Nursing students' perceptions of their clinical learning environment in placements outside traditional hospital settings.

AIMS AND
OBJECTIVES: To explore students' opinions of the learning environment during clinical placement in settings outside traditional hospital settings.
BACKGROUND: Clinical placement experiences may influence positively on nursing students attitudes towards the clinical setting in question. Most studies exploring the quality of clinical placements have targeted students' experience in hospital settings. The number of studies exploring students' experiences of the learning environment in healthcare settings outside of the hospital venue does not match the growing importance of such settings in the delivery of health care, nor the growing number of nurses needed in these venues.
DESIGN: A survey design was used.
METHOD: The Clinical Learning Environment Inventory was administered to two cohorts of undergraduate nursing students (n = 184) after clinical placement in mental health care, home care and nursing home care.
RESULTS: Nursing students' overall contentment with the learning environment was quite similar across all three placement areas. Students in mental health care had significantly higher scores on the subscale individualisation, and older students had significantly higher scores on the total scale. Compared with other studies where the Clinical Learning Environment Inventory has been used, the students' total scores in this study are similar or higher than scores in studies including students from hospital settings.
CONCLUSION: Results from this study negate the negative views on clinical placements outside the hospital setting, especially those related to placements in nursing homes and mental healthcare settings. RELEVANCE TO CLINICAL PRACTICE: Students' experience of the learning environment during placements in mental health care, home care and nursing homes indicates the relevance of clinical education in settings outside the hospital setting.

Nursing students report that they are fairly content with the clinical learning environment in mental health care, nursing homes and home care.

There is room for improvement in the learning environment, especially concerning teaching innovation.

Future research should move into testing interventions that aim to improve the clinical environment.

Introduction

Hospital wards have been the traditional clinical placement setting for nursing students. Depending on the country and the healthcare system, students have also practised in community care, mental health care, nursing homes, as well as in nontraditional settings such as parishes, prisons or children's day care (Harwood ). Clinical placements for nursing students are important in many respects and characterised as an irreplaceable component of nursing education (Tanner 2006). From a legal perspective, practice in clinical settings is a requirement to ensure fitness to practise as a nurse. From an educational perspective, the clinical placement is the venue where skills, knowledge and attitudes developed in the theoretical part of the curriculum are applied, developed and integrated (Newton ). From a clinical perspective, the nurses who preceptor and guide nursing students through weeks of learning experiences see them as potential new recruits to their specialty field of nursing (Storey & Adams 2002, Happel 2008a). From a student perspective, clinical placements are both stressful (Timmins & Kaliszer 2002) and rewarding (Hartigan-Rogers ) and also viewed as the most important part of nursing education (Kinsella , Myrick ). Regardless of the perspective on clinical placements, a plethora of studies have found that clinical placement experiences may influence positively on nursing students attitudes towards the clinical setting in question (see, e.g., Fagerberg , Abbey , Happel & Platania-Phung 2012 and a recent review by Happel & Gaskin 2013). Graduate nurses contend that they are more likely to apply for work in settings where they had positive experiences during undergraduate clinical placements (Courtney , Edwards ). It is therefore an important task to ensure good learning environments in all clinical settings used in nursing education. The clinical learning environment has mostly been studied in hospital settings. The purpose of this study was to explore students' opinions of the learning environment during clinical placement in settings outside traditional hospital settings, more specifically home care, mental health care and nursing homes.

Clinical placements in the Norwegian bachelor programme in nursing

In the Norwegian bachelor of nursing, students are assigned to clinical placements for 42% of the total education time. Five placement areas are obligatory: surgical nursing, medical nursing, mental health care, home care and nursing homes. Students must be assigned to any three of these areas for at least eight weeks and the other two for at least six weeks, and they study for 30 hours/week in the clinical area. These placements are defined as supervised practice. In supervised practice, the students are preceptored by a registered nurse. The teacher mostly acts as a liaison to the school. Only in a few schools does the teacher still supervise in the clinical setting and only during the students' first year of education. Instead, the teacher arranges meetings during the placement period, with student and preceptor, to discuss the students' written plan and objectives for the placement period and to carry out mid-term and final evaluation. Unlike many other western countries, Norwegian nursing students have been assigned to clinical placements in mental health care and nursing homes since 1962 and home care since 1975.

