ABSTRACT
This study investigated the actual and preferred hospital clinical learning environment (CLE) of
student nurses in Enugu state. This research specifically assessed the student nurses view of
their actual and preferred hospital CLE, determine if differences exist in student nurses view of
their actual and preferred hospital CLE, establish the association between the actual and
preferred hospital CLE and students’ age, gender, location and year of study and identify factors
that influence student nurses opinion of their hospital CLE. A cross sectional descriptive survey
design was adopted for the study which permits the observation, description and
documentations of aspects of a situation as it naturally occurred. The sample size of 454 nursing
students was purposively chosen for the study. Data were collected using two validated
instrument thus; researcher developed questionnaire and adapted 42 item standardized clinical
learning environment inventory (CLEI) (Actual and Preferred) questionnaires. Data analysis
was done using frequency counts, simple percentages, means and standard deviation for
research objectives, while t-test with cut off point of 2.50 MANOVA and ANOVA were
employed in testing the eight null hypotheses at .05 level of significance. The findings revealed
that there is significant difference in the student nurses view of their actual and preferred
hospital CLE (p<0.05) in all the subscales. Student nurses view of their actual hospital CLE is
significantly negative (Mean scores <2.50 and p<0.05) and that of preferred hospital CLE is
positive (mean scores (> 2.50 and p<0.05). Only gender and year of study in the preferred
hospital clinical learning environment were significant (p = 0.041 and p = 0.000) respectively.
They were agree to be the factors that influence student nurses opinion of their hospital CLE
(mean scores >2.50 and p<0.05), except age of student (p = 0.694) and gender of student (p = 0.
189). In conclusion, student nurses in Enugu State have significant negative view of their actual
hospital CLE. The importance of helping students feel valued and interpersonal relationships in
the clinical area need to be highlighted in the preceptor preparation programmes.
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CHAPTER ONE
INTRODUCTION
Background to the Study
Nursing is a practice based profession with clinical education as an essential part of the
nursing curriculum. Clinical practice is the focus for students learning and clinical placement/
posting constitutes one of the most integral components in the nursing education. Clinical
placement is the venue where skills, knowledge and attitudes developed in the theoretical part
of the curriculum are applied, developed and integrated into practice (Newton, Jolly, Ockerby
& Cross, 2010).
According to Norman (2009), clinical practice setting provides students with unique
learning opportunities in which classroom theory and skills are put to the test with real life
situations. Besides the clinical training foster students in the application of knowledge, skill and
attitude to clinical field of situations, it is vital that valuable clinical time should be utilized
effectively and productively.
Zilembo and Montereso (2008) stressed the implication of practicing in an appropriate clinical
learning environment at the proper time in order that theory and practice can complement each
other. Nursing students perceived the clinical setting as the most influential context for
acquiring knowledge and nursing skills (Al-Kandari, Vidal & Thomas 2009).
The importance of learning in the clinical area has been a major emphasis in the United
Kingdom and other parts of the world, Nigeria inclusive. Providing quality clinical training with
an emphasis on improvement and development is paramount in ensuring that students
experience good quality care and treatment of patients and clients (E.N.B & D.O.H 2001). In
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addition there is need for provision of adequate support and supervision of students in the
clinical areas.
In Nigeria, nursing education programmes are offered at both the hospital level also
known as hospital based and university level also known as baccalaureate. The hospital based
nursing education program lasts for three years and that of baccalaureate lasts for five years for
the generic and four years for direct entry students and besides the theoretical component, each
program has a clinical component. The clinical education takes place in a clinical setting most
often a hospital and part in the community.
During the three, four and five year’s program, students are rotated through a variety of settings.
Each new posting means the student must socialize into a new setting, establish relationship
with staff while being exposed to the new clinical situations with different patient populations.
At the same time students clinical performance is continuously being evaluated by a teacher
(Mleck, 2011).
It is acknowledged that all learning takes place within a social context; the social context
of clinical practice embraces many more variables than classroom setting. Learning activities in
the classroom are mostly structured in contrast to clinical learning activities. In clinical training
the environment is unpredictable (koontz, Mallory, Burns & Chapman, 2010) with students
involved in unplanned activities. Learning experience in this unpredictable environment
presents a greater threat to students than learning in the classroom. As a consequence there is
less control over the learning experiences of students making it hard to plan for an optimal
clinical learning environment (C.L.E) (Papp, Markkanen and Ven Bonsdorff, 2003).
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The essential element of the C.L.E is the hospital ward and its characteristics because most part
of the clinical education takes place there. The ward environment is considered as exerting great
influence on all those engaged in ward life, student nurses inclusive. Therefore student nurses
perspective of the hospital based clinical experiences is a summary of the meanings that the
students derived from their interactions in this social context.
