Survey
General characteristics of participants
Three-quarters of the participants were within the age group between 20-25 years old. The proportion of females was slightly higher than males (54% compared to 46%). More than three quarters of the participants were nurse-midwife technician students pursuing a college diploma in Nursing and Midwifery. More than half of the participants (57%) were in the third year of study (see Table 1).
Table 1: General characteristics of the study participants (N=126)
Variable
|
n (%)
|
Age
≤20
20-25
≥25
|
4 (3)
96 (76)
26 (21)
|
Sex
Female
Male
|
68 (54)
58 (46)
|
Program of study
BSc Nursing & Midwifery
Nurse Midwife Technician
|
15 (12)
111 (88)
|
Year of study
Second
Third
Fourth
Missing
|
39 (31)
72 (57)
14 (11)
1 (1)
|
Clinical placement
Central hospital
District hospital
Others
Missing
|
44 (35)
54 (43)
25 (20)
3 (2)
|
Recent clinical Placement*
Medical
Surgical
Labour and delivery
Postnatal
Antenatal
Paediatric
Family planning
Under 5 clinic
Theatre
Missing
|
10 (8)
13 (10)
29 (23)
10 (8)
11 (9)
32 (25)
3 (2)
2 (2)
7(6)
9 (7)
|
Length of current clinical placement
<3weeks
3-8weeks
>8weeks
Missing
|
14 (11)
77 (61)
31 (25)
4 (3)
|
The scores among the participants ranged from 97 to 164 (Mean [M] 131, Standard deviation [SD] = 13.28). Satisfaction subscale had the highest mean score (M = 26.93, SD = 4.82), followed by Personalisation (M= 23.27, SD=4.02) while Individualisation had the lowest mean score (M = 18.01, SD =3.50) (see Table 2). There was no significant difference between the total score of subscales score with age, gender, students study program and students’ institution.
We used Satisfaction subscale as the outcome measure, with the other subscales as explanatory variables. Students’ satisfaction with the clinical learning environment was positively correlated with all the other subscales. Pearson correlation coefficient ranged from 0.20 (Individualisation subscale, p = < 0.05) to 0.54 (Personalisation subscale, p = < 0.001) See Table 3.
Table 2: Mean scores of Total and subscales of CLEI Actual form (N=126)
CLEI Scale
|
Mean ± SD
|
Range
|
Minimum
|
Maximum
|
CLEI total scale
|
131.29 ± 13.28
|
67
|
97
|
164
|
Satisfaction
|
26.93 ± 4.82
|
25
|
9
|
34
|
Personalization
|
23.27 ± 4.02
|
20
|
12
|
32
|
Student involvement
|
22.67 ± 3.04
|
22
|
12
|
34
|
Task orientation
|
21.73 ± 3.52
|
18
|
13
|
31
|
Innovation
|
18.68 ± 2.89
|
16
|
12
|
28
|
Individualization
|
18.01 ± 3.50
|
20
|
7
|
27
|
Table 3: Correlation between satisfaction subscale and other subscales of the CLEI Actual form
CLEI Subscales
|
R
|
p value
|
Personalization
|
0.54
|
0.000
|
Student involvement
|
0.23
|
0.005
|
Task orientation
|
0.30
|
0.000
|
Innovation
|
0.27
|
0.001
|
Individualization
|
0.20
|
0.014
|
Authors of clinical learning environment research who have used Fraser’s social-psychological conceptual framework [30] have found a relationship between satisfaction subscale scale and other CLEI subscales [31-33]. We, therefore, conducted multiple linear regression analysis to assess the association between satisfaction with clinical learning as a dependent variable and other psychosocial characteristics of CLEI (subscales) as independent variables. The findings of the multivariate analysis showed statistically significant association between Satisfaction with clinical learning environment and Personalization (β = 0.50, p = < 0.001) and Task orientation (β =0.16 p= < 0.05). The two variables retained in the model explain 31% of the variability of the student satisfaction with their clinical learning environment (See Table 4).
Table 4: Multiple linear regression with Satisfaction as a dependent variable and other subscales of the Actual CLEI scale as independent variables
Independent variables
|
Beta
(95% confidence interval)
|
p Value
|
R2
|
F
|
Personalization
|
0.50 ( 0.41-0.78)
|
0.000
|
0.31
|
28.35
|
Task orientation
|
0.16 (0.12-0.43)
|
0.038
|
|
|
Focus group discussion
Three focus groups were conducted with 30 nursing students (one focus group per training institution). Each focus group had 10 participants. Participants in the focus group discussion were conveniently drawn from those who responded to the survey questionnaire. Three main themes emerged for the data. These included: 1) Clinical teaching and supervision; 2) Working relationship and support; and 3) Teaching and learning resources.
Clinical teaching and supervision
There was a great discussion related to lack of clinical teaching and supervision among participants. This discussion mainly focused on the following areas 1) student accompaniment in the clinical area, 2) assessment and feedback, and 3) integration of theory into practice.
Student accompaniment in the clinical area
Students in this study indicated that they were left alone in the clinical area most of the times, without any guidance and supervision. Many participants in all the three focus groups reported that they wished their lecturers and their clinical instructors accompanied them to the clinical area and stayed with them for the first week to orient them to the ward routines. One student reported:
“I think teachers must be around for a week or so when we are just beginning the clinical allocation to orient us. Let’s say we are doing labour and delivery for 4 weeks, if they can come twice during the allocation that can be better than not coming at all”.