Background

Most studies exploring the quality of clinical placements have targeted students' experience in traditional hospital settings. Several qualitative and mixed methods studies (most often with locally developed questionnaires) have focused on one or a few aspects of the learning environment. They have extracted a variety of themes within different theoretical perspectives and across clinical settings such as the impact of different supervision models (Saarikoski , Croxon & Maginnis 2009, Lindgren & Athlin 2010), tutorial strategies (Brugnolli ) or how leadership characteristics of the preceptor could enhance students' practice (Zilembo & Monterosso 2007). Some small-scale qualitative studies have explored students' experiences of the learning environment in a more holistic fashion. Solvoll and Heggen (2010) highlighted that tutors and nurses failed to encourage reflection on the students' experiences of care showing how only practical problem-solving and theoretical perspectives came to the forefront. Holmsen (2010) explored the development of students' confidence during clinical placement emphasising the importance of structure, feedback, openness about expectations, time for reflection and being welcomed and appreciated. Students in Papp ) also felt the need to be appreciated and supported. Other themes relevant to experiencing good learning environments in this study was encountering high-quality care by personnel in the ward and having the opportunity to gain independence in their work by being self-directed. Newton followed six students through all clinical placements and also found that being able to gain independence was an important aspect of a good learning environment. Creation of learning opportunities by the staff and becoming part of the team were the two other central themes in this study. Levett-Jones suggest that students' sense of belonging in a clinical placement improves confidence and motivation in learning. They interviewed students on the impact of staff–student relationships during clinical placements. Learning and belongingness were promoted when the relationship between students and staff was characterised by receptiveness, recognition and appreciation, challenge and support, inclusion and legitimisation of the student role.

The number of studies exploring students' experiences of the learning environment in healthcare settings outside of the hospital venue does not match the growing importance of such settings in the delivery of health care, nor the growing number of nurses needed in these venues. For example, we found only two studies that reported on student experiences of the learning environment in community care (Baglin & Rugg 2010, Murphy ) and two studies in mental health (Happel 2008a, O'Brien ).

Baglin and Rugg (2010) analysed students' reflective diaries from their clinical placements. Students highlighted the importance of relationships with mentors and other team members and the opportunity to practise basic skills. Murphy compared student satisfaction with placement in a variety of hospital and community settings and found that district nursing was the best liked placement in the community. Studies exploring students' views of the learning environment in mental healthcare placements reported that students felt welcomed, oriented and supported during their placements (Happel 2008a, O'Brien ). Staff's lacking familiarity with the students' learning objectives was criticised, as well as the length of the placement that was deemed too short at two or four weeks (Happel 2008a). Students with the longer placements were generally more satisfied.

More studies have focused on students' experiences of the learning environment in nursing homes. Students underscore the positive experience of being met by prepared staff that are both welcoming, accepting, including and appreciative (Banning , Nordhagen & Engelien 2008, Skaalvik ). The clinical supervisors (Banning , Skaalvik ) and the teacher (Rogan & Wyllie 2003) have pivotal roles in supervising learning processes. Negative experiences of the learning environment were also evident such as lacking initial orientation (Robinson & Cubit 2007) and impoverished learning environments where staffs' negative attitudes towards working with elderly pervaded the learning environment (Happel 2002, Brown ).

Several instruments have also been developed that measure students' overall perceptions of clinical learning environments including aspects such as the quality of staff–student relationships, how students are welcomed and accepted in the ward, role of the teacher, and the availability and variety of nursing tasks in the ward (e.g. Chan 2001, 2002, Saarikoski & Leino-Kilpi 2002, Saarikoski , Sand-Jecklin 2009). Clinical Learning Environment Inventory (CLEI) (Chan 2001, 2002) is the instrument that has been used most often. The majority of studies using CLEI have either exclusively studied students in hospital settings or included a group of students from several different settings, but without discriminating their experiences in relation to the different settings. To our knowledge, only a few studies have surveyed students in other settings such as nursing homes (Berntsen & Bjørk 2010), hospitals and nursing homes (Skaalvik ), mental health care (Saarikoski ), and hospitals and the community (Murphy ).

