Perception of Nursing and Midwifery Trainees towards Clinical Environment at Cape Coast in the Central Region of Ghana ()
1. Background
Clinical Learning Environment is defined as a complex network of forces that are effective on clinical learning outcomes [1]. Clinical Learning Environment is a multidimensional entity with a complex social context. It includes hospitals, wards, clinics, health departments, hospice units, and other health care settings utilized for student learning [2]. The overall goal of student education in the Clinical Learning Environment is to enrich clinical learning experiences and prepare competent graduate student nurses with transfer of knowledge and practice for any healthcare setting [2]. Clinical Learning Environment is also defined as an interactive network of forces within the clinical setting that influence the students’ clinical learning outcomes [3]. The Clinical Learning Environment differs from the classroom setting in many ways. The Clinical Learning Environment is unpredictable and relatively out of the nursing instructor’s control. Within Ireland, it is been shown that a variety of factors for example age of the student and year of study can influence student nurses’ perception of the Clinical Learning Environment [4] [5]. There is clinical gap between the expectations and reality of the clinical learning environment for the students in nursing [6]. Reorganization of the educational framework is needed with an emphasis on innovation and individualization. The student-supervisor relationship, that is, the relationship between the student and their clinical teachers or nurses in the health care team, is the most important factor influencing students’ satisfaction with the clinical learning environment [7]. Nursing students’ perceptions of the Clinical Learning Environment at a Greek nursing school were assessed by Papathanasior et al. [6] using the Clinical Learning Environment Inventory (CLEI) [8]. The students in this study considered good supervisory relationships to be the key enabler of good learning experiences in the clinical setting. The purpose of this study was to investigate the perception of nursing and midwifery trainees towards clinical environment.
1.1. Limitations of the Study
The major constraint encountered was on how to access the data on time. This was due to the fact that some respondents were on clinical attachment outside the Cape Coast metropolis. Due to this the data collection was done when all the students were present in class.
1.2. Research Questions
1) What is nursing and midwifery students’ perception of clinical learning environment?
2) What is the perception of the nursing and midwifery students’ on the relationship they have with the staff in the ward.
2. Methods
2.1. Research Design
Quantitative paradigm and cross-sectional survey approach was used to conduct the study. A descriptive survey concerns itself with present phenomena in terms of situations and practices, provides a picture of a phenomenon as they naturally are and can be used to justify current practice and make judgment. Quantitative research paradigm was use for study because it is based on the philosophy that every phenomenon in the world can only be explained by a positivist paradigm. The truth and explanation of a phenomenon of the study was reached through empirical methods and quantitative methodologies. Quantitative research was done because the authors had the intention to quantify variables and solve problems using numeric assessment. Quantitative research is also highly generalizable as compared to the qualitative research.
2.2. Population
The population for the study was all students at Nursing and Midwifery Training Colleges. The target population consisted of students between the ages of 18 yrs and 35 yrs, married and single, Christians and Muslims. All the students offering the following programmes in the colleges were included. They were first to third year students offering Registered General Nursing (RGN), Registered Midwifery (RM) and Registered Mental Nursing (RMN) diploma programmes. The total target population for the study was 1534 students consisting of 459 RGNs, 425 RMs and 650 RMNs in both colleges.
2.3. Sample Size
The sample size representative of the students for the study was 605. According to Ogah [9] sample size calculation, the sample size to use was 310 but in cross sectional study, one needs a larger population so 95% of the sample size which translates into about two hundred and ninety-five (295) respondents was added, bringing the number of respondents to 605.
2.4. Sampling Procedure
Proportional, stratified and simple random sampling were employed to select the respondents for the study. The population was stratified into nine (9) main homogeneous groups and because each stratum did not have the same number of students, proportionate sampling was employed to ensure that the number of elements in each stratum is determined in relation to the total population. Simple random sampling was then employed to select the respondents from the various strata in order to ensure representativeness of the various programmes under the selected classes.
