INTRODUCTION
Internationally, pre-registration nursing programmes provide different curriculum structures, theoretical and clinical content, and time allocations to facilitate students’ learning (Deng, 2015). In the majority of countries, the regulatory authority has the control and authority to approve these pre-registration programmes (National Council of State Boards of Nursing, 2020). In Aotearoa New Zealand, all pre-registration nursing education programmes must be accredited and approved by the regulatory authority, the Nursing Council of New Zealand (NCNZ). As well as meeting Te Tiriti o Waitangi obligations, each educational provider must develop the nursing curriculum in consultation with local stakeholders and must meet all the NCNZ specified education standards (NCNZ, 2021). These standards include minimum time frames and supportive measures that must be provided to ensure optimal learning experiences.
Student learning in clinical practice is an essential component of becoming a competent registered nurse (Chen et al., 2020; Jayasekara et al., 2018). In an undergraduate Bachelor of Nursing degree in Aotearoa New Zealand the clinical learning experiences for students occur across a range of public, private and non-government health organisations. The clinical placements for each pre-registration undergraduate student must include acute care, aged care, community health, disability, te ao Māori, and a mental health setting (NCNZ, 2021). The number of hours of clinical practice learning is currently sitting at a minimum of 1100 hours across the three-year degree (NCNZ, 2021).
Impact of the covid-19 pandemic on the nursing workforce
Covid-19 became a global pandemic in 2020, with New Zealand shutting its international borders on the 19th March 2020 and going into a nationwide lockdown a week later, the 26th March (Baker et al., 2020). Hospitals and other health providers were deemed essential workers, with nursing management from the clinical providers and tertiary providers working together to ensure clinical placements were continued where possible. The clinical areas that were most reluctant to accommodate student nurses were in the continuing care placement in aged residential care in year one, and the community placements in year three.
International research including studies in Ireland (Magner et al., 2021), Australia (Hill et al., 2022), China (Wang et al., 2021) and Germany (Jerg-Bretzke et al., 2021) found that health care workers reported more occupational stress, emotional distress, and concern around exposure to covid-19 and concern regarding transmitting the disease to patients and colleagues. Magner et al. (2021) discuss the demands on health care workers who witnessed increased patient deaths, and were exposed to increased workload and questionable practice, with Hill et al. (2022) discussing health care workers being asked to either disregard precautions or being asked to work with inadequate personal protection equipment (PPE). These working conditions may lead to increased stress and pressure, resulting in fatigue and burnout. Research in Aotearoa New Zealand includes that by Cook et al. (2021) where nurses reported feeling vulnerable to contracting covid-19 due to inadequate availability of personal protection equipment (PPE) alongside having to re-evaluate how they were performing their nursing tasks. Common themes amongst these nurses were the anxiety or apprehension around spreading the virus within the community. Alongside this anxiety, nurses reported dissatisfaction with nursing leadership during the early stages of the pandemic. New Zealand government supported a call to nurses who had expired or inactive practicing certificates to return to the workforce, many staffing vaccination clinics and involved with contact tracing Popoola (2021).
Increased demand on the nursing workforce during the covid -19 pandemic, with reports of increased stress and burnout may have a detrimental effect on student nurses working in these clinical areas. Registered Nurses being too busy or too stressed to provide effective precepting, with less time and energy to put into ensuring students receive appropriate learning opportunities may impact negatively on the student’s perception of the clinical placement. Some nursing students were reporting to nursing lecturers increased incidences of perceived stress on the nursing workforce and some incidences where nursing students reported times when registered nurses treated them unkindly, seemed disinterested in precepting students and in some instances, students reported feeling unsafe in the clinical environment. These informal discussions with nursing students, and my awareness of the increased stress in the clinical environment, led to the assumption that students were perceiving their clinical placements more negatively then pre covid-19 times.
It is important to evaluate the students’ experiences of their clinical learning in order to leverage successful experiences and prevent negative learning experiences which might undermine confidence and commitment to their programme of study. This evaluation is therefore important as a quality assurance tool (Ramsbotham et al., 2019) and also a planning mechanism. The aim of this evaluation was to determine undergraduate nursing students’ perceptions of their clinical placements and the impact covid-19 may have had on their experiences. Results can contribute to ongoing delivery of nursing education that prepares new graduates for a fulfilling career in nursing, as well as emphasising the need for, and value of, clinical placements in any future pandemic or similar public health crisis.
