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Nursing Students’ and Tutors’ Satisfaction With a New Clinical Competency System Based on the Nursing Interventions Classification Maria Rosa Iglesias-Parra, PhD, MSc, RN, Silvia García-Mayor, PhD, MSc, RN, Shakira Kaknani-Uttumchandani, MIH, RN, Álvaro León-Campos, MIH, RN, Alfonso García-Guerrero, PhD, MSc, RN, and José Miguel Morales-Asencio, PhD, BSc, RN Maria Rosa Iglesias-Parra, PhD, MSc, RN, is a Professor of Geriatric Nursing, Department of Nursing and Podiatry, Faculty of Health Sciences, University of Málaga, Málaga, Spain, Silvia García-Mayor, PhD, MSc, RN, is a Research Associate, Faculty of Health Sciences, University of Málaga, Málaga, Spain, Shakira Kaknani-Uttumchandani, MIH, RN, is a Research Associate, Faculty of Health Sciences, University of Málaga, Málaga, Spain, Álvaro León-Campos, MIH, RN, is a Research Associate, Faculty of Health Sciences, University of Málaga, Málaga, Spain, Alfonso García-Guerrero, PhD, MSc, RN, is a Coordinator of Community Nursing Services, Health Centre Colonia Santa Inés-Teatinos, District of Primary Health Care of Málaga, Málaga, Spain, and Clinical Lecturer, University of Málaga, Málaga, Spain, José Miguel Morales-Asencio, PhD, BSc, RN, is Director of the Department of Nursing and Podiatry, Professor of and Research and Evidence Based Health Care, Faculty of Health Sciences, University of Málaga, Málaga, Spain.

Search term: Clinical teaching (health education), competency based education, nursing education Author contact: [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected], with a copy to the Editor: [email protected]

PURPOSE: To assess students’ satisfaction with their clinical tutors, their clinical practices, and tutors’ satisfaction with the new approach of clinical placements and tutorship. METHODS: A cross-sectional study was used, with a study population of second and third year nursing students and clinical tutors. RESULTS: Global satisfaction was 7.47 (SD 1.61) (range from 1 to 9). Regarding students’ satisfaction, 75.67% of the items were equal to or greater than 4 (range from 1 to 5). The overall mean score was 4.05 (DE 1.08). CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE: A competency-structured practicum, assessed through the Nursing Interventions Classification and supported on information and communications technologies, is a reliable and valid method that encourages students and tutors to an active participation, and implies a high degree of satisfaction in both tutors and students.

Introduction The Bologna process was a reform of higher education systems carried out in 1999 in European countries, resulting in the European Higher Education Space. Among the main objectives established were to homologate European higher education to promote the free movement of students across the European Union (Collins & Hewer, 2014), and to increase the international attractiveness of European higher education. The reform claims for the need to develop policies to expand access opportunities and support for all groups of students, as well as the importance of promoting research in this area, to avoid discrimination in higher education systems (European Higher Education Area (EHEA, 2012; Egido Galvez, Fernandez Diaz, & Galan, 2014). One of the consequences for the Nursing Degree in Spain is that from 2010, it became a 4-year degree with 240 European credits (ECTS), from which 84 ECTS correspond to clinical training. Students achieve clinical competencies through © 2015 NANDA International, Inc. International Journal of Nursing Knowledge Volume ••, No. ••, •• 2015

clinical placements with real patients, supervised and assessed by licensed professionals, named as clinical tutors, who provide feedback and promote reflection (Epstein & Hundert, 2002). Clinical tutorship has been consistently acknowledged in the literature as a strategy to maximize the benefits of clinical nursing education in terms of knowledge and skill acquisition, confidence, and professional socialization (Happell, 2009). Preceptors play a key role in the socialization, teaching, and assessment of nursing students, helping them to integrate theory with practice (Gleeson, 2008). In addition, health services are growing in complexity, which generates diverse learning opportunities, both formal and informal (Brown et al., 2011). This implies that nursing faculties have the challenge of educating future professionals to achieve essential skills and knowledge for critical thinking and prioritization (Dillard et al., 2009), to handle ambiguous situations, to tolerate uncertainty (Epstein & Hundert, 2002), and to provide care and make decisions 1

