INTRODUCTION

Many authors have approached the learning environment concept from different perspectives^1)(2)(3)(4. Hiemstra⁵⁾ stated that the learning environment represents multiple things to students. As well as the physical atmosphere, it also provides psychological and emotional conditions and the social or cultural influences that affect the growth and development of the learning process. Similarly, Knowles⁶ stated that the concept of the learning climate highlights the importance of physical, human, interpersonal and organizational characteristics, and mutual respect and trust between teachers and students. Fraser⁴ expanded on these ideas, describing science learning environments. And recently, the concept and methodology have also been review by Clevenland and Fisher⁷.

When addressing the concept of the learning environment, it should be remembered that nursing is essentially a practice-based profession, so clinical practice placements in health institutions are an essential component of the undergraduate student curriculum ^8)(9)(10. By the Bologna Declaration and with the European Directive, the clinical training component of a nursing degree in Spain now accounts for a minimum of 90 ECTS (11). Clinical placements are distributed throughout the degree course, although more are undertaken during the third and fourth academic years^12). As a result, of these recent changes, in-depth studies of the characteristics of the clinical environment could be of interest to nursing educators.

Background

In nursing education context the concept of Clinical Learning Environment (CLE) has been defined as interactive network or set of characteristics inherent to the practices that influence learning outcomes and professional development nurse¹³⁾⁽¹⁴. Thus the internship position, offers students optimal scenarios to observe models and reflect on what is seen, heard, it is perceived or made¹⁵⁾⁽¹⁶, thus is generated and guides the professional socialization process of the student¹⁷.

According to previous literature, Flott and Linden¹⁶ explain that the CLE concept encloses four attributes that influence student learning experiences: the physical space, the psychosocial and interactions factors, the organizational culture, and the elements of the teaching-learning process. That is, the clinical learning environment is the "clinical classroom" with a complex social climate in which students, nurses, teachers and patients interact¹⁸.

Therefore, a cultural understanding of the CLE should be reflected in the nursing curriculum in higher education in the international context ^16)(19)(20. In this line, the Erasmus programme has facilitated clinical training for student nurses some at universities around Europe²¹. Furthermore, a need has been identified to define areas of competence in the context of European nursing education ²². Given the importance of the CLE, understanding how it is perceived by students and how it influences their learning process becomes relevant. Most of the previous studies on learning environment use a quantitative methodology, and the ones that approach students’ perceptions from the qualitative perspective are less.

METHODS

Aim

The aim of this study is to determine how a sample of Spanish nursing students perceives the CLE in which they undertake their practice placements.

Design

A qualitative design was used to research this phenomenological study. Through the results of this study, it is not possible to make generalizations, but we can understand the individual characteristics and experience of these students during their clinical practices. For this reason, an interpretive phenomenological approach based on the understanding of experiences, and the articulation of similarities and differences in the meanings and experiences of human beings²³, can be the most appropriate one for achieving the objectives.

Consolidated criteria for reporting qualitative studies (COREQ) was used to improve the quality of reporting of the present study ²⁴.

Sample and setting

The participants were the total of students from the University of Alicante (Alicante, Spain) that performed their clinical practice placements at the University Hospital of San Juan de Alicante in May 2012. Neither of them refused or dropped out of the study. The purposive sample consisted of 48 students (Table 1).

Table 1 Study population description and data collection context. 

Legend: ¹Female; ²Male; ³Academic year; ⁴Student codes.

As in previous research in Spanish context ²⁵⁾⁽²⁶, the students in this study identified the roles of “nurse tutor”, “nurse” and “ward manager” as members of the supervision team in the ward context. Centring on the roles, while a nurse tutor is a nurse who has been assigned 2-4 students and is directly responsible for their learning and evaluation, a nurse has no designated student, but occasionally participates in a learning activity.

