Journal of Nursing Education

Major Article 

Structural Model of Professional Socialization of Nursing Students With Clinical Practice Experience

Soo-yeon Kim, PhD; Yong Soon Shin, PhD

Abstract

Background:

This study developed a structural model of the professional socialization of nursing students with clinical practice experience and tested its validity based on Meleis's transition theory.

Method:

Participants were third- and fourth-year nursing students with at least one semester of clinical experience. Cross-sectional data from 412 participants were analyzed.

Results:

The goodness of fit of the model was satisfactory. Regarding the differences in educational year, the effects of the clinical learning environment on adaptation to a clinical practicum were not significant for third-year students but were significant for fourth-year students. The effects of clinical practice competency on professional socialization were significant only for fourth-year students. Transition shock and adaptation to clinical practicum paths were significant factors in both groups.

Conclusion:

Clinical adaptation is important for developing professional socialization in nursing students. Clinical adaptation can be achieved by improving the clinical learning environment and facilitating the development of clinical practice competency. [J Nurs Educ. 2020;59(3):133–141.]

Abstract

Background:

This study developed a structural model of the professional socialization of nursing students with clinical practice experience and tested its validity based on Meleis's transition theory.

Method:

Participants were third- and fourth-year nursing students with at least one semester of clinical experience. Cross-sectional data from 412 participants were analyzed.

Results:

The goodness of fit of the model was satisfactory. Regarding the differences in educational year, the effects of the clinical learning environment on adaptation to a clinical practicum were not significant for third-year students but were significant for fourth-year students. The effects of clinical practice competency on professional socialization were significant only for fourth-year students. Transition shock and adaptation to clinical practicum paths were significant factors in both groups.

Conclusion:

Clinical adaptation is important for developing professional socialization in nursing students. Clinical adaptation can be achieved by improving the clinical learning environment and facilitating the development of clinical practice competency. [J Nurs Educ. 2020;59(3):133–141.]

Clinical practice is essential for nursing education because nursing is a practice-based science (Lee, Clarke, & Carson, 2018). In Korea, nursing students currently complete at least 1,000 hours of clinical practice during their undergraduate education (Korean Accreditation Board of Nursing Education, 2016). This prepares students for the nursing profession systematically by allowing them opportunities to apply their professional knowledge in actual patients (Arkan, Ordin, & Yilmaz, 2018; Jayasekara et al., 2018).

For nursing students, their clinical practicum is a course in which they learn about nurses' qualifications and roles (Stalmeijer et al., 2013). During this period in their education, nursing students internalize their experiences and develop their skills, attitudes, beliefs, values, and ethical standards related to nursing (Schuler, 2016). This process is known as “professional socialization,” and previous studies have related it to being a role model, portraying a professional image, and establishing values in clinical practice (Choi & Ha, 2009; Halperin & Mashiach-Eizenberg, 2014; Jiménez-López, Roales-Nieto, Seco, & Preciado, 2016). Therefore, nursing students need to invest considerable effort into developing professional socialization during their clinical practicum.

Nurses can develop professional socialization at any phase of their career or education; however, nursing students need to take a cautious approach, depending on the type of education they have received and their clinical practice experience (Howkins & Ewens, 1999). Nursing students usually participate in their clinical practicum during their third and fourth years. Because third- and fourth-year students differ in their emotional perceptions of clinical practice, educational environments, and levels of stress related to practice (Cho & Kang, 2017; Khater, Akhu-Zaheya, & Shaban, 2014), it is necessary to consider these differences when helping nursing students develop professional socialization during their clinical practicum. Clarifying the differences between educational levels in terms of their effects on professional socialization can provide a basis for interventions appropriate for each phase of nursing education.

Because most of the previous studies related to the professional socialization of nursing students are exploratory research examining the relevance of specific factors (Choi & Ha, 2009, 2011; Ham, Kim, Cho, & Im, 2011; Oh, Choi, Kwon, & Park, 2005), there is insufficient evidence for establishing educational strategies by comprehensively understanding the development of professional socialization in a clinical practicum. The clinical practicum is known as a course for transitions, wherein students can learn the role of a professional nurse (Xu, Xu, & Zhang, 2000). Therefore, professional socialization should be understood as a part of the development inherent in this transition, and its influencing factors also should be considered. In addition, a model that systematizes these factors should present direct or indirect paths between factors that affect professional socialization to ensure it can be used as a basis for educational interventions. The transition theory of Meleis, Sawyer, Im, Hilfinger Messias, and Schumacher (2000) was developed to help individuals understand their experiences of and reactions to transitions, as well as to predict weak points and facilitate adaptation. Thus, this theory is appropriate for nursing students as they prepare for their clinical practicum and transition toward real clinical practice.

