YNEDT-02670; No of Pages 5 Nurse Education Today xxx (2014) xxx–xxx
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Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale☆ Elisabeth Carlson a,⁎, Ewa Idvall a,b a b
Department of Care Science, Faculty of Health and Society, Malmö University, Jan Waldenströms Gata 25, SE-20506 Malmö, Sweden Department of Intensive Care and Perioperative Medicine, Skåne University Hospital, Malmö, Sweden
a r t i c l e
i n f o
Article history: Accepted 21 January 2014 Available online xxxx Keywords: CLES + T Nursing education Nursing homes Nursing students
s u m m a r y Background: One major challenge facing the health care systems worldwide is the growing demand for registered nurses able to provide qualified nursing care for a vulnerable population. Positive learning experiences during clinical practice influence not only learning outcomes, but also how students reason in relation to future career choices. Objectives: To investigate student nurses' experiences of the clinical learning environment during clinical practice in nursing homes, and to compare perceptions among student nurses with or without prior work experience as health care assistants in elderly care. Design: A cross-sectional study was designed, utilising the Swedish version of the CLES + T evaluation scale. Methods: 260 student nurses (response rate 76%) who had completed a five week long clinical placement in nursing homes returned the questionnaire during the data collection period in 2011–2012. Data were analysed using descriptive statistics. Mann–Whitney U-test was used to examine differences in relation to students with or without prior experience of elderly care. Results: Overall, the clinical learning environment was evaluated in a predominantly positive way. The subdimension Supervisory relationship displayed the highest mean value, and the lowest score was calculated for the sub-dimension Leadership style of the ward manager. Statistical significant differences between sub-groups were displayed for four out of 34 items. Conclusion: The supervisory relationship had the greatest impact on how student nurses experienced the clinical learning environment in nursing homes. It is therefore, of utmost importance that collaborative activities, between educational and nursing home settings, supporting the work of preceptors are established and maintained. © 2014 Elsevier Ltd. All rights reserved.
Introduction One major challenge facing health care systems worldwide is the growing demand for registered nurses able to provide qualified nursing care for a vulnerable population. In Sweden, the National Board of Health and Welfare (2012) disclosed in a report that out of the 12,316 registered nurses working in nursing homes, only 1.6% had a specialist competence in geriatric care. Adding to this rather bleak picture are findings from several previous studies (Kloster et al., 2007; Stevens, 2011) describing students' beliefs about elderly care as a negative career pathway in a boring and depressing environment. The quality of the clinical learning environment and the interactions with staff and preceptors directly impact not only what students will learn in clinical practice, but also their career intentions (Henderson et al., 2009; McKenna
et al., 2010). In a recent study by Carlson (2013), students described their experiences of elderly care as independent and autonomous work with plenty of opportunities to practice advanced nursing care. Caring for patients and their families over an extended time-period made the work meaningful and was put forward as a reason for a career in elderly care. However, students also presented their arguments against a career when they described caring for older people as slow-paced providing no real action as well as being hopeless and boring. There is most likely a variety of reasons influencing nursing students' career choices. Considering the increasing need for well-educated and specialised registered nurses it is relevant as well as necessary to describe the clinical learning environment with a focus on geriatric nursing care within the undergraduate nursing programme. Background
☆ Funding Statement: This research was made possible by generous grants funded by the Postdoctoral Programme for Quality Development in Higher Education at Malmö University, Sweden. ⁎ Corresponding author. Tel.: +46 406657451. E-mail address: [email protected] (E. Carlson).
It is not unusual that elderly care is one of the first clinical settings for undergraduate nursing students. Nursing homes can prove to be valuable learning environments allowing students to participate in the care of a population in need of fundamental as well as advanced nursing
0260-6917/$ – see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2014.01.009
Please cite this article as: Carlson, E., Idvall, E., Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.01.009
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E. Carlson, E. Idvall / Nurse Education Today xxx (2014) xxx–xxx
care. However, it requires that students are properly introduced to an environment that might present itself as not only depressing, but also scary by engaged and knowledgeable preceptors (Carlson and Bengtsson, 2013). In a recent study, Sundler et al. (2013) concluded that students preferred a system with designated and personal preceptors. Brown et al. (2008) described an enriched learning environment supportive of student learning as an environment where students were invited by the preceptors to a variety of nursing activities. This is in accordance to findings from a Greek study by Papathanasiou et al. (2014) discussing participation in real clinical settings as an important predictor for student satisfaction within the professional environment. The clinical learning environment is influenced by a range of factors including: the atmosphere at the ward, interaction with ward staff, and relationship with preceptors (Saarikoski et al., 2008; Chuan and Barnett, 2012; Sundler et al., 2013). In this process, the supervisory relationship seems to be of utmost importance (Saarikoski et al., 2008; Warne et al., 2010; De Witte et al., 2011). On the one hand, if students experience impoverished care environments, and poor quality of nursing care they may develop negative attitudes to elderly care (Shen and Xiao, 2012). On the other hand, a positive work and learning environment appears to be crucial in attracting nursing students to elderly care (Chenoweth et al., 2010). In a study by Skaalvik et al. (2011), the ratings from students practising in nursing homes were in general more negative than students practicing in hospital settings. Interesting enough, in a recent study by Haron et al. (2013) it was concluded that the design and quality of nurse training programs in relation to care for older people were not associated with more positive attitudes to geriatric care. Rather, it was suggested that good pay and the creation of clinical nurse specialist roles would increase the recruitments of newly graduated nurses. However, we found no studies exploring the clinical learning environment in nursing homes specifically, and we argue that this is warranted considering the ever increasing need to recruit and retain nurses to elderly care. The Study Objectives The objectives of this study were to investigate nursing students' experiences of the clinical learning environment during clinical practice in nursing homes, and to compare perceptions among nursing students with or without prior work experience as health care assistants in elderly care. Design This was a cross-sectional study utilising the Clinical Learning Environment and Nurse Teacher (CLES + T) evaluation scale (Saarikoski et al., 2008). Setting In Sweden, social welfare and health care for older people are the responsibilities of local municipalities, usually organised as home-based care or long-term care in nursing homes. The needs of the patients range from complex medical conditions to dementia, cognitive impairment, end of life care and assistance in completing everyday activities. The participating students were first year nursing students in their second semester having completed a mandatory five week long clinical placement in a nursing home. The main learning outcomes are that students, under supervision, should be able to: 1) communicate with patients and their families, 2) plan, perform and assess patient-centred nursing care, and 3) identify and reflect on ethical aspects. Supervision is provided by a registered nurse, usually in the form of one preceptor to one student. Students and preceptors are supported by nurse teachers (NT), defined by Saarikoski et al. (2008 and 2013) as a qualified
nurse teacher employed by the educational setting. The role of the NTs in the current study includes theoretical teaching in relation to geriatric nursing prior to clinical practice, participation during assessment, grading of students in clinical practice, and to be available for students and preceptors where difficult situations arise.
Data Collection The study commenced in September 2011 and was terminated one year later. Data were consecutively collected from three cohorts of nursing students (N = 341) in their second semester of a three year Bachelor of Nursing programme at a university in southern Sweden using the CLES + T evaluation scale (Saarikoski et al., 2008). For this study we used the Swedish version of the instrument (Johansson et al., 2010), proven to be a valid and reliable instrument in psychometric testing among Swedish nursing students in hospital settings (Johansson et al., 2010), as well as in primary health care settings (Bos et al., 2012). Prior to the study, approval to use the scale was given by Sarikooski. The scale consists of five sub-dimensions and a total of 34 items: Pedagogical atmosphere on the ward (nine items), Leadership style of the ward manager (four items), Premises of nursing on the ward (four items), Supervisory relationship (eight items), and Role of the nurse teacher in clinical practice (nine items). The statements are responded to on a five point Likert scale ranging from: fully disagree (1), disagree to some extent (2), neither agree nor disagree (3), agree to some extent (4), to fully agree (5). Added to the questionnaire were background variables for age, sex and previous experience from elderly care.