Nursing Students’ and Tutors’ Satisfaction autonomously across different contexts and situations (Davies, 2008). A competence-based curriculum could reduce routine tasks that many times add little to the curriculum and generate a waste of time, at the sacrifice of effective learning opportunities (Mallaber & Turner, 2006). In 2002, a systematic review evaluated 61 studies of clinical competencies in nursing published in the last two decades of the twentieth century (Watson, Stimpson, Topping, & Porock, 2002). The lack of methodological strength of most of the studies was a constant in the results, as was poor conceptual development. A decade later, a similar review found that advances in the conceptual definition of the competencies had failed to clarify those uncertainties (Yanhua & Watson, 2011). The assessment and evaluation of competencies have deployed a diverse and heterogeneous set of methods and instruments. Many of these instruments have been developed with methodological limitations (Calman, Watson, Norman, Redfern, & Murrells, 2002), and many of them are unrelated to each other, despite having acceptable reliability. The Nursing Competencies Questionnaire (NCQ) (Bartlett, Westcott, & Hind, 1998), the Key Areas Assessment Instrument, and the Self-Evaluated Core Competencies Scale (Hsu & Hsieh, 2009) have shown good psychometric properties, but with important heterogeneity about their areas of evaluation (Calman et al., 2002). Another recent approach has been the inclusion of Standardized Nursing Languages Systems (SNLSs) as a guidance for structuring the curriculum around competencies, grounded in the definitions that these systems provide (King & Donahue, 2004; Powelson & Leiby, 2003). The availability of the Nursing Interventions Classification (NIC) (Bulechek, Butcher, & Dochterman, 2008) has generated an ideal framework to support nursing practice due to its inclusion in the information systems of different health services (Hyun & Park, 2002). The Department of Nursing at the University of Málaga (Spain) created an online application for clinical tutors with 26 competencies and NIC interventions that allows to follow up the transition from novice to expert, being in accordance with the Dreyfus model (Dreyfus & Dreyfus, 2005). For a better students’ and tutors’ understanding on how to acquire each competency, each NIC intervention was described with up to 10 activities, included into this classification. The required level to acquire each competency was assessed using a Likert scale from 1 to 5 for each intervention at the end of each clinical placement, with 1 being described as “I do not feel able to perform this intervention in any clinical situation, even with support or clinical supervision,” and 5 as “I feel proficient to perform this intervention without support or supervision, regardless the complexity of the clinical scenario.” In addition, a number of resources that serve to support the acquisition of some skills (scales, summaries of basic physiological, pharmacological management guide, etc.) were included in a textbook called “Clinical Notebook,” which was delivered to students at the beginning of the clinical placement, both in hardcopy and online formats. 2

M. R. Iglesias-Parra et al. The validation of this evaluation system has been reported elsewhere (Morales et al., 2011), but the Department of Nursing considered it necessary to test its acceptability for students and tutors. Despite satisfaction with organization of clinical practices having been evaluated both in students (Dennison & El-Masri, 2012) and clinical tutors in many other studies with positive results (Carlson, 2009; Madhavanpraphakaran, Shukri, & Balachandran, 2014; Salamonson, Halcomb, Andrew, Peters, & Jackson, 2010), uncertainty about the perception from students and tutors remained. The aim of this study was to assess students’ satisfaction with their clinical tutors, and their clinical practices, together with tutors’ satisfaction with the new approach of clinical placements and tutorship. Methods Design A cross-sectional study involving second and third year nursing students and clinical tutors was used. Theoretical framework. The whole system of competencies assessment is based on the evolution from novel- to expert-proposed models, like Dreyfuss (Dreyfus & Dreyfus, 2005) or Benner, widely used in nursing (Benner, 1982). This theoretical approach places the acquisition of highest state of proficiency at the expert level, being able to deliver intuitive judgments in their final stages through deep knowledge and experience. NIC interventions related to each competence (Bulechek et al., 2008) were used as the criteria to establish operative indicators of competency assessment. Thus, 74 NIC interventions were associated with 26 competencies for the first clinical placement (second year), adding 19 interventions with the same methodology to describe more clinical competencies to be achieved in successive clinical placements, reaching a total of 93 interventions (Table 1). Subjects The study involved nursing students from the second and third year courses and their clinical tutors. Fourth year students had not started yet from the implementation of the new degree. Sample All the students (n = 194) were selected, and no sampling was carried out. The response rate obtained was 69.07% (n = 134). Regarding clinical tutors, a sample was calculated to obtain their satisfaction. For a total population of 950 clinical tutors in 2011, for an alpha error of 0.05, assuming p = q = 0.5, and a precision of 8%, 195 subjects were necessary. This sample was overestimated up to 15%, to cover potential nonresponse rates. Therefore, the final sample was 224, randomly selected among 464 that had signed up in the

