From Classroom Learning to Clinical Practicum: Qualitative and Quantitative Evaluation of Undergraduate Students’ Learning in Adult Nursing

doi:10.21203/rs.3.rs-3139182/v1

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Research Article

From Classroom Learning to Clinical Practicum: Qualitative and Quantitative Evaluation of Undergraduate Students’ Learning in Adult Nursing

https://doi.org/10.21203/rs.3.rs-3139182/v1

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Background: Because the nursing field is both theoretical and practical, it is crucial that the connection between the two is reflected in the curriculum.

Objective: This study investigated educators’ perspectives on the contribution of Adult Nursing classrooms to clinical learning.

Methods: Data were gathered from 153 retrospective records of undergraduate nursing students, 32 clinical facilitator feedback reports on students' practicum, and 12 in-depth interviews. The study was conducted in Taiwan between February and September 2019. Quantitative results were analyzed using appropriate descriptive and inferential statistics, while qualitative data were analyzed using content analysis following the COREQ guidelines.

Results: Research findings indicate a positive relationship between classroom learning and practical application in Adult Nursing. Specifically, the study revealed that theoretical (β=.246; t=3.03; p <.005) and laboratory (β=.201; t=2.25; p = .014) components of Adult Nursing are strong predictors of success in the practicum. This highlights the importance of gaining theoretical knowledge and clinical experience.

The teaching and learning experience in the Adult Nursing practicum can be categorized into three stages: struggling to adapt, improving care abilities, and revising guidance plans. There were several phases throughout the internship, including orientation, assessment, implementation, evaluation, and independent work, which lasted several weeks.

Conclusion: The quantitative results indicated that the scoring system was consistent and reliable. The predictors highlight the accumulation of theoretical knowledge, laboratory skills, and clinical experience. Students struggled to adapt to the Adult Nursing practicum due to the unfamiliar work environment and care roles. Positive feedback from clinical instructors encouraged and motivated students to improve their clinical performance, which enabled them to work independently in the third week. The results offer valuable insights into the facilitators’ perspectives on students' clinical learning. The study found a positive correlation between academic performance and practical application, contributing to the overall organization of the Adult Nursing course.

Practicum

Clinical instructors

Adult Nursing

Undergraduate students

Nursing is a practice-based profession. The nursing curriculum, therefore, must effectively integrate theoretical knowledge with clinical learning. The clinical practicum allows students to apply theoretical knowledge in clinical practice. In this context, the practicum is considered a vital transitional period that bridges the gap between the classroom and the work setting [1]. A successful clinical practicum helps students identify and commit to future career development [2]. However, failure to connect theory and practice may affect students’ interest in clinical learning [3], thus discouraging them from pursuing a nursing career in the future [4].

This study explored the association between classroom learning and clinical performance from the perspective of lecturers and clinical instructors (CIs). CIs are full-time university employees whose primary role is to guide students’ clinical learning [5]. Because academic results do not fully correlate with clinical performance [6], CIs seek to develop students’ clinical practice in relation to educational goals around core nursing values as well as providing role models of good clinical care [7]. Accordingly, CIs make an essential contribution to students’ ability to integrate care knowledge and skills and become effective nurse clinicians.

Student nurses with limited clinical experience are required theoretical and practical knowledge to provide safe care and avoid possible patient harm [8]. Although formative and summative evaluations are essential for students' learning outcomes and processes [9], numerical grades are frequently used to evaluate learning. These numerical grades do not reflect or guarantee to provide safe care to patients. Understanding CIs’ perspectives on evaluation is crucial for improving students’ learning confidence and competence as part of their professional development [10] and their ability to provide efficient and effective care.

This study explored the association between Adult Nursing classroom learning and clinical performance based on lecturers’ and CIs’ scores and perceptions. The research questions were: (1) How do CIs assess and score students’ clinical performance? (2) Can classroom and laboratory learning results predict students ' clinical performance in the clinical practicum? (3) How do the CIs influence nursing students’ clinical performance?

Study design

A mixed-methods research design was employed. Qualitative data were collected from CIs through feedback on student’s clinical performance and in-depth individual interviews. Quantitative data were obtained from students’ final scores in the Adult Nursing practicum (ANP), classroom learning theory, and skills practice. The study was conducted from February to September 2019.

