Assessing the quality of nursing clinical placement: A quantitative cross‐sectional study

Abstract

Aim

To evaluate the quality of nursing clinical placement among nursing students.

Design

This is a descriptive cross‐sectional study.

Methods

Two hundred eighty two nursing student completed self‐administered, online questionnaires. The questionnaire assessed participants' socio‐demographic data, and the quality of their clinical placement.

Results

The students had a high mean score for the overall satisfaction of their clinical training placement with high mean score for the item of “patient safety was fundamental to the work of the units” and the item of “I anticipate being able to apply my learning from this placement,” while the lowest mean score was related to “This placement was a good learning environment” and “Staff were willing to work with students.” Patient or Public Contribution: Quality of clinical placement is critical for improving the everyday quality of care for patients who are in desperate need of caregivers with professional knowledge and skills.

1. INTRODUCTION

Contemporary Nursing science is founded on theoretical teaching through the classroom and practical teaching through laboratory simulation and clinical settings (Hashemiparast et al., 2019; Pattison et al., 2022). In Saudi Arabia, nursing students are required to complete up to 75 credit hours of practical experience (Aljohani, 2020). The practical teaching allows students to learn to translate classroom learning into patient care in order to build competent nurses in the various fields of nursing (Hashemiparast et al., 2019). Practical learning occurs during clinical training in different healthcare settings, such as hospitals, primary care centers, elderly centers, and rehabilitation centers (Asadizaker et al., 2015).

Educational institutions are tasked with evaluating the educational process, whether theoretical or practical (Asadizaker et al., 2015). Each nursing school has a unique method for determining the effectiveness of clinical placement (MacLean et al., 2018). In Saudi Arabia, there is no overall agreement on an evaluation tool. Several universities evaluate the clinical setting based on student or faculty input (Al Mutair, 2015), while, others assess students' experiences based on the clinical area's overall atmosphere (Alatawi et al., 2020). However, according to the current research study, several important elements may be overlooked when assessing student experience. These include student orientation, and assistance with learning.

2. BACKGROUND

Developing competent nurses is vital to improving the quality of the health care system and this requires quality nursing education to help them gain the necessary knowledge and skills (Kieft et al., 2014). Multiple studies stress the innovative and effective strategies needed to develop and train clinical mentors for nursing students in diverse healthcare environments (Gropelli & Shanty, 2018; Oikarainen et al., 2018). Further, clinical training is complex and rapidly changing and provides real opportunities for students to transfer knowledge to practical situations (Needham et al., 2016; Pitkänen et al., 2018). Nursing students spend up to 50 percent of their time in clinical settings (Nursing and Midwifery Council, 2008); therefore, evaluating the clinical placement teaching process is valuable and has the potential to improve the quality of nurse education (Lasmarías et al., 2020).

Previous research identified a variety of elements that influence student experience, including preparation for placement, the supervision or preceptor model, and clinical setting services (Hanson et al., 2020; McKellar, 2017; Papastavrou et al., 2016). A variety of measures have been developed to assess the quality of the student experience (Laugaland et al., 2020; Mansutti et al., 2017).

In Saudi Arabia, the educational factors that help or hinder nursing students in the clinical placement are challenging to identify. This may be because evaluation tools are performed at each nursing college separately and are not adequately publicized. There is a lack of a standardized system for all nursing schools. There is a need for a comprehensive evaluation tool for clinical placement including essential components covering all the aspects of the quality of training.

This research aimed to evaluate clinical placement using Placement Evaluation Tool (PET) which provides direct student feedback about their perceptions of learning during a clinical practice placement.

3. METHODS

3.1. Aim of the study

To evaluate the quality of Bachelor of Nursing students' clinical placement, using The Placement Evaluation Tool (PET; Cooper et al., 2020).

3.2. Research design

Descriptive, cross‐sectional survey design was used for this study.

3.3. Settings

College of Nursing at Princess Nourah bint Abdulrahman University. Bachelor of Nursing students from one university who experience clinical practice placement across the variety of acute and general care hospitals at Riyadh, KSA. The placement duration is ranged from 8 to 13 weeks through the academic semester of the academic year.

