Nursing is a discipline that requires substantial levels of clinical training and competence prior to professional registration. Clinical learning experience is an integral component of any baccalaureate nursing course and is vital for integration of theory to practice and development of professional competencies (Thomas, Jinks, & Jack, 2015). Widening access government initiatives to improve participation of students from underrepresented groups in higher education have resulted in a change in demographics of the traditional nursing student (Koch, Everett, Phillips, & Davidson, 2015). The described characteristics of students who undertake nursing courses includes those without English as their first language, older students without final year secondary education completion, those with degrees in other disciplines, and those working full time and studying part time, in addition to the traditional school leaver (Bradley, Noonan, Nugent, & Scales, 2008; Naylor, Baik, & James, 2013). The diversity of student backgrounds influences learning needs and, subsequently, overall success in achieving all assessment criteria (Maringe & Sing, 2014). As such, it is essential that providers of undergraduate nurse education seek to understand their student population needs to determine, develop, and implement the best strategies to support students while on placement.
Significant research has been published related to the academic success of nursing students; however, a paucity of literature exists in relation to clinical performance. The impact of grade point average (GPA) has been examined in the literature as a predictor of student academic success, rather than clinical performance specifically. Although some studies concluded a significant positive relationship existed between GPA and program success (Buhat-Mendoza, Mendoza, Tianela, & Fabella, 2014; Crouch, 2015; Romeo, 2013), other studies found GPA to not be significant (Beery, 2014; Jackson, 2010). Furthermore, an integrative review by Pitt, Powis, Levett-Jones, and Hunter (2012) that aimed to identify factors influencing clinical performance in addition to academic performance and attrition in preregistration nursing education found that academic performance was affected by factors including age, gender, English as a second language, and admission qualifications. A notable conclusion was that there was an absence of research on the factors that affect students' clinical performance. Donnelly, McKiel, and Hwang (2009) identified that nursing students who had English as a second or additional language found clinical situations to be particularly challenging. Difficulties were cited relating to inability to voice concerns over clinical situations and engaging in assertive conversations with peers, instructors, and patients, with outcomes being that the students doubted their ability to deliver patient care at the required standard. Similarly, Crawford and Candlin (2013), in an Australian setting, identified that language barriers of students with English as a second or additional language included difficulty with the use of not only health-related technical terms, but also Australian idioms (Crawford & Candlin, 2013). The potential outcome relating to a lack of confidence in communication, along with being self-conscious about their grammar, results in difficulty forming of therapeutic relationships with patients. Although there is no conclusive evidence, these factors could be suggested to potentially affect the achievement of successful clinical placement.
The gap in the literature relating to clinical performance success is evident. Considering the practical nature of nursing, this is an area that needs prompt exploration.
Historically, nursing education in Australia, where this study was conducted, was predominantly a hospital-based apprenticeship style system. During the mid-1980s, nursing education commenced a period of reform resulting in a transition from the hospital- to tertiary-based education, with only the practical clinical experience conducted in hospitals at various times throughout the course (Health Workforce, 2014). Current guidelines stipulate that a minimum of 800 hours of clinical learning experience is required to be undertaken throughout a nursing course to be eligible for initial registration as an RN (Nursing and Midwifery Board of Australia, 2010). Success of clinical performance is determined by assessment of student professional knowledge, skills, and attributes against assessment criteria that comprise a set of national competency standards (Nursing and Midwifery Board of Australia, 2010). While on clinical placement, student performance is overseen by a clinical instructor or an instructor who liaises between the education provider and clinical environment.
During clinical placement, students are supported by clinical instructors in one of two models: in a group of up to eight students, or with an instructor working one-to-one with a single student. Instructors may be employed by the university or may be hospital staff who are employed directly from the hospital where they work to supervise the students for the duration of placement. Clinical instructors are responsible for assessing students' performance during the clinical placement using a purpose designed Clinical Assessment Tool (CAT). This tool was developed using the Australian Nursing and Midwifery Council (Australian Nursing and Midwifery Council, 2005) Competency Standards for Registered Nurses as a framework. The CAT form provides guidance to both students and instructors regarding expected clinical performance and provides a framework for consistent formative and summative feedback. It contains four domains each consisting of individual criteria. The four domains are professional practice, critical thinking and analysis, provision and coordination of care, and collaborative and therapeutic practice (Australian Nursing and Midwifery Council, 2010).
Based on student performance, constructive notes or learning contracts may be implemented. A constructive note is a formally written note acknowledging below standard performance and include strategies by which to improve performance. The constructive note is a useful tool for detecting patterns and deficits in clinical performance, as well as raising student awareness of performance issues. If a student's clinical performance does not improve following the delivery of a constructive note, a learning contract is implemented. A learning contract is a written agreement between the instructor and student that explicitly outlines what is expected of the student in order to achieve specified learning outcomes and subsequently be successful in the subject (Frank & Scharf, 2013).
