Robyn Nash Thesis

Queensland University of Technology
School of Nursing
Faculty of Health
‘Collaboration in clinical education: Development, implementation and

evaluation of an innovative model of clinical education for undergraduate
nursing students’
Robyn Nash
BA, MHlthSc
This thesis is submitted to fulfill the requirement for the award of Doctor of
Philosophy at the Queensland University of Technology
2007
KEY WORDS
Models of clinical education
Clinical learning environment
Clinical supervision
Clinical placement
Clinical learning outcomes
Quality of clinical experience and undergraduate students
ii
ABSTRACT
Introduction
The purpose of this study was to enhance the prac experience of undergraduate nursing
students and registered nursing staff. An innovative model of clinical education, the
Clinical Education Unit (CEU) model was developed, implemented and evaluated.
Background to the study
Clinical education is a vital component of the undergraduate nursing curriculum. ‘Real
world’ practice provides students with the opportunity to develop the knowledge,
attitudes and skills needed to function effectively as a registered nurse. Despite the
commitment of universities to produce competent graduates, there has continued debate
regarding the preparedness of new graduates for practice as registered nurses. This
has focussed continued attention on the adequacy of students’ clinical education and, in
particular, on the models used for clinical facilitation/supervision. There is little published
evidence that clearly demonstrates the effectiveness of any of the current models of
clinical education or that any particular model is better than any other in achieving quality
outcomes (Wellard, Williams and Bethune 2000; Clare, White, Edwards and Van Loon
2002). Hence, as recommended in the recent National Review of Nurse Education
(2002), ongoing evaluation of nursing curricula and teaching practice, including clinical
education, is clearly warranted.
Methods
The study utilised action research methodology to examine the effects of the Clinical
Education Unit (CEU) on the quality of clinical prac as experienced by undergraduate
nursing students and registered nurses working with the students in wards where they
iii
were placed for their practicums. It was undertaken in two iterations or phases: Phase 1
– Development, implementation and initial evaluation of an innovative model of clinical
education (the CEU model) and Phase 2 – Refinement and re-evaluation of the CEU
model of clinical education. Using focus group discussions and survey questionnaires,
qualitative and quantitative data were collected from undergraduate nursing students
and clinical nursing staff in conjunction with each iteration of the study.
Results
Phase 1 results indicated that the CEU model was evaluated more positively by students
and registered nurses than were the non-CEU models that were used for comparison.
This result was demonstrated in the comments of students and registered nurses with
regard to the respective models of clinical education and supported by their ratings of
the quality of clinical experience through the QPE-Phase questionnaires. A similar trend
was found in the results from Phase 2. The CEU-2 model was again evaluated more
positively by students and registered nurses than were the non-CEU models that were
used for comparison.
Conclusion
In summary, the results of this study indicate that the CEU model had a positive impact
on the prac experience of students and registered nurses. In both phases of the study,
students and registered nurses in wards where the CEU model was being used
evaluated the prac experience more positively than did students and registered nurses in
wards where non-CEU models were being used. Two key factors were found to be
important in achieving this outcome: the collaborative nature of the CEU model and
nursing staff ownership of students’ clinical education. These factors provided an
operating framework which enabled the development of positive learning environments
iv
in the wards where students were placed for prac. Equally important were arrangements
for the supervision of students’ practice which involved local clinical facilitation and the
explicit inclusion of other nursing staff in the ward. Further, continued support from the
university to allow the clinical facilitators to take a supernumary role when facilitating
students, to provide staff development for clinical education and to support staff on a
day-to-day basis during the prac was also important, if not essential. It is proposed that
these factors, acting synergistically, promoted enhanced access to learning opportunities
for students and improved learning outcomes for students and staff. The study makes
an important contribution to nursing education by providing evidence that can inform
future developments in the area of undergraduate clinical education. It has potential
benefits for nursing education not only in the local context, but within the international
arena as well.
v
TABLE OF CONTENTS
TITLE PAGE i
KEY WORDS ii
ABSTRACT iii
TABLE OF CONTENTS vi
LIST OF TABLES x
LIST OF FIGURES xi
GLOSSARY xii
STATEMENT OF ORIGINAL AUTHORSHIP xiii
DECLARATION OF ENROLMENT xiv
ACKNOWLEDGEMENTS xv
CHAPTER 1: Introduction and Summary 1
1.1 Background and Significance 1

1.2 Problem statement 2
1.3 Aims 3
1.3.1 Aims of the research 3
1.3.2 Research questions 5
1.4 Research Design and Methodology 5
1.5 Expected Outcomes 6
CHAPTER 2: Literature Review 8
2.1 Introduction 8
2.2 Nursing education: an overview 9
2.2.1 Changes in nurse education 9
2.2.2 Outcomes of pre-registration programs 11
2.3 Clinical education: an overview 15
2.3.1 Nature of clinical education 15
2.3.2 The context of clinical education 18
2.4 Clinical learning environment 20
2.5 Models of clinical education 24
2.5.1 Full-time academic staff 26
2.5.2 Sessional facilitators 27
2.5.3 Seconded facilitators 28
2.5.4 Preceptors 29
2.5.5 Beyond traditional supervision and preceptorship 31
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2.6 Clinical facilitators 32
2.7 Findings from an evaluation study 36
2.7.1 What the students said 36
2.7.2 What the facilitators said 37
2.7.3 What the health care facility representatives said 39
2.7.4 The “ideal” model? 40
2.8 Summary 41
CHAPTER 3: Methodology 43
3.1 Introduction 43
3.2 Research questions 43
3.3 Research paradigm 44
3.3.1 Fundamental concepts of action research 45
3.3.2 Key characteristics of action research 47
3.3.3 Issues regarding action research as a research methodology 49
3.4 Research design 52
3.4.1 Setting 52
3.4.2 Study participants 55
3.4.3 Change intervention 60
3.5 Data collection 62
3.5.1 Focus groups 65
3.5.2 Survey questionnaires 68
3.6 Data analysis 71
3.6.1 Qualitative data 71
3.6.2 Quantitative data 72
3.7 Ethical considerations 73
3.8 Summary 75
CHAPTER 4: Change intervention 76
4.1 Introduction 76
4.2 Background 76
4.3 The CEU model 77
4.3.1 Theoretical basis 79
4.3.2 Core principles underpinning the CEU 80
4.3.2.1 Collaboration 80
4.3.2.2 Positive learning environment 82
4.3.3.3 ‘Whole of unit’ commitment 82
4.3.3 Structural elements of the CEU 83
4.3.3.1 Clinical Associates 83
4.3.3.2 Clinical Partners 85
4.3.3.3 Academic liaison 86
4.3.3.4 Continuity of student placement 87
4.4 Implementation of the CEU model 88
4.5 Non-CEU models for this study 90
4.6 Summary 91
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CHAPTER 5: Results – Phase 1 92
5.1 Introduction 92
5.2 Students 92
5.2.1 Research question 1 93
5.3 Registered nurses 110
5.4 Summary 124
CHAPTER 6: Results – Phase 2 126
6.1 Introduction 126

6.2 Students 126
6.3 Registered nurses 140
6.4 Summary 152
CHAPTER 7: Discussion 154
7.1 Introduction 154

7.2 Phase 1 157
7.2.1 Students’ perspectives 157
7.2.2 Registered nurses’ perspectives 160
7.3 Phase 2 162
7.3.1 Students’ perspectives 162
7.3.2 Registered nurses’ perspectives 165
7.4 What influenced the CEU outcomes? 167
7.4.1 Collaboration 169
7.4.2 Sense of ‘local ownership’ 171
7.4.3 Positive learning environment 173
7.4.5 Improved supervision arrangements 174
7.4.6 ‘Good’ outcomes for students and staff 176
7.5 Limitations of the study 179
7.6 Summary 181
CHAPTER 8: Implications and Recommendations 183
7.7 Implications 183

7.8 Recommendations 187
7.9 Conclusions 188
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APPENDICES
Appendix 1: Overview of the key findings from the Evaluating the Quality and
Effectiveness of Selected Models Pre-registration Clinical Education
project (Nash et al. 1999)
Appendix 2: Focus group questions: Phase 1
Appendix 3: Focus group questions: Phase 2
Appendix 4: Quality of Prac Experience questionnaire (Phase 1): Students
Appendix 5: Quality of Prac Experience questionnaire (Phase 1): RNs
Appendix 6: Quality of Prac Experience questionnaire (Phase 2): Students
Appendix 7: Quality of Prac Experience questionnaire (Phase 2): RNs
REFERENCES
ix
List of Tables
Table 2.1 Most commonly identified characteristics of ‘good’ clinical 35

educators / mentors
Table 5.1 Themes and categories from the student focus groups (Phase 1) 93
Table 5.2 Demographic characteristics of the student sample (QPE-Phase 1) 104
Table 5.3 CEU and non-CEU students’ responses to the QPE-Phase 1 105
(Student) questionnaire
Table 5.4 Mean ratings for CEU and non-CEU students on QPE-Phase 1 109
(Student) questionnaire items
Table 5.5 Themes and categories from the registered nurse focus groups 110
(Phase 1)
Table 5.6 Demographic characteristics of the RN sample (QPE-Phase 1) 119
Table 5.7 CEU and non-CEU RNs’ responses to the QPE-Phase 1 (RN) 121
questionnaire
Table 5.8 Mean ratings of CEU and non-CEU RNs on QPE-Phase 1 (RN) 122
questionnaire items
Table 5.9 Mean ratings of CEU students and CEU RNs on common QPE- 124
Phase 1 questionnaire items
Table 6.1 Themes and categories from the student focus groups (Phase 2) 127
Table 6.2 Demographic characteristics of the student sample (QPE-Phase 2) 136
Table 6.3 CEU and non-CEU students’ responses to the QPE-Phase 2 138
(Student) questionnaire
Table 6.4 Themes and categories from the registered nurse focus groups 141
(Phase 2)
Table 6.5 Demographic characteristics of the RN sample (QPE-Phase 2) 147
Table 6.6 CEU and non-CEU RNs’ responses to the QPE-Phase 2 (RN) 149
questionnaire
Table 6.7 Mean ratings of CEU and non-CEU RNs on QPE-Phase 2 (RN) 150
questionnaire items
Table 6.8 Mean ratings of CEU students and CEU RNs on common QPE- 152
Phase 2 questionnaire items
x
List of Figures
Figure 2.1 Trigonal model of clinical education 18

Figure 2.2 Initial conceptualisation of factors impacting on the quality of 20
students’ clinical experience
Figure 3.1 Study design 49
Figure 4.1 Schematic representation of the CEU model (Phase 1) 79
Figure 4.2 Schematic representation of the CEU model (Phase 2) 89
Figure 7.1 Re-conceptualisation of factors impacting on the quality of students’ 169
clinical experience in settings where they are on prac.
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GLOSSARY
Buddy / buddy RN A registered nurse working in a particular health care

facility/service who is informally ‘paired up’ with an
undergraduate nursing student during the course of a
clinical practicum in that clinical area
Clinical Associate A registered nurse working in a CEU unit who is formally

appointed to the supernumary CA role for the duration of a
clinical practicum/s – similar to the Clinical Associate role in
non-CEU areas
Clinical facilitator A registered nurse who is formally appointed to a

supernumary clinical facilitation role and charged with the
key responsibility for the clinical learning of a group of
undergraduate nursing students undertaking a clinical
practicum in a particular health care facility/service –
usually a 1:8 ratio of facilitator to students
Clinical Partner A registered nurse working in a CEU unit who is informally

‘paired up’ with an undergraduate nursing student
undertaking a clinical practicum in that clinical area –
similar to the buddy RN role in non-CEU clinical areas
Grads A common colloquial term for graduate nurses
Prac A common colloquial term for clinical practice that is used

by students, academic staff and clinical nurses
Sessional facilitator A registered nurse employed directly by the university to act

as a supernumary clinical facilitator for the duration of a
clinical practicum
Seconded facilitator A registered nurse employed in a health care facility who is

appointed under agreement between a university and a
health care facility to act as a supernumary clinical
facilitator for the duration of a particular clinical practicum/s
Out on prac A common colloquial term used by students to denote the

undertaking of a clinical practicum in a health care setting
Preceptor A registered nurse employed in a health care facility who

formally agrees to work with an individual student on a 1:1
basis for the duration of a clinical practicum
Uni A common colloquial term for University that is used by

students, academic staff and clinical nurses
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STATEMENT OF ORIGINAL AUTHORSHIP
The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the
best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made.
Signature
Date
xiii
DECLARATION OF ENROLMENT
I, Robyn Elizabeth Nash, a candidate for the degree of Doctor of Philosophy at the
Queensland University of Technology, have not been enrolled for another tertiary award
during the term of my PhD candidature without the knowledge and approval of the
University’s Research Degrees Committee.
Candidate’s signature
Date
xiv
ACKNOWLEDGEMENTS
The completion of a PhD thesis is rarely a solitary activity. Besides the researcher-writer
many others are involved, and their support and encouragement is crucial to successful
completion. I wish to gratefully acknowledge the following:
Firstly, I would like to acknowledge and thank the Royal Brisbane and Womens’ Hospital
for the support they provided with respect to the development, implementation and
evaluation of the Clinical Education Unit (CEU) model of clinical education. The
continued willingness and commitment of staff to work collaboratively toward a ‘better’
way to provide quality clinical learning for undergraduate nursing students was
exemplary.
I would like to express my deep appreciation for the magnificent support provided by Ms
Pam Lemcke in the School of Nursing at QUT. Her unflagging enthusiasm and sustained
commitment to the project were absolutely invaluable.
I would also like to thank all the participants in this study. This includes the many
students, nursing staff, clinical supervisors and academic staff who were involved in
either the first iteration (Phase 1) or the second iteration (Phase 2). Without their
commitment the study would not have been possible.
I also express my appreciation and thanks to my supervisors Professor Helen Edwards

and Dr. Ian McPherson. Their patience, critical comment and continued guidance have
been a wonderful source of motivation and encouragement.
Finally, I would like to acknowledge and thank my family who have patiently lived
through the journey with me. Their unqualified support has been inspirational.
Robyn Nash
xv
CHAPTER 1
INTRODUCTION AND SUMMARY
1.1 Background and Significance
Nursing is a practice-based discipline that requires a minimum level of competence for
entry into practice as a registered nurse. The ability of newly registered nurses to
effectively fulfil their clinical roles is dependent to a large extent on the quality of the
clinical preparation that occurs during the pre-registration course. The clinical education
program provides students with real world opportunities to develop the knowledge,
attitudes and skills implicit in the Australian Nursing and Midwifery Council (ANMC)
Competencies and the organisational abilities needed to function effectively as a
registered nurse. Clinical experience enables students to have direct contact with
patients, clients, families and staff within the health care milieu. Despite the ongoing
commitment of universities to produce competent graduates, there has been a growing
tension between universities and health care facilities with respect to the preparedness
of new graduates for practice as registered nurses. As noted in the National Review of
Nursing Education Discussion Paper (2001), this has focussed continued attention on
the adequacy of students’ clinical education and, in particular, on the models used for
clinical facilitation/supervision.
There is little published evidence that demonstrates the effectiveness of any of the
current models of clinical facilitation, or that any particular model is better than any other
in achieving quality outcomes (Wellard, Williams and Bethune 2000; Clare et al. 2002).
The quality of the clinical experience program and, in particular, the facilitation provided
is a key element in the preparation of pre-registration students for professional practice.
1
With respect to the educational preparation of registered nurses, the National Review of
Nurse Education (2002) recommended that “there is ongoing evaluation of curricula and
teaching practice in light of changes in nursing practice, research on learning and
broader developments in professional and para-professional preparation” (p. 24). Thus,
further exploration of the models used to facilitate students’ learning in the clinical setting
is clearly warranted. The knowledge gained from such exploration will add to the
evidence base that can be used in the management of clinical programs and on which to
develop innovative strategies for the clinical education of pre-registration students. This
will contribute toward improvement in the preparation of students for practice and their
ability to function as newly graduated registered nurses.
1.2 Problem statement
Currently there is a relative absence of knowledge and understanding about the
differential impact of various models of facilitation on students’ clinical education
experience and learning outcomes achieved in the clinical setting (McKinley et al. 2002).
Much of the current literature is descriptive in nature and relates to particular aspects of
clinical facilitation rather than models of clinical education, per se. Research reports
have typically involved small scale qualitative studies focussing on the experiences of
particular student cohorts (eg. first year students etc.) or cross-sectional quantitative
studies that have focussed solely on students’ perceptions regarding clinical education.
There has been very little systematic consideration of registered nurses’ perceptions and
their relationship to students’ perceptions, and/or the sustainability of stakeholder
perceptions over time.
2
However, evidence available to date indicates that there are both advantages and
disadvantages associated with the various models that are most commonly used, and
that no one model stands out as an ideal model of clinical facilitation (Nash et al. 1999).
Therefore the challenge is to be able to maximise the identified strengths of various
models, whilst at the same time minimising the disadvantages and maintaining the
flexibility needed to implement the model across different settings with different groups
of students. Given the importance of clinical education within pre-registration
undergraduate courses, and continued tensions surrounding the preparedness of
graduates for practice, the need to develop more innovative strategies for enhancing the
facilitation of students’ learning in the clinical setting is clear.
1.3 Aims
1.3.1 Aims of the research
The primary aim of this project was to develop, implement and evaluate the impact of an
innovative model of clinical supervision (the Clinical Education Unit or CEU) on the
clinical prac experiences of pre-registration nursing students and clinical nurses working
with the students. The objectives of the study were to:
• Design and implement an innovative model of clinical supervision (the CEU) in
collaboration with clinical colleagues at a major tertiary hospital;
• Examine the impact of the CEU on the perceptions of undergraduate nursing
students; and
• Examine the impact of the CEU on the perceptions of registered nursing staff
working with the students.
3
Secondary aims of the study were to strengthen the relationships between academic
and clinical staff with respect to undergraduate clinical education, promote critical debate
between the key players about undergraduate clinical education, and create an
environment that sustains ongoing improvement on a collaborative basis.
The study utilised action research methodology to examine the effects of the Clinical
Education Unit (CEU) on the quality of clinical prac as experienced by undergraduate
nursing students and clinical nurses working with the students in wards where they were
placed for clinical practicums. Following an earlier investigation of the advantages and
disadvantages of existing models of clinical education (Nash et al. 1999), the study
involved two iterations of a change intervention (the CEU model of clinical education) –
referred to as Phase 1 and Phase 2 - and the collection of qualitative and quantitative
data from undergraduate nursing students and registered nursing staff in conjunction
with each iteration. The specific objectives for each phase of the study were to:
• Compare the perceptions of undergraduate students with regard to CEU and non-
CEU models of clinical education and the quality of their prac experience;
• Compare the perceptions of registered nurses (RNs) with regard to CEU and non-
CEU models of clinical education and the quality of students prac;
• Identify similarities and/or differences in the perceptions of students and RNs with
regard to models of clinical education; and
• Provide recommendations for the future provision of undergraduate clinical education
4
1.3.2 Research questions
In order to achieve the primary aim and objectives of this study, the following research
questions were examined:
• What are the perceptions of undergraduate nursing students with respect to the CEU
model of clinical education, and how do they compare with students’ perceptions
regarding non-CEU models?
• What are the perceptions of registered nurses (RNs) with respect to the CEU model
of clinical education, and how do they compare with RNs’ perceptions regarding non-
CEU models?
• How do CEU students rate the quality of their practicum experience, and how do
their ratings compare with those of non-CEU students?
• How do CEU RNs rate the quality of students’ practicum experience, and how do
their ratings compare with those of non-CEU RNs?
• What factors influence the outcomes for students and registered nurses?
1.4 Research Design and Methodology
This study used action research methodology to investigate the key issues of interest.
The study was undertaken in two iterations or phases:
• Phase 1 – Development, implementation and initial evaluation of an innovative model
of clinical education (the CEU model); and
• Phase 2 – Refinement and re-evaluation of the CEU model of clinical education.
5
Phase 1 of the study was based on the findings of a study undertaken earlier to evaluate
four models of clinical facilitation (Nash et al. 1999). Throughout the study data was
collected through focus group discussions that were conducted to explore participants’
perceptions regarding issues relevant to the study objectives. In addition, survey
questionnaires were used to examine relevant issues in greater detail. Participants in the
study were undergraduate (pre-registration) nursing students and registered nursing
staff in the health care facilities where students were placed for their clinical practicums.
1.5 Expected Outcomes
Expected outcomes of this study included:
• an improved understanding of factors that influence the education of undergraduate
nursing students in clinical practice settings;
• the identification of a ‘best practice’ model for the clinical education of undergraduate
nursing students;
• a better understanding of the dynamics of clinical learning environments for
undergraduate nursing students; and
• the further development of collaborative relationships between academic and clinical
nursing staff with respect to the clinical education of undergraduate nursing students.
These data respond to issues addressed as part of the National Review of Nursing
Education (2002), and the work that is currently being conducted by the National Nursing
and Nursing Education Taskforce (N³ET) to progress and monitor many of the
6
recommendations in the Our Duty of Care Report (2002). They add to the evidence base
that can be used to inform policy development in the area of clinical education, and the
further development of innovative models that contribute to improved quality in the
clinical education of undergraduate nursing students.
7
CHAPTER 2
LITERATURE REVIEW
2.1 Introduction
This chapter presents a review of literature related to clinical education for
undergraduate nursing students. The main strategy used to identify relevant literature
included searching the CINAHL, Medline and ERIC databases using a number of key
words that were developed in consultation with the Health Librarian at the QUT Library.
These included clinical education, clinical supervision, clinical learning, clinical learning
environment, clinical placement and nurse education. Additional information sources
such as monographs, reports, theses and dissertations were also identified with
assistance from the Health Librarian.
The chapter begins with a brief overview of background issues related to the move of
nursing education into the tertiary sector and the debates that continue regarding the
quality of graduates. This is followed by a discussion on clinical education within
undergraduate nursing programs and challenges that are faced by students when they
are on prac. The literature review then addresses three key factors which impact on the
quality of clinical education: the clinical learning environment, models of clinical
education, and clinical facilitators and clinical facilitation. Finally, the findings of an earlier
study led by the author to evaluate four models of clinical facilitation and investigate
‘best practice’ in clinical education for pre-registration nursing students are reported. The
chapter then concludes with a brief summary.
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2.2 Nursing education: An overview
2.2.1 Changes in nurse education
Nursing is a practice-based discipline and a minimum level of competence, regulated
through the Australian Nursing and Midwifery Council (ANMC) competencies for
beginning practitioners, is required for registration/licensure to practice as a nurse. In
Australia the nursing workforce is a group that includes registered nurses (RNs),
enrolled nurses (ENs), assistants in nursing (AINs) and personal care assistants (PCAs).
Overall, almost three quarters (74%) of all nursing work in Australia is carried out by
RNs, with the remainder being carried out by ENs (9%) and AINs and PCAs (16%)
(Heath 2002). According to an earlier report by Reid (1994) the proportion of nursing
work carried out by registered nurses is approximately 80% in large metropolitan
teaching hospitals and 94% in community health centres. Importantly, even though a
proportion of nursing work is carried out by ENs and AINs, it is RNs who determine the
level of care required, provide appropriate supervision and guidance on a continuing
basis and who retain accountability for the care provided (NHMRC 1991). Thus the
effectiveness of undergraduate programs that prepare students for their role as
registered nurses is a highly important issue.
Prior to the 1978 Sax Report, most registered nurse preparation in Australia took place
in hospitals and was based on a traditional apprenticeship model of training. However, it
was generally recognised that this system was failing to equip nurses with skills required
for health care provision into the 1980/90s and beyond (Greenwood 2000). The Sax
Report, for example, noted that the apprenticeship system of nurse education was
producing nurses who were "restricted in outlook, resistant to change and unable to
cope with the scientific and technical advances in medicine" (Sax 1978). Similar issues
9
were raised in the Brigg’s Report (1972) in the UK. Nurses trained under the Nightingale
system, world wide, were doers rather than thinkers as a result of their socialisation into
the authoritarian nursing culture of the time which emphasised doing and service
(Greenwood 2000, 18). Consequently key arguments put forward to support the move of
nursing education into the higher education sector included:
• the changes in health care needs and in systems for supplying health services;
• the rapid expansion of knowledge and technology;
• the perceived inadequacies of traditional hospital programs in meeting the health
care needs of society and the educational needs of students; and
• claims that education in a multidisciplinary environment would advantage both
students and society (Australian Tertiary Education Commission Committee of
Enquiry into Nurse Education and Training 1978, 4)
Nationally and internationally, undergraduate degree and diploma programs in nursing
aim to provide a comprehensive professional preparatory education that can be built on
at the postgraduate level for more focussed specialist/advanced practice. In general,
pre-registration programs aim to produce nurses who are competent beginning
practitioners in nursing, able to practice across multiple contexts and equipped with
basic skills that health services require now, and – perhaps more importantly – skills that
will be required in the future (Reid 1994; Greenwood 2000). In Australia, ‘standard’
degree programs for nurses are three years in length (full-time) and are accredited by
the individual universities and the nurse regulatory bodies in each state/territory. They
comprise both theoretical and practical studies, with an average of approximately 900
10
hours of clinical practice or roughly 50% of most undergraduate curricula (Clare et al.
2002).
There is, however, an important comment about the types of skills that are emphasised
in tertiary pre-registration nursing programs. In addition to the development of clinical
knowledge and skills required for beginning level practice, tertiary programs are
characterised by their more explicit emphasis on critical thinking, decision-making,
priority setting, clinical judgement, and evidence-based approaches to practice. Thus,
the important shift is from a system that emphasised doing to one that emphasises
thinking and doing within a context that, arguably, still appears to focus on doing - or at
the very least - doing and thinking.
2.2.2 Outcomes of pre-registration programs
Despite the continued commitment of universities to produce competent graduates, rapid
changes in health care and higher education coupled with cultural problems arising from
the transfer of nursing education into the higher education sector (Reid 1994) have
impacted synergistically on the conduct of nursing programs and posed significant
challenges to the provision of quality education. Although the recent Review of Nursing
Education (Health 2002, 149) found that there is “much to celebrate in the innovation,
flexibility and quality in the educational preparation of nurses in Australia”, the report also
noted that “despite these successes, there are tension and pressures that put the future
quality of graduates at risk and areas that need further development” (Heath 2002, 149).
Issues at the macro level include changes in health care management and delivery,
technological advances, increasing expectations of employers and health consumers,
the knowledge explosion, changes in the delivery of education and increasing demands
11
on academic productivity across the board. Changes at a more local level that continue
to have major impact, particularly in the clinical component of programs, include
reductions in bed numbers and increasing patient acuity in acute care facilities, a lack of
community health placements for students, the (nurse) staffing profiles in public health
care facilities, the mainstreaming of mental health facilities/services with a consequent
reduction in the availability of mental health placements for students, continued pressure
on university funding and, more specifically, on clinical education budgets, continued
pressure on staff development budgets in health care facilities with implications for the
support available to new graduates and expectations of their performance once they ‘hit
the floor’. At the same time it appears that many health care agencies expect/need
graduates who can hit the ground running (Greenwood 2000, 19). New graduate nurses
enter into a complex and turbulent service environment that is characterised by heavy
workloads and stressful working conditions (Stallkneckt 2000). Within this context it is
perhaps not surprising that a range of issues concerning the processes and outcomes of
undergraduate nursing programs and, more specifically, the clinical preparation of
students continue to be debated.
Despite these pressures there is increasing evidence to suggest that pre-registration
programs are relatively successful in achieving their aims (Macleod Clark et al. 1997;
Kelly 1998). Madger et al. (1997, p.ix) found that new graduates go through a
demanding, and at times, stressful process of transition to practice, but that in most
cases they do so successfully. Within three-six months many beginning practitioners
experience a dramatic increase in their level of competence and feel confident and ready
to carry out their responsibilities within the health care team (Madger et al. 1997, ix).
Indeed, the consensus of newly registered/more experienced nurse participants in this
project was that current graduates of nursing undergraduate programs in New South
12
Wales met the competency standards required by the NRB for entry into practice. More
recently, findings from a national study by Clare et al. (2002) supported these trends
from the perspectives of newly graduated registered nurses and employers. Both
Madger et al. (1997) and Clare et al. (2002) noted that whilst the transition may
inevitably take longer for some graduates this cannot be solely attributed to their level of
competence on entry as other factors, such as socialisation and the amount and quality
of support received in the workplace, also play an important part. Indeed, the National
Review of Nursing Education (Heath 2002, 160) recommended not only that the initial
preparation of registered nurses should remain in universities but there was not a case
to support an increase in the length of the ‘standard’ bachelor degree from the current
three-year degree program to a four-year degree program.
Nevertheless, concerns about the performance of new graduates have been repeatedly
highlighted in contemporary literature and in professional forums across the country.
Thus the preparedness of new graduates has been a highly contentious issue that has
contributed to the increasing tension between universities and health care facilities in
recent years (Nolan 1998; Spouse 2001; Williams et al. 2001). Moreover, university
preparation of nurses has been blamed for a perceived lack of clinical skills in new
graduates. Assessment of the theoretical background of new graduates is generally
high. However, there has been ongoing concern about a range of performance
deficiencies, most notably that of time management (Duffield 2001; Heath 2002). Issues
such as the perceived inability to manage multiple tasks simultaneously and difficulty in
prioritising work have been raised repeatedly in recent years (Clare et al. 2002). Further,
Edmond suggests that this level of synthesis is more characteristic of experienced rather
than novice practitioners, and only conspicuous when it is absent:
13
“It is a composite of skills that once it is mastered is internalised and becomes so
automatic to them that it is invisible and usually referred to in only the most
cryptic terms. Yet, it is what nurses do” (Edmond, 2001, 253)
Despite this, there have been strongly voiced concerns about the performance of new
graduates with respect to issues such as time management and prioritisation (Brans
1997; Fisher and Parolin 2001; Reid 1994), as well as the performance of clinical skills
(Reid 1994; Madger et al. 1997), documentation (Anders et al. 1995), communication
with other nurses and medical staff (Anders et al. 1995) and medication administration
(Brans 1997; Fisher and Parolin 2001).
According to a NSW Project to review and examine expectations of new graduates in the
workforce (Madger et al. 1997), new graduates themselves indicate that they do not feel
competent or are not sure of their competence in areas other than medical-surgical
nursing or in locations other than city or regional hospitals. They have high expectations
of themselves and assess themselves as having adequate professional and clinical
competence – but feel strongly that guidance from more experienced practitioners will be
required. Despite this, the research also found that within three to six months many of
the new graduates felt comfortable and able to carry out their assigned workload. More
recent research Clare et al. (2002) extends these findings. These researchers surveyed
new graduates and Directors of Nursing (DONs) and found that both groups rated the
attributes performed least well by new graduates were: ability to manage a patient load
that included complex care, knowledge of agency policies and protocols; problem
solving and the usage of research. In addition the DONs highlighted the performance of
technical skills. What this study also showed, however, was that both new graduates and
DONs perceived great gains in performance over the first 12 month period of
14
employment. In the area of ability to manage a patient load, for example, the percentage
of DONs who rated this as excellent or good increased from 6% in the first six months to
43% in the second six months. Notwithstanding such improvement, new graduates’
ability to manage patient workloads remains a strongly felt concern as evidenced by the
following statement from a Director of Nursing: “our main concern with new graduates is
their inability to manage an average patient workload (excluding complex care) from Day
1” (Clare et al. 2002, 116).
Comments such as these continue to fuel the tension that has surrounded pre-
registration nursing curricula – in particular the clinical education component. Ironically,
although there is widespread agreement that clinical learning activities are at the “heart
of nursing’s professional program” (Infante 1981, 16), it is clear that they also represent
what is possibly the most challenging aspect of nursing education.
2.3 Clinical education: An overview
2.3.1 Nature of clinical education
Clinical education is a vital component in preparing students for the reality of their role as
health professionals (Williams and Webb 1994). Perhaps not surprisingly, this
experiential learning, or learning through placement experience, is often deemed by
students as more meaningful than that received in classrooms (Lambert and Glacken
2005). Clinical education focuses on, and is located in the so-called ‘real world’ of
professional practice where learning is by necessity wholistic and requires the transfer,
reorganisation, application, synthesis and evaluation of previously learned acquired
knowledge along with the acquisition of new knowledge and skills (McAllister et al. 1997,
6). The clinical setting promotes the integration of the theoretical and skills based
15
components of the curriculum and the reorganisation of knowledge so that it may be
applied to problem solving and clinical decision making for real patient situations. In
addition, Benner highlighted another important element to clinical teaching and learning
which she described as the uncovering of the “complexity and richness of the practice
that we want to teach” (Benner 1989, 25). In other words, through its emphasis on the
relationship between theory and practice, clinical education can, and should, assist
students to not only apply theory but also search for ways that nursing theory can
emerge from the rich texture of practice.
Within the context of the 1994 National Review of Nursing in the Higher Education
Sector, the Australian Council of Deans of Nursing stated that:
. . the recognised strength of nursing undergraduate programs has always been
the integration of theory and practice. Unlike medicine where clinical application
is not made until well into the program, nursing in most instances allows its
students to experience the clinical field from the first year. Such a strength is
enhanced by the control that the nursing academics have retained over the
clinical placements. Clinical experiences have been geared to the objectives of
the program, and although requiring some clinical teaching to be provided by
expert clinicians, the nursing academics have kept a presence in the clinical field,
providing the expert link between theory and practice” (Reid 1994, 193).
In the clinical setting students not only apply knowledge, skills and concepts introduced
in classroom/laboratory situations, they also learn to engage their compassion, thoughts,
and judgements and acquire the attitudes and values necessary for professional practice
(Barnard 1994; Dunn 1995). The exposure to clinicians, opportunity to communicate
face-to-face with patients and their families, interact with health care teams, provide care
16
and practice skills under supervision, receive feedback on performance and reflect on
experience is vital to the development of competence and the ability to function
effectively as a new graduate (Bjork 1999; Davies et al. 1999; Howie 1988).
However, there are considerable differences for students between learning in the
classroom and learning in the clinical setting. Whilst classroom sessions are relatively
controlled and somewhat anonymous for students, the clinical environment is
unpredictable, turbulent, dynamic, close and personal (White and Ewan 1991, 3). The
presence of patients, their families, nursing staff and other health professionals, and the
direct contact that students have with these groups, make learning in the clinical setting
potentially stressful and anxiety provoking whilst at the same time an incredibly positive
and rewarding experience.
Importantly, learning from clinical experience is not, or should not, be the simple
“learning by doing” which has been accepted in the past. Accounts of the learning
potential of experience (Dewey 1983; Kolb 1984) highlight the challenging nature of
learning in real world settings and emphasise what students stand to gain from their
experience. Dewey, for example, made the point that it is not enough to simply provide
experiences for students, everything depends on the quality of what is experienced.
. . . the central problem of an education based on experience is to select the kind
of present experiences that live fruitfully and creatively in subsequent
experiences (Dewey 1938, 28)
This resonates with Benner’s work on the skilled practitioner in nursing (1988),
particularly in relation to her notion of perceptual awareness and skilled clinical
knowledge development. The aspects of a nursing situation that are recognised and
17
acted upon are those for which there is sufficient prior knowledge, and knowledge-in-
action, to be able to discriminate between relevant/irrelevant and important/unimportant
cues. Thus, the essential issue for Benner is critical reflection on practice, not merely the
opportunity to experience practice, per se. These views highlight the potential richness
of clinical experience for learning and emphasise the importance of the processes that
occur during students’ experience in order that optimal learning outcomes can be
achieved.
2.3.2 The context of clinical education
It is widely held that experiences in the clinical setting can affect the degree and type of
learning that takes place, and impact significantly on how students are socialised into the
nursing profession (Reider and Riley-Giomariso 1993; Ridley, Laschinger and
Goldenberg 1995). In most, if not all, undergraduate nursing programs, students
undertake their clinical experience in a variety of settings that include hospitals, mental
health facilities, community services and long-term care facilities. In all of these settings
there are multiple factors that can impact on the provision of quality clinical education
and, thus, on students’ clinical learning and subsequent development of competence.
Some years ago Farmer and Farmer (1989) proposed a generalist Trigonal Model of
clinical education that highlights three main elements: Constituents, Concepts and
Contexts.
This figure is not available online.