Aim and Hypothesis

This study aimed to develop a theoretical model that systematizes factors affecting professional socialization, using transition theory as the theoretical framework, and to verify the effects of the relationships among the variables used in the model. The study also examined interventions for the development of professional socialization based on the differences between third- and fourth-year nursing students. Thus, the objectives of this study were to verify the suitability of the professional socialization model of nursing students based on the transition theory of Meleis et al. (2000), clarify the direct and indirect effects of related factors, and delineate the differences between third- and fourth-year nursing students.

Conceptual Framework and Theoretical Model

Transition theory presupposes a transitional experience related to an individual's specific situation, such as pregnancy, menopause, or immigration (Meleis et al., 2000). Transition theory is applicable to the process by which nursing students gain clinical practice experience because they transition from the school-based learning environment to a clinical learning environment, and this change requires them to assume a more complex role (McClure & Black, 2013).

Transition theory consists of various types of transitions, attributes of aspects and experiences, transition conditions, process indicators, and result indicators (Meleis et al., 2000). Transitions can be a developmental phase shift (e.g., puberty, marriage, or pregnancy), a contextual transition (e.g., the loss of a child or unemployment), or a health-related transition associated with an acute or chronic disease, and the transition pattern can be single or multiple (Meleis et al., 2000). This study considered the types of transitions and their aspects as they related to nursing students' clinical practicum course. The theoretical model was established based on the transition conditions, course elements, and result indicators (Figure 1). Variables were derived with consideration to transition theory and previous studies.

Hypothetical model based on transition theory (Meleis, Sawyer, Im, Hilfinger Messias, & Schumacher, 2000).

Figure 1.

Hypothetical model based on transition theory (Meleis, Sawyer, Im, Hilfinger Messias, & Schumacher, 2000).

Transition conditions can inhibit or facilitate adaptation during the transition period (Meleis et al., 2000). These can include personal conditions, such as cultural beliefs and attitudes, socioeconomic status, preparation, and knowledge, as well as community or social conditions (Meleis et al., 2000). In the current study, clinical practice competency and the clinical learning environment were treated as transition conditions. Clinical practice competency refers to the ability to integrate and apply skills, knowledge, and judgment to clinical practice (Blum, Borglund, & Parcells, 2010). A lack of clinical practice competency among nursing students makes it difficult for them to adapt to the clinical environment (Chernomas & Shapiro, 2013). Furthermore, nursing students' skills and expertise (Oh et al., 2005), their interpersonal skills, and the implications of nursing affect their professional socialization (Choi & Ha, 2011).

“Clinical learning environment” refers to an interactive network that facilitates students' learning outcomes in clinical settings (Dunn & Burnett, 1995). Supportive environments have been shown to positively affect competence and satisfaction with clinical practice (Choi, 2009; Han & Park, 2011), whereas hierarchical environments different from those students experienced at school had a negative influence (Lee et al., 2018). Other elements of a positive learning environment that affect professional socialization include educator preceptorship, the presence of a role model, and appropriate feedback in the practice environment (Dinmohammadi, Peyrovi, & Mehrdad, 2013). Accordingly, these factors are aligned with transition conditions and thus were considered exogenous variables in this study.

Process indicators relate to whether the transition is proceeding in a sound direction and reflect networking, relationships and social interactions, developing confidence, and coping in a transitional environment (Meleis et al., 2000). In the context of professional socialization, “a sound direction” means an appropriate transition into a professional role. Transition into a professional role depends on congruence between values, norms, educational expectations, and the reality of vocational conditions (Blais, Hayes, Kozier, & Erb, 2015). Therefore, professional socialization during the transition process can be evaluated based on the intensity of the transition shock that students experience as they adjust to a different reality (Duchscher, 2009) and the adaptation that results in appropriate attitudes and behaviors (Jang, 2005).