Ethical Considerations Ethical approval was granted from the Ethical Advisory Board at Malmö University. Prior to the study, written information about the purpose of the study was posted on the students' virtual learning platform. For each semester, the first author was invited to one of the mandatory lectures by the responsible teacher to inform the students of the study. Thus, the students received written as well as oral information. In the classroom it was stressed that participation was voluntarily and non-participation would not affect the individual nursing student in any sense. Participants were assured of confidentiality and the right to withdraw from the study at any time without further explanation. The questionnaires were handed out to all students in the classroom during the mandatory lecture, and by completing and returning the questionnaire students gave their informed consent. The researchers have not been involved in teaching or grading participants.
Data Analysis Statistical analysis was performed by the SPSS version 20. Data have been analysed using descriptive statistics (mean, standard deviation and median). Mann–Whitney U-test was used to examine differences in relation to students with or without prior experience of elderly care. The Mann–Whitney U test is a nonparametric test used to compare differences between two independent groups when the dependent variable is either ordinal or continuous, but not normally distributed. The statistical significance level was set to 5% (p = 0.05).
Internal Consistency We calculated Cronbach's coefficient alpha for internal consistency of the total scale as well as of the five sub-dimensions. The alphavalue was 0.95 for the total scale, and ranged from 0.76 to 0.97 for the sub-dimensions.
Please cite this article as: Carlson, E., Idvall, E., Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.01.009
E. Carlson, E. Idvall / Nurse Education Today xxx (2014) xxx–xxx
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Results
Discussion
A total of 260 nursing students completed the questionnaire, and this equals a response rate of 76%. The participants were between 18 and 50 years old (mean 25). The majority were female (n = 212, 82%). The percentage of male students is in concordance to the ratio of Swedish male to female registered nurses. Experience as health care assistants in elderly care prior to commencing nursing education was almost equally distributed, 134 nursing students (51.7%) reported previous experience versus 125 nursing students (48.3%) with no previous experience (Table 1). Overall, the students evaluated the clinical learning environment positively. The mean values (range from 1 to 5) for the sub-dimensions varied between 3.39 for Leadership style of the ward manager to 4.07 for Supervisory relationship. The latter sub-dimension displayed not only the highest mean value, but it was also the most consistent as the alpha value was 0.97. The high mean values and the negative skewness values for all sub-dimensions (−0.60, −0.47, −0.62, −1.13, −0.38 respectively) lean in the direction of positive values of the evaluations of the clinical learning environment. Mean scores for single items varied from 2.44 to 4.25. The highest score (4.25) was given to the item My supervisor showed positive attitudes towards supervision measuring Supervisory relationship. This sub-dimension had an overall high evaluation, scores for single items ranged from 3.83 to 4.25 (Table 2). The lowest score was given to one item measuring Role of the Nurse Teacher (NT): The NT was like a member of the nursing team (2.44), followed by The NT was capable to give his or her pedagogical expertise to the clinical team (2.74), and one item measuring Leadership style of the Ward Manager (WM): Feedback from the WM could easily be considered a learning situation (2.98) (Table 2). We examined if any statistical differences existed between two subpopulations, namely students with or without work experience from elderly care prior to commencing nursing education. Out of the 34 items, only four items were statistically significant (p b 0.05). The items the staff was easy to approach and the WM regarded the staff on her/his ward as key resources proved to be statistically significant with more positive evaluations for students with no previous work experience from elderly care. The opposite was shown for the items the supervision was based on a relationship of equality and promoted my learning and the supervisory relationship was characterised by a sense of trust displaying more positive values for students with prior work experience. For the remaining items the mean values were almost equal, displaying no significant differences between the groups (Table 2).
On the whole, the clinical learning environments in the nursing homes were evaluated in a positive way by participating nursing students, thus challenging the somewhat prevailing picture of elderly care as boring and undemanding. One prominent feature of the current study is that the dimension with the highest mean score, Supervisory relationship, can be compared not only to studies that took place within mixed settings (Sundler et al., 2013) but also to studies comparing nursing homes and hospital settings (Skaalvik et al., 2011) as well as studies comparing the duration of placements (Warne et al., 2010). Students in our study evaluated the supervisory relationship more in line with hospital settings and clinical placements longer than seven weeks. This indicates that the students participating in the current study have been supervised by registered nurses prioritising the precepting role aware of the impact of a supportive learning environment. According to Carlson and Bengtsson (2013) nursing homes can prove to be excellent learning environments when students participate in nursing for a frail and sick population, working alongside engaged and knowledgeable preceptors. In addition, students in the current study were supervised by a personal preceptor during the five week long placement; thereby, supporting results from a study by Sundler et al. (2013) concluding that a personal preceptor had a direct impact on students' satisfaction with the clinical learning environment. The items the supervision was based on a relationship of equality and promoted my learning and the supervisory relationship was characterised by a sense of trust were statistically significant with more positive values for students with prior work experience as health care assistants for older people. This can probably be contributed to a familiarity with a clinical setting as well as having met with, and cared for older people, and thereby gained invaluable basic know-how. On the contrary, the statistical significance for the item the staff was easy to approach disclosed positive values for students with no previous work experience neither from nursing homes nor from hospital settings. We suggest that this can be explained by students not having to prove their skills and knowledge as might be expected by students with prior work experience as care assistants. The result implies that it is easier for them to approach the staff with questions without being judged as less competent. The dimension Role of the NT displayed low scores from both subgroups i.e. students with or without previous work experience from elderly care, indicating a general uncertainty among the students in relation to what they could expect from the nurse teacher. More specifically, the items describing the NT as a team member of the nursing team, and the capability of the NT to provide educational advice to the clinical teams had the overall lowest scores, concordant to previous results (Johansson et al., 2010; Warne et al., 2010). In the present study, this can be contributed to the fact that the main role of the nurse teachers was to provide preceptors with educational guidelines and assessment forms prior to students arriving in clinical practice, and later support students and preceptors during final assessment discussing and evaluating learning outcomes. Consequently, the NTs had no formal pedagogical responsibility towards the clinical staff, and this is evidently a weakness that renders further research honouring the differences and the complexity of the NT's clinical role from an international perspective as discussed by Saarikoski et al. (2013). Finally, to our knowledge, no comparable studies have been conducted utilising the CLES + T scale measuring the clinical learning environment in nursing homes specifically. In previous studies, nursing homes have been part of the total studied clinical settings. For example, when Johansson et al. (2010) validated the Swedish version of the CLES + T only 8% of the students responded to the questionnaire in relation to the clinical learning environment in nursing homes. In other studies, approximately one third of the students rated their experiences in relation to nursing homes, for example 36% in the study by Skaalvik et al. (2011), and 39% in a recent study by Sundler et al. (2013). Considering the imminent global need for nurses in geriatric
Table 1 Demographic characteristics of students responding to CLES + T (n = 260, 76%)a. Total
Autumn 2011
Spring 2012
Autumn 2012
Variables
n (%)
n
n
n
Gender Female Male Missing Total n (%)
212 (81.9) 47 (18.1) 1 260 (70.5)
Age (Years) Mean Range
25.2 18–50
66 10
72 23
74 14
96
88
1 76
25.1 19–42
24.8 18–50
Work experience as health care assistants in elderly care Yes 134 (51.7) 34 43 No 125 (48.3) 41 53 Missing 1 1
25.7 20–45
57 31
a Percentage of the total number of eligible students (N = 341) during the data collection period of the following semesters: Autumn 2011; Spring 2012; Autumn 2012.