Please consult the hardcopy thesis
available from the QUT Library
Figure 2.1. Trigonal model of clinical education (Farmer and Farmer 1989)
18
The constituents, or people, involved in the process of clinical education include clinical
educators, students, clinicians, patients and families. Maloney and Sheard (1992)
suggest that it is important to not overlook the role of patients and their families, as noted
in this model, because they tend to be overlooked in discussions of clinical education.
Additionally, it is critical to realise that although clinical educators in nursing play a very
important role in students’ clinical education, registered nursing staff on the wards where
students are placed have an extremely powerful, if not the most powerful, impact on the
overall effectiveness of the clinical experience with respect to the achievement of
learning outcomes and student satisfaction with their experiences (eg. Chan 2004; Ip
and Chan 2005). The concepts include the ideas and theories relevant to clinical
education. From a nursing perspective this encompasses both nursing and pedagogical
theory as well as concepts and principles from the biological, psychological and social
sciences and humanities, and reinforces the wholistic perspective on learning that was
highlighted earlier in the discussion. The contexts are the settings where clinical
education occurs and as mentioned above include a wide range of health care facilities
and services.
Additional factors that have been highlighted in the literature, but not specifically
addressed within this model, include more operational issues such as the length of
clinical practicums (Olsen, Gresley and Heater 1984), the type of setting used for
placement (Slimmer, Wendt and Martinkus 1990; Leschinger, McWilliam and Weston
1999), the number of clinical hours in the program (Battersby and Hemmings 1990) and
the types of experiences available on any given clinical unit (Atack et al. 2000).
Notwithstanding the importance and potential impact of these and other issues, is
argued here that, from an undergraduate nursing perspective, three key factors are
central to the quality of students’ clinical experience in any given setting: the nature of
19
the clinical learning environment in which the students are placed, the model of clinical
education that is used for their supervision and the quality of clinical
facilitation/supervision that they receive. An initial conceptualisation of these factors is
shown below in Figure 2.2. The sections that follow present a detailed discussion
regarding these and related issues.
Clinical setting
Clinical learning
environment
Quality of student
Model of clinical
experience
education
Quality of clinical
facilitation
Figure 2.2. Initial conceptualisation of factors impacting on the quality of students’

clinical experience
2.4 Clinical learning environment
The clinical learning environment has been described by Dunn and Hansford as “an
interactive network of forces influencing student learning outcomes in the clinical setting”
(1997, 299). It refers broadly to the social context of students’ clinical experience and
encompasses elements such as organisational/ward culture, relationships between
students and staff, atmosphere in the ward or clinical unit, team spirit, attitudes toward
teaching/learning and attitudes toward students (Lambert and Glacken 2005; Moss and
Rowles 1997; Quinn 1995; Wilson-Barnett et al. 1995).
20
Not surprisingly, the clinical learning environment has been identified as having a
powerful influence on students that directly affects their learning (Palmer et al. 2005;
Pearcey and Elliott 2004). Furthermore. the clinical setting is a particularly challenging
environment for students in terms of achieving effective learning. Unlike classroom
learning, students in the clinical setting frequently find themselves involved in unplanned
activities with patients and other health care providers (Dean and Kenworthy 2000).
Although nursing students perceive the clinical setting as the best place for acquiring
knowledge and skills, they frequently feel vulnerable in the clinical environment
(Campbell et al. 1994). Clinical experiences require difficult adjustments for students as
they move from an environment that encourages thinking to one that typically
encourages doing (Chan 2002, 70). Students are present in the clinical setting on a
supernumary basis and usually for relatively short periods of time, such as 2-4 weeks.
They are essentially unknown to registered nursing staff in the placement areas and,
although they participate in the provision of patient care, they are not necessarily seen
as bona fide members of the health care team. This problem is exacerbated by students
undertaking their practicums in different clinical settings where there is a need to
continually re-orient themselves to the setting and the staff, and re-learn the policies and
procedures in that organisation.
A study by Pearcey and Elliott (2004, 384) found that students’ descriptions of their
clinical experiences were mostly negative and that the impact of a good ward “cannot be
overstated”. Similarly, Chan (2004) reported that that, in general, students preferred a
more positive and favourable clinical environment than they perceived as being actually
present. Not infrequently students have been perceived as a burden to staff in health
care facilities (Reid 1994). Anecdotally there has been a sense of resentment on the part
of some registered nurses about “having to have” the students in their ward for
21
placement. This has been exacerbated by increasingly busy workloads and ongoing
problems with recruitment and retention of registered nursing staff. Nursing students can
therefore find themselves in a somewhat anomalous position when out on prac and it is,
perhaps, not surprising that the clinical experience is perceived as anxiety provoking
(Davies 1993; Jackson and Mannix 2001; Kushnir 1985).
Beck (1993) explored the experiences of 18 undergraduate nursing students’ first
encounter in the clinical setting. Six themes emerged from this study: Pervading anxiety,
Feeling abandoned, Encountering reality shock, Envisioning self as incompetent,
Doubting choices and Uplifting consequences. Comments such as “diarrhoea from
nervousness”, “I was left alone with a real patient”, “I felt totally stupid” and “had I made
a mistake in choosing a nursing career?” portray some of the issues impacting on
students’ sense of ease/unease at being in the clinical environment. Similar findings
have been reported by Neil et al. (1998) with respect to first year students. Nolan (1998)
studied a group of second year students and found that, whilst anxiety at being there
was still reported as an issue, students also talked about becoming more confident and
more involved with patients’ perspectives. These findings are consistent with previous
research by Windsor (1987) who explored the perceptions of third year students
regarding their clinical experience and proposed a 3 stage model of development:
Anxiety and obsession with the rules, Transition period - identifying the roles of nurses,
and Becoming comfortable with performing nursing tasks.
These findings highlight the importance of the clinical environment in clinical education
programs and its potential impact on students’ learning (Ip and Chan 2005; Clare et al.
2002; Clare et al. 2003). Previous research indicates that “good” clinical learning
environments are characterised by factors that variously include non-hierarchical
22
structures, good communication, team spirit, a positive atmosphere, democratic
leadership styles and positive interactions with staff (Fretwell 1983; Levec and Jones
1996; Neville and French 1991; Orton 1983; Pierce 1991). Additionally, Wilson-Barnett
et al. (1995) suggested that when ward staff worked together and were motivated,
students felt both supported and well supervised. Conversely, situations that have been
identified as contributing negatively to students’ clinical learning include unreceptive or
ambivalent staff, lack of direction, poor communication with staff, preceptors who are
unattentive or who don’t like students, and a lack of collaboration between staff and
students (Freiburger 1996; Grindel et al. 2001).
Moreover, in an Australian study, Hart and Rotem (1994) found that nursing students
valued positive relationships with clinicians and appreciated recognition for their
contribution to patient care. Students’ need to belong and be accepted by the clinicians
was a common theme in their responses. Students enjoyed being busy and having an
appropriate level of autonomy, but found this difficult to achieve unless their role as
students was clear to to members of the clinical staff.
Another Australian study by Dunn and Hansford (1997) identified five areas that
influenced undergraduate students’ learning in the clinical setting: staff-student
relationships, nurse manager commitment to teaching, patient relationships, student
satisfaction, eg. opportunities on the ward for learning, and hierarchy and ritual, eg.
organizational and/or ward culture. Of these five areas, student satisfaction was
consistently identified as the most reliable index of clinical learning environment. Results
from the study indicated that student satisfaction was both a cause and an effect of a
positive learning environment. A productive, stimulating and supportive environment
23
created more satisfied students, and more satisfied students facilitated the achievement
of a more effective clinical learning environment (Dunn and Hansford 1997, 1306).
Recent research by Saarikoski et al. (2002) identified that positive ward atmosphere and
effective clinical supervisory relationships with staff were the most important factors
contributing to the quality of clinical learning among the second and third year nursing
students who participated in their study (N=416). Similar results were found by Atack et
al. (2000) who used a phenomenological approach to gain an understanding of the lived
experience of students and staff within a clinical practice unit. Findings from the student
interviews in Atack et al’s study (2000) highlighted the importance of staff-student
relationships in terms of creating a positive learning experience in the practice setting.
Elements of this included the notion of students being treated as colleagues, students
feeling more comfortable in dealing with staff, being part of a team and staff involving
students more directly in decision making about patient care. The findings from both
students and staff also highlighted the issue of supervisory relationships (Atack et al.
2000). Students indicated that observations made as early as the first day of prac about
staff’s willingness to teach students often set the tone for the rest of the experience on
the unit. From their perspective, staff talked about the importance of students not
missing learning opportunities and indicated that they took on the roles of educator
and/or coach especially if the instructor was not readily available.
2.5 Models of clinical education
In Australia, two models have been commonly used for the purpose of educating
students in the clinical setting: supervision and preceptorship (Grealish and Carroll
1998). Essentially the supervision model involves a facilitator (employed by the
university) working directly, ie. on a supernumary basis, with a group of students (usually
24
on a 1:8 ratio) in a clinical setting (McKenna and Wellard 2004). The facilitator’s
responsibilities typically include student briefing and debriefing, the assessment of
students’ learning needs, organisation of the learning activities, clinical
teaching/supervision of students’ practice, close liaison with health care agency and
university staff, consultation with students’ regarding their progress and evaluation of
their performance. Three variations of the supervision model involve facilitators who are
fulltime academic staff, registered nurses employed by the university on a sessional
basis or health care agency staff who are seconded to the university for the period of the
clinical practicum. Students experiencing the supervision model (via one or other of the
three variations of clinical facilitation) have reported feeling supported by a ‘dedicated’
clinical teacher, particularly someone who is not ‘connected’ to the organization in which
students are placed and who can therefore maintain a ‘teaching’ focus (Nehls, Rather
and Guyette 1997). However, they have also expressed frustration at the lack of
individual attention that is an inherent drawback of this model (Nehls, Rather and
Guyette 1997).
Consistent with overseas literature (Nordgren, Richardson and Laurella 1998), the
preceptorship model generally involves a practising registered nurse providing on-site
individual clinical supervision/teaching on a 1:1 basis for an agreed period of time. The
preceptor’s responsibilities are essentially the same as for the supervision model
however, unlike the supervision model, the preceptor continues to carry her/his normal
clinical workload. In general, this model has been used - where possible - in the clinical
education of final year students as a specific means of preparation for transition to
practice as new graduates (Grealish and Carroll 1998). Following is a brief discussion
regarding each of these four models.
25
2.5.1 Full time academic staff
University-based facilitation can be described as that which is carried out using staff who
are employed directly by the university. The facilitator is assigned to a clinical setting
with an effort being made to match his/her area/s of expertise with the clinical case mix
which is typical in that setting. Importantly, however, university facilitators are not
members of the health agency staff and have therefore been seen as “outsiders” by
health care facility staff. In Australia, the facilitator:student ratio has commonly been 1:8
(Grealish and Carroll 1998) and the facilitator is responsible for student briefing and
debriefing, organisation of student assignments, direct clinical teaching, liaison with
health agency staff, consultation with students regarding their progress and student
assessment. Two common variations of this model are (1) the use of full-time academic
staff and (2) the employment of sessional facilitators.
From the results of several studies conducted through the 1980s and 1990s (Alexander
1983; Baillie 1994; Clifford 1993; Crotty 1993; Jones 1985) it appears that, although the
nature of clinical activities undertaken may be changing, the role of full-time nursing
faculty has generally included a component of direct clinical teaching/supervision. Full-
time staff bring invaluable expertise to the teaching/learning process and can facilitate
and catalyse the awareness, excitement, and personal growth of those they teach
(Melander and Roberts 1994). However, Karuhije (1986) and Pierce (1991) have made
the observation that those who are competent in the classroom are not necessarily
skilful at teaching in the practice setting.
In most universities full-time faculty members are busy with their teaching, scholarly, and
community service activities and clinical teaching, per se, is not an academically valued
pursuit (Karuhije 1986). Full-time faculty usually have classes to prepare and conduct,
26
marking and administrative functions to attend to during the time they are also involved
in facilitating students’ off-campus clinical experiences. The amount of time faculty
members expend on clinical instruction has been demonstrated to be negatively
correlated with publication productivity, a factor holding credit towards promotion. In
combination with increasing student enrolments, these factors have necessitated the
employment of sessional clinical facilitators in Australia (Duke 1996).
2.5.2 Sessional Facilitators
Sessional facilitators are generally hired for short periods of activity when students are
on clinical placement (Napthine 1996; Wong 1987). Importantly, these staff may have
clinical expertise, but less academic preparation and less familiarity with the curriculum
than full-time faculty members and have little or no knowledge of and/or experience in
clinical teaching (Packer 1994). Thus, although orientation and professional
development sessions are part of their preparation for the role (Duke 1996), these
facilitators are generally less attuned to the curriculum, program goals and objectives
than full-time faculty, they have limited contacts with their peers and program
coordinators and can experience a range of difficulties including the evaluation of
student performance (Duke 1996; Wong 1987).
The recruitment and retention of sessional clinical facilitators is also difficult as the
workload is sporadic, there is no security of tenure, and the casual nature of the work
means that these staff do not qualify for sick leave, annual leave, or other entitlements
that other employees enjoy (Napthine 1996). Similarly to full-time academic staff,
sessional clinical facilitators are guests in the host institution, they have to get to know
the industry staff, their routines, policies, procedures, politics, where equipment is stored
and a host of organisational idiosyncrasies - tasks which may be extremely difficult even
27
if they are consistently placed within the same setting (Packer 1994). Within the clinical
environment full-time academic facilitators may feel they lack the support and collegial
consultation generally experienced in the university, and may feel that they face the
difficulties associated with clinical teaching ‘alone’. However, these difficulties are
intensified for sessional clinical facilitators, and subsequently the quality of teaching and
learning may suffer (Richardson et al. 2001; Wong 1987). When health care facilities
are able to accommodate a number of student groups simultaneously facilitators may
then benefit from the support of their peers and enjoy access to a full-time academic
facilitator for the duration of the clinical placement. However in health care agencies
where only one group of students can be accomodated, both full-time academic and
sessional university-based facilitators may feel quite isolated both professionally and
socially. The lack of belongingness within the health care facility, and the associated
powerlessness and isolation that can accompany this, have been seen as major
drawbacks to this role (Brennan and Huth 2001; de Sales 1996).
2.5.3 Seconded Facilitators
Health care agency-based facilitators can be described as registered nurses who are
employed in the health care agency where students are placed, and who are appointed
to act as clinical facilitators for the duration of the clinical practicum. They are generally
regarded as experienced clinicians with valuable clinical decision making and critical
thinking abilities who are able to make important and direct contributions to students’
clinical education (Melander and Roberts 1994; Lambert and Glacken 2005). Similarly to
the university-based facilitators, health agency-based facilitators are responsible for
student briefing and debriefing, organisation of student assignments, direct clinical
teaching, liaison with university staff, consultation with students regarding their progress
and student assessment. Although there are a number of ways in which health agency
28
staff participate in students’ clinical education, two common models by which they are
“formally” appointed to this role are (1) secondment and (2) preceptorship.
Health care agency staff may be seconded by the university for the duration of the
clinical placement, i.e. they are relieved of their normal work responsibilities in order that
they can function in the role of a clinical facilitator for the duration of the clinical
practicum. The National Review of Nurse Education (Reid 1994) suggested that while
some seconded staff were regarded as very good clinical teachers, others lacked
pedagogical preparation and/or sufficient knowledge about the course and recent
developments in clinical practice, had weak attachments to both the agency and
university, and experienced difficulty in stepping aside from their other responsibilities for
the period of the clinical educational program (Reid, 1994). At the behest of health care
facilities this model has been used increasingly over the past five or so years, but with
the increasing busyness of health care facilities the problems associated with wearing
“two hats” have increased (Ellis and Hogard 2001; Tyrell and Leahy-Warren 2000).
2.5.4 Preceptors
The preceptorship model involves the allocation of a student to a designated clinical
nurse - who is termed a preceptor – often, though not always, for the duration of a
clinical practicum. Preceptoring is based on the premise that a one-to-one relationship
facilitates effective learning and provides a mode of entrance for the outsider (the
student), into the clinical organisation including knowledge of norms, mores, and role
expectations (Clayton 1989; Myrick and Barrett 1994, Pellatt 2006). Preceptorship
within a nursing education context is thought to have originated in the USA during the
1970s (Letizia and Jennrich 1998) and was adopted in Australia in an attempt to improve
upon the difficulties associated with facilitation model (including financial costs). Similarly
29
to the sessional and seconded facilitators, preceptors are responsible for assessing
learner needs; for planning, teaching, supervising and role modelling; and for providing
evaluative feedback (Morgan 2005; Stuart-Siddall 1983).
From an educational point of view the preceptorship role is generally viewed positively
(Bain 1996; Kavaini and Stillwell 2000). The benefits of preceptorship for both students
and preceptors are well documented (Grant et al. 1996; Grealish and Carroll 1998;
Nehls, Rather and Guyette 1997; Spouse 2001). However the role is demanding and
stressful, as well as challenging, and can lead to ‘burnout’ - especially when one
preceptor is used repeatedly (Chow and Suen 2001; Edmond 2001; Hancock 2003;
Goldenberg 1987/88). For example, Grant et al’s study (1996) revealed that almost 25%
of the registered nurse preceptors who were surveyed found teaching nursing students
to be too time consuming. Preceptors may not have the skills expected for their teaching
role, particularly in the area of assessment/evaluation (Infante, 1985). In addition, there
is the problem of clinical work overtaking teaching and learning (Grealish and Carroll
1998). Faculty, administrators, and experienced preceptors have identified good
communication skills, honesty, organisational ability and a genuine concern for the
preceptee to be equally as important as knowledge, teaching experience and clinical
ability in this intense one-to-one relationship (Lewis 1986; Myrick 1994). Ideally faculty
members experienced in clinical practice and teaching should work closely with
preceptors to provide a role model that fosters the preceptor’s socialisation and
facilitates the preceptor’s role transition (Myrick 1994).
The tangible benefits for health care agency staff who facilitate or precept undergraduate
nursing students are not widely known. Preceptors have identified that most of the
rewards they gain are intangible (Alspach 2003; Cotugna 1990). Tangible rewards that
30
have been identified include active involvement in curriculum development, attendance
at faculty meetings, luncheons, workshop involvement and seminar teaching
opportunities (Davis 1989; Goldenberg 1987/88; Hayes 1994; Modic and Schoessler
2006). However, the question concerning benefits to health agency staff who facilitate
or precept students is an important one for, if the only benefits to be gained are intrinsic
or intangible in nature, the long term involvement of these staff in students’ clinical
education may not be sustainable.
2.5.5 Beyond ‘traditional’ supervision and preceptorship
Whilst the models described above are still commonly used, findings from a study by
Wellard, Williams and Bethune (2000) highlight the push for diversification that has
occurred more recently in Australia. An example of such diversification includes the
Dedicated Unit Model (DEU) model developed by Flinders University (Edgecombe et al.
1999; Gonda et al. 1999). Reasons for the perceived need to diversify include economic
pressures affecting both the health and higher education sectors, difficulties in attracting
and retaining sessional staff, difficulties in having hospital RNs released (i.e. seconded)
to provide clinical supervision, difficulties associated with role confusion for RNs
seconded to the university on a temporary basis and, due to a scarcity of clinical places,
the need to use all available options even where the facilitator: student ratio may be
higher than 1:8. However, Wellard, Williams and Bethune (2000) also note that, despite
the creativity of universities in addressing these issues, there was no evidence to
support the notion of scholarship in clinical supervision roles, nor of clinical supervision
being a professional activity. Further, there was no evidence of the development of any
indicators on which to base judgements about the teaching performance of clinical
supervisors, particularly in relation to the quality of student learning during the clinical
31
practicum (Wellard, Williams and Bethune 2000, 553-554). Given the issues that
surround current approaches to clinical education, these authors raise the question as to
why these models continue to persist. They also make the point that, if clinical education
is indeed central to the preparation of undergraduate nursing students, then “more work
needs to be done to identify the pedagogy required to support clinical learning” (Wellard,
Williams and Bethune 2000, 554).
2.6 Clinical facilitators and clinical facilitation
An implicit element in the discussion regarding models of clinical education is the
particular role played by the clinical facilitator. The importance of this role is clearly
identified both nationally and internationally (Andrews 2003; Campbell et al. 1994;
Davies et al. 1999; Duke 1996). There is an interesting discussion by McAllister et al.
(1997) about the terminology of clinical educator vis-à-vis clinical teacher, clinical
supervisor and/or clinical tutor. Further, McAllister et al. (1997) argue that the term
clinical educator is more appropriate as it gets away from the more constrained and
traditional notions of drilling and controlling that were more prevalent in the past, and
emphasizes more strongly the nurturing element of clinical education with respect to
students’ professional development. Consistent with this argument, the term clinical
facilitator is used more commonly in Australia to denote the role that is undertaken by
the person charged with the key responsibility for students’ learning in the clinical
setting, and is the term that will be adopted for the purpose of this discussion.
Definitional issues notwithstanding, there is general agreement that clinical facilitators
have a crucial role which encompasses coaching, role modeling, counselling, inspiring,
assessment, liaising and supporting the professional growth and development of
32
students (Andrews 2003; Andrews and Chilton 2000; Baillie 1992; Bain 1996; Clifford
1993; Crotty 1993; Davies et al. 1999; Grealish 2000; Lee 1996; Ohrling and Hallberg
2001; Quinn 1995; Spouse 2001).
A number of descriptive and interpretive studies have been conducted to investigate
clinical educator/mentor characteristics that are perceived by student nurses to facilitate
learning. The most commonly identified characteristics are summarised in Table 2.1.
From the findings shown in this table it can be seen that characteristics such as being
prepared/organized and confident about the role, enjoyment of nursing and
demonstrating clinical competence were identified most frequently. Notably, Nehring
(1990) and Kotzabassaki et al. (1997) found that the most positive characteristics of a
mentor include the creation of a positive non-threatening environment, competence of
the instructor as a clinician and as an instructor and the provision of constructive
feedback. Similar findings were also reported by Davies (1993), Glover (2000) and
Langridge and Hauck (1998). However, Lee, Cholowski and Williams (2002) replicated
earlier research by Mogan and Knox (1987) which investigated and described
characteristics of ‘best’ and ‘worst’ clinical educators. Unlike Mogan and Knox (1987)
but consistent with Kotzabassi et al. (1997), Lee et al. (2002) found that interpersonal
relationships were rated as the most highly valued characteristic by both Australian
students and clinical educators. Nursing competence and evaluation were rated second
and third highest by both groups, but there was a difference in the order in which these
were rated by the two groups. Students rated evaluation and nursing competence as the
second and third most highly valued characteristics, whereas clinical educators rated
these characteristics in the reverse order. Interestingly, teaching ability and personality
characteristics were ranked second lowest and lowest by both groups (ie. rated 4th and
5th out of five subsets of effective clinical educator characteristics). Similar trends were
33
found by Beitz and Weiland (2005) in their survey of junior and senior baccalaureate
nursing students to investigate students’ perceptions of personally and professionally
inviting teaching behaviours of nursing faculty. In general, students rated clinical faculty
highly for effective teaching behaviours. Consistent with previous research, students’
qualitative comments highlighted characteristics such as supportiveness, mutual
respect, role modeling, clinical competence, interested in clinical teaching and gives
positive feedback as important to the quality of their clinical learning.
The issue of quality with respect to clinical educators has also been explored in health
professions other than nursing. Interestingly, the findings from studies in the fields of
physical therapy, occupational therapy and physiotherapy are consistent with those in
nursing. Perhaps this is also related to the potential for professionally supportive
behaviours of clinical teachers to lower student anxiety in the clinical setting as has been
demonstrated by Cook (2005) within a nursing context. Positive characteristics
highlighted through these studies include competence as a clinician and as an instructor,
good interpersonal skills, and someone who is non-threatening, provides constructive
feedback and creates a positive learning environment (Emery 1984; Christie et al. 1985;
Hummell 1997; Onuoha 1994).
34
Table 2.1: Characteristics of ’good’ clinical educators/mentors
Campbell et al.
et
Lee, Cholowski &

Knox
Gray and Smith
Beitz & Weiland

Williams, (2002)
Nehring (1990)
Kotzabassaki
Wong (1978)
&
al. (1997)
(20055
Mogan
(1994)
(1987)
(2000)
Organised / well prepared for role * * * * *
Enjoys nursing * * * *
Demonstrates clinical skills * * * * * *
Shows confidence * * * * *
Takes responsibility for actions * * * *
Willing to answer questions * * * * *
Being available when needed * *
Good role model * * * * *
Is not threatening * * * *
Approachable/supportive * * * * *
Enthusiastic * * * *
In summary, literature on clinical educator attributes that support student learning in the
clinical setting highlights the importance of the person in this role being competent as a
practitioner and as a teacher; creating a positive learning environment through being
approachable, enthusiastic about students and about professional practice, respectful of
students and available when needed; communicating effectively and providing
constructive feedback on students’ performance. Significantly, the antithesis of these
comments is also true. It is hardly surprising that when these characteristics are absent,
or the reverse is present, students report feelings of frustration and a lack of satisfaction
with their clinical experience.
35
2.7 Findings from an earlier evaluation study
This section briefly reports the key findings of a study that was undertaken earlier to
evaluate four models of clinical facilitation and investigate “best practice” in clinical
education for pre-registration nursing students. This discussion has been included
because it is highly relevant to the present study, and activities undertaken during the
project paved the way for the initiation of discussions that led to the development of the
CEU model. The study was carried out by Nash and co-workers as a follow-on from the
National Review of Nursing Education in the Higher Education Sector: 1994 and Beyond
(Reid 1994) and funded by the National Priority (Reserve) Fund Scheme.
The models targeted in the study were those that were being used most commonly for
the provision of clinical education through supervision and/or preceptorship. Altogether
four specific models were evaluated: (1) full-time academic staff facilitating on a 1:8
basis; (2) sessional staff facilitating on a 1:8 basis; (3) seconded staff facilitating on a 1:8
basis; and (4) preceptors facilitating on a 1:1 basis. Data collection involved second and
third year students enrolled in a Bachelor of Nursing (Pre-registration) course conducted
by a large Brisbane university, clinical facilitators and preceptors, and health care facility
representatives. Following is a brief synopsis of the main comments made each of these
keystakeholder groups. A more detailed report is included as Appendix 1.
2.7.1 What the students said
Data from the questionnaire and the focus group discussions indicated strongly that
students enjoyed their clinical placements – regardless of the model of facilitation that
was used - and valued the opportunity to “put their theory into practice”. In particular,
36
they valued the input from their clinical facilitators and felt that these people had played
a key role in their clinical learning and development.
Notwithstanding the strongly positive view that was held by students with regard to
clinical facilitation, two key issues were raised as concerns: (1) facilitators “knowing” the
organisation and (2) relationships with registered nursing staff. The main concerns
highlighted in their comments are shown below:
Knowing the organisation Relationships
• university facilitators not known/part of • perception of not being welcome in

the environment in health care facilities health care facilities
• difficulties associated with facilitators not • negative attitudes of RN buddies

having a good working knowledge of towards university students
hospital policies, procedures and a
thorough understanding of local culture • potential conflict between hospital
and politics important staff and university facilitators
• access to clinical learning often • these problems often compounded

depended on who the facilitator knew by health care facility staff not
and/or to what extent the facilitator was knowing the students and having
known. unrealistic expectations of their
performance
2.7.2 What the facilitators said
Similarly to the students, the common view from clinical facilitators highlighted the
perceived importance and value of clinical facilitation with respect to students’ learning in
the clinical setting. Regardless of the model used, all participants were strongly
supportive of the facilitator role and felt that the facilitator played an essential role in
students’ clinical education. However, there were a range of comments about the
advantages and disadvantages of each model. These are summarised below:
37
Full-time academic staff
Advantages Disadvantages
• enhanced synthesis of theoretical, conceptual • pressure of balancing a “prac” workload

and practical knowledge in the clinical with other academic commitments and
environment the perception that there was
insufficient time to do either job
• academic visibility with health care effectively.
environments
• improved opportunities for collaboration

between the university and health care
facilities
Sessional staff
• well placed to assist students’ integration of • not able to give students enough time
theory within the clinical setting through their individually – this was related to having
close (employment) relationship with the 8 students spread across different ward
School and a good understanding of the areas
theory and clinical subjects in the curriculum
• feeling isolated when out on prac.
• not hampered by hospital politics or “internal
intrigues” and thus able to retain students as • feeling in no man’s land in the clinical
their primary focus throughout the practicum setting. Ie. neither a university nor
health care facility person, and quite
stressed as a result.
Seconded staff
• “superior” knowledge of the health care • regardless of preparation provided by

facility and/or specific clinical area in which the university, feeling somewhat
students were placed for clinical experience unprepared for the role
• a strong profile as experienced practitioners • feeling frustrated and isolated because

of difficulties in communicating easily
• motivation to participate in students’ clinical with staff in the university
experience and share their knowledge and
expertise with the “nurses of the future” • the pressure of role conflict between
workplace needs and the students’
• being better able - than university based educational needs.
facilitators - to help the students feel part of
the clinical team
38
Preceptors
• closer exposure, than other models, of • the additional workload required, ie. on
students to the reality of the workplace top of a normal workload.
• students a part of the team. Preceptors • the need for “time out” from students to
commented that they were able to involve reduce / avoid interpersonal “burnout”,
their students completely in all levels of particularly for those who precepted on
patient care a regular basis.
• improved student readiness to accept • lack of recognition for their contribution