M. R. Iglesias-Parra et al.

Nursing Students’ and Tutors’ Satisfaction

Table 1. NIC Interventions Selected for the Evaluation of Competencies in Nursing Students Second year Code

Intervention

Code

Intervention

Code

Intervention

221 740 840 970 1160 1570 1801

4920 5270 5340 5460 5510 6240 6320

Active Listening Emotional Support Presence Touch Health Education First Aid Resuscitation

2395 2440 2620 2690 2760 3140 3250

Medication Reconciliation Venous Access Device Maintenance Neurologic Monitoring Seizure Precautions Unilateral Neglect Management Airway Management Cough Enhancement

6482

Oxygen Therapy

3480

Lower Extremity Monitoring

1804

Self-Care Assistance: Toileting

6489

3500

Pressure Management

1805 1870 1874 1876 2210 2304 2308 2310 2311

Self-Care Assistance: IADL Tube Care Tube Care: Gastrointestinal Tube Care: Urinary Analgesic Administration Medication Administration: Oral Medication Administration: Ear Medication Administration: Eye Medication Administration: Inhalation Medication Administration: Intradermal Medication Administration: Intramuscular Medication Administration: Intravenous Medication Administration: Rectal Medication Administration: Skin Medication Administration: Subcutaneous

6490 6540 6610 6680 7310 7370 7400 7460 7660

Environmental Management: Comfort Environmental Management: Home Preparation Environmental Management: Worker Safety Fall Prevention Infection Control Risk Identification Vital Signs Monitoring Admission Care Discharge Planning Health System Guidance Patient Rights Protection Emergency Cart Checking

3320

1803

Exercise Therapy: Ambulation Bed Rest Care Positioning Transfer Nutritional Monitoring Vomiting Management Self-Care Assistance: Bathing/Hygiene Self-Care Assistance: Dressing/Grooming Self-Care Assistance: Feeding

3540 3584 3590 3740 4035 4070 4130 4190 4200

Pressure Ulcer Prevention Skin Care: Topical Treatments Skin Surveillance Fever Treatment Capillary Blood Sample Circulatory Precautions Fluid Monitoring Intravenous (IV) Insertion Intravenous (IV) Therapy

7680

Examination Assistance

4238

Phlebotomy: Venous Blood Sample

7690

Laboratory Data Interpretation

4110

Embolus Precautions

7820

Specimen Management

7880 7920 7960

Technology Management Documentation Health Care Information Exchange

1802

2312 2313 2314 2315 2316 2317

6485

Third year Code

Intervention

Code

Intervention

Code

Intervention

480 1020

Ostomy Care Diet Staging

3900 4220

6784 6930

Family Planning: Contraception Postpartal Care

1640 2130 2900 2930 3160 3660

Ear Care Hypoglycemia Management Surgical Assistance Surgical Preparation Airway Suctioning Wound Care

4260 4820 5244 5248 5622 6403

Temperature Regulation Peripherally Inserted Central (PIC) Catheter Care Shock Prevention Reality Orientation Lactation Counseling Sexual Counseling Teaching: Safe Sex Abuse Protection Support: Domestic Partner

7040

Caregiver Support

NIC, Nursing Interventions Classification.

online platform for evaluating students of the survey. The study was carried out from 2011 to 2012. Variables Measured variables were those related with tutors’ satisfaction about students in the clinical environment, infor-

mation, and support received by the health institution and the University (Table 2); those associated with students’ satisfaction with the clinical environment, tutors, and resources given by the Nursing Department, both in the second and third year courses (Table 3); and students’ satisfaction both in primary health care (PHC) and hospital (Tables 4 and 5). 3

Nursing Students’ and Tutors’ Satisfaction Table 2. Tutors’ Satisfaction Variables Tutors’ variables

Mean (SD)

Information, objectives, and general contents of Practicum 1 Information, objectives, and general contents of Practicum 1 Information, schedules, and rotations Information and attendance control Information about EVALComp Support center in the tutorial activities Support of the nursing department Student motivation Student participation Students demand explanations Attention to explanations Compliance schedules Respect for patients and families Attitude helps patients and families Clinical safety surveillance Relationship with other professionals Ability for the clinical assessment of student Adequacy of my unit for the acquisition of skills Adequacy of supporting material Adequacy of the contents of the practicum regarding expectations of students Utility of practicum training for future graduates Satisfaction with EVALComp Overall satisfaction of tutors