In summary, numerous studies have explored nursing students' experience and perceptions of the learning environment during clinical placement. Many of these studies have focused on one or a few aspects of the learning environment. During the last decade, several instruments have been developed that intend to measure overall perceptions of the clinical learning environment. Nearly all studies using these instruments have targeted nursing students in hospital settings. There is a lack of knowledge concerning students' perceptions of the clinical learning environment outside traditional hospital settings, such as mental health care, community care and nursing homes.

Methods

Design

A survey design using the CLEI (Chan 2001, 2002) was used to collect data. The present study is part of a larger study that was developed to evaluate and improve the learning environment for nursing students at a university college in Norway.

Setting and sample

The participants were two cohorts of nursing students in their last year of the bachelor of nursing at a university college in the eastern part of Norway. They were assigned to clinical placements in three different areas: mental health care, nursing homes and home care. The placements lasted between seven and nine weeks. The students spent 30 hours/week in the clinical area during placement, had one named teacher as their educational supervisor and were each allocated to a nurse preceptor in the clinical setting. Information about the study was posted on the electronic learning platform at the nursing college in advance. In addition, written information was attached to the questionnaire. Students were given the opportunity to answer the questionnaires either in the classroom during theoretical study one week after their placement or at the end of the placement if they were moving directly into another clinical placement. The latter students returned the questionnaire in a preaddressed envelope to the nursing department in the college. The study population consisted of 242 students, and 184 questionnaires were returned giving a response rate of 76%.

The questionnaire elderly patients

The questionnaire consisted of two sections: demographic variables and the CLEI. Demographic variables were age, higher education before entering nursing education and work experience in healthcare settings before nursing education. CLEI was developed to assess student nurses' perception of the learning environment during clinical placement (Chan 2001, 2002). The instrument is based on a conceptual framework that includes three basic dimensions characteristic to all human environments: a relationship dimension, a personal dimension, and a system maintenance and system change dimension (Moos 1974 in Chan 2001). CLEI includes 42 statements that are grouped into six subscales with seven items each; personalisation – emphasis on opportunities for individual student to interact with their clinical teacher/clinician and on concern for student's personal welfare; individualisation – the extent to which students are allowed to make decisions and are treated differentially according to ability or interest; innovation – the extent to which clinical teacher/clinician plans new and interesting ward experiences, teaching techniques, learning activities and patient allocations; involvement – the extent to which students participate actively and attentively in hospital ward activities; task orientation – the extent to which ward activities are clear and well organised; satisfaction – the extent of enjoyment of clinical placement. The 42 items are a mixture of positive and negative items. Responses to each item are marked on a four-point Likert-type scale with the following response alternatives: 5 (strongly agree), 4 (agree), 2 (disagree) and 1 (strongly disagree). Omitted or invalid responses were scored 3 as suggested by Chan (2001). To calculate mean scores, the scores on negative items were reversed. Higher scores on each subscale indicate better satisfaction.

Chan (2001) developed two similar forms of the CLEI, one that asked students to score with their actual experiences in the clinical placement in mind (the actual form) and one where students were asked to score based on how they preferred the learning environment to be (the preferred form). In this study, we have only used the actual form. The questionnaire has been translated into Norwegian and used in a former study in Norway (Berntsen & Bjørk 2010). Internal consistency estimated with Cronbach's α in Chan's (2001, 2002) original study was reported in the range of 0·73–0·84. In later studies, Cronbach's α has been reported in the range of 0·45–0·90 (Ip & Chan 2005, Perli & Brugnolli 2009, Berntsen & Bjørk 2010, Murphy ). In the present study, Cronbach's α for the subscale involvement was quite low at 0·46, high at 0·92 for the subscale satisfaction and it varied between 0·533–0·681 for the other subscales.

Data analysis

Data were optically scanned and entered into spss, version 18 (IBM Corporation, Armonk, NY, USA). Data were analysed with descriptive statistics, anova and linear regression.

Ethics

According to Norwegian regulations, the study did not need ethical approval as patients or sensitive data were not involved. The dean at the university college had the authority to review and make decisions on the research protocol. To hinder the possibility of recognition of students, we were asked to remove a demographic question that asked for gender as there were so few male students in the programme and to use age groups as response alternatives instead of specific age on the question about respondent's age. The students were notified on the electronic learning platform and in the information attached to the questionnaire that returned questionnaires signified acceptance of participation in the study.