responsibility for patient loads to students’ clinical education and
feeling undervalued for the time and
energy that they put in to the role.
2.7.3 What the health care facility representatives said
Similarly to the students and clinical facilitators, there was a strongly held view from
health care facility representatives about the importance and value of students’
experience in the clinical setting. However, they expressed a deal of concern with
respect to the perceived effectiveness of three facilitation models, specifically the usage
full-time staff, sessional staff and seconded staff. Their concerns centred around (1) the
unfamiliarity of full-time academics and sessional staff with organisational policies and
procedures, (2) the unavailability of clinical facilitators, (3) issues related to students’
acculturation to the “real world” of nursing, and (4) the importance of the clinical nurse
buddies. Their views are summarised as follows:
• university staff are not always familiar with hospital policy/procedure – this causes
situations that conflict with particular hospitals’ policies, and unnecessary time spent
by hospital staff in trying to bring full-time and sessional staff up to speed
39
• clinical facilitators working on a 1:8 basis are restricted in the amount of time that
they can spend with each student individually – this increases the demands on
hospital staff
• students need better acculturation to the real world of nursing. There was a very
strong view that university based models of facilitation tended to keep the students
separate from the mainstream of the wards thus reducing students’ opportunities to
fit in to the working world of health care
• there is a lack of recognition for the major contribution made by clinical nurses in the
ward areas to students’ clinical education, particularly buddy nurses.
2.7.4 The ‘ideal’ model?
All participant groups in this study were asked for their opinions regarding what might be
called an ‘ideal’ model of clinical facilitation. Given the range of views expressed about
clinical facilitation it was, perhaps, not surprising that there was not a clear consensus on
this issue. However, a number of themes emerged from participants’ comments and
these included:
• the importance of clinical facilitation - generally - for achieving learning outcomes;
• a positive learning environment ;
• familiarity of clinical facilitators with and within the clinical learning environment;
• the role of clinical nurses or buddies in students’ learning;
• adequate preparation, and ongoing support for facilitators to enable students’
integration of theory and practice, appropriate assessment of their performance and
enhancement of learning opportunities;
40
• continuity in the placement of students to reduce the time spent in settling in to new
organizations thus maximizing the time available for them to meet their clinical
objectives and develop the required professional competencies; and
• the importance of students feeling part of the clinical team.
2.8 Summary
Nursing is a practice-based discipline and a minimum level of competence is required for
registration/licensure to practice as a nurse. The ability of newly registered nurses to
effectively fulfil their clinical roles is dependent to a large extent on the clinical
preparation that occurs during the pre-registration course. Both students and
facilitators/supervisors agree that clinical education is a critical component of pre-
registration nursing courses (Marrow and Tatum 1994). However, a number of factors
impact on the quality of clinical education and thus on students’ learning in the clinical
setting. Three key factors are the clinical learning environment, the model/s used for the
provision of clinical education and the quality of clinical facilitation/supervision received
by students.
Optimal clinical learning requires adequate practice environments, good relationships
with individuals who have sound theoretical knowledge and good clinical skills, and
stimulating dialogue which includes the assessment of learners’ needs, structured
guidance and constructive feedback on performance (Field 2004). From the findings of
the evaluation study it is clear that the model used for clinical facilitation is central to the
quality students’ clinical education as this factor has the potential to significantly affect
both the role of the clinical facilitator and the clinical learning environment. It is also
clear that none of the four models evaluated necessarily stood out in terms of
41
effectiveness – from neither the students’, the clinical facilitators’, nor the health care
facility representatives’ points of view. Advantages and disadvantages were identified for
all models.
Currently there is a relative absence of knowledge and understanding about the
differential impact of various models of facilitation on students’ clinical education
experience and learning outcomes achieved in the clinical setting. From the foregoing,
the challenge is to be able to maximise the identified strengths of various models, whilst
at the same time minimising the disadvantages, and maintaining the flexibility needed to
implement the model across different settings with different groups of students. Given
the importance of clinical education within the pre-registration undergraduate course,
and the continued tensions surrounding the preparedness of graduates for practice, the
need to pursue the development of innovative strategies for enhancing the facilitation of
students’ learning in the clinical setting is clear. Thus, as Tanner suggests,
“revolutionising clinical education is no longer an option – we must” (2002, 52).
42
CHAPTER 3
METHODOLOGY
3.1 Introduction
This chapter describes the methodology used to answer the research questions for this
study. The chapter begins by presenting the research questions. The following
discussion focuses on the research paradigm, research design, study participants, data
collection methods, data analysis procedures and ethical considerations associated with
the study. The change intervention used in this study is described in detail in Chapter
Four. The chapter then concludes with a brief summary.
3.2 Research questions
The primary aim of this study was to examine the impact of an innovative model of
clinical education (the Clinical Education Unit or CEU) on the clinical prac experience of
undergraduate nursing students and registered nurses (RNs) working with the students.
Secondary aims were to strengthen the relationships between academic and clinical
staff with respect to undergraduate clinical education, promote critical debate between
the key players about undergraduate clinical education, and create an environment that
would sustain ongoing improvement on a collaborative basis. To achieve the primary
aim of the study the following research questions were examined:
• What are the perceptions of undergraduate nursing students with respect to the CEU
43
• What are the perceptions of registered nurses (RNs) with respect to the CEU model
of clinical education, and how do they compare with RNs’ perceptions regarding non-
CEU models?
• How do CEU students rate the quality of their practicum experience, and how do
their ratings compare with those of non-CEU students?
• How do CEU RNs rate the quality of students’ practicum experience, and how do
their ratings compare with those of non-CEU RNs?
• What factors influence the outcomes for students and registered nurses?
3.3 Research paradigm
In terms of research paradigm, an action research approach was used to investigate the
key issues of interest in this study. Broadly speaking, action research can be defined as
“the study of a social situation with a view to improving the quality of action within it”
(Elliott 1991, 69). Despite some conjecture about the origin of action research, it is
generally accepted that the term was first used by Kurt Lewin, a social psychologist, who
felt that the research needed for social practice should be a form of ‘social management’
carried out by researchers and practitioners working together to achieve social change
through joint problem solving (Meyer 1993; Warrican 2006). Lewin’s pioneering work
(1947) involved a range of groups including factory workers and disadvantaged
immigrants however, as interest grew, its usage extended to a variety of other contexts
such as business, industry and education. Since the 1990s the use of action research
has also increased in health care, for example in the fields of occupational therapy,
social work and nursing. With respect to nursing in particular, there has been a
sustained argument that, with its focus on social practices, action research is ideally
suited to the kind of problem solving and evaluation research that is needed in nursing
44
(Greenwood 1994; Kelly and Simpson 2001; Smith et al. 2000; Taylor et al. 2005; Webb
1989; Webb, Turton and Pontin 1998).
3.3.1 Fundamental concepts of action research
As indicated above, action research addresses real world problems occurring within
complex social contexts. According to Fals Borda:
“action research aims to help people investigate reality in order to change it, and
to change reality in order to investigate it – in particular, by changing their
practices through a spiral of cycles of critical and self critical action and reflection,
as a deliberate process designed to help them learn more about (and theorise)
their practices, their knowledge of their practices, the social structures
surrounding their practices and the social media in which their practices are
expressed and realised. It is a process of learning by doing – and learning with
others by changing the ways they interact in a shared world” (1979, 24).
Thus action research is focussed on actual or ‘real world’ concerns - not abstract
practices, and involves learning about the day-to-day, material, concrete, particular
practices of particular people in particular circumstances or situations (Kemmis and
Wilkinson 1998). The investigation takes place in the workplace and no attempt is made
to control the research context or to design an experiment, per se. Indeed action
research explicitly acknowledges the essentially uncontrolled world of practice and the
issues that social participants negotiate on a daily basis but, at the same time, does not
shy away from attempting to confront complex organisational processes (Kelly and
Simpson 2001). On the contrary, action research acknowledges the day-to-day
dynamism of real world environments and attempts to initiate change through
collaboration. Action research aims explicitly at both taking action and creating
knowledge or theory about that action (Gummesson 2000; Hart and Bond 1995; Reason
and Bradbury 2001; Susman and Evered 1978). According to action research
proponents, this theory-generating function of action research is what characterises it as
45
a form of research (Greenwood 1994) and what makes it an important means by which
to bridge “the divide between research and practice” (Somekh 1995, 340) .
In contrast to more positivist paradigms, action research is concerned with doing
research with and for people rather than on people (Reason 1988). Given the intensely
interpersonal nature of the present study, this is an especially important point.
Consistent with these emphases action research is underpinned by the belief that
knowledge about human situations can be generated from our commitment to practical
situations, and that practical involvement can in itself create the understanding that the
circumstances require. It embodies a fundamental optimism concerning people’s ability
to work constructively together, and ideals regarding democracy and responsible
citizenship which relate to the fundamental notion of action research as an empowering
process for the so-called subjects of enquiry (Van Manen 1990; Winter and Munn-
Giddings 2001). Thus the methodology of action research is based on values which are
not inconsistent with contemporary nursing practice - participation, commitment to
improvement, critical reflection, responsiveness and contextual sensitivity (Elliott 1991;
McTaggart 1994; Winter 1989; Winter and Munn-Giddings 2001).
The current study was set in the real world of clinical practice for undergraduate nursing
students. The impetus for the study arose from a ‘felt need .. to initiate change’ (Elliott
1991, 53) from both clinical and academic staff involved in the management and day-to-
day conduct of students’ practicums. This was prompted by questions that arose from
the concerns of both parties about the practice of clinical education and, thus, the aim of
both parties was to improve the way that clinical practice was done. Thus, on reflection,
action research with its emphasis on real world settings, collaboration and situation
46
improvement was considered to provide the best ‘fit’ with the aims and objectives, nature
and context of the present study.
3.3.2 Key characteristics of action research
The action research methodology employed in this study was largely informed by the
writings of Argyris et al. (1985) and Kemmis and Wilkinson (1998). According to Argyris
et al. (1985) the central tenets of action research include:
• change experiments on real problems in social systems;
• iterative cycles of identifying a problem, planning, acting and evaluating;
• changing established patterns of thinking and action;
• challenging the status quo from a participative perspective; and
• simultaneous contribution to social science and social action in everyday life.
Kemmis and Wilkinson (1998) elaborate on this view in their discussion about the
relationship between participatory action research and the study of practice. They
suggest that there are seven key features of action research. In their view participatory
action research is iterative, social by nature, participatory, practical and collaborative,
emancipatory, critical and recursive, ie. reflexive, dialectical. Kemmis and McTaggart
(2000, 600) argue that these features are at least as important as the self-reflective
spiral which, for many, constitutes what action research is about. In their view issues
regarding research methods are not unimportant but what makes action research
‘research’ is an abiding concern with the relationships between theory and practice
within the social context in which the practice occurs.
47
The present study attempted to achieve these qualities, with particular emphasis being
placed on the participatory, practical and collaborative, and critical dimensions. This was
done through academic and clinical staff working collectively and individually from the
outset to try to understand how practice, ie. clinical facilitation, can be improved,
grounding and conducting the work in the real world of undergraduate clinical
experience, engaging with clinical nurses in an examination of mutual understandings,
values and skills regarding clinical education, deliberately challenging current ways of
thinking and doing with respect to clinical education and keeping a focus on the
development of a model that would have improved outcomes for all key players and lead
to a cultural shift in clinical education for undergraduate nursing students.
As indicated earlier, the methodology of action research typically consists of a series of
commitments to observe and identify problems in practice, and proceeds in a series of
spirals each composed of planning, action, observation and evaluation of the result of
the action (Carr and Kemmis 1986). Further, Lathlean (1994) has argued that, because
action research is context specific and always about taking action and evaluating the
impact of that action on practice, a change intervention is central to the model. Thus the
study was undertaken in successive iterations with each iteration comprising a basic
action research cycle of planning-action-evaluation-reflection (Kock, McQueen and
Corbin 1997). As shown in Figure 3.1 there were two main phases or cycles conducted
during the present study: Phase 1 - Development, implementation and initial evaluation
of a change intervention, ie. an innovative model of clinical education (the CEU model),
and Phase 2 - Refinement, re-implementation and re-evaluation of the CEU model of
clinical education (the CEU-2 model). It is important to note that the initial assessment
phase of the project where the awareness of a ‘felt need’ (Elliott 1991, 53) was
established, was undertaken prior to the present study and was reported in Chapter 2,
48
Section 2.7. Thus the present study built on to this earlier evaluation with two
successive cycles of an action research process.
Change intervention
Identifying practice needing change*
Phase 1 Developing a plan to effect change
Implementing the plan and

monitoring outcomes
Reflection and evaluation
Phase 2 Replanning and re-implementation
Figure 3.1. Study design (adapted from Pratt et al. 2001)
* This phase was contained within the earlier evaluation study that was reported in Chapter 2, Section 2.7.
3.3.3 Issues regarding action research as a research methodology
As shown though the preceding discussion, action research is seen to have several
important advantages over more traditional positivist research paradigms in terms of
investigating issues occurring within complex social contexts with the aim of improving
the status quo. This is not to say, however, that there are no counter views that should
be considered. Four reasonably common criticisms of action research include:
contingency of the research findings, poor control of the environment, low technical
rigour and personal over-involvement of the researcher.
External validity of the findings. This issue arises because many action research projects
feature in-depth involvement with a discrete area/organisation or small number of
49
areas/organisations. Thus the criticism is made that action research findings are not
generalisable across a number of areas/organisations and therefore lack external validity
(Hall 2006). Winter and Munn-Giddings (2001) argue strongly against this proposition by
making the point that the unique nature of action research allows the discovery of
significant situational structures that will resonate strongly with a wide variety of other
situations. They assert that not only are action research reports generalisable in the
‘usual’ provisional sense, but that like other research it needs to be made public (Winter
and Munn-Giddings 2001, 21). According to Kock et al. (1997) one of the ways in which
the generalisability of action research projects can be improved is to increase the
number of units under study in successive iterations of the change intervention.
Arguably, this was the case in the present study where the first iteration involved two
CEU wards and two non-CEU wards at the Hospital, and the second involved eleven
CEU wards (at the Hospital) and five wards in two non-CEU hospitals other than the
Hospital. Further the second iteration occurred approximately two years after the first
iteration. This meant that the second iteration also involved different students and, in
many cases, different clinical nurses. Following Kock et al’s argument, it is suggested
that this expansion of scope added strength to the research findings and contributed
toward improved generalisability of the results, albeit in a tentative, restricted way.
Poor control of the environment. It was indicated earlier that action research essentially
makes no attempt to control the research context in the manner that is traditionally
associated with experimental research per se. Indeed, in a manner similar to qualitative
research, action research rejects the notion of attempting to control the social world of
human endeavour because this misses out the essential qualities that need to be
understood. Instead of trying to achieve objectivity through strategies such as controlling
the variables, setting up sample populations to receive carefully constructed
50
questionnaires, action research aims to achieve consensus about the meaning of a
situation in order to work constructively towards changing the situation (Winter and
Munn-Giddings 2001).
Having said this, it is undeniable that low control over the variables in a system being
studied can hamper the testing of causal links between the variables. To do this,
however, requires that the variables and their hypothesised relationships are clearly
stated a priori. In turn this focuses the research on a limited set of variables and neglects
others that may be relevant to an informed understanding of the situation under
consideration. This can have the effect of limiting the research findings and/or leading to
studies that have little organisational relevance. Kock, McQueen and Scott (1997) argue
that low control of the research environment is therefore more of an advantage of action
research than a disadvantage because it is more likely to lead to the generation of
“timely evidence that can be used in the real time process of transformation” (Kemmis
and McTaggart 2000, 591). In addition, the cyclic nature of action research goes some
way toward to meeting the demands of scientific rigor in that the successive iterations of
an action research project allow for both data collection at different times, eg. different
times in the year, and over different time periods, eg. long term assessment of early
intervention effects (Coghlan and Casey 2001; Greenwood 1994).
Personal over-involvement of the researcher. A further criticism of action research is the
results may be biased because the researcher is involved in rather than detached from
the research. Kock, McQueen and Scott (1997) comment that this may be particularly
true when the situation under investigation is small and the intensity of involvement is
high. From a nursing perspective Coghlan and Casey (2001) suggest that action
researchers who are working from ‘the inside’ may assume too much, find it hard to
51
cross functional or hierarchical boundaries to obtain relevant data and/or probe
participants’ thinking in order to expose underlying assumptions and unreflected actions.
Situational “pre-understanding” (Gummesson 2000, 57) can be advantageous in terms
knowing who, what and where to look for information that can lead to richer data than
might otherwise have been possible. However, personal involvement can also lead to
the possibility of distorting the way in which people, including the action researcher,
perceive events and situations particularly when there is a high degree of emotional
response involved. As leader of this project the researcher played a directive role which
was used in a positive way to support the research. However, the possibility of distortion
was controlled through the use of an ‘outsider-insider’ approach which allowed the
researcher to be closely involved in the ongoing proceedings yet appropriately objective
in terms of the analysis, reflection and interpretation of the research findings. This was
assisted by the involvement of academic colleagues who managed the day-to-day
issues at the research coalface and research assistants who were largely responsible for
the collection of research data.
3.4 Research design
This study employed a two-phase prospective follow-up design which involved two
iterations of a change intervention (the CEU model of clinical education) and the
collection of qualitative and quantitative data from undergraduate nursing students and
clinical nursing staff involved in students’ clinical placement in conjunction with each
iteration.
3.4.1 Setting
The main setting for this study was a large tertiary referral hospital (hereafter referred to
as the Hospital) located in the inner metropolitan area of Brisbane. The Hospital is a
52
major teaching facility that provides clinical placements for medical, nursing and allied
health students across a large number of clinical areas including a full range of medical-
surgical and mental health specialties.
Phase 1
During Phase 1 of the study the CEU model was implemented in two wards/clinical
areas of the Hospital. The wards used in this phase of the project were selected on the
basis of staff’s agreement to be involved in the project, the high bed occupancy of these
wards and the wide variety of clinical services that were provided. Both wards had a bed
capacity of approximately 32 beds, and a bed occupancy rate of approximately eighty-
five percent. One ward was an acute renal and general medical unit. The casemix
included patients with acute and chronic renal failure, haemodialysis, peritoneal dialysis,
cerebrovascular accident (CVA) and other neurological disorders, cardiac, endocrine
and respiratory disorders. The second ward was a mixed public/private surgical ward
where the casemix included urology, neurosurgery, maxillofacial surgery, orthopaedics
and chronic pain. The non-CEU wards selected for the purpose of Phase 1 were also
located at the Hospital. The bed capacities and staffing arrangements of the non-CEU
wards were similar to those of the CEU wards. The case mix of the non-CEU wards
included gastroenterology, rheumatology, internal medicine, urology and vascular
surgery. All wards selected for Phase 1 of the study were experienced in the provision of
clinical placements for undergraduate nursing students and had similar bed capacities,
occupancy rates and staffing profiles.
Phase 2
During Phase 2 a refined CEU model (CEU-2) was implemented in eleven wards/clinical
areas of the Hospital. As in Phase 1, the wards used in this phase of the project were
53
selected on the basis of staff’s expressed desire to be involved in the project, the high
bed occupancy of these wards and the wide variety of clinical services that were
provided. However, a little differently to Phase 1, the majority of wards participating in
Phase 2 asked spontaneously to be able to implement the CEU model. All wards had a
bed capacity of approximately 30 beds and a bed occupancy rate of approximately
eighty-five percent. The casemix included renal and general medical, urology,
neurosurgery, maxillofacial surgery, orthopaedics, chronic pain, thoracic medicine; upper
gastrointestinal, colorectal and general surgery, endocrinology, rheumatology, internal
medicine, nephrology and infectious diseases.
The non-CEU wards for Phase 2 of the study were located in health care facilities other
than the Hospital. This was necessitated by the growth in the CEU wards that occurred
at the Hospital during the intervening period. By Phase 2 eleven wards at the Hospital
had become CEU wards which meant that there were insufficient non-CEU wards to
allow the collection of comparative data from students and clinical nurses. For this
purpose it was therefore necessary to use clinical facilities other than the Hospital. In
order to enhance internal validity of the Phase 2 component of the study (Polit and Beck
2004), the non-CEU facilities were selected on the basis of their similarity to the Hospital
with respect to experience with undergraduate clinical placement, clinical casemix,
registered nurse staffing arrangements and the models of clinical education used in
those facilities. In addition, clear guidelines for the conduct of the practicums were
developed and disseminated to all placement settings. The facilities selected were a
public hospital and an acute private hospital located in a geographically similar area to
that of the Hospital. Each of these non-CEU hospitals was experienced in the provision
of clinical placements for undergraduate nursing students and placed students in various
54
medical and surgical wards that had similar bed capacities, occupancy rates and staffing
profiles to that of the CEU wards at the Hospital.
3.4.2 Study participants
Phase 1
During Phase 1 the CEU model of clinical education was implemented in two wards of
the Hospital. To enable comparison of data, non-CEU wards also included. During
Phase 1, the usual models of clinical education were used in the two non-CEU wards.
These were the sessional and seconded models of clinical education. Briefly, the
sessional model involved the employment of a registered nurse by the university to
facilitate a group of eight undergraduate students at the Hospital. This person was not
an employee of the Hospital and was employed on a casual basis for the duration of the
clinical practicum. The seconded model involved a registered nurse from the Hospital
being appointed to act as the clinical facilitator for a group of eight undergraduate
nursing students for the duration of their practicum at the Hospital. In accordance with
operating guidelines of this model, the appointee undertook the facilitation in a
ward/clinical area that was different to his/her own ward area. Participants in this first
phase of the study included both undergraduate nursing students and clinical nursing
staff in the participating ward areas.
Students
The target group for Phase 1 of the study was undergraduate students enrolled in
second and third year clinical units in a Bachelor of Nursing course conducted by the
School of Nursing (SoN) at a major university located in Brisbane. These units were
Clinical Practice 2 and Clinical Practice 3 (Year 2) and Clinical Practice 4 and Clinical
Practice 5 (Year 3). All units included off-campus clinical practicums undertaken in block
55
format and, with the exception of the final third year practicum (which was six weeks or
240 hours in duration), the length of the individual practicums was four weeks (160
hours). As per the usual clinical placement arrangements, students self-selected their
placements and were placed in clinical groups of approximately eight students per
group. The following inclusion criteria were used:
• students enrolled in second and third year clinical practice units offered during
Phase 1 of the study,
• placement undertaken in the wards designated as CEU and non-CEU during
Phase 1 of the study, and
• > 90% attendance at the relevant clinical practicum
Altogether, 96 students met the inclusion criteria for Phase 1 of the study. A total of 58
students took part in the focus group discussions that were conducted during this phase.
This included 35 students who were placed in the two CEU wards operating during
Phase 1 (23 second year students and 12 third year students), and 23 students who
were placed in the two non-CEU wards included in the study (17 second year students
and 6 third year students) and represented an overall participation rate of 60.4%. During
Phase 1, a total of 56 completed surveys were received from students (representing an
overall response rate of 58.3%). This comprised 37 survey questionnaires from students
in CEU wards and 19 survey questionnaires from students in non-CEU wards. The
majority of both CEU and non-CEU respondents were female (83.8% and 73.7%
respectively) and enrolled in third year clinical units (59.9% and 52.6% respectively).
There were, however, some differences in the age ranges of both groups. Forty six
percent of the CEU respondents were aged between 17-25 years with a further 37%
aged between 31-40 years. In contrast 79% of the non-CEU respondents were aged
between 17-25 years.
56
Clinical nurses
The target group for Phase 1 of the study was clinical nursing staff employed in the
designated CEU and non-CEU ward areas of the Hospital. The following inclusion
criteria were used:
• registered nursing staff (RNs) working in the CEU and non-CEU wards during the
clinical practicums undertaken during Phase 1 of the study
• present in the designated CEU/non-CEU ward areas for the majority of students’
placement during the relevant practicums
Altogether, a total of 35 RNs took part in the focus group discussions. This included 22
RNs from the two CEU wards operating during Phase 1, and 13 RNs from the two non-
CEU wards that were included in the study. The overall staffing profile varied slightly
across the wards but, in general, comprised a mix of registered nurses from Level C
(Clinical Nurse Consultant) to Level A (registered nurse). The CEU nurse participants
comprised 4 Clinical Associates (similar to clinical facilitators in the non-CEU models), 4
Clinical Nurse Consultants and 14 Clinical Partners (similar to buddy nurses in the non-
CEU models). The nurses who were selected to take on the role of Clinical Associate
were Level 2 RNs. The non-CEU nurse participants comprised 2 seconded clinical
facilitators and 11 buddy nurses.
During Phase 1, a total of 84 completed survey questionnaires were received from RNs.
This comprised 23 survey questionnaires from RNs in CEU wards and 61 survey
questionnaires from RNs in non-CEU wards. The majority of CEU and non-CEU RNs
were female (91% and 89% respectively). For both groups, the majority of respondents
were aged between 21-30 years (74% and 57% respectively). However, there was a
lower proportion of CEU RNs in the 31-40 and 40+ age ranges. Thirteen percent of the
57
CEU RNs were aged between 31-40 years and 40+ years respectively. In contrast 22%
of the non-CEU RNs were aged between 31-40 years, and 21% were aged 40 years or
more.
Phase 2
During Phase 2 of the study, the CEU-2 model of clinical education was implemented in
eleven wards of the Hospital. Non-CEU ward areas were again included to enable
comparison of data. As explained earlier (Section 3.4.7) the non-CEU wards for Phase 2
were located in health care facilities other than the Hospital, and included three wards in
a separate public hospital facility and 2 wards in a separate private hospital facility. As
for Phase 1, participants in the second phase of the study included both undergraduate
nursing students and clinical nursing staff in the participating ward areas.
Students
The target group for Phase 2 of the study was undergraduate students enrolled in the
final clinical unit of their Bachelor of Nursing course (Clinical Practice 5). Due to a course
change that had been made during the intervening period, the practicum for Clinical
Practice 5 comprised 2 clinical blocks of 4 weeks each (a total of eight weeks as
compared to six weeks in Phase 1). As previously, all of the students self-selected their
preferred clinical placements from a list of available placements. However, during Phase
2 this was done using an electronic Clinical Placement System that students could
access from home and/or the university. As per the usual clinical placement
arrangements, students were placed in clinical groups of approximately eight students
per group. The following inclusion criteria were used:
58
• students enrolled in Clinical Practice 5 during Phase 2 of the study,
• placement undertaken in the wards designated as CEU and non-CEU wards
during Phase 2 of the study, and
• > 90% attendance at the clinical practicum
Altogether, 205 students met the inclusion criteria for Phase 2 of the study. A total of 63
third year students took part in the focus group discussions (an overall participation rate
of 30.7%). This comprised 38 students from the CEU wards operating during Phase 2,
13 students from the (separate) public hospital which did not use the CEU model, 7
students from the (separate) private hospital which did not use the CEU model and 5
students from various non-CEU hospitals who attended a focus group held on-campus.
During Phase 2, a total of 144 completed survey questionnaires were received
(representing a response rate of 70.2%). This comprised 59 survey questionnaires from
students in CEU wards, 56 from students at the non-CEU public hospitals and 29 from
students at the non-CEU private hospital. Similarly to Phase 1, the majority of CEU and
non-CEU students were female (89.8% of CEU students as compared to 89.4% of the
non-CEU students) and enrolled on a full-time basis (92.3% of CEU students as
compared to 94.2% of the non-CEU students). However, during Phase 2, there was a
similar age profile across both groups with the majority of participating students aged
<20 years to 29 years.
Clinical nurses
The target group of RNs for Phase 2 of the study was clinical nursing staff employed in
the designated CEU and non-CEU ward areas. The following inclusion criteria were
used:
59
• registered nursing staff (RNs) working in Hospital wards designated as CEU
wards during Clinical Practice 5 in Phase 2 of the study
• RNs working in the wards designated as non-CEU wards during Clinical Practice
5 in Phase 2 of the study
• present in the designated CEU or non-CEU wards for the majority of students’
placement during the relevant practicum
Altogether, a total of 7 Clinical Associates took part in the focus group discussions held
during Phase 2. These participants were all female and employed as Level 2 RNs
(Clinical Nurses). They had all undertaken the Clinical Associate role at least once prior
to the period during which Phase 2 was conducted. The Hospital was extremely busy at
the time and undergoing a period of organisational change. Registered nurses employed
in both the CEU and non-CEU wards indicated that it was extremely difficult for them to
attend the focus group discussions. Consequently, it was agreed that they would provide
detailed feedback via the open questions on the survey questionnaires. Altogether, a
total of 210 completed Phase 2 survey questionnaires were received from eligible RNs.
Of the RNs who returned the survey forms, 108 were working in CEU wards (51.4%) and
102 were working in non-CEU wards (48.6%). Of the 102 non-CEU RNs, 68
respondents (66.6%) were working in the non-CEU public hospital and 34 respondents
(33.3%) were working in the non-CEU private hospital.
3.4.3 Change intervention
The change intervention for this study, ie. the CEU model of clinical education, was
underpinned broadly by findings from the evaluation study undertaken by Nash et al
(1999) that was reported in Chapter 2 (Section 2.6). Consistent with action research
60
methodology the development, implementation and evaluation of the CEU model was
undertaken in collaboration with clinical nursing staff at the Hospital. The conceptual
framework was Briefly, Clinical Education Unit or CEU is the name given to, and
accepted by, a clinical unit that agrees to provide clinical experiences for undergraduate
nursing students from the SoN at QUT in accordance with the core principles and
structural elements of the CEU model. The key structural elements of a CEU involve (1)
a supernumary Clinical Associate role that is undertaken by an RN/s from the
designated clinical area/s, (2) a Clinical Partner role that is taken by all other RNs
working in the designated clinical area/s, (3) an Academic Support/Liaison role that is
undertaken by a faculty staff member and (4) continuity, or consistency, in student
placement in the particular CEU across an academic year. There are also three core
principles which are (1) collaboration between academic and clinical staff, (2)
commitment to a positive learning environment and (3) a “whole of clinical unit”
commitment to students’ clinical learning.
The key differences between the CEU and other commonly used models of supervision,
eg. secondment and sessional models (described briefly in Chapter 2, Sections 2.5.2
and 2.5.3), are that clinical facilitators in the CEU model are working in the ward area in
which students are placed, all nursing staff in the ward are explicitly regarded as playing
an important role in students’ learning, there is a tangible partnership between academic
and clinical staff through the on-site presence of an academic liaison person, and
students undertake all clinical placement across an academic year, eg. Year 3, within
the same CEU ward area. Full details of the model and its development are presented
in Chapter 4.
61
For the purposes of comparison, students and staff from non-CEU wards were included
in this study. In the non-CEU wards, the usual models of clinical education were
continued. In Phase 1, the non-CEU wards used the seconded model as this was the
model of clinical education preferred by the Hospital at the time. In Phase 2, the non-
CEU wards used the sessional and seconded models as this were the models they
preferred and had been using for some time. Both sessional and seconded models were
implemented in accordance with the broad descriptions given in Chapter 2, Section 2.5.
3.5 Data collection
A mixed methods approach using methodological triangulation was used for the
collection of data in this study. The term mixed methods is defined broadly as "research
designs using qualitative and quantitative data collection and analysis techniques in
either parallel or sequential phases" (Tashakkori and Teddlie, 2003, p. 11). According to
Shih (1998) the word 'triangulation' was introduced in the field of social sciences as a
metaphor to describe the use of multiple methods to evaluate a single construct (Shih
1998). This is especially relevant in researching complex human phenomena where a
single research method may be insufficient to fully understand the phenomenon under
study (Erzberger and Kelle 2003; Sandelowski 2000, Shih 1998).
The word 'triangulation' can be traced as far back as the Ancient Greeks and to the
origins of modern mathematics (Oiler Boyd 1993). In the field of navigation, triangulation
describes the process of using two known points to determine the location of a third
(Nolan and Behi 1995). The concept can be linked to research through the use of two or
more research methods to strengthen the overall design and increase the researchers'
62
ability to interpret findings (Thurmond 2001). Triangulation can be variously achieved
through combining two or more methods, investigators, theories and/or analysis within
one study (Kimchi, Polivka and Stevenson 1991; Thurmond 2001; Oiler Boyd 1993).
With respect to methodological triangulation, combinations may involve a within-methods
approach (using, for example, qualitative participant observation and qualitative
interviews) or, as in the present study, may involve a between-methods approach (using,
for example, qualitative focus groups and quantitative survey questionnaires) within the
research design (Begley 1996; Kimchi, Polivka and Stevenson 1991; Thurmond 2001;
Oiler Boyd 1993).
The major aims of a triangulated research design are to provide confirmation and/or
completeness of data by overcoming the biases or limitations inherent with using a
single-method, single-investigator or single-theory approach (Foster 1997; Monti and
Tingen 1999; Shih 1998; Winter 1989). This is consistent with the view that, in the field
of modern human research, one research method alone provides, at best, a partial
picture of complex phenomena that contain many perspectives or aspects that need to
be understood (Halcombe and Andrew 2005). A combination of methods or perspectives
has the potential to provide a richness of detail and a more complete understanding of
the phenomenon, especially when there are multiple perspectives to consider (Oiler
Boyd 1993; Shih 1998). It is argued that this promotes enhanced validity and reliability of
studies through increased trustworthiness of the data and its interpretation (Breitmayer
1993; Coyle and Williams 2000; Foss and Ellefsen 2002; Rose and Webb 1997).
However, Halcombe and Andrew (2005) make the point that triangulation is not, or
should not be a simple aggregation of data collection strategies. This is consistent with
63
earlier literature exploring the advantages and disadvantages of triangulation. Sim and
Sharp (1998), for example, have argued that triangulation, particularly for the purpose of
confirmation, is fraught with difficulty and should be approached with caution. Reasons
for this include difficulties associated with the mixing methods when these arise from
differing, and sometimes opposing, epistemologies. This may be a particularly important
consideration in the case of qualitative methodologies where simple assumptions of
commonality should not be taken for granted (Barbour 1999). Mason (1999), for
example, has made the important distinction between ‘collecting’ and ‘generating’ data
underlining the role of the qualitative researcher vis-à-vis the quantitative researcher. A
similar distinction has been made by Barbour (2000) with respect to the production of
‘findings’ rather than ‘results’. There is also the possibility that differing methods may
yield differing findings (Razum and Gerhardus 1999).
Notwithstanding ongoing debates about the strengths and weaknesses of triangulation,
there is a strong view that drawing data from different contexts can allow a ‘true’ state of
affairs to emerge from a research study thus increasing the study’s validity (Silverman
2000, 2001; Tashakkori and Teddlie, 2003; Thurmond 2001). Further, Foss and Ellefsen
(2002) argue that triangulation can be viewed as a distinct epistemological position in
which different methods, of equal importance, offer insights across a knowledge
continuum. Consistent with these views, Kitzinger and Barbour (1999), for example,
describe how qualitative data obtained through the use of focus groups can illuminate
issues that questionnaires present in a less accessible manner, challenging or
confirming their findings.
64
In keeping with the real world context of the present study (Hart and Bond 1995), the
multi-faceted nature of the issues being investigated and the aim of achieving a
situational understanding of the issues (Elliott 1993, 66), triangulation was used to
deepen the analysis, give completeness and enhance the trustworthiness of the data
(Shih 1998). In light of the earlier discussion regarding potential disadvantages of
triangulation, attention was given to issues of coherence among the purpose of the
study, research questions and research methods (Silverman 2000). Following
recommendations by Morse (2003) and Morgan (1998), and reflection on what was most
important to the study’s aims and objectives (Happ et al. 2006), focus group
methodology as the priority method was paired with survey questionnaire methodology
to contribute to overall completeness of the data and enhance its understanding and
interpretation.
3.5.1 Focus groups
Focus groups were held with both key stakeholder groups relevant to this study, ie.
students and clinical nurses in the health care facilities where students were placed for
clinical practicums. Focus groups were selected as a method of data collection as they
provide a useful means of bringing together people with a common interest to explore a
specific set of issues. A key advantage of focus group methodology is the possibility of
gaining quality data by using the social dynamic of the group to facilitate participants to
contribute with candour and spontaneity in the same way as a normal conversation (Frith
2000; Knodel 1995; Carey and Smith 1994; Nyamathi and Shuler 1990). Capturing this
‘everyday conversation’ allows the researcher to “draw on people’s normal experiences
of talking and arguing with family, friends and colleagues about events and issues” as
they might in their everyday lives (Wilkinson 1999, 225). This encourages further
65
communication and debate on the issues at hand. According to Mummery (cited in
Jamieson and Mosel Willliams 2003) the philosophical underpinning of this methodology
is the premise that attitudes and perceptions are not developed in isolation but through
interaction with others. Focus group participants are encouraged to talk with and ask
questions of each other, agree and/or disagree with each other, comment on others
opinions and exchange anecdotes (Wilkinson 2004; Kitzinger 1994). The group synergy
and interaction that can be realised using this methodology potentially leads to a rich set
of data on the topic that, according to Blumer can “do more to lift the veils covering this
sphere of life that any other device that I know of” (1969, 41).
A key element of this study was the exploration of how changed “objective”
circumstances, ie. arrangements for the provision of clinical facilitation, shape and are
shaped by the “subjective” perspectives of participants (Kemmis and Wilkinson 1998,
34). This necessarily involves consideration of participants’ meanings, intentions and
values about the change particularly as they relate to the broader context of
organisational, cultural and social issues that impact on participants’ experience. This
highlights the importance of dialogue with, and between, the key players to facilitate an
understanding of their perceptions and, hence, progress toward the development of the
“situational understanding” or “sympathetic introspection” (Mannheim 1936, 266) that
was alluded to earlier.
Prior to the focus groups held in both phases of the project, question guides were
devised. The purpose of this was to reduce the possibility of interviewer bias during the
discussion and an emphasis of the researcher’s issues rather than those of the
participants (Bloor et al. 2001; Greenbaum 1998; Morgan 1995). As suggested by
Krueger (1998) the questions used to frame the discussion were constructed around the
66
following categories: opening, introductory, transition, key and ending. The questions
were purposively kept few in number and semi-structured in nature. Prior discussions
with both stakeholder groups indicated that participants were very likely to have a range
of views on the issues that they would be keen to express. Thus the intent of the
questions was to act more as a trigger, or prompt, for discussion than a specific guide
which could have the effect of stifling the conversation (Higginbotham, Albrecht and
O’Connor 2001). The questions used to frame the discussions held during Phase 1 and
Phase 2 of the study are shown in Appendix 2 (CEU students and staff) and Appendix 3
(non-CEU students and staff).
The discussions were all held toward the end of students’ practicums in suitable venues
within the hospitals where they were placed, and were all approximately 40-50 minutes
in duration. Each interview was moderated by an experienced research assistant.
Having explained the purpose of the project, the moderator began the discussion with
open questions about clinical education. This was followed by questions and discussion
framed by the relevant focus group script (as indicated above). As the discussions
proceeded, probing questions were used to elicit more in-depth responses about issues
of interest which emerged. The possibility of ‘group think’ was a consideration for the
moderator as this is a potential disadvantage of focus group discussions (Nyamathi and
Shuler 1990). ‘Group think’ occurs when individuals within a group conform to the
opinion of the majority (Crawford and Acorn 1997). This was reduced by the moderator
being aware of reinforcing diversity of opinion, and limiting participant domination of the
discussions (Krueger and Casey 2000). All discussions were audiotaped and transcribed
verbatim. The tapes were transcribed by research assistants engaged for the purpose
of data transcription to allow the use of people experienced in transcribing from
audiotaped material and, at the same time, detached from the study as a whole.
67
3.5.2 Survey questionnaires
In addition to the focus group discussions, survey questionnaires were used to examine
students’ and registered nurses’ opinions on a range of issues that were germane to this
study. During the course of the study two questionnaires were used to collect this data
and each questionnaire was adapted, as necessary, for completion by both students and
clinical staff. The questionnaires were administered on completion of the students’
practicums. Students completed the questionnaires after they had returned to ‘uni’ in
order to maximise the independence of their responses. The RN survey questionnaires
were sent individually through the internal mail system to the registered nurses working
in the relevant ward areas. The questionnaires for both students and RNs were
distributed in sealed envelopes and included a self-addressed envelope for return of the
completed questionnaire. Students returned completed questionnaires to a designated
locked box in the Nursing Building, and the completed questionnaires from RNs were
collected from designated storage facilities located in the relevant wards.
Phase 1
The Phase 1 questionnaire (Quality of Prac Experience [QPE] - Phase 1) was adapted
from the tool that was used in the earlier evaluation study described in Chapter 2
(Section 2.6). The earlier tool was modified from the Clinical Learning Environment
Scale (CLES) which provides a methodology for the evaluation of affectively relevant
factors in the clinical learning environment (Dunn and Burnett 1995). The CLES is a 23-
item instrument with each item rated on a 5-point Likert scale ranging from 1=Strongly
agree to 5=Strongly disagree. There are 5 sub-scales: staff-student relationships, nurse
manager commitment, patient relationships, interpersonal relationships and student
satisfaction. According to Dunn and Burnett (1995) these factors were shown to have
68
“strong substantive face validity and construct validity as determined by confirmatory
factor analysis” (p. 1170). The subscales have reliability co-efficients ranging from 0.85
(student satisfaction) to 0.63 (patient relationships).
Concepts of particular interest to the present study included staff-student relationships,
ward environment, clinical learning opportunities, learning outcomes and student/staff
satisfaction. To investigate these issues, items from the staff-student relationships, nurse
manager commitment, student satisfaction and interpersonal relationships subscales of
the CLES were modified to suit the focus and structure of the CEU environment, and to
be more reflective of changes that had occurred within nursing since the development of
the original CLES. Additional items were developed to explore issues relating to the
ward environment, clinical learning and achievement of learning outcomes.
The same basic questionnaire was used for both students and registered nurses,
however a number of survey items needed to be modified to ensure their relevance for
the registered nurse respondent group. The student version of the QPE-Phase 1
questionnaire contained 23 items, whilst the RN version contained 18 items. All items
were scored on a 5-point Likert scale ranging from 1=Strongly Agree to 5=Strongly
Disagree. Both versions of the QPE-Phase 1 included a short series of open questions
asking for respondents’ comments regarding strengths and weaknesses of the clinical
education model they had experienced, invited their suggestions for improvement and
gave them the opportunity to describe what, in their opinion, were the key components of
an “ideal” model of clinical education. A short series of demographic questions were also
included. The Phase 1 questionnaires for students and registered nurses in CEU and
non-CEU wards are shown in Appendices 4 and 5 respectively.
69
Phase 2
The survey questionnaire used in Phase 2 of this study (Quality of Prac Experience
[QPE] – Phase 2) was modified from the Phase 1 tool. Similarly to Phase 1, the key
concepts examined included staff-student relationships, ward environment, clinical
learning opportunities, learning outcomes and student/staff satisfaction. However, due to
significant unexpected organisational pressures at the Hospital during Phase 2,
feedback from students and clinical staff regarding the Phase 1 questionnaire and
dialogue with the key clinical partners, it was felt necessary to reduce the number of
items in order to maximise the response rate from both students and nursing staff.
Consequently, taking the key themes on the Phase 1 questionnaire, and preliminary
analysis of Phase 1 data into account, the items that were perceived to be most useful to
the examination of outcomes from Phase 2 were selected and reworded, where
necessary, to facilitate as much clarity as possible for respondents. The student version
of the QPE-Phase 2 questionnaire contained 24 items, whilst the RN version contained
15 items. All items were scored on a 4-point Likert scale ranging from 1=Strongly Agree
to 4=Strongly Disagree.
In light of the organisational pressures being experienced during Phase 2, and the
expected impact on respondents’ willingness to engage in a detailed consideration of the
issues, a 4-point scale was chosen for the Phase 2 questionnaire. It is acknowledged
that, in general, a neutral option or middle alternative should be allowed to avoid the
possibility of ‘forcing’ people into giving an opinion when they don’t really have one and
potentially creating false or unreliable responses (de Vaus 2002, 106). However,
circumstances were such that the questionnaire needed to be ‘sharp’ and ‘to the point’ to
facilitate a good response rate. Thus a 4-point Likert scale was used in the QPE-Phase
2 questionnaire and the possibility of not accounting satisfactorily for people’s views was
70
off-set, to some extent, through the inclusion of open questions which allowed
respondents to make any comments they wished. As in Phase 1 the same basic
questionnaire was used for both students and registered nurses and survey items were
modified as appropriate for the respective cohorts. The Phase 2 questionnaires for
students and registered nursing staff are shown in Appendices 6 and 7 respectively.
3.6 Data analysis
3.6.1. Qualitative data
Qualitative data in this study were analysed using thematic analysis (Stewart 1988) and
procedures adapted from Silverman (2000; 2001) and Miles and Huberman (1994;
2002). Comprehensive analysis of the data took place when all focus groups had been
conducted however there was a degree of analysis after each group in order to
determine when response saturation had occurred (Jamieson and Mosel Williams 2003).
A general review of the transcripts was undertaken by the researcher and members of
the research team and apparent trends noted. The transcripts were then examined in
detail and recurring patterns, or categories, extracted and agreed by the research team.
The data were coded using similar words, phrases, examples and/or concepts. The
coded data were then manually placed into the agreed categories to enable data to be
managed more easily and to be analysed as aggregate data. This process was
undertaken by the researcher and a team member working separately from each other.
Comparison of the categorisations identified a small number of discrepancies which
were discussed and resolved before final categorisation was agreed (Bowling 1997).
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Following this, themes were generated by grouping similar phenomena (categories) into
conceptual clusters. This process was undertaken by the researcher and is consistent
with what Fielding (1993) calls ‘coding up’, that is coding from the data rather than the
constructs of a pre-established theory. Throughout the analysis process there was
constant referral back to the original transcripts to ensure that all relevant data had been
categorised and group impact accounted for (Catterall and Maclaran 1997). Validation of
the identified themes was addressed in two main ways: 1) continual referral back to the
original transcripts and 2) reassessment of the themes after the researcher had been
distanced from the analysis for a period of time (Nyamathi and Shuler 1990). In addition,
the identified themes were also subjected to scrutiny by members of the research team
who were somewhat ‘distanced’ from this part of the analysis process. For the purpose
of this study, the data were analysed with respect to the demographic groups of interest.
All focus group data were analysed using the same process.
3.6.2 Quantitative data
Data from the QPE survey questionnaires were analysed using SPSS for Windows
Release 13.0. Data were coded according to a standardised protocol. To check for data
entry errors, 10% of the data were double entered. The normality of the data was
investigated using histograms, normal and de-trended q-q plots, the 5% trimmed mean
statistic, skewness and kurtosis statistics and found to be reasonably satisfactory. Data
from the QPE-Phase 2 questionnaire tended to be more skewed than the Phase 1 data.
However, in light of the larger sample sizes for the Phase 2 questionnaire, the possibility
of a potentially inflated Type 1 error rate was not regarded as a problem (Gravetter and
Wallnau 2000; Myers and Well 1995). In order to analyse the self report data, frequency
analyses were conducted to compare the pattern of responses to individual survey items
72
by students and registered nurses from CEU and non-CEU wards/units. In addition, the
procedure was used to investigate differences between the mean ratings of CEU and
non-CEU students and CEU and non-CEU RNs on individual survey items. The
Student’s t-test was selected as it is an appropriate statistical test for comparing two
groups with respect to a particular trait to see if they are sufficiently dissimilar that it is
possible to say that they do not belong to the same population (Black 1999). It is the
most commonly used test to evaluate differences in the means between two groups.
The primary assumptions of the t-test are interval or ratio level measurement of the
criterion variables, random sampling from the populations of interest and the
independence of each observation from other observations, normal distribution and
homogeneity of variance for the criterion variables (O’Rourke, Hatcher and Stepanski
2005). However, depending on sample size and the type and magnitude of the violation,
the t-test is relatively insensitive to violations of normality and homogeneity of variance
(Pagano 1994). Following statistical consultation in relation to the research questions for
this study and the type and nature of data to be analysed, the t-test was selected as the
key statistical method for analysing the quantitative data from Phase 1 and Phase 2 of
the study.
3.7 Ethical considerations
Ethical approval to conduct this study was obtained from the relevant bodies. At the time
of Phase 1 of the study, formal approval was not required by the QUT Human Research
Ethics Committee or the RBH Research Ethics Committee. For Phase 2, however,
formal approval to conduct this component was obtained from the Queensland
73
University of Technology Human Research Ethics Committee and the Royal Brisbane
and Womens’ Hospital Ethics Committee (Appendix 8).
Prior to involvement in the study, participants were informed verbally and in writing
regarding the processes involved. Student participation in the study was on a voluntary
basis, and participants were assured that they could withdraw at any time without
comment or consequence of any sort. This was done through information sessions that
were held prior to the commencement of each phase of the project. Students were
notified of the information sessions through the normal communication channels, eg. in
class, via email and notices posted around the Nursing Building. Students chose
individually to attend (or not) and no pressure was applied to encourage student
attendance. It was made very clear to students that attendance (and participation) was
entirely voluntary and separate from successful completion of their clinical units in which
they were enrolled. The participation of registered nurses as Clinical Associates was
also on a voluntary basis. Following lengthy discussions with Hospital staff the process
used to recruit potential Clinical Associates involved advertising the opportunity through
the Hospital’s communication channels, eg. newsletter, ward meetings etc. Following
this, a series of information sessions were provided for interested staff to attend and ask
questions. No pressure was applied by the hospital or the university to encourage
registered nurse attendance at these sessions. It was made very clear to attendees that
participation in the study was entirely voluntary and not related to their employment at
the Hospital. All participants were also assured that all information was collected
anonymously and treated with strict confidentiality. The audio tapes from the focus group
discussions were transcribed by research assistants who were employed for that
purpose. They were not involved in the study in any other way. No student/registered
74
nurse names appeared on any results and aggregate data, only, has been reported.
Students and registered nurses were assured that non-participation or withdrawal from
the study would not affect their academic progress/employment in any way or their
opportunity to access other clinical placements/employment opportunities as ‘normal’.
It was considered that the risks associated with this study were low. However, it was
possible that a potential risk existed if students in the CEU groups perceived ‘pressure’
to continue in the group (even though they might not wish to) or felt threatened by
perceptions about heightened expectations of their performance. In order to reduce
these risks for students, pre-briefing sessions were held with all interested students and
the ethical conditions described above were explained to them. Students were visited
on a 1-1 basis during the course of the practicums by the co-ordinators of the units in
which they were enrolled. This provided the opportunity for students to speak freely with
an ‘un-involved’ staff member if they had any concerns about any aspect of their clinical
experience.
3.8 Summary
This chapter has outlined the methodology used in this study. Chapter 4 presents a
detailed description of the conceptualisation and implementation of the CEU model of
clinical education. The results of the study are presented in the chapters that follow.
75
CHAPTER 4
CHANGE INTERVENTION
4.1 Introduction
This chapter outlines the development of the CEU model of clinical education that
constituted the change intervention for this study. The chapter begins by presenting a
brief overview of the background to the model. This is followed by discussion on the
theoretical underpinnings of the model, the structural elements and core principles of the
CEU, and the key issues associated with implementation of the model during Phase 1
and Phase 2. The chapter then concludes with a brief summary.
4.2 Background
As reported in Chapter 2, Section 2.6, Nash et al. (1999) undertook a previous study to
review the models of clinical education being used at that time in the undergraduate
nursing program. The models reviewed included three variations of the supervision
model (using faculty, sessional and seconded staff) and preceptorship, and each model
was reviewed in terms of keystakeholder perceptions (students, facilitators and health
care facility personnel), student outcomes and the costings associated with each model.
A key finding from this project was the identification of factors associated with an “ideal”
model of clinical education. These included:
• facilitators who know the organisation,
• students feeling part of a team,
• a positive learning environment within the ward/clinical area,
• bridging the gap between classroom and clinical learning, and
• continuity of student placement within a particular clinical setting.
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Following detailed reflection on the findings of the Review (Nash et al. 1999), literature
on clinical education (particularly in relation to the clinical learning environment) and,
most importantly, detailed collaborative discussions between academic staff from the
SoN and clinical nurses at the Hospital, the Clinical Education Unit (CEU) concept was
developed and elaborated into a model of undergraduate clinical education.
4.3 The CEU model
Clinical Education Unit or CEU is the name given to, and accepted by, a clinical unit that
agrees to provide clinical experiences for undergraduate students in accordance with the
principles of the CEU model (outlined below). The type of clinical unit that can become a
CEU is flexible and can include single wards within a hospital facility, a group of wards
(e.g. a floor or a department), a health care service or an entire health care facility.
Consistent with the essence of the model, the option of becoming a CEU is discussed
jointly by faculty staff from the SoN and clinical staff from the health care facility, and the
decision as to whether a clinical unit will take up this option (or not) is arrived at
collaboratively taking into account the needs, aspirations and resources etc. of both
partners.
The CEU model symbolizes a shared vision of a ‘better’ way to provide quality clinical
learning for undergraduate nursing students. The framework represents a shift away
from a more university-driven model to one that embodies a collaborative approach
between academic and clinical staff. It was felt that the mutual dialogue would facilitate
the shaping of roles that would enhance personal as well as professional satisfaction for
both sets of stakeholders. In the case of clinical staff this has been shown previously to
77
lead to improvements in the teaching and evaluating skills of preceptors (Melander and
Roberts 1994). Further, more recent research into the relationship between the social
climate of the clinical learning environment and student learning outcomes (Chan 2002;
2004) highlights the potential for enhanced ‘local ownership’ of students’ clinical
education to facilitate improved learning experiences and outcomes for students (Chan
2004).
The overall aim of the CEU model was to facilitate quality clinical education for
undergraduate nursing students. Consistent with the findings from the evaluation study
undertaken earlier (see 4.1 above), the specific objectives of the CEU model were to:
• promote a positive learning environment in wards where students were placed for
‘prac;
• improve the processes of clinical facilitation for both students and nursing staff;
• promote quality learning outcomes for students; and
• improve student and nursing staff satisfaction with the overall quality of clinical
education.
To achieve the overall aim and objectives the CEU model was developed around four
key structural elements that were underpinned by three core principles. The structural
elements were (1) a supernumary Clinical Associate role; (2) a Clinical Partner role; (3)
an Academic Support/Liaison role; and (4) continuity, or consistency, in student
placement in the particular clinical unit across an academic year. There were also three
core operational principles that were felt to be as important as the structural elements:
(1) collaboration between academic and clinical staff, (2) commitment to a positive
learning environment and (3) a ‘whole of clinical unit’ commitment to students’ clinical
78
learning. These principles and the key structural elements of the CEU are shown
schematically in Figure 1 and described in more detail in the following section.
Clinical Academic/Faculty
Associate/s Liaison Person
Clinical unit Core Principles: Clinical unit