Transition shock varies depending on the extent of personal preparation or competency and the given environment (Kramer, Brewer, & Maguire, 2013; Kumaran & Carney, 2014; Sin, Kwon, & Kim, 2014). Based on previous studies that posit these factors affect adaptation (Duchscher, 2009; Riordan & Goodman, 2007) and professional socialization (Blais et al., 2015), the paths to adaptation and professional socialization also were established. Because transition shock and adaptation to clinical practice are both affected by personal competency and the given environment, these factors were considered as endogenous variables in this study. Based on previous findings that a high level of satisfaction with practice increased the level of professional socialization, the path to professional socialization was further established (Choi & Ha, 2011).

Proficiency and integrative identity were the outcome indicators used in this study. Proficiency indicates an individual's mastery of the actions necessary to manage a new environment, and an integrative identity is a flexible identity that has been reshaped through the transition experience, allowing for an individual to merge multiple social identities (Meleis et al., 2000). These factors were considered endogenous variables in this study because they align with professional socialization. Paths affected directly or indirectly by clinical practice competency, the clinical learning environment, and transition shock, or those that affected clinical practice directly, were established in this study.

In summary, transition conditions comprise both clinical practice competency and the clinical learning environment. Process indicators include transition shock and adaptation to clinical practice, whereas outcome indicators include professional socialization. Paths between variables were established based on transition theory. In total, nine hypothetical paths were established with clinical practice competency and the clinical learning environment as exogenous variables, and transition shock, adaptation to clinical practice, and professional socialization as endogenous variables.

Method

Design

This was a structural model study used to establish a theoretical model by collecting factors that affect the professional socialization of nursing students with clinical practice experience and to verify the suitability of the model and the study's hypotheses through cross-sectional data collection.

Participants

Data were collected from third- and fourth-year nursing students who had undergone at least one semester of clinical practice at one of seven nursing colleges in Korea. Participants met selection criteria if they were currently enrolled in a clinical practice course or had completed a clinical practice course within the 4 weeks prior to the study. Students who were in their third year and had experienced clinical practice only in local communities, such as in health or community centers, were excluded. Fourth-year nursing students were included if, at the time of the study, they were currently in or had recently completed clinical practice in a hospital, even if they had previous clinical practice experience in a community nursing setting. Students who only had experience from community nursing settings were not considered because these settings have different characteristics from hospitals, which account for a large proportion of clinical practice sites, and the majority of nursing students most likely will be employed in hospitals in the future. Assuming that 200 to 400 individuals would be appropriate when applying the maximum likelihood estimation (Yu, 2014), the estimated number of participants considered appropriate for the study was 440, which would account for the expected dropout rate. Data from 412 questionnaires were analyzed in this study; thus, the number of samples was considered appropriate.

Procedure

Data for this study were collected from September 6 to October 23, 2018, at nursing colleges in seven regions of Korea. The researcher used convenience sampling, and data were collected from at least 30 nursing students at each school; all of the students agreed to participate via a written consent form. With cooperation from the nursing colleges, the researcher (S.-Y.K.) distributed and collected the questionnaires in person or via mail. The questionnaire was designed to collect general demographic information such as sex, age, year of education, and school location, as well as progress rate in a clinical practicum. Of 440 questionnaires that were distributed, 430 were returned. Eighteen questionnaires with incomplete answers were excluded, leaving a total of 412 questionnaires in the final analysis.

Measurements

Clinical Practice Competency. In this study, the Nursing Competence Scale developed by Joo and Sohng (2014) was used to measure clinical practice competency. Furthermore, a confirmatory factor analysis was performed to extract sub-factors. The 19 items used measured communication skills, core nursing skills, integrated nursing through critical thinking, nursing leadership, and stress management on a 5-point Likert scale. A high score indicated a high level of clinical practice competency. At the time of development, reliability was high, with Cronbach's alpha = .91 (Joo & Sohng, 2014); in the current study, Cronbach's alpha was .93. The validity of subfactors was good (ß = .56∼.84).

Clinical Learning Environment. For the clinical learning environment, the definition by Kim, Yoo, and Kim (2018) was applied, and the Korean version of the Clinical Learning Environment, Supervision and Nurse Teacher Evaluation Scale (CLES+T), which is an adaptation of the CLES by Saarikoski and Leino-Kilpi (2002), was used. For this study, a confirmatory factor analysis was performed to extract subfactors. The 19 items measured the learning environment in wards, leadership styles of ward managers, students' relationships with supervisors, and nursing care on the wards, rated on a 5-point Likert scale. A high score indicated a high-level clinical learning environment. In previous studies, reliability was high, with Cron-bach's alpha = .94 (Kim et al., 2018), and in this study, it was .93. The validity of subfactors was good, with ß = .60 ∼ .76.