The purpose of this study was to examine factors that affect clinical performance (as determined by constructive notes, learning contracts, and successful completion of clinical placement) of second- and third-year baccalaureate nursing students at a large metropolitan university. Knowledge of factors that could be associated with success on clinical placement will assist with early identification of students at risk of failing to meet learning outcomes, allowing for implementation of additional support. Specifically, this study aimed to investigate the influence of GPA, domestic or international student status, graduate entry students' previous discipline, and enrollment in a single- or dual-degree course. The terms used in this discussion are context specific; therefore, relevant terms are defined. Domestic students are those who are Australian citizens, Australian permanent residents, or New Zealand citizens; international students are those not covered by domestic status. A graduate-entry student is a student who has previously successfully completed a course of study. GPA is generated from a student's academic achievement for each subject a student has completed, calculated on a 1 to 7 scale, with 1 equating to a low fail, 4 a pass, and 7 a high distinction. (Queensland University of Technology, 2013). Student clinical performance is graded as satisfactory or unsatisfactory and therefore does not contribute to the GPA.
This study used a retrospective audit design where the academic records of students in the second-year, second-semester clinical subject or the third-year, first-semester clinical subject in 2014 were reviewed.
This study was conducted at a large metropolitan Australian university. At the time of the study, the school of nursing had approximately 2,900 continuing undergraduate students across the 3-year nursing course that consisted of 24 subjects delivered across six semesters (3 years full time). Clinical learning experience was embedded in the final five semesters of the course, and students attended a wide range of health care facilities in various settings, including community, primary health care, residential facilities, and acute care hospitals.
All students enrolled in either the second-year, second-semester clinical subject or the third-year, first-semester clinical subject were included in the study. There were 665 students enrolled: 439 second-year students and 226 third-year students. All students attended 4 weeks of clinical placement.
Assessment of Clinical Performance
A data collection instrument was developed to collect demographic information (age, sex, type of graduate entry qualification, single or double degree enrollment, and GPA). In addition, five outcome variables were recorded: receipt of a constructive note (yes or no), domain criterion identified in the constructive note, receipt of a learning contract (yes or no), domain criterion identified in the learning contract, and the clinical placement performance result (successful or unsuccessful).
Following ethical approval and approval by the head of school, hard copies of student clinical placement documents (CAT forms, constructive notes, and learning contracts) were retrieved, and two authors entered data into an electronic database. All students enrolled in the two clinical subjects were recorded in a master log and assigned a study number, and data were extracted using the data collection tool. A random 10% of all data were cross-checked for accuracy.
Data were entered into SPSS® version 21.1 software. Demographic data were analyzed using descriptive statistics of frequencies, means, and standard deviation. Categorical variable data were analyzed using chi-square goodness-of-fit tests to measure association between variables. The level of significance selected for all analyses was alpha < .05.
All constructive notes and learning contracts were analyzed by two of the authors using quantitative content analysis techniques (Neuendorf, 2017) and a predetermined matrix. The domain criterion identified on notes and contracts were recorded and counts were used to identify the criterion most frequently recognized as an area of concern. Comparisons of the criterion counts were then made between the second- and third-year students.
This study was approved by the university's human research ethics committee.
Records from 665 students (226 third-year and 439 second-year) were retrieved. Four students (0.6%) withdrew from the clinical subjects after attending clinical placement and received a fail grade for their clinical assessment. Because those students had withdrawn after clinical placement had been assessed, their data were included in the sample. Characteristics of the demographic data are provided in Table 1.
Sample Characteristics (N = 665)
Table 2 provides the number of constructive notes, learning contracts, and overall achievement of clinical placement assessment criteria received by students.
Constructive Notes, Learning Contracts, and Overall Student Results (N = 665)
Results show a statistically significant association between students' graduate entry qualification (health science or non-health science) and receipt of a constructive note (χ2 = 8.678, df = 3, p = .034) and learning contract (χ2 = 15.834, df = 3, p = .001) while on clinical placement. Graduate students from a non-health science discipline were more likely to receive a constructive note and learning contract. Further, students with a lower GPA were more likely to receive a constructive note (t[3.862], df = 663, p < .001) and learning contract on placement (t[5.231], df = 663, p < .001). International students were also more likely than domestic students to receive a constructive note (Fisher's exact test = 8.581, df = 1, p = .003) and learning contract (Fisher's exact test = 12.187, df = 1, p = .001) during clinical placement. Enrolment in a single or double degree course was not associated with receipt of a constructive note or learning contract (Table 3).