designated designated
Academic -clinical collaboration
as a CEU as a CEU
Positive learning environment
‘Whole-of-clinical unit commitment
Clinical
Students
Partners
Figure 4.1: Schematic representation of the CEU model (Phase 1)
4.3.1 Theoretical basis
From a theoretical point of view, the CEU model is informed by Boud, Cohen and
Walker’s (1993) writing on the nature of learning from experience. Consistent with Kolb’s
work which conceptualises experiential learning as “the process whereby knowledge is
created through the transformation of experience” (1984, 38), Boud, Cohen and Walker
(1993) have described five propositions which offer “a range of perspectives to … make
sense of the most basic but elusive aspect of learning” (Boud et al. 1993, 16):
Proposition 1: Experience is the foundation of, and the stimulus for learning,
Proposition 2: Learners actively construct their experience,
Proposition 3: Learning is a holistic process,
Proposition 4: Learning is socially and culturally constructed, and
Proposition 5: Learning is influenced by the socio-emotional context in which it

occurs (Boud et al. 1987, 8-16)
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In particular, Boud et al. (1993) highlight the issues of context and purpose in terms of
experiential learning. In defining the concept of experience, they draw on Dewey’s work
which includes both “having” and “knowing” (Duff 1990, 465). “Having” relates to the
immediacy of contact with the events of life and ‘knowing’ relates to the interpretation of
the event. The important point here is that experience is not simply an event that
happens, it is an event with meaning. Thus experience, or experiential learning, can be
conceptualised as a meaningful encounter with the environment which requires,
amongst other things, the active engagement of learners with and within the milieu
“creating an interaction which becomes the individual as well as the shared learning
experience” (Boud et al. 1993, 6-7). From the issues highlighted in the foregoing
discussion, and key findings from the Review (Nash et al. 1999), it was felt that these
propositions related closely to the context of undergraduate clinical education and
provided an appropriate theoretical framework to use as a basis for the development of
the CEU model.
4.3.2 Core principles underpinning the CEU
4.3.2.1 Collaboration
Consistent with the acknowledged importance of collaboration to “enriched clinical
learning experiences for students” (Kirkpatrick et al. 1991, 101), the CEU model is
underpinned by a strong commitment to collaboration between academic and clinical
staff involved in the clinical education of undergraduate students. This principle was also
informed by findings from the Review (Nash et al. 1999) which highlighted, amongst
other things, the respective strengths of both academic and clinical staff with respect to
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students’ clinical education. Whilst academic staff were perceived to be in a better
position to assist students in making the links between theory and practice, clinical staff
were perceived as knowing the real world of clinical practice. Their familiarity with, and
credibility within the clinical environment was felt to be quite crucial in terms of students’
access to learning opportunities, being more readily accepted as part of the ward
environment and experiencing real world practice.
There was thus a clear imperative to develop a model that would facilitate meaningful
collaboration by clinical and academic staff through mutual trust and respect,
acknowledgement of the respective clinical and teaching strengths of both parties, a
clear understanding of joint responsibilities and a joint focus on beneficial outcomes for
all parties (Downie et al. 2001; Shah and Pennypacker 1992). However, despite the
strong rhetoric on the importance of collaboration within this context (e.g. Chalmers,
Swallow and Miller 2001; Downie et al. 2001; Edgecombe et al. 1999; Nordgren,
Richardson and Laurella 1998), effective inter-sectoral collaboration can be time
consuming and often difficult to achieve (Lasker, Weiss and Miller 2001; Linden 2002).
Reasons for this include the accelerating pace of change and increasing service
demands in both the health and education sectors. One of the challenges, therefore,
was to create a model that would facilitate collaboration between academic and clinical
staff within the context of clinical education that was not only meaningful but also
potentially sustainable. This has been addressed through the roles that are described
briefly in Section 4.2.3 (Structural elements of the CEU).
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4.3.2.2 Positive learning environment
The CEU model also embodies an agreed commitment by both parties to foster positive
learning environments for students. This principle is supported by a growing international
literature that affirms the centrality of clinical learning environments to the quality of
students’ experiences (e.g. Bezuidenhout, Koch and Netshandama 1999; Dumas,
Villneuve and Chevrier 2000; Hart and Rotem 1995; Savage 1998; Twinn and Davies
1996). Characteristics of good clinical learning environments include positive interactions
with staff, good communication, opportunities for student learning, students being
accepted as part of the ward team and a positive atmosphere (Dunn and Hansford 1997;
Fretwell 1983; Levec and Jones 1996; Neville and French 1991; Orton 1983; Pierce
1991). A recent study by Papp, Markkanen and von Bonsdorff (2003) concluded that a
positive learning environment is demonstrated when there is close and positive co-
operation between academic and clinical staff, as reflected in the way that students are
provided with learning opportunities. However, the increasing complexity and intensity of
service delivery requirements continue to impact on the perceived capacity of many RNs
to work meaningfully with nursing students on a regular basis. Consequently, another
goal of the CEU model was to facilitate the development of positive learning
environments that would effectively support both students and staff in the pursuit of
clinical education.
4.3.2.3 Whole-of-clinical unit commitment
The third core principle emphasises the importance of a team, or whole-of-clinical unit,
approach to the clinical education of students. Primarily this principle grew out of the
findings from the Review (Nash et al. 1999) that highlighted the critical, but to some
extent unrecognised, role played by RN buddies – RNs who are paired up with students
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on a 1:1 basis to provide informal mentoring and clinical support. It is also consistent
with Dunn and Hansford’s (1997) findings that, apart from students themselves, RNs
were the most important factor in the clinical learning environment. More recently,
Saarikoski and Leino-Kilpi (2002) found that the relationship between student nurses
and their staff nurse mentors was in fact the most important factor contributing to clinical
learning. In developing the CEU it was therefore felt to be important to design an
inclusive model that incorporated the buddies as an explicit component of the clinical
education process.
4.3.3 Structural elements of the CEU
As indicated earlier, there are four key structural elements to the CEU model of clinical
education. These are Clinical Associates, Clinical Partners, Faculty/Academic Staff and
Continuity of Student Placement.
4.3.3.1 Clinical Associates
Clinical Associates (or CAs) are registered nurses working in a clinical unit/s where
students are placed who are appointed to the supernumary CA role for the duration of a
clinical practicum/s. In this role they are responsible for the overall supervision/clinical
teaching and performance assessment of students who are placed in that unit. Their
responsibilities include student briefing/debriefing, assessment of learning needs,
ensuring that students are paired up appropriately with RNs who are working in the
clinical unit (Clinical Partners) on a 1:1 basis and able to access the types of learning
experiences that will enable them to meet their clinical objectives, close liaison with staff
83
in the unit and the university (via the Academic/Faculty Support Person described
below), consultation with students regarding their progress and evaluation of their
performance. Clinical Associates are prepared for their CA role through educational
workshops that are provided by faculty staff from the School of Nursing. The workshops
are usually held at the university, however - if more convenient - they are held on-site in
the health care facility. There are also regular pre-briefings and de-briefings facilitated
by faculty staff before and after each clinical practicum, and the Academic Liaison staff
member meets informally with CAs on a weekly basis throughout the practicum.
As compared to traditional supervision using sessional and/or seconded facilitation
models (Grealish and Carroll 1998), there are two key differences in the CA role: (1) CAs
remain in their own clinical unit, and (2) the supervision ratio is 1:4 rather than 1:8. The
latter is made possible by allocating an entire clinical group of 8 students to a single
CEU ward (rather than several different, and sometimes geographically distant wards, as
is usually the case) and the group is ‘subdivided’ across the morning and afternoon
shifts, thus allowing the supervision ratio for individual CAs to be 1:4 per shift rather than
1:8. To enable each CA to function on a supernumerary basis, and be in a position to
properly facilitate and assess student learning, the health care facility is financially
reimbursed by the university so that work relief can be provided for CAs’ normal clinical
load.
The notion of CAs facilitating in their own clinical units is consistent with Brennan and
Huth’s (2001) discussion regarding criteria for success in terms of clinical facilitation.
From their experience they make the point that positive impact is more likely when the
incumbent/s have recent clinical practice, are part of the organisation in which students’
84
clinical experience is to occur and facilitation is able to be concentrated over a limited
(geographic) area. Further, because the clinical facilitator (ie. the CA) is already part of
the nursing team, it avoids the sense of isolation that can be experienced by sessional
staff or seconded staff working outside of their ‘normal’ wards (Carlisle 1997; Smyth
1998) and provides an important opportunity to encourage and/or reinforce the
contribution of other nursing staff on the ward to students’ learning (Brennan and Huth
2001).
In the first iteration of the study, two clinical nurses from each CEU ward were appointed
to the CA role. The purpose of this was to reinforce a whole-of-ward approach to
supervision, provide extra on-ward support for individual CAs (as needed) and assist in
the assessment of students’ performance. Each CA functioned in the role on a .5 basis
for the duration of the clinical practicum. To achieve this, their time (per week) was
divided into “off-line” or clinical supervision time, and ‘on-line’ or normal clinical workload
time. Thus in the course of a 4-week clinical practicum each CA had 10 ‘on-line’ shifts
and 10 “off-line” shifts. The allocation of individual CAs to ‘on-line’ and ‘off-line’ shifts in
the ward was determined by the CAs themselves in consultation with ward staff.
4.2.3.2 Clinical Partners
Clinical Partners (or CPs) are the buddy RNs who work alongside students each day on
an informal 1:1 basis. The buddy role in the CEU is similar to more recent descriptions of
the role of staff nurses, e.g. informal mentoring and support of students as they practise
the application of knowledge, skills and concepts introduced in classroom/laboratory
situations (Burns and Paterson 2004; Papp et al. 2003; Saarikoski and Leino-Kilpi 2002).
85
Although the buddies do not hold formal responsibilities in relation to students’ clinical
education, the articulation of the Clinical Partner role and its explicit inclusion in the CEU
model emphasises the importance of these staff within the clinical learning environment.
It was felt that this would reinforce the CEU’s whole-of-ward approach and the notion
that all RNs on the ward are necessarily involved in, and contribute directly to the quality
of students’ experience.
Throughout each clinical practicum CPs liaise closely with the CA in their clinical unit
and, if desired, with the Faculty/Academic staff member (see below) when he/she visits
the unit. Similarly to the Clinical Associates, CPs are prepared for their role through the
provision of on-site workshops that are facilitated by faculty staff from the School of
Nursing and are supported throughout the practicum by the CA and the designated
Faculty/Academic staff member. In addition, CAs and CPs can connect to the Work
Integrated Learning (WIL) website that has been purpose-built by the SoN to provide
students and all staff involved in the supervision of students with ready access to
information regarding the clinical program. Along with relevant CAs, nursing
administration staff and academic staff, CPs (or their representatives) are involved in all
ongoing consultations about the CEU model.
4.3.3.3 Academic Liaison
The third structural element of the CEU model is an academic staff member who
liaises/consults directly with ward staff and students throughout the practicum/s to assist
with the integration of theory and practice, and achievement of course expectations,
goals and objectives. The academic staff member visits the CEU on a regular basis
86
throughout students’ practicums, eg. weekly (or more often if required), to provide a
critical and tangible link between the university, the curriculum and the clinical setting.
The role of the academic staff member involves working directly with students and
clinical staff in relation to curriculum implementation. This includes information provision,
problem solving, role modelling and/or trouble shooting etc. within the context of
students’ clinical experience. At the outset of this project it was also envisaged that the
presence created by this role, together with the tangible demonstration of academic-
clinical collaboration, would further the development of a collaborative ethos and lead to
other activities/projects jointly involving academic and clinical staff, eg. research,
publications etc. Recently this has started to become a reality with clinical staff from
several of the CEU units joining academic staff from the SoN in a large teaching and
learning project that is being implemented during 2005-2006.
4.3.3.4 Continuity of student placement
The final key structural element of the CEU is continuity of student placement. This is
similar to the notion of consistent clinical assignment as described recently by Adams
(2002) and, in the CEU context, occurs in two ways: (1) an entire student clinical
placement group, ie. 8 students, is placed in a single CEU clinical unit - rather than
dispersed across 2 or 3 different clinical/ward areas (as discussed earlier); and (2) the
student group is placed in the same CEU clinical unit across both semesters of the
academic year. This strategy is based primarily on findings from the Review (Nash et al.
1999) that highlighted the very real difficulties faced by students and staff in association
with students changing their placement area from prac to prac. From discussions with
students and staff it was felt that continuity of placement, particularly during the final year
of the undergraduate course, offered potentially significant added-value for students in
87
terms of the consolidation of knowledge/skills and employment opportunities as a new
graduate, and for staff in terms of recruitment possibilities and the opportunity to prepare
students as well as possible for making the transition to professional practice.
4.4 Implementation of the CEU model
An overview of key issues associated with the implementation of the CEU model during
Phase 1, and changes that were made for Phase 2, is given below.
Phase 1
For the purposes of Phase 1, two registered nurses in each of the selected wards were
appointed to the role of Clinical Associate (CA). Each CA functioned in the role on a .5
basis for the duration of the clinical practicum. To achieve this, their time (per week) was
divided into ‘off-line’ or clinical supervision time and ‘on-line’ or normal clinical workload
time. Thus in the course of a 2-week clinical practicum there were 5 on-line shifts and 5
off-line shifts per CA. The allocation of individual CAs to on-line and off-line shifts in the
ward was determined by the CAs themselves in consultation with ward staff. When the
CAs were ‘off-line’ they facilitated students on a 1:4 basis (as students were distributed
across two shifts instead of all eight students together on one shift), and work relief was
provided for the CAs to have the off-line time needed to properly facilitate student
learning. As there was only one ‘off-line’ shift per CA per day, and students were placed
on both morning and afternoon shifts, it was essential to have an arrangement in place
for student supervision during the non-CA facilitated shift each day. To accommodate
this, it was agreed that, during this time, the ward staff (ie. the Clinical Partners or CPs)
would assume responsibility for the students’ supervision and would liaise closely with
both CAs regarding students’ progress.
88
Phase 2
Throughout Phase 1 there was an ongoing dialogue involving all key players, such as
students, clinical staff and academic staff. Apart from the evaluation of outcomes from
Phase 1, the purpose of this was to further inform CEU model in light of the common
understandings that were reached. From these discussions the key structural elements
and core principles of the CEU model were re-endorsed by all participants. Thus, as
shown in Figure 4.2, the Phase 1 CEU model was carried through to Phase 2 of the
study.
Clinical Academic/Faculty
Associate/s Liaison Person
Clinical unit Core Principles: Clinical unit

designated designated
Academic -clinical collaboration
as a CEU as a CEU
Positive learning environment
‘Whole-of-clinical unit’ commitment
Clinical
Students
Partners
Figure 4.2: Schematic representation of the CEU model (Phase 2)
However, comments of clinical and academic staff highlighted a number of important
operational issues. These included:
• a degree of role confusion for both CAs and CPs with regard to the ‘off-line’/’on-line’
concept;
• lack of flexibility for CAs with regard to the AM/PM shifts worked; and
• the need to provide better back up arrangements for CAs
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Subsequently, several minor changes were made to improve the operational aspects of
the original CEU model (giving rise to the CEU-2 model of clinical education). The key
changes incorporated within CEU-2 were:
• one registered nurse in each of the CEU wards appointed to the role of Clinical
Associate. The CA functioned in that role on a full-time basis, ie. 5 days per week for
the duration of the clinical practicum. Thus, each CA was, in effect, ‘off-line’ for the
entire clinical practicum;
• CAs were able to choose to work a week of morning shifts followed a week of
evening shifts, or vice versa, or to work a series of 9am-6pm shifts that cut across
both morning and afternoon shifts; and
CAs in adjoining wards agreed to provide backup for each other as necessary. The
design of the new Hospital facility (which had been completed during the intervening
period) made this possible due to the flow through design between ward areas that were
once geographically separate. Thus it was quite feasible for CAs from two wards in the
same clinical area to know and look after the combined group of 8 students who were
placed in those areas.
4.5 Non-CEU models for this study
To evaluate the impact of the CEU, the model was implemented in selected wards and
results were compared with those from student and staff in non-CEU wards. In the non-
CEU wards, the usual models of clinical education were continued. In Phase 1, the non-
CEU wards used the seconded model as this was the model of clinical education
preferred by the Hospital at the time. In Phase 2, the non-CEU wards used the sessional
and seconded models as these were the models preferred in the non-CEU facilities and
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had been used there for some time. Both sessional and seconded models were
implemented in accordance with the broad descriptions given in Section 2.5.
4.6 Summary
This chapter has outlined the conceptualisation and implementation of the CEU model
that was used in this study. The results of the study are presented in the following
chapters. The chapter began with a brief overview of the background to development of
the CEU model. This was followed by discussion on the theoretical underpinnings of the
model, the structural elements and core principles of the CEU, and key issues
associated with implementation of the model during Phase 1 and Phase 2. The
following chapters present the results of the study.
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CHAPTER 5
RESULTS - PHASE 1
5.1 Introduction
This chapter presents the results from Phase 1 of the study. The first section presents
the analysis of the data from the focus group discussions with students and the Phase 1
survey questionnaire completed by students (Research Questions 1 and 2). The section
that follows presents the results from the focus group discussions with registered nurses
(RNs) and the Phase 1 survey questionnaire completed by RNs (Research Questions 3
and 4). The procedures for data collection and data analysis were described in Chapter
3. The chapter concludes with a brief summary of the Phase 1 results.
5.2 Students
This section presents the analysis of the data from the focus group discussions
conducted with students during Phase 1 of the study. The findings are presented using
examples from the transcripts, the categories and themes generated from the open
coding and verbatim quotations from the transcripts. The data from students who were
placed in the CEU wards were analysed separately to the data from students who were
placed in the non-CEU wards. However, as the analysis proceeded it became clear that,
whilst there were differences in the specifics of what students from both groups had to
say, the categories and themes emerging from their comments were similar. Thus the
data are presented as an integrated whole with the inclusion of quotations from CEU and
non-CEU students to illustrate similarities and/or differences in their perceptions.
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5.2.1. Research question 1
What are the perceptions of undergraduate nursing students with respect to the CEU
As shown in Table 5.1, four key themes emerged from the analysis of students’
comments regarding models of clinical education. These themes are described below,
incorporating examples from the data to illustrate the dimensions of each category.
Table 5.1: Themes and categories from the student focus groups (Phase 1).
Themes Categories
Learning environments • Relationships
and prac
• Supportive/unsupportive environments
Facilitation that ‘works’ • Availability of the supervisor
• Familiarity of the supervisor with the local environment
Clinical learning • Continuity in clinical placement
• Access to clinical experiences
Prac outcomes • Development of clinical knowledge/skills and
confidence in the clinical role
• Overall satisfaction with the clinical practicum
Learning environments and prac
Throughout the focus group discussions both groups of students made a number of
comments that highlighted the importance of wards where students are placed for prac
functioning as learning environments, for example:
Well, I’m glad that our student nurse days are nearly over. Just so much depends
on the registered nurses that you are with. I think it’s a massive issue. It covers
the whole spot. It would be excellent if RNs wanted to have students with them
(Year 3 non-CEU student).
It’s just great when there’s more cooperation with everyone. The learning
environment is more relaxed. (Year 3 CEU student).
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Two aspects that were particularly evident in students’ comments about this issue were
(1) relationships between clinical facilitators and ward staff, and (2) the notion of
supportive/unsupportive environments.
Relationships between clinical facilitators and ward staff
With regard to relationships, students from the CEU and the non-CEU wards
commented about previous practicum experiences where their facilitators had been
employed on a sessional/casual basis by the university. They drew attention to issues of
potential (and actual) conflict between their facilitators and registered nurses in the
wards where they were placed, and the impact of this on the quality of their experience.
As one CEU student commented:
My facilitator had a lot of trouble last year with staff on the ward because, I don’t
know why, but I assume because she didn’t work there they didn’t know her and
she wasn’t approaching them at good times and couldn’t get things done (Year 2
CEU student).
When students commented about the CEU model being implemented in the present
study, however, there was a clear sense that this model facilitated better relationships
between clinical facilitators and staff in the wards:
I think it (the CEU model) works well because on previous pracs there is quite
often some pressure between staff in the wards and the facilitator and the
students there. Having your facilitator from that particular ward makes it easier –
even further than that because when the facilitator is from that ward the staff are
more accepting of students as well (Year 3 CEU student).
It’s good because you don’t get that conflict between the facilitator and the staff
that I’ve seen before with the facilitator trying to get things done and the staff are
just trying to get their jobs done and they don’t want students there. There’s not
that friction (Year 3 CEU student).
In contrast, students from the non-CEU wards commented that:
Buddy nurses don’t feel comfortable with facilitators that they don’t know. This
makes it harder for things to go well. Relationships can be tense and we feel
stressed (Year 3 non-CEU student).
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If the facilitator is seen as an outsider there isn’t always good rapport between
her and the staff. This affects communication and can make a difference to what
we can do…we can’t afford to waste our time on prac! (Year 2 non-CEU student).
Good relationships are the thing. It was OK this time but in my experience it just
doesn’t work when there’s friction between the facilitator and the staff (Year 3
non-CEU student).
Supportive/unsupportive environments
The second aspect to this theme was the notion of supportive/unsupportive
environments. In reflecting on their experiences during previous practicums both groups
of students made similar observations about the apparent attitudes of registered nursing
staff towards students being there. Following are some examples of their comments:
Well, it all depends whether they want you there or not. If they want you there….
Of course if it’s busy they need to get things done, they just have to do them. But
if they’re calm about students being there it’s easier (Year 2 non-CEU student).
Sometimes you just get those looks like - Oh God, here comes a student. You
can feel it. It makes it so hard.(Year 2 CEU student).
Within the context of students’ experiences during the course of the present study, the
issue of supportive/unsupportive environments didn’t emerge as a particular focus for
discussion among the non-CEU students. However, it was a strongly positive feature of
the comments expressed by CEU students:
Like they were really keen to say well come and do this whereas last year (non-
CEU model) it was sometimes like you would have to ask what is happening and
can I help - whereas here I found that they were saying to me come and do this,
and have a go at this yourself. It was great (Year 2 CEU student).
I found it (CEU ward) much better here. I never got those looks, like Oh God here
comes a student. I haven’t had that (Year 3 CEU student).
I think it (CEU) works well because on previous pracs there is often some
pressure between staff on the wards and facilitators (sessional staff employed by
the university). Because the facilitator (supervisor) is part of the ward I find that
other staff are more accepting of students (Year 3 CEU student).
95
Facilitation that ‘works’
A second theme in students’ comments about their “pracs” related to what might be
thought of as ‘operational’ aspects of their clinical facilitation. Two issues that were
particularly evident in students’ comments were (1) the notion of supervisor availability
and (2) familiarity of the supervisor with the environment.
Supervisor availability
Students from the non-CEU wards expressed their concerns about the clinical facilitator
not being readily available. Representative comments include the following:
You see the facilitator/supervisor mainly when she comes down to assess you
and she’s watching you and you get so nervous because she’s not around all of
the time (Year 2 non-CEU student).
They’re (facilitators/supervisors) not around a lot? We seem to hardly see them.