Transition Shock. For transition shock, a measurement scale developed by Kim, Yeo, and Yi (2017), which was revised by Kim and Shin (2018) specifically for nursing students, was used. Subfactors were extracted through confirmatory factor analysis. The 14 items measured the domination of an overwhelming workload, confusion in professional nursing values, daunting relationships, loss of social support, and disharmony between personal life and practice rated on a 4-point Likert scale. A high total score indicated a high level of transition shock. In a previous study by Kim and Shin (2018) on nursing students, the reliability was high, with Cronbach's alpha = .83, and in this study, it was also .83. The validity of subfactors was an acceptable value, with ß = .49 ∼ .67.

Adaptation to the Clinical Practicum. For adaptation to the clinical practicum, a measurement scale developed by Yi (2007) was used. The original scale contained only a single factor and no subfactors; however, based on the results of an exploratory factor analysis, this researcher (S.-Y.K.) classified the items into the following three factors: adaptation to assignments (seven items), adaptation to the environment (three items), and satisfaction with clinical practice (four items). The items were measured using a 5-point Likert scale. A high total score indicated a high level of adaptation to the clinical practicum. When the original scale was developed, reliability was high with Cron-bach's alpha = .86 (Yi, 2007), and in this study, it was .85. The validity of subfactors was nearly acceptable, with ß = .38 ∼ .81. Adaptation to the environment was shown to be slightly lower with a standard regression weight (ß = .38), but if there are fewer than three observational variables, it is better not to remove them, as that can cause problems in identifying the latent variable (Yu, 2014).

Professional Socialization. For nursing students' professional socialization, the Professional Socialization Scale developed by du Toit (1995) and adapted by Oh et al. (2005) based on the Korean experience was used. In the exploratory factor analysis, most items were classified as in the original scale, but 18 items with a factor loading less than .4 were excluded since they were not appropriate as subfactors. The remaining 34 items measured the domain of a calling, maturity, independence, and decision making, rated on a 5-point Likert scale. A high total score indicated a high level of professional socialization. In a previous study on nursing students, the scale demonstrated high reliability with Cronbach's alpha = .93 (Oh et al., 2005), and in this study, it was .92. The validity of subfactors was an acceptable value, with ß = .48 ∼ .79.

Ethical Considerations. This study was performed after the research plan was approved by the Institutional Review Board of Hanyang University. Data were collected from nursing students who agreed to participate in the research voluntarily and provided a signed consent form. All of the tools used were approved for use via e-mail from the developer.

Data Analysis

Data were analyzed using SPSS® version 24.0 and AMOS version 24.0. General characteristics of the participants and research-related variables were analyzed to calculate frequency, percentage, average, and SD. The reliability of the research tools was determined based on Cronbach's alpha. Validity was verified through exploratory and confirmatory factor analyses, and specific factors for analysis were extracted. Multicollinearity between variables was determined using Pearson's correlation coefficient. The model was verified based on x2, x2/df, goodness of fit index (GFI), Tucker-Lewis Index (TLI), comparative fit index (CFI), and root mean square error of approximation (RMSEA). The regulatory effect of the differences between third- and fourth-year students was determined through multiple group analysis.

Results

Participant Demographics

A total of 412 nursing students participated in this study. Of the participants, 220 (53.4%) were in their third year and 192 (46.6%) were in their fourth year. Average age of participants was 23.9 years (SD, 3.67); 344 (83.5%) participants were women, and 68 (16.5%) participants were men. General characteristics of the participants are summarized in Table 1.

Characteristics of Participants (N = 412)

Table 1:

Characteristics of Participants (N = 412)

Research Variables and Regularity, and Multicollinearity Testing

The descriptive statistics of the measurement variables are listed in Table 2. The absolute value of the skewness of each variable did not exceed 2 and that of kurtosis did not exceed 4. Thus, every factor demonstrated a normal distribution. The variance inflation factor of every variable between measurement variables was between 1.48 and 2.14, and all were less than 10. The tolerance limit was between .47 and .72, and all were more than 0.1. The absolute value of the correlation coefficient (r) of every variable was between .47 and .64. Furthermore, no multicollinearity was evident. Discriminant validity was regarded as secure, as the average variance extracted (AVE) value was larger than the absolute value of the correlation coefficient. In this study, the largest value of the correlation coefficient was .64, and the squared value was smaller than every AVE value. As the conditions of AVE = .50 and composite reliability = .70 were satisfied for every variable, except the AVE value of transition shock at .47, convergent validity was confirmed.