Some students indicated that the presence of a clinical instructor or lecturer facilitated their learning as they were free to ask questions and learn different skills, which was not the case when they were with unfamiliar nurses in the ward. One student narrated:
“My expectation is that the lecturers should be visiting us frequently…. we are used to our lecturers and we feel free to ask them questions. In the ward, you are unsure of how the qualified staff will react to your question because you are new and unfamiliar.”
Although many students preferred their lecturers to accompany them to the clinical areas, some students reported that in certain clinical placements, staff were adequately prepared and welcoming to students despite having a huge workload. This is illustrated in the following comment:
“Qualified staff working in the ward were willing to help us to learn through these conditions. But though trying, they had a lot of work to do but were committed to teach and help us with some problems.”
While some students reported having support from the qualified nurses, there were others who experienced an unwelcoming and unattractive learning environment, where ward staff expected them to do the work of a qualified nurse in the ward.
“The qualified staff in the ward, most of the time think that if students are in the second, third or fourth year, they know everything, forgetting that we are not there to do their work but to learn….they just leave us to work unsupervised.”
Students had expectations in the ward and one of them was that qualified nurses would supervise and give them feedback whenever they were doing any procedure on a patient. Some students reported that the District Health Officers and the District medical officers were helpful to them as they were teaching them how to manage patients of different conditions.
Clinical Assessment and feedback
There was also a big discussion around clinical assessment and feedback in the clinical area. Majority of students complained that clinical assessments were not done in time and feedback was not given to students sometimes. Some students gave accounts of delayed assessments as narrated by one participant:
You find that most of the clinical assessments that were supposed to be done in first year are carried over to the third year, which puts pressure on us as we would have to do so many clinical assessments within a short period.
A few students complained that sometimes clinical assessments were not done until they finished their clinical placement.
Arrangements would be made to have the assessment at a different hospital where they would often be assessed on different things from what they had learnt in their initial clinical placement.
Integration of theory into practice
Students reported that it was difficult for them to integrate theory into practice in the clinical area because the majority of the qualified staff were using short cuts to perform procedures. Students stated that the only time they practised what they learnt in class was when their clinical supervisor was with them. This is illustrated in the following comments:
“It becomes a problem to integrate what we learnt in class and what we meet in the ward. During classes, we leant procedures comprehensively, but when we go to the clinical areas, we sort of cut corners unless the clinical supervisor is around’
Students narrated that the first weeks of their clinical placement, they tried to do what they learnt in class but with the passage of time, they also joined the qualified nurses in using shortcuts to perform procedures. Most of the students reported that huge workload was the reason behind qualified nurses’ use of shortcuts during procedures in the clinical area. One student reported:
“When a lecturer is there, you do a comprehensive sort of history taking aligning with what you learnt in the class, but when you are with qualified nurses….. maybe its due to high workloads, they cut corners and you learn nothing.”
Working relationship and support
Several students reported that their clinical experiences were negatively impacted by the poor relationship with some clinical staff. Students recalled some experiences when qualified clinical staff shouted at them in the presence of patients and fellow students. One student reported:
“When a student is wrong, the qualified nurse would shout at you in the presence of patients and in front of everyone else. It was making my day bad and contributed to not meeting your objectives because I was stressed up or pissed off, so it wasn’t okay”
Students stated that they would have loved if qualified staff would politely correct them when they make mistakes during procedures. Moreover, some students narrated that as a result of qualified staff’s poor communication skills, they were uncomfortable to perform procedures in the presence of clinical staff for fear of being shouted at if they make any mistake.
“Sometimes, it happens that you are doing a procedure in the ward and as a student, you may fail or not do it properly. You find that staff members criticise you you right there that you were not supposed to do that. This flattens my morale and we are not comfortable doing procedures with them. We would love to be criticised in private if there is a problem and not in the presence of all patients because they lose trust in you.”
Additionally, while some students reported a good relationship with counterparts from other institutions, several students were not comfortable with having high numbers of nursing students from different institutions in the same ward, which resulted into fighting over patients as one student explained:
“In the ward, you can have students from Mzuzu University, Ekwendeni College of Nursing and, St Johns College of Nursing. All of you would want to pick and care for patients as your case studies for assessments. We end up fighting over patients instead of assisting them”
Teaching and learning resources
Many students reported a lack of an adequate number of qualified staff in the clinical area was affecting their clinical learning and experience. Many students explained that as a result of the shortage of staff in the ward, most of them found themselves working without supervision to cover the shortage in the ward rather than learning to gain clinical skills.; One student reported: “We have a shortage of resources….we are failing to achieve things because of lack of mentors in the clinical area” Another student reported:
“I expect to have enough resources in each and every department and adequate staff…we have observed that they are trying to cover shortage with us students, they forget that students are there to learn”
Material resources
Apart from human resources, students also reported lacking resources to help them attain their clinical competencies. Students reported that they lacked clinical equipment and protective gear. One participant said: “When it comes to real practice, you find that most of the equipment or accessories that you learned in class are not available in the ward.”
Students reported that most of the procedure they learned in class were developed in Western Countries, and the challenge of implementing the procedures in the clinical area in Malawi was related to lack of equipment. As a result, students reported improvising, which affected the quality of their clinical learning.
“I said sometimes it is difficult because what you learn is from Western Countries and here in Malawi we do not have the resources in the ward, so we end up improvising, which is a challenge.”