas Innovation had the lowest mean score (Table 1).
The subscale Personalization belongs to the relationship dimensions (Chan, 2001b), one of the three human environment categories that identify the nature and intensity of personal relationships within the environment and the extent to which people are involved and support and help each other. High scores on Personalization may be related to the individual orientation toward students found in the supervisory system in the nursing homes. This is supported by the fact that two of the four items with highest mean scores belong to this category (Table 2). Valuation of Personalization concurs with findings in studies in the hospital setting (Chan, 2002; Ip & Chan, 2005; Midgley, 2006); however, these studies do not discuss what supervisory system the students encountered in their hospital practice. The importance of Personalization was further emphasized in these studies because students also scored this domain as the most important in their valuation of a preferred learning environment (Chan, 2002; Ip & Chan, 2005; Midgley, 2006).
The Innovation subscale scored poorly with this group of students, especially students with former experience from a university or college. This indicates that teachers and preceptors were not capable of taking on all aspects of this role. Of note, similar results were found among students in hospital settings (Chan, 2002; Ip & Chan, 2005; Midgley, 2006). It may seem that nursing teachers and clinicians in general pay more attention to students’ personal welfare than they do to creating interesting and innovative ward experiences. The results of this study and former studies clearly indicate that Innovation is an area in which clinical teachers and nurses need to invest more time.
A limitation of this study is the small number of respondents, although the sample included nearly the total population of first-year nursing students at the university college. Using only the scale exploring students’ perceptions of their actual learning environment, and not the scales for preferred clinical learning environment, may also be viewed as a limitation. A comparison of nursing students’ perceived and preferred clinical learning environment would supplement the present understanding of the learning environment and afford a tool for a more specific strategy to increase quality in student learning. This study assessed only the students’ perspectives of the clinical learning environment. Including perceptions from the perspectives of clinicians and clinical teachers would provide a broader perspective to complete the picture.
Care for older adults comprises a crucial and growing field in nursing, and the need for nurses will increase. Therefore, nursing homes are considered as central placements for nursing students in the future. If nursing students judge nursing homes as good placements during their clinical studies, chances are they also will consider nursing homes as a future workplace. Although nursing students were moderately satisfied with the clinical learning environment, the results of this study indicate that work to improve all aspects of the learning environment is needed, especially related to sustaining innovative learning environments. Limitations of the current study suggest the need for designing a larger study that can give such improvement a more convincing direction. Including different countries in a comparative study could contribute to further development of the CLEI as a cross-cultural instrument.
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Total and Subscale Scores on Clinical Learning Environment Inventory Among All Students (N = 74)
|Total Scalea||Subscales Measuring Specific Aspects of the Learning Environment||Satisfactionb Subscale|
Clinical Learning Environment Inventory Items with High and Low Mean Scores
|The clinical teacher is unfriendly and inconsiderate toward students.||Personalization||74||4.55a||0.71|
|The clinical teacher is not interested in students’ problems.||Personalization||73||4.24a||1.02|
|The clinical teacher dominates debriefing sessions.||Involvement||72||4.11a||0.99|
|Students in this ward pay attention to what others are saying.||Involvement||73||4.19||0.59|
|Getting a certain amount of work done is important on the ward.||Task orientation||73||2.19||1.02|
|New and different ways of teaching students are seldom used on the ward.||Innovation||72||2.49||1.17|
Correlation Between Satisfaction and Other Subscales of Clinical Learning Environment Inventory
|Multiple correlation coefficient||0.68***|