Challenging clinical learning environments: Experiences of undergraduate nursing students

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Abstract

Clinical learning is an essential component of becoming a nurse. However at times, students report experiencing challenging clinical learning environments (CCLE), raising questions regarding the nature of a challenging clinical learning environment, its impact on students' learning and how students might respond within a CCLE. Using an Interpretive Descriptive study design, researchers held focus groups with 54 students from two Canadian sites, who self-identified as having experienced a CCLE. Students defined a CCLE as affected by relationships in the clinical area and by the context of their learning experiences. CCLE decreased students' learning opportunities and impacted on them as persons. As students determined which relationships were challenging, they tapped other resources and they used strategies to rebuilt, reframe, redirect and/or retreat relative to the specific challenge. Relationships also acted as buffers to unsupportive practice cultures. Implications for practice and research are addressed.

Introduction

Effective clinical nursing education is critical to prepare nurses for their practice-based profession. It provides essential opportunities for students to integrate theoretical nursing knowledge into nursing care, build clinical judgment, and develop a professional identity. The clinical environment within which nursing education occurs is dynamic and encompasses complex variables which may influence students' learning experiences (Campbell et al., 1994, Papp et al., 2003, Wilson, 1994). In this paper we will examine a challenging clinical learning environment from a student perspective.

Research exploring the relationship between students' learning experiences and the clinical learning environment [CLE] describes student perceptions of CLEs that are ‘supportive’ (Chan, 2002a, Henderson et al., 2006), ‘pleasant’ (Windsor, 1987), and ‘good’ (Papp et al., 2003), contrasted with less favourable environments deemed ‘nonsupportive’ (Dunn and Hansford, 1997, Hartigan-Rogers et al., 2007). In the literature on clinical learning environments, the quality of students' relationships with clinical faculty (Cook, 2005, Gillespie, 2002, Gillespie, 2005), and staff nurses (Chesser-Smyth, 2005, Henderson et al., 2006) significantly impact students' perception of the CLE by rendering experiences challenging when clinical faculty and staff nurses are not supportive.

Elements of nursing unit culture and practice positively influence students' perceptions of the CLE: teamwork and good staff morale (Lofmark and Wikblad, 2001), positive staff attitude toward patient care, quality patient-centered care, (Dunn and Hansford, 1997, Robinson et al., 2006) and access to positive role models (Hart and Rotem, 1994). In contrast, rigid, hierarchical environments (Chan, 2002b), lack of nursing practice guidelines (Lofmark and Wikblad, 2001), and lack of awareness of students' learning needs (Dunn and Hansford, 1997) contribute to an unsupportive CLE.

Researchers have used inventories as quantitative tools to study students' perceptions of CLEs (Chan, 2002a, Saarikoski and Leino-Kilpi, 2002, Smedley and Morey, 2010). Inventories generate standardized and comparable data, however, they are limited to the extent by which they can capture the complex, dynamic and relational nature of the CLE.

Authors indicate that unsupportive CLEs negatively impact students' learning, yet scant attention has been given to explicit examination of challenging clinical learning environments (CCLE). In two studies exploring clinical faculty perceptions of their roles (O’Mara et al., 2004, O’Mara et al., 2006), CCLE emerged as an important determinant. Faculty identified CCLEs as characterized by unwelcoming nursing staff, clinical faculty's lack of expertise in the clinical area, or a lack of fit between students' abilities and patient acuity. The research by O'Mara et al. (2006) raised questions about the experiences of students in a CCLE such as whether their perceptions of a CCLE mirror those identified by faculty, or do students perceive different aspects of a CLE as challenging? Further, with discrete exceptions (Dunn and Hansford, 1997), students' responses to unsupportive CLEs are largely absent from reported findings. Thus, a research study was proposed to explore students' perceptions of challenging clinical learning environments, their responses within CCLEs, and the impact of a CCLE on their learning experiences.

Section snippets

Purpose

The purpose of this study was to explore students' perceptions of a CCLE. The research questions included: (1) How do students define a challenging clinical learning environment? (2) How do students perceive the impact of a CCLE on their learning? and (3) How do students respond to a CCLE?

Study design and ethics

A qualitative study design using an Interpretive Descriptive method (Thorne et al., 1997) was used. This design is suited to nursing practice research and emphasizes inclusion of existing knowledge in an

Findings

The conceptual model (Fig. 1) represents students' perceptions of a CCLE and provides insight to the three research questions. Students' clinical learning experiences occur within a multidimensional context that is shaped by the nursing unit, nursing program and curriculum. Students experience challenges that arise from their relationships with others in the CLE, particularly clinical faculty and staff nurses, and from the larger practice context. Students identify the impact of these

Defining the CCLE: relationships and context matter

The study findings extend knowledge about how students define a CCLE. Although it is well established that relationships in the CLE are fundamental to clinical learning in both a positive and negative sense (Chesser-Smyth, 2005, Dunn and Hansford, 1997, Gillespie, 2002, Gillespie, 2005, Hartigan-Rogers et al., 2007), our findings suggest that positive relationships also act as buffers to unsupportive practice cultures, and negative clinical unit cultures and relationships. As students

Implications

In the past two decades of research in nursing education, authors espouse a humanistic orientation to teaching and learning. Caring connections between students and teachers are critical for students' success (Gillespie, 2002, Gillespie, 2005). Despite this, clinical learning is fraught with complexities that persist despite ‘caring’ intentions. Clinical faculty cannot ensure that students never have negative experiences; however, they can facilitate students' capacities in reflection and to

Conclusion

Clinical learning remains crucial to nursing education. Our findings emphasize the importance of listening to students, attending to how relationships and contexts impact learning, and of supporting clinical faculty to create positive clinical environments. Clinical faculty play an essential role in creating positive environments where students can tap their resilience and develop strategies to learn in spite of the difficulties and complexities inherent in clinical learning.

Acknowledgements

Students who participated and Professor Barbara Carpio (retired) for her assistance with initial study design, ethics approval and data collection. This study was funded by a Centre for Leadership and Learning grant at McMaster University and also by an Internal grant, School of Nursing UBC.

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