They ask the RNs how we’re going. I’d like to see her more often (Year 3 non-
CEU student).
However, as illustrated by the following examples, CEU students expressed the opposite
view:
We couldn’t get a facilitator (supervisor) last time. We had to wait for them to
come, and then they didn’t come or we couldn’t get hold of them when we
needed them. Here, they’re always in the ward – it’s heaps better (Year 2 CEU
student).
This (CEU) is much better ‘cos when if they’re (facilitators/supervisors) aren’t

here all the time they see you doing one thing wrong and they think it’s a big deal
because they haven’t been around to see you doing other things right! (Year 2
CEU student).
Familiarity with the environment
The second category related to familiarity of the supervisor with the environment and,
similarly to above, there were alternative views expressed by students according to the
clinical education model that they were experiencing/had experienced previously.
Representative comments from non-CEU students included the following:
96
Last year I had a facilitator who wasn’t a fulltime person on staff at the uni, she
just came in to do pracs. You couldn’t ask her about things because she didn’t
know. So you had to go and ask the staff and that was sort of difficult because
they expected her to know… (Year 3 non-CEU student).
CEU students, on the other hand, unanimously expressed a different point of view:
The CEU is good. Clinical associates can encourage the ward staff to help us a
lot more effectively. They already know them and they know what to say a lot
better (Year 2 CEU student).
This (CEU) is much better than before. I’ve had facilitators that I haven’t seen for
two or three days, then they appear and assess you! And you can accept the
feedback a lot better because you know the nurses are actually doing it all the
time, not like the facilitator who is looking after students (Year 3 CEU student).
Clinical learning
A third theme to emerge from students’ comments was concerned with clinical learning
during the practicum, and factors that had positive and/or negative effects on this. Two
key aspects to this theme were: (1) access to quality clinical experiences whilst on
practicum and (2) continued placement, or continuity, in the same ward area across the
academic year.
Access to quality clinical experiences
Students from both CEU and non-CEU groups had quite a number of comments around
the issue of access to quality clinical experiences. This was a topic they all felt strongly
about. As expressed by one student:
You want them to let you do the hard stuff and not just the obs all the time. If
you’re not certain or very confident you want them to run you through it - talk you
through it, you know what I mean? What’s difficult when you’re in different areas
and you’re dealing with different staff who don’t know you they can get trivial over
the simplest things, like folding things certain ways and stuff like that, and you
don’t get to do procedures and other things that take you to the next level (Year 3
CEU student).
However, there were some interesting differences in the perceptions of CEU and non-
CEU students with regard to learning experiences during their current practicums. A
97
discernible sense of disappointment/frustration appeared to underlie the comments of
non-CEU students. Representative comments included the following:
Well they (RNs) will do things before you get to them. They say to you ”Look, tell
me what you want to do for the day, so you organise things so that you can get
experience doing the procedures but it’s all dependant on whether or not they’ve
already done them and if they get to them before you do. I get the feeling that it’s
all based on them having a good day, they want to run on time and they’re in
control (Year 3 non-CEU student).
All we get to do is showers, meds and that stuff. Maybe if we did lates (shifts)
instead of earlies? There might be something else to see, something to do? It
just depends on what ward you’re in and who you’re with (Year 2 non-CEU
student).
In contrast, CEU students expressed a much more strongly positive view:
The staff here guide us and help us to develop our skills. They let us participate
and do procedures and things.…they did that on my pracs too but somehow the
staff here (CEU ward) know it is a teaching ward and their attitude is a lot better
(Year 2 CEU student).
It’s funny, but I found that if something was happening here the nurses would tell
us to go and be involved – to not worry about the obs because they would do
them for us! It’s like they really want us to learn (Year 2 CEU student).
Continuity in the same ward area
Despite some reservations with regard to continuity of clinical placement CEU students
generally agreed that being placed in the same ward area for more than one practicum
was advantageous. However, some hesitation about this aspect of the CEU model was
expressed by some of the second year students. As one student commented:
I think it could specialise us a bit too much if you did it for the whole time. I think
you need to get the feel of different areas in first and second year, then go in and
do your concentrated learning in third year. But what I’ve found is that even on
the same ward you can get lots of different experiences. Like going to theatre,
radiology etc. with our patients and following them through right to discharge
Even so, the general views about this issue are summed up in the following comment:
It’s really good that it’s (the placement) going to be continued next prac. We can
come back and feel comfortable and know what we’re doing. Especially dealing
with staff because the first week of a new prac you’re watching the staff, you
know watching the dynamics, who you want to work with ….And going through all
98
the anxiety (of being new) again. And it’s good where staff remember familiar
faces, it just helps with reinforcement of what you’re doing. Also gives you a bit of
a foot in the door for when you’re finished the course? (Year 3 CEU student).
Prac outcomes
The final theme which emerged from the focus group discussions with students was
concerned with their perceptions about what they had learned during their clinical
practicums and, to some extent, the degree to which this might advantage their future
job prospects. Notably, almost all of this commentary came from students who had
been in the CEU wards. Two key sub-themes were evident in their comments: (1)
development of clinical knowledge/skills and confidence in the clinical role, and (2)
overall satisfaction with the clinical practicum.
Development of clinical knowledge/skills and confidence in the clinical role
In general, CEU students reported a greater sense of achievement during their pracs in
the CEU wards than what they had experienced previously, for example:
It’s a lot better. I think we’ve got a lot more out of it. You’re getting more in-depth
knowledge, you get to really hone your theory and get your practical …I mean
doing it on a continual basis you get to feel confident within yourself (Year 3 CEU
student).
The facilitator/supervisor plays more of a teaching role here (CEU wards) more
than I’ve had before. She’s always there helping you. You get a lot more
feedback (Year 2 CEU student).
I think the facilitator/supervisor plays more of a teaching role in this model than a
normal facilitator. The RNs that I had on other pracs hardly see the facilitator, at
least here you have the facilitator who’s always there and focussed on teaching
more than doing like before. (Year 3 CEU student).
Further, several comments made during the discussions suggested that continuity (being
placed in the same placement/ward area across an academic year) was an important
contributor to these outcomes, for example:
Well, there’s not the apprehension like there is when you go on a normal prac
because we know the staff and we know the facilitator/supervisor and we know
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what we’re going to be doing … so it’s not like when you have to go to a new
ward for the first time (Year 2 CEU student).
When you’re starting up a new prac they ask you what you’re objectives are …..
at least this time we have realistic objectives because we know what the ward is
like and we know what level of experience you need to get out of the ward … so
it makes it much easier (Year 3 CEU student).
Overall satisfaction with the clinical practicum.
For the CEU students, the perception of having ‘moved’ their clinical knowledge and
skills to a higher level appeared to translate to an improved sense of confidence and
greater satisfaction with the experience as a whole. Whilst the second year students
were slightly less enthusiastic than the third year students, there were uniformly positive
views about these issues, for example:
I think I’m looking forward to going back. You do feel more comfortable knowing
where you’re going to be going. I won’t have to spend the few days making
mistakes. But maybe I won’t see a good range of things? (Year 2 CEU student).
This (model) builds our skills and confidence and that’s pretty much because of
the facilitator (Clinical Associate). She’s part of the ward, and has made us
comfortable here. Also the staff because they’re more confident in us doing
things too. They say “Have a go”. I’m very satisfied with how it went (Year 3 CEU
student).
This has been good – I’m very satisfied. To come back a second time will be
great. I can get to do those skills again and get really good at them. When you go
somewhere different you don’t ever get really good because you’re always doing
things for the first time. Besides this is the biggest hospital in Brisbane, there’s a
good range of patients and you’re always building your skills (Year 3 CEU
student).
Non-CEU students, on the other hand, had a lot less to say about the issue of learning
outcomes. Whilst the general view was that their prac had been ‘good’, there appeared
to be a perceptible undertone to their comments, for example:
The ward and the length of time (4 weeks) was good ….. you can really get into it
(Year 3 non-CEU student).
It was OK but I feel like I was just doing tasks? (Year 3 non-CEU student).
The RN stands there and says “You just do your plan and come and grab me
when you want me because I’ve got obs and other things to do”. The nurses
100
don’t have time to be with us. You’re lucky if you get a good nurse who has time
to go through things with you. They forget we probably haven’t had these
patients before… (Year 2 non-CEU student).
Summary
In summary, four common themes emerged from the analysis of students’ comments
regarding models of clinical education: Learning environments and Prac, Facilitation that
‘works’, Clinical learning and Prac outcomes. This suggests that, irrespective of
particular models of clinical education, eg. CEU or non-CEU, students perceive these
issues as important to the quality of their clinical experience. However, there were both
similarities and differences in the views of CEU Vs non-CEU students regarding these
themes. Both CEU and non-CEU students emphasised the importance of the learning
environment. Particular aspects of this that were highlighted by both groups included
relationships between clinical facilitators and ward staff and the perceived
supportiveness/unsupportiveness of the environment. However, there were also some
qualitative differences in students’ perceptions according to the model of clinical
education they had experienced. CEU students felt that this model facilitated better
relationships between clinical facilitators and staff in the wards and a supportive
environment whereas the non-CEU students emphasised the issue of strained
relationships when the facilitator is an outsider to the organisation.
As regards Facilitation that works, CEU students perceived their facilitators to be familiar
with, and within the ward/hospital environment and available to support them in their
learning. In contrast the non-CEU students spoke about problems that occur when the
facilitator is not familiar with the environment and/or not readily available to support
individual students in their clinical learning. With respect to Clinical Learning and Prac
Outcomes, both groups of students agreed on the importance of access to clinical
101
learning opportunities. CEU students tended to perceive that the CEU staff had
facilitated “good” access to learning opportunities and generally these students felt a
sense of achievement and satisfaction with the progress they had made during the prac.
The issue of CEU continuity of placement was raised by these students as a factor in
these outcomes. On the other hand, the non-CEU students felt frustrated about a
perceived lack of staff support for them to “do things” and were less expressive about
the overall outcomes they had achieved. Taken together, the data from these focus
groups would appear to highlight the importance of the learning environment and the
clinical facilitator to students’ perceptions of “good” prac experiences. The data also
suggest that some of the key features of the CEU model of clinical education, eg. whole-
of-ward approach, local clinical facilitation arrangements and continuity of placement,
may facilitate “better” clinical experiences for students.
5.2.2. Research question 2
How do CEU students rate the quality of their practicum experience, and how do their
ratings compare with those of non-CEU students?
As detailed in Chapter 3, students and RNs from CEU and non-CEU wards were invited
to respond to the Quality of Prac Experience (QPE-Phase 1) questionnaire during Phase
1 of the study. The student version of the QPE-Phase 1 questionnaire contained 23
items designed to explore students’ perceptions regarding the quality of their clinical
prac experience. All items were scored on a 5-point Likert scale ranging from 1=Strongly
Agree to 5=Strongly Disagree. Negative items were recoded such that higher scores
reflected more positive perceptions. The analysis of students’ responses to the
questionnaire is presented below.
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Demographic characteristics of student respondents
A total of fifty-six students completed the QPE-Phase 1 survey questionnaire. Table 5.2
shows the demographic characteristics of the sample. As expected, the sample
consisted mainly of female students (82.1%) almost all of whom were enrolled in the
course on a fulltime basis (96.4%). Participants’ ages ranged from less than 20 years to
more than 40 years with the majority aged between 20-39 years (69.7%). Approximately
half of the sample consisted of 2nd year students with the remainder consisting of Year 3
students. Chi square tests were conducted to assess any age or gender differences
between the CEU and non-CEU students. There was no significant difference between
the groups with respect to gender (χ2 [2, n=55] = .554, p = .758). However, there was a
significant CEU difference in terms of age (χ2 [4, n=56] = 12.816, p = .012). Fourteen
percent of the CEU respondents were <20 years with a further 49% aged 20 to 29 years.
In contrast 42% of the non-CEU respondents were <20 years with a further 42% aged
20-29 years.
103
Table 5.2: Demographic characteristics of the student sample (QPE-Phase 1).
f %
n=56
Age:
< 20 years 13 23.2
20 – 29 years 24 42.9
30 – 39 years 15 26.8
> 40 years 2 3.6
Gender:
Female 46 82.1
Male 10 17.9
Year level in course:
2nd year 25 44.6
Year 3 29 51.8
Enrolment in course:
Full-time 53 96.4
Part-time 2 3.6
Mode of clinical education model:
CEU 37 66.1
Non-CEU 19 33.9
Analysis of student responses to the QPE-Phase 1 (Student) questionnaire
To examine the pattern of CEU students’ ratings of the quality of their clinical
experience, and how this compared with non-CEU students’ ratings, frequency analyses
were conducted on their responses to individual survey items. The results for both
groups are presented below in Table 5.3. In general, the CEU students’ responses to
the QPE survey items were more positive than those of the non-CEU students.
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Table 5.3: CEU and non-CEU students’ responses to the QPE-Phase 1 (Student) questionnaire
Strongly Strongly
agree Disagree
1 2 3 4 5
%
All nurses on the unit, from the CNC to the newest student, felt CEU 45.9 32.4 10.8 5.4 5.4
part of the nursing team
Non-CEU 36.8 36.8 15.8 10.5 -
In general, ward staff helped students to gain the widest possible CEU 59.5 29.7 5.4 5.4 -
experience
Non-CEU 31.6 42.1 26.3 -
-
The Clinical Associate (CA)* put a lot of effort into teaching CEU 64.9 18.9 2.7 10.8 2.7
nursing students
Non-CEU 42.1 31.6 15.8 10.5 -
This was a good unit for nursing students to learn about clinical- CEU 67.6 24.3 8.1 - -
practice
Non-CEU 50.0 22.2 11.1 - 16.7
It was always easy to know the standard of performance CEU 35.1 35.1 16.2 13.5 -
expected from students
Non-CEU 15.8 21.1 42.1 15.8 5.3
The CA* made a real effort to understand difficulties students CEU 59.5 29.7 8.1 2.7 -
might be having with their work
Non-CEU 36.8 31.6 21.1 5.3 5.3
In general, undertaking "prac" on this unit motivated students to CEU 70.3 24.3 5.4 - -
do their best work
Non-CEU 26.3 31.6 21.1 15.8 5.3
The Clinical Partners (CPs)/buddy nurses attached a great deal CEU 37.8 32.4 21.6 5.4 2.7
of importance to the learning needs of students
Non-CEU 5.3 42.1 31.6 15.8 5.3
It was often hard to discover what the ward staff expected of CEU 8.3 8.3 19.4 38.9 25.3
students during this practicum
Non-CEU - 42.1 21.1 26.1 10.5
This experience has made me more eager to become a CEU 59.5 18.9 13.5 - 8.1
Registered Nurse
Non-CEU 36.8 31.6 10.5 10.5 10.5
I felt that I was able to make a useful contribution to the nursing CEU 62.2 29.7 2.7 5.4 -
team on the unit
Non-CEU 15.8 52.6 26.3 - 5.3
I usually had a clear idea of where I was going and what was CEU 45.9 45.9 2.7 5.4 -
expected from me during this practicum
Non-CEU 31.6 15.8 26.3 21.1 5.3
This practicum helped me to further develop my problem-solving CEU 59.5 29.7 5.4 2.7 2.7
skills
Non-CEU 21.1 57.9 5.3 10.5 5.3
The ward staff put a lot of effort into commenting on my CEU 10.8 45.9 32.4 5.4 5.4
performance
Non-CEU 10.5 31.6 36.8 15.8 5.3
This practicum helped me to further develop my communication CEU 56.8 37.8 - 5.4 -
skills
Non-CEU 31.6 52.6 10.5 - 5.3
I generally received constructive feedback on how I was going CEU 45.9 37.8 8.1 2.7 5.4
Non-CEU 15.8 42.1 26.3 10.5 5.3
This practicum helped me to further develop my technical skills CEU 75.7 16.2 8.1 - -
Non-CEU 26.3 47.4 10.5 5.3 10.5
105
Strongly Strongly
agree disagree
1 2 3 4 5
%
On the whole, I was clear about what I was doing well and what I CEU 59.5 32.4 - 8.1 -
needed to improve
Non-CEU 21.1 36.8 31.6 5.3 5.3
This practicum helped me to further develop my reflective skills CEU 45.9 32.4 18.9 2.7 -
Non-CEU 15.8 42.1 31.6 5.3 5.3
My performance was assessed in an open, consultative way CEU 64.9 24.3 5.4 5.4 -
Non-CEU 21.1 47.4 15.8 10.5 5.3
This "prac" helped me to further develop my organisation/time CEU 73.0 27.0 - - -

management skills
Non-CEU 36.8 42.1 10.5 5.3 5.3
This practicum helped me to further develop my understanding of CEU 59.5 29.7 8.1 2.7 -
concepts/principles of nursing practice 52.6
Non-CEU 15.8 52.6 21.1 5.3 5.3
Overall, I feel that this practicum was a worthwhile learning CEU 78.4 16.2 5.4 - -
experience
Non-CEU 36.8 36.8 10.5 10.5 5.3
* the term Clinical Associate (CA) was modified to Clinical Facilitator (CF) for the non-CEU students
However, for some items, the differences between their ratings were much more
apparent. For example, four of the items demonstrated a difference of 30% or greater in
the proportion of CEU students who agreed/strongly agreed with the item as compared
to the proportion of non-CEU students who agreed/strongly agreed with the same item.
The four items were ‘I usually had a clear idea of where I was going and what was
expected from me during this practicum’, ‘in general, undertaking prac on this ward
motivated students to do their best work’, ‘it was always easy to know the standard of
performance expected from students’ and ‘on the whole, I was clear about what I was
doing well and what I needed to improve’.
Ninety two percent of CEU students agreed/strongly agreed that they usually had ‘a
clear idea of where they were going and what was expected from them during this
practicum’, 95% agreed/strongly agreed that ‘in general, undertaking prac on this ward
106
motivated students to do their best work’, 70% agreed/strongly agreed that ‘it was
always easy to know the standard of performance expected from students’ and 92%
agreed/strongly agreed that, on the whole, they were ‘clear about what they were doing
well and what they needed to improve’. In comparison, the proportion of non-CEU
students who agreed/strongly agreed with the same items was 47%, 58%, 40% and 58%
respectively. To a slightly lesser extent, the same pattern was shown on three further
survey items. Sixty four percent of CEU students disagreed/strongly disagreed that ‘It
was often hard to discover what the ward staff expected of students during the
practicum’, 84% agreed/strongly agreed that ‘they generally received constructive
feedback on how they were going’ and 92% agreed/strongly agreed that they felt they
were ‘able to make a useful contribution to the nursing team on this unit’. In comparison,
the proportion of non-CEU students who agreed/strongly agreed with the same items (or
disagreed/strongly disagreed in the case of ‘It was often hard to discover what the ward
staff expected of students during the practicum’) was 37%, 58% and 67% respectively.
Notably, there were four items which attracted more equivocal responses from students:
‘all nurses on the unit from the CNC to the newest student felt part of the nursing team’,
‘the Clinical Associate/Clinical Facilitator put a lot of effort into teaching nursing
students’, ‘this experience has made me more eager to become a registered nurse’ and
‘ward staff put a lot of effort into commenting on my performance’. Whilst CEU students’
ratings on these items were still more positive than those of non-CEU students the
difference in the respective proportions was 10% or less.
To further examine differences in students’ ratings of the quality of their clinical
experience, independent sample t-tests were conducted to compare the mean scores of
CEU and non-CEU students on individual survey items. The difference in sample sizes
between the CEU and non-CEU students was noted. However, the t-test is robust to
107
differences in sample size provided that the variances are equal (Myers and Well 2000)
and the sample sizes are greater than 10 (Polit 1996). Where indicated by the Levene’s
test for unequal variances, t-test results assuming unequal variances were used.
In all, 23 comparisons were made. A Bonferroni correction was not applied based on the
premise that each comparison constituted an individual or separate event, rather than
multiple comparisons on the same data set (Munro 2001). On this basis, it is contended
that the chance of a Type 1 error on each test was not artificially inflated, and the
Bonferroni adjustment to the alpha level was not required (Uitenbroek 1997).
Consequently, for the purpose of these analyses, .05 was used as the level of
significance. The mean scores for CEU students were significantly higher than those of
non-CEU students on 15 of the 23 survey items. These are shown in Table 5.5. No other
significant differences were found.
The results from this analysis are not inconsistent with the pattern that emerged from the
frequency analysis presented earlier. As shown in Table 5.4, the ratings for CEU
students were significantly different to those of non-CEU students for the items
‘undertaking prac on this unit motivated students to do their best work’, ‘I felt that I was
able to make a useful contribution to the nursing team on the unit’ and ‘I usually had a
clear idea of where I was going and what was expected from me during this practicum’.
Other significant results included ‘this practicum helped me to further develop my
understanding of concepts/principles of nursing practice’, ‘on the whole, I was clear
about what I was doing well and what I needed to improve’, ‘my performance was
assessed in an open, consultative way’, ‘this practicum helped me to further develop my
understanding of concepts/principles of nursing practice’ and ‘‘this practicum helped me
to further develop my technical skills’.
108
Table 5.4: Mean ratings for CEU and non-CEU students on QPE-Phase 1 (Student) questionnaire items
Mean SD T df P
It was always easy to know the standard of performance expected CEU 2.08 1.038 -2.196 54 .032
from students
Non-CEU 2.74 1.098
The Clinical Associate/Clinical Facilitator made a real effort to CEU 1.54 .767 -2.192 54 .033
understand difficulties students might be having with their work
Non-CEU 2.11 1.150
In general, undertaking "prac" on this unit motivated students to CEU 1.35 .588 -3622 22.413 .001*
do their best work
Non-CEU 2.42 1.216
The Clinical Partners/buddy nurses attached a great deal of CEU 2.03 1.040 -2.455 54 .017
importance to the learning needs of students
Non-CEU 2.74 .991
I felt that I was able to make a useful contribution to the nursing CEU 1.51 .804 -3.128 54 .003
team on the unit
Non-CEU 2.26 .933
I usually had a clear idea of where I was going and what was CEU 1.68 .784 -2.607 24.839 .015*
expected from me during this practicum
Non-CEU 2.53 1.307
This practicum helped me to further develop my problem-solving CEU 1.59 .927 -2.222 54 .030
skills
Non-CEU 2.21 1.084
I generally received constructive feedback on how I was going CEU 1.84 1.068 -2.107 54 .040
Non-CEU 2.87 1.073
This practicum helped me to further develop my technical skills CEU 1.32 .626 -3.103 22.823 .005*
Non-CEU 2.26 1.240
On the whole, I was clear about what I was doing well and what I CEU 1.57 .867 -3.025 54 .004
needed to improve
Non-CEU 2.37 1.065
This practicum helped me to further develop my reflective skills CEU 1.78 .854 -2.476 54 .016
Non-CEU 2.42 1.017
My performance was assessed in an open, consultative way CEU 1.51 .837 -3.306 54 .004
Non-CEU 2.32 1.108
This "prac" helped me to further develop my organisation/time CEU 1.27 .450 -2.762 21.120 .012*
management skills
Non-CEU 2.00 1.106
This practicum helped me to further develop my understanding of CEU 1.54 .767 -3.220 54 .002
concepts/principles of nursing practice
Non-CEU 2.32 1.003
Overall, I feel that this practicum was a worthwhile learning CEU 1.27 .560 -2.883 22.137 .009*
experience
Non-CEU 2.11 1.197
* equal variances not assumed
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5.3 Registered nurses
5.3.1 Research question 3
What are the perceptions of registered nurses (RNs) with respect to the CEU model of
clinical education, and how do they compare with RN perceptions regarding non-CEU
models?
This section presents the analysis of data from the RN focus groups conducted during
Phase 1 of the study. The findings are presented using examples from the transcripts,
the categories and themes generated from the open coding and verbatim quotations
from the transcripts. As for the student data, data from the registered nurse focus groups
were analysed separately. However, similarly to the commonality of categories and
themes that emerged, the data are presented as an integrated whole with the inclusion
of quotations from CEU and non-CEU nurses to illustrate similarities and/or differences
in their respective perceptions. Four key themes emerged from the analysis of RNs’
comments regarding models of clinical education (Table 5.5). These themes are
described below, incorporating examples from the data to illustrate the dimensions of
each category.
Table 5.5: Themes and categories from the registered nurse focus groups (Phase 1).
Themes Categories
Team spirit • Relationships between key players
• Pulling together
Facilitation that ‘works’ • Familiarity of the supervisor with the local environment
• Availability/non-availability of the supervisor
• Support from the ‘uni’
Clinical learning • Quality of knowledge/skill development
• Continuity of student placement
Future employment prospects • Good grounding
• Recruitment advantages
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Team spirit
Throughout the focus group discussions nurses from both CEU and non-CEU wards
made a number of comments about the ‘social climate’ when students ‘were there’. The
common theme that emerged from these comments related to the notion of team spirit.
Particular aspects of this were (1) relationships between key players, eg. clinical
facilitators, registered nurses, students and academic staff, and (2) ward staff and
students ‘pulling together’ as a group.
Relationships between key players
Despite their impression that they “made it work”, nurses from the non-CEU wards
expressed continued frustration with the way “things were”:
Last year we had someone from outside (a sessional facilitator). It was just a
disaster in my opinion. Nobody knew anybody or anything. This year was better,
the (seconded) facilitator came from the ward around the corner - but we didn’t
see her often enough because she had to visit students in other wards, and we
lost her expertise from our ward for the length of the prac. You just can’t develop
a relationship and this affects everything (non-CEU RN).
On the other hand CEU nurses commented that:
With this (CEU) model the Clinical Partners (ward nurses) have a more vested
interest in students. They are more interested in making the students part of the
team – knowing they’re coming back to the ward they’re teaching them properly
so that next time it will be easier and better (Nurse Manager, CEU wards).
I get the feeling from staff and patients who’ve been in the ward for a while that
this model is a bit different. The students are motivated and focussed because
they know they’re coming back, and staff are happy that they’re coming
back…the CA knows the ward and the staff, and vice versa, and the CNC often
gives a bit more support because she’s part of it too (CA).
This (CEU model) is better. We’re more able to talk to them (the CAs) and if they
have anything they want to talk to us about, like regarding students, we’re more
open to talking with them because it’s someone we know. .. they’re not
outsiders….we can say what we feel without having to dart around anything…
and they can say things to us and we won’t be offended as much as we would if
it was a stranger telling us (CEU RN).
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‘Pulling together’
The notion of ‘pulling together’ emerged only from the discussions with CEU registered
nurses and associated nursing staff, eg. Nurse Unit Managers. It appeared to
complement their comments regarding ‘relationships with key players’ and emphasise
the importance of a team approach to clinical education.
The ward has enjoyed it. I haven’t had as many complaints as I normally
would…I think the strength is that the students feel part of the team and that’s
great. They assimilate much quicker and there seems to be enthusiasm on both
sides and it’s put the two sides into a more cohesive team (NUM-CEU wards).
They (students) become more a part of the team when the person (CA) is on the
ward all the time... and it’s less stress on them because they don’t have to be at
peak performance when the facilitator (CA) comes in for 10 minutes or so to visit
and see if everything’s OK (CP).
It’s definitely better for students. They’re able to be, like, more part of the team
and socialise into the ward environment. It feels like we’re all pulling together.
It’s much better. This is how we’ll improve things (CA).
Facilitation that ‘works’
A second theme that emerged from the focus group discussions related to the
operational aspects of clinical facilitation and the impact on their day-to-day work with
patient care and with students. Aspects that were particularly evident in their comments
were (1) the familiarity/unfamiliarity of the clinical facilitator with the ward environment,
(2) the availability/non-availability of the clinical facilitator and (3) support from the ‘uni’.
Familiarity/unfamiliarity of the clinical facilitator
Familiarity of the supervisor with the environment was a topic that all participants felt
strongly about. There was general agreement about the importance of clinical facilitators
being familiar with the ward environment/s in which students were undertaking their
clinical experience. However, there were some interesting differences in the perceptions
of CEU and non-CEU nurses with regard to their experiences during previous
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practicums and the practicum which was part of the present study. Without exception,
nurses from non-CEU wards expressed frustration with the perceived unfamiliarity of the
clinical supervisor with the prac environment, for example:
Last year we had a facilitator who came from the uni and didn’t know the hospital
at all. It was so frustrating, she didn’t know how anything worked. Because she
didn’t know the system she didn’t know where things were, couldn’t show
students how to page some etc. etc. It was so frustrating.
It makes it hard when the facilitator doesn’t come from the ward or that area. It’s
tiring. They’re not familiar with how things work. They’re not really ‘in’ with the
staff and don’t have the inside touch. And sometimes an outside facilitator will
allocate students to RNs who shouldn’t have students – there are some that
aren’t right with students and not the best choice ….but how would they
(facilitators) know?
On the other hand, nurses from the CEU wards had more positive views:
It’s (CEU model) better because the CA is in her own ward and students are
being facilitated by someone who we know is giving them correct information as
far as our ward goes. Where it’s been difficult before is when facilitators just
come in to the ward for the prac.
Having CAs in their own wards is much better because they have a good
understanding of the wards so you’re not getting differing ideas from facilitators
who supervise across lots of wards but never really get a grasp on each. Better
for students too.
You just feel more confident when you know the staff member who is looking
after the students. They know how things are run … it’s a lot easier.
Notwithstanding the foregoing, CEU nurses also expressed some qualifications about
the nexus between familiarity and the ward environment:
If students have a problem with their buddy RN or whatever they may be less
willing to tell the CA because they think that she is her friend, or because they
get on well together and chat at teatime – they sort of don’t want to bring it up.
Overall being familiar with the ward is an advantage, even though it’s sometimes
a disadvantage. You know who to buddy the student with but then you can have
a preconceived idea about what an RN is like. Maybe they’d be fine with a
student but because of your preconceived idea you don’t put a student with them.
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Availability/non-availability of the supervisor
This was also a topic that all participants felt strongly about. Again, however, there were
contrasting perceptions according to the model of clinical education that had been
operating in the participating wards. Nurses from the non-CEU wards indicated that:
We never seemed to see the facilitator. She was probably around but must have
been doing things with other students. How do they really know what students
are going? (non-CEU nurse).
The facilitator can’t be everywhere at once, but you never seem to see them?
They have to rely on a lot of feedback from us about how the students are
performing. They don’t have time to assess students properly themselves. (non-
CEU nurse).
They’re (facilitators) never there when you want them. I’ve seen facilitators
running up and down the ward being paged because they have students in other
wards. They’re just spread too thin. (non-CEU nurse).
whereas nurses from CEU wards commented that:
One of the good things about the (CEU) model is that the facilitator (CA) is there.
She’s based in her home ward … she’s there all the time (CEU nurse).
The CEU facilitator (i.e. the CA) is there. Students can be monitored for a full 8
hour period … not just ten minutes at a go. Even though they might be on the
other side of the ward you can get the gist of how they’re going and go over if
needs be (CEU nurse).
Support from the ‘uni’
The commentary on this issue came solely from the CEU participants. Unlike a number
of the other issues, this was not something that provoked much spontaneous comment
from the RNs who participated in the focus group discussions. However, when asked
about academic liaison with the ‘Uni’, the CEU RNs indicated that they had appreciated
the support provided through the Academic Support role which was structured into the
CEU model:
I felt more supported by the uni with this (CEU) model. There was more support
than with other models, or at least that’s my opinion. L. (the Academic Support
Person) was around, she would come in during the day or whenever. I didn’t
personally have any problems but she was there if I needed to contact her (CA).
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Clinical learning
The third theme to emerge from the focus group discussions was concerned with nurses’
perceptions about the development of clinical knowledge and skills by students. Two key
aspects to this theme were (1) quality of clinical knowledge/skill development, and (2)
continuity in students’ placement.
Quality of students’ knowledge/skill development
This issue did not emerge from the discussions with non-CEU nurses. However, CEU
nurses had a number of comments about what they perceived as ‘different’ in terms of
the learning outcomes that students in the CEU units had achieved, for example:
Students in this (CEU) model have been different...they’re more motivated and
focussed because they know they’re coming back. They want to get a good
grasp of what’s really going on…they get into the more in-depth staff like patient
education…they want that base of knowledge when they come back to us.
They’re really looking forward to coming back. And they get to take a patient load
(CEU nurse).
There is a definite advantage with this (CEU) … students just get in there and do
the whole time management thing. They can easily take a patient load now
instead of, you know, having to work at grass roots level (CA).
They’re only orientated in depth to one specialty but I don’t think that has much
bearing as they (students) get so stressed every time they go to a new ward. The
CEU is better because their stress levels are down and their capacity to learn is
much better.
Continuity in students’ placement
Related to the development of clinical knowledge and skills was the issue of continuity,
or consistency, in students’ placement across the academic year. Both CEU and non-
CEU nurses highlighted what they perceived as the problems associated with students
‘moving’ from ward to ward and the impact of this ‘discontinuity’ on students’ clinical
learning. Comments from non-CEU nurses indicated an underlying dissatisfaction with
the lack of continuity in students’ clinical placements:
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They’re (students) just never up and running when they come to the ward….it’s
always new to them. it makes your day ten times longer having a student and
you ask yourself ‘what have I been doing all day?’ …it’s time consuming, Maybe
the uni can do something about it.
On the other hand, CEU nurses expressed satisfaction with students ‘coming back’ to
the CEU and the potentially positive impact on their clinical learning:
..well the students come back to the same ward during the year. They know the
staff, the staff know them. They feel a lot more comfortable. They can
concentrate on building time management and their confidence really.
being moved around all the time is bad. They just get to know a place then
they’re gone again. This (CEU) lets them build up their confidence. Third years
need to consolidate their clinical knowledge and skills. Continuity is good for
them. Probably not so good for second years who should still be seeing as much
as possible.
Future employment prospects
The final theme that emerged from the registered nurse focus group discussions was
concerned with CEU nurses’ perceptions about the future prospect of employing
students who had undertaken their clinical experience “with them” as newly graduated
RNs. The prospective opportunity for recruitment of CEU students as new graduates
was seen to be a distinct advantage and an important value-adding aspect of the CEU
model:
For the unit as a whole, it (the CEU model) will have great benefits in the long
run, and I’m thinking about recruiting staff. I think it will help them step into their
role as new graduates.
They (students) get a really good grounding and orientation, well I mean if all the
grads came out with that grounding it would be great (CA).
It will be an advantage for our unit to be able to take in the ones who have done
their prac on our ward…they will have had a really good orientation of everything
which you just don’t get these days. This will definitely make recruiting easier.
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Summary
In summary, four common themes emerged from the analysis of registered nurses’
comments regarding models of clinical education: Team spirit, Facilitation that works,
Clinical learning and Future employment prospects. Notably, the first three of these
themes are consistent with the outcomes from the student focus groups. This reinforces
the general importance of issues such as clinical learning environment, clinical
facilitation and clinical learning to the quality of clinical experience as it is perceived by
students and registered nurses at “ground level”. More particularly, as regards Team
spirit, CEU RNs perceived that this model had facilitated good relationships between
themselves and students and that they had all ‘pulled together’ as a group. In general,
they also felt that the CEU model provided facilitators who were familiar with the
environment and readily available to students. Further, they highlighted what they
perceived to be better clinical learning outcomes from students and, albeit with some
qualification, the positive effect of continuity of placement on the overall quality of the
clinical experience. On the other hand, non-CEU nurses generally felt frustrated about
the perceived lack of relationship development between themselves and clinical
facilitators, the unfamiliarity of “outside” clinical facilitators with the local environment and
their relative unavailability to individual students, and the lack of continuity in students’
placements on clinical prac. Taken together, the data from these focus groups would
appear to reinforce the importance of the learning environment, the clinical facilitator
and, to some extent, continuity of student placement to the notion of “good” prac
experience. The data also provide further support for some of the key features of the
CEU model of clinical education, particularly whole-of-ward approach, local clinical
facilitation arrangements and continuity of student placement.
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How do CEU RNs rate the quality of students’ practicum experience, and how do their
ratings compare with those of non-CEU RNs?
The QPE-Phase 1 questionnaire for RNs contained 18 items designed to explore their
perceptions regarding the quality of students’ clinical prac experience. All items were
scored on a 5-point Likert scale ranging from 1=Strongly Agree to 5=Strongly Disagree.
Negative items were recoded such that higher scores reflected more positive
perceptions. The results commence with the demographic characteristics of RN
respondents to the QPE-Phase 1 (RN) questionnaire. This is followed by the analysis of
their responses to the survey items.
Demographic characteristics of RN respondents
A total of eighty-four RNs completed the QPE-Phase 1 survey questionnaire. Table 5.6
shows the demographic characteristics of the sample. Of the sample of eighty-four RNs,
twenty-three (27.4%) were from the CEU wards and sixty-one (72.6%) were from non-
CEU wards. This disparity in numbers is due to a slightly less stable staffing pattern in
the non-CEU wards during Phase 1 which led to a higher pool of potential RN
respondents. In addition, the response rate from CEU RNs was less than desired in
Phase 1 most probably due to the intensity of their involvement in the project and
provision of feedback through the focus group discussions as well as other informal
communication. As expected, the overall sample consisted mainly of female RNs
(91.5%) with 5-10 years of clinical experience (54.8%). Participants’ ages ranged from
20-29 years to more than 40 years, with the majority (61.7%) aged between 20 and 29
years. As expected, the majority of CEU and non-CEU RNs were female (91% and 89%
respectively). For both groups, the majority of respondents were aged between 20-29
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years (74% and 57% respectively). However, there was a lower proportion of CEU RNs
in the 30-39 and 40+ age ranges. Thirteen percent of the CEU RNs were aged 30-39
years and 40+ years respectively. In contrast 22% of the non-CEU RNs were aged
between 30 and 39 years, and 21% were more than 40 years of age. Chi square tests
were conducted to further assess age and gender differences between the CEU and
non-CEU nurses. There were no significant differences between the groups with respect
to age (χ2 [2, n=84] = 2.025, p = .363) or gender (χ2 [1, n=84] = .001, p = .974).
Table 5.6: Demographic characteristics of the RN sample (QPE-Phase 1).
f %
n=84
Age:
20 – 29 years 50 61.7
30 – 39 years 16 19.8
> 40 years 15 18.5
Gender:
Female 75 91.5
Male 7 8.5
Years of clinical experience
< 5 years 16 19.1
5 – 10 years 46 54.8
> 10 years 22 26.1
Type of clinical education model:
CEU 23 27.4
Non-CEU 61 72.6
Analysis of RN responses to the QPE-Phase 1 (RN) questionnaire
To examine the pattern of CEU RNs’ ratings of the quality of students’ clinical
experience, and how this compared with the ratings of non-CEU RNs, frequency
analyses were conducted on their responses the individual survey items. The results for
both groups are presented below in Table 5.7. Similarly to the student cohorts, the CEU
RNs generally responded more positively than the non-CEU RNs to the QPE survey
items. However, for some items, the differences in their ratings were much more
apparent. Seven of the items, for example, demonstrated a difference of 17% or greater
119
in the proportion of CEU RNs who agreed/strongly agreed with the item as compared to
the proportion of non-CEU RNs who agreed/strongly agreed with the same item. These
items were ‘working with students is a positive experience’, ‘this was a good unit for
nursing students to learn about clinical practice’, ‘there was a great deal of importance
attached to the learning needs of students’, ‘the facilitator put a lot of effort into helping
students’, ‘all nurses on the unit from the CNC to the newest students felt part of the
nursing team’, ‘I enjoy working with students’ and ‘it was easy to know what to expect
from students’.
Ninety one percent of CEU RNs agreed/strongly agreed that ‘working with students is a
positive experience’, 96% agreed/strongly agreed that ‘this was a good unit for nursing
students to learn about clinical practice’, 89% agreed/strongly agreed that ‘there was a
great deal of importance attached to the learning needs of students’, 82%
agreed/strongly agreed that ‘the facilitator put a lot of effort into helping students’, 70%
agreed/strongly agreed that ‘all nurses on the unit from the CNC to the newest students
felt part of the nursing team’, 74% agreed/strongly agreed that they enjoyed ‘working
with students’ and 47% agreed/strongly agreed that ‘it was easy to know what to expect
from students‘. In comparison, the proportion of non-CEU RNs who agreed/strongly
agreed with the same items was 57%, 79%, 62%, 63%, 51%, 54% and 22%
respectively. Items that attracted more equivocal responses from the registered nurse
participants included ‘there was a lot of effort put into commenting on students’
performance’ and ‘on the whole, I felt this practicum was a good experience’. Whilst
CEU RNs’ ratings on these items were still more positive than those of non-CEU RNs
the difference in the respective proportions was approximately 10% or less.
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Table 5.7: CEU and non-CEU RNs’ responses to the QPE-Phase 1 (RN) questionnaire
Strongly Strongly
agree Disagree
1 2 3 4 5
%
All nurses on the unit, from the CNC to the newest student, felt CEU 13 56.5 21.7 4.3 4.3
Non-CEU 13.1 37.7 39.3 8.2 1.6
In general, ward staff helped students to gain the widest possible CEU 60.9 30.4 8.7 - -
experience
Non-CEU 27.9 62.3 8.2 1.6
-
There was a great deal of importance attached to the learning CEU 47.8 39.1 8.7 4.3 -
needs of nursing students
Non-CEU 34.4 27.9 27.9 6.6 3.3
Nursing students were regarded as workers rather than learners CEU 21.7 34.8 34.8 8.7 -
Non-CEU 29.5 36.1 14.8 14.8 4.9

