Perceptions Of Actual And Preferred Hospital Clinical Learning Environment Of Student Nurses

Project and Seminar Material for Nursing (Science)

Abstract

This study investigated the actual and preferred hospital clinical learning environment (CLE) of student nurses in Enugu state. This research specifically assessed the student nurses view of their actual and preferred hospital CLE, determine if differences exist in student nurses view of their actual and preferred hospital CLE, establish the association between the actual and preferred hospital CLE and students’ age, gender, location and year of study and identify factors that influence student nurses opinion of their hospital CLE. A cross sectional descriptive survey design was adopted for the study which permits the observation, description and documentations of aspects of a situation as it naturally occurred. The sample size of 454 nursing students was purposively chosen for the study. Data were collected using two validated instrument thus; researcher developed questionnaire and adapted 42 item standardized clinical learning environment inventory (CLEI) (Actual and Preferred) questionnaires. Data analysis was done using frequency counts, simple percentages, means and standard deviation for research objectives, while t-test with cut off point of 2.50 MANOVA and ANOVA were employed in testing the eight null hypotheses at .05 level of significance. The findings revealed that there is significant difference in the student nurses view of their actual and preferred hospital CLE (p<0.05) in all the subscales. Student nurses view of their actual hospital CLE is significantly negative (Mean scores <2.50 and p<0.05) and that of preferred hospital CLE is positive (mean scores (> 2.50 and p<0.05). Only gender and year of study in the preferred hospital clinical learning environment were significant (p = 0.041 and p = 0.000) respectively. They were agree to be the factors that influence student nurses opinion of their hospital CLE (mean scores >2.50 and p<0.05), except age of student (p = 0.694) and gender of student (p = 0. 189). In conclusion, student nurses in Enugu State have significant negative view of their actual hospital CLE. The importance of helping students feel valued and interpersonal relationships in the clinical area need to be highlighted in the preceptor preparation programmes.

Table of Content

Title Page
Certification
Dedication
Acknowledgement
Table of Content
List of Tables
Abstract

Chapter One:

Introduction

1.1 Background of the Study
1.2 Statement of the Problem
1.3 Objective of the Study
1.4 Research Questions
1.5 Research Hypothesis
1.6 Significance of the Study
1.7 Scope of the Study
1.8 Limitation of the Study
1.9 Definition of Terms
1.10 Organisations of the Study

Chapter Two:

Review of Literature

2.1 Conceptual Framework
2.2 Theoretical Framework
2.3 Empirical Review

Chapter Three:

Research Methodology

3.1 Research Design
3.2 Population of the Study
3.3 Sample Size Determination
3.4 Sample Size Selection Technique and Procedure
3.5 Research Instrument and Administration
3.6 Method of Data Collection
3.7 Method of Data Analysis
3.8 Validity of the Study
3.9 Reliability of the Study
3.10 Ethical Consideration

Chapter Four:

Data Presentation and Analysis

4.1 Data Presentation
4.2 Analysis of Data
4.3 Answering Research Questions
4.4 Test of Hypotheses

Chapter Five:

Summary, Conclusion and Recommendation

5.1 Summary
5.2 Conclusion
5.3 Recommendation
REFERENCES
APPENDIX
QUESTIONNAIRE

Chapter One

Introduction

1.1 Background to the Study

Nursing is a practice based profession with clinical education as an essential part of the nursing curriculum. Clinical practice is the focus for students learning and clinical placement/ posting constitutes one of the most integral components in the nursing education. Clinical placement is the venue where skills, knowledge and attitudes developed in the theoretical part of the curriculum are applied, developed and integrated into practice (Newton, Jolly, Ockerby & Cross, 2010).

According to Norman (2009), clinical practice setting provides students with unique learning opportunities in which classroom theory and skills are put to the test with real life situations. Besides the clinical training foster students in the application of knowledge, skill and attitude to clinical field of situations, it is vital that valuable clinical time should be utilized effectively and productively.

Zilembo and Montereso (2008) stressed the implication of practicing in an appropriate clinical learning environment at the proper time in order that theory and practice can complement each other. Nursing students perceived the clinical setting as the most influential context for acquiring knowledge and nursing skills (Al-Kandari, Vidal & Thomas 2009).

The importance of learning in the clinical area has been a major emphasis in the United Kingdom and other parts of the world, Nigeria inclusive. Providing quality clinical training with an emphasis on improvement and development is paramount in ensuring that students experience good quality care and treatment of patients and clients (E.N.B & D.O.H 2001). In addition there is need for provision of adequate support and supervision of students in the clinical areas.