An understanding of the social climate as the personality of a setting or environment can
provide insight into peoples’ actions and feelings. Thus, understanding the student nurses
perceptions of their actual and preferred hospital based clinical learning environment may
reveal aspects of the actual environment that require improvement in order to maximize student
learning in practice. Likewise an understanding of students’ perspective of the clinical
environment and social climate within this milieu may assist in improving the educative quality
of their clinical training.
Across different countries students report similar perceptions about clinical learning
environment. Some of the studies reported that there were significant differences between
students’ perceptions of the actual clinical learning environment with and their preferred
learning environment (Papathanasioir, Tsaras & Sarafis, 2014, D’souza, Venkatesaperumal,
Radhakrishon, & Balachandran, 2013, Chan, 2003). Generally students preferred a more
positive and favourable clinical environment than they perceived as being actually present
(Carlson & Idvall, 2014, Chan, 2003). According to Midgley (2006) students would prefer an
environment with higher levels of individualization, innovation in teaching and learning
strategies, student involvement, personalization and task orientation. Bjork, Berntsen, Brynil
and Henstetun, (2014) opined that clinical placement experiences may influence positively on
nursing students attitudes towards the clinical setting in question. Another study by Rahmani,
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Zamanzadeh, Abdullah-zadeh, Lotfi and Hassanpour, (2011) showed that majority (93.2%) of
student nurses in Iran had a negative view point about C.L.E. Henderson, Cooke, Creedy &
Walker (2012) in their study showed that across different countries, students reported similar
perceptions about clinical learning environment and some of the findings were that sense of task
accomplished rated high, and feedback measuring whether students’ individual needs and views
were accommodated rated low. Furthermore CLEs are most effective in promoting safe practice
and are inclusive of student learners but not readily open to innovation and challenges to routine
practices. Clinical learning experience requires difficult adjustments for students as they come
from different socio-economic and cultural backgrounds (D’souza et al, 2013) and positive
learning experiences during clinical practice influence not only learning outcomes, but also how
students reason in relation to future career choices (Carlson & Idvall, 2014).
Minimal studies have been conducted on the C.L.E which has considered the student
nurses’ perception of the actual C.L.E as well as the C.L.E ideally liked or preferred. Indeed,
there is no published research in nursing literature in Nigeria which has explored the clinical
learning environment from the students perspective. Therefore this study is designed to assess
nursing students’ perceptions of actual and preferred hospital clinical learning environment in
Enugu State.
Statement of Problem
Despite the fact that clinical learning is an integral part of nursing education, yet it has
been problematic. Various studies have suggested that not all practice settings are able to
provide nursing students with a positive learning environment (Chan, 2004).
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Clinical experience has been linked to high levels of stress and anxiety in nursing students and
literature shows that there is a link between the nursing student attrition and the stress related to
the clinical experience (Mlek, 2011). Evidence also shows that clinical experience is one of the
most anxiety producing components of the nursing program (Sharif & Masoumi, 2005) and
some of the anxiety producing situations identified by nursing students include lack of clinical
experience, unfamiliar areas, difficult patients, fear of making mistakes and being evaluated by
faculty members.
In addition nursing students in other studies (Levett-Jones, Latta, Hygins & McMillan, 2009)
described nursing staff as unfriendly, hostile, indifferent, unreceptive and unapproachable. Their
feelings of inclusion/exclusion affected directly their sense of belonging and subsequently
increased their anxiety, capacity and motivation to learn (D’souza et al, 2013). Though mild
anxiety is not detrimental to learning and may even enhance perception and memory but
moderate or severe anxiety can alter one’s ability to learn and perform in a clinical setting
(Levett-Jones et al 2009).
The researcher having taught in School of Nursing for over five (5) years now have
listened to comments from students regarding their perceived difficulties while on clinical
placements. Some of the difficulties focused on their perceived lack of support and direction,
not feeling part of the team and concerns regarding interpretation of their supernumerary status
in the clinical areas. Supernumerary status means that student nurses are additional to the
clinical workforce and undertake a placement in clinical practice to learn, not as members of
staff (NMC, 2004 in Allan, 2009). However, this does not mean that students do not work while
on placement, they are expected to learn through supervised participation in clinical work
(Arkell & Bayliss-Pratt, 2007).
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The researcher is interested in assessing perceptions of students’ actual clinical learning
environment experiences and to determine what they would prefer this environment of
experience to be like. Such an assessment is necessary in order to facilitate and maximize
student nurses’ clinical training (Chan, 2002).
Few studies have been conducted on the clinical learning environment (C.L.E) which has
considered the students’ perceptions of the actual C.L.E as well as the C.L.E ideally liked or
preferred (Chan 2002) in other countries. Unfortunately, in Nigeria, there is apparently no
published research on students’ perceptions of the clinical learning environment in nursing
literature.
Purpose of the study
The purpose of this study is to assess student nurses perceptions of their actual and preferred
clinical learning environment in hospital settings in Enugu State. The researcher is interested in
bringing the students’ perceptions into the public domain to ensure they have a voice within the
wider nursing arena.