Sampling

Purposive and convenience sampling were used to recruit participants who taught or guided in the Adult Nursing course, forming part of the undergraduate nursing program at the University of Taiwan’s south campus. This course organizes students into three classes for their theoretical (knowledge) and laboratory (practice) learning. The four-year undergraduate nursing program consists of eight clinical terms, one in the first academic year (Fundamental Nursing practicum), two in the second year (ANP, including Medical and Surgical Nursing), and five in the fourth year (Obstetrics, Pediatrics, Psychiatric, Community, and elective practicum). The elective internship is chosen according to the student's intended career pathway. Students complete Biosciences, Fundamental Nursing theory and laboratory and practicum courses, and Adult Nursing theory and laboratory practicum before enrolling in the ANP. The ANP consists of three weeks each of medical and surgical nursing and is divided into Modules I and II.

Measures

Both quantitative and qualitative measures were employed. The quantitative data comprised students’ scores in the classroom (theory and laboratory) and practicum (clinical) of the ANP. ANP included Module I (medical care or surgical care) and Module II (surgical or medical care). The qualitative data comprised the CIs’ feedback reports and the transcripts of their in-depth interviews.

Five lecturers collaborated in the classroom and laboratory teaching for the three classes. The ANP team leader, the principal investigator, was responsible for classroom teaching but did not directly facilitate the students' ANP. Several meetings were conducted to ensure consensus on the goals of the ANP and consistent implementation. The curriculum of the ANP was based on 10 core nursing values developed by the nursing department. All the CIs met before and after the practicum to ensure consensus on the grading parameters and confirm the final scores, demonstrating acceptable internal consistency and reliability.

With CIs' consent, feedback reports on the ANP were obtained from each CI in every unit (ward) to illustrate the student's clinical performance. The principal investigator conducted interviews with all the CIs, ensuring rigorous qualitative data collection.

Data collection

The quantitative data set comprised classroom (theory and laboratory) and practicum scores from 173 students. The scores from 14 students who re-enrolled in the Adult Nursing course and six who withdrew from the practicum were excluded. Thus 153 students' scores were obtained for the quantitative data set. Practicum scores were obtained from 11 hospitals (including medical centers and regional and district hospitals) with 29 units (wards). Each CI evaluated six or seven students’ performance in the practicum. The qualitative data comprised feedback reports on students’ clinical performance from 32 CIs in the middle of the practicum and individual interviews with 12 CIs at the end of the practicum. These data were provided to the authors when the classroom teaching and practicum had been completed. All CIs were invited via email to participate in individual in-depth interviews about how they evaluated and scored the students’ clinical performance. A total of 12 CIs responded positively to the invitation. Interviews lasted from 45–60 minutes and were audiotaped and transcribed verbatim. The interviews began with an open question, “Could you please share your experience grading the ANP?” An interview guide was utilized to ensure consistency in data collection, but this was followed flexibly to enable participants to respond in their way.

Data analysis

Quantitative data were analyzed using SPSS for Windows version 18.0 (SPSS, Chicago, IL, USA). Scores were compared between the groups using the paired t-test, t-test, and one-way ANOVA. Pearson’s correlation coefficient (r) was used to assess the significance of the association between the two variables. Multiple linear regression (MLR) analyses were used to evaluate the independent effect of the variables on the ANP scores. A p-value less than .05 was considered statistically significant.

Content analysis [11] was used to analyze the qualitative data. The feedback reports and interview transcripts were merged into two separate files. The audio recordings of the interviews were listened to repeatedly to gain a deeper insight into the data, and memo writing was undertaken during this process. The analysis was conducted in four stages: decontextualization, recontextualization, categorization, and compilation [12]. All of the data were carefully read line by line and broken down into codes. The meaning of each code was developed through group discussions among the research team. Codes with related meanings were grouped into subcategories. The group and its name were considered in the initial texts to ensure the meaning of the text. A further categorization stage identified and categorized all homogeneous categories from a list of code definitions. The final step, compilation, involved drawing realistic conclusions from the data in relation to the research question.