Results

Demographic information about the students in total and according to the clinical area of placement is reported in Table1.

Table 1

Demographic variables in the sample

	All students n = 184 n (%)	Students in nursing homes n = 61 n (%)	Students in home care n = 53 n (%)	Students in mental health n = 70 n (%)	χ2	p
Age
19–24 years	100 (54·6)	35 (58·3)	29 (45·7)	36 (51·4)	1·765	0·78
25–29 years	52 (28·4)	16 (26·7)	13 (24·5)	23 (32·9)
≥30 years	31 (16·9)	9 (15·0)	11 (20·8)	11 (15·7)
Total	183	60	53	70
Missing	1	1
Worked in healthcare settings before education
Yes	112 (66·3)	33 (60·0)	33 (67·3)	46 (70·8)	1·581	0.45
No	57 (33·7)	22 (40·0)	16 (32·7)	19 (29·2)
Total	169	55	49	65
Missing	15	6	4	5
University/college education before nursing education
Yes	53 (29·8)	18 (31·0)	15 (29·4)	20 (29·0)	0·068	0·97
No	125 (70·2)	40 (69·0)	36 (70·6)	49 (71·0)
Total	178	58	51	69
Missing	6	3	2	1

The sample was characterised by many students in the youngest age group, two-thirds of the students had worked in health care before they started nursing education, and approximately one-third of the students had previous university or college education. Chi-square tests showed no significant differences between the student groups in the three practice areas in relation to their age, experience in health care or higher education before entering nursing education.

A one-way anova with correction for multiple comparisons (Bonferroni correction where equal group variances could be assumed and Tamhane's T2 where equal group variances could not be assumed) was performed to find whether there were differences in students' mean scores on the total scale or the subscales of CLEI depending on area of placement (Table2).

Table 2

Mean scores of Clinical Learning Environment Inventory (total scale and subscales) by placement areas

	All students	Nursing homes	Home care	Mental health	panova
Total scale (SE)	151·23 (1·568)	148·07 (2·576)	152·53 (2·415)	153·00 (2·933)	0·364
Personalisation (SE)	26·26 (0·313)	26·48 (0·566)	25·89 (0·525)	26·36 (0·529)	0·741
Involvement (SE)	27·28 (0·312)	26·79 (0·445)	27·55 (0·390)	27·53 (0·659)	0·284
Task orientation (SE)	25·27 (0·321)	25·30 (0·495)	26·32 (0·480)	24·46 (0·616)	0·062
Individualisation (SE)	24·95 (0·334)	23·70* (0·594)	25·15 (0·587)	25·87* (0·532)	0·022
Innovation (SE)	20·45 (0·322)	19·62 (0·568)	20·83 (0·554)	20·87 (0·539)	0·199
Satisfaction (SE)	26·85 (0·497)	26·18 (0·741)	26·79 (0·850)	27·49 (0·940)	0·544

SE, standard error.

Significant difference between students in nursing homes and mental health p = 0·019.

There were no significant differences in the three student groups' overall perception of the learning environment as measured by scores on the total scale. Students assigned to mental health care had significantly higher scores than students in nursing homes on the subscale individualisation, 25·87* and 23·70*, respectively, p = 0·019. There were no significant differences between students on the other subscales.

As placement area hardly seemed to influence the students' scores, linear regression was performed to gauge the influence of the following demographic variables on the students' scores on CLEI: age, higher education before entering nursing education and work experience in healthcare settings before nursing education. The explanatory variable ‘age’ was originally coded 1 (<25 years), 2 (25–29 years) and 3 (>29 years). It was replaced by two dummies: ‘dummymid’ (25–29) and ‘dummyold’ (>29), using as our reference group the largest student group (those with age < 25). There were no significant findings related to the influence of demographic variables on the subscales, but older students had significantly higher total scale scores on CLEI than the other age groups (Table3).

