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Introduction

Clinical learning is a significant component of the Bachelor of Nursing (BN) program (Student Orientation Guide, 2003). It is integral to the BN program because it provides opportunities for students to learn experientially. Students are encouraged to actively learn from their individual experiences while on clinical placement. Real-life experience is valuable and each experience may be treated as a unique but interrelated learning episode. There is immense learning that occurs in the workplace and academics in the Discipline of Nursing and Rural Health believe that workplace-based learning will help prepare students for work following graduation. The current program includes a range of clinical practice courses. Each clinical course has a specific focus, and clinical placements in a range of organisations are a compulsory component of those courses. Students undertaking the BN program have opportunities to select preferred venues for their clinical placements, from a range of available venues.

Within the program, clinical experiences are assessed by the use of a clinical assessment tool based on the Australian Nursing and Midwifery Council competencies. The tool measures the level of competency in the cognitive, psychomotor and affective domains. In particular, the competencies examined include professional and ethical practice, critical thinking and analysis, management of care and enabling, problem-solving, and performance is assessed against a set of standards. Student performance is rated as being independent, assisted, supported, directed or dependent and the descriptors of standard of performance are articulated in the clinical assessment tool. Both student and preceptor or supervisor discuss and evaluate performance against each competency; areas of strength and areas needing improvement are identified. A reflective journal is kept by students and is another method by which students are prompted to think critically about their clinical experiences. Journalling provides time for reflection and focus on particular problems, issues or critical incidents that might lead to improvements in practice and delivery of patient care.

The value of clinical placement experiences cannot be overemphasised. It is imperative that the program provides clinical environments that are supportive and capable of nurturing meaningful learning and optimal performance in students. Students are viewed as consumers or customers, rightfully demanding the highest quality of education available. With the increased flexible delivery of university programs, students may decide to shift to other universities if dissatisfied or distressed with their learning environment (Cotton, Dollard, & Dejonge, 2002). It is important therefore to establish that the clinical venues being used extend theoretical knowledge and clinical learning, and provide continual feedback on performance and practice as well.

Acknowledging that an encouraging and supportive clinical venue is conducive to positive learning outcomes, the Discipline introduced recently a clinical placement venue evaluation instrument. Essentially, the instrument was designed to measure student satisfaction with the venue. Also, while clinical placements provide valuable learning experience of the 'real world', students undertaking them may have problems that need identifying and addressing (Hughes, 1998). The clinical placement evaluation is supported by Hughes' (1998, p. 225) statement on the need for more 'empirical research into the characteristics of the workplace as a learning environment'. Moreover, it was anticipated that this evaluation would lead to collaborative partnership in clinical learning for students, meet organisations' expectations, and fulfil the university requirements for course and placement evaluations.

Literature review

The literature that discusses the value of clinical placement experiences is located in work-based or workplace learning. This learning approach involves learning in authentic work contexts or situations (Garrick & Kirkpatrick, 1998). 'Authentic' means the daily routine practices inherent in the culture (Brown, Collins, & Duguid, 1989). The demands of the work practice dictate the learning that emerges in this approach. Learning is facilitated by the collaboration of the university, industry partner and student. The theoretical underpinnings of workplace learning can be traced from various theories of adult learning that include 'reflection-in-action, critical reflection, and experiential learning' (Garrick & Kirkpatrick, 1998, p. 172). Others are borrowed from the field of cognitive psychology and situated cognition and Kulewicz (2001) refers to this as service learning.

Lave (1988) and Lave and Wenger (1991) argue that learning is a function of the 'activity, context and culture' in which it occurs. This is to say that learning is situated. By comparison with traditional classroom activities, knowledge is presented in context. Also, the social interaction involved in this setting is an important component of this type of learning. Learners become enmeshed in the practice and acquire certain beliefs, practices and behaviours promoted by the people in the practice. The process is called 'legitimate peripheral participation', where beginners (i.e. nursing students in our case) move from the periphery into the centre of the occupation (i.e. the nursing profession), and as students move towards the centre, they become more active and immersed within the nursing culture. With support and mentoring, the novices acquire the role and confidence to consolidate their practice.