Please cite this article as: Carlson, E., Idvall, E., Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.01.009
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Total population (n = 260) Mean (SD) Pedagogical atmosphere (α = 0.91) The staff was easy to approach I felt comfortable going to the ward at the start of my shift During staff meetings (e.g. before shifts) I felt comfortable taking part in the discussion There was a positive atmosphere on the ward The staff were generally interested in student supervision The staff learned to know the students by their personal names There were sufficient meaningful learning situations on the ward The learning situations were multidimensional in terms of content The ward can be regarded as a good learning environment Leadership style of the ward manager (α = 0.87) The WM regarded the staff on her/his ward as key resource The WM was a team member Feedback from the WM could easily be considered a learning situation The effort of individual employees was appreciated Premises of nursing on the ward (α = 0.76) The ward's nursing philosophy was clearly defined Patients received individual nursing care There were no problems in the information flow related to patients' care Documentation of nursing (e.g. nursing plans, daily recording of nursing procedures, etc.) was clear Supervisory relationship (α = 0.97) My supervisor showed a positive attitude towards supervision I felt that I received individual supervision I continuously received feedback from my supervisor Overall I am satisfied with the supervision I received The supervision was based on a relationship of equality and promoted my learning There was a mutual interaction in the supervisory relationship Mutual respect and approval prevailed in the supervisory relationship The supervisory relationship was characterised by a sense of trust Role of nurse teacher (α = 0.87) In my opinion, the NT was capable to integrate theoretical knowledge and everyday practice of nursing The NT was capable of operationalise the learning goals of this clinical placement The NT helped me to reduce the theory–practice gap The NT was like a member of the nursing team The NT was capable to give his or her pedagogical expertise to the clinical team The NT and the clinical team worked together supporting my learning The common meetings between myself, mentor and NT were comfortable experiences Climate of the meetings was congenial Focus in the meetings was on my learning needs a b c
3.63 (0.86) 3.96 (0.87) 3.95 (1.12) 3.42 (1.09) 3.55 (1.08) 3.26 (1.19) 3.94 (1.16) 3.48 (1.17) 3.39 (1.15) 3.64 (1.20) 3.39 (0.98) 3.93 (1.08) 3.29 (1.26) 2.98 (1.19) 3.40 (1.10) 3.57 (0.76) 3.33 (1.13) 3.83 (1.01) 3.35 (1.16) 3.75 (1.13) 4.07 (0.99) 4.25 (1.02) 4.14 (1.08) 3.83 (1.24) 4.05 (1.19) 4.10 (1.12) 4.06 (1.14) 4.22 (1.07) 4.21 (1.05) 3.44 (0.81) 3.96 (0.94) 4.18 (2.67) 3.73 (1.07) 2.44 (1.28) 2.74 (1.29) 3.07 (1.31) 4.19 (1.06) 3.14 (1.26) 3.84 (1.06)
N = 259, one missing. Mann–Whitney U-test, significance level 5%, significant levels in italics. 1 = Fully disagree; 2 = Disagree to some extent; 3 = Neither agree nor disagree; 4 = Agree to some extent; 5 = Fully agree.
Medianc Agree to some extent Agree to some extent Agree to some extent Agree to some extent Neither agree nor disagree Agree to some extent Agree to some extent Neither agree nor disagree Agree to some extent Agree to some extent Neither agree nor disagree Neither agree nor disagree Neither agree nor disagree Neither agree nor disagree Agree to some extent Agree to some extent3.32 (1.20) Agree to some extent Fully agree Fully agree Agree to some extent Agree to some extent Agree to some extent Agree to some extent Fully agree Fully agree Agree to some extent Agree to some extent Agree to some extent Disagree to some extent Neither agree nor disagree Neither agree nor disagree Fully agree Neither agree nor disagree Agree to some extent
Previous experience (n = 134)a
No previous experience (n = 125)
Mean (SD)
Mean (SD)
3.60 (0.83) 3.81 (0.91) 3.94 (1.09) 3.44 (1.08) 3.52 (1.06) 3.21 (1.20) 3.84 (1.22) 3.49 (1.21) 3.40 (1.15) 3.64 (1.19) 3.31 (1.04) 3.78 (1.13) 3.17 (1.31) 2.89 (1.27) 3.39 (1.14) 3.57 (0.83) 3.78 (1.07) 3.80 (1.04) 3.32 (1.20) 3.78 (1.07) 4.22 (0.92) 4.34 (1.00) 4.22 (0.99) 3.92 (1.20) 4.12 (1.19) 4.27 (0.97) 4.22 (1.10) 4.36 (0.89) 4.37 (0.96) 3.49 (0.82) 3.98 (0.93) 4.09 (0.95) 3.73 (1.08) 2.55 (1.27) 2.75 (1.28) 3.09 (1.29) 4.20 (0.99) 3.24 (1.29) 3.93 (1.02)
3.66 (0.86) 4.12 (0.80) 3.97 (1.14) 3.41 (1.10) 3.58 (1.11) 3.31 (1.19) 4.05 (1.08) 3.49 (1.14) 3.39 (1.16) 3.65 (1.21) 3.49 (0.91) 4.10 (1.01) 3.41 (1.21) 3.08 (1.11) 3.43 (1.05) 3.57 (0.87) 3.31 (1.19) 3.87 (0.99) 3.39 (1.12) 3.72 (1.21) 4.00 (1.06) 4.16 (1.06) 4.06 (1.17) 3.73 (1.29) 3.98 (1.19) 3.92 (1.25) 3.90 (1.25) 4.07 (1.23) 4.05 (1.13) 3.39 (0.80) 3.94 (0.96) 4.26 (0.73) 3.71 (1.07) 2.33 (1.29) 2.73 (1.32) 3.05 (1.35) 4.18 (1.13) 3.02 (1.23) 3.72 (1.10)
p-valueb
0.587 0.005 0.654 0.767 0.618 0.493 0.201 0.911 0.897 0.944 0.178 0.017 0.139 0.265 0.795 0.998 0.806 0.628 0.805 0.883 0.124 0.130 0.398 0.274 0.223 0.033 0.054 0.151 0.009 0.173 0.750 0.357 0.764 0.129 0.767 0.770 0.563 0.140 0.150
E. Carlson, E. Idvall / Nurse Education Today xxx (2014) xxx–xxx
Please cite this article as: Carlson, E., Idvall, E., Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.01.009
Table 2 Item statistics and comparison of means for students with and without prior experience of aged care.