Table 3

The significance of demographic variables on the Clinical Learning Environment Inventory total scale score

Variables	B	p
Higher education before nursing education	−2·036	0·633
Worked in healthcare settings before nursing education	6·275	0·078
Dummymid (25–29)	4·476	0·310
Dummyold (>29)	10·997	0·038*

Dummymid and dummyold are two dummy variables that replace the noncontinuous variable AgeInThreeGroups. Dummymid identifies participants between 25–29 years of age, and dummyold identifies those above 29. Their regression coefficients show how much these age groups differ from the reference group (participants under 25) in terms of the dependent variable.

Older students had significantly higher scores on total scale.

Discussion

A major finding in this study was that nursing students' overall contentment (as presented in the total scores) with the learning environment was quite similar across all three placement areas. Compared with other studies where the CLEI instrument has been used, the students' total scores are similar and often higher than scores in studies including students from hospital settings (Ip & Chan 2005, Midgley 2006, Perli & Brugnolli 2009). This result negates the negative views on clinical placements outside the hospital setting, especially those related to placements in nursing homes (Happel 2002, Robinson & Cubit 2007, Brown ). However, Skaalvik who also recently tested a Norwegian population of nursing students' satisfaction with the learning environment found that students in nursing homes assessed their clinical learning environment more negatively than students in hospital wards.

One interpretation of these differing results may be related to the instruments used. Skaalvik used the CLES + T (Saarikoski ) that focuses more on supervision than CLEI. The more negative assessment in nursing homes may be related to a lack of qualified nursing staff that can cover the students' needs for supervision. Lack of qualified nurses in nursing homes has been reported both in Norway (Bergland & Lærum 2002, Kloster ) and in other countries (Abbey , Harrington ). Student contentment with clinical placement in the community (district nursing) has also been reported to match contentment with placements in some hospital settings such as intensive care, high dependency and cardiologic departments (Murphy ). One reason for these positive views was suggested to result from a close relationship with mentors.

A significant difference in overall contentment was also related to students' age. Older students (>29 years) scored as much as 11 points higher than younger students (<25 years) on the total score scale. As age did not show up in significant differences between students' subscale scores, this means that older students' higher total score was evenly dispersed between all subscale scores. This generally higher level of positive perceptions of the learning environment in older students has not been reported in other studies, as analysis related to students' age has not been published. Although based on speculation, this result may be related to student motivation. Older students may be more motivated when they finally enter nursing education, and as a consequence, they might have a positive attitude towards clinical placement in general. Older age may also indicate more maturity which makes it easier to tackle the varied challenges in different placement settings. How students' age may influence learning in clinical settings should be explored in future studies.

Students in mental healthcare placements had the highest total scores, although not significantly higher than the other students, and were significantly more satisfied on the subscale score of individualisation. In a Norwegian study on preferences in choice of nursing area after graduation, Kloster found that first-year students ranked mental health care as number seven, before both home care and aged care institutions. By their third and last year of education, the same cohort of students ranked mental health care as their third choice. This evolving positive attitude towards working in mental health care is starkly different from the views of students reported in the review by Happel and Gaskin (2013). They conclude that for more than 30 years, students have put mental health care as the last of their preferred areas of work after graduation. Happel (2008a) and O'Brien did report general student satisfaction with psychiatric placements, although there was no comparative aspect in their studies. Happel (2008b) also showed that students were more satisfied when the placement period increased from two to four weeks. In comparison, the students' placement in the present study was approximately eight weeks long and afforded more time to ‘feel at home’ and to practise psychiatric nursing. Mental healthcare practice is often seen as a bit scary (Henderson ), and clinical supervisors work more closely with students in this area in Norway than in other placements. In a closer relationship with the clinical supervisor, the student may feel that supervision is tailored and this may have influenced the students experiences of follow up related to individualisation in the psychiatric setting. An interpretation in the same vein is that mental health care is characterised by an attitude of individual orientation towards the patient. This attitude might spill over onto the supervision relationship between student and mental healthcare nurse. Happel (2008b) reported that enough time and support from clinical staff was an important aspect of a positive clinical placement in mental health care.

