Evaluating the quality of workplace learning for student nurses in hospital settings

Researchers

• Paul Watson RN, BA (Hons First Class), PhD
  Senior Lecturer, School of Nursing and Human Services, CPIT, Christchurch
• Philippa Seaton RN, BA, MA (Hons), PhD
  Principal Lecturer, School of Nursing and Human Services, CPIT, Christchurch
• Ms Deborah Sims -RN, Cert Clin Tchg, Cert Adult Tchg, Adv Dip N, MA (Applied) Nursing
  Senior Lecturer, School of Nursing and Human Services, CPIT, Christchurch
• Rose Whittle RN, BA(Ed), MEd (Dist)
  Clinical Manager, School of Nursing and Human Services, CPIT, Christchurch
• Isabel Jamieson RN, Cert Adult Tchg, BN, MN
  Senior Lecturer, School of Nursing and Human Services, CPIT, Christchurch
• Mikko Saarikoski RN, RMN, RNT, M Nursing Science, PhD
  Research and Development Manager, Principal Lecturer, Department of Health Care, Turku University of Applied Sciences, Turku, Finland
• Jane Mountier Cert Adult Tchg, BA
  Research Assistant, School of Nursing and Human Services, CPIT, Christchurch

For a copy of the full report please contact :
Bridget O'Regan
Coordinator, Southern Hub
T: +64 3 345 8339
M: +64 21 981 245
bridget.oregan@canterbury.ac.nz

Executive Summary

Background

The educational preparation of many professionals includes a practice component where learning is integrated in workplaces. This is an important part of teaching and learning in the applied professions, particularly in health care (Benner, Sutphen, Leonard, & Day, 2010; Mulholland, Mallik, Moran, Scammell, & Turnock, 2005). Bachelor of Nursing students in New Zealand undertake a significant proportion of their learning in workplaces, commonly referred to as clinical placements. With student nurses’ educational outcomes partly dependent upon the quality of the teaching and learning environment provided in the clinical placements, sound educational practice requires a process for monitoring and evaluating the quality of those placements. However, no instrument for evaluating student nurses’ perceptions of clinical learning environments has been validated in New Zealand.

A number of instruments for assessing clinical learning environments have been developed for different health disciplines, in a variety of countries. However, differences in context, such as discipline or country, may limit the application of these tools in nursing education in New Zealand. A review of instruments in the international nursing literature demonstrated a paucity of information about the psychometric testing and international validation of these tools that would enable confident use of them in the New Zealand nursing education setting. Saarikoski’s (2002) Clinical Learning Environment and Supervision (CLES) scale and Saarikoski, Isoaho, Warne and Leino-Kilpi’s (2008) Clinical Learning Environment, Supervision and Nurse Teacher (CLES+T) scale, developed in Finland to assess hospital learning environments, appear to be the most robust of the tools available. The CLES+T (or its earlier version, the CLES) have been used as a research instrument in over twenty countries and translated into 16 languages (M. Saarikoski, personal communication 4 July, 2008) making the CLES+T one of the most widely used measures of student nurses’ perceptions of the quality of their clinical learning experience in a hospital setting. This study continued the psychometric development of the CLES+T scale.

Aims

The aims of this study were to:

• Determine the face validity of the Clinical Learning Environment, Supervision and Nurse Teacher Scale (CLES+T) for evaluating the quality of the clinical learning environment, supervision, and teaching of nursing students in hospital and community settings in New Zealand.
• Explore the construct validity of the CLES+T in hospital settings in New Zealand.
• Confirm whether the CLEST+T has the same construct structure in hospital settings in New Zealand as has been reported in Finland.
• Evaluate the internal reliability of the sub-dimensions of the CLES+T in the context of hospital settings in New Zealand.
• Describe nursing students’ perceptions of their clinical learning environment, supervision and teaching in hospital settings in New Zealand.
• Pilot test the feasibility of using Digium Enterprises internet-based information collection and feedback management software service for distributing evaluative surveys and for collecting and analysing information.