Brown, Collins, and Duguid (1989, p. 32) similarly asserted that 'knowledge is situated' and that the transfer of knowledge is not limited to conventional schooling. They explain the concept of cognitive apprenticeship, which puts the transfer of knowledge through concrete situations. Cognitive apprenticeship is said to support 'learning in a domain by enabling students to acquire, develop and use cognitive tools in authentic domain activity' (Brown, Collins, & Duguid, 1989). Learning advances through collaborative social interaction and social construction of knowledge, occurring during schooling and at work. Another related concept is situated cognition and embedded in situated cognition are learning environments that unlike 'sterile' classrooms are rich with authentic problem-rich activities to produce meaningful thinking and learning opportunities that represent ordinary practices (Choi & Hannafin, 1995). In these settings, knowledge is transformed from the classroom to real-life situations and students begin to put theory into practice, distinguish between different settings, internalise learning and develop self-monitoring skills.

Such theories enable us to understand how knowledge is applied in the practice setting, specifically during clinical placements where the focus is on work-based learning and problem-solving. Providing opportunities to work in hospitals or community health centres where students are immersed in authentic problem-rich environments will hone their thinking, facilitate clinical knowledge acquisition, enhance problem-solving and self-correction. Learning is continuous and the socialisation with clients, nurses, and other health professionals, will further enrich their capacity to interact, reflect, collaborate and value the roles played by professional nurses.

The current studies surrounding clinical teaching and learning in nursing are directed at providing nursing students and new graduates with positive placement experiences and facilitating the meeting of goals and expectations. In order to enable students to experience learning-by-doing, curriculum changes may be required and learning gained in service areas formalised. MacLeod and Farrel (1994) warn us of the need to revise structural and power relationships between education and practice. They talk about a practice-driven approach, which should be the central theme of curriculum change. Powerful economic forces are driving systems of higher education to implement change, according to Myer (1999). Myer suggests the need to develop an outcomes-based educational delivery system. The most important performance indicator is to determine whether or not students have learned. Previously, Williams and others (1993) have challenged educators to find more efficient methods of developing nurses by asserting that collaborative approaches to education have many benefits.

While students are now able to choose the speciality and location of their clinical placements, the amount of time and type of experience needed in the clinical setting is still subject to debate. More recently, authors such as Oliver (2002, 2004) have drawn our attention to the trajectory of experience and the context of clinical learning in becoming competent in practice and have debunked the myth that more clinical hours are necessary to assist students in their clinical learning and gaining experience. Nonetheless, both tertiary education institutions and service areas are expected to collaborate in order to increase the learning opportunities for nursing students (Dufault, et al., 1992; Kulewicz, 2001). Through a consortium trialled at Rhode Island, it was concluded that colleges and hospitals working together presented exciting opportunities to share and learn from one another. Other benefits included increased recruitment and retention of participating nurses and greater ease in transition to the workforce. A similar concept was used at the Georgetown University School of Nursing, where a three-tiered team model demonstrated the effectiveness of the undergraduate preceptorship program to enter the workforce (Zerbe & Lachat, 1991). Students in this study reported an increased sense of independence with patient care and satisfying clinical experience when clinical teaching was shared among key stakeholders. The Discipline of Nursing and Rural Health at the University of South Australia concurs and believes that rural health services and agencies are the prime partners in preparing students for professional practice (Clinical Facilitators Resource Manual, 2004).

Moreover, clinical supervision through preceptorship or supervisor programs has received much attention in the literature. The collaborative partnership between preceptor (i.e. tutor) or supervisor (i.e. official advisor with regards to work performance) or mentor (i.e. an experienced registered nurse), student and faculty is valuable for providing student support, knowledge transfer to the clinical setting and problem-solving (LeGris & Cote, 1997; MacLeod & Farrel, 1994). Teasdale, Brocklehurst and Thom (2001) have highlighted the significance of both formal and informal support for nurses. Additionally, the characteristics and attributes as well as responsibilities of a clinical teacher have been identified and reported. Clinicians and practitioners, in assuming their new role, however, need to be prepared for this role (Hinchcliff, 1999). They should be equipped with adequate knowledge and understanding of the concepts upon which clinical supervision is based. Clinical venues should be informed of the underpinnings, process and structure of clinical supervision (Draper, et al., 1999; Gallinagh & Campbell, 2000; van Ooijen, 2000). To this end, the Discipline of Nursing and Rural Health is addressing the issue by conducting regular meetings and workshops on preceptorship and supervision for clinicians and practitioners.

But how can the workplace experience be objectively assessed? There are a number of direct and indirect approaches that may be useful (Boulton-Lewis, 1995); of the range of procedures, we have chosen an evaluation instrument to provide an overview of the learning experiences as perceived by students. The instrument is a catalyst for collaborating in teaching and learning between faculty members, service organisations and students. Most nursing students value highly their clinical experiences and feedback that is provided to all participating services and agencies further strengthen the ties between the institutions.