Trustworthiness of qualitative data

Lincoln and Guba [13] proposed four criteria to assess the reliability and validity of the findings from qualitative data analysis: credibility, dependability, transferability, and conformability. All interviews were conducted by the principal investigator, who has extensive training and experience in qualitative research, which helped to ensure consistency and credibility. All interview transcripts were carefully transcribed and checked by the team members to ensure accuracy, thus ensuring dependability. Transferability was achieved by providing raw data in verbatim quotes from participants' reports and interviews. Confirmability related to the objectivity of the research ensured the trustworthiness of the process and the study’s methods and procedures. The study adhered to the criteria for reporting qualitative studies (COREQ) [14]. The study process is therefore considered to be rigorous.

Ethical considerations

Ethical approval

was obtained from the Institutional Review Board (IRB: 201802251B0) of Chang Gung Medical Foundation. All of the quantitative data were coded with numbers. Potential participants were informed that (1) participation was voluntary and (2) their rights to privacy and anonymity were guaranteed. All the data were kept confidential in accordance with the IRB’s standards, and pseudonyms were used to ensure anonymity.

The quantitative data set comprised 153 valid scores from theory, laboratory, and ANP Modules I and II. The majority of participants were female (88%) and aged 20–21 years; 19 male students accounted for 12% of the group. Prior to enrolling in the ANP, students had only completed one clinical practicum in Fundamental Nursing.

Quantitative results

As shown in Table 1, no significant differences were observed between (among) the scores in different classes for theory (F = 1.07; p = .35) and laboratory (F = 2.32; p = .10). Moreover, there were no significant differences between the other classes in ANP Module I (F = 0.73; p = .48) and Module II (F = .10; p = .91). There were no significant differences in the grades obtained by students who practiced in different levels of the hospital for ANP Module I (F = 2.97; p = .054) and Module II (F = 0.45; p = .64). The results show that the grades obtained by students in Adult Nursing in the classroom and ANP were consistent and reliable.

Table 1

Classroom and Practicum Scores from Different Classes and Hospitals
Variables	Classes			P	F	Hospital levels			F	p
	1(n = 54)	2 (n = 47)	3 (n = 52)	P	F	District	Regional	Medical center	F	p
	Mean (SD)	Mean (SD)	Mean (SD)			Mean (SD)	Mean (SD)	Mean (SD)
Theory	72.63(6.58)	71.08(6.72)	70.86(7.13)	.346	1.07
Laboratory	70.75(8.09)	67.36(6.98)	68.92(8.47)	.10	2.32
ANP module I	80.80(3.29)	79.83(3.07)	80.19(5.40)	.73	0.73	76.50(8.26)	80.52(3.94)	79.96(2.90)	2.97	.054
ANP module II	81.02(4.44)	80.81(3.18)	81.13(3.44)	.91	0.10	81.25(2.50)	81.14(3.49)	80.44(4.66)	0.45	.64
ANP: Adult Nursing practicum; SD = standard deviation.

We analyzed the scores of APN Module I and II using a paired t-test. Results showed a slight increase in the mean score of .699 at ANP Module II (t = 1.99; p = .049), indicating that the clinical learning experience was cumulative and improved over time (Table 2). As shown in Table 3, the associations between ANP Module I and classroom learning (r = 0.18; p = .03) and Module II (r = .36; p < .0001) were measured using the Pearson correlation coefficient. Laboratory scores correlate positively with ANP Module I (r = 0.23; p = .004) and Module II (r = .25; p = .002). There was a positive correlation between ANP Module I and Module II (r = .38; p < .001). The higher the Adult Nursing score in theory, the higher the laboratory grades and the higher the ANP Module I and II scores. These associations indicated that the Adult Nursing course effectively bridges the gap between classroom and clinical learning.

Table 2

Comparison of scores on ANP Module I and II
Variables	Mean	SD	Mean diff. (SD)	r	t	p
ANP Module I	80.29	4.09	-0.7 (4.35)	.38^**	-1.99	.049^*
ANP Module II	80.99	3.73	-0.7 (4.35)	.38^**	-1.99	.049^*
p < .05; p < .01; **p < .0001; ANP: Adult Nursing practicum

Table 3

Correlation between classroom and clinical learning (n = 153)
Variables		Theory	Laboratory	ANP Module I	ANP Module II	ANP Module I&II
Classroom learning	Theory	1
Classroom learning	Laboratory	.36^***	1
Clinical learning	ANP Module I	.18^*	.23^**	1
	ANP Module II	.36^***	.25^**	.38^***	1
	ANP Module I &II	.32^**	.29^**	.85^**	.81^**	1
p < .05; p < .01; **p < .0001; ANP: Adult Nursing practicum