5.45 (2.44) 5.38 (2.34) 5.5 (2.5) 5.87 (2.6) 5.81 (2.45) 6.34 (2.47) 6.05 (2.3) 7.55 (1.4) 7.57 (1.28) 7.45 (1.34) 7.74 (1.29) 8.05 (1.28) 8.16 (1.08) 7.97 (1.14) 7.44 (1.29) 7.52 (1.44) 6.96 (1.45) 7.27 (1.65) 6.72 (1.74) 6.78 (1.61) 7.35 (1.67) 6.52 (1,86) 7.47 (1.61)

Analysis Descriptive statistics were completed with measures of central tendency and dispersion, as well as percentages distribution. Internal consistency was calculated using Cronbach’s alpha. Construct validity was assessed using exploratory factor analysis, with the extraction method of principal axes and orthogonal rotations (varimax, quartimax, and equamax) and nonorthogonal (oblimin and promax), to determine the most appropriate factorial solution, finally opting for the varimax rotation, since no evidence of high correlation was found between the elements. Previously, Bartlett’s test of sphericity and KMO test had been performed, to determine its relevance. Likewise, the inter-item and item-total correlations were analyzed. Descriptive statistical measures of central tendency and dispersion were completed by means and standard deviations. The normality of the distributions was calculated by Kolmogorov–Smirnov, asymmetries, and kurtosis. Bivariant analysis included Student’s t-test and ANOVA. Variances’ homogeneity was checked by Levene test, Brown–Forsythe robustness test was applied, and post-hoc analysis using Bonferroni test, or Games–Howell test in case of heteroskedasticity. Results Students’ satisfaction was measured by a questionnaire that was previously validated in a pilot sample of 92 second 4

M. R. Iglesias-Parra et al. year students. The Cronbach’s alpha obtained was 0.92 and the inter-item correlation was r = 0.33, and item-total correlation oscillated from 0.31 to 0.73. Factor analysis yielded a rotated solution of 6 factors that explained 64.65% of the total variance; KMO 0.847 and test of sphericity were significant (p < .0001). Tutors’ satisfaction was evaluated by a questionnaire previously validated among a sample of 83 clinical tutors. The Cronbach’s alpha obtained was 0.92, and the inter-item correlation was r = 0.41 (values ranged from 0.47 to 0.74). Factor analysis yielded a rotated solution of 4 factors that explained 70.05% of the total variance; KMO 0.88 and test of sphericity were both significant (p < .0001). There were 223 tutors (response rate: 99.5%) who responded to the questionnaire. The tutors’ mean age was 44.91 years old (SD 7.41), with mean years in practice of 21.98 (SD 7.20). Women represented 66.81% of the sample. Regarding their qualifications, 84.30% were RN, and 15.69% had a master’s degree or PhD of the tutors, 38.56% practiced in PHC and 61.43% in hospital. Finally, of those who responded, 47.08% had participated in any of the continuous educational activities for tutors organized by the Department of Nursing to improve tutors’ competence. The average number of students tutored per year was 3.59 (SD 3.54). The results of tutors’ satisfaction are detailed in Table 2. The global satisfaction was 7.47 (SD 1.61) (range from 1 to 9). The most highly rated aspects were the respect of the students toward patients and their families, as well as schedules’ compliance, helping attitude showed toward patients and their families, and their attention to explanations and participation. There was no difference between the overall satisfaction of primary healthcare tutors and hospital tutors (7.69 vs. 7.64; p = .113). Similarly, there was no difference between overall satisfaction according to gender: women 7.51 (SD 1.44) versus men 7.39 (SD 1.90); p = .606. Satisfaction with the support received from their work center to perform the tutoring function was significantly higher in primary healthcare nurses against the hospital nurses: 7.00 (SD 2.32) versus 5.92 (SD 2.47); p = .001. Clinical tutors with more years of practice were more satisfied with the demand for explanations from their tutored students. Thus, professionals with less than 15 years of practice obtained a mean of 7.09 (SD 1.53) versus 8.00 (SD 0.92) for professionals with more than 30 years of practice; p = .015. No differences in terms of professional experience and the perceived usefulness of the practicum for the training of future nurses were detected. Tutors who had participated in training activities organized by the department had significantly better satisfaction: 7.71 (SD 1.45) versus 7.75 (SD 1.70); p = .033. No correlation was detected between the years of professional experience and overall satisfaction (r = 0.10; p = .122). Regarding students’ satisfaction, 75.67% of the items were equal to or greater than 4 (range from 1 to 5). The overall mean score was 4.05 (DE 1.08). There were nonsignificant differences between students’ satisfaction from second and third year, except for aspects relating to