Purpose of study

The aims of this study were as follows:

1. To evaluate existing clinical venues providing placement to the Discipline of Nursing and Rural Health nursing students at the University of South Australia, Whyalla Campus;
   
   
2. To develop an evaluation tool that will measure student satisfaction with clinical venues;
   
   
3. To provide an opportunity for students to comment on their perception on clinical learning;
   
   
4. To identify areas of strengths and/or limitations of clinical placement venues;
   
   
5. To identify problems that occur during student placements and address these accordingly;
   
   
6. To assist clinical venues in improving and enhancing the learning environment they provide students;
   
   
7. To ensure high quality clinical learning experience; and
   
   
8. To meet university requirements regarding evaluation of learning.
   
   

The specific aims of this paper are: to describe the process by which the evaluation instrument was developed, to convey the results of survey and to explore the learning outcomes that might result with the use of such an instrument.

Methodology

Likert-type survey approach was used in this study. A twelve-item structured instrument was developed to gather evaluative data. The clinical placement evaluation tool was designed to measure student satisfaction with the general ambiance of the venue (Questions 1 and 8) and support provided by the staff members (Question 9). The tool provided information about the capacity of the venue to meet learning objectives (Question 3), afford learning opportunities (Questions 4, 5, 6 and 11), and provide orientation to students (Question 7). Having undertaken a placement at the venue, students were given the opportunity to report its impact on their confidence levels (Question 10) and perceived value of the clinical experience for other students (Question 12). 'Preparedness' or 'readiness' for placement was another indicator that was measured by the instrument (Question 2). Student satisfaction for each of these criteria was quantitatively measured using a Likert scale from 1 to 5, where 1 represent 'strongly disagree' while 5 represent 'strongly agree'.

Fifteen (15) health services and agencies across rural South Australia, offering placements to our nursing students, were randomly selected and requested to review the clinical venue instrument developed by faculty. Letters introducing the project were distributed to the respective Heads or Directors of Nursing. The letter included the purpose of the evaluation, the benefits to be derived from evaluating clinical venues and actual involvement of the heath service or agency. They were requested to submit their comments and suggestions about the instrument to us. Following feedback, iterations were made and the final twelve-item instrument was constructed and trialled in 2002. (Please refer to Appendix 1 for details.)

Two hundred (200) nursing students who were undertaking placement were invited to participate in this evaluation activity. The students were recruited through clinical instructors and course coordinators, who distributed the questionnaires. Both instructors and coordinators explained the aims of the evaluation, the benefits to be derived from the activity, students' actual involvement, the voluntary nature of participation, and assurance of confidentiality of information provided. The students were told that they were not obliged to participate in the study. They were assured that their names were not required on the questionnaire and that their names would not appear at any stage of the project including collecting, analysing and reporting of data. Those interested in participating were instructed to complete and submit the questionnaire after placement. A consent form was not used. Completing and submitting the evaluation instrument was taken as consenting to participate in the study.

Results

Having described the process by which the evaluative instrument was developed, this section illustrates the feedback provided by the representatives of the health services and agencies surveyed.

Health services and agencies

The written and verbal comments from key stakeholders about the questionnaire were very encouraging. Some responses included:

I feel that this questionnaire will be most beneficial to student nurses and will assist in identifying problems that occur during student placements. This will assist our hospital in our attempts to improve and enhance the learning environment during a student's clinical placement.
(Graduate Nurse Coordinator and Clinical Nurse)

We are happy for students to use this evaluation tool. We would be very interested in getting feedback from your students.
(Clinical Placement Coordinators)

... The tool appears to be quite appropriate, and useful. Do you think that the information that you receive from the tool will be fed back to the organisation providing the clinical experience? I believe that would have obvious benefits for us all.
(Clinical Nurse Consultant)

The Clinical Placement Evaluation Form I believe is a great idea. ... I believe that we need to encourage and teach students ... while on their placements to enhance their continuing growth in the nursing field. ... A chance for students to record their placement assessment is important so that if a site of clinical placement continues to rate poorly then facilitators will inform other students that the site is inappropriate with documented evidence as support.
(Acting Clinical Nurse and Preceptor)

... Apart from one indicator, I am happy with your clinical placement evaluation instrument. Thank you for the opportunity to be involved.
(Clinical Placement Facilitator)

I found the instrument sent to me for comment to be appropriate in nature, and comprehensive to collect the information you need regarding the general ambiance of a health unit ...
(Chief Executive Officer and Director of Nursing)

Nursing students

Following positive feedback from stakeholders, the instrument was distributed to students and the summary of the results of student responses is shown below.