Regression analysis was used to explore the predictive factors of ANP performance. The laboratory scores obtained during classroom learning were found to predict ANP Module I (β = 0.193; t = 2.285; p = .024), with 5.22% of the variance explained (adjusted R2 = .051; F = 5.219; p = .024). Additionally, the theory grades were found to predict APN Module II (β = .309; t = 3.836; p < .0001), with 22.18% of the variance explained (adjusted R2 = .122; F = 22.18; p < .0001). The results show that scores in Adult Nursing theory (β = .246; t = 3.03; p < .005) and laboratory (β = .201; t = 2.25; p = .014) are predictors of scores in ANP. These predictions highlight the accumulation of theoretical knowledge and clinical experience (Table 4).

Table 4

Clinical Performance Prediction Model (n = 153)
Variables	β	t	95% CI	p	Adjust R²	F	P
ANP Module I
Theory	.108	1.276	(-.035, .164)	.204	.024	4.792	.030
Lab.	.193	2.285	(.13, .183)	.024	.051	5.219	.024
ANP Module II
Theory	.309	3.836	(0.082, 0.257)	< .0001	.122	22.175	< .0001
Lab.	.138	1.713	(-0.010, 0.139)	.089	.133	2.934	.089
ANP Module I & II
Theory	.246	3.031	(.041, .193)	.003	.094	16.792	< .0001
Lab.	.201	2.475	(.016. .147)	.014	.124	6.123	.014
ANP: Adult Nursing practicum; Lab.: Laboratory

Qualitative results

The feedback reports and CI interviews were analyzed to describe students' progress in ANP. As shown in Fig. 1, three categories were identified: struggling to adapt, improving care ability, and revising guidance plans. These are elaborated below, using pseudonyms for the participating CIs.

Struggling to adapt. Participants reported that the students were under so much stress from the unfamiliar environment that it affected their practicum performance, and they, therefore, received negative feedback from the CIs. This level of anxiety was not conducive to the student’s learning and may have increased the knowledge gap between their clinical experiences in Fundamental Nursing and Adult Nursing. Therefore, students were reluctant to answer questions in case they gave an incorrect answer. For example:

During the first week of the ANP, many students were apprehensive and often chose to remain quiet when asked questions. Evidently, they needed to improve their theoretical knowledge of Adult Nursing significantly [CI Haung].

Some students may have received negative feedback from their CIs because they have been perceived as passive or inactive learners due to difficulty adapting to the new environment. For example:

The students' learning attitudes were often passive and inactive and they needed to practice their Fundamental Nursing skills more. In addition, they tended to execute technical procedures with only one password and one action, which could be improved [CI Chia].

Part of the reason for the knowledge gap was that the student’s clinical experiences during their Fundamental Nursing practicum were not transferred into their ANP. This is likely to reflect the long period of time (six months) between the two courses. To address this problem and alleviate students' anxiety, it was suggested that they should review their previous clinical learning before entering the new clinical setting.

The nursing students were initially unfamiliar with fundamental techniques and required frequent reminders about aseptic procedures. However, in their eagerness to master these techniques, they sometimes overlooked the importance of considering their patients' feelings. Fortunately, with encouragement and guidance, the students made significant progress in this area. Therefore, students must practice and review the basic skills before visiting hospitals [CI Lin].

In other words, CIs regarded the first week of the ANP as an orientation period that allowed students to acclimate to the new environment and CIs to assess their care competencies and help everyone get to know one another.

Improving care ability. Although the CIs expressed dissatisfaction with the student’s performance during orientation, they reported a marked improvement after the second week. As a result, the CIs observed progress in students’ clinical learning as they began to perform their work more effectively and provide care more professionally. For example:

Although the students still required guidance and suggestions to carry out care, they showed substantial progress since the second week. For instance, they actively monitored intravenous infusion drips after adding drugs to the IV bag [CI Lee].

Several students needed more enthusiasm during their practicum, often appearing nervous and disoriented in the first week. However, there was a remarkable improvement in their learning and behavior from the second week onwards, as they acted like true care professionals [CI Chen].