This was a good unit for nursing students to learn about clinical- CEU 73.9 21.7 4.3 - -
practice
Non-CEU 44.3 34.4 11.5 8.2 1.6
The facilitator put a lot of effort into helping students CEU 56.5 26.1 17.4 - -
Non-CEU 31.1 32.8 27.9 4.9 3.3
It was always easy to know what to expect from students CEU 4.3 43.5 30.4 17.4 4.3
Non-CEU 8.2 14.8 34.4 31.1 11.5
I felt adequately prepared to buddy a student CEU 21.7 47.8 13.0 8.7 8.7
Non-CEU 25.0 41.7 15.0 13.3 5.0
Working with students is a positive experience CEU 30.4 60.9 8.7 - -
Non-CEU 26.2 31.1 29.5 11.1 1.6
Students are there to work rather than learn CEU 4.3 - 4.3 47.8 43.5
Non-CEU 1.6 3.3 9.8 39.3 45.9
There was a lot of effort put in to commenting on students’ CEU 47.8 17.4 17.4 13.0 4.3
performance
Non-CEU 21.7 43.3 13.3 15.0 6.7
I enjoy working with students CEU 30.4 43.5 26.1 - -
Non-CEU 29.5 24.6 31.1 11.5 3.3
Students getting the most out of prac requires commitment from CEU 69.6 26.1 4.3 - -
nursing staff
Non-CEU 49.2 39.3 8.2 3.3 -
I knew who to talk to if I needed help in working with a student CEU 56.5 34.8 4.3 4.3 -
Non-CEU 47.5 36.1 9.8 3.3 -
Working with students is too time consuming CEU 4.3 21.7 34.8 26.1 13.0
Non-CEU 9.8 21.3 42.6 21.3 4.9
I understand the model of clinical education being used on my CEU 26.1 43.5 17.4 4.3 8.7
unit
Non-CEU 24.6 23.0 27.9 6.6 18.0
I knew what students needed to do when they were in the ward CEU 17.4 21.7 30.4 30.4 -
Non-CEU 13.3 13.3 31.7 30.0 11.7

On the whole, I felt that this practicum was a good experience CEU 43.5 39.1 13.0 4.3 -
Non-CEU 19.7 52.5 19.7 6.6 1.6
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To further examine differences in RNs’ ratings of the quality of students’ clinical
CEU and non-CEU RNs on individual survey items. As for the student cohort, the
difference in sample sizes between the CEU and non-CEU RNs was noted. However, for
the reasons explained in the previous section, it was not regarded as a problem. Key
assumptions for using the independent-samples t-test were met. Where indicated by the
Levene’s test for unequal variances, t-test results assuming unequal variances were
used. In all, 19 comparisons were made. However, using the same logic as described
under the Analysis of student responses to the QPE-Phase 1 (Student) questionnaire
(Section 5.2.1), the Bonferroni correction was not applied. Consequently, a .05
significance level was used for the purpose of these analyses. The mean ratings of CEU
RNs were significantly different to those of non-CEU RNs on 4 of the 19 survey items.
These are shown in Table 5.8. Consistent with the frequency analysis presented earlier,
CEU RNs reported significantly more positive attitudes regarding their wards/units as
learning environments for students, the experience of working with students and the
commitment of the clinical facilitator to helping students during the practicum.
Table 5.8: Mean ratings for CEU and non-CEU RNs on QPE-Phase 1 (RN)
questionnaire items
Mean SD T df P
This was a good unit for nursing students to learn about clinical- CEU 1.30 .559 -2.587 82 .001*
practice
Non-CEU 1.89 1.018
Working with students is a positive experience CEU 1.78 .600 -2.291 82 .005*
Non-CEU 2.31 1.041
The facilitator put a lot of effort into helping students CEU 1.61 .783 -2.329 82 .022
Non-CEU 2.16 1.036
In general, ward staff helped students to gain the widest possible CEU 1.48 .665 -2.268 82 .026
experience
Non-CEU 1.84 .637
*equal variances not assumed
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Analysis of CEU Student/ RN responses to the QPE-Phase 1 questionnaire
As an additional analysis of the Phase 1 data, differences between the ratings of CEU
students and CEU RNs on the Phase 1 questionnaire were examined. This analysis was
undertaken to gain a deeper understanding of the relationships between the perceptions
of the two groups who were involved in the change intervention for this study.
Independent sample t-tests were conducted on the mean scores of survey items that
were common to both student and RN versions of the questionnaire (see Table 5.9). Key
assumptions for using the independent-samples t-test were met. For one item the
Levene’s test indicated unequal variances. For this item, the t-test result assuming
unequal variances was used. As with the other t-test analyses reported above, .05 was
used as the level of significance.
As shown in Table 5.9 the scores for CEU nurses were significantly different to those of
CEU students on two survey items: it was always easy to know the standard of
performance expected of students (t [58] = -2.453, p = .02) and overall, this prac was a
worthwhile experience (t [58] = -2.817, p = .02). There were no other significant
differences in the scores for CEU students and CEU RNs. The magnitude of the
differences in the means for these two items was moderate (eta squared = 0.09) and
large (eta squared=.12) respectively.
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Table 5.9: Mean ratings of CEU students and CEU RNs on common QPE-Phase 1 questionnaire items
Mean SD T df P
All nurses on the unit from the CNC to the newest CEU students 1.91 1.140 -1.365 58 0.178
student felt part of the nursing team
CEU RNs 2.30 0.9261
In general ward staff helped students to gain the widest CEU students 1.84 1.1.67 -1.515 58 0.139*
possible experience
CEU RNs 1.28 1.806
The Clinical Associate put a ot of effort into teaching CEU students 1.68 1.132 -.372 58 0.711
nursing students
CEU RNs 1.78 0.998
The Clinical Associate attached a lot of importance to CEU students 1.57 1.568 -.554 58 0.582
the learning needs of nursing students
CEU RNs 1.70 1.70
It was always easy to know the standard of performance CEU students 2.08 1.038 -2.453 58 .02
expected from nursing students
CEU RNs 2.34 1.697
Overall, this prac was a worthwhile experience CEU students 1.27 0.56 -2.817 58 .02
CEU RNs 1.78 0.85
*equal variances not assumed
5.4 Summary
This chapter presented the results from the focus group discussions and survey
questionnaires conducted during Phase 1 of the study. Overall, the data indicate that
CEU students and CEU RNs had more positive perceptions regarding students’ clinical
practicum experience than did non-CEU students and non-CEU RNs. This was
demonstrated in the commentary of the focus group discussions with students and
registered nurses, and supported by the results from the Quality of Prac Experience
survey questionnaires. Despite differences in the specifics of participants’ comments,
there were similarities in the themes that emerged from the focus group discussions.
Students and registered nurses from both CEU and non-CEU wards highlighted issues
related to ‘facilitation that works’ and ‘clinical learning’. The notion of ‘relationships
between key players’ and a supportive social climate were also identified as important
aspects of the clinical learning environment.
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On all of these issues, CEU students and RNs described more positive perceptions of
their prac experiences in the CEU units than did non-CEU students and RNs. In general,
CEU students perceived that CEU provided a supportive learning environment, ready
access to facilitators who ‘knew the environment’, good learning opportunities and
promoted their development of clinical knowledge and skills. Generally, these views
were reflected in the comments of the CEU RNs, albeit from their own perspective. An
additional point that emerged from the focus group discussions with the CEU RNs
identified the possibility of employing well prepared new ‘grads’ as a particular value-
adding aspect of the CEU model.
The results from the analysis of the QPE-Phase 1 questionnaires tended to support the
focus group results. In general CEU students and CEU RNs rated the quality of students’
clinical prac experience more positively than did the non-CEU students and RNs. This
was particularly the case in relation to items relating to clear expectations about prac,
relationships between students and staff and the ward as a learning environment. The
following chapter presents the results from Phase 2.
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CHAPTER 6
RESULTS - PHASE 2
6.1 Introduction
This chapter presents the results from Phase 2 of the study. As outlined in Chapter 3,
the study comprised two iterations of a change intervention (the CEU model of clinical
education) and the collection of qualitative and quantitative data from undergraduate
nursing students and registered nursing staff involved in students’ clinical placement in
conjunction with each iteration. As described in Chapter 4 (Section 4.4) the original CEU
model was evaluated in light of the data collected during Phase 1 and the ongoing
dialogue with academic and clinical colleagues. Subsequently, a slightly revised CEU
model (CEU-2) was implemented during Phase 2 of the study. The first section of this
chapter presents the analysis of data from the Phase 2 focus group discussions and
survey questionnaire completed by students. The section that follows presents the
analysis of data from the focus group discussions and Phase 2 survey questionnaires
completed by registered nurses. The chapter concludes with a brief summary of the
Phase 2 results.
6.2 Students
Following is the analysis of data from the student focus groups conducted during Phase
2 of the study. The findings are presented using examples from the transcripts, the
categories and themes generated from the open coding and verbatim quotations from
the transcripts. The data from students who were placed in the CEU wards were
analysed separately to the data from students who were placed in the non-CEU wards.
However, similarly to Phase 1, the categories and themes emerging from their
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comments were similar. Thus the data are presented as an integrated whole with the
inclusion of quotations from CEU and non-CEU students to illustrate similarities and/or
differences in their perceptions.
As shown in Table 6.1, four key themes emerged from the analysis of students’
comments regarding models of clinical education. These themes are described below,
incorporating examples from the data to illustrate the dimensions of each category.
Table 6.1: Themes and categories from the student focus groups (Phase 2).
Themes Categories
Enjoying being there • supportive environment
• part of the team
Good facilitation • facilitator familiarity with the organisation
• ‘seeing’ more of the facilitator
Opportunities for learning • staff involvement
• given ‘dirty’ work to do
Learning outcomes • learned a lot
• role of staff
Enjoying being there
Both CEU and non-CEU students regarded the pracs they had undertaken as generally
positive experiences. However, there were very different emphases in their comments
according to whether they had been in CEU or non-CEU wards. CEU students spoke
enthusiastically about their experience as a whole, for example:
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The staff have been an excellent support and their friendliness and acceptance
of us into the environment was wonderful – it makes all the difference (Year 3
CEU student).
Very positive experience. Gained a lot of information and experience in a wide

range of surgical situations (Year 3 CEU student).
I had a great time this prac. The CEU model was excellent, particularly in the
Year 3. Coming back for the second rotation, knowing the clinical area, the ward
and the staff, made it much easier to settle back into it (Year 3 CEU student).
Non-CEU students, on the other hand, spoke more about the clinical facilitator and, to a
lesser extent, staff they had encountered and/or the health care facility as a placement
venue:
X is excellent - supportive and helpful as a facilitator (Year 3 non-CEU student).
Facilitator excellent, dedicated. Staff reluctant towards students even after proof
of ability. Institution – good resources (Year 3 non-CEU student).
Regardless of the clinical education model they had experienced, the issue that
appeared to have most influence on their views was the perceived supportiveness or
unsupportiveness of the clinical learning environment. CEU students highlighted the
team atmosphere they had experienced and the perception of feeling accepted and
being valued by staff:
The staff were all involved – the education was great. We became more familiar
with the doctors and physios too (CEU student group).
The staff liked having us - they knew us from the previous prac. They trusted us
and knew our capabilities. We fitted right in (CEU student group).
I had a great time on this prac. Reflecting back on previous pracs I felt that
sometimes it is difficult to join the team because many RNs do not know the
students in the clinical environment. This was different (Year 3 CEU student).
I really enjoyed this prac. I was treated like a staff member because I knew the
ward routine really well. I was also able to have some autonomy in my practice
On the other hand, non-CEU students talked more about the perception that they had
provided “extra pairs of hands” and/or a lighter burden for staff in the clinical
environment:
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The staff were good. They were happy to have our help because they were pretty
busy (Year 3 non-CEU student).
The prac was pretty good. Students are not really a hindrance by third year (Year
3 non-CEU student).
When there was a big workload we (students) offered to do all the showers, but
staff made sure we did other stuff as well (Year 3 non-CEU student group).
The staff were very supportive. But I felt like management saw me as an extra
pair of hands rather than a student who needed teaching (Year 3 non-CEU
student).
Good facilitation
A second theme to emerge from students’ comments related to the quality of clinical
facilitation they had received during the practicums. All students spoke strongly about
the importance of ‘good facilitation’. Notably, for many of the students the quality of what
they had previously experienced was variable. As expressed by one student:
Facilitators make differences to your experience at prac. Facilitators who are

keen allow students to feel confident and motivated. Yet, some facilitators in the
past have put me down by not explaining things and spending time with some
students rather than others. Facilitators are important to prac! (Year 3 non-CEU
student).
With regard to their experiences during this study, two aspects were particularly evident
in students’ comments about this theme: (1) the issue of facilitator familiarity with the
environment, (2) and seeing more of the facilitator.
Familiarity with the environment
Both CEU and non-CEU students commented about the importance of facilitators being
familiar with, and within, the clinical environment in which students are placed. However,
as shown in the following comments, the students had different reflections on this issue
according to the clinical education model that they had experienced. The comments of
non-CEU students highlighted some of the well known problems that can occur when
facilitators are perceived as “outsiders” by the ward staff, for example:
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It’s just better when the facilitator is familiar with the hospital. I had an issue with
the facilitator not being allowed by staff to be involved in care and I don’t know
why (Year 3 non-CEU student).
When facilitators are not familiar with the hospital/specialties/wards etc. things
can be difficult (Year 3 non-CEU student).
CEU students, however, expressed strongly positive views - albeit with some
qualification, particularly as regards ‘issues’ to do with staff and/or staff practices :
The CEU is good. RNs who work in the clinical environment are better to
facilitate because they know the most suitable people to place students with and
they’re able to impart pertinent information (Year 3 CEU student).
Having someone who knows the ward is like a Catch 22. It’s great that they know
the routine, the care etc. and that the other RNs know them, but you can’t bring
up issues to do with ward staff? (Year 3 CEU student).
Having a facilitator that was a staff member on ward was handy to ask where
things are, but inappropriate for reflecting on the staff practices!! (Year 3 CEU
student).
Seeing more of the facilitator
The second aspect to this theme related to the notion of seeing more of the clinical
facilitator during the practicum. This was related to the perceived availability/non-
availability of the facilitator to support students’ clinical learning. Similarly to the above,
students had different perspectives on this according to the model of clinical education
they had experienced. Students from non-CEU wards emphasised the difficulties
associated with sessional or seconded facilitators who have students “dispersed” across
several different areas of a health care facility:
Like some facilitators are more supportive than others but even so they have to
divide their time with seven other students. So you don’t see them much (Year 3
non-CEU student).
It would have been better if our facilitator had spent more time on the wards with
us and not just come to the ward if I paged her (Year 3 non-CEU student).
What I’d like to suggest is that the ratio of facilitators to students goes up and
there are less students per facilitator (Year 3 non-CEU student).
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On the other hand, CEU students had very few comments at all about needing to ‘see
more’ of the facilitator. When these students did comment, they highlighted the
advantages associated with the physical proximity of the facilitator within the CEU
model, for example:
Facilitators (Clinical Associates) and staff (Clinical Partners) have been great –
always there when you need them (Year 3 CEU student).
Opportunities for learning
The third theme to emerge from students’ comments was concerned with opportunities
for clinical learning during the practicum. This was another issue that both groups of
students felt strongly about. Regardless of the clinical education model students had
experienced, the general consensus was that the prac had been ‘good’ in terms of
opportunities to advance their clinical knowledge and skills. However, as with other
themes and categories, there were different emphases in the reflections of CEU and
non-CEU students on this issue. CEU students tended to highlight the more ‘holistic’ role
played by ward staff in facilitating access to ‘good’ clinical learning experiences, for
example:
Staff were great. Many have an education focus. Staff trust you more because
they know the facilitator. They had trust and confidence in you to do your own
meds (Year 3 CEU student).
CEUs are excellent in order to learn clinical skills rather than just viewing
different areas and procedures (Year 3 CEU student).
Education seems to be a strong focus here. Staff know you and they more
inclined to help. They let you do more (Year 3 CEU student).
In contrast, non-CEU students emphasised the individual input from their clinical
facilitators.
Well, she (the facilitator) was always around to make sure we were doing alright
and whether we wanted help. She was very approachable, easy to talk to and
explained things when we didn’t understand (Year 3 non-CEU student).
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Our facilitator really helped. She was very supportive. Different RNs are more or
less encouraging and some are good teachers and some are not – it varies (Year
3 non-CEU student).
Facilitators make things happen. Some staff are accepting, some not as much.
Some let you do things, others don’t (Year 3 non-CEU student).
As in Phase 1 of the study, there were some comments from students that highlighted
the potential advantage of continuity within the CEU ward in terms of ‘opening up’ more
learning opportunities than would otherwise be the case, for example:
The CEU model was excellent, particularly in the Year 3. Coming back for the
second rotation, knowing the clinical area, the ward and the staff, made it much
easier to settle back into it. I didn’t have to orientate myself all over again. Also,
the staff know you and you feel easily accepted. It saves days of getting used to
a new place (Year 3 CEU student).
Notwithstanding their positive views, however, CEU students also drew attention to the
issue of being given ‘dirty work’ to do.
Prac still seems to be about task orientation. Understaffing on the wards

sometimes gave us the impression we were being used as a backup and didn’t
give us enough time to focus on our learning (Year 3 CEU student).
When the staffing levels are down they get us to do all the obs, beds, showers
etc. but keep the IVs, drains and stuff like that for themselves (Year 3 CEU
student).
Learning outcomes
The final theme which emerged from students’ comments regarding models of clinical
education was concerned with their perceptions about how they had advanced their
clinical knowledge and skills during the clinical practicums. Of note, the majority of this
commentary came from students who had been in the CEU wards specifically. The
general consensus from these students was that they ‘learned a lot’ during the prac and
that this was due, in part, to the positive involvement of ward staff and the expectations
that staff had of them (and that they had of themselves), for example:
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The staff here (CEU unit) know our strengths and weaknesses, they really know
how to help (Year 3 CEU student).
Learned heaps….staff in the CEU unit expect you to know because you’ve been
with them before – and you expect it of yourself (Year 3 CEU student).
I think CEU models work exceptionally well. If other wards were CEUs I believe
our competencies would be second to none (Year 3 CEU student).
There were few comments on this issue from the non-CEU students. Those who
commented indicated that, in general, the ‘prac had gone well’ and they had experienced
‘good’ outcomes. What was most noticeable about comments from this group of
students was the continued emphasis on the facilitator role and its importance in terms
of student learning during the clinical practicum. Representative comments include the
following:
it’s just so much better when the facilitator is familiar with the hospital (Year 3
non-CEU student).
If things are not working out the facilitator will intervene for us – facilitators are
there for us (Year 3 non-CEU student).
Summary
In summary, four common themes emerged from the Phase 2 analysis of students’
comments regarding models of clinical education: Enjoying being there, Good
facilitation, Opportunities for learning and Learning Outcomes. Notably, there is a strong
similarity between these themes and those that emerged during Phase 1 of the study.
This tends to reinforce the general importance of these issues to the perceived quality of
students’ clinical experience. Similarly to Phase 1, both CEU and non-CEU expressed
the view that they had had generally positive prac experiences. Key factors influencing
this for both groups were supportiveness/unsupportiveness of an environment, good
facilitation and “good” access to learning opportunities. However, according to the model
of clinical education they had experienced, there were qualitative differences in the
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perceptions of both groups as regards their prac experience. Consistent with Phase 1,
CEU students felt that this model facilitated “better” relationships between themselves
and the RN staff and a team environment for clinical prac. They also re-emphasised the
benefits associated with clinical facilitators who are familiar with the local environment
and readily available to students. Further, CEU students again highlighted the ward
staffs’ involvement in facilitating “good” access to learning opportunities and the
perception that they had “learned heaps” as a result. On the other hand, non-CEU
students tended to perceive the clinical environment in terms of themselves as “extra
pairs of hands”. As in Phase 1, they highlighted the problems associated with facilitators
who are unfamiliar with the environment and/or not readily available to individual
students. Further, in relation to learning opportunities, the emphasis of these students
remained on the clinical facilitator rather than the ward staff as a whole.
How do CEU students rate the quality of their practicum experience, and how do their
ratings compare with those of non-CEU students?
As detailed in Chapter 3, students and RNs from CEU and non-CEU wards were invited
to respond to the Quality of Prac Experience (QPE-Phase 2) questionnaire during Phase
2 of the study. As for Phase 1, the same general questionnaire was used for both
students and registered nurses with the appropriate modifications for the respective
respondent groups. The student version of the QPE-Phase 2 questionnaire contained 24
items designed to explore students’ perceptions regarding the quality of their clinical
prac experience. All items were scored on a 4-point Likert scale ranging from 1=Strongly
Agree to 4=Strongly Disagree. Negative items were recoded such that higher scores
134
reflected more positive perceptions. The analysis of students’ responses to the
questionnaire is presented below.
Demographic characteristics of student respondents
A total of one hundred and forty four students completed the QPE-Phase 2 survey
questionnaire. Table 6.3 shows the demographic characteristics of the sample. Of the
sample of 144 students, fifty nine were in CEU wards (41%) and eighty five were in non-
CEU wards (59%). As expected, the sample consisted mainly of female students
(89.6%) who were enrolled in the course on a fulltime basis (94.2%). Participants’ ages
ranged from less than 20 years to more than 40 years with the majority aged from < 20
years to 29 years (81.3%). Approximately half of the sample reported having previous
nursing experience (52.9%) which, in the main, consisted of 1-2 years of employment
(72.2%) as Assistants in Nursing (95%). Chi square tests were conducted to further
assess any demographic differences between the CEU and non-CEU students. There
were no significant differences between the groups with respect to age (χ2 [3, n=144] =
1.115, p = .774), gender (χ2 [1, n=144] = .936, p = .583), or nursing experience (χ2 [2,
n=144] = .897, p = .639).
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Table 6.3: Demographic characteristics of the student sample (QPE-Phase 2).
f %
n=144
Age:
< 20 years 42 29.2
20 – 29 years 75 52.1
30 – 39 years 16 11.1
> 40 years 11 7.6
Gender:
Female 129 89.6
Male 15 10.4
Year level in course:

2nd year 56 38.9
Year 3 88 61.1
Enrolment in course:
Full-time 135 93.8
Part-time 9 6.2
Nursing experience:
Yes 72 52.9
No 64 47.1
Type of nursing experience:

Assistant in nursing 137 95.1
Enrolled nurse 6 4.2
Personal carer 1 0.7
Clinical education model:

CEU 59 41
Non-CEU 85
Analysis of student responses to the QPE-Phase 2 (Student) questionnaire
To re-examine the question of CEU students’ ratings of the quality of their clinical
experience, and how these ratings compared with those of non-CEU students, frequency
both groups are presented below in Table 6.4. In general, the CEU students’ responses
to the QPE survey items were more positive than those of the non-CEU students
although, for a number of items, the difference was slight. An exception, however, was
students’ responses to the item ‘this prac has really sharpened my time management
136
skills’ where ninety five percent of the CEU respondents agreed/strongly agreed with this
statement as compared to 73% of the non-CEU students. A different type of exception
occurred in relation to the items ‘I could ask as many questions as I wanted’, ‘it was easy
to feel like a burden on staff during this prac’, ‘it was hard to get feedback on progress
during this prac’, I was encouraged to reflect on issues that arose during the prac’, ‘it
was easy to get assistance in dealing with/undertaking new situations’ and ‘it was hard
to discover what was expected of me during this prac’. For these items, the proportion of
non-CEU students who responded positively (ie. agree/strongly agree or
disagree/strongly disagree as appropriate) was slightly higher than the proportion of
CEU students. Notably, there were four items which attracted almost equivocal
responses from students: ‘students were taken seriously by staff in the ward area’, ‘there
was a real sense of camaraderie between students and staff in the ward/unit’, ‘during
this prac staff put a lot of time into commenting on my work’ and ‘overall, I am satisfied
with the quality of this prac’.
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Table 6.4: CEU and non-CEU students’ responses to the QPE-Phase 2 (Student) questionnaire
Strongly Strongly
agree Disagree
1 2 3 4
%
It was easy to feel part of the nursing team CEU 28.8 66.1 5.1 -
Non-CEU 35.3 52.9 11.8 -
Students were taken seriously by staff in the ward/area CEU 25.4 64.4 6.8 3.4
Non-CEU 28.2 57.6 14.1 -
There were plenty of opportunities to practise different skills CEU 32.2 55.9 10.2 1.7
Non-CEU 25.9 56.5 17.6 -