In Nigeria, nursing education programmes are offered at both the hospital level also known as hospital based and university level also known as baccalaureate. The hospital based nursing education program lasts for three years and that of baccalaureate lasts for five years for the generic and four years for direct entry students and besides the theoretical component, each program has a clinical component. The clinical education takes place in a clinical setting most often a hospital and part in the community.

During the three, four and five year’s program, students are rotated through a variety of settings. Each new posting means the student must socialize into a new setting, establish relationship with staff while being exposed to the new clinical situations with different patient populations. At the same time students clinical performance is continuously being evaluated by a teacher (Mleck, 2011).

It is acknowledged that all learning takes place within a social context; the social context of clinical practice embraces many more variables than classroom setting. Learning activities in the classroom are mostly structured in contrast to clinical learning activities. In clinical training the environment is unpredictable (koontz, Mallory, Burns & Chapman, 2010) with students involved in unplanned activities. Learning experience in this unpredictable environment presents a greater threat to students than learning in the classroom. As a consequence there is less control over the learning experiences of students making it hard to plan for an optimal clinical learning environment (C.L.E) (Papp, Markkanen and Ven Bonsdorff, 2003).

The essential element of the C.L.E is the hospital ward and its characteristics because most part of the clinical education takes place there. The ward environment is considered as exerting great influence on all those engaged in ward life, student nurses inclusive. Therefore student nurses perspective of the hospital based clinical experiences is a summary of the meanings that the students derived from their interactions in this social context.

An understanding of the social climate as the personality of a setting or environment can provide insight into peoples’ actions and feelings. Thus, understanding the student nurses perceptions of their actual and preferred hospital based clinical learning environment may reveal aspects of the actual environment that require improvement in order to maximize student learning in practice. Likewise an understanding of students’ perspective of the clinical environment and social climate within this milieu may assist in improving the educative quality of their clinical training.

Across different countries students report similar perceptions about clinical learning environment. Some of the studies reported that there were significant differences between students’ perceptions of the actual clinical learning environment with and their preferred learning environment (Papathanasioir, Tsaras & Sarafis, 2014, D’souza, Venkatesaperumal, Radhakrishon, & Balachandran, 2013, Chan, 2003).

Generally students preferred a more positive and favourable clinical environment than they perceived as being actually present (Carlson & Idvall, 2014, Chan, 2003). According to Midgley (2006) students would prefer an environment with higher levels of individualization, innovation in teaching and learning strategies, student involvement, personalization and task orientation. Bjork, Berntsen, Brynil and Henstetun, (2014) opined that clinical placement experiences may influence positively on nursing students attitudes towards the clinical setting in question. Another study by Rahmani, Zamanzadeh, Abdullah-zadeh, Lotfi and Hassanpour, (2011) showed that majority (93.2%) of student nurses in Iran had a negative view point about C.L.E. Henderson, Cooke, Creedy & Walker (2012) in their study showed that across different countries, students reported similar perceptions about clinical learning environment and some of the findings were that sense of task accomplished rated high, and feedback measuring whether students’ individual needs and views were accommodated rated low. Furthermore CLEs are most effective in promoting safe practice and are inclusive of student learners but not readily open to innovation and challenges to routine practices. Clinical learning experience requires difficult adjustments for students as they come from different socio-economic and cultural backgrounds (D’souza et al, 2013) and positive learning experiences during clinical practice influence not only learning outcomes, but also how students reason in relation to future career choices (Carlson & Idvall, 2014).

Minimal studies have been conducted on the C.L.E which has considered the student nurses’ perception of the actual C.L.E as well as the C.L.E ideally liked or preferred. Indeed, there is no published research in nursing literature in Nigeria which has explored the clinical learning environment from the students perspective. Therefore this study is designed to assess nursing students’ perceptions of actual and preferred hospital clinical learning environment in Enugu State.

1.2 Statement of Problem

Despite the fact that clinical learning is an integral part of nursing education, yet it has been problematic. Various studies have suggested that not all practice settings are able to provide nursing students with a positive learning environment (Chan, 2004).

Clinical experience has been linked to high levels of stress and anxiety in nursing students and literature shows that there is a link between the nursing student attrition and the stress related to the clinical experience (Mlek, 2011). Evidence also shows that clinical experience is one of the most anxiety producing components of the nursing program (Sharif & Masoumi, 2005) and some of the anxiety producing situations identified by nursing students include lack of clinical experience, unfamiliar areas, difficult patients, fear of making mistakes and being evaluated by faculty members.