Data collection

Data were collected by three semi-structured focus group interviews that were conducted during a weekly clinical session, and recorded in audio format (Table 1). Two of the researchers were presented during the focus group interviews. While one of them was conducting the session, the other one made field notes. Table 2 lists all the focus group interview questions.

Table 2 Focus-group questions. 

Ethical considerations

This study has adhered to the ethical requirements governing researcher and teacher responsibilities²⁷ and approved by the Ethics Committee of the University of Alicante.

During the transcription of the interviews, “St” codes were used for referencing all participating.

Data analysis

Semi-structured focus group interviews were transcribed verbatim, and then analysed using the “stage by stage” method²⁸. This process of analysis consisted of the following steps: 1) labelling the data and establishing a data index, 2) categorizing the content of the data into meaningful categories, and 3) determining a mutually agreed category list of themes (Table 3). The QSR NUD*IST 5 software was used for these analyses to categorise qualitative data.

Table 3 Category list of themes: definitions of the concepts. 

Rigour

We performed an interview triangulation (second interviewer) during focus group interviews and an investigator triangulation in the analysis process. Students were given a transcript of the interview upon completion and asked to verify that the information was correct (corroborating findings).

RESULTS

The interviews were transcribed and codified according to the different interviews questions (Table 2), creating a tree structure with the following main categories: individualization, innovation in clinical teaching, student participation, and nurse tutor-student nurse relationship (Table 3).

Individualization

Generally, nurses allowed students to make decisions but did not differentiate between advanced and beginner students. Students controlled their activities according to their auto-perceived ability:

‘I see autonomy as the freedom they give you for doing something. And there is no difference between first- and second-year students. They say: do this, and if they say it to you, you say to you partner: will you come with me? But they don’t discriminate…’ (St24)

‘In my ward, a job that perhaps should be for third-year students is given to us […] it gives you a lot of self-confidence. But sometimes, I think that this isn’t normal.’ (St12)

Students often call for more supervision from the tutor nurse, as this helps them to feel more secure, and involved with patient safety:

‘I think that when [the tutor nurse] asks you to do something, and you go on your own, it’s good that they give you freedom to go, and do it yourself, but it wouldn’t be bad if they accompanied you, because […] something happens, and you can’t leave the job half done, and then you have to run to ask for help, and you’re in a situation where you don’t know what to do or how to act.’ (St18)

Innovation in clinical teaching

First-year students say that everything is new when they arrive at the hospital. Unfortunately, they did not pay enough attention to previous laboratory training:

‘I think that everything is new for us, [...] I am going to be sincere, when I had skill labs, from 4 to 9 [P.M.], I arrived at the sessions, and... You don’t think it’s very important. You think that real practice placements are coming soon, and I didn’t pay attention. Well, I did pay some attention, [collective laughter]... but I wasn’t much focused, […] And soon enough I arrived here, and boy, the time I had lost! I mean, I should have been more attentive in the skills lab....’ (St1)

Regarding the explanations received from nurses, students report that any doubts are generally clarified very well:

‘Sometimes they study in the evening [consult books and other sources] to answer your question [the following day].’ (St29)

‘Yes, they take care of us. You can see which nurses care, and you go directly to them to ask your questions [several students nod].’ (St47)

‘I think that some of the ward managers are committed to teaching. Perhaps he or she doesn’t know it very well [does not have much training], but he or she tries hard. And you can feel it; he or she stays for an extra hour to teach us if necessary. And they do it with all their heart…’ (St32)

Nurses are very meticulous in their use of techniques and procedures necessary for student learning:

‘There are many nurses who put sterile gloves on because we are in the room. Sometimes they wear sterile gloves for the smallest wound! And they admit it, saying: because you are here, I am doing it properly, so you can learn...’ (St16)

Third-year students receive updated information on the use of clinical equipment:

‘They do talk about equipment. About pumps, about ventilators, about that sort of thing; they do talk. They say: this one is more modern than that one, or this one needs that piece... But this depends on the person [that is, some nurses explain the equipment while others do not].’ (St36)

