Study design and setting
This was a cross-sectional study involving undergraduate nursing and midwifery students of the University for Development Studies on clinical placement in health facilities in the Tamale Metropolis.
The Tamale Metropolitan Assembly (normally of a population of ≥250, 000) is one of the 260 Metropolitan, Municipal (normally of a ≥95,000 population) and District (normally of a ≥75,000 population) Assemblies in Ghana. Tamale is the capital town of the metropolis and the Northern region of Ghana. Until 2004, it was a municipality. It is the largest of the 16 metropolitan, municipal and district assemblies in the northern region of Ghana. According to the 2010 population and housing census, the metropolis has a population 223,252 made up of 49.8% and 50.2% males and females respectively. Though the main language of the people is Dagbani, due to its cosmopolitan nature, all the different Ghanaian languages can be heard in the municipality .
Apart from the University for Development studies which trains nurses and midwives among other health professionals, the metropolis has two of the oldest nursing training institutions in Ghana; the Tamale Nursing and midwifery training college and the Tamale community health nursing school. One of the three teaching hospitals in Ghana- The Tamale Teaching Hospital, is located in this metropolis. Students are, therefore, placed in this hospital and three other public hospitals (Tamale Central, West and the Seventh Day Adventist hospitals) for the clinical practicum.
Sampling and clinical placement
Purposive and convenient sampling techniques were used. Purposive, because only students who were toward the end of their studies (third and fourth years’ students) for nursing and midwifery degree were selected to participate in the study. Undergraduate education in Ghana is for four years and range from level 100 to level 400. The clinical supervisors sign off the clinical assessment of the students. This assessment constitutes 40% of the mark a student will score in his or her practical exams for the semester. The rest of the 60% is from Objective Structured Clinical Examination (OSCE) conducted by the training institutions (the school). The clinical placement of undergraduate students is divided into intra semester (students are placed for one day each week whiles they continue with their lectures and academic activities) and after semester (when students are done with their lectures and examination for the semester and proceed to spend the rest of it clinical placement. This comprise of four to ten weeks block for first and second semesters respectively). This was to ensure that students had enough exposure to clinical placement to enable them to evaluate their experience. However, it was convenient because students in these year levels who were available and willing to participate were selected.
The questionnaire was administered to students by the researchers in the university campus. The questionnaire was self-administered and participants were allowed to take the questionnaires home and return completed copies to the researchers.
The study questionnaire
We used the English version of the Clinical Learning Environment and Supervision + Nurse Teacher (CLES +T) evaluation scale  with prior permission. This psychometric testing scale consists of a total of 34 items within five sub-dimensions. The sub-dimensions are: pedagogical atmosphere on the ward (nine items), leadership style of the ward manager (four items), premises of nursing on the ward (four items), supervisory relationship (eight items), and role of the nurse teacher in clinical practice (nine items). The questions were scored on a five-point Likert scale of 1 to 5. The scores were as follows: 1=fully disagree, 2=disagree to some extent, 3=neither agree nor disagree, 4=agree to some extent and 5=fully agree. We added questions on programme of study and level.
Statistical analyses were done using SPSS version 21. Demographic characteristics of students are presented as frequencies and percentages. Internal consistency was checked for the overall scale and each of the five dimensions using Cronbach’s alpha. There was high internal consistency of the overall CLES +T (Cronbach’s alpha = 0.904). The five dimensions also showed high internal consistency with Cronbach’s alpha values ranging from 0.713 to 0.903 which showed the suitability of the use of this scale (Additional file 1). The method of supervision was categorised into three based on responses to six questions. Unsuccessful supervision was assigned based on a combination of three alternative questions: (i) the student did not have a named supervisor; (ii) a personal supervisor was named, but the relationship with this person did not work; and (iii) the named supervisor changed during the training course. Team supervision was assigned based on a combination of: (i) the supervisor varied according to shift or place and (ii) the supervisor had several students. Successful supervision was where students had a named mentor and the relationship worked in practice [23, 24].
An overall mean score of the questionnaire was calculated for each student by calculating the mean score of all questions. Scores on the five sub-dimensions were also calculated for each student using scores of the questions that make up those dimensions. Higher scores indicate more agreement with the statements.
The association between student demographic characteristics and clinical placement experience and mean scores was determined using t-test or ANOVA as appropriate. We determined associations of the overall mean score on CLES+T and the sub-dimensions using the mean scores (continuous) as dependent variable and demographic characteristics (binary/categorical) and clinical experience (binary/categorical) as independent variables.