METHODS
This evaluation involved a retrospective, cross-sectional and descriptive design. Retrospective data collected over five and a half years, from 2017 to mid-2022, were analysed to identify nursing students’ perceptions of their clinical placements. The data was collected utilising an online survey using the ‘Clinical Learning Environment, Supervision and Nurse Teacher Scale’ (CLES+T scale) tool.
Participants
The online survey was offered to all BN students who completed the clinical courses across the three years of the programme between 2017 and 2022. Some students therefore were offered this survey multiple times (up to five). The number of surveys completed was 2,012 creating a response rate of 36%.
Prior to completing the CLES+T scale, students provided consent on the online survey to share their perceptions with the clinical placements and clinical lecturers, and to use their data for research related to clinical learning environments (Supplementary file: S1). Data was extracted and condensed and anonymised and shared with the clinical lecturer as part of annual performance reviews. Qualitative data was used to discuss concerns in the clinical placement with stakeholders.
Data collection
CLES+T Scale
The CLES+T scale is a tool commonly used by nurse education providers in this country and overseas to measure students’ perceptions of their clinical learning experiences. The scale evaluates the learning environment, clinical supervision and the pedagogical dimension of the nurse teacher (Saarikoski et al., 2008). The CLES+T scale has been used internationally in published studies to assess students’ perceptions of their clinical placement (Al-Anazi et al., 2019; Bisholt et al., 2014; Bos et al., 2015; Carlson & Idvall, 2014; Dimitriadou et al., 2015; Doyle et al., 2017; D’Souza et al., 2015; Gurková et al., 2018; Johannessen et al., 2021; Magnani et al., 2014; Manninen et al., 2022). Ara utilises the Finnish version of the CLES+T scale with minor changes to the original wording for the Aotearoa New Zealand context, for example, replacing the word “ward” with “placement”, and the word “mentor” with “supervisor”. This scale has been shown to have ‘good’ internal reliability and validity for use within hospital settings, for educators, clinical staff and researchers to monitor student nurses’ perceptions of the quality of their clinical placements (Watson et al., 2014).
Ara added an extra question to the CLES+T scale (question 35), to reflect Te Tiriti o Waitangi and the commitment to cultural safety of nurses in Aotearoa New Zealand. The additional question asks students to respond to the following statement: “I felt my own cultural perspective was acknowledged and valued in the placement”. This additional question recognises the multicultural demographic of nursing students.
The CLES+T scale consists of five sub dimensions: the role of the nurse teacher, pedagogical atmosphere, the supervisory relationship, leadership style of the ward manager, and nursing care on the ward (Saarikoski et al., 2008). Each sub dimension has between four and nine questions (Supplementary file: S2) that students rated on a five-point Likert scale; “fully agree”, “agree to some extent”, “neither agree nor disagree”, “disagree to some extent”, “fully disagree”, with five being fully agree and one being fully disagree.
Procedure
Pre-recorded survey data (2017 – mid 2022) from 2,012 Bachelor of Nursing students were sourced from the nursing school’s administrator. Qualtrics software was used to develop the online survey and collect all the data. Data included that collected from students who had completed the online survey following one of five clinical placements: aged-care, mental health, medical/surgery, community, or transition placement (chosen from the previous four options). Clinical placement data was collected for three years prior to the covid-19 pandemic (2017, 2018, 2019) and two and a half years during the pandemic (2020, 2021 and half of 2022).