Association Between Receipt of Constructive Note and Learning Contract and Graduate Entry Qualification, Grade Point Average (GPA), International Student Status, and Course Type (N = 665)
Content Analysis Results
Second-Year Students. A total of 75 constructive notes were given to the second-year student cohort (n = 439) during clinical placement. Of these, 41 (55%) constructive notes identified deficits in CAT domain 2, Critical Thinking and Analysis, specifically criterion 2.1, which “explores the application of evidence to decision making regarding care of assigned patients.” A total of 11 learning contracts were given to second-year students, with nine (82%) relating to the domain of Critical Thinking and Analysis. The most frequently identified individual criteria within this domain were 2.1 and 2.3: “reflects on own performance to identify professional development needs and/or opportunities.”
Third-Year Students. There were 75 constructive notes given to the third-year nursing student cohort (n = 226), with the most frequently cited criterion (n = 41, 55%) relating to the professional practice domain, specifically criterion 1.1, which “demonstrates accountability and responsibility for own actions.” Further, 18 learning contracts were consequently issued to third-year students, with the most frequently identified domain (n = 14, 78%) being Professional Practice criterion 1.1, as above.
Results from this study suggest that entering the nursing course via a graduate entry pathway without a health science background, students with a lower GPA, and international students were all factors associated with receipt of a constructive note or learning contract during clinical placement. This study has identified a positive correlation between students who commenced a baccalaureate of nursing course as a graduate student from a non-health science discipline and the receipt of constructive notes and contracts while on clinical placement. Providers of nursing courses have established precedents for students with previous degrees to complete an abridged 2-year course, regardless of educational discipline. However, the discipline of nursing is founded on understanding of human biological sciences; therefore, graduates from disciplines without this foundational knowledge experience challenges on clinical placement. This may suggest that abridged courses do not meet the learning needs of students from a non-health science background. Many nursing activities in clinical practice are underpinned by science, and a sound understanding of appropriate theory could support clinical decision making (Boddey & de Berg, 2015). The implementation and subsequent evaluation of the effectiveness of a science-based bridging course to assist graduate-entry nursing students is an area for future consideration. Educators in this nursing course must be proactive in the science learning space and include measures to promote the clinical perspective—that is, making explicit the relevance for RN practice (Gordon & Hughes, 2013) to increase student engagement and subsequent learning. A simple yet effective strategy that could be implemented is through a small-group learning activity where a student-generated question bank is developed and shared with other students. Christensen, Craft, Shaw, and Bakon (2017) found that not only was this learning and teaching approach rated positively by nursing students, but students also reported writing questions improved their understanding of content and assisted in their active reflection of content.
The findings of this study suggest a relationship between lower GPA and poorer clinical performances. As previously noted, there is a lack of literature in relation to GPA and clinical success; therefore, this is an important finding and an area requiring further research. The theoretical component of the nursing course in question places a focus on critical thinking and therefore students' academic results, including GPA, may translate to better clinical performance by the application of theory to practice (Kowitlawakul, Brenkus, & Dugan, 2013). Students with lower academic results may also be likely to experience lower confidence, hindering their clinical performance (McClelland, Horne, Dearnley, Raynsford, & Irving, 2015). As part of a preclinical placement preparation, at-risk students with a low GPA could be provided extra tutorials and practical sessions, incorporating the use of active and cooperative learning strategies that activate a cognitive triggering process suggested to improve critical thinking (Kaddoura, 2013). Further research to determine the effectiveness and, in turn, the optimal timing, delivery, and duration of this support would be required.
In this study, international students received constructive notes and learning contracts more frequently than domestic students. The reasons for this were not specifically the focus of this research; however, as increasing numbers of international students are accepted into nursing courses, it is incumbent on education providers to provide scaffolding workshops and skill laboratories to adequately prepare them (Zheng, Everett, Glew, & Salamonson, 2014). This study did not examine participants' engagement with support courses; however, all students had access to academic learning, language, and support workshops. For clinical instructors working with international students, specific workshops should be provided by the university, including awareness of cultural background, learning preferences, behaviors, and identifying cultural features of communication. Improved understanding of these groups is essential to be able to facilitate learning. In addition, support programs for students, including role-play focusing on how communication is enacted in clinical settings, would be beneficial (Attrill, Lincoln, & McAllister, 2016).
Among the second-year cohort, the domain criterion most frequently noted as an area of poor performance was “exploring the application of evidence to decision making regarding the care of assigned patients.” However, among third-year students, “demonstrating accountability and responsibility for own actions” was the most frequently identified domain criterion of concern. The differing criteria between second- and third-year students may be related to the students' stage of learning and expectations of student performance appropriate to each year level. During the second year of an undergraduate nursing course, students may be intent on mastering a skill rather than the demonstration of appropriate integration and application of evidence to nursing practice. This highlights the need for continued work in nursing curriculum to strengthen students' understanding of evidence-based practice. The development of RN capabilities is a focus in the third year of the course. Results indicate that students need support in the transition of student to new graduate because they may not fully understand their scope of practice and its implications on the delivery of safe nursing care.