E. Carlson, E. Idvall / Nurse Education Today xxx (2014) xxx–xxx
care, it seems to be crucial to evaluate learning environments, specifically in nursing homes. Such evaluations could provide nurse educators with an increased understanding of a learning environment surrounded by beliefs that elderly care is undemanding, depressing, and a negative career pathway (Kloster et al., 2007; Stevens, 2011) in order to possibly influence future changes to nursing curricula. Methodological Considerations The limitations of the study mainly concern the lack of factor analysis in relation to the use of the instrument solely in nursing home settings. However, when critically examining our results we found alpha values for all sub-dimensions similar to those reported in previous studies. For example, we reported alpha values ranging from 0.76 to 0.97, compared to 0.73 to 0.94 in the original instrument (Saarikoski and Leino-Kilpi, 2002), 0.77 to 0.96 in the extended version including the NT (Saarikoski et al., 2008), 0.75 to 0.96 in the validation of the Swedish version (Johansson et al., 2010), and 0.70 to 0.97 in relation to the organisation of supervision (Sundler et al., 2013). The sub-dimension Premises of nursing on the ward had the lower rating, similar to the value reported by Sundler et al. (2013) while Supervisory relationship displayed the highest rating in accordance with previous studies (Johansson et al., 2010; Sundler et al., 2013). In addition, corrected item-total correlation ranged from 0.49 to 0.88 compared to the study by Johansson et al. (2010). This implies that the CLES + T scale is a valid and reliable instrument to be used for evaluating nursing homes as clinical learning environments. However, the overall high alpha values indicate that the number of single items may be reduced. Bos et al. (2012) validated the CLES + T for clinical learning in primary health care settings using exploratory factor analysis providing information about how the different factors affected learning as well as confirmatory factor analysis describing associations between factors. We propose a similar design for validating CLES + T in nursing home settings. We acknowledge the fact that our results are interpreted in light of the limitations that may occur in connection with a convenience sample as well as self-reporting on variables. However, our study provides valuable and positive insights into nursing students' learning experiences in an environment that has previously been described as boring and depressing. Conclusion The supervisory relationship had the greatest impact on how nursing students experienced the clinical learning environment in nursing homes. It is therefore, of utmost importance that collaborative activities between educational and nursing home settings, supporting the work of preceptors, are established and maintained. One example might be mutual work shops where preceptors, nurse managers, and nurse teachers can reflect upon didactical as well as organisational matters that might influence the provision of supportive supervision. Previous or lack of previous work experience from elderly care did not seem to impact how students rated the learning environment. Rather, the students in the current study evaluated the learning environment in a predominantly positive way. Therefore, every attempt should be made by schools of nursing to promote nursing homes as positive learning environments thus balancing the somewhat prevailing picture of elderly care as a dead end for a future career. Finally, in light of the expected shortage of nurses caring for older people we propose further studies
5
measuring possible correlations between students' evaluation of the clinical learning environment and future career intentions. Acknowledgment The authors wish to extend their gratitude to all the student nurses who participated in the study for sharing their time and experience. References Bos, E., Alinaghizadeh, H., Saarikoski, M., Kaila, P., 2012. Validating the ‘clinical learning environment, supervision and nurse teacher’ CLES + T instrument in primary healthcare settings using confirmatory factor analysis. J. Clin. Nurs. 21 (11–12), 1785–1788. Brown, J., Nolan, M., Davies, S., Nolan, J., Keady, J., 2008. Transforming students’ views of gerontological nursing: realising the potential enriched environments of learning and care: a multi-method longitudinal study. Int. J. Nurs. Stud. 45 (8), 1214–1232. Carlson, E., 2013. Meaningful and enjoyable or boring and depressing? The reasons nursing students give for and against a career in aged care. J. Clin. Nurs. http://dx.doi.org/ 10.1111/jocn/12425. Carlson, E., Bengtsson, M., 2013. The uniqueness of elderly care: registered nurses’ experience as preceptors during clinical practice in nursing homes and home-based care. Nurse Educ. Today. http://dx.doi.org/10.1016/j.nedt.2013.07.017. Chenoweth, L., Yun-Hee, J., Merlyn, T., Brodaty, H., 2010. A systematic review of what factors attract and retain nurses in aged and dementia care. J. Clin. Nurs. 19 (1–2), 156–167. Chuan, O.L., Barnett, T., 2012. Student, tutor and staff nurse perceptions of the clinical learning environment. Nurse Educ. Pract. 12 (4), 192–197. De Witte, N., Labeau, S., De Keyzer, W., 2011. The clinical learning environment and supervision instrument (CLES): validity and reliability of the Dutch version (CLES + NL). Int. J. Nurs. Stud. 48 (5), 568–572. Haron, Y., Levy, S., Albagli, M., Rotstein, R., Riba, S., 2013. Why do nursing students not want to work in geriatric care? A national questionnaire survey. Int. J. Nurs. Stud. 50 (11), 1558–1565. Henderson, A., Twentyman, M., Eaton, E., Creedy, D., Stapleton, P., Lloyd, B., 2009. Creating supportive clinical learning environments: an intervention study. J. Clin. Nurs. 19 (1–2), 177–182. Johansson, U.-B., Kaila, P., Ahlner-Elmqvist, M., Leksell, J., Isoaho, H., Saarikoski, M., 2010. Clinical learning environment, supervision and nurse teacher evaluation scale: psychometric evaluation of the Swedish version. J. Adv. Nurs. 66 (9), 2085–2093. Kloster, T., Høie, M., Skår, R., 2007. Nursing students’ career preferences: a Norwegian study. J. Adv. Nurs. 59 (2), 155–162. McKenna, L., McCall, L., Wray, N., 2010. Clinical placements and nursing students’ career planning: a qualitative study. Int. J. Nurs. Pract. 16 (2), 176–182. National Board of Health and Welfare in Sweden, 2012. Increased competence in geriatric care and gerontology. Proposed implementation of the initiative (Ökad kompetens inom geriatriks och gerontologi, förslag till utförande och genomförande av satsning). In Swedish . Papathanasiou, I.V., Tsaras, K., Sarafis, P., 2014. Views and perceptions of nursing students on their clinical learning environment: teaching and learning. Nurse Educ. Today 34 (1), 57–60. Saarikoski, M., Leino-Kilpi, H., 2002. The clinical learning and supervision by staff nurses: developing the instrument. Int. J. Nurs. Stud. 39 (3), 259–267. Saarikoski, M., Isoaho, H., Warne, T., Leino-Kilpi, H., 2008. The nurse teacher in clinical practice: developing the new sub-dimension to the Clinical Learning Environment and Supervision (CLES) scale. Int. J. Nurs. Stud. 45 (8), 1233–1237. Saarikoski, M., Kaila, P., Lambrinou, E., Canaveras Pérez, R.M., Tichelaar, E., Tomietto, M., Warne, T., 2013. Students’ experiences of cooperation with nurse teacher during their clinical placements: an empirical study in a Western European context. Nurse Educ. Pract. 13 (2), 78–82. Shen, J., Xiao, L.D., 2012. Factors affecting nursing students’ intention to work with older people in China. Nurse Educ. Today 32 (3), 219–223. Skaalvik, M., Normann, H.K., Henriksen, N., 2011. Clinical learning environment and supervision: experiences of Norwegian nursing students—a questionnaire study. J. Clin. Nurs. 20 (15–16), 2294–2304. Stevens, J.A., 2011. Nursing students’ career preferences for working with older people: a replicated longitudinal survey. Int. J. Nurs. Stud. 48 (8), 944–951. Sundler, A.J., Björk, M., Bisholt, B., Ohlsson, U., Engström Kullén, A., Gustafsson, M., 2013. Nursing students’ experiences of the clinical learning environment in relation to the organisation of supervision: a questionnaire study. Nurse Educ. Today. http:// dx.doi.org/10.1016/j.nedt.2013.06.23. Warne, T., Johansson, U.B., Papastavrou, E., Tichelaar, E., Tomietto, M., Van den Bossche, K., Moreno Vizcaya, M.F., Saarikoski, M., 2010. An exploration of the clinical learning experience of nursing students in nine European countries. Nurse Educ. Today 30 (8), 809–815.