2.5. Data Collection Instrument
Data was collected using an adapted Clinical Learning Environment Inventory (CLEI) questionnaire. Majority of the questions were closed-ended questions as they were easy to fill, save time and keep the respondents focused on the subject. The questionnaire was divided into sections in relation to the different variables involved. The questionnaire was made up of two parts. The first part was on personal data where students gave information about themselves. The second part was made up of close-ended questions on nursing student’s perceptions of their clinical learning environment. Face validity, was ensured by applying a superficial and subjective assessment of whether or not the questionnaire measured what it was supposed to measure. Content validity was ensured by making sure that the questionnaire actually measure what it was to measure. Thirty (30) nursing student were used to pre-test the questionnaire. The result of the pretest was used to modify, reconstruct and correct the questionnaire.
2.6. Data Collection Procedures
In order to have access to the sample and information that would reflect the general views and characteristics of the population, an extensive plan was required to provide direction for the data collection. Ahead of the data collection, copies of an introductory letter were obtained from the Department of Health, Physical Education & Recreation (HPER), University of Cape Coast, to the principals of Cape Coast nursing and midwifery training college and Ankaful Psychiatric nursing training college to seek permission for their students to be engaged for the research and also to create cooperation and rapport. The nursing students were met and the purpose of the study was explained to them. An appropriate time for the administration of the instruments was schedule.
2.7. Ethical Considerations
Introductory letter was sent to the school to seek for permission from the authorities. The procedure for this research was subjected to ethical considerations. The participants were informed about the study, its relevance and what they were expected to do. The respondents consented willingly before answering the questionnaire. They were informed about their right to interrupt the data collection process at any time or decline from the study without any fear of future prejudice. Individuals participating were not asked any personal identifiable information. All information given was treated as confidential.
2.8. Data Processing and Analysis
Descriptive and inferential statistics was used to analyse the data with the support of Statistical Product and Service Solution (SPSS) version 22. The results were presented in frequencies, percentages. Means and standard deviations were done and presented in tables.
3. Results
3.1. Background Information of the Respondents
From Table 1, majority of the respondents (n = 418; 84.3%) were females, between 18-22years (n = 229; 46.2%), Christians (n = 446; 93.3%), singled (n = 446; 89.9%), and attended CCNMTC (n = 294; 59.3%). Out of 496 student nurses, 214 (43.1%) of them were in third year (final year). However, the majority (n =
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Table 1. Demographic profile of student respondents.
395; 79.6%) of the nursing students never had prior professional qualification in nursing. About 235 (47.5%) of the student-nurses had their vocation clinical experiences in Central region.
3.2. Students’ Perception of Clinical Learning Environment
Concerning student-nurses’ perception on personalisation as clinical learning environment, majority of the student-nurses agreed that the nursing staff helped them when they were having problems with their work (M = 3.99; SD = 0.85). The students indicated that the nursing staff were friendly and considerate towards them (M = 3.62; SD = 1.29). However, the standard deviation score indicated that the student-nurses’ responses to the statement were widely dispersed from the mean score. They, similarly, revealed that the nursing staff go out of their way to help them (M = 3.55; SD = 1.15). However, the standard deviation score indicated that the student-nurses’ responses to the statement were widely dispersed from the mean score.
Concerning student-nurses’ perception on students’ involvement as clinical learning environment, majority of the respondents agreed that students had opportunity to be involved with the process of handing over to staff in the ward for the next shift (M = 3.64; SD = 1.42). However, they uncertainly believed that the nursing staff dominated the debriefing sessions (M = 3.30; SD = 1.08). They, also, indicated that there were opportunities for them to express their opinions in the wards (M = 3.14; SD = 1.34). Regarding student-nurses’ perception of students’ satisfaction of clinical learning environment, majority of the participants strongly enjoyed going to the ward (M = 4.12; SD = 1.03). They, also, agreed that they had a sense of satisfaction after their shifts (M = 3.55; SD = 1.25) and they were neutrally satisfied with what had been done in the ward (M = 3.04; SD = 1.42). With regards to student-nurses’ perception on task orientation as clinical learning environment, majority of the student-nurses agreed with the statement that workload allocations were carefully planned in the ward (M = 3.76; SD = 1.26). The student-nurses, also, revealed that ward assignments were clear that students knew what to do (M = 3.49; SD = 1.37). Similarly, they irresolutely agreed that the staff were often punctual to ward (M = 3.46; SD = 1.40). Pertaining to student-nurses’ perception on innovation as clinical learning environment, most of the student-nurses variedly agreed with the statement that students did the same type of tasks in every shift (M = 3.50; SD = 1.51). In addition, they neutrally believed that new and different ways of teaching were used in the ward (M = 3.20; SD = 1.30). They, also, indicated that teaching approaches in this ward were characterized by innovation and variety (M = 3.22; SD = 1.22). However, they variedly believed that the nursing staff never thought of interesting activities in the ward (M = 2.63; SD = 1.23). Finally, concerning student-nurses’ perception on individualisation as clinical learning environment, most of the student-nurses agreed with the statement that there was opportunity for them to pursue their particular interest in the ward (M = 3.66; SD = 1.29). However, they believed that teaching approaches used in the ward never allowed them to proceed at their own pace (M = 2.82; SD = 1.35). The student-nurses also revealed that they were not allowed to negotiate their work load in the ward (M = 2.82; SD = 1.35). Overall, student nurses had positive perception of clinical learning environment during clinical practice (M = 3.36; SD = 1.28). The results were presented in Table 2.