Student participation

Second-year students state that they do not have full participation in some ward activities, such as the nursing shift report:

‘You don’t participate in nursing shift reports, for example. Perhaps, they [nurses] are speaking, and you make a comment. You get into their conversation. They look at you like that [the student shows an indifference glance] and they say to you: ok.’ (St18)

In contrast, there is full student involvement in other activities, such as wound treatment. Nurses even provide information for the following day’s shift:

‘[...] on wound treatment, for example, they say: when the other nurse comes tomorrow, you tell her that we have put this on him [on the patient]’ (St23)

Third-year students considered that their engagement level in ward activities depended on themselves, the characteristics of the ward and its staff, but not on the students’ level of expertise:

‘The extent to which you engage depends on yourself, on the person and your level of interest. Another factor that affects the way we engage is the tutor nurse’s working method. If you see that the nurse totally takes care of the patient, worries about all the finer details and is concerned with everything to do with the patient, you’ll do the same. However, if you’re with a tutor nurse who doesn’t work well, you aren’t going to learn much, and you aren’t going to worry so much about the details involved in the patent's care. And those details might be very important for the patient…’ (St48)

Nurse tutor-student nurse relationship

Students did not always perceive that the tutor nurse role was clearly defined. When they did, they stated the following on the relationship with the nurse:

‘To have a good relationship with a tutor, it doesn’t matter how much the tutor knows; it depends on her desire to teach... When they [nurses] do it, they are there [they get closer to the student], and we feel supported.’ (St24)

Students give their opinion about the role that the tutor nurse, a nurse that gives them individualised and continuous feedback and support in practice, should play.

‘[…] one day a nurse arrived and said: today you are going to be the nurse, and I am going to be your student’. I thought to myself: what if I do something wrong, what will happen? She said: I’m going to be with you all the time. You can ask me anything you need. In other words, she explained everything to me. All morning! The entire shift. And I learned more that day than in the whole month!’ (St31)

Based on what students say, it seems that they often feel like temporary workers whose pay is education:

‘I think that they [tutor nurse] see us as workers. You don’t come to the hospital to work, your pay is learning, your pay is training... I know they have a lot of work to do... We can help them, and they can teach us.’ (St29)

‘Students are sometimes like office boys. You often have the feeling that you’re doing the work of professionals other than nurses [such as assistant nurses], you know? […] you aren’t doing a nurse’s work. You’re not learning anything.’ (St5)

As for the age of the tutor nurse, students indicate the difference in attitude that they perceive between the “young” and “old” nurses. Above all, they emphasize their empathy with the young nurses.

‘[…] the young nurses have recently finished their studies, they put themselves in our shoes... those who studied a long time ago, the older ones, don’t count on you for certain things.’ (St11)

‘In my case, the younger ones are more considerate with me. They respect me. Just by saying: Do you want to do this? I always observe the nurse, until she gives me the opportunity to do something... They invite to you to do something; they don’t use a dictatorial tone.’ (St28)

However, young nurses have less experience and may, therefore, be at a disadvantage when clarifying certain doubts:

‘[…] I asked my tutor nurse a question... She is a young girl and admitted that she didn’t know the answer. She asked me to put the question to another nurse, one with more experience.’ (St36)

DISCUSSION

One of the aspects most frequently addressed in the literature about the clinical learning environment is how it is perceived by students. In other words, this perception corresponds to the student perspective in the process of adapting to the sociocultural scene in the clinical climate. This research gives a view about how nursing students perceive the clinical learning environment. The main topics of interest were “individualization”, “innovation in clinical teaching”, “student participation” and “nurse tutor-student nurse relationship”.