Please cite this article as: Carlson, E., Idvall, E., Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.01.009
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Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale☆ Elisabeth Carlson a,⁎, Ewa Idvall a,b a b
Department of Care Science, Faculty of Health and Society, Malmö University, Jan Waldenströms Gata 25, SE-20506 Malmö, Sweden Department of Intensive Care and Perioperative Medicine, Skåne University Hospital, Malmö, Sweden
a r t i c l e
i n f o
Article history: Accepted 21 January 2014 Available online xxxx Keywords: CLES + T Nursing education Nursing homes Nursing students
s u m m a r y Background: One major challenge facing the health care systems worldwide is the growing demand for registered nurses able to provide qualified nursing care for a vulnerable population. Positive learning experiences during clinical practice influence not only learning outcomes, but also how students reason in relation to future career choices. Objectives: To investigate student nurses' experiences of the clinical learning environment during clinical practice in nursing homes, and to compare perceptions among student nurses with or without prior work experience as health care assistants in elderly care. Design: A cross-sectional study was designed, utilising the Swedish version of the CLES + T evaluation scale. Methods: 260 student nurses (response rate 76%) who had completed a five week long clinical placement in nursing homes returned the questionnaire during the data collection period in 2011–2012. Data were analysed using descriptive statistics. Mann–Whitney U-test was used to examine differences in relation to students with or without prior experience of elderly care. Results: Overall, the clinical learning environment was evaluated in a predominantly positive way. The subdimension Supervisory relationship displayed the highest mean value, and the lowest score was calculated for the sub-dimension Leadership style of the ward manager. Statistical significant differences between sub-groups were displayed for four out of 34 items. Conclusion: The supervisory relationship had the greatest impact on how student nurses experienced the clinical learning environment in nursing homes. It is therefore, of utmost importance that collaborative activities, between educational and nursing home settings, supporting the work of preceptors are established and maintained. © 2014 Elsevier Ltd. All rights reserved.
Introduction One major challenge facing health care systems worldwide is the growing demand for registered nurses able to provide qualified nursing care for a vulnerable population. In Sweden, the National Board of Health and Welfare (2012) disclosed in a report that out of the 12,316 registered nurses working in nursing homes, only 1.6% had a specialist competence in geriatric care. Adding to this rather bleak picture are findings from several previous studies (Kloster et al., 2007; Stevens, 2011) describing students' beliefs about elderly care as a negative career pathway in a boring and depressing environment. The quality of the clinical learning environment and the interactions with staff and preceptors directly impact not only what students will learn in clinical practice, but also their career intentions (Henderson et al., 2009; McKenna
et al., 2010). In a recent study by Carlson (2013), students described their experiences of elderly care as independent and autonomous work with plenty of opportunities to practice advanced nursing care. Caring for patients and their families over an extended time-period made the work meaningful and was put forward as a reason for a career in elderly care. However, students also presented their arguments against a career when they described caring for older people as slow-paced providing no real action as well as being hopeless and boring. There is most likely a variety of reasons influencing nursing students' career choices. Considering the increasing need for well-educated and specialised registered nurses it is relevant as well as necessary to describe the clinical learning environment with a focus on geriatric nursing care within the undergraduate nursing programme. Background
☆ Funding Statement: This research was made possible by generous grants funded by the Postdoctoral Programme for Quality Development in Higher Education at Malmö University, Sweden. ⁎ Corresponding author. Tel.: +46 406657451. E-mail address: [email protected] (E. Carlson).
It is not unusual that elderly care is one of the first clinical settings for undergraduate nursing students. Nursing homes can prove to be valuable learning environments allowing students to participate in the care of a population in need of fundamental as well as advanced nursing
0260-6917/$ – see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2014.01.009
Please cite this article as: Carlson, E., Idvall, E., Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.01.009
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E. Carlson, E. Idvall / Nurse Education Today xxx (2014) xxx–xxx
care. However, it requires that students are properly introduced to an environment that might present itself as not only depressing, but also scary by engaged and knowledgeable preceptors (Carlson and Bengtsson, 2013). In a recent study, Sundler et al. (2013) concluded that students preferred a system with designated and personal preceptors. Brown et al. (2008) described an enriched learning environment supportive of student learning as an environment where students were invited by the preceptors to a variety of nursing activities. This is in accordance to findings from a Greek study by Papathanasiou et al. (2014) discussing participation in real clinical settings as an important predictor for student satisfaction within the professional environment. The clinical learning environment is influenced by a range of factors including: the atmosphere at the ward, interaction with ward staff, and relationship with preceptors (Saarikoski et al., 2008; Chuan and Barnett, 2012; Sundler et al., 2013). In this process, the supervisory relationship seems to be of utmost importance (Saarikoski et al., 2008; Warne et al., 2010; De Witte et al., 2011). On the one hand, if students experience impoverished care environments, and poor quality of nursing care they may develop negative attitudes to elderly care (Shen and Xiao, 2012). On the other hand, a positive work and learning environment appears to be crucial in attracting nursing students to elderly care (Chenoweth et al., 2010). In a study by Skaalvik et al. (2011), the ratings from students practising in nursing homes were in general more negative than students practicing in hospital settings. Interesting enough, in a recent study by Haron et al. (2013) it was concluded that the design and quality of nurse training programs in relation to care for older people were not associated with more positive attitudes to geriatric care. Rather, it was suggested that good pay and the creation of clinical nurse specialist roles would increase the recruitments of newly graduated nurses. However, we found no studies exploring the clinical learning environment in nursing homes specifically, and we argue that this is warranted considering the ever increasing need to recruit and retain nurses to elderly care. The Study Objectives The objectives of this study were to investigate nursing students' experiences of the clinical learning environment during clinical practice in nursing homes, and to compare perceptions among nursing students with or without prior work experience as health care assistants in elderly care. Design This was a cross-sectional study utilising the Clinical Learning Environment and Nurse Teacher (CLES + T) evaluation scale (Saarikoski et al., 2008). Setting In Sweden, social welfare and health care for older people are the responsibilities of local municipalities, usually organised as home-based care or long-term care in nursing homes. The needs of the patients range from complex medical conditions to dementia, cognitive impairment, end of life care and assistance in completing everyday activities. The participating students were first year nursing students in their second semester having completed a mandatory five week long clinical placement in a nursing home. The main learning outcomes are that students, under supervision, should be able to: 1) communicate with patients and their families, 2) plan, perform and assess patient-centred nursing care, and 3) identify and reflect on ethical aspects. Supervision is provided by a registered nurse, usually in the form of one preceptor to one student. Students and preceptors are supported by nurse teachers (NT), defined by Saarikoski et al. (2008 and 2013) as a qualified
nurse teacher employed by the educational setting. The role of the NTs in the current study includes theoretical teaching in relation to geriatric nursing prior to clinical practice, participation during assessment, grading of students in clinical practice, and to be available for students and preceptors where difficult situations arise.
Data Collection The study commenced in September 2011 and was terminated one year later. Data were consecutively collected from three cohorts of nursing students (N = 341) in their second semester of a three year Bachelor of Nursing programme at a university in southern Sweden using the CLES + T evaluation scale (Saarikoski et al., 2008). For this study we used the Swedish version of the instrument (Johansson et al., 2010), proven to be a valid and reliable instrument in psychometric testing among Swedish nursing students in hospital settings (Johansson et al., 2010), as well as in primary health care settings (Bos et al., 2012). Prior to the study, approval to use the scale was given by Sarikooski. The scale consists of five sub-dimensions and a total of 34 items: Pedagogical atmosphere on the ward (nine items), Leadership style of the ward manager (four items), Premises of nursing on the ward (four items), Supervisory relationship (eight items), and Role of the nurse teacher in clinical practice (nine items). The statements are responded to on a five point Likert scale ranging from: fully disagree (1), disagree to some extent (2), neither agree nor disagree (3), agree to some extent (4), to fully agree (5). Added to the questionnaire were background variables for age, sex and previous experience from elderly care.