Reception from center professionals Initial guidance on the first day Level of support provided in the first moments Reception from center professionals (2nd rotation) Initial guidance on the first day (2nd rotation) Level of support provided in the first moments (2nd rotation) Reception from center professionals (3rd rotation) Initial guidance on the first day (3rd rotation) Level of support provided in the first moments (3rd rotation) Resources inserted in the Virtual Campus Clinical Notebook Resources inserted in the Virtual Campus (2nd rotation) Clinical Notebook (2nd rotation) Resources inserted in the Virtual Campus (3rd rotation) Clinical Notebook (3rd rotation) Tutors’ dedication Explanations offered Tutors’ interest by the level of understanding of their explanations Searching clinical scenarios and learning opportunities for students Resolving doubts through mentoring Promoting a work environment and participation Development of a fluid and spontaneous communication Respect in dealing with students Tutors’ dedication (2nd rotation) Explanations offered (2nd rotation) Tutors’ interest by the level of understanding of their explanations (2nd rotation) Searching clinical scenarios and learning opportunities for students (2nd rotation) Resolving doubts through mentoring (2nd rotation) Promoting a work environment and participation (2nd rotation) Development of a fluid and spontaneous communication (2nd rotation) Respect in dealing with students (2nd rotation) Tutors’ dedication (3rd rotation) Explanations offered (3rd rotation) Tutors’ interest by the level of understanding of their explanations (3rd rotation) Searching clinical scenarios and learning opportunities for students (3rd rotation) Resolving doubts through mentoring (3rd rotation) Promoting a work environment and participation (3rd rotation) Development of a fluid and spontaneous communication (3rd rotation) Respect in dealing with students (3rd rotation) Adequacy of site rotation to achieve the competencies Duration

−0.05 −0.34 −0.12 0.00 −0.13 0.03 −0.16 −0.27 −0.04 0.46 0.48 0.42 0.31 0.41 0.48 −0.20 −0.02 −0.05 −0.07 −0.13 0.21 0.19 0.24 −0.25 −0.16 −0.02 −0.24 −0.21 −0.21 −0.12 −0.10 0.14 0.23 0.18 0.09 0.21 0.07 0.27 0.09 −0.02 −0.30 4.06 3.66 3.96 4.11 3.92 4.11 3.97 3.87 4.07 4.00 4.11 3.97 4.07 4.01 4.11 3.79 4.07 4.01 3.93 4.06 4.18 4.23 4.51 3.87 4.01 4.03 3.77 4.04 3.90 4.06 4.31 4.14 4.23 4.24 4.15 4.37 4.23 4.37 4.58 4.03 3.37

4.11 4.00 4.08 4.11 4.05 4.08 4.13 4.14 4.11 3.54 3.63 3.56 3.76 3.60 3.63 3.98 4.10 4.06 4.00 4.19 3.97 4.03 4.27 4.13 4.17 4.05 4.02 4.25 4.11 4.17 4.41 4.00 4.00 4.06 4.06 4.16 4.16 4.10 4.49 4.05 3.67

0.91 1.15 1.15 0.96 1.02 1.01 1.15 1.24 1.15 0.83 0.89 0.91 1.00 0.84 0.93 1.07 1.07 0.99 1.11 0.95 1.03 0.96 0.77 1.11 1.01 1.16 1.21 1.02 1.15 1.16 1.12 1.15 1.07 1.05 1.18 0.88 1.10 0.97 0.86 0.83 1.11

1.17 1.16 1.08 1.15 1.21 1.32 1.17 1.11 1.12 0.93 0.99 0.89 0.96 0.98 1.07 1.28 1.12 1.15 1.20 1.00 1.22 1.22 1.23 1.20 1.20 1.35 1.30 1.12 1.26 1.24 0.99 1.19 1.18 1.16 1.18 1.12 1.11 1.15 0.93 0.81 0.95

Third

Standard deviation/course

Second Third Second

Mean/Course

Table 3. Differences in Students’ Satisfaction Between Second and Third Year Courses