3.3. Students’ Perception of Staff-Student Relationships
Majority of the student-nurses divergently agreed with the statement that they had a good working relationship with the nursing staff (M = 4.03; SD = 1.01). Most of them dissimilarly indicated that the nursing staff focused on meeting their learning needs (M = 3.61; SD = 1.15). The student-nurses variedly revealed that the common meetings between themselves, supervising registered nurses and clinical instructors were comfortable (M = 3.56; SD = 1.17). They further diversely believed that the clinical instructor and the clinical team worked together in supporting their learning (M = 3.53; SD = 1.29). To the statement “mutual relationship and approval prevailed in the supervisory relationship”, most of the student-nurses agreed with the statement (M = 3.52; SD = 1.14). However, the standard deviation scores indicated that student-nurses’ responses concerning staff-student relationships were widely spread from the mean scores. Overall, student nurses had positive perception on the Staff-Student Relationship (M = 3.65; SD = 1.15). The results were presented in Table 3.
3.4. Difference in Student-Nurses’ Perception of Clinical Learning Environment Based on Region of Vacation Clinical Experience?
The data was analysed using One-way Anova. The descriptive statistics shows that students who had their vacation clinical experience in the Northern Region (M = 3.70; SD = 0.00) had high positive perception towards clinical learning environment. This was followed by students who had their vacation clinical experience in Ashanti Region (M = 3.49; SD = 0.49) and Eastern Region (M = 3.44; SD = 0.43) while students who had their vacation clinical experience in Western Region (M = 3.29; SD = 0.41) and Greater Accra Region (M = 3.27; SD = 0.37). The result is presented in Table 4.
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Table 2. Students’ perceptions of clinical learning environment.
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Table 3. Students’ perception on the staff-student relationship.
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Table 4. Difference in students’ perception of clinical learning environment based on region of vacation clinical experience.