Data analysis
The dataset obtained from the Qualtrics website was downloaded as a Microsoft Excel spreadsheet and the data were cleaned where incomplete data sets existed, and any other outlier data was removed. As the researcher was a staff member of the academic institution where the data was collected, care was taken to ensure all data was anonymised by removing entire columns of data which contained any identifiers. An independent statistician was recruited to conduct the data analysis. The data was initially transferred to the Statistical Analysis System v 9.4 (SAS Institute; Cary, NC, USA) for analysis. The data was then visually checked for outliers and inaccurate data, by investigating the distribution and probability plots. Means and standard deviations along with frequencies and percentages were calculated for the various dependent variables (that is, the five sub dimensions of the CLES+T questionnaire including pedagogical atmosphere on the ward, supervisory relationship, leadership style of ward managers, premises of nursing care, and the role of the nurse teacher).
Comparisons between groups (clinical placements of continuing care, mental health, medical/surgery, community health, or transition) and covid – 19 time points (prior to 2020 and after 2020) were analysed using analysis of variance (ANOVA). There were no substantial changes found between covid - 19 time points, therefore the data was pooled and the differences between the five sub dimensions between the various clinical groups were analysed. A type I error of 5% was chosen for declaration of statistical significance; precision of estimates was represented by the 95% confidence limits.
RESULTS
Bachelor of Nursing students scored their clinical experiences very positively, with an overall mean of 4.5 +/- 0.5. The covid-19 pandemic appeared to have minimal impact on student experiences of clinical placement. The student perceptions of the supervisory relationship (p=0.0383) and in the nurse teacher (p=0.0291) sub dimensions were higher in the years during the covid-19 pandemic than in the years pre-covid – 19 for the medical surgical placements. In contrast, the community placement scored lower during covid-19 in the nurse teacher sub dimension (p=0.0032). All other variables did not reach statistical significance; therefore, it was concluded that the student perceptions of clinical experience were minimally impacted by the covid-19 pandemic.
Data was therefore pooled to determine which clinical learning environment was perceived by nursing students to provide the best learning experiences, relating to clinical placement area and sub dimension of the CLES+T scale. Students perceived the transition placement, completed at the end of their three-year degree, to provide a more positive experience compared to the other four clinical areas (Table 1).
Several sets of results were statistically significant across the different sub dimensions of the CLES+T scale. Transition placement scored higher across the majority of sub dimensions versus all other clinical areas. Transition versus the continuing care placement and the medical surgical placements showed statistical significance (p<0.05) in all sub dimensions. Transition versus mental health placement scored higher (p<0.05) in pedagogical atmosphere, the role of the ward manager and nursing care on the ward. Transition versus the community placement scored higher with p<0.05 in all but the supervisory relationship. Other results from the other clinical areas also showed statistical significance but were not consistent across the sub dimensions of the CLES+T scale. Several factors must be considered when discussing statistical significance. The large sample size of N=2,012 data sets for this evaluation may affect the results around statistical significance, therefore the effect size and practical significance were considered.
The effect size was calculated using the magnitude-based decision method proposed by Hopkins (Hopkins, 2020). The difference between the means for different clinical areas was entered into the spreadsheet with the p value and the threshold value calculated for each set of results. The results are presented as a percentage indicating the likelihood of this effect being “likely positive”, “trivial”, or “likely negative”. Only the data that showed a statistically significant difference (p<0.05) on comparison of clinical areas had an effect size calculated. Out of the 28 sets of data which were statistically significant, all had a trivial likelihood (98-100%) of being practically significant. Overall, this shows that although some results were statistically significant, it is likely there is no meaningful difference between the student perception of different clinical experiences.
Overwhelmingly, students scored the clinical learning environment positively, with means ranging from 3.99 to 4.83, indicating that across the different sub dimensions of the CLES+T scale students received a satisfactory clinical learning experience. However, there were trends showing individual questions within the CLES+T scale which scored lowest and highest across the different sub dimensions. Some examples of higher scoring questions were “mutual respect and approval prevailed in the supervisory relationship”, “there were significant meaningful learning situations on the placement” and “in my opinion the nurse teacher was capable of integrating theoretical knowledge and the everyday practice of nursing”; whereas the questions “I continuously received feedback from my supervisor”, “the staff were generally interested in student supervision” and “the placements’ nursing philosophy was clearly defined” were the lowest scoring. However, neither extreme was deemed to be statistically significant.