With regard to “individualization”, the students identified that there is no individualization in the clinical learning process. They do not think that aspects such as students’ experience and confidence help them to be more self-sufficient in making decisions and more autonomous in how they participate in ward activities. Nevertheless, students often call for more supervision from the tutor nurse in order to feel more secure. Usually, the tutor nurse feedback is negative, with poor communication, or what it worse, it does not exist. Constructive feedback can also help students to reflect on and to understand the theory, the practice, and their learning and socialisation experience^9)(10)(29.

Feelings of anxiety or vulnerability are common in nursing students, mainly at the beginning of the clinical placement^{9)(10)(30)(31)(32)(33)(34)(35}. This kind of stress can be related to the reality shock, the fear of making mistakes, feeling incompetent, feeling ignored, or the shame to talk with other professionals^10)(31)(32. Other times, the situation is worse, and the students can feel a bullying situation^31)(34)(36. Fortunately, this circumstance was not informed by our participants.

The findings of “innovation in clinical teaching” emphasized that clinical practice placements represent an adequate context where students obtain up-to-date information and training. First-year students recognized they didn’t pay enough attention to the laboratory training. As Ewertsson et al.³⁷ explained, this training “constitutes a bridge between the university and the clinical settings.” Kaphagawani and Useh⁹ also described how students transferred knowledge and abilities from the classroom and simulation laboratories to the clinical context. Also, it has been suggested that longer placements in the same clinical setting and the use of different pedagogical approaches (problem-based learning, reflective learning, evidence-based learning, or e-learning) could help to solve the theory-practice gap^{21)(38)(39)(40)(41)(42)(43}.

Students believe that “student participation” in activities depends on their experience, the characteristics of the ward, the nursing team and the tutor nurse. They recognize that they may have complete involvement in some ward tasks. Previous studies agree with these results^{9)(21)(33)(41}. However, students argued that they had done routine activities and non-nursing duties during the clinical placement. The literature evidence that the clinical learning process will be successful if students report a variety of challenging learning opportunities which encourages them to become critical thinkers, but without increase the students' workload^9)(43)(44.

Concerning “clinical supervision”, although there are a variety of nursing students supervisory models in European countries, many authors agree to consider the tutor nurse as the key role in the process of clinical supervision^{9)(21)(41)(42)(44)(45}. In addition, the student-nurse tutor relationship seems to be decisive for the students’ learning, both epistemologically and ontologically⁴³. However, in this study, the majority of the students do not feel that the tutor nurse role was clearly defined. The nurses’ shifts and the students’ work schedule are noted as one of the most important causes for our participants. In that sense, the role of the tutor nurse should be clarified, enriched, and upgraded internationally^16)(42)(43.

Based on our students’ comments, it seems that they often feel like temporary workers who are paid in learning. Melia⁴⁶ explained this feeling regarding mistaken student identity, as in “Am I a student or a worker?” Other authors have suggested that nursing students are sometimes treated as members of the nursing team in clinical areas, even though that is not their position⁴⁷⁾⁽⁴⁸. Sometimes students felt that their primary purpose on placement was to support staff rather than develop their skills and enhance their learning.⁴⁸⁾

Finally, students reported feeling more empathy with young than with older tutors. In this sense, Houghton¹⁰ found that approachability, confidence, and motivation are characteristics of good tutors, which could be in line with our findings.

Limitations of the study

We are aware that the results of this study are limited to the students’ perspective of this purposive sample. Including the perceptions of nurses, nurse tutors, teachers, and patients of the clinical learning environment would be possible with further research, along with a cross-cultural and international perspective.

CONCLUSION

This study shows that: 1) no individualization is involved in the clinical learning process; 2) student participation in ward activities depends on the student`s experience, the characteristics of the ward, the nursing team and nurse tutor; 3) students feel that the role of the nurse tutor is not clearly defined; 4) anxiety, vulnerability and feelings of being “temporary workers” are common in nursing students.

These results should prompt reflection on these aspects of the supervisory process. Clinical learning is one of the most important of all students' experiences while on placement, given that it is during this period of training when they put the knowledge, skills and attitudes required for their future working life into practice.