As, by now, the CLEI instrument has been used in several studies on nursing students' perceptions of their learning environment, we made a comparison of total and subscale scores across the present study and all other studies that used Chan's (2001) original method of scoring (Ip & Chan 2005, Midgley 2006, Perli & Brugnolli 2009, Berntsen & Bjørk 2010, Smedley & Morey 2010, Murphy ). In the present study and in other studies where Chan's six subscales were used (except Murphy ), the subscales personalisation, involvement and satisfaction have the highest scores, ranked 1, 2 or 3 (Ip & Chan 2005, Perli & Brugnolli 2009, Berntsen & Bjørk 2010). Task orientation, innovation and individualisation have the lowest scores in these studies, ranked 4, 5 and 6. In studies where the satisfaction subscale has not been used, personalisation and involvement are still ranked highest and task orientation, innovation and individualisation are the lowest (Chan 2001, Smedley & Morey 2010). What do these similarities in student responses mean?

One interpretation of these similarities is that there may be something genuinely similar in students' learning environments across clinical settings and national borders. Looking back to the theoretical underpinning of the CLEI (Chan 2001), we are reminded that Moos (1974) developed his original instrument based on three basic dimensions characteristic to all human environments: a relationship dimension, a personal dimension, and a system maintenance and system change dimension. All these dimensions are certainly evident in clinical settings. The relationship between staff and students is underscored as the most important influence on nursing students' sense of belonging and learning (Levett-Jones ). The students' high scores on personalisation and student involvement in the present and other studies with CLEI may indicate that students often enter into responsive and trusting relationships with their supervisors regardless of clinical placement setting.

Being a learner in a workplace environment is viewed by Lave and Wenger (1991) and Heggen (1995) as involving some common features. Students inhabit a peripheral position when they start out in practice and must actively work to acquire a legitimate position closer to the essence of the tasks and culture of the workplace to learn the trade or profession in question. In this situated view of learning, it is participation and dialogue that are the vehicles of learning (Solvoll & Heggen 2010) and these are generic activities that all students need to participate in when they are placed in clinical settings.

An important message from comparing results from studies that have used the CLEI instrument is that student scores in all studies, although more positive than negative, show there is a potential for improvement in all aspects of the clinical learning environment. Some aspects of the clinical learning environment are perceived more negatively than others, particularly innovation in learning methods and also task orientation and individualisation. Tanner (2006) states that methods to clinically train nursing students have not changed over the past 30 years, and more studies and reports in the USA urgently advocate for innovative ways to educate nursing students in the clinical setting to better prepare them for healthcare challenges of today (Moscato , NLN 2008, Benner , Niederhauser ). Central advice in these reports is to increase collaboration between faculty and nurses in the clinical setting and to integrate the learning that goes on in the clinical setting with learning in the classroom. Although clinical education differs between USA, where these reports are from, and European countries, this is still sound advice as students still claim there is a gap between learning in school and learning in the clinical setting.

Limitations

This is a survey and interpretation of the results must be carried out with caution. There is always a risk of bias as respondents may answer what they think is expected and not in accordance with own experience. Although more than 75% of the sample answered the questionnaire, students are recruited from one college only. Several studies that use the CLEI instrument, including the present study, have reported low Cronbach's α scores on a few of the CLEI subscales. This indicates a low internal consistency and a need to look closer at the items that are included to represent the subscale constructs.

Conclusion

The evidence in this study suggests that students are fairly content with the learning environment during clinical placements in mental care, home care and nursing homes. Compared with scores obtained in studies where nursing students have their placement in hospital settings, there was no great difference. However, in general, there is room for improvement. Since its development in 2001, the CLEI has been used in many studies in many different countries and continents and with quite similar results in both total and subscale scores. It seems relevant to consider a next step in knowledge development that brings us further. This might include studies that try to intervene to improve those areas of the learning environment that consistently have the lowest scores as perceived by students, such as innovation, task orientation and individualisation.

Relevance to clinical practice

Over the last years, community health care has expanded in most developed countries, and more nurses are needed to ensure appropriate nursing care in the home, nursing homes and mental healthcare settings. This expansion increases the relevance of using a variety of settings in community health care as clinical placements for nursing students. As undergraduate nursing education is considered one important means in attracting nurses to apply for work in different nursing specialties, it is important to consider improvement in the clinical learning environment. Both this and similar studies suggest that such improvement can better the total experience of being a student on clinical placement and thereby influence students views on a future career in community health care.

Disclosure

The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.

Funding

This study was partly funded by the Norwegian Nurses Association.