During this prac it as easy to know where I was going and what CEU 35.6 54.2 8.5 1.7
was expected
Non-CEU 30.6 52.9 16.5 -
There was a real sense of camaraderie between students and CEU 25.9 60.3 13.8 -
staff in the ward/area
Non-CEU 31.3 50.6 18.1 -
I could ask as many questions as I wanted to CEU 55.9 37.3 6.8 -
Non-CEU 52.9 42.4 4.7 -
It was easy to feel like a burden on staff in this ward/area CEU - 17.2 60.1 20.7
Non-CEU - 15.3 62.4 22.4
In general, I felt well supported by staff during this prac CEU 32.8 63.8 3.4 -
Non-CEU 35.3 55.3 9.4 -

During this prac I found it hard to get enough practice on different CEU 5.1 25.4 59.3 10.2
skills
Non-CEU 10.6 24.7 54.1 10.6
I was given opportunities to be involved in making decisions CEU 25.4 59.3 15.2 -
about patient care
Non-CEU 21.2 58.8 17.6 2.4
As a result of this prac I am confident about my ability to reflect CEU 23.7 69.5 5.1 1.7
critically on nursing care
Non-CEU 22.4 68.2 9.4 -
It was hard to get feedback on progress during this prac CEU 1.7 15.3 62.7 20.3
Non-CEU 4.7 18.8 56.5 20.0
I was encouraged to reflect on issues that arose during the prac CEU 13.6 66.1 13.6 6.8
Non-CEU 21.2 67.1 11.8 -
It was easy to get assistance in dealing with/undertaking with CEU 27.1 62.7 8.5 1.7
new situations
Non-CEU 27.7 68.7 3.6 -
I was given opportunities to take some responsibility for patient CEU 47.5 52.5 - -
care in this ward/area
Non-CEU 50.6 45.9 3.5 -
My critical thinking skills really improved during this prac CEU 27.1 71.2 1.7 -
Non-CEU 30.6 64.7 4.7 -
During this prac I felt well supported in undertaking new skills CEU 39.0 61.0 - -
Non-CEU 36.5 58.8 4.7 -
This prac has made me keener than ever to become a registered CEU 29.3 62.0 8.6 -
nurse
Non-CEU 41.5 42.7 14.6 1.2
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Strongly Strongly
agree Disagree
1 2 3 4
%
It was hard to discover what was expected of me during this prac CEU 1.7 17.2 63.8 17.2
Non-CEU 4.7 9.4 65.9 20.0
This prac has really sharpened my time management skills CEU 35.1 59.6 5.3 -
Non-CEU 21.2 51.8 22.4 4.7
During this prac staff put a lot of time in commenting on my work CEU 10.2 47.5 39.0 3.4
Non-CEU 9.5 45.2 40.5 4.8
As a result of this prac, I am confident about my ability to plan CEU 25.4 69.5 5.1 -
patient care
Non-CEU 28.2 60.0 11.8 -
My problem solving skills really improved during this prac CEU 16.9 76.3 7.8 -
Non-CEU 23.5 65.9 10.6 -
Overall, I am satisfied with the quality of this prac CEU 37.3 52.5 10.2 -
Non-CEU 34.1 56.5 9.4 -
To further examine differences in students’ ratings of the quality of their clinical
CEU and non-CEU students on individual survey items. Key assumptions for using the
independent-samples t-test were met. Where indicated by the Levene’s test for unequal
variances, t-test results assuming unequal variances were used. In all, 23 comparisons
were made. However, using the same logic as described under the Analysis of student
responses to the QPE-Phase 1 (Student) questionnaire (Section 5.2.1), the Bonferroni
correction was not applied. As in Phase 1, a significance level of .05 was used for the
purpose of these analyses. Significant differences were found on two survey items: I was
encouraged to reflect on issues that arose during the prac, t (144) = 2.12, p =.04 and
This prac has really sharpened my time management skills, t (144) = -3.12, p = <.01.
CEU students reported significantly less agreement that they had been encouraged to
reflect on prac issues (M=2.14; SD=.73) than did non-CEU students (M=1.91; SD=.57).
In contrast, CEU students reported a significantly higher level of agreement that the prac
139
had sharpened their time management skills (M=1.72; SD=.62) than did non-CEU
students (M=2.11; SD=.79). No other significant differences were found.
6.3 Registered nurses
clinical education, and how do they compare with RN perceptions regarding non-CEU
models?
This section presents the analysis of data from the RN focus groups conducted during
Phase 2 of the study. As for the student data presented in 6.1.1, the findings are
presented using examples from the transcripts, the categories and themes generated
from the open coding and verbatim quotations from the transcripts. Data from registered
nurses working in the CEU wards and non-CEU wards were analysed separately. As
before, the categories and themes that emerged from nurses’ comments were similar.
Thus, the registered nurse data are presented as an integrated whole with the inclusion
of quotations from CEU and non-CEU nurses to illustrate similarities and/or differences
in their respective perceptions. Three key themes emerged from the analysis of RNs’
comments regarding models of clinical education (Table 6.2). These themes are
described below, incorporating examples from the data to illustrate the dimensions of
each category.
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Table 6.2: Themes and categories from the registered nurse focus groups (Phase 2).
Themes Categories
Working together • Building rapport
• Developing relationships
Feeling supported • Familiarity of the facilitator with the environment
• Readily available to staff in the ward
Learning outcomes • Student attributes
• Graduate employment
Working together
An issue that emerged strongly from the discussions with RNs emphasised good
working relationships between all key players and the importance of being able to build
rapport. This issue resonated particularly strongly with the CEU nurses. In the main their
perceptions about this were extremely positive and, as shown below, tended to explicitly
incorporate a student perspective:
In the CEU we’re able to build rapport .. there’s a strong integration of students
and staff (CEU nurse).
It works well. The students get to know us, the patients and vice versa… they
feel that they belong (CEU nurse).
However, the comments from non-CEU nurses tended to focus more on the facilitator
and difficulties they had experienced in regard to working effectively with (sessional)
clinical facilitators:
We don’t always see the facilitator. How can you develop any sort of
relationship? (non-CEU nurse).
We’re not always clear on the facilitator’s expectations or what the students
need. It makes it hard (non-CEU nurse).
It’s better when we see the same facilitator each time the students are here. It
gives you a chance to get to some common ground and develop rapport (non-
CEU nurse).
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Feeling supported
The issue of ‘feeling supported’ during students’ clinical practicums emerged strongly
from clinical nurses’ verbal comments during the focus group discussion and their written
survey responses. Whilst there was a common perception that nurses are “happy to help
out with students” many participants commented about their increasingly busy and
complex clinical workloads and the very real difficulties they faced when they “had to
fully supervise students as well”. Regardless of whether nurses were working in CEU or
non-CEU wards, there was general agreement about the importance of having clinical
facilitators who are (1) familiar with, and within, the ‘local’ ward/hospital environment,
and (2) readily available to ward staff and students. To a lesser extent, nurses in the
CEU units also commented favourably on the “uni liaison” in that it provided a link
between themselves and the “academic side of things”. In particular this included
general details regarding the students’ course, expectations of the practicum and
assessment of students’ performance.
Nurses from both CEU and non-CEU wards commented strongly on the importance of
facilitators being familiar with the ward and/or hospital in which students are placed. This
included people, policies and procedures as well as cultural nuances, systems and
routines of individual wards. As expressed by one nurse, “it works well when it all
meshes together – you know them, they know you and they know the facility”. However,
as shown in the following comments, the nurses had different reflections on this issue
according to the clinical education model that had been used in their wards. CEU nurses
tended to reinforce the perceived benefits obtained from CAs facilitating in their “own”
clinical areas, for example:
It works great. Our own staff facilitate (supervise)… they know the unit, the
policies, personalities etc. … they know us and we know them so it’s easy to ask
them questions (CEU nurse).
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On the other hand, non-CEU nurses commented from a more “negative” perspective, for
example:
It only works well when the facilitator is familiar with the environment, otherwise
it’s just an increased burden on staff (non-CEU nurse).
As testament to the strength of their feeling on this issue nurses working in non-CEU
wards indicated that they preferred to “have their own staff supervising students” rather
than “outsiders who don’t know the hospital or the clinical area” even though (with a
secondment model) it could “take valuable staff away from ward where their clinical
expertise is needed”.
The availability of the facilitator was also a topic that all participants felt strongly about,
although to a lesser extent than the familiarity issue discussed above. Again, however,
there were contrasting perceptions from nurses according to the model of clinical
education that had been operating in their ward areas. Nurses from non-CEU wards
indicated that:
We need to have the facilitator on hand, but they’re not that visible … we need a
strong presence in the ward (non-CEU nurse).
There’s extensive time taken in supervising students – particularly with med

rounds. The facilitator is often busy when you need her most (non-CEU nurse).
whereas nurses from CEU wards commented that:
The CEU facilitator is there … he/she is easily identified. Problems can be

conveyed quickly (CEU nurse).
Well there’s a smaller ratio of students in the CEU unit. That makes it much
easier for the facilitator to be on hand. It works well (CEU nurse).
Notably, despite these positive comments, nurses from CEU wards raised concerns
about facilitation “out of hours”, i.e. during the AM/PM shift that wasn’t “covered by” the
appointed CA (facilitator). Nurses’ perceptions about this issue are captured in the
following comment:
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The CEU model is good. I think the only drawback is that there isn’t a CA on both
shifts. This leads to increased pressure on staff in the ward as your workload
doesn’t decrease when you have students with you. Our area can be very busy
with lots of demands. The more time facilitators can be with students the less
demands on RNs (CEU nurse).
Student learning outcomes
A third theme to emerge from the analysis of nurses’ comments was concerned with
their perceptions about students’ development of clinical knowledge and skills. Notably,
although CEU nurses had strongly positive comments about this topic, it emerged much
less frequently and only indirectly from the responses of non-CEU nurses. The
comments of non-CEU nurses tended to focus on the role of the facilitator and their
perceived objectivity in terms of student assessment. This was due to facilitators’
employment by, or secondment to, the university which, in nurses’ opinions, allowed
them to be more “detached” than clinical staff in their appraisals of student performance.
On the other hand, CEU nurses had a number of comments about what they perceived
as ‘better’ about the learning outcomes that students in the CEU units had achieved, for
example:
The improvement in student ability and confidence could be noticed and

feedback given to them (CEU nurse).
There was great in terms of learning for students … they took their own patient
loads (CEU nurse).
Well .. the students coming back to the CEU unit are already oriented and set to
go. They start working from day one (CEU nurse).
This was an excellent outcome. We employed some of the students as new

graduates. Staff felt valued for their contribution by seeing this outcome (CEU
nurse).
As shown above, there was a perception that the continuity, or consistency, in students’
placement in the same CEU ward across the academic year contributed to the learning
outcomes achieved. Whilst this was generally seen to be a strength of the CEU model,
questions were raised about potential “downsides” for the students:
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If students don’t like the area, why do they have to come back? (CEU nurse).
Some students want more diverse experience when studying (CEU nurse).
Is there a lack of exposure to different areas? (CEU nurse).
Summary
In summary, four common themes emerged from the analysis of registered nurses’
comments regarding models of clinical education: Team spirit, Facilitation that works,
Clinical learning and Future employment prospects. Notably, these are consistent with
themes that emerged from the Phase 2 student focus groups, and themes that emerged
from the Phase 1 focus group discussions with both students and registered nurses.
This more strongly reinforces the general importance of issues such as clinical learning
environment, clinical facilitation and clinical learning to the quality of clinical experience
as it is perceived by students and registered nurses at “ground level”. As regards Phase
2 more specifically, CEU RNs perceived that this model had enabled them to build
rapport and good working relationships between themselves and students. They also felt
that the CEU model provided facilitators who were familiar with the environment and
readily available to students. Further, they highlighted what they perceived to be better
clinical learning outcomes from students and, with similar qualifications to those of
Phase 1, the potential benefits of continuity of placement on the overall quality of the
clinical experience. On the other hand, non-CEU nurses tended to emphasise the
problems associated with sessional facilitators, particularly their unfamiliarity with the
local environment and relative unavailability to individual students. Taken together, the
data from these focus groups would appear to reinforce the importance of the learning
environment, the clinical facilitator and, to some extent, continuity of student placement
to the notion of “good” prac experience. Arguably, the data also provide further, albeit
tentative, support for some of the key features of the CEU model of clinical education,
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particularly whole-of-ward approach, local clinical facilitation arrangements and
continuity of student placement.
The QPE-Phase 2 questionnaire for RNs contained 15 items designed to explore their
perceptions regarding the quality of students’ clinical prac experience. All items were
scored on a 4-point Likert scale ranging from 1=Strongly Agree to 4=Strongly Disagree.
Negative items were recoded such that higher scores reflected more positive
perceptions. The results commence with the demographic characteristics of RN
respondents to the QPE-Phase 2 (RN) questionnaire. This is followed by the analysis of
their responses to the survey items.
Demographic characteristics of RN respondents
A total of two hundred and ten RNs completed the Phase 2 survey questionnaire. Table
6.5 shows the demographic characteristics of the sample. Of the sample of 210 RNs,
one hundred and eight (51.4%) were from the CEU wards and one hundred and two
(48.6%) were from non-CEU wards. As expected, the overall sample consisted mainly
of female RNs (88.6%). Participants’ ages ranged from 20-29 years to more than 40
years, with the majority (63.8%) aged between 20 and 29 years. The majority of CEU
and non-CEU RNs were female (92% and 87% respectively). For both groups, the
majority of respondents were aged between 20 and 29 years (70% and 61%
respectively). There were no significant differences between the groups with respect to
age (χ2 [2, n=210] = 2.025, p = .363) or gender (χ2 [1, n=210] = .001, p = .974).
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Table 6.5: Demographic characteristics of the RN sample (Phase 2).
f %
n=210
Age:
20 – 29 years 134 63.8
30 – 39 years 44 20.9
> 40 years 32 15.2
Gender:
Female 186 88.6
Male 24 11.4
Clinical education model:
CEU 108 51.4
Non-CEU 102 48.6
Analysis of RN responses to the QPE-Phase 2 (RN) questionnaire
To re-examine the question of CEU RNs’ ratings of the quality of students’ clinical
experience, and how these ratings compared with those of non-CEU RNs, frequency
both groups are presented below in Table 6.6. Similarly to the student cohort, the CEU
RNs generally responded more positively than the non-CEU RNs to the QPE survey
items. However, for some items, the differences in their ratings were much more
apparent.
Ninety nine percent of CEU RNs agreed/strongly agreed that ‘there was a real sense of
camaraderie between students and staff in the ward/unit’, 91% agreed/strongly agreed
that ‘staff value having students on prac’, 75% agreed/strongly agreed that ‘it was easy
to know what students were aiming to achieve during the prac’ and 94% agreed/strongly
agreed that ‘overall, I am satisfied with the clinical education arrangements (model) for
this prac’. In contrast, the proportion of non-CEU RNs who agreed/strongly agreed with
these items was 81%, 72%, 59% and 77% respectively. A similar pattern was found in
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the results for four other survey items although the differences between the CEU and
non-CEU ratings were smaller. These items were: “there were plenty of opportunities for
students to practise different skills”, “staff felt well prepared to support students”, “giving
students feedback on their progress was a priority” and “staff felt valued for their
contribution to students’ learning”.
Unexpectedly, there was a higher proportion of agreement/strong agreement from non-
CEU as compared to CEU RNs on three items. Ninety five percent of non-CEU RNs
disagreed/strongly disagreed that ‘commenting on students’ work takes too much time’,
93% disagreed/strongly disagreed that ‘it was hard to know what students’ were there for
during the prac’ and 96% disagreed/strongly disagreed that “staff felt like they were on
their own with assisting students during the prac”. In comparison, the proportion of CEU
RNs who disagreed/strongly disagreed with the same items was 90%, 85% and 85%
respectively, thus indicating a more positive response from the non-CEU RNs. The
reasons for these results are not clear, however may have related to the relative stability
of the non-CEU environments during Phase 2 (as compared to the CEU environments at
the Hospital) and the long term nature of the employment/secondment of the clinical
facilitators in the non-CEU areas.
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Table 6.6: CEU and non-CEU RNs’ responses to the QPE-Phase 2 (RN) questionnaire
Strongly Strongly
agree Disagree
1 2 3 4
%
Staff found it easy to include students as part of the nursing team CEU 28.7 70.4 0.9 -
Non-CEU 24.5 70.6 4.9 -
In general, staff knew what was expected of students CEU 19.4 75.0 5.6 -
Non-CEU 8.8 79.4 9.8 2.0
There were plenty of opportunities for students to practise different skills CEU 43.5 55.6 0.9 -
Non-CEU 21.6 67.6 10.8 -
Staff felt well prepared to support students CEU 20.6 70.1 9.3 -
Non-CEU 9.8 69.6 16.7 3.9
There was a real sense of camaraderie between students and staff in the CEU 28.7 70.4 0.9 -
ward/area
Non-CEU 20.2 61.6 17.2 1.0
Staff had clear expectations about students’ learning CEU 11.1 72.9 15.9 -
Non-CEU 3.9 75.5 19.6 1.0
Staff value having students on clinical practicum CEU 24.1 66.7 9.3 -
Non-CEU 15.0 57.0 26.0 2.0
Giving students feedback on their progress was a priority CEU 19.4 68.5 12.0 -
Non-CEU 11.8 64.7 23.5 -
It was easy to know what students were aiming to achieve during the prac CEU 9.3 64.8 25.9 -
Non-CEU 2.0 57.8 39.2 1.0
In general, staff felt well supported in working with students CEU 18.7 68.2 11.2 1.9
Non-CEU 8.9 67.3 19.8 4.0
Commenting on students’ time takes too much time CEU - 10.4 75.5 14.2
Non-CEU - 5.1 73.7 21.2
Staff felt valued for their contribution to students’ learning CEU 13.2 76.4 9.4 0.9
Non-CEU 6.9 74.3 15.8 3.0
It was hard to know what students were ‘there for’ during the prac CEU - 15.9 67.3 16.8
Non-CEU - 7.2 70.1 22.7

Staff felt like they were ‘on their own’ with assisting students during the CEU - 15.4 64.4 20.2
prac
Non-CEU - 4.2 68.4 27.4
Overall, I am satisfied with the clinical education arrangements (model) for CEU 22.6 69.8 5.7 1.9
this prac
Non-CEU 3.9 73.5 19.6 2.9
To further examine differences in RNs’ ratings of the quality of students’ clinical
experience during Phase 2, independent sample t-tests were conducted to compare the
mean scores of CEU and non-CEU RNs on individual survey items. Key assumptions for
using the independent-samples t-test were met. Where indicated by the Levene’s test for
unequal variances, t-test results assuming unequal variances were used. In all, 15
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comparisons were made. Using the same logic as described under the Analysis of
student responses to the QPE-Phase 1 (Student) questionnaire (Section 5.2.1), the
Bonferroni correction was not applied. As in Phase 1, a significance level of .05 was
used for the purpose of these analyses. The mean scores for CEU RNs were
significantly different to those of non-CEU RNs on 11 of the 15 survey items (Table 6.7).
Consistent with the frequency analyses presented earlier, CEU RNs reported
significantly more positive attitudes than non-CEU RNs regarding their wards/units as
learning environments for students, the experience of working with students and the
commitment of the clinical facilitator to helping students during the practicum.
Table 6.7: Mean ratings of CEU and non-CEU RNs on QPE-Phase 2 (RN) survey items
Mean SD T df P
In general, staff knew what was expected of students CEU 1.86 .483 -2.731 208 .007
Non-CEU 2.05 .515
There were plenty of opportunities for students to practice CEU 1.57 .515 -4.282 208 .00
different skills
Non-CEU 1.89 .561
Staff felt well prepared to support students CEU 1.89 .538 -3.188 207 .002
Non-CEU 2.15 .636
There was a real sense of camaraderie between students and CEU 1.72 .470 -3.426 205 .001
staff in the ward/area
Non-CEU 1.99 .647
Staff value having students on clinical practicum CEU 1.85 .561 -3.439 206 .001
Non-CEU 2.15 .687
Giving students feedback on their progress was a priority CEU 1.93 .559 -2.429 208 .016
Non-CEU 2.12 .585
It was easy to know what students were aiming to achieve during CEU 2.17 .572 -2.914 208 .004
the prac
Non-CEU 2.39 .548
In general, staff felt well supported in working with students during CEU 1.96 .613 -2.588 206 .010
the prac
Non-CEU 2.19 .644
Staff felt valued for their contribution to students’ learning CEU 1.98 .516 -2.212 205 .028
Non-CEU 2.15 .572
Staff felt like they were ‘on their own’ with assisting students CEU 3.05 .597 -2.311 197 .022
during the prac
Non-CEU 3.23 .515
Overall, I am satisfied with the clinical education arrangements CEU 1.87 .587 -4.383 206 .000
(model) for this prac
Non-CEU 2.22 .556
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Analysis of CEU Student/ RN responses to the QPE-Phase 2 questionnaire
As in Phase 1, an additional analysis of the Phase 2 data was undertaken to compare
the ratings of CEU students and CEU RNs. Independent sample t-tests were conducted
on the mean scores of survey items that were common to both student and RN versions
of the questionnaire (see Table 5.9).To investigate differences between the ratings of
CEU students and CEU RNs on the Phase 2 questionnaire, independent sample t-tests
were conducted on the mean scores of survey items that were common to both student
and RN versions of the questionnaire (see Table 6.8). Key assumptions for using the
independent-samples t-test were met. Where indicated, t-test results assuming unequal
variances were used.
The mean ratings for CEU nurses were significantly different to those of CEU students
on four of the six ‘common’ survey items. These are shown in Table 6.8. With one
exception, ie. ‘it was easy to know where I was going and what was expected/it was
easy to know what students were aiming to achieve’, the mean ratings of CEU RNs were
significantly higher than those of CEU students. This pattern was reversed in the case of
‘it was easy to know where I was going and what was expected/it was easy to know
what students were aiming to achieve’. For this item the mean rating of CEU students
was significantly higher than that of the CEU RNs.
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Table 6.8: Mean ratings of CEU students and CEU RNs on QPE-Phase 2 survey items
Mean SD T df P
Plenty of opportunities to practise skills CEU students 1.81 .682 2.554 165 .012
CEU RNs 1.57 .515
Easy to know where I was going and what was expected/Easy CEU students 1.76 .678 -4.081 165 .000
to know what students were aiming to achieve
CEU RNs 2.17 .572
There was a strong sense of camaraderie between students CEU students 1.90 .667 1.958 164 .052
and staff
CEU RNs 1.72 .470
Staff put a lot of time into commenting on my work/ Giving CEU students 2.36 .713 4.301 165 .000
students feedback on their progress was a priority
CEU RNs 1.93 .559
It was easy to feel part of the nursing team / staff found it easy CEU students 1.78 .589 .689 165 .492
to include students as part of the nursing team
CEU RNs 1.72 .470
Overall, I was satisfied with the quality of/clinical education CEU students 1.75 .685 -1.398 164 .164
arrangements for this prac
CEU RNs 1.93 .904
6.4 Summary
This chapter presented the results from the focus group discussions and survey
questionnaires conducted during Phase 2 of the study. Overall, the data suggest that
CEU students and CEU RNs had more positive perceptions regarding students’ clinical
experience than did non-CEU students and non-CEU RNs. This was demonstrated in
the content of the focus group discussions with students and registered nurses and the
results from the Quality of Prac Experience survey questionnaires. As in Phase 1, there
were similarities in the themes that emerged from the focus group discussions with
students and RNs. Students and registered nurses from both CEU and non-CEU wards
highlighted issues related to the social environment of the ward, clinical facilitation and
learning outcomes achieved. The notion of opportunities for learning was also identified
as an issue by the student participants although not by the RNs. In relation to the social
milieu, the issue that students felt most strongly about was the perceived
supportiveness/unsupportiveness of the ward environment. This issue was also
identified in the analysis of student data from Phase 1 of the study. Also consistent with
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results from Phase 1, students and RNs in Phase 2 spoke about familiarity of the
facilitator with the environment and good accessibility to students and staff as important
aspects of clinical facilitation. With regard to learning outcomes, both groups highlighted
students’ development of clinical knowledge and skills and, to some extent, the impact
on this of the clinical education model that had been used. As they had in Phase 1, the
CEU RNs again drew attention to the possibility of employing CEU students as new
graduate RNs.
On all of these issues, CEU students and RNs described more positive perceptions of
their prac experiences in the CEU units than did non-CEU students and RNs. In general,
CEU students perceived that CEU provided a supportive learning environment where
they felt part of the team, ready access to facilitators who ‘knew the environment’, good
learning experiences which were promoted by staff and good outcomes in terms of their
development of clinical knowledge and skills. In general, these views were reflected in
the comments of the CEU RNs, albeit from their particular perspective. An additional
point that emerged from the focus group discussions with the CEU RNs identified the
possibility of employing well prepared new ‘grads’ as a particular value-adding aspect of
the CEU model.
The results from the analysis of the QPE-Phase 2 questionnaires tended to support the
focus group results. In general, CEU students and CEU RNs rated the quality of
students’ clinical prac experience more positively than did the non-CEU students and
RNs, although not to the same extent as in Phase 1. Further, several of the survey items
on the Phase 2 questionnaire were rated more highly by non-CEU students as
compared to CEU students. The following chapter presents a discussion of the Phase 1
and Phase 2 results from this study.
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CHAPTER 7
DISCUSSION
7.1 Introduction
Nursing is a practice-based discipline that requires a minimum level of competence for
entry into practice as a registered nurse. The ability of newly registered nurses to
effectively fulfil their clinical roles is dependent to a large extent on the quality of the
clinical preparation that occurs during the pre-registration course. Clinical education
programs provide students with real world opportunities to develop the knowledge,
attitudes and skills implicit in the ANMC Competencies and the organisational abilities
needed to function effectively as a registered nurse. Both students and
facilitators/supervisors agree that clinical education is a critical component of pre-
registration nursing courses (Marrow and Tatum 1994).
Optimal clinical learning requires adequate practice environments, good relationships
with individuals who have sound theoretical knowledge and good clinical skills, and
stimulating dialogue which includes the assessment of learners’ needs, structured
guidance and constructive feedback on performance (Field 2004). However, issues at
both the ‘macro’ as well as ‘micro’ levels continue to impact on the ability of universities
to provide clinical education programs that are consistent with these principles. As noted
in the National Review of Nursing Education Discussion Paper (2001), this has focussed
continued attention on the adequacy of students’ clinical education and, in particular, on
the models used for clinical facilitation/supervision. Ironically, although there is
widespread agreement that clinical learning activities are at the “heart of nursing’s
professional program” (Infante 1981, 16), it is clear that they also represent what is
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possibly the most challenging aspect of nursing education. There is little published
evidence that demonstrates the effectiveness of any of the current models of clinical
facilitation, or that any particular model is better than any other in achieving quality
outcomes (McKinley et al. 2002; Wellard, Williams and Bethune 2000) and, indeed, the
National Review of Nurse Education (2002, 24) recommended ongoing evaluation of
curricula and teaching practice in light of changes in nursing practice, research on
learning and broader developments in professional and para-professional preparation.
The change intervention implemented in this study, ie. the Clinical Education Unit (CEU)
model, offered an innovative approach to the provision of clinical education for
undergraduate nursing students. The CEU model is based on the findings of an earlier
evaluation study (Nash et al. 1999) and dialogue with clinical and academic colleagues.
The broad intent of the model was to represent a shared vision of a ‘better’ way to
provide quality clinical learning for undergraduate nursing students. Thus a key element
that underpins the CEU model is a shift from a more university-driven approach to one
that embodies collaboration between academic and clinical staff. Key differences
between the CEU and other commonly used models of clinical education, eg. the
secondment and sessional models, are that clinical facilitators in the CEU model are
working in the ward area in which students are placed (although they become
supernumary for the purposes of clinical education), nursing staff in the ward take on a
Clinical Partner role which emphasises the importance of their contribution to students’
clinical education, there is tangible contact with the uni through the on-site presence of
academic staff, and students undertake all clinical placement across an academic year,
eg. Year 3, within the same CEU ward area. The sense of clinical ownership that is
implicit within the CEU model, supported by ongoing collaboration between academic
and clinical staff, was expected to facilitate a more positive environment for prac,
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improved learning experiences for students and enhanced outcomes for both students
and clinical nursing staff.
Chapters 5 and 6 outlined the results from quantitative and qualitative analyses of data
collected during the Phase 1 and Phase 2 evaluations of the Clinical Education Unit
(CEU) model of clinical education. In Phase 1 of the study students who undertook
clinical practice in CEU wards and registered nurses working in the CEU wards
evaluated the CEU model of clinical education by participating in focus group
discussions and completing the QPE-Phase 1 questionnaire. These results were
compared with the evaluations of students and registered nurses in non-CEU wards.
Reflection on these results and ongoing dialogue with key stakeholders informed the
further development of the CEU model to a refined version (CEU-2) which was
implemented and re-evaluated in Phase 2.
Phase 1 results indicated that the CEU model was evaluated more positively by students
and registered nurses than were the non-CEU models that were used for comparison.
This result was demonstrated in the comments of students and registered nurses with
regard to the respective models of clinical education and supported by their ratings of
the quality of clinical experience through the QPE-Phase questionnaires. In general, a
similar trend was found in the results from Phase 2. Despite the use of three external, or
non-Hospital facilities during Phase 2 for the collection comparative data, the CEU-2
model was again evaluated more positively by students and registered nurses than were
the non-CEU models that were used for comparison.
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This final chapter discusses the evidence found in this study in response to the research
questions and in relation to the key elements of the CEU model. The first two sections
outline the results for students and RNs in Phase 1 and Phase 2 of the study. The
section that follows draws the results together and discusses them under the headings
of collaboration, ‘local ownership’, the prac environment, clinical learning experiences
and outcomes for students and staff. The chapter then concludes with a discussion of
the limitations for this study.
7.2 Phase 1
7.2.1 Students’ perspectives
Research Question 1:
How do CEU students rate the quality of their practicum experience, and how do they
compare with the ratings of non-CEU students?
Overall, the Phase 1 data suggest that CEU students had more positive perceptions of
their clinical practicum experience than did non-CEU students. This finding was
demonstrated in students’ commentary during the focus group discussions and
supported by the results from the Quality of Prac Experience (Phase 1-Student) survey
questionnaires. Four themes emerged from students’ comments during the focus group
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discussions : “learning environments and prac”, “facilitation that works”, “clinical learning
opportunities” and “prac outcomes”. These themes are very consistent with previous
research by Nash et al. (1999) and literature in the area of clinical education (eg. Dunn
and Hansford 1997; Chan 2004; Pearcey and Elliott 2004; Saarikoski et al. 2002). It is
also of interest that they are not inconsistent with points raised in the previous National
Review of Nurse Education (Reid 1994) - particularly the discussion on models of clinical
education and students’ perceptions of being in the clinical setting. This serves to
highlight the very real difficulties that exist in terms of achieving sustainable
improvements to clinical education – a challenge made more difficult by the rapidly
changing health care and higher education environments. In general, CEU students held
more positive views on each of the four themes than did non-CEU students. The CEU
wards were perceived as providing a supportive learning environment that enabled
ready access to facilitators who knew the environment and facilitated good learning
opportunities. These factors appeared to interact synergistically to promote students’
development of clinical knowledge and skills and confidence regarding practice. In
contrast, non-CEU students described a more ‘hit and miss’ situation characterised by
some uncertainty as to whether they would be welcome in the ward, ‘patchy’ access to
clinical facilitators who were regarded as ‘outsiders’ to the organisation and frustration
regarding good access to clinical learning opportunities.
The results of the Quality of Prac Experience Questionnaire (QPE-Phase 1) for students
tended to support the trends demonstrated through the focus group discussions. For
more than half of the survey items, CEU students’ ratings of the quality of their prac
experience were significantly higher than those of non-CEU students. These items
related to issues which included the ward as a learning environment, development of
clinical knowledge and skills, feeling part of the ward team and overall satisfaction with
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the experience. Notably, approximately 95% of the CEU students agreed/strongly
agreed that undertaking prac in the CEU unit motivated them to do their best work as
compared to 58% (approximately) of their non-CEU counterparts. Consistent with the
comments and themes emerging from the focus group discussions, CEU students were
significantly more positive than non-CEU students about the importance attached to their
learning by the Clinical Associates and Clinical Partners (or buddy nurses), knowing
what was required of them and how to improve their performance, and the development
of their clinical knowledge and problem solving, technical, time management and
reflective skills. CEU students were also significantly more positive than non-CEU
students about making a useful contribution to the ward team and, perhaps not
surprisingly, that their prac had been a worthwhile learning experience.
The continuity element of the CEU model appeared to be an important mediator of these
outcomes for students. Because the CEU students undertook their practicums in the
same clinical area across the academic year there was no need for them to continually
re-orient themselves to new prac settings and new staff or to ‘re-learn the ropes’ in terms
of policy and procedure applicable to different clinical settings. This had the effect of
easing the pathway into students’ next prac and boosting their confidence in what they
were doing thus allowing them to actually build on their clinical knowledge and skills.
This translated to a greater sense of enthusiasm for, and satisfaction with clinical
learning outcomes they had achieved. Taken together, the Phase 1 student results
suggest that the more positive social climate in the CEU wards, acting together with
improved clinical supervision from the RN buddies as well as the clinical facilitators,
enabled better learning opportunities for CEU students and the achievement of improved
learning outcomes.
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7.2.2 Registered nurses’ perspectives
clinical education, and how do they compare RNs’ perceptions regarding non-CEU
models?
Overall, Phase 1 data suggest that CEU RNs had more positive perceptions regarding
students’ clinical experience than did non-CEU RNs. This was demonstrated in
registered nurses’ comments during the focus group discussions and supported by the
results from the Quality of Prac Experience (Phase 1-RN) survey questionnaires. From
the focus group discussions with CEU and non-CEU registered nurses, four themes
emerged from their comments: “team spirit”, “facilitation that works”, “clinical learning”,
“future employment prospects”. With the exception of “future employment prospects”’,
which only emerged from the RN discussions, these are generally consistent with the
themes that emerged from the student focus groups.
In general, CEU RNs expressed more positive views with respect to each of the four
(RN) themes than did their non-CEU counterparts. CEU RNs perceived that the CEU
model enabled a more positive environment for clinical prac, a greater sense of staff and
students ‘pulling together’ in a more cohesive way, better access to facilitators who
knew, and were known, in the organisation and the wards where students were placed,
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and good student learning outcomes. They also saw the potential for future employment
of well prepared new grads as a value-adding aspect of the CEU model. In contrast,
non-CEU RNs felt frustrated with unreliable access to facilitators who were unfamiliar
with the local environment, ongoing difficulties in establishing good working relationships
with clinical facilitators and uncertainty with regard to the quality of students’ learning
outcomes.
The results of the Quality of Prac Experience questionnaire (QPE-Phase 1) for RNs
tended to support the trends demonstrated through the focus group discussions, albeit to
a lesser extent than for the student results from Phase 1. Consistent with the comments
and themes emerging from the focus group discussions, CEU RNs were more positive
than non-CEU RNs about the quality of the unit for students to learn about clinical
practice, the quality of clinical facilitation, students’ access to clinical learning
opportunities and their clinical learning outcomes. Notably, approximately 91% of the
CEU RNs agreed/strongly agreed that working with students is a positive experience as
compared to 57% of their non-CEU counterparts. A similarly large difference was found
between the views of CEU and non-CEU RNs in response to the item ‘there was a great
deal of importance attached to the learning needs of students’. CEU RNs were
significantly more positive than non-CEU RNs about working with students, the quality of
the unit for students to learn about prac, the effort of the clinical facilitator in helping
students and the commitment of staff to helping students gain experience.
Apart from the improved clinical facilitation arrangements, the continuity element of the
CEU model again appeared to be an important ‘mediator’ of these outcomes. CEU RNs
were pleased that students would be ‘coming back’ to the CEU for future pracs and felt
that this was advantageous, not only from an interpersonal perspective, but also
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because it allowed students to consolidate their development of clinical skills. It is
notable that their views on this issue are generally in agreement with the literature
(Adams 2002) and those of the students in the Phase 1 of the study.
7.3 Phase 2
7.3.1 Students’ perspectives
What are the perceptions of undergraduate nursing students with respect to the CEU-2
How do CEU students rate the quality of their practicum experience, and how do they
compare with the ratings of non-CEU students?
Overall, the Phase 2 data are consistent with the results for Phase 1 and suggest that
CEU students again had more positive perceptions of their clinical practicum experience
than did non-CEU students. This was demonstrated in students’ commentary during the
focus group discussions and supported by the results from the Quality of Prac
Experience (Phase 2-Student) survey questionnaires. Despite the positive trend,
however, it was apparent that the Phase 2 results were somewhat less positive than the
Phase 1 results. This was most probably related to two main factors: (1) the turbulent
organisational context that existed at the Hospital during Phase 2 as compared to the
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relative environmental stability of the non-CEU hospitals; and (2) the increase in the
number of wards using the CEU model from two in Phase 1 to eleven in Phase 2.
During Phase 2 of the study the Hospital was experiencing a number of significant
challenges, particularly in relation to nursing staff shortages and organisational re-
structuring. Although these changes did not involve students directly, there were flow-on
effects that impacted on staff’s commitment to and prioritisation of students’ learning.
Further, in light of the positive Phase 1 outcomes, staff at the Hospital wanted to grow
the CEU model and extend its usage to other wards. Their desire to do this concurrently
(rather than incrementally) was also prompted by the imminent completion of a major
building reconstruction which, in their view, provided an opportune time for doing things
differently. However, the extension of the model from two to eleven wards necessarily
provided a number of additional challenges. On the other hand, the non-CEU placement
settings were ‘business as usual’. They did not have the additional pressures that were
present at the Hospital and the clinical facilitators in each of these settings were well
known to the nursing staff and respected for their facilitation with students. It is notable
that, despite these contextual issues, CEU students had more positive perceptions of
their clinical practicum experience than did non-CEU students as was the case in Phase
1 of the study. Nevertheless, given the ongoing nature of the nursing shortage and
associated issues, the lower positivity seen in students’ ratings during Phase 2 may
signal the importance of context to the quality of clinical practicums- irrespective of the
model/s of clinical education that are used.
Four themes emerged from the Phase 2 focus group discussions with CEU and non-
CEU students: “enjoying being there”, “good facilitation”, “opportunities for learning” and
“prac outcomes. It is interesting that, despite a 2-year gap between Phase 1 and Phase
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2, the themes identified above remained very consistent with those that emerged from
the focus group discussions with students during Phase 1 of the study. This validates
the importance of these issues in relation to students’ experience on prac. Similarly to
Phase 1, CEU students perceived that the CEU wards provided a positive learning
environment where students felt accepted as part of the team. There was good access
to clinical facilitators who had knew the environment and, generally speaking, staff in the
CEU wards facilitated students’ access to good learning opportunities. Not surprisingly,
the general consensus from CEU students was that they ‘had learned a lot’ during their
pracs and that this was related to the positive involvement of ward staff in their clinical
education as well as the expectations that staff, and they themselves, had of their
performance.
The results of the Quality of Prac Experience questionnaire (QPE-Phase 2) for students
partially supported the trends demonstrated through the focus group discussions. In
general, the results for CEU students were more positive than those of the non-CEU
students although the difference was slight on a number of items. Unexpectedly, several
items were rated more positively by non-CEU students than CEU students. These items
included ‘asking as many questions as students wanted’, ‘feeling like a burden on staff’,
‘getting feedback on progress during the prac’ and ‘getting assistance in dealing
with/undertaking new situations’. Given the nature of the issues targeted by these items,
it is likely that the reasons for this contradictory outcome relate to the contextual issues
described above.
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7.3.2 Registered nurses’ perspectives
clinical education, and how do they compare RNs’ perceptions regarding non-CEU
models?
The Phase 2 results for RNs were consistent with the Phase 1 results in that CEU
registered nurses had generally more positive perceptions regarding students’ clinical
experience than did non-CEU registered nurses. As for Phase 1, this was demonstrated
in the comments of RNs during the focus group discussions and supported by results
from the Quality of Prac Experience (Phase 2-RN) survey questionnaires. In comparison
to the student results, there was a greater consistency between the Phase 1 and Phase
2 results for RNs. Notably, this occurred despite the challenging circumstances which
were present at the Hospital during Phase 2 of the study. A possible explanation for the
different trends in the Phase 1 – Phase 2 results of students and RNs relates to the
sustained enthusiasm of clinical nurses and nursing management at the Hospital for the
CEU model. Although they were aware that circumstances were less than ideal, RNs
retained a positive attitude towards students’ clinical education and generally felt that
they were ‘doing their best’ to give students a ‘good’ experience. Students, on the other
hand, were more ‘tuned in’ to the reality of their everyday experiences on the wards and
were much less aware of the broader contextual issues on their impact of staff. Hence it
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is plausible that students’ views in Phase 2 may not have been as favourable as their
views in Phase 1 or, indeed, the views of RNs in Phase 2 of the study.
From the focus group discussions with CEU and non-CEU registered nurses, three
general themes emerged from their comments: ‘working together’, feeling supported’
and learning outcomes’. In general, CEU RNs described more positive perceptions in
relation to each of these themes than did their non-CEU counterparts. CEU RNs
perceived that the CEU model enabled the development of good working relationships
between key players, the usage of their own staff as clinical facilitators for students,
good learning outcomes for students and, as for Phase 1, the potential for employing
well prepared new ‘grads’ in the future. In contrast, non-CEU RNs highlighted their
concerns about working with sessional clinical facilitators that they ‘didn’t know’, felt
frustrated with the lack of ready access to facilitators who had students ‘spread’ across
several wards and were somewhat uncertain about students’ development of clinical
knowledge and skills. The results of the Quality of Prac Experience questionnaire (QPE-
Phase 2) for RNs tended to support the trends demonstrated through the focus group
discussions. The mean scores for CEU RNs were significantly different to those of non-
CEU RNs on more than half of the survey items. Items that were rated more positively
by CEU RNs, as compared to non-CEU RNs, related to issues which included the ward
as a learning environment, the experience of working with students, the quality of clinical
facilitation for students, students’ access to learning opportunities and overall
satisfaction with the clinical education arrangements.
Similarly to Phase 1, the issue of good relationships between key stakeholders such as
students and staff was raised by RN participants in the Phase 2 focus groups. Whilst
CEU RNs spoke about developing rapport with students and students’ perceptions of
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feeling that they belonged in the environment, non-CEU RNs spoke more about their
difficulties in relation to not seeing clinical facilitators enough to find common ground and
build working relationships.
7.4 What influenced the CEU outcomes?
The overall aim of the CEU model was to facilitate quality clinical education for
undergraduate nursing students. Building on findings from the evaluation study
undertaken earlier (Nash et al. 1999), the specific objectives of the CEU model were to:
• promote a positive learning environment in wards where students were on prac;
• improve the processes of clinical facilitation for both students and nursing staff;
• promote quality learning outcomes for students; and
• improve student and nursing staff satisfaction with the overall quality of clinical
education.
The results of this study support the contention that these objectives were largely met,
albeit on the basis of self-report data from students and registered nurses. A similar
pattern emerged for both phases of the project with respect to students and registered
nurses. CEU students and registered nurses who participated in the study were
consistently more positive in relation to the prac than were non-CEU students and
registered nurses. This was demonstrated in the findings from the focus group
discussions and supported by the results from the Quality of Prac Experience survey
questionnaires. In particular, CEU participants had more positive perceptions than non-
CEU participants regarding the ward as a learning environment, the functionality of
clinical facilitation, students’ access to learning opportunities and learning outcomes
achieved by students. Overall satisfaction with the prac was also higher for CEU
participants, although this was more the case for CEU RNs than for CEU students.
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Literature on change management suggests that it is very likely that several factors,
other than the CEU model itself, contributed significantly toward the achievement of
these outcomes. These factors included a ‘felt need’ for change in the way that
undergraduate clinical education was being implemented at the Hospital (Kotter 1996;
Rycroft-Malone et al. 2002), sustained commitment from nursing administration staff as
well as clinicians (Baker et al. 2000; Iles and Sutherland 2001), financial resourcing to
allow each Clinical Associate to function on a supernumerary basis for the purpose of
facilitating students’ clinical education (Cohen et al. 2004; Redfern and Christian 2003)
and continued support from academic staff in terms of the provision of role development
workshops, regular in-person liaison and de-briefing meetings which were conducted on-
site for nurses in the CEU wards (Redfern and Christian 2003).
However, in reflecting on the overall findings of the study it is proposed that several
factors related to the CEU structure and principles were instrumental in achieving
apparently better outcomes: (1) the collaborative basis of the CEU model, (2) a sense of
local ownership for students’ clinical education which was engendered by the CEU
model, (3) positive environments for learning and (4) supervision of students’ practice. It
is also proposed that, together with the continuity in students’ placements, these factors
acting synergistically promoted enhanced outcomes for CEU students and staff. This re-
conceptualisation of factors impacting on the quality of students’ clinical experience is
shown schematically in Figure 7.1. The next section presents a detailed discussion on
these and related issues.
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Effective clinical Positive clinical Quality of student
Academic / Clinical Collaboration
supervision learning experience