DISCUSSION
The aim of this evaluation was to identify whether the Covid-19 pandemic had an impact on student nurses’ perceptions of their clinical experience during this time, as well as to see which clinical area the students perceived to provide the best learning experiences. This developed from anecdotal conversations with students who were expressing their displeasure with how they were being treated in the clinical areas and thought that the learning experiences had changed with the introduction of new clinical placements, as well as students seeming to prefer more acute clinical settings over less acute areas.
Internationally, research has shown that applications for the BN degree increased immediately post the initial stages of the pandemic, however concern was raised about attrition rates also increasing, in Australia the attrition rate was 17% and, in the UK, as high as 33% (Henshall et al., 2023). These higher than usual non completion rates may have been related to students observing poor staffing levels, and working alongside RN’s who were experiencing increased work pressure, leading to higher reporting of stress and depression amongst RN’s (Henshall et al., 2023). Rohde et al. (2023) believed that student nurses may have felt vulnerable during the outbreak, calling into question their resilience due to isolation and loneliness, with 70% of these students reporting concerns related to the quality of their education.
Thomson et al. (2021) discuss the role of student nurses in the early stages of the pandemic as being non-essential workers with some clinical experiences not able to go ahead. Ara introduced new clinical placements in the later stages of the covid-19 impacted times in managed isolation and quarantine facilities (MIQF) and telehealth placements for students in their community and transition semesters, as well as having new aged residential care facilities offering a clinical experience over this time. The stigma nurses faced working in MIQF has been documented by Jamieson et al. (2021), debriefing with student nurses who were placed in MIQF follows the same feedback from the RN’s. The main concerns expressed to clinical lecturers at this time was around public perception, which was compounded with some negative media reporting at the time. Of note, nursing leaders within the Canterbury District Health Board (now Te Whatu Ora – Waitaha Canterbury) were proactive in working with academic leaders at Ara to create new learning opportunities for nursing students. Ara also had changes in staffing over this time, where new lecturers were offering academic support for the first time, with support from senior staff where possible. However, quantitative survey data made it clear that despite a handful of negative comments, overall, the pandemic did not impact on the students’ perceptions of their clinical placement. This finding is reassuring for clinical and academic management, and suggestive that students with an unsatisfactory placement experience were in the minority.
On comparison of the different clinical areas, students scored their clinical experiences in their transition placement options at the end of their final year of study the highest, and there was statistical but not practical significance with these results. This finding may be due to multiple factors, including readiness to practice due to being in their final semester of study, and being in a clinical setting where they have had some choice in where they have been placed. Gonzalez-Garcia et al. (2021) believe that the longer the clinical placement the more satisfaction is reported with the learning environment, which correlates with this transition placement being a minimum of 360 hours as sanctioned by NCNZ. These results allow academic managers to feel confident that all the clinical learning environments are offering high quality learning opportunities appropriate to the learning needs of the students.
Significance of the evaluation
This evaluation shows that overall, the students who are responding to the survey are scoring their clinical experiences positively, however the minority of respondents who scored a 1 on the Likert scale 1 (1.13% of the responses) should not be ignored. There was no statistical difference between students’ responses pre and during the covid-19 pandemic. This is a positive outcome and may reflect any extra effort taken by nurse managers, lecturers and clinicians to minimise any impact on students’ experiences. Although there was statistical significance when comparing the clinical areas, the effect sizes were small enough to show no practical significance.
An ideal aim for academic institutions is for all students to have a positive experience while on clinical placement, as research shows how important the clinical experience is for students’ overall satisfaction. Anyango et al. (2024) discuss the influence clinical placements have on supporting students to link theory to practice and to experience different clinical environments to guide students’ decision making on where they may like to seek employment. Exposure to negative experiences while on clinical placement coupled with poor learning opportunities may influence overall outcomes for the student (Fadana & Vember, 2021) and may discourage the student from pursuing a particular branch of nursing in their future. The finding that there is no clinical significance between the perceptions of different clinical areas is important to remind students about, especially if they express concerns about a clinical area. The data can be used to reassure students that their peers have deemed learning opportunities to be positive across all five clinical areas and within the five sub dimensions.