Ethical Considerations Ethical approval was granted from the Ethical Advisory Board at Malmö University. Prior to the study, written information about the purpose of the study was posted on the students' virtual learning platform. For each semester, the first author was invited to one of the mandatory lectures by the responsible teacher to inform the students of the study. Thus, the students received written as well as oral information. In the classroom it was stressed that participation was voluntarily and non-participation would not affect the individual nursing student in any sense. Participants were assured of confidentiality and the right to withdraw from the study at any time without further explanation. The questionnaires were handed out to all students in the classroom during the mandatory lecture, and by completing and returning the questionnaire students gave their informed consent. The researchers have not been involved in teaching or grading participants.
Data Analysis Statistical analysis was performed by the SPSS version 20. Data have been analysed using descriptive statistics (mean, standard deviation and median). Mann–Whitney U-test was used to examine differences in relation to students with or without prior experience of elderly care. The Mann–Whitney U test is a nonparametric test used to compare differences between two independent groups when the dependent variable is either ordinal or continuous, but not normally distributed. The statistical significance level was set to 5% (p = 0.05).
Internal Consistency We calculated Cronbach's coefficient alpha for internal consistency of the total scale as well as of the five sub-dimensions. The alphavalue was 0.95 for the total scale, and ranged from 0.76 to 0.97 for the sub-dimensions.
Please cite this article as: Carlson, E., Idvall, E., Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.01.009
E. Carlson, E. Idvall / Nurse Education Today xxx (2014) xxx–xxx
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Results
Discussion
A total of 260 nursing students completed the questionnaire, and this equals a response rate of 76%. The participants were between 18 and 50 years old (mean 25). The majority were female (n = 212, 82%). The percentage of male students is in concordance to the ratio of Swedish male to female registered nurses. Experience as health care assistants in elderly care prior to commencing nursing education was almost equally distributed, 134 nursing students (51.7%) reported previous experience versus 125 nursing students (48.3%) with no previous experience (Table 1). Overall, the students evaluated the clinical learning environment positively. The mean values (range from 1 to 5) for the sub-dimensions varied between 3.39 for Leadership style of the ward manager to 4.07 for Supervisory relationship. The latter sub-dimension displayed not only the highest mean value, but it was also the most consistent as the alpha value was 0.97. The high mean values and the negative skewness values for all sub-dimensions (−0.60, −0.47, −0.62, −1.13, −0.38 respectively) lean in the direction of positive values of the evaluations of the clinical learning environment. Mean scores for single items varied from 2.44 to 4.25. The highest score (4.25) was given to the item My supervisor showed positive attitudes towards supervision measuring Supervisory relationship. This sub-dimension had an overall high evaluation, scores for single items ranged from 3.83 to 4.25 (Table 2). The lowest score was given to one item measuring Role of the Nurse Teacher (NT): The NT was like a member of the nursing team (2.44), followed by The NT was capable to give his or her pedagogical expertise to the clinical team (2.74), and one item measuring Leadership style of the Ward Manager (WM): Feedback from the WM could easily be considered a learning situation (2.98) (Table 2). We examined if any statistical differences existed between two subpopulations, namely students with or without work experience from elderly care prior to commencing nursing education. Out of the 34 items, only four items were statistically significant (p b 0.05). The items the staff was easy to approach and the WM regarded the staff on her/his ward as key resources proved to be statistically significant with more positive evaluations for students with no previous work experience from elderly care. The opposite was shown for the items the supervision was based on a relationship of equality and promoted my learning and the supervisory relationship was characterised by a sense of trust displaying more positive values for students with prior work experience. For the remaining items the mean values were almost equal, displaying no significant differences between the groups (Table 2).
On the whole, the clinical learning environments in the nursing homes were evaluated in a positive way by participating nursing students, thus challenging the somewhat prevailing picture of elderly care as boring and undemanding. One prominent feature of the current study is that the dimension with the highest mean score, Supervisory relationship, can be compared not only to studies that took place within mixed settings (Sundler et al., 2013) but also to studies comparing nursing homes and hospital settings (Skaalvik et al., 2011) as well as studies comparing the duration of placements (Warne et al., 2010). Students in our study evaluated the supervisory relationship more in line with hospital settings and clinical placements longer than seven weeks. This indicates that the students participating in the current study have been supervised by registered nurses prioritising the precepting role aware of the impact of a supportive learning environment. According to Carlson and Bengtsson (2013) nursing homes can prove to be excellent learning environments when students participate in nursing for a frail and sick population, working alongside engaged and knowledgeable preceptors. In addition, students in the current study were supervised by a personal preceptor during the five week long placement; thereby, supporting results from a study by Sundler et al. (2013) concluding that a personal preceptor had a direct impact on students' satisfaction with the clinical learning environment. The items the supervision was based on a relationship of equality and promoted my learning and the supervisory relationship was characterised by a sense of trust were statistically significant with more positive values for students with prior work experience as health care assistants for older people. This can probably be contributed to a familiarity with a clinical setting as well as having met with, and cared for older people, and thereby gained invaluable basic know-how. On the contrary, the statistical significance for the item the staff was easy to approach disclosed positive values for students with no previous work experience neither from nursing homes nor from hospital settings. We suggest that this can be explained by students not having to prove their skills and knowledge as might be expected by students with prior work experience as care assistants. The result implies that it is easier for them to approach the staff with questions without being judged as less competent. The dimension Role of the NT displayed low scores from both subgroups i.e. students with or without previous work experience from elderly care, indicating a general uncertainty among the students in relation to what they could expect from the nurse teacher. More specifically, the items describing the NT as a team member of the nursing team, and the capability of the NT to provide educational advice to the clinical teams had the overall lowest scores, concordant to previous results (Johansson et al., 2010; Warne et al., 2010). In the present study, this can be contributed to the fact that the main role of the nurse teachers was to provide preceptors with educational guidelines and assessment forms prior to students arriving in clinical practice, and later support students and preceptors during final assessment discussing and evaluating learning outcomes. Consequently, the NTs had no formal pedagogical responsibility towards the clinical staff, and this is evidently a weakness that renders further research honouring the differences and the complexity of the NT's clinical role from an international perspective as discussed by Saarikoski et al. (2013). Finally, to our knowledge, no comparable studies have been conducted utilising the CLES + T scale measuring the clinical learning environment in nursing homes specifically. In previous studies, nursing homes have been part of the total studied clinical settings. For example, when Johansson et al. (2010) validated the Swedish version of the CLES + T only 8% of the students responded to the questionnaire in relation to the clinical learning environment in nursing homes. In other studies, approximately one third of the students rated their experiences in relation to nursing homes, for example 36% in the study by Skaalvik et al. (2011), and 39% in a recent study by Sundler et al. (2013). Considering the imminent global need for nurses in geriatric
Table 1 Demographic characteristics of students responding to CLES + T (n = 260, 76%)a. Total
Autumn 2011
Spring 2012
Autumn 2012
Variables
n (%)
n
n
n
Gender Female Male Missing Total n (%)
212 (81.9) 47 (18.1) 1 260 (70.5)
Age (Years) Mean Range
25.2 18–50
66 10
72 23
74 14
96
88
1 76
25.1 19–42
24.8 18–50
Work experience as health care assistants in elderly care Yes 134 (51.7) 34 43 No 125 (48.3) 41 53 Missing 1 1
25.7 20–45
57 31
a Percentage of the total number of eligible students (N = 341) during the data collection period of the following semesters: Autumn 2011; Spring 2012; Autumn 2012.