3.4. Population and sample

The population of interest was nursing students studying Bachelor of Nursing at Princess Nourah bint Abdulrahman University. The inclusion criteria include: (1) nursing students studying BSN program at Princess Nourah bint Abdulrahman University, (2) students who completed one clinical nursing rotation/unit, (3) internship students who practice a year of clinical nursing skills in different healthcare settings and different nursing specialties among 12 months per year. A population power calculation identified a sample size of 282 participants based on a small effect size of 0.25 since this is a survey design with no intervention. The probability for a type one error is 0.05 yielding power of 0.8.

3.5. Tool

3.5.1. The placement evaluation tool

Data were collected using The Placement Evaluation Tool (PET) which was developed by Cooper et al. (2020), who found it valid, and reliable (α = 0.83) with two subscale factors: Clinical Environment (Cronbach's α = 0.94) and Learning Support (α = 0.96). The Placement Evaluation Tool was used to measure the students' perception regarding the quality of their clinical placement experience.

The PET includes 19 items (each rated 1 “strongly disagree” _to 5 “strongly agree”) and a 20th global overall rating of the placement (rated 1 “very dissatisfied” _to 10 “extremely satisfied”). A short demographic response section was included. For each factor and for the overall satisfaction item, higher scores indicate higher quality perceptions. Questionnaires were constructed in the English language.

3.5.2. Ethical consideration

Institutional Review Board (IRB) approval (No. 21‐0168) was attained from REDACTED. Written approval to conduct the study was obtained from the administrative authority of the study setting. The first page of the questionnaire clarified the purpose of the study, assured the voluntary and confidential nature of responses, and stated that the authors would regard the completion and submission of the questionnaires as consent to participate. The subject's right to withdraw from the study was assured.

3.5.3. Data collection

The questionnaire was distributed online to the students from 2nd to 5th year nursing who who had completed a clinical placement for practical teaching during study time. Reminders were sent for the questionnaire to be completed at the end of their scheduled training.

3.6. Statistical analysis

Data were collected online by the university survey software (REDCAP). Data were downloaded and analysed using the computer software program IBM SPSS Statistics for Windows, Version 24.0. IBM Corp. Descriptive analysis of study variables was used to analyse the results of the study. Relationships between students' clinical placement related factors, overall satisfaction and demographic characteristics were tested using Kruskal Willis Test. All reported p‐values are two‐tailed, and 0.05 level was used for statistical significance.

4. RESULTS

There were N = 282 completed surveys returned from nursing students that were used for analysis. This equates to a 100% response rate as the researchers targeted to reach to the calculated sample from the total population of the nursing students when there is missed responses. Table 1 presents student characteristics and the nursing student participants' enrolment across academic years. Students were distributed throughout the course years with the highest number as 48.6% (n = 137) in the internship year. Almost half (48.9%, n = 138) of the students were placed in chronic health care systems followed by 35.5% (n = 100) placed in acute care health care systems. As well, more than half (51.4%, n = 145) of the students were supervised in clinical placement by university educators followed by more than one third (31.9%, n = 90) supervised by a clinical educator employed by the healthcare service.

TABLE 1.

Demographic characteristics of the study samples (n = 282).

Demographics	No.	%
Academic year of study
2nd year	51	18.1
3rd year	45	16.0
4th year	49	17.4
Internship	137	48.6
Type of healthcare system is the current placement
Chronic care	138	48.9
Primary service	35	12.45
Tertiary care	9	3.2
Acute care	100	35.5
Primary clinical supervisor
Registered Nurse	47	16.7
Clinical Educator	90	31.9
University Educator	145	51.4

Table 2 showed that the overall satisfaction of the students was high with a mean score of 7.57 of a possible 10 points. This is equivalent to a satisfaction rating of 76%. The mean score (±standard deviation) of students' perception of the Clinical Environment factor was 3.90. Of the eight items in the factor, the students' highest mean score (4.13) was recorded for the item of “patient safety was fundamental to the work of the units” while the lowest mean score was “Staff were willing to work with students,” with a mean score of 3.70. As well as, the mean score of students' perception of Learning Support factor was 3.96. Of the 11 items, the students' highest mean score (4.10) was “I anticipate being able to apply my learning from this placement,” while the lowest mean score was “This placement was a good learning environment” with a mean score of 3.67.