Of the 200 questionnaires that were distributed, 107 questionnaires were received, representing a 54% return rate. Overall, the students gave very positive feedback regarding their clinical placement experience. The majority of the students 'agreed' to 'strongly agreed' on the parameters set describing their clinical placement.

Table 1. Clinical placement evaluation

Criterion	Response (% percentage) N=107
Placement was a pleasant learning experience.	94
Student was well prepared for the placement.	78
Student met objectives satisfactorily.	95
Clinical placement assisted student learning.	95
Clinical placement enhanced clinical skills.	93
Clinical placement was supportive of professional growth.	96
Student was provided with adequate orientation.	86
Student was expected by the venue.	93
The staff members were very willing and available to assist learning.	95
Student felt confident working in the venue as a result of clinical experience.	95
Clinical placement provided many learning opportunities for student.	89
The clinical experience would benefit other students.	93

An insignificant number of respondents were dissatisfied with some clinical venues rating them poorly in some areas examined. The frequency results are tabulated in Appendix 2.

Discussion

As a regional university campus, we rely heavily on rural and regional health facilities to provide our students with the necessary clinical experience to prepare them as beginning registered nurses. We are keen to hear about clinical learning and teaching experiences while students are on placement. It is widely acknowledged that placement evaluations are useful and are a valuable strategy to adopt (Reilly & Oermann, 1992). Through the evaluative process, clinical instructors and coordinators can better facilitate student learning in a variety of areas because there is tangible evidence supporting students' learning. Evaluations provide students with the opportunity to reflect and examine issues of practice, enabling them to focus on particular issues or concerns, e.g. adequate orientation to the workplace, availability of assistance from staff members and so forth. Moreover, placement evaluations allow students to express their general satisfaction or dissatisfaction with clinical venues.

It is not only the students who benefit by such an exercise but the academics and industry partners benefit as well. The benefits come in the form of collaboration with agencies during the planning, resource allocation and monitoring of clinical placements. The challenge is to maintain the quality of the placement experience or improve such experiences. Additionally, the evaluations might assist other campuses in making decisions about rural placements for students, as has happened in our multi-campus university.

The responses to the instrument showed that the majority of students' impressions about placement were favourable. Most important is that the students believed they learned. Results of this survey showed that the majority of students perceived their clinical placement as rich in learning experiences. The venues were supportive of learning, professional growth, skills development and practice. Students' experiences with the clinical settings were pleasant and the outcomes of the experiences satisfying. Students were expected at the venues and they recognised and valued staff members who provided them with adequate orientation and were available for support, instruction and supervision during placement. Having been exposed to a wide range of clinical experiences, many of the students reported that they met their objectives, felt confident about working in the same area in the future, and thought that other students would benefit from the same clinical experiences. The faculty members and clinicians involved were very satisfied by these outcomes.

While the majority benefited from their clinical placements, a few of the students reported dissatisfaction as well. They rated particular clinical venues poorly. While this may be a peculiar case, an exception more than the rule, these venues will be monitored closely in subsequent evaluations to detect a pattern of student dissatisfaction. These clinical venues might benefit from ongoing feedback from and collaboration with the faculty. Some educational strategies have been identified as being helpful for these participating organisations, e.g. exploring quality clinical supervision, initiating preceptorship programs, emphasising effective interactions between nurses, independent learning facilitation, all important elements comprising effective clinical environments. These have been previously identified by Hughes (1998), Patton and Dowd (1994), Rafferty and Coleman (1996), Sykes (1996), and Williams, et al. (1993).

At present, the course coordinators meet regularly with clinical placement coordinators from various rural hospitals. The purpose of these three-monthly meetings is to share the responsibility for clinical teaching and learning and to continue improving the quality of clinical experiences. The learning needs and expectations of students and the expectations of health organisations are addressed appropriately at these meetings. A number of positive outcomes have arisen from this regular exchange. Information sessions about performance evaluation were conducted and workshops on clinical supervision were organised and conducted by the academics in order to assist partner organisations. We have conducted annual nursing career expositions to allow students to meet face-to-face with industry employers as well as learn about the numerous employment opportunities in rural areas. Our partnership with rural health services and agencies has resulted in a Clinical Facilitator's Resource Manual, which will assist clinical facilitators in providing with students clinical knowledge and experience.