Please cite this article as: Carlson, E., Idvall, E., Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.01.009
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Total population (n = 260) Mean (SD) Pedagogical atmosphere (α = 0.91) The staff was easy to approach I felt comfortable going to the ward at the start of my shift During staff meetings (e.g. before shifts) I felt comfortable taking part in the discussion There was a positive atmosphere on the ward The staff were generally interested in student supervision The staff learned to know the students by their personal names There were sufficient meaningful learning situations on the ward The learning situations were multidimensional in terms of content The ward can be regarded as a good learning environment Leadership style of the ward manager (α = 0.87) The WM regarded the staff on her/his ward as key resource The WM was a team member Feedback from the WM could easily be considered a learning situation The effort of individual employees was appreciated Premises of nursing on the ward (α = 0.76) The ward's nursing philosophy was clearly defined Patients received individual nursing care There were no problems in the information flow related to patients' care Documentation of nursing (e.g. nursing plans, daily recording of nursing procedures, etc.) was clear Supervisory relationship (α = 0.97) My supervisor showed a positive attitude towards supervision I felt that I received individual supervision I continuously received feedback from my supervisor Overall I am satisfied with the supervision I received The supervision was based on a relationship of equality and promoted my learning There was a mutual interaction in the supervisory relationship Mutual respect and approval prevailed in the supervisory relationship The supervisory relationship was characterised by a sense of trust Role of nurse teacher (α = 0.87) In my opinion, the NT was capable to integrate theoretical knowledge and everyday practice of nursing The NT was capable of operationalise the learning goals of this clinical placement The NT helped me to reduce the theory–practice gap The NT was like a member of the nursing team The NT was capable to give his or her pedagogical expertise to the clinical team The NT and the clinical team worked together supporting my learning The common meetings between myself, mentor and NT were comfortable experiences Climate of the meetings was congenial Focus in the meetings was on my learning needs a b c
3.63 (0.86) 3.96 (0.87) 3.95 (1.12) 3.42 (1.09) 3.55 (1.08) 3.26 (1.19) 3.94 (1.16) 3.48 (1.17) 3.39 (1.15) 3.64 (1.20) 3.39 (0.98) 3.93 (1.08) 3.29 (1.26) 2.98 (1.19) 3.40 (1.10) 3.57 (0.76) 3.33 (1.13) 3.83 (1.01) 3.35 (1.16) 3.75 (1.13) 4.07 (0.99) 4.25 (1.02) 4.14 (1.08) 3.83 (1.24) 4.05 (1.19) 4.10 (1.12) 4.06 (1.14) 4.22 (1.07) 4.21 (1.05) 3.44 (0.81) 3.96 (0.94) 4.18 (2.67) 3.73 (1.07) 2.44 (1.28) 2.74 (1.29) 3.07 (1.31) 4.19 (1.06) 3.14 (1.26) 3.84 (1.06)
N = 259, one missing. Mann–Whitney U-test, significance level 5%, significant levels in italics. 1 = Fully disagree; 2 = Disagree to some extent; 3 = Neither agree nor disagree; 4 = Agree to some extent; 5 = Fully agree.
Medianc Agree to some extent Agree to some extent Agree to some extent Agree to some extent Neither agree nor disagree Agree to some extent Agree to some extent Neither agree nor disagree Agree to some extent Agree to some extent Neither agree nor disagree Neither agree nor disagree Neither agree nor disagree Neither agree nor disagree Agree to some extent Agree to some extent3.32 (1.20) Agree to some extent Fully agree Fully agree Agree to some extent Agree to some extent Agree to some extent Agree to some extent Fully agree Fully agree Agree to some extent Agree to some extent Agree to some extent Disagree to some extent Neither agree nor disagree Neither agree nor disagree Fully agree Neither agree nor disagree Agree to some extent
Previous experience (n = 134)a
No previous experience (n = 125)
Mean (SD)
Mean (SD)
3.60 (0.83) 3.81 (0.91) 3.94 (1.09) 3.44 (1.08) 3.52 (1.06) 3.21 (1.20) 3.84 (1.22) 3.49 (1.21) 3.40 (1.15) 3.64 (1.19) 3.31 (1.04) 3.78 (1.13) 3.17 (1.31) 2.89 (1.27) 3.39 (1.14) 3.57 (0.83) 3.78 (1.07) 3.80 (1.04) 3.32 (1.20) 3.78 (1.07) 4.22 (0.92) 4.34 (1.00) 4.22 (0.99) 3.92 (1.20) 4.12 (1.19) 4.27 (0.97) 4.22 (1.10) 4.36 (0.89) 4.37 (0.96) 3.49 (0.82) 3.98 (0.93) 4.09 (0.95) 3.73 (1.08) 2.55 (1.27) 2.75 (1.28) 3.09 (1.29) 4.20 (0.99) 3.24 (1.29) 3.93 (1.02)
3.66 (0.86) 4.12 (0.80) 3.97 (1.14) 3.41 (1.10) 3.58 (1.11) 3.31 (1.19) 4.05 (1.08) 3.49 (1.14) 3.39 (1.16) 3.65 (1.21) 3.49 (0.91) 4.10 (1.01) 3.41 (1.21) 3.08 (1.11) 3.43 (1.05) 3.57 (0.87) 3.31 (1.19) 3.87 (0.99) 3.39 (1.12) 3.72 (1.21) 4.00 (1.06) 4.16 (1.06) 4.06 (1.17) 3.73 (1.29) 3.98 (1.19) 3.92 (1.25) 3.90 (1.25) 4.07 (1.23) 4.05 (1.13) 3.39 (0.80) 3.94 (0.96) 4.26 (0.73) 3.71 (1.07) 2.33 (1.29) 2.73 (1.32) 3.05 (1.35) 4.18 (1.13) 3.02 (1.23) 3.72 (1.10)
p-valueb
0.587 0.005 0.654 0.767 0.618 0.493 0.201 0.911 0.897 0.944 0.178 0.017 0.139 0.265 0.795 0.998 0.806 0.628 0.805 0.883 0.124 0.130 0.398 0.274 0.223 0.033 0.054 0.151 0.009 0.173 0.750 0.357 0.764 0.129 0.767 0.770 0.563 0.140 0.150
E. Carlson, E. Idvall / Nurse Education Today xxx (2014) xxx–xxx
Please cite this article as: Carlson, E., Idvall, E., Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.01.009
Table 2 Item statistics and comparison of means for students with and without prior experience of aged care.