In addition nursing students in other studies (Levett-Jones, Latta, Hygins & McMillan, 2009) described nursing staff as unfriendly, hostile, indifferent, unreceptive and unapproachable. Their feelings of inclusion/exclusion affected directly their sense of belonging and subsequently increased their anxiety, capacity and motivation to learn (D’souza et al, 2013). Though mild anxiety is not detrimental to learning and may even enhance perception and memory but moderate or severe anxiety can alter one’s ability to learn and perform in a clinical setting (Levett-Jones et al 2009).

The researcher having taught in School of Nursing for over five (5) years now have listened to comments from students regarding their perceived difficulties while on clinical placements. Some of the difficulties focused on their perceived lack of support and direction, not feeling part of the team and concerns regarding interpretation of their supernumerary status in the clinical areas. Supernumerary status means that student nurses are additional to the clinical workforce and undertake a placement in clinical practice to learn, not as members of staff (NMC, 2004 in Allan, 2009). However, this does not mean that students do not work while on placement, they are expected to learn through supervised participation in clinical work (Arkell & Bayliss-Pratt, 2007).

The researcher is interested in assessing perceptions of students’ actual clinical learning environment experiences and to determine what they would prefer this environment of experience to be like. Such an assessment is necessary in order to facilitate and maximize student nurses’ clinical training (Chan, 2002).

Few studies have been conducted on the clinical learning environment (C.L.E) which has considered the students’ perceptions of the actual C.L.E as well as the C.L.E ideally liked or preferred (Chan 2002) in other countries. Unfortunately, in Nigeria, there is apparently no published research on students’ perceptions of the clinical learning environment in nursing literature.

1.3 Objectives of the Study

The objectives of the study are to:

Determine student nurses view of their actual hospital clinical learning environment.
Establish student nurses preferred hospital clinical learning environment.
Determine if differences exist in student nurses view of their actual and preferred hospital clinical learning environment.
Identify differences between the actual and preferred clinical learning environment and students’ age, gender, location and year of study.
Identify factors that influence student nurses opinion of their hospital clinical learning environment.

1.4 Research Questions

How do nursing students see their actual hospital clinical learning environment?
What is the student nurses preferred hospital clinical learning environment?
What differences exist between perceptions of actual and preferred hospital clinical learning environment of student nurses?
What differences exist between the actual and preferred clinical learning environment and the students’ age, gender, location and year of study?
What factors influence student nurses’ opinions of their hospital clinical learning environment?

1.5 Statement of Hypothesis

There will be no significant difference in the students’ perception of the actual and preferred hospital clinical learning environment.
There will be no significant difference in students’ perception of the actual hospital clinical learning environment between baccalaureate (UNEC) and hospital based (schools of Nursing-UNTH and Bishop Shanahan).
There will be no significant difference in students’ perception of the preferred hospital clinical learning environment between baccalaureate (UNEC) and hospital based (schools of Nursing-UNTH and Bishop Shanahan).
There will be no significant difference in students’ perception of the actual and preferred hospital clinical learning environment between baccalaureate (UNEC) and hospital based (schools of Nursing-UNTH and Bishop Shanahan).

1.6 Significance of the Study

The focus of this study is on the perceptions of actual and preferred clinical learning environment of student nurses in Enugu State. The findings of this study will reveal the students’ perceptions of actual and preferred clinical learning environment in the hospital setting, whether the practice settings are able to provide nursing students with a positive learning environment. It will also reveal a better understanding of what constitutes quality clinical education from the students’ perspective. An understanding of the students’ perceptions of their actual and preferred hospital clinical learning environment may reveal aspects of the actual environment that require improvement in order to maximise students’ learning in practice. Findings if published and utilized will also assist in improving the educative quality of students’ clinical education through understanding their perspective of clinical learning environment and the social climate in which they are (ward). It will also help nurse educators, hospital administrators, Nursing and Midwifery Council of Nigeria as well as Ministry of Education in ensuring that the problems identified by students in the clinical area is addressed accordingly by monitoring the activities in the clinical setting. This study will equally serve as a reference for future researchers writing on similar topic. The findings of this study will also contribute to the existing body of knowledge on the clinical learning environment in nursing literature in Nigeria. It is believed that the present study will provide a preliminary data that will fill the gap in the knowledge in nursing literature in this area.

1.6 Scope of Study

This study is delimited to student nurses in Enugu State. This includes second and third year students in schools of nursing, UNTH Enugu, and Bishop Shanaham, Nsukka respectively and fourth and fifth year nursing students in the department of nursing sciences, UNEC, because they had experienced adequate clinical exposure to be able to comment on a variety of situation. The study is delimited to actual and preferred hospital clinical learning environment of nursing students. It includes students of both sexes.

1.8 Limitation of the Study

In the course of carrying out this study, the researcher experienced some constraints, which included time constraints, financial constraints, language barriers, and the attitude of the respondents. However, the researcher were able to manage these just to ensure the success of this study.