Participants also noted a need for a better connection between what is taught in the classroom and what is learned during clinical training in Biosciences and Adult Nursing, such as Health Assessment. The CIs evaluate students' practical skills based solely on their theoretical knowledge. However, providing quality care requires knowledge, skills, and additional clinical learning.

Many students need help to apply their previous learning to patient care, particularly when it comes to understanding the mechanisms of illness. This lack of understanding can negatively affect their ability to make informed health assessments. For instance, their knowledge of pathophysiology and pharmacology may need to be improved to provide proper care for various health conditions [CI Fan].

In summary, the CIs reported using the second week of the ANP to evaluate students' clinical learning in order to enhance their care skills, minimize potential mistakes, and achieve the learning goals of the ANP. In this way, both CIs and students contributed to ensuring a successful teaching and learning experience.

Revising guidance plans. By the third week, both parties were comfortable in their respective roles and had developed a mutual appreciation based on understanding and positive feedback. Despite the unfamiliarity of the learning environment, students quickly adapted and redirected their learning focus, which resulted in the CIs revising their negative perceptions of their students and adopting more optimistic learning goals.

Students progress so quickly ... They understand theoretical knowledge thoroughly and make inferences about other cases from one instance, practice therapeutic communication, demonstrate logical and critical thinking and problem-solving abilities, understand the meaning of the results of patient health surveys, physically assess patients, understand the point of questions, and are aware of their learning problems [CI Chen].

In other words, the development of mutual understanding between students and CIs led to enhanced clinical performance among students and met the expectations of both parties regarding the ANP. The process involved continuous progression, interaction, and feedback. During the first week, positive feedback from the Cis helped to develop students’ motivation for learning rather than their technical skills. CI Lai, for instance, described the students as:

… well-behaved, obedient, and polite. They displayed positive attitudes toward teamwork and helping professionals to care for patients. Additionally, their social communication skills surpassed their therapeutic communication skills. They were also diligent in completing their assigned tasks within the given timeframe.

Once the students had developed a positive outlook toward learning, the ANP involved a progressive and mutually beneficial adaptation of teaching and learning.

Analysis of the quantitative data found no significant differences in the grades for clinical learning between different levels of the hospital. This indicated that the scoring system was consistent and reliable. However, a positive correlation was found between students’ classrooms and ANP learning. We found that grades in classroom learning could predict the students' clinical performance. This answered the second research question. In relation to the third research question, the results indicated that the collaborative teaching strategy [15] with clear practicum goals [16] and consistent evaluation [17] did not negatively impact the third study question. Although the scores in ANP Module II were slightly higher than those in Module I, the practicum goals for Module II were more advanced, and the results of Module I predicted the outcomes of Module II. Ultimately, the minor difference in scores between ANP Module I and II showed progress towards achieving the goals of ANP Module II. These predictions highlight the accumulation of theoretical knowledge, laboratory skills, and clinical experience. However, the progress made in ANP I and II may hold little significance, as ANP I or II presents an entirely new environment, role, and student experience.

According to the CIs, the students struggled during the first week of the ANP due to a need for more understanding of their work environment and care roles. This led to substandard care behaviors and negative feedback, which has been shown in other studies to have a detrimental effect on students’ learning [18]. The students’ lack of confidence in their care knowledge was manifested in their reluctance to answer questions for fear of making mistakes. This has been observed in other studies [19] and has been identified as having the potential to create an unconducive learning environment [7].

However, our results are inconsistent with those from other studies, which have found no significant correlation between academic achievement and clinical learning [6]. The clinical learning environment has been described as a hidden curriculum that can instill professional values and commitment [20]. The CIs in our study played a crucial role in increasing the student's motivation for learning, which ultimately helped them become effective learners. By sharing their knowledge and experience, the CIs enabled the students to locate their learning in real life.

CIs play an essential role in guiding students' clinical learning. CIs' positive feedback has been found to enhance students’ learning experiences [21]. Such encouragement can also alleviate students' psychosocial stress in unfamiliar environments [22]. At the same time, while CIS needs to create a challenging learning environment, they need to ensure that their expectations are not too high, which can result in students losing motivation. A nurse student is a student to learn their care performance is not as good as an experienced preceptor. Optimistic guidance can inspire students to enhance their care competencies and commitment without fear of negative consequences. It also helps students feel more engaged and effective in their learning. As Walsh, Anstey, and Tracey [23] suggest, constructive feedback is more effective than criticism in helping students improve their skills. Inculcating professional values and attitudes in clinical settings, such as prioritizing patient safety, fosters accountability and responsibility as well as helping to reduce students’ anxiety [24]. However, students' clinical performance should not be assessed rigidly, as they are still learning and lack the experience of nursing professionals.

