Learning Environment

Clinical learning is an integral part of nursing education; yet, clinical education has been problematic. Why are some clinical experiences better than others? Various studies have indicated that not all practice settings are able to provide student nurses with a positive learning environment. The clinical learning environment is a multidimensional entity with a complex social context. Classroom learning environment research based on psychosocial educational conceptual frameworks has been well established in the past 30 years, with evidential benefits. Previous research on clinical learning environment was examined. However, minimal studies have been conducted on hospital learning environments from the psychosocial educational perspective. To maximize nursing students' clinical learning experiences, the author developed the Clinical Learning Environment Inventory based on the theoretical framework in psychosocial education. C linical education is a vital component in the curricula of nursing programs because it provides C student nurses with opportunities to develop competencies in nursing practice. The clinical learning environment is a multidimensional entity with a complex social context. Classroom learning environment Dr. Chan is Associate Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong. Address correspondence to Dominic Chan, RGN, RPN, BEd, MNSt, PhD, Associate Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong; e-mail: [email protected]. research based on psychosocial educational conceptual frameworks has been well established in the past 30 years, with evidential benefits. However, minimal studies have been conducted on clinical learning environments from the psychosocial educational perspective. Moos (1987) asserted that an understanding of social climate can provide insight into people's actions and feelings and can be a resource for helping people improve their lives. Identification of factors of the social climate that characterize a clinical learning environment could lead to strategies that foster those factors most predictive of student learning outcomes. This article highlights some important issues of the clinical learning environment and describes the development of an instrument (i.e., the Clinical Learning Environment Inventory), based on the theoretical framework in psychosocial education, to assess nursing students' perceptions of the clinical learning environment. A detailed description of the theoretical concepts underpinning the development of the instrument are provided. CLINICAL LEARNING ENVIRONMENT Nursing education occurs in many different settings and formats. As in most other tertiary disciplines, lecture, tutorial, workshop, seminar, and laboratory are the most common variations of classroom environments student nurses encounter. Clinical field placement is another essential part of the nursing curriculum because clinical education is vital to the curriculum of preregistration nursing courses. Clinical practice is a period of transition, which allows students to consolidate knowledge and practice skills acquired during fieldwork practice in a working situation. During clinical field placement, students are expected to develop competencies in the application of knowledge, skills, attitudes, and values inherent in the nursing profession. February 2002, Vol. 41, No. 2 69 CLINICAL LEARNING ENVIRONMENT INVENTORY Massarveh (1999) described the clinical setting as the clinical classroom. In contrast to classroom teaching, clinical education occurs in a complex social context where a teacher monitors clients', students', anid clinicians' needs. Unlike classroom learning in which student activities are structured, students in clinical classrooms frequently find themselves irvolved in unplanned activities with patients and other health care providers. It is not surprising that learning in the clinical area presents a bigger threat to students than learning in the classroom. Many nursing students perceive the clinical experience as anxiety provoking (Kushnir, 1986). Windsor (1987) suggested that student anxiety in the clinical setting is an area of concern for nurse educators. She argued that students' relationship with the instructor, staff nurses, other students, and patients is imrportant in their clinical experience, and asserted that these people help provide a pleasant working environment, as well as help students learn (Windsor, 1987). Nursing students frequently feel vulnerable in the clinical environment (Campbell, Larrivee, Field, Day, & Reutter, 1994). This may be because they are learning to provide care, but they also may be concerned with the reaction of nursing staff to their efforts. Melia (1987) suggested that student nurses have difficulty differentiating their roles of learner and worker. Inevitably, student nurses are thrust into the clinical area as short-term members of the patient care team. Therefore, their position is anomalous, and their motive for involvement in patient care usually is different from that of permanent employees (Ashworth & Morrison, 1989). Clinical experiences require difficult adjustments for students as they move from an environment that encourages thinking to an environment that encourages doing. Knowles (1990) indicated that a supportive learning climate is a critical element of human resource development. He asserted that there is a need for both direct and indirect facilitation of the development of individuals through improving the educative -quality of their e-nvironments. Similarly, Betz (1985) stated that supportive aspects, in an optimum clinical placement, would include experiences to strengthen students' independent professional growth and encourage peer-level interactions with other health care professionals. Hart. and Rotem (1995) further substantiated Betz's (1985) suggestions and identified six independent variables that characterize clinical learning environments. These independent variables are autonomy and recognition, role clarity, job satisfaction, quality of supervision, peer support, and opportunity for learnir.g. Nursing students perceive the practice setting as the most influential context for acquiring nursing skills and knowledge. Clinical placement provides students with optimal opportunities to observe role models, practice by oneself, and reflect on what is seen, heard, sensed, and done (Thorell-Ekstrand & Bjorvell, 1995). Furthermore, the professional socialization of nurse learners occurs largely in the practice setting (Lee & French, 1997; Windsor, 1987). Overall, the clinical learning environment is a multidimensional entity that directly affects the outcomes of students' clinical placement. RESEARCH INVOLVING THE HOSPITAL LEARNING ENVIRONMENT The evaluation of clinical teaching and learning has been of interest for many years. Of particular concern is the perceived demiand for high-quality, cost-effective clinical education experiences that facilitate student learning in the clinical environment. The clinical learning environment is the interactive network of forces within the clinical setting that influence students' learning outcomes. Central to many studies of nursing in the clinical setting is the concept of ward learning environments. The related concept of learning climate also emphasizes the importance of the physical, human, interpersonal, and organizational properties and mutual respect and trust among teachers and studlents (Knowles, 1990). Of the 15 highest priorities for nursing research identified by Tanner and Lindeman (1987), 10 focused on clinical education. Previous studies suggest the nurse manager of a clinical unit plays a key role in establishing and maintaining an atmosphere conducive to learning. Nursing students perceived that the management style and interpersonal skills, including approachability, of clinicians are of prime importance and that the provision of learning opportunities is more important than formal teaching (Ogier, 1981; Sellek, 1982; Smith, 1988). It is apparent that highly structured clinical settings with rigid task allocation and strict hierarchical systems are unlikely to meet the learning needs of students (Fretwell, 1980; Pembrey, 1980). Students prefer clinical settings with a high degree of staff support and morale (Orton, 1981). Moreover, students see interpersonal relationships and evaluation processes as significant sources of both satisfaction and anxiety, depending on whether these elements are positive or negative (Seliek, 1982). In a qualitative study, Hart and Rotem (1994) found that students valued positive relationships with clumicians and appreciated recognition for their contribution to patient care. Students' need to belong and be accepted by the clinicians was a common theme. Students enjoyed being busy and having an appropriate level of autonomy but found this difficult to achieve unless their role as student was clear to members of th.e clinical staff. In a survey study to ident.ify nurses' perceptions of professional development in clinical settings, Hart and Rotem (1995) identified a significant positive correlation between professional development and six independent variables (i.e., autonomy and recognition, role clarity, job satisfaction, quality of supervision, peer support, opportunities for learning). Although Hart and Rotem's (1995) study targeted RNs, the conceptual framnework may have broad application within nursing practice as a means of predicting professional development. Most important, the study offers a perspective that supports close cooperation Journal of Nursing Education 70