We can appreciate the value of the workplace experience in coaching nursing students but while the placement venues provided authentic experiences, good learning environments need work and sustaining. Hughes (1998) speaks about egalitarian, cooperative and personal attributes characterising ideal workplaces. In addition, being supportive of the learner as a whole person and being respectful of learning processes are requisites of situating learning in environments.

One of the deficiencies identified by students was the feeling of being inadequately prepared for clinical placement. This is an important aspect that was identified by some 22% of students. Student concerns about preparation, confidence and expectations about what they can do or cannot do need examining. Undoubtedly, there is a need to adequately prepare all students for placement. Hence, in addition to the current ways of preparing students for practice, some innovative approaches may need exploring. For instance, students might benefit from attending additional sessions, extra-coaching as heeded by Aviram, et al. (1998), the use of clinical challenge or contract, and use of more clinical laboratory simulation, which has been shown to improve transition of theory to practice (Olesinski, Brickell, & Pray, 1998). Directing students to preceptors or clinical supervisors is another strategy suggested by many scholars (Dusmohamed & Guscott, 1998; LeGris & Cote, 1997; Nordgren, Richardson & Laurella, 1998; & Teasdale, Brocklehurst and Thom, 2001). Preceptors and supervisors are valuable for professional and personal support and instruction (Hawkins & Shohet, 2000). These mechanisms have been shown to yield more productive and meaningful experiences and increase self-confidence among students. We have taken these ideas on board and working with students to facilitate clinical learning.

While there may be some divergence in views held by faculty and industry partner, the most important consideration is to provide students the opportunity to experience their new knowledge on their perception and understanding of the work environment (Choi & Hannafin, 1995). Moreover, the focus or goal should be 'furthering the learning and development of (the) student, (and) not the needs of the placement organisation' as cautioned by Hughes (1998, p. 224). It must be remembered also that positive outcomes are achieved when student and service goals and expectations are met.

In exploring maximizing students' learning during placements, the following are being considered by the faculty:

• Ensure the student understands the purpose and criteria of the evaluation;
  
  
• Direct students to reflect on the learning process;
  
  
• Assist in developing skills in evaluating the quality of clinical placement;
  
  
• Furnish copies of the overall evaluation reports to participating health services and agencies;
  
  
• Provide participating health services or agencies access to data on request;
  
  
• Monitor student feedback and act accordingly;
  
  
• Work closely and collaboratively with industry partners and support the same.
  
  

Conclusion

We have presented the findings derived from the evaluation of the clinical placement experiences of nursing students enrolled in the BN program in the Discipline of Nursing & Rural Health, University of South Australia, Whyalla Campus. The evaluation instrument was developed in collaboration with industry partners. These key stakeholders were keenly interested in providing high quality clinical experience for nursing students and establishing a working and sustainable culture of clinical learning for future graduates and employees.

We have provided an overview of a small-scale study (N=107) designed to measure overall student satisfaction on clinical placement venues. The instrument was carefully constructed to determine how the students evaluated the clinical venue in terms of meeting their objectives and expectations, provision of an environment supportive of learning, professional growth and skills development, and availability of clinical supervision.

The most obvious perception in the qualitative data was that the majority of students found their clinical placement venues to be supportive of learning, professional growth, skills development and practice. Their experiences with the clinical settings were pleasant and the outcomes satisfying. This is interesting because the literature on workplace learning continually emphasises the significant impact of context on student learning and satisfaction. The situational environment provided is paramount to gaining conceptual and procedural knowledge and understanding gained by students.

This small-scale research project provided the opportunity for collaboration and development of collegial relationships between academics and service providers. The importance of feedback from all participants has been invaluable. Various mechanisms and processes addressing the concerns of the minority of students who felt that they were ill-prepared for placement and were dissatisfied with some clinical venues, have also been identified and currently being addressed.

The project has unravelled a number of challenges. As the evaluation instrument provided objective, direct and prompt feedback on learning experiences on clinical venues, it is recommended that evaluations be conducted as an ongoing basis and will consist of both process and outcome assessments. It is also recommended that we provide each participating health service or agency with a copy of the summary of the survey results. Access to specific research data will be provided on request by the health services or agencies that have provided clinical placements. More importantly, it has been agreed by all parties that partnership and collaboration will continue to explore mechanisms and processes by which clinical placements can be further improved and developed.

References

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APPENDIX 1 & APPENDIX 2

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