The identification of different domain criteria between the two year levels may also have been affected by duration of clinical placement. Although all students completed a total of 4 weeks of clinical placement, second-year students completed two rotations of 2 weeks as opposed to a continuous 4-week block undertaken by third-year students. Students who complete only 2 weeks of placement and lack basic comprehension of the patient context may struggle to understand both the relevance and the how to of applying evidence to decision making in this relatively short time frame. The placement time frame may also influence instructors' management of students. If student performance deficits are not identified quickly and strategies implemented in a timely manner, students are not afforded every opportunity to be successful on placement. It is noted that 17% (75 of 439) of second-year compared with 33% (75 of 226) of third-year students received a constructive note. This may be due to instructors' attitudes toward a second-year (developing) student as opposed to a third-year (consolidating) student, or may be again related to the time frame that the instructor has to work with and assess the student. The length of clinical placement and attitudes of instructors are, however, potentially influential factors in relation to student performance that have not been examined in this research.
To ensure optimum opportunity for students to achieve the desired outcome on clinical placement, education of the instructor is essential. As there are differing models of student supervision, formal training in assessment and ongoing assessment of instructor competence is required to ensure consistency of assessment practices. A comprehensive overview of supportive strategies to effectively assist clinical instructors with their role is not well described in literature and is therefore an additional area requiring further research (Jetha, Boschma, & Clauson, 2016).
This study is limited by the retrospective nature of the research design. During data extraction, inaccurate and incomplete documentation was identified in approximately 12 (11%) of the constructive notes. Inaccuracies in documentation included the domain criteria documented on the constructive note did not match criteria on CAT forms or learning contracts and some criteria were recorded with invalid numbers.
Students' clinical placement performance in this study was evaluated by a variety of different clinical instructors who were likely to have different expectations of students. The study setting offers regular, continued workshops targeting clinical instructor education and support; however, variance is inevitable with large numbers of assessors. In addition, students completed clinical placements in a variety of practice areas and settings, which may have affected their performance. Student assessment and the perception of student competence is subjective, based on the assessors' understanding of the CAT form criteria. In addition, the study undertaken involved students from a single university only and the findings therefore cannot be considered generalizable.
As population health demands increase and the need for highly competent and capable graduates continues, it is essential to further identify which factors have greatest effects on student successful completion and implement appropriate support strategies. Granting an abridged course for students with non-health science qualifications is setting these students up for a much larger challenge. Non-health science graduates, lower GPA, and international status emerged as predictors of clinical placement performance in the studied cohort. This article adds to the limited research that attempts to identify such predictors. The findings have highlighted several issues regarding the provision of student support and the importance of a cohesive approach between the university and the clinical instructor responsible for assessing students.
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Sample Characteristics (N = 665)
|Mean age, years (SD, range)||26.2 (8.15, 19 to 64)|
| Baccalaureate of nursing||608 (91.4)|
| Baccalaureate of nursing and second qualification||55 (8.2)|
|Graduate entry||144 (21.7)|
| Graduate qualification in health science||70 (10.4)|
|Domestic student||545 (82)|
|Mean grade point average (SD, range)||5.14 (0.81, 3.0 to 7.0)|
|Clinical subject result: fail||29 (44)|
Constructive Notes, Learning Contracts, and Overall Student Results (N = 665)
|Student Outcome||n (%)|
|Total constructive notes given||167 (25.1)|
|Total learning contracts given||45 (6.7)|
|Students who received a failing grade for the clinical placement subject||29 (4.3)|
Association Between Receipt of Constructive Note and Learning Contract and Graduate Entry Qualification, Grade Point Average (GPA), International Student Status, and Course Type (N = 665)
|Receipt of Constructive Note During Clinical Placement||Test||Result||p|
|Graduate entry qualification (health science or non-health science)||χ2||8.678||.034*|
|GPA||t test||3.862||< .001*|
|International student status||Fisher's exact test||8.581||.003*|
|Type of course enrolment (single or double degree)||χ2||5.833||.323|
|Receipt of a Learning Contract During Clinical Placement||Test||Result||p|
|Graduate entry qualification (health science or non-health science)||χ2||15.834||.001*|
|GPA||t test||5.231||< .001*|
|International student status||Fisher's exact test||12.187||.001*|
|Type of course enrolment (single or double degree)||χ2||4.203||.521|