1.9 Operational Definition of Terms

1. Perception

Refers to the rating by student nurses of items of the actual and preferred clinical learning environment inventory (CLEI 42 items), contained in the questionnaire. These ratings are based on the observations and experiences and exposures of the student nurses.

2. Perceptions of actual hospital clinical learning environment

Refers to student nurses description of what their clinical learning experience is actually like in the hospital setting as contained in the CLEI such as the CPC/Nursing staff considers students, Students are dissatisfied with what is done in the ward among others.

3. Perceptions of preferred hospital clinical learning environment

Refers to description of what or how students want their experience in the clinical area of the hospital to be like as contained in the CLEI such as the CPC/Nursing staff would consider students, Students would be dissatisfied with what is done in the ward among others .

4. Hospital clinical learning environment

Refers to student nurses’ clinical experience in the hospital setting.

5. Clinical learning environment

Is defined as an interactive network of forces within the clinical setting that influence the students’ clinical learning outcomes. It includes hospitals, wards, clinics, health departments, hospice units, and other health care settings utilized for student learning such as community visits, nursing homes, and mental health homes among others.

6. Clinical education

Is the teaching learning process which occurs in the context of real health care clinical practice mostly in a hospital setting. It involves practical integration and application of knowledge, skills and attitudes learned at the classroom and it is facilitated with professional support, supervision, feedback and evaluation among others.

1.10 Organization of the Study

This research work is organized in five chapters, for easy understanding, as follows.

Chapter one is concern with the introduction, which consist of the (overview, of the study), historical background, statement of problem, objectives of the study, research hypotheses, significance of the study, scope and limitation of the study, definition of terms and historical background of the study.
Chapter two highlights the theoretical framework on which the study is based, thus the review of related literature.
Chapter three deals on the research design and methodology adopted in the study.
Chapter four concentrate on the data collection and analysis and presentation of finding.
Chapter five gives summary, conclusion, and recommendations made of the study.

Chapter Five

Summary, Conclusions and Recommendations

This chapter discussed the summary conclusion and recommendations.

5.1 Summary

This research assessed the perceptions of actual and preferred hospital clinical learning environment of student nurses in Enugu State. The research was prompted by the fact that not all practice settings are able to provide students with a positive learning environment and verbal expressions of frustrations by students on clinical posting.

Five research objectives and eight hypotheses were formulated. Social climate theory was considered appropriate to analyse student nurses perceptions of their actual and preferred hospital CLE. 454 students formed the sample size. Validated standardized Clinical Learning Environment Inventory (CLEI) and researcher’s developed questionnaires were utilized for the study. The findings show that there is significant difference in the student nurses’ view of their actual and preferred hospital CLEI. They have negative view of the actual hospital CLE.

5.2 Conclusion

Student nurses in Enugu State have significant negative view of their actual hospital CLE (mean scores <2.50 and p<0.05). Their view of the preferred hospital CLE is always higher than their view of the actual hospital CLE.

On the difference between the actual and preferred hospital CLE, only gender and year of study in the preferred hospital CLE were significant (p<0.05). Female had a higher preferred hospital CLE than the male. More so, the higher the study year, the lower the preferred hospital CLE, except only in fifth year where the preferred hospital CLE is higher than third year.

Finally, factors that influence student nurses opinion of their actual and preferred CLE were year of study, interest in nursing education, student self concept, mood of the learner, intellectual abilities of the learner, having worked in health care setting before nurse education, socio-cultural conditioning among others.

5.3 Recommendations

Based on the findings, the following recommendations were made;

Allocating students to preceptors with a patient/ client caseload would be a means towards improving students’ perception of ward and workload organization.
The importance of helping students feel valued and interpersonal relationships in the clinical area need to be highlighted in the preceptor preparation programmes.
Also the ratio of student to clinical instructor/ nursing staff needs to be addressed in order to increase individual interaction with their clinical instructors.
The students responses indicate that new ideas and approaches to teaching are seldom tried, and that they do the same type of tasks in every shift. In order to maximise the learning opportunities available, staff need to be prepared adequately to help them recognise and create learning opportunities and ensure adequate supervision of students.
The responses indicate that students ‘‘clock watch’’ and that they would prefer more opportunities to express opinions. The more involved students perceive themselves to be, the more satisfaction they express with CLE. The importance of involving students in clinical activities needs to be addressed at several levels. Staff acceptance and support in this regard cannot be underestimated.
Closer liaison between clinical instructor, preceptors, clinical staff and nurse tutors/link lecturers through regular meetings in the practice setting would help ensure that students’ needs remain salient and that preceptors and clinical staff have ongoing network of support.

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