Descriptive Statistics of Research Variables (N = 412)

Table 2:

Descriptive Statistics of Research Variables (N = 412)

Testing the Structural Model of the Study

Theoretical Model Suitability and Measurement Model Homogeneity. The suitability index of the theoretical model proposed in this study and the results of the homogeneity test of the measurement model for third- and fourth-year students are shown in Table 3. The suitability index of the theoretical model was considered appropriate based on the following conditions: x2 = 475.162, df = 176, x2/df = 2.70, GFI = .903, TLI = .891, CFI = .909, and RMSEA = .064. Homogeneity tests were conducted on the measurement model to determine whether there was a difference between education years. The unconstrained model had no assumption of the homogeneity of the groups, and the constrained model assumed the same factor load between groups. The conditions of the unconstrained model were: x2 = 660.584, df = 352, x2/df = 1.877, GFI = .870, TLI = .888, CFI = .906, and RMSEA = .046. The conditions of the constrained model were: x2 = 683.635, df = 368, x2/df = 1.858, GFI = .866, TLI = .890, CFI = .904, and RMSEA = .046. The difference in the degrees of freedom between the two models can be considered insignificant when the value is smaller than x2 = 26.30. In this study, the value was ∆x2 = 23.051; thus, cross-validity was confirmed.

Comparisons Between Unconstrained and Constrained Models

Table 3:

Comparisons Between Unconstrained and Constrained Models

Difference in Paths to Professional Socialization. A multi-group analysis was conducted for third- and fourth-year students to determine the differences between the models for the third and fourth years of nursing education. Third-year students' path to professional socialization is shown in Figure 2 and that of fourth-year students is shown in Figure 3. To determine the differences in paths, the cross-group equality constraint method was used (Table 4). In the multiple group analysis, the clinical learning environment had no significant impact on third-year students' adaptation to the clinical practicum (ß = −.17, p = .064) but significantly affected fourth-year students' adaptation (ß =.10, p = .024). Although transition shock and the path to adaptation to the clinical practicum were significant in both groups, the impact of transition shock on adaptation to the clinical practicum was more significant for third-year (ß = −.72, p < .001) than for fourth-year (ß = −.34, p < .001) students. The effect of clinical practice competency on professional socialization was significant only for fourth-year students (ß = .82, p < .001).

The third year's path to professional socialization.

Figure 2.

The third year's path to professional socialization.

The fourth year's path to professional socialization.

Figure 3.

The fourth year's path to professional socialization.

Standardized Estimates of Variables According to Grade

Table 4:

Standardized Estimates of Variables According to Grade

When comparing the paths of third- and fourth-year students, one constraint was that the path coefficients of the nine paths among latent variables were the same for the two groups. Under this condition, the following paths demonstrated significant differences: clinical learning environment→adaptation to the clinical practicum, transition shock→adaptation to the clinical practicum, and clinical practice competency→professional socialization.

Discussion

Based on the transition theory of Meleis et al. (2000), a theoretical model was established to explain the professional socialization of nursing students with clinical practice experience, and the validity of the model was verified. This study aimed to improve understanding of the course of clinical practice and professional socialization. Furthermore, it sought to propose strategies for improving clinical practice to promote adaptation based on the relationships of the variables suggested in the model of this study and professional socialization. To assist in the development of professional socialization based on the education phases of nursing students, differences between third- and fourth-year students were identified.

Regarding the paths to adaptation to the clinical practicum in the educational environment of clinical practice, a significant impact was observed for fourth-year students only. Previous studies have shown that the educational environment of clinical practice affects students' adaptation to the course (Han & Park, 2011; Lee et al., 2018; Stalmeijer et al., 2013). However, the findings of the present study suggest that in students' third year, when their clinical practicum is still in the initial stage, the environment is not directly related to adaptation.

During their clinical practice course, nursing students experience high stress based on their fear of mistakes or because of unfamiliar circumstances (Blomberg et al., 2014). In the third year, which includes only one semester of practice, it is highly likely that the clinical practicum itself is unfamiliar to the students, which increases their tension. Thus, it is thought that whatever environment they are in will not affect their adaptation directly. In contrast, as fourth-year students have accumulated experience in various environments, they can recognize and evaluate the clinical learning environment, which therefore can be a meaningful variable that directly affects their adaptation to clinical practice.