TABLE 2.

Nursing students' evaluation of their clinical placement (n = 282).

The placement evaluation tool (PET)	Mean ± SD
Total clinical environment factor	3.90 ± 1.17
1. I was fully orientated to the clinical area	3.90 ± 1.30
2. Staff were willing to work with students	3.70 ± 1.27
3. Staff were positive role models	3.75 ± 1.23
4. Staff were ethical and professional	3.91 ± 1.22
5. Staff demonstrated respect and empathy toward patients/clients	3.79 ± 1.15
6. Patient safety was fundamental to the work of the unit(s)	4.13 ± 1.03
7. I felt valued during this placement	4.06 ± 1.07
8. I felt safe in the clinical environment (e.g., physically, emotionally, culturally)	3.99 ± 1.13
Total learning support factor	3.96 ± 1.23
9. This placement was a good learning environment	3.67 ± 1.34
10. My supervisor(s) helped me identify my learning objectives/needs	4.01 ± 1.26
11. I was adequately supervised in the clinical environment	3.98 ± 1.12
12. I received regular and constructive feedback	4.0 ± 1.18
13. I was supported to work within my scope of practice	4.07 ± 1.19
14. My supervisor(s) understood how to assess my clinical abilities	4.08 ± 1.24
15. I had opportunities to enhance my skills and knowledge	3.98 ± 1.30
16. I had opportunities to interact and learn with the multi‐disciplinary team	4.01 ± 1.27
17. I achieved my learning objectives	3.82 ± 1.25
18. I have gained the skills and knowledge to further my practice	3.87 ± 1.26
19. I anticipate being able to apply my learning from this placement	4.10 ± 1.14
Total clinical placement	4.00 ± 1.15
Global rating
20. I was satisfied with this placement experience	7.57 ± 2.14

Among the respondents, 2nd year students showed the lowest placement evaluation score of total mean with a satisfaction rate of 6.49 (65%). Table 3 shows that clinical placement factors were positively associated with their academic year of study (H = 68.997, p‐value = <0.005), type of healthcare system of current placement (H = 16.844, p‐value = 0.005), and the type of their primary clinical supervisor (H = 10.390, p‐value = 0.006). As well as students' overall satisfaction with clinical placement experience was positively associated with their academic year of study (H = 28.314, p‐value = <0.001), type of healthcare system of their current placement (H = 50.766, p‐value <0.001), and the type of their primary clinical supervisor (H = 8.796, p‐value = 0.012).

TABLE 3.

Correlation between students' clinical placement related factors, overall satisfaction and their demographic characteristics (n = 282).

Demographics	Students' clinical placement factors	Overall satisfaction with clinical training placement experience
	Mean ± SD	Mean ± SD
Academic year of study
2nd year	3.18 ± 0.90	6.49 ± 1.88
3rd year	3.85 ± 0.80	7.84 ± 1.96
4th year	3.68 ± 0.84	7.18 ± 1.78
Internship	4.31 ± 0.80	7.97 ± 2.28
H (p)	68.997* (<0.001*)	28.314* (<0.001*)
Type of healthcare system is the current placement
Chronic care	3.56 ± 1.08	5.67 ± 0.50
Primary service	4.02 ± 0.88	7.71 ± 2.33
Tertiary care	3.91 ± 0.84	6.75 ± 1.14
Acute care	4.44 ± 0.67	8.38 ± 2.13
H (p)	16.844* (0.005*)	50.766* (<0.001*)
Primary clinical supervisor
Registered Nurse	3.78 ± 0.91	7.24 ± 1.78
Clinical Educator	4.08 ± 0.79	7.64 ± 1.89
University Educator	3.98 ± 0.96	7.66 ± 2.30
H (p)	10.390* (0.006*)	8.796* (0.012*)

Note: H, H for Kruskal Wallis test.

^*Statistically significant at p ≤ 0.05.