One main challenge is bridging the gap between biosciences, care knowledge, and clinical experience. In this context, it is important to understand the learning needs of students in the early stages of the practicum process and consider these when assessing their performance. Knowledge of biosciences is essential for students’ understanding of care practices in relation to different illnesses. However, students often struggle to apply bioscience knowledge to clinical practices such as physical assessment [25]. Currently, bioscience subjects are taught by educators in different disciplines who, while they may be outstanding in their respective scientific fields, might be unfamiliar with patients' needs and nursing students’ care roles. Accordingly, it has been argued that the teaching curriculum should focus on biosciences relevant to clinical settings [26]. In addition, learning strategies should be adapted to reflect students’ increasing knowledge as they progress through the program [27]. Educators can improve classroom engagement and clinical learning by integrating knowledge from the biosciences with care practices [28, 29].

CIs also play a crucial role in promoting student-centred learning approaches to nursing professional development in the clinical setting [30]. The current ‘digital generation’ of student nurses needs innovative teaching strategies, such as incorporating audio-visual aids, to meet their learning needs [31]. Both faculty and CIs need to understand the learning characteristics of today’s students and acknowledge that their role has shifted from that of an information provider to that of a facilitator. As assessors or learning planners, CIs can guide and encourage student growth and enhance the quality of the learning process [32].

This study found that students improved their clinical learning performance in the ANP course, gradually evolving its teaching and learning methods, beginning with orientation, assessment, implementation, and evaluation. It is crucial to give students sufficient time to adapt to their practicum in order to reduce their work-related stress and enhance their clinical performance. Although time restrictions to clinical practicum, strategy is required to help students enter fields comfortably to adjust to the practicum environment. Although there was a positive association between students’ grades in Adult Nursing (theoretical and laboratory) and their clinical performance, early evaluations of students' performance by CIs raised some concerns that indicated the need for more comprehensive studies better to understand the process of students' clinical learning.

Limitations

The results of this study reflect the opinions of CIs within a nursing program at a university in Taiwan. Therefore, the applicability of these findings is restricted to students in similar programs or universities. Conducting this research at multiple sites and understanding the perspectives of CIs across different nursing programs would yield more comprehensive information to inform the development of an effective clinical nursing education framework.

Ethics approval and consent to participate: The principles of the Declaration of Helsinki were performed in this study. Full ethics approval has been obtained from the Chang Gung Medical Foundation Institutional Review Board (201802251B0). The University has also approved the study. All potential participants received an email invitation outlining the objectives of this study, the voluntary participation. Confidentiality of the participants’ information was ensured, and no personally identifiable information was released. Informed consent to participate was obtained from all participants. The research met the ethical standards set by the IRB.

Consent for publication: Not Applicable. According to IRB standards, disclosing any information about research participants is not permissible. All the quotes used in this article are anonymous.

Dara Availability: The data supporting this study’s findings are available from the corresponding author upon reasonable request.

Competing interests: The authors have declared no conflict of interest.

Funding: Not applicable

Authors' contributions: L-C Chen and C-C Lin designed and organized the original study, data collection and analysis, and drafted the initial manuscript. C-Y Han performed qualitative data analysis and interpretation and approved the final draft. Y-L Huang conducted quantitative data analysis and interpretation and proofreading. All authors reviewed the manuscript.

Acknowledgments: The authors would like to sincerely thank all participants, lecturers, and clinical instructors involving this study.

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No competing interests reported.

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From Classroom Learning to Clinical Practicum: Qualitative and Quantitative Evaluation of Undergraduate Students’ Learning in Adult Nursing

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Abstract

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Background

Methods

Study design

Sampling

Measures

Data collection

Data analysis

Trustworthiness of qualitative data

Ethical considerations

Results

Quantitative results

Qualitative results

Discussion

Conclusion

Limitations

Declarations

References

Additional Declarations

Status:

Version 1