4. Discussion
Out of 496 respondents, the majority were female. This disparity between the male and female nursing students’ population forms the basis of the existing trend in the nursing profession where females dominate the field. In the late 19th Century in America, women were unable to enroll in most colleges and universities [1] therefore the nursing education which was not done in institutions of higher education became their solution to having some skill. Even though this trend has changed and women now acquire any level of education nursing read in institutions of higher learning have females still dominating the field. Most of the student nurses attended CCNMTC. Within these two colleges, majority of the student nurses pursued Registered Mental Nursing (RMN). These results could help provide different perspectives on their clinical skills acquisition and clinical learning environment. Although the colleges used for the study were located in the Central Region, the students vacation clinical placements happened within the ten (10) regions of Ghana. The expectation was realized as majority of the student-nurses had their vocation clinical experience in the Central region. There is an indication that the hospitals chosen for clinical experiences were chosen also for convenience and not just based on the abilities of the hospital’s staff to impart knowledge. In clinical practice, many factors may affect students’ learning, these factors are listed as students related issues, clinical instructor related issues and clinical environment related issues. In order to plan an effective learning, it is essential to specify these factors and organize them in a way that will support the students’ learning [10]. It is obvious from the findings that most of the students agreed with the statements concerning their clinical learning environment except with a few statements. For example, concerning student-nurses’ perception on personalisation as clinical learning, majority of the student-nurses agreed that the nursing staff helped them when they were having problems with their work. The student-nurses, also, indicated that the nursing staff were friendly and considerate towards them. They, similarly, revealed that the nursing staff went out of their way to help them. These findings imply that most of the student-nurses had positive perception towards personalisation as clinical learning environment. Under this item it was again noticed that those who were unsure and those who disagreed were nursing students who largely had their clinical experiences outside the Central Region. This indicates that nurses from the Central Region Nursing Colleges were more likely to have helpful nurses who were willing to train them in hospitals within the Region. The environment should be favourable for students learning, and this should include a good student teacher relationship [11] [12]. The learner, the teacher and the method used also contribute to learning of students in the clinical area. Concerning student-nurses’ perception on students’ involvement as clinical learning environment, it was found that majority of the respondents agreed that students had opportunity to be involved with the process of handing over to staff in the ward for the next shift. However, they believed that the nursing staff dominated the debriefing sessions. Nursing Staff in such instances may assume that student nurses were not yet sufficiently informed about the running of the ward to play a major role in debriefing. They also indicated that there were opportunities for them to express their opinions in the wards. These finding means that most of student-nurses had positive perception towards student-involvement as clinical learning environment. However, the standard deviation scores indicated that student-nurses’ responses to student-involvement items or statements were widely spread from the mean scores. This explains that student-nurses had mixed views concerning their involvement as clinical learning environment. Regarding student-nurses’ perception on students’ satisfaction as clinical learning environment. These finding suggests that most of the student-nurses were satisfied with the clinical learning environment. Thus, they had positive perception towards students’ satisfaction as clinical learning environment, however, the standard deviation scores indicated that student-nurses’ responses concerning student-satisfaction statements were widely spread from the mean scores. This explains that student-nurses had diverse understanding concerning their satisfaction as clinical learning environment. These statistics shows that student nurses may have had expectations that may not have been met on the ward but still had a sense of satisfaction based on other factors or activities they enjoyed doing on the ward. In terms of student-nurses’ perception of task orientation as clinical learning environment, it was found that majority of the student-nurses agreed with the statement that workload allocations were carefully planned in the ward. The finding also revealed that ward assignments were clear that students knew what to do. This explains that student-nurses had different opinion concerning task orientation as clinical learning environment. Pertaining to student-nurses’ perception on innovation as clinical learning environment, it was found that most of the student-nurses variedly agreed with the statement that students did the same type of tasks in every shift. In addition, they neutrally believed that new and different ways of teaching were used in the ward. They also indicated that teaching approaches in this ward were characterized by innovation and variety. The teacher and the method used contributes to learning of students in the clinical area hence this admission of variation in the training methods, mean staff nurses and instructors were thoughtful and considered the plight of student nurses in the course of their clinical training [11]. This means nursing staff would need to be more innovative in impacting clinical knowledge to make the task appear to be changing. These results infer that most of the student-nurses had positive perception towards innovation practices as clinical learning environment. However, the standard deviation scores indicated that student-nurses’ responses concerning innovation statements were widely spread from the mean scores. This explains that student-nurses had unlike thoughts concerning innovation as clinical learning environment. Finally, concerning student-nurses’ perception on individualisation as clinical learning environment, it was found that most of the student-nurses agreed with the statement that there were opportunities for the student nurses to pursue their