5. DISCUSSION

Clinical experiences differ based on organizational management, supervisory relationships, and students' expectations, according to previous research (Cooper et al., 2020; Saarikoski & Strandell‐Laine, 2018). These influences need to be considered to prepare nursing students to practice safely post‐graduation (Cooper et al., 2020). This study aimed to measure the quality of nursing clinical placement using the tool developed by Cooper et al. (2020) and to assess the satisfaction of students within this placement. The tool enabled students to evaluate the clinical environment and their learning experience with the end goal of identifying the relationship between the clinical site, the training instructor, and the quality of the training.

The tool used was statistically valid and head reliable properties proven with a coronbachs alpha score of 0.83 for the PET scale that was developed by Cooper et al., 2020. Most students' responses described a positive clinical placement experience. The overall satisfaction of the students with their clinical training placement was high with ahigh mean score 7.57 (976%). The lowest item score was related to “This placement was a good learning environment” with a mean score of 3.67 of five and “Staff were willing to work with students” with a mean score of 3.70 of five. This indicates that many students rated the items neutrally, neither agreeing nor disagreeing. This finding might be explained by the fact that these two important characteristics represent the ideal, a student perceiving welcoming environment and educational support offered by nurses, as emphasized in other published instruments (for example, the Clinical Learning Environment S‐scale also used to evaluate education in health care; Saarikoski & Strandell‐Laine, 2018).

Despite a positive satisfaction rating in the current survey, 20.43% of respondents were unsatisfied with staff willingness/attitudes toward students in the learning environment. This outcome is concerning and emphasizes the importance of a quality evaluation method and regular placement reviews. Previous research has indicated comparable positive experiences based on individualization of placement, teachers' competence and devotion to students, and education (Cooper et al., 2020; d'Souza et al., 2015; Papastavrou et al., 2016; Sigalit et al., 2017). Our findings on student satisfaction are slightly lower than those of Cant et al. (2021) who studied international literature and Luders et al., 2021, who discovered Australian nursing students. This suggests there is room for improvement in Saudi Arabia.

Exclusion is a problem that has an influence on the whole experience since students need to feel like they belong (Jack et al., 2018) and are welcomed (Lamont et al., 2015) in a friendly environment (Van Der Riet et al., 2018). Furthermore, the educational environment was a barrier when it was not connected with students' stage of development, with worries that assignments such as elderly care were not sufficiently challenging (Robinson & Cubit, 2007). The ‘Environment’ factor (which included the placement setting as well as staff attitudes) included placement applicability, safety, supervision and evaluation, and professional culture are relevant. Students judge the placement's relevance in terms of their knowledge and abilities, as well as the extent to which they might improve educationally. Löfmark et al. (2012) discovered that students had comparable judgements of the importance of completing learning goals in clinical practice. Specialty placement such as Mental Health, rural, and overseas placement were highly received according to existing studies both worldwide and in Australia (Giralt Palou et al., 2020; Halcomb et al., 2018; McInnes et al., 2015; Peters et al., 2015).

Concerns have already been raised about workplace orientation, scope of practice, supervisory issues, and evaluation requirements (Bongar et al., 2019; Jarvelainen et al., 2018). Communication between clinical and university partners must improve to ensure clinical partners are aware of students' skills throughout year levels and that appropriate skill competency is maintained. Personal identity safety may have a substantial influence on the students' experience, with some students reflecting on racism in the clinical setting. Mikkonen et al. (2016) observe that culturally and linguistically diverse students frequently encounter clinical learning settings that are oblivious of their learning difficulties and are consequently regarded negatively. Uncivil behaviour in general is a source of worry for all students, and as seen by staff attitudes, it is frequently associated with marginalization and the impression of being a burden. However, Minton and Birks (2019) observe that pupils frequently lack a clear concept of what constitutes bullying.