4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 5.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 5.00 5.00 5.00 5.00 5.00 5.00 5.00 5.00 5.00 4.00 3.00

Second 5.00 4.00 4.00 5.00 4.00 5.00 5.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 5.00 4.00 4.00 5.00 5.00 5.00 5.00 5.00 5.00 5.00 5.00 5.00 4.00 4.00 4.00 4.00 5.00 5.00 5.00 5.00 4.00 4.00

Third

Median/Course

1.00 2.00 2.00 2.00 2.00 1.00 2.00 2.00 2.00 2.00 1.00 2.00 1.00 2.00 1.00 2.00 1.00 2.00 2.00 2.00 1.00 1.00 1.00 2.00 2.00 2.00 2.00 1.00 2.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

2.00 2.00 2.00 1.00 2.00 2.00 1.00 1.00 1.00 1.00 1.00 1.00 2.00 1.00 1.00 2.00 1.00 2.00 2.00 1.00 2.00 1.00 1.00 1.00 1.00 2.00 2.00 1.00 1.00 1.00 1.00 2.00 2.00 2.00 2.00 1.00 2.00 2.00 1.00 2.00 1.00

.278 .056 .563 .622 .193 .482 .316 .200 .933 .004 .003 .007 .041 .014 .008 .103 .763 .504 .542 .299 .389 .565 .721 .065 .116 .478 .130 .073 .108 .273 .616 .462 .254 .376 .577 .413 .761 .194 .536 .962 .108

Second Third p

Interquartile range/course

M. R. Iglesias-Parra et al. Nursing Students’ and Tutors’ Satisfaction

5

6

M. R. Iglesias-Parra et al.

1.04 1.21 1.12 0.86 0.94 1.28 1.17 1.15 1.19 1.05 1.20 1.20 1.16 0.85 1.02

.917 .829 .222 .088 .584 .071 .399 .147 .276 .115 .009 .010 .133 .788 .795

provided learning resources for their practices, such as the “Clinical Notebook” and resources into the Virtual Campus, being slightly higher in second year students (Table 3). Higher rated items were the respect shown by tutors when dealing with students’ demand, how they resolved any questions raised, and how they promoted fluid and spontaneous communication. The worst rated items were the available resources in virtual campus, and the reception on the first day of practice. However, all the ratings were higher than 3.78. Also, on the first rotation, differences between hospital and PHC were found on the items “promoting a work environment and participation” and “development of a fluid and spontaneous communication,” in favor of PHC. On the second rotation, similar differences were found between both contexts of care, obtaining higher rates for items related to the warmth in the tutor–student relationship, the first day orientation, the PHC tutors’ dedication, and the tutors’ effort to search for clinical scenarios and learning opportunities for students (Tables 4 and 5).

0.02 0.10 0.21 −0.30 −0.10 0.52 0.25 0.37 0.28 0.35 0.57 0.60 0.39 −0.01 0.02

The aim of this study was to assess students’ satisfaction with their clinical tutors, and their clinical practices, together with tutors’ satisfaction with the new approach of clinical mentorship. Students’ Satisfaction

PHC, primary health care.

Reception from center professionals Initial guidance on the first day Level of support provided in the first moments Resources inserted in the Virtual Campus Clinical Notebook Tutors’ dedication Explanations offered Tutors’ interest by the level of understanding of their explanations Searching clinical scenarios and learning opportunities for students Resolving doubts through mentoring Promoting a work environment and participation Development of a fluid and spontaneous communication Respect in dealing with students Adequacy of site rotation to achieve the competencies Duration

37 37 37 37 37 37 37 37 37 37 37 37 37 37 37

4.05 3.86 4.14 3.54 3.81 4.22 4.24 4.27 4.14 4.35 4.46 4.51 4.65 4.00 3.51

Discussion

90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

4.03 3.77 3.92 3.84 3.91 3.70 3.99 3.90 3.86 4.00 3.89 3.91 4.26 4.01 3.49

1.05 1.06 1.16 0.93 1.00 0.79 0.89 0.80 0.98 0.75 0.84 0.65 0.59 0.75 1.12

Hospital PHC Mean dif Hospital (n = 90) PHC (n = 37) Hospital PHC (n = 37)

N Institution 1

Table 4. Students’ Satisfaction in PHC and Hospital in the First Rotation

Mean Institution 1

Standard deviation Institution 1

Asymp. Sig. (2-tailed)