The impact of transition shock on adaptation to the clinical practicum was more significant for third-year students. It is thought that as transition shock increases, third-year students find it more difficult to adapt to a clinical practicum than fourth-year students. Transition shock more significantly affects nursing students experiencing clinical practice for the first time, probably because this transition shock is a reaction that occurs during the first stage of transition (Duchscher, 2009).

Negative emotions experienced by nursing students are reported mostly as clinical stress. However, the findings of this study suggest third-year students' responses to adversity should be viewed as emotional reactions to change, rather than as clinical stress. One study comparing third- and fourth-year students' stress levels found the stress index was higher among the former rather than the latter. The authors concluded this was because the same high levels of expertise and skill associated with professional nurses are also expected of upper-level nursing students (Khater et al., 2014). In other words, even if students have similar emotional reactions to their clinical practicums, interventions must take different perspectives based on the students' years of schooling.

The impact of transition shock on fourth-year students' adaptation to their clinical practicum also was significant, indicating this was not a temporary emotional reaction in the course of adaptation. This corresponds to the previous research finding that as transition shock does not diminish even with increased clinical experience, mere continued exposure to practice cannot reduce its impact (Newton & McKenna, 2007). In addition, because transition shock is related to the conflict between reality and professional values (Kramer, 1974), it is thought that fourth-year students react to inappropriate clinical settings more sensitively because they have more knowledge than third-year students, and they also have accumulated experiences on which they can base their comparisons of different situations in a clinical practicum. Even if the tension and anxiety in unfamiliar environments decrease, they still feel the significant gap between reality and their values. Thus, because transition shock can continue when students undergo another clinical practicum after their first, active interventions must be applied to reduce transition shock from the first experience of clinical practice.

The path from clinical practice competency to professional socialization was significant only for fourth-year students. Specifically, the findings indicated that when the level of clinical practice competency was high for fourth-year students, their level of professional socialization also was high. To nursing students, the fourth year is a crucial time to improve their competency as professional nurses before they graduate (Wieland, Altmiller, Dorr, & Wolf, 2007), and the perceived meaning they develop of the nursing profession is important throughout their careers (Nash, Lemcke, & Sacre, 2009). Particularly in the fourth year, clinical practice competency was the only factor that significantly affected professional socialization, indicating its importance. Likely, clinical practice competency significantly affected professional socialization because it indicates the extent to which students perceived themselves as prepared for professional employment (Lee, Uhm, & Lee, 2014).

In contrast, the path from clinical practice competency to professional socialization was not significant for third-year students, probably because their clinical practice was primarily in the form of observations, and direct involvement in nursing services was more limited than for fourth-year students. However, previous studies have noted that such dissatisfaction with reality could negatively affect their views on the profession of nursing (Ham et al., 2011); thus, further verification is needed regarding this issue.

Furthermore, it can be concluded that plans are needed to reduce transition shock from a clinical practicum, particularly for third-year students, and to help fourth-year students develop professional socialization through clinical practice competency. Thus, competency enhancement programs should be developed and should include nursing knowledge, application of nursing processes, and core nursing skills. In addition, more opportunities to be involved directly in nursing services must be provided in clinical practice courses, and clinical environments that are more friendly and positive toward nursing students should be created to ensure that nursing students can succeed in their careers as professional nurses following graduation.

Conclusion

This study established and verified a theoretical framework for the comprehensive understanding of nursing students' professional socialization, based on the transition theory of Meleis et al. (2000). The findings of this study suggest third-year nursing students need active interventions to help them cope with both transition shock and the path to professional socialization through adaptation to clinical practice. In addition, the findings of this study confirm that clinical practice competency is a major variable of professional socialization for fourth-year students, emphasizing the need to further develop clinical practice competency. The findings of this study suggest nursing programs that can improve the educational environment of clinical practice and help students develop clinical practice competency should be developed.