Among the respondents, 2nd year students showed the lowest placement evaluation score of total mean with a satisfaction rate of 6.49 (65%). This shift in scores could be due to the second year being the first in hospital clinical exposure of students. This shift could prove challenging for students and leading to the lower rating. This finding supports the study by Admi et al. (2018) which identified that the preclinical expected levels of students' stress were significantly higher than the actual stress experienced by the same group of students later on. Students in this stage often experience high stress resulting from situations in which they lack the knowledge or the necessary training to meet clinical practice demands (Pulido‐Martos et al., 2012). Previous studies about students beginning nursing programs supported these findings of inadequacy of knowledge and skills which lead to stress related to their clinicals and education (Admi et al., 2018; Jamshidi et al., 2016). Admi et al. (2018) found that the topmost stressful situations for second year students were related to inadequate preparation to cope with knowledge and skill demands. This could indicate that teaching second year students to cope with skill demands could help to improve their satisfaction rate.

A study from 2020 stated that developing a standard for the curriculum is essential for providing a consistent, systematic and comprehensive approach to patient safety education in nursing programs (Lee et al., 2020). This along with students stating the prevalence and importance of patient safety in clinical environments indicates the importance of patient safety education. This PET score also indicates that students are satisfied with this indicating that Princess Nourah bint Abdulrahman University‐patient safety curriculum is sufficient for students' skills and education with room for improvement.

5.1. Implications of the study

The long‐term aim of this study is to provide a baseline for the success of nursing programs in preparing students for nursing practice and to suggest areas for improvement. Overall, the outcomes of this study can be used to improve clinical outcomes through applicable quality improvement programs targeting the factors studied. Whilst the students' experience in clinical settings was generally positive, a minority were exposed to negative experiences. Further work is required to achieve in depth understanding of student, supervisor and educators' experiences to develop quality standards for nursing students' placement including resources to support the process. One thing that could improve both the placement evaluation, satisfaction rate and learning environment could be to have both the clinical and university educators involved with students during clinicals. Combining these could give students the best that both have to offer in terms of skills and education experience in the field.

5.2. Limitations of the study

Some limitations of the study are recognized. As the study sample was taken from a single institution for convenience, the generalizability of results is limited. Second, the current results are prone to response bias and subjectivity since they are based on self‐reported data. Finally, this study just demonstrates connections between study variables; no directionality or causal relationship can be shown.

Future research will attempt to develop a placement evaluation instrument that can be used in a variety of health fields throughout the developed world. As a result, the primary development of the placement evaluation tool in Saudi Arabia is limited because it focuses on one field–nursing. Future iterations will thus require a national Saudi nursing trial, testing and development for other health disciplines, and extensive translations (forward and backward) into additional languages. Additionally, larger sample sizes are required to ensure test–retest reliability. The placement assessment instrument is an individual self‐rating of experience that must take into account additional stakeholder reviews, such as educators, and hard result measurements, such as practice observation, student retention, employment offers, and so on. To summarize, widespread use of a tool such as the placement evaluation tool, perhaps as part of a suite of assessment tools within a national registry of clinical placement, is likely to have an impact on both educational and clinical outcomes through applicable quality improvement programs that ensure the right education, in the right place, at the right time. Longitudinal, experimental, and multi‐site studies may help to resolve these limitations in the future.

6. CONCLUSION

The current study examined nursing students' perceptions of clinical placement quality in Saudi Arabia. The findings revealed that nursing students held a positive views of the quality of clinical placement and were satisfied with their clinical training experience. There were significant differences in satisfaction by year of course enrolment, with less experience's students being less satisfied. Future study is required to identify techniques that effectively improve students' overall satisfaction and the benefit of clinical placement and training. Student satisfaction with placement experiences in chronic care settings was rated the lowest. Clinical placement areas and educational institutions should work closely together to investigate and create models of learning and supervision that are suited for the nursing home context, models that improve the learning environment for both students and staff. This is critical not just for recruiting new professionals to the elderly care industry, but also for improving the everyday quality of care for patients who are in desperate need of caregivers with professional knowledge and skills.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest to disclose.

FUNDING INFORMATION

Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2023R293), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

Baghdadi, N. A. , Alotaibi, T. , & Abdelaliem, S. M. F. (2023). Assessing the quality of nursing clinical placement: A quantitative cross‐sectional study. Nursing Open, 10, 6143–6149. 10.1002/nop2.1836

DATA AVAILABILITY STATEMENT

The datasets generated and/or analyzed during the current study are not publicly available due to data privacy but are available from the corresponding author on reasonable request.