Objectives of the Study
The objectives of the study are to:
1. determine student nurses view of their actual hospital clinical learning environment.
2. establish student nurses preferred hospital clinical learning environment.
3. determine if differences exist in student nurses view of their actual and preferred
hospital clinical learning environment.
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4. identify differences between the actual and preferred clinical learning environment and
students’ age, gender, location and year of study.
5. identify factors that influence student nurses opinion of their hospital clinical learning
environment.
Research Questions
1. How do nursing students see their actual hospital clinical learning environment?
2. What is the student nurses preferred hospital clinical learning environment?
3. What differences exist between perceptions of actual and preferred hospital clinical
learning environment of student nurses?
4. What differences exist between the actual and preferred clinical learning environment
and the students’ age, gender, location and year of study?
5. What factors influence student nurses’ opinions of their hospital clinical learning
environment?
Statement of Hypothesis
1. There will be no significant difference in the students’ perception of the actual and
preferred hospital clinical learning environment.
2. There will be no significant difference in students’ perception of the actual hospital
clinical learning environment between baccalaureate (UNEC) and hospital based
(schools of Nursing-UNTH and Bishop Shanahan).
3. There will be no significant difference in students’ perception of the preferred hospital
clinical learning environment between baccalaureate (UNEC) and hospital based
(schools of Nursing-UNTH and Bishop Shanahan).
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4. There will be no significant difference in students’ perception of the actual and preferred
hospital clinical learning environment between baccalaureate (UNEC) and hospital
based (schools of Nursing-UNTH and Bishop Shanahan).
5. There will be no significant age difference in the students perception of actual hospital
clinical learning environment
6. There will be no significant age difference in the students’ preferred hospital clinical
learning environment
7. There will be no significant difference in students’ perceptions of actual and preferred
hospital clinical learning environment and the year of study.
8. There will be no significant gender difference in students’ perception of the actual and
preferred hospital clinical learning environment.
Significance of the Study
The focus of this study is on the perceptions of actual and preferred clinical learning
environment of student nurses in Enugu State. The findings of this study will reveal the
students’ perceptions of actual and preferred clinical learning environment in the hospital
setting, whether the practice settings are able to provide nursing students with a positive
learning environment. It will also reveal a better understanding of what constitutes quality
clinical education from the students’ perspective. An understanding of the students’ perceptions
of their actual and preferred hospital clinical learning environment may reveal aspects of the
actual environment that require improvement in order to maximise students’ learning in
practice. Findings if published and utilized will also assist in improving the educative quality of
students’ clinical education through understanding their perspective of clinical learning
environment and the social climate in which they are (ward). It will also help nurse educators,
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hospital administrators, Nursing and Midwifery Council of Nigeria as well as Ministry of
Education in ensuring that the problems identified by students in the clinical area is addressed
accordingly by monitoring the activities in the clinical setting. This study will equally serve as a
reference for future researchers writing on similar topic. The findings of this study will also
contribute to the existing body of knowledge on the clinical learning environment in nursing
literature in Nigeria. It is believed that the present study will provide a preliminary data that will
fill the gap in the knowledge in nursing literature in this area.
Scope of Study
This study is delimited to student nurses in Enugu State. This includes second and third
year students in schools of nursing, UNTH Enugu, and Bishop Shanaham, Nsukka respectively
and fourth and fifth year nursing students in the department of nursing sciences, UNEC, because
they had experienced adequate clinical exposure to be able to comment on a variety of situation.
The study is delimited to actual and preferred hospital clinical learning environment of nursing
students. It includes students of both sexes.
Operational Definition of Terms
1. Perception - refers to the rating by student nurses of items of the actual and preferred
clinical learning environment inventory (CLEI 42 items), contained in the questionnaire.
These ratings are based on the observations and experiences and exposures of the
student nurses.
2. Perceptions of actual hospital clinical learning environment – refers to student
nurses description of what their clinical learning experience is actually like in the
hospital setting as contained in the CLEI such as the CPC/Nursing staff considers
students, Students are dissatisfied with what is done in the ward among others.
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3. Perceptions of preferred hospital clinical learning environment – refers to
description of what or how students want their experience in the clinical area of the
hospital to be like as contained in the CLEI such as the CPC/Nursing staff would
consider students, Students would be dissatisfied with what is done in the ward among
others .
4. Hospital clinical learning environment – refers to student nurses’ clinical experience
in the hospital setting.
5. Clinical learning environment – is defined as an interactive network of forces within
the clinical setting that influence the students’ clinical learning outcomes. It includes
hospitals, wards, clinics, health departments, hospice units, and other health care settings
utilized for student learning such as community visits, nursing homes, and mental health
homes among others.
6. Clinical education - is the teaching learning process which occurs in the context of real
health care clinical practice mostly in a hospital setting. It involves practical integration
and application of knowledge, skills and attitudes learned at the classroom and it is
facilitated with professional support, supervision, feedback and evaluation among
others.