Design & Methods

This study was conducted in association with a second study that focussed on the use of the CLES+T in community health care settings. There were three phases to establishing the validity and reliability of the CLES+T in the New Zealand (NZ) context. Phase one sought to establish the face validity of the CLES+T in hospital and community settings in NZ. Phase two investigated the construct validity and reliability of the CLES+T in hospital settings in NZ. Phase three, was the second study which is reported elsewhere, and explored the validity and reliability of the CLES+T in community settings in NZ. The study was approved by the Christchurch Polytechnic Institute of Technology (CPIT) Ethics Committee and the CPIT Nursing & Human Services Research Committee.

Sample: In phase one, the face validity was determined by a purposively selected expert panel of three nursing students, two clinical supervisors, two managers and four nurse teachers, from hospital and community settings. In phase two, first, second, and third year Bachelor of Nursing students at CPIT, who were completing hospital placements between July 2008 and December 2009, were invited to participate in the study. Valid responses were received in relation to 416 student nurse placements (response rate 41%).

Data Collection: The CLES+T consists of 34 items which are all positively phrased to illustrate an optimal state. A cultural safety item was added to the CLES+T scale and some terminology adapted to clarify meaning in the NZ context. Respondents were asked to rate each items on a Likert scale. The CLES+T questionnaire was administered online for both phases; in phase two some paper-based questionnaires were also used.

Analysis: In phase one descriptive statistics were used to report the consensus level regarding the face validity of each item. Suggestions for alterations to items were recorded as written by respondents. In phase two, statistical analysis was performed using SPSS 17.0. Exploratory Factor Analysis was used to establish: (i) the construct validity of the CLES+T (NZ version) in NZ hospitals and (ii) comparison of the construct structure between hospital settings in New Zealand and Finland. The internal reliability of the sub-dimensions of the CLES+T (NZ) was ascertained by calculating Cronbach’s alpha coefficient and correlations between sub-dimensions. Demographic and placement variables’ effects on students’ perceptions of their clinical learning environment, supervision, and teaching in hospital settings were determined using correlation coefficients and ANOVA.

Results

In phase one, most of the panel agreed all the items on the CLES+T have face validity for evaluating student nurses’ perceptions of clinical learning environments, supervision and teaching in both hospital and community settings in New Zealand. However, minor alterations may be required to some items in order to improve their face validity.
In determining the construct validity of the CLES+T, Exploratory Factor Analysis found the strongest statistical support for a four factor model. Saarikoski et al. (2008) also found an almost identical four factor model to be statistically the most coherent model. Thus, two studies on independent samples from different countries have shown that the most robust factor model has four similar factors. The factors in this New Zealand study have been named: Connecting with, and learning in, communities of clinical practice; Role of the nurse teacher; Supervisory relationship; and Leadership style of the manager.

All four factors were found to have Cronbach’s α > .8 (highly reliable). The results also indicate that the factors were internally consistent. Three of the four factors had excellent alpha values (> .9) and the fourth factor had a good alpha value (> .8), particularly as it only has three items. These results demonstrate that the CLES+T is a reliable tool to measure student nurses’ perceptions of their clinical learning environments, supervision, and nurse teachers in hospital settings in New Zealand.

Only limited comparison of specific factors between this study and that of Saarikoski et al. (2008) in Finland were possible. On the two identical factors (Supervisory relationship and Nurse teacher) the results show that NZ nursing students from CPIT rate their relationship with their supervisor and their nurse teacher significantly higher than do Finnish nursing students.

Demographic and placement variables effects on students’ perceptions of their clinical learning environment, supervision, and teaching in hospital settings showed:

1. There were no significant correlations between the students’ age and the four factors.
2. There were significant differences in student’ place in the BN programme (year 1, 2, or 3) on students’ perceptions of three of the four factors. There is an increasingly positive perception of connecting with, and learning in, communities of clinical practice as students’ progress through the three years of the programme. First year students perceived their nurse teacher significantly better than both second and third year students. On average, third year students perceived significantly better supervisory relationships than second year students.
3. There is a significant correlation between duration of the placement and students’ perception of their clinical learning environment. As the duration of the placement increased the students’ perception of connecting with, and learning in, communities of clinical practice increased, as did their perception of the supervisory relationship, however their perception of the nurse teacher decreased.

Conclusion

Construct validity and reliability data from this study support the use of the CLES+T to evaluate students’ clinical learning environments in hospital settings in New Zealand. The CLES+T appears to have sufficient validity and reliability to be used by researchers, educators and clinicians who wish to monitor the quality of clinical learning environments.