Nursing Students’ and Tutors’ Satisfaction

The clinical learning environment (CLE) in which clinical practices are developed, as well as the ward organization, seems to be a major issue in the level of satisfaction and success for nursing students (Chuan & Barnett, 2012; Jokelainen, Turunen, Tossavainen, Jamookeeah, & Coco, 2011). Chuan and Barnett (2012) noted that students in some hospital wards were frustrated when they carried out activities that they did not consider as nursing-related tasks. In addition, several studies agreed on the importance of the creation of a confident-based relationship between students and tutors, highlighting the importance of the implication of tutors to reduce the feelings of isolation in CLEs (Braine & Parnell, 2011). In this sense, Omer et al. (2013) found more satisfactory for students a preceptorship model that incorporated intensive mentoring than a model where increasing students’ independence and self-directed learning was promoted. Similar values in all items of the survey were found in students both from second and third year, except those related to the reception of the first day of clinical practices, where satisfaction was higher in third year students, and useful resources from the Virtual Campus, where satisfaction was higher in second year students. In both cases, the higher maturity and experience of third year students could make them more demanding with learning opportunities, as well as more confident with themselves in the clinical environment. We also found that the availability of the “Clinical

M. R. Iglesias-Parra et al.

Nursing Students’ and Tutors’ Satisfaction

Table 5. Students’ Satisfaction in PHC and Hospital in the Second Rotation

Reception from center professionals Initial guidance on the first day Level of support provided in the first moments Resources inserted in the Virtual Campus Clinical Notebook Tutors’ dedication Explanations offered Tutors’ interest by the level of understanding of their explanations Searching clinical scenarios and learning opportunities for students Resolving doubts through mentoring Promoting a work environment and participation Development of a fluid and spontaneous communication Respect in dealing with students

N Institution 2

Mean Institution 2

Standard deviation Institution 2

PHC

Hospital

PHC

Hospital

Mean dif

PHC

Hospital

p

54 54 54 54 54 54 54 54

71 71 71 71 71 71 71 71

4.3889 4.2963 4.5556 3.7778 3.7407 4.4259 4.4444 4.4444

3.9296 3.7887 3.8028 3.7465 4.0704 3.6620 3.8310 3.7606

0.46 0.51 0.75 0.03 −0.33 0.76 0.61 0.68

.91973 .94429 .83929 .83929 .97488 .88172 .88310 .92485

1.05997 1.17005 1.26061 .96686 .96101 1.19456 1.15864 1.33593

.006 .010 .000 .981 .050 .000 .001 .001

54

71

4.2963

3.5775

0.72

.98344

1.34867

.002

54 54 54

71 71 71

4.5000 4.3889 4.4815

3.8732 3.7324 3.8451

0.63 0.66 0.64

.84116 .89899 .86310

1.15795 1.29789 1.32717

.000 .002 .003

54

71

4.7407

4.0986

0.64

.58874

1.20895

.001

PHC, primary health care.

Notebook” had significant better scores at hospital, which could be related to the ease to carry it, compared with PHC, where students need to go outside to develop home care. Tutors’ Satisfaction Tutors’ satisfaction seemed to be determined by the context of care and by the fact of having attended any of the educational activities organized by the Department of Nursing. In the first case, tutors in hospital wards found themselves less protected by their organization than those in PHC. This could explain the positive differences perceived by students in terms of respect, communication, and reception during the practices in PHC. These differences seem to be related with the high workload of tutors in hospital wards, due to reductions in clinical staff derived from the financial crisis in Spain, which has raised the nurses’ workload. This issue has been noticed by other authors (Madhavanpraphakaran et al., 2014). Tutors are essentials in the learning process of nursing students, with a motivational and supportive role (Carlson, 2009), as well as guiding students in their clinical practices by providing skills and key knowledge in the correct acquisition of the necessary competencies. Madhavanpraphakaran et al. (2014) described this comprehensive approach with the so-called “clinical preceptorship” as a role model, teacher, facilitator, guide, and evaluator. In our study, higher scores have been found in the items that assessed tutors’ respect when dealing with students. In addition, high scores were found in those items that assessed teaching methods used by tutors. This point has to be highlighted, taking into account that tutors’ behavior is key to improve critical thinking in nursing students (Carlson, 2009) to acquire the required competencies (Madhavanpraphakaran et al., 2014).