E. Carlson, E. Idvall / Nurse Education Today xxx (2014) xxx–xxx
care, it seems to be crucial to evaluate learning environments, specifically in nursing homes. Such evaluations could provide nurse educators with an increased understanding of a learning environment surrounded by beliefs that elderly care is undemanding, depressing, and a negative career pathway (Kloster et al., 2007; Stevens, 2011) in order to possibly influence future changes to nursing curricula. Methodological Considerations The limitations of the study mainly concern the lack of factor analysis in relation to the use of the instrument solely in nursing home settings. However, when critically examining our results we found alpha values for all sub-dimensions similar to those reported in previous studies. For example, we reported alpha values ranging from 0.76 to 0.97, compared to 0.73 to 0.94 in the original instrument (Saarikoski and Leino-Kilpi, 2002), 0.77 to 0.96 in the extended version including the NT (Saarikoski et al., 2008), 0.75 to 0.96 in the validation of the Swedish version (Johansson et al., 2010), and 0.70 to 0.97 in relation to the organisation of supervision (Sundler et al., 2013). The sub-dimension Premises of nursing on the ward had the lower rating, similar to the value reported by Sundler et al. (2013) while Supervisory relationship displayed the highest rating in accordance with previous studies (Johansson et al., 2010; Sundler et al., 2013). In addition, corrected item-total correlation ranged from 0.49 to 0.88 compared to the study by Johansson et al. (2010). This implies that the CLES + T scale is a valid and reliable instrument to be used for evaluating nursing homes as clinical learning environments. However, the overall high alpha values indicate that the number of single items may be reduced. Bos et al. (2012) validated the CLES + T for clinical learning in primary health care settings using exploratory factor analysis providing information about how the different factors affected learning as well as confirmatory factor analysis describing associations between factors. We propose a similar design for validating CLES + T in nursing home settings. We acknowledge the fact that our results are interpreted in light of the limitations that may occur in connection with a convenience sample as well as self-reporting on variables. However, our study provides valuable and positive insights into nursing students' learning experiences in an environment that has previously been described as boring and depressing. Conclusion The supervisory relationship had the greatest impact on how nursing students experienced the clinical learning environment in nursing homes. It is therefore, of utmost importance that collaborative activities between educational and nursing home settings, supporting the work of preceptors, are established and maintained. One example might be mutual work shops where preceptors, nurse managers, and nurse teachers can reflect upon didactical as well as organisational matters that might influence the provision of supportive supervision. Previous or lack of previous work experience from elderly care did not seem to impact how students rated the learning environment. Rather, the students in the current study evaluated the learning environment in a predominantly positive way. Therefore, every attempt should be made by schools of nursing to promote nursing homes as positive learning environments thus balancing the somewhat prevailing picture of elderly care as a dead end for a future career. Finally, in light of the expected shortage of nurses caring for older people we propose further studies
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measuring possible correlations between students' evaluation of the clinical learning environment and future career intentions. Acknowledgment The authors wish to extend their gratitude to all the student nurses who participated in the study for sharing their time and experience. References Bos, E., Alinaghizadeh, H., Saarikoski, M., Kaila, P., 2012. Validating the ‘clinical learning environment, supervision and nurse teacher’ CLES + T instrument in primary healthcare settings using confirmatory factor analysis. J. Clin. Nurs. 21 (11–12), 1785–1788. Brown, J., Nolan, M., Davies, S., Nolan, J., Keady, J., 2008. Transforming students’ views of gerontological nursing: realising the potential enriched environments of learning and care: a multi-method longitudinal study. Int. J. Nurs. Stud. 45 (8), 1214–1232. Carlson, E., 2013. Meaningful and enjoyable or boring and depressing? The reasons nursing students give for and against a career in aged care. J. Clin. Nurs. http://dx.doi.org/ 10.1111/jocn/12425. Carlson, E., Bengtsson, M., 2013. The uniqueness of elderly care: registered nurses’ experience as preceptors during clinical practice in nursing homes and home-based care. Nurse Educ. Today. http://dx.doi.org/10.1016/j.nedt.2013.07.017. Chenoweth, L., Yun-Hee, J., Merlyn, T., Brodaty, H., 2010. A systematic review of what factors attract and retain nurses in aged and dementia care. J. Clin. Nurs. 19 (1–2), 156–167. Chuan, O.L., Barnett, T., 2012. Student, tutor and staff nurse perceptions of the clinical learning environment. Nurse Educ. Pract. 12 (4), 192–197. De Witte, N., Labeau, S., De Keyzer, W., 2011. The clinical learning environment and supervision instrument (CLES): validity and reliability of the Dutch version (CLES + NL). Int. J. Nurs. Stud. 48 (5), 568–572. Haron, Y., Levy, S., Albagli, M., Rotstein, R., Riba, S., 2013. Why do nursing students not want to work in geriatric care? A national questionnaire survey. Int. J. Nurs. Stud. 50 (11), 1558–1565. Henderson, A., Twentyman, M., Eaton, E., Creedy, D., Stapleton, P., Lloyd, B., 2009. Creating supportive clinical learning environments: an intervention study. J. Clin. Nurs. 19 (1–2), 177–182. Johansson, U.-B., Kaila, P., Ahlner-Elmqvist, M., Leksell, J., Isoaho, H., Saarikoski, M., 2010. Clinical learning environment, supervision and nurse teacher evaluation scale: psychometric evaluation of the Swedish version. J. Adv. Nurs. 66 (9), 2085–2093. Kloster, T., Høie, M., Skår, R., 2007. Nursing students’ career preferences: a Norwegian study. J. Adv. Nurs. 59 (2), 155–162. McKenna, L., McCall, L., Wray, N., 2010. Clinical placements and nursing students’ career planning: a qualitative study. Int. J. Nurs. Pract. 16 (2), 176–182. National Board of Health and Welfare in Sweden, 2012. Increased competence in geriatric care and gerontology. Proposed implementation of the initiative (Ökad kompetens inom geriatriks och gerontologi, förslag till utförande och genomförande av satsning). In Swedish . Papathanasiou, I.V., Tsaras, K., Sarafis, P., 2014. Views and perceptions of nursing students on their clinical learning environment: teaching and learning. Nurse Educ. Today 34 (1), 57–60. Saarikoski, M., Leino-Kilpi, H., 2002. The clinical learning and supervision by staff nurses: developing the instrument. Int. J. Nurs. Stud. 39 (3), 259–267. Saarikoski, M., Isoaho, H., Warne, T., Leino-Kilpi, H., 2008. The nurse teacher in clinical practice: developing the new sub-dimension to the Clinical Learning Environment and Supervision (CLES) scale. Int. J. Nurs. Stud. 45 (8), 1233–1237. Saarikoski, M., Kaila, P., Lambrinou, E., Canaveras Pérez, R.M., Tichelaar, E., Tomietto, M., Warne, T., 2013. Students’ experiences of cooperation with nurse teacher during their clinical placements: an empirical study in a Western European context. Nurse Educ. Pract. 13 (2), 78–82. Shen, J., Xiao, L.D., 2012. Factors affecting nursing students’ intention to work with older people in China. Nurse Educ. Today 32 (3), 219–223. Skaalvik, M., Normann, H.K., Henriksen, N., 2011. Clinical learning environment and supervision: experiences of Norwegian nursing students—a questionnaire study. J. Clin. Nurs. 20 (15–16), 2294–2304. Stevens, J.A., 2011. Nursing students’ career preferences for working with older people: a replicated longitudinal survey. Int. J. Nurs. Stud. 48 (8), 944–951. Sundler, A.J., Björk, M., Bisholt, B., Ohlsson, U., Engström Kullén, A., Gustafsson, M., 2013. Nursing students’ experiences of the clinical learning environment in relation to the organisation of supervision: a questionnaire study. Nurse Educ. Today. http:// dx.doi.org/10.1016/j.nedt.2013.06.23. Warne, T., Johansson, U.B., Papastavrou, E., Tichelaar, E., Tomietto, M., Van den Bossche, K., Moreno Vizcaya, M.F., Saarikoski, M., 2010. An exploration of the clinical learning experience of nursing students in nine European countries. Nurse Educ. Today 30 (8), 809–815.
Please cite this article as: Carlson, E., Idvall, E., Nursing students' experiences of the clinical learning environment in nursing homes: A questionnaire study using the CLES + T evaluation scale, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.01.009