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Characteristics of Participants (N = 412)

Characteristicn (%)
Gender
  Male68 (16.5)
  Female344 (83.5)
Age (y), mean ± SD (range)23.91 ± 3.67
(21 to 54)
Education year
  Third year220 (53.4)
  Fourth year192 (46.6)
Location of college
  Seoul City47 (11.4)
  Gyeonggi Province85 (20.6)
  Chungcheong Province30 (7.3)
  Gyeongsang Province44 (10.7)
  Jeolla Province104 (25.2)
  Gangwon Province57 (13.8)
  Jeju City45 (10.9)
Clinical practicum progress rate (per 1,000 hr)
  <25%100 (24.3)
  25% to 50%120 (29.1)
  50% to 75%24 (5.8)
  75% to 100%168 (40.8)

Descriptive Statistics of Research Variables (N = 412)

Latent VariablesMeasurement VariablesMean ± SDActual RangeSkewnessKurtosisAVECR
Clinical learning environmentLearning environment in wards3.38 ± 0.841.00 to 5.00−0.240.030.530.85
Leadership styles of ward managers3.67 ± 0.711.00 to 5.00−0.370.28
Nursing care on the ward3.66 ± 0.671.00 to 5.00−0.410.59
Supervisory relationship3.16 ± 0.851.00 to 5.00−0.370.20
Clinical practice competencyIntegrated nursing through critical thinking3.72 ± 0.591.00 to 5.00−0.251.060.640.90
Communication skills3.96 ± 0.572.00 to 5.00−0.200.29
Nursing leadership3.62 ± 0.591.00 to 5.00−0.080.66
Stress management3.53 ± 0.771.00 to 5.00−0.310.10
Core nursing skills3.55 ± 0.831.00 to 5.00−0.11−0.07
Transition shockOverwhelming workload2.26 ± 0.641.00 to 4.000.260.140.470.83
Loss of social support2.00 ± 0.691.00 to 4.000.37−0.34
Daunting relationships2.75 ± 0.641.00 to 4.00−0.100.02
Confusion in professional nursing values2.35 ± 0.661.00 to 4.000.380.54
Disharmony between personal life and practice2.12 ± 0.671.00 to 4.000.25−0.09
Adaptation to clinical practicumAdaptation to assignments3.55 ± 0.731.00 to 5.00−0.460.200.580.79
Satisfaction with clinical practice2.78 ± 0.781.00 to 5.000.17−0.37
Adaptation to environment3.33 ± 0.601.57 to 5.00−0.22−0.04
Professional socializationCalling3.69 ± 0.581.91 to 5.00−0.230.080.640.89
Maturity3.35 ± 0.641.50 to 5.00−0.020.07
Independence4.18 ± 0.512.40 to 5.00−0.35−0.15
Decision making3.49 ± 0.531.89 to 5.00−0.010.39

Comparisons Between Unconstrained and Constrained Models

Modelx2dfx2/dfGFITLICFIRMSEAx2
Hypothetical model475.1621762.70.903.891.909.06423.051
Unconstrained model660.5843521.877.870.888.906.046
Constrained model683.6353681.858.866.890.904.046

Standardized Estimates of Variables According to Grade

Exogenous VariableEndogenous VariableJuniors (n = 220)Seniors(n = 192)x2/df (p)


βCR (p)βCR (p)
Clinical practice competency→Transition shock−0.26−2.986 (.003)−0.30−2.911 (.004)0.073 (.787)
Clinical learning environment−0.5−4.763 (<.001)−0.37−3.332 (<.001)0.155 (.693)
Clinical practice competency→Adaptation to clinical practicum0.475.15 (<.001)0.595.929 (<.001)0.025 (.875)
Clinical learning environment−0.17−1.851 (.064)0.101.157 (.024)4.799 (.028)
Transition shock−0.72−5.802 (<.001)−0.34−3.477 (<.001)11.406 (.001)
Clinical practice competency→Professional socialization0.291.576 (.115)0.824.73 (<.001)6.795 (.009)
Clinical learning environment0.171.431 (.152)0.151.909 (.056)0.072 (.789)
Transition shock0.280.923 (.356)0.040.385 (.700)0.589 (.443)
Adaptation to clinical practicum0.812.13 (.033)0.040.217 (.828)3.048 (.081)
Authors

Dr. Kim is Researcher, and Dr. Shin is Professor, School of Nursing, Hanyang University, Seoul, Korea.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Yong Soon Shin, PhD, Professor, School of Nursing, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea; e-mail: ysshin2k@hanyang.ac.kr.

Received: July 25, 2019
Accepted: November 04, 2019

10.3928/01484834-20200220-03

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