particular interest in the ward. However, they believed that teaching approaches used in the ward never allowed them to proceed at their own pace. This means that the teaching approaches used in the ward were lecturer-centered. The student-nurses also revealed that they were not allowed to negotiate their work load in the ward. This is equivalent to working under stress and may not allow the students to give off their best. This finding implies that most of the students had negative perception towards individualisation as clinical learning environment. This means that student-nurses had contrasting judgements concerning individualisation as clinical learning environment. This clinical learning environment created by the staff could positively engage the student-nurses during clinical sessions and in turn influence their clinical skills acquisition and academic performance. This finding of the study is consistent with the study of Papathanasior et al. [6] who found that there was a noticeable gap between the expectations and reality of the clinical learning environment for the students in nursing. Similarly, Bjørk et al. [12] found that students were fairly content with the learning environment during clinical placements in mental care, home care and nursing homes. The findings in this study also highlighted that students encountered inconsistencies when they were taught to do a skill differently in clinical practice to the skill procedure taught in the Clinical Skill Learning. Lack of time on the ward and staff being under stress with their workload resulted in missed learning opportunities, which hindered the students’ learning experiences in practice. The results of the study agrees with the study of Perli and Brugnolli [13] who found that Italian student nurses had positive perception of the clinical learning environment. There were significant differences between Hong kong nursing students’ perceptions of the actual clinical learning environment and the ideal clinical learning environment they desired [14]. Finnish nursing students feeling appreciated and supported in the clinical area, the quality of mentoring, patient care and the opportunity for self-directed learning as the elements of clinical learning environment [15]. However, Rahmani et al [1] found that students in Iran had a negative viewpoint about clinical learning environment. Majority of the student-nurses divergently agreed with the statement that they had a good working relationship with the nursing staff. Also, most of them dissimilarly indicated that the nursing staff focused on meeting their learning needs. The student-nurses variedly revealed that the common meetings between themselves, supervising registered nurse and clinical instructors were comfortable. They further diversely believed that the clinical instructor and the clinical team worked together in supporting their learning. To the statement “mutual relationship and approval prevailed in the supervisory relationship”, it was found that most of the student-nurses agreed with the statement. However, the standard deviation scores indicated that student-nurses’ responses concerning staff-student relationships were widely spread from the mean scores. This explains that student-nurses had contrasting judgments concerning staff-student relationships. The implication of these results is that, on average, the student-nurses agreed with the statements concerning staff-student relationships. Thus, the student-nurses had positive perception concerning staff-student relationships. Relationship is essential for maintaining student’s interest to the profession [16] and it is also essential for professional promotion of nursing students. In fact, the type of relationships can help make qualified clinical placement scenario [17]. Students, who experienced supportive relationships from their teachers, expressed high quality of education [16]. Building such relationships reduced anxiety, foster socialization, confidence and self-esteem. The results of the study confirmed the study of Papathanasior et al [6] who found that good supervisory relationships to be the key enabler of good learning experiences in the clinical setting. Similarly, Rani et al. [3] and Andrist [16] study revealed that positive staff-student relationships, a high commitment by the preceptors and good relationship with patients had effect on students clinical performance. Further, there was evidence of high satisfaction among students. Nurses are considered role models to student nurses, and the utilization of preceptors in the clinical learning environment enhances student nurse learning [18]. The results of the study were consistent with the study of Warne et al [19] who indicated the supervisory relationship was the single most important factor in the clinical learning environment that influenced the quality of their clinical learning experience. The study further found that respondent was mainly satisfied with their clinical placements. However, the results of the study was not in conformity with the study of Levett-Jones and Lathlean [20] who reported that nursing staff’s lack of receptiveness and approachability affected negatively their sense of belongingness and subsequently increased their anxiety, capacity and motivation to learn. One-way Anova was used to assess the differences in perception of clinical learning environment among students based on their academic class. The descriptive statistics showed that students in Year 1 (Level 100) had high positive perception towards clinical learning environment. However, the standard deviation scores indicated that year 2 (Level 200) student-nurses’ responses is more clustered to the mean score than those student-nurses in year 3 and 1 (Level 300 and 100).
5. Conclusion
In conclusions, it is observed that on average, most of the student-nurses agreed with the statements concerning clinical learning environments (personalisation, student-involvement, student satisfaction, tasks orientation, innovations and individualisation). Thus, they had positive perception towards personalisation, student-involvement, student satisfaction, tasks orientation, innovation as clinical learning environments except individualisation. Nursing students should be allowed to keep personal log book in addition to what is provided by their training institutions to ensure that they also learn at their own pace.
Consent for Publication
Not applicable.
Funding
Not applicable.
Acknowledgements
The authors would like to thank the respondents for their willingness to participate in the study. Without whose consent this research work would not have come into existence.
Our utmost gratitude also goes to the authors of the various publications used for this study.