The correct acquisition of clinical competencies would help nursing students in their transition from students to registered nurses. Key elements found by Cooper, Taft, and Thelen (2005) to obtain success in this transition were being aware of human vulnerability, feeling the weight of nurses’ responsibility and accountability, recognizing limits, evaluating self, seeing the patient/family perspective, confronting ethical issues, and facing reality versus expectations. In our study, tutors highlighted the respect students showed toward patients and families, as well as punctuality, a helping attitude toward patients and families, and their attention to their explanations and participation. Conclusions The NIC provides a reliable and valid framework to assess the acquisition of competencies and clinical skills in second and third year nursing students. A “Clinical Notebook,” which was given to each student at the beginning of the clinical placement, and was also accessible online, was created. It also included other resources such as clinical scales, summaries of basic physiological, a pharmacological management guide, multidimensional assessment instruments, and so on. This new clinical learning and assessment model, which resulted from the Bologna Process, implies high degrees of satisfaction in nursing students and clinical tutors. Limitations The main limitation of this study is that it has been carried out in only one university. A multicenter evaluation in other universities would be needed to assess the external validity of the model. However, by employing SNLSs, the 7

Nursing Students’ and Tutors’ Satisfaction chances of widespread use are much greater, and the familiarity of clinical mentors with the NIC contributes to improve its external validity. In addition, there could exist selection bias because the tutors’ sample was selected from those that had previously been registered and, consequently, showed a high motivation to participate. In future investigations, we will also measure whether the students’ confidence during their clinical practices grows as they acquire new competencies, supported by their clinical tutors. References Bartlett, H., Westcott, L., & Hind, P. (1998). An evaluation of pre-registration nursing education: A literature review and comparative study of graduate outcomes. Oxford Centre for Health Care Research and Development. Benner, P. (1982). From novice to expert. American Journal of Nursing, 82(3), 402–407. Braine, M. E., & Parnell, J. (2011). Exploring student’s perceptions and experience of personal tutors. Nurse Education Today, 31(8), 904–910. doi:10.1016/j.nedt.2011.01.005 Brown, T., Williams, B., McKenna, L., Palermo, C., McCall, L., Roller, L., & Aldabah, L. (2011). Practice education learning environments: The mismatch between perceived and preferred expectations of undergraduate health science students. Nurse Education Today, 31(8), e22–e28. doi:10.1016/j.nedt.2010.11.013 Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (2008). Nursing interventions classification (NIC). St. Louis: Mosby. Calman, L., Watson, R., Norman, I., Redfern, S., & Murrells, T. (2002). Assessing practice of student nurses: Methods, preparation of assessors and student views. Journal of Advanced Nursing, 38(5), 516–523. Carlson, C. L. (2009). Use of three evidence-based postoperative pain assessment practices by registered nurses. Pain Management Nursing: Official Journal of the American Society of Pain Management Nurses, 10(4), 174–187. doi:10.1016/j.pmn.2008.07.001 Chuan, O. L., & Barnett, T. (2012). Student, tutor and staff nurse perceptions of the clinical learning environment. Nurse Education in Practice, 12(4), 192–197. doi:10.1016/j.nepr.2012.01.003 Collins, S., & Hewer, I. (2014). The impact of the Bologna process on nursing higher education in Europe: A review. International Journal of Nursing Studies, 51(1), 150–156. doi:10.1016/j.ijnurstu.2013.07.005 Cooper, C., Taft, L. B., & Thelen, M. (2005). Preparing for practice: Students’ reflections on their final clinical experience. Journal of Professional Nursing: Official Journal of the American Association of Colleges of Nursing, 21(5), 293–302. doi:10.1016/j.profnurs.2005.07.002 Davies, R. (2008). The Bologna process: The quiet revolution in nursing higher education. Nurse Education Today, 28(8), 935–942. doi:10.1016/ j.nedt.2008.05.008 Dennison, S., & El-Masri, M. M. (2012). Development and psychometric assessment of the undergraduate nursing student academic satisfaction scale (UNSASS). Journal of Nursing Measurement, 20(2), 75–89. Dillard, N., Sideras, S., Ryan, M., Carlton, K. H., Lasater, K., & Siktberg, L. (2009). A collaborative project to apply and evaluate the clinical judgment model through simulation. Nursing Education Perspectives, 30(2), 99–104. Dreyfus, H. L., & Dreyfus, S. E. (2005). Peripheral vision: Expertise in real world contexts. Organization Studies, 26(5), 779–792. doi:10.1177/ 0170840605053102

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