Recommendations for practice
Paying attention to the sub dimensions which scored lowest across the different clinical areas shows the nursing managers where to focus their attention to increase student perceptions, and to further explore why these may have lower scores. The continuing care placements in the aged care sector were scored lower over the five different sub dimensions. Meeting with students after their continuing care placement to gain an understanding of why this is the case would be beneficial.
Clinical placements that occurred during the Covid-19 times, students perceived the supervisory relationship with the clinical staff and the relationships with the academic team (nurse-teacher sub dimension) higher then pre Covid-19 times, especially in the medical – surgical areas. This may be due to the resilience of nursing staff and nursing management should be applauded for ensuring their nurses were able to continue to mentor nursing students positively during this stressful time.
Even though students scored their experiences positively overall, the three questions which scored lowest “I continuously received feedback from my supervisor”, “the staff were generally interested in student supervision” and “the placements’ nursing philosophy was clearly defined”. Nursing management from both sectors have a responsibility to react to this feedback and make the necessary changes. Nursing students are valued members of the health care team (Rosaria et al., 2023) and contribute by assisting with workload, bringing new ideas and best practice into the clinical area, along with energy and enthusiasm for nursing. Consideration to a robust orientation programme where the clinical areas nursing philosophy is clearly defined, discussions with nursing staff as to the importance of making students feel welcome and wanted, as well as encouraging nursing staff to give both positive and constructive feedback in a timely manner to students would all address these concerns. More regular meetings with clinical lecturers and preceptors to discuss student progress would help nurses with the expectations that are expected of them.
Transition placement versus the continuing care placement and the medical surgical placements showed statistical significance (p<0.05) in all sub dimensions showing students perceived this final placement more highly then their first placement in the aged residential care sector. Nursing schools have a responsibility to ensure all clinical areas are portrayed positively to nursing students. Providing testimonials from new graduate registered nurses working in all clinical areas, as well as having nurse managers from these areas provide students with reassurance around job security for example may improve students views of these areas. Some students in the continuing care clinical areas work alongside health care assistants who are under the supervision of registered nurses, for their whole shift. Having access to clinical handovers, doctors rounds and one on one time with Registered Nurses may encourage student nurses to be more excited about the continuing care environment. This would involve both clinical and academic managers to work together to ensure expectations are being met. Meeting with students after completion of the clinical placement to help students make sense of the learning, make links from theory to practice and to recognise the complexities of the clinical areas may help increase perception of this area. Many student nurses in Aotearoa New Zealand work as health care assistants during their studies, it is important that when they are on clinical placement, they are learning skills and increasing knowledge above what they already are doing as health care assistants.
Recommendations for future research
Opportunities for future research include qualitative research in smaller groups, with the potential to follow one cohort through their Bachelor of Nursing programme and compare the responses over the course of their degree. Although this evaluation focussed on the quantitative aspect of the CLES+T scale, the survey sent to the students also included a free text question to allow them to provide additional feedback. This allowance suggests a further opportunity to mine the existing data for additional insights, as if students know their concerns are being addressed, they are more likely to respond in the future. A final recommendation is that consideration should be given to finding an alternative evaluation tool and conducting a comparative study. Several tools have been identified to evaluate the quality of the clinical learning environment (Mansutti et al., 2017). The CLES+T scale has many strengths; however, the length of the survey and ambiguity of the questions may be a deterrent to some students.
CONCLUSION
Bachelor of Nursing students’ clinical experiences are impacted by many factors. However, the covid-19 global pandemic did not negatively impact the students’ perceptions of their clinical placement during the two and a half years of the pandemic, despite earlier anecdotal indicators that this may have been the case. There was no practical significance found between the different clinical areas, although the transition clinical experience did score more highly than the other clinical areas across the majority of sub dimensions of the CLES+T scale. Essentially, this evaluation has shown that in times of challenge, health educators need to adapt as necessary to ensure planned delivery can proceed, and to remain focused on the value of clinical placements. It is a reminder, too, that quantifiable data is important to counteract claims which may only represent minority interests. Clinical placements remain an essential component in all undergraduate nursing curricula.
Acknowledgement
Thanks to all participants who contributed to this evaluation.
Funding
None
Conflict of interest
None