environment
• Joint operations and ownership
Local ‘ownership’ of Supportive Access to learning

students’ clinical atmosphere experiences
Continuity of placement
education
• Sustained engagement
‘Good’ working Development of clinical

• Mutual goals, values
Clinical & organisational knowledge & skills

relationships
credibility of facilitators between all key
Confidence &
players satisfaction with clinical
Engagement with
clinical education roles preparation
Team
Support provided for environment for Readiness for transition
staff in their clinical prac to professional practice
education roles
Figure 7.1. Re-conceptualisation of factors impacting on the quality of students’

clinical experience in settings where they are on prac.
7.4.1 Collaboration
Collaboration between academic and university staff was a key element in the design,
implementation and evaluation of the CEU model. The issue of collaboration by
universities and health care facilities with regard to clinical education for undergraduate
nursing students is by no means new (Dunn and Burnett 1995; Gonda et al. 1999;
Wellard et al. 2000; Williams and Webb, 2001; Wotton and Gonda 2004) but, arguably,
remains a challenge in terms of finding appropriate ways and means to ensure that it is
meaningful and sustained. However, a strong imperative for embracing collaborative
rather than more organisationally individualistic (Hudson et al. 1999) approaches to
clinical education is described as the ‘collaborative advantage’ (Huxham 1996; Huxham
and Vangen 2001). This concept refers to the notion that far greater and more creative
outcomes can be achieved by working collaboratively than could have been achieved by
partners working alone. The potential magnification of achievement (Brown, White and
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Leibbrandt 2006) is made possible through the synthesis of perspectives, skills and
resources from both sides of the collaboration, or partnership, in a way that transcends
what might otherwise have been achieved. Given the continued strength of the dialogue
surrounding clinical education, collaboration and the rich potential that it holds for
improving the ‘status quo’ is clearly an important issue.
As discussed by Downie et al. (2001) collaboration, or collaborative partnerships, should
involve an association that is based on commitment and trust, and that brings mutual
benefits to both or all partners. Importantly, for collaborative partnerships to work there
must be genuine two-way dialogue that is sustained throughout, careful negotiation and
agreement about the roles and responsibilities of all parties, mutual respect and
recognition for each others’ contribution and potential and a constant process of
reflection and evaluation on the collaborative process as well as the desired outcomes
(Clare et al. 2003; Downie et al. 2001). A key point here is that, if a partnership or
coalition is going to be collaborative in the ‘true’ sense, it must involve joint effort and
ownership rather than simply shared data, and joint operations rather than simply polite
co-operation (Linden 2002).
Throughout the CEU journey academic and clinical staff there was a concerted effort to
work from a position of mutual understanding, respect for each other’s expertise and a
joint commitment to open communication between all stakeholders. Whilst not
everything went smoothly, a collaborative spirit pervaded the actions of staff from both
sectors. In the non-CEU environments business continued as usual. Student placements
were organised and supported in the normal manner which, from the discussion above,
was rather more organisationally individualistic (Hudson et al. 1999) than collaborative in
nature. Consistent with Rice’s (2003) views on collaboration, it is argued that the
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collaborative spirit which pervaded the manner in which the CEU model was
conceptualised, developed, implemented and evaluated facilitated the development of a
shared ethos, effective working relationships, respect for the issues of both partners and
a joint commitment to ‘making it happen’. Arguably, the CEU model went some way
toward Huxham’s (1996) concept of collaborative advantage, as described above, in the
sense that the synergism created through this model promoted the achievement of
qualitatively better outcomes than those achieved through the more traditional non-CEU
models .
7.4.2 Sense of local ownership
From the outset, enhanced ownership of students’ clinical education by registered
nurses was seen to be an important factor in achieving the objectives of the CEU model.
Elements of the CEU model that were designed to promote this ownership included the
changed arrangements for clinical facilitation which allowed Clinical Facilitators (ie.
Clinical Associates) to remain in their own wards whilst supervising students, the
articulation of a more explicit Clinical Partner role for the registered nurse buddies which
validated the importance of their contribution to students’ experience and the continuity
of student placements in the same ward area across the academic year. Staff ownership
of any proposed innovation or change is an essential ingredient for a successful change
process (Dopson et al. 1999; Redfern and Christian 2003). The notion of ownership is a
somewhat elusive one but relates broadly to the embracing of an innovation or change
by those most affected and an acceptance of responsibility for their part in the enterprise
(Cross et al. 2006; Sirkin, Keenan and Jackson 2005). Its importance lies in a
heightened sense of empowerment for the individuals involved and, in turn, greater
motivation and commitment to act effectively in relation to the task at hand.
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However, ownership within the context of clinical education is not a straight forward
matter. In broad terms, responsibility for students’ course and its outcomes is ‘owned’ by
the university. Equally, given the substantial involvement of health care facilities in
respect to the students’ clinical education, there is the question of ownership from their
perspective as well. Extrapolating from the work of Davies, Spence Laschinger and
Andrusyszyn (2006), and the results of this study, it would appear that a genuine sense
of ownership for students’ clinical education among nursing staff can facilitate a more
empowering situation and assist the development of better outcomes for all parties.
Thus, reaching a common understanding of ownership that respects and embraces the
expertise of both parties, and how it is best played out in the clinical setting, would
appear to be an important issue.
The results of the study suggest that the strategies included in the CEU model to
facilitate local ownership of students’ clinical education did play an integral part in the
development of more positive learning environments in the CEU wards and promoted
the sustained involvement of staff in students’ experience. More so than the non-CEU
RNs, CEU RNs enjoyed working with students and felt valued for their contribution to
students’ development. There was a much stronger sense of students and nursing staff
working together in the CEU wards, and investment by staff in ensuring that students
had a good experience. In reflecting on the literature regarding change management, it
is postulated that CEU RNs felt more empowered with respect to students’ clinical
education than did non-CEU RNs, and that this was an important factor in mediating
their more positive approaches of CEU RNs to student learning (Redfern and Christian
2003; Sirkin, Keenan and Jackson 2005).
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7.4.3 Positive learning environment
The promotion of a positive learning environment was a key objective of the CEU model.
This was consistent with the growing international literature on the importance of good
environments to students’ learning in the clinical setting (Atack et al. 2000; Dunn and
Hansford 1997; Papp, Markkanen and von Bonsdorff 2003; Saarikoski et al. 2002). It
was anticipated that the collaborative framework of the CEU model, in conjunction with
strategies to promote local ownership, would enable the development of a positive
learning environment in the wards where students were placed for their clinical
experience. The results of the study suggest that the social climate in the CEU wards
was regarded more positively by both students and RNs than was the case for students
and RNs in the non-CEU wards. Notably, CEU students and CEU RNs expressed
common views about the presence of team spirit and good relationships within the CEU
wards. Students felt part of the team and valued for their contribution to patient care.
Registered nurses felt that students were integrated into their units and that this enabled
the key players to ‘pull together’ with respect to students’ clinical education. It is also
notable that these perceptions extended beyond the Clinical Associate, or clinical
facilitator, to the buddy RNs, or Clinical Partners, as well. Contrary to the detachment of
registered nurses from their teaching role with students which has been found elsewhere
(Van Rhyn 2004), registered nurses in the CEU units enjoyed working with students and
actively facilitated students’ access to learning experiences that would assist their
development of knowledge and skills.
The positive learning environment created in the CEU wards appeared to translate to
improved learning outcomes for students and increased satisfaction with their prac
experiences. Of particular interest is the notion that, similarly to previous research by
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Dunn and Hansford (1997), it is also possible that there was an interactive effect
between student satisfaction and the quality of the environment such that more satisfied
students facilitated the development of more productive, stimulating and supportive
environments for learning and vice versa. The importance of these findings is
underscored by research which demonstrates the pivotal role of the registered nurse in
students’ experiences (eg. Donaldson and Carter 2005; Jackson and Mannix 2001;
Papp, Markkanen and von Bonsdorff 2003; Stockhausen 2004). Therefore, it is critical
that registered nurses have positive attitudes towards students and are willing to share
their expertise with them. It is only when this students experience their prac from this
perspective that real progress can be made in terms of developing the knowledge and
skills that are required for competent practice as a new graduate RN.
7.4.4 Improved supervision arrangements
Along with the approaches described above which were designed to collectively promote
a positive ethos regarding clinical education, strategies that targetted the more functional
aspects of clinical education were incorporated within the CEU model. Specific examples
included the changed arrangements for clinical facilitation, continued reimbursement of
the health care facility to allow Clinical Associates to assume supernumary status for the
purpose of clinical facilitation and the provision of staff development workshops and on-
site liaison with ward staff. Several factors emphasised the need to address functional as
well philosophical issues in the design of the CEU model. Firstly, findings from the
evaluation study undertaken by Nash et al. (1999) highlighted strongly held concerns
from both students and nursing staff regarding difficulties associated with traditional
models of clinical facilitation. Further, for an innovation to be successful the necessary
resources need to be in place for staff to ‘make it happen’, and these include time,
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training and support that is appropriate to what is being asked (Kotter 1996; Redfern and
Christian 2003). With the increasing complexity of clinical facilities such as the Hospital,
and the impact of this on the day-to-day experience of registered nurses in the wards, it
was acknowledged from the outset that the instrumental needs of staff were just as
important as the more philosophical cultural change factors in achieving a successful
outcome.
The results of the study suggest that the changed clinical facilitation arrangements of the
CEU model, supported through the supernumary status of the Clinical Associate, was
regarded more positively by both students and RNs in the CEU wards than were the
more traditional sessional and seconded models used in the non-CEU wards. In general,
CEU students felt that they had good access to facilitators who were ‘there’, clinically
credible (Carlisle, Kirk and Luther 1997; Chapple and Aston 2004; Clifford 1999;
Williamson and Webb 2001) and who ‘knew’ the organisation. From the RNs’
perspective they were confident in the facilitator’s ability to effectively interpret the
policies and procedures of the ward, and the organisation, to students, and that the
facilitator was ‘there’ and able to provide ready backup when they needed assistance
with students. Moreover, RNs perceived there were more open patterns of
communication on the CEU wards which allowed them to say what they felt to the
Clinical Associates without having ‘to dart around anything’ or causing offence. For both
groups there was also greater efficiency in the processes of facilitation which enabled
more time to be spent on students’ clinical learning rather than waiting for the facilitator
to arrive from another ward or sorting out problems of miscommunication etc.
Despite these advantages, however, there were some issues for Clinical Associates
particularly in terms of role confusion which, at times, proved to be difficult - especially if
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the ward was busy and/or short staffed. Nevertheless, it would appear that the
positioning of the Clinical Associate within his/her own ward provides significant
advantages for the provision of much needed day-to-day support for RNs working with
students in the clinical area.
7.4.5 ‘Good’ outcomes for students and staff
Results from the study indicated that CEU students perceived that they better access to
‘good’ learning opportunities on prac and had progressed their development of clinical
knowledge and skills more effectively than non-CEU students. A similar trend was found
in the results of CEU as compared to non-CEU RNs. However, it should be noted that
the data obtained in this study is self-report data and, as such, leaves open the question
of whether and to what extent the CEU students actually learned more than the non-
CEU students. Irrespective of CEU or non-CEU status, students’ performance was
assessed using the standard performance assessment methodology used by the School
of Nursing. This comprised a criteria-based tool that was designed to be consistent with
the ANCI Competencies with each criterion graded on an Achieved/Not Achieved (ie.
non-numerical) basis. It was therefore not possible to examine any quantitative
differences in students’ learning outcomes from the perspective of performance
assessment. Consequently, the focus of this research was on students’ and registered
nurses’ perceptions of learning outcomes and it is acknowledged that these may not be
an objective measure of what students actually learned.
In general, CEU students in the present study reported being involved in a wider range
of learning opportunities than their non-CEU counterparts and drew attention to the
enthusiasm of nursing staff in the CEU wards with respect to students’ learning. Despite
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some instances of being given the “dirty work” to do when staffing levels were “down” or
there was more of a “task orientation” approach to nursing care, CEU students felt that
their experience was superior to what they had experienced previously with more
traditional models of clinical education. CEU students also described a strong sense of
achievement during their pracs in the CEU wards which led to a clear sense of
confidence and satisfaction with their clinical development. In contrast, non-CEU
students appeared to depend heavily on the clinical facilitator to ensure that they had
access to appropriate learning opportunities. For them, staff on the wards were more
equivocal about students’ learning, and the degree to which students were able to be
usefully involved in patient care activities was rather uncertain. Notably, non-CEU
students were less enthusiastic than CEU students about the learning outcomes they
had achieved.
The importance of students being able to access good learning opportunities on prac is
inarguable. Students’ exposure to clinicians, opportunity to communicate face-to-face
with patients and their families, interact with health care teams, provide care and
practice skills under supervision, receive feedback on performance and reflect on
experience is vital to the development of competence and the ability to function
effectively as a new graduate (Bjork 1999; Davies et al. 1999; Donaldson and Carter
2005; Howie 1988). Although the non-CEU students felt that their prac had generally
been “good”, the tenor of their comments serves to highlight the variability which still
exists across the range of placement areas as regards ward staff and their role in
facilitating student access to meaningful learning opportunities.
The importance of issues such as access to learning experiences and learning
outcomes is underscored by the ongoing debate on the preparedness of new graduates
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for practice (Health 2002) and concerns that have been expressed about graduates’
performance deficiencies in practice (Duffield 2001). The centrality of good clinical
experiences to the development of students’ development of clinical knowledge and
skills is well known (Clare et al. 2002; Dunn and Hansford 1997) and supported research
findings such as those of Dunn et al. (2000). With traditional models of clinical education
students are in the clinical setting on a supernumary basis and often for relatively short
periods of time, such as 2-4 weeks. They are often unknown to registered nurses in the
placement areas and, although they participate in the provision of patient care, they are
not usually seen as bona fide members of the health care team. Under these sorts of
circumstances it is not surprising that, although nursing students perceive the clinical
setting as the best place for acquiring knowledge and skills, they frequently feel
extremely vulnerable when they’re on prac (Campbell et al. 1994) and unless they find
themselves in an environment which allows them to practice as fully as possible their
development of knowledge and skills may be hindered. Importantly, the earlier
comments about the possible interactive effects between student (and possibly staff)
satisfaction and the quality of the learning environment apply here as well. A particular
advantage for staff was the possibility of employing well prepared new graduates on
completion of their course. This provided additional incentive for staff to maintain their
commitment to the project. However, as the effect of the CEU on students’ development
of knowledge and skills became apparent, this not only enhanced students’ satisfaction
with their experience but provided RNs with a useful outcome for their efforts as well – a
‘win-win’ situation for both parties.
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7.5 Limitations of the study
A general limitation of this study is the reliance on self report data from students and
registered nurses. The data obtained from the focus group discussions and the Quality
of Prac Experience (QPE) questionnaires provide an estimate of outcomes achieved. In
the area of students’ development of knowledge and skills the lack of direct observation
of their performance precludes definitive conclusions being drawn about these
outcomes. Three other limitations of this study are identified. Firstly, the generalisability
of the results to other contexts is a limitation of the results. Secondly, the purposive
recruitment processes used in both phases provides an additional limitation. Thirdly, the
lack of psychometric reliability and validity for the Quality of Prac Experience
questionnaire poses a limitation.
Generalisability
An argument was presented earlier with regard to the issue of generalisability and action
research (Section 3.3.3). Notwithstanding these comments, several additional issues
with regard to present study should be noted. Phase 1 of the study was conducted with a
single hospital facility which may not be adequately representative of the range of clinical
settings in which students undertake clinical placements. Given the range of placement
opportunities that exist in various geographic locations across the fields of acute
medical-surgical care, mental health and community health, it is probable that this is the
case. Further, as the selection of wards for this study was not on a random basis, there
is a potential selection bias which further limits the generalisability of the results to a
larger population. Moreover, the study could not be undertaken in a blinded manner and
this may have introduced bias into the results. Registered nurses and students in the
CEU and non-CEU wards were fully aware of the study, and it is conceivable that this
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may have influenced their responses to the focus group discussions and/or the survey
questionnaires. Although purposive sampling has been criticised for its lack of precision
as a sampling methodology, it was considered appropriate within the context of this
study, particularly in light of the organisational commitment required with regard to the
CEU model.
Recruitment
The second issue that limits the generalisability of findings from this study relates to the
methods of recruitment. Students were made aware of the project and provided with the
opportunity of choosing/not choosing their placements within a CEU unit. Subsequently,
the actual placement process for students was undertaken in the ‘normal’ way by staff
involved in the administration of clinical placement. However, results from the CEU
students may have been somewhat biased because of the possibility that, a priori,
students placed in these units had more positive attitudes than students who chose their
placements elsewhere. Counterbalancing this is the alternative possibility that students
who chose the CEU units also had greater expectations of this ‘new’ environment for
prac and were therefore likely to be more critical in the evaluation of their experience.
Quality of Prac Experience questionnaire
The survey questionnaires used in this study (Quality of Prac Experience-1 and Quality
of Prac Experience-2) were designed for the purpose of this study. The QPE-Phase 1
questionnaire was adapted from the Clinical Learning Environment Scale (CLES)
developed earlier by Dunn and Hansford (1997). The main reasons for not using the
CLES in the present study were, firstly, because the focus of the CLES was on the
clinical learning environment, per se, and the present study was targeting a wider range
of concepts than this. Secondly, a number of the original items on the CLES were no
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longer relevant due to changes in nursing workforce structures and processes for clinical
education which had occurred over the intervening period. In addition, the original CLES
was designed specifically for students and the present study was designed to investigate
the perceptions of both students and registered nurses. The Phase 2 version of the QPE
questionnaire was adapted from the QPE-Phase 1 version. The reasons for this were
explained more fully in Chapter 3 (Section 3.5.2). Whilst it is argued that both QPE-
Phase 1 and QPE-Phase 2 had face validity (established through the review of clinical
colleagues at the Hospital), it is acknowledged that the lack of psychometric reliability
and validity for the QPE-Phase 1 and QPE-Phase 2 questionnaires limits the extent to
which survey results from this study can be generalised.
7.6 Summary
In summary, the results of this study indicate that the objectives of the CEU model were
largely met. Students and registered nurses in wards where the CEU model was being
used evaluated the prac experience more positively than did students and registered
nurses in wards where non-CEU models were being used. This result was consistent
across both phases of the study. Two key factors were found to be important in
achieving this outcome: the collaborative nature of the CEU model and nursing staff
‘ownership’ of students’ clinical education. These factors provided an operating
framework which enabled the development of positive learning environments in the
wards where students were placed for prac. Equally important were arrangements for
the supervision of students’ practice which involved local clinical facilitation and the
explicit inclusion of other nursing staff in the ward. Further, continued support from the
university to allow the clinical facilitators to take a supernumary role when facilitating
students, to provide staff development for clinical education and to support staff on a
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day-to-day basis during the prac were also important, if not essential. It is proposed that
these factors, acting synergistically, promoted enhanced access to learning opportunities
for students and improved learning outcomes for students and staff.
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CHAPTER 8
IMPLICATIONS AND RECOMMENDATIONS
This chapter outlines implications arising from the findings of this study and proposes
recommendations for future actions.
8.1 Implications
Clinical education is a vital component of undergraduate nursing courses. As evidenced
by the continued debate surrounding the preparation of new graduates for practice the
need to pursue the development of innovative strategies for enhancing the facilitation of
students’ learning in the clinical setting is clear. As supported by Christine Tanner (2002,
52), “revolutionising clinical education is no longer an option – we must”. The CEU
model of clinical education implemented in this study offered an innovative approach to
undergraduate clinical education for nursing students. The model was evaluated
positively by students and registered nurses in both phases of the study. There are
several implications arising from the findings of the study and these are addressed
below.
Collaboration
Collaboration between academic and university staff was a key element in the design,
implementation and evaluation of the CEU model. An explicit shift away from a more
traditional university-driven approach to one of genuine collaboration was critical to
attaining, and sustaining, the commitment of clinical staff to students’ clinical education.
However, despite the strong rhetoric on the importance of collaboration within this
context (e.g. Chalmers, Swallow and Miller 2001; Downie et al. 2001; Edgecombe et al.
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1999; Nordgren, Richardson, and Laurella 1998; Wotton and Gonda 2004), effective
inter-sectoral collaboration can be time consuming and often difficult to achieve (Lasker,
Weiss and Miller 2001). From a clinical education perspective, reasons for this include
the accelerating pace of change, increasing service demands and fiscal restraints in
both the health and education sectors. Although the outcomes being achieved with the
CEU model appear to outweigh the disadvantages, the issue of sustainability over the
longer term remains an important question. In light of the increasingly ‘tight’
environments in which academic and clinical staff work, resource efficient strategies that
enable genuine collaboration to be maintained over the ‘long haul’ will need to be
developed.
Local ownership of students’ clinical education
Improved ownership of clinical education by registered nurses in the ward where
students were placed for their pracs was seen to be an important factor in achieving the
objectives of the CEU model. Broadly speaking, the results of the study supported this
contention. However, macro issues such as the current nursing workforce shortages are
beginning to impact on staffing structures within health care facilities and, importantly, on
the workloads and day-to-day clinical experience of many registered nurses. For a
genuine sense of local ownership to be sustained, a common understanding of what
ownership means and how it should be played out needs to be reached by academic
and clinical partners. Current experience suggests that the outcomes of discussions
such as these will not necessarily be the same for different organisations. Hence, if
sustainable outcomes are to be achieved, flexibility and creativity will be important
aspects of these negotiations.
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Clinical supervision of students’ practice
The CEU model offers a more devolved model of clinical education (or supervision) that
retains the clinical facilitator in his/her own ward and emphasises the contributory role of
other registered nurses on the ward. As compared to non-CEU models of supervision
which tend to focus more strongly around the sessional/seconded clinical facilitators, all
nurses in the CEU wards have a greater prominence in students’ clinical education
through the Clinical Associate and Clinical Partner roles. As demonstrated in the results
of the study, there were positive outcomes on both fronts, ie. improved quality of clinical
facilitation and stronger involvement of the buddy registered nurses in students’
experience.
There are two key challenges to sustaining these outcomes over the longer term. Firstly,
the issue of escalating costs associated with undergraduate clinical education for
nursing students is well known, and was the subject of detailed discussion in the recent
National Review of Nurse Education (Heath 2002). Continued reimbursement of health
care facilities to allow Clinical Associates to assume supernumary status for the purpose
of clinical facilitation is an increasingly costly activity and, under the present conditions,
may not be sustainable in the long term.
The second issue relates to the impact of nursing workforce shortages on current
staffing structures, in particular the increasing trend towards casualisation, and nurses’
job satisfaction. Over the past decade there has been a dramatic shift away from
standard full-time employment for nurses in Australia to non-standard forms of
employment such as part-time, casual, temporary and contract-based employment
(Creegan, Duffield and Forrester 2003, 202). The AIHW (2001) reported a national
increase in proportion of nurses working part-time from 48.6% in 1994 to 51.7% in 1997.
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At the same time the current shortage of registered nurses is impacting unfavourably on
factors which include nurses’ job satisfaction. A recent study by Hegney, Plank and
Parker (2006) reported that work stress among nurses in Queensland was high and
morale was low and decreasing.
With respect to clinical education, these issues are important because they have the
potential to significantly influence the nature of the clinical learning environment and,
more specifically, the type and extent of registered nurses’ involvement in students’
learning. It is possible that models such as the CEU may not be sustainable in their
‘pure’ form in the future. Although registered nurses will continue to play a central role in
the provision of ‘good’ clinical experiences for students (Clare et al. 2002; Stockhausen
2004), flexibility in the strategies by which their supervision is provided is likely to be an
important element in future discussions between individual health care facilities and
universities with respect to undergraduate clinical education. In order to sustain the
supervisory advantages demonstrated by the CEU model, cost effective strategies that
are cognisant of, and sensitive to, the current contexts of nursing care provision will
need to be developed.
Academic support
Although it was not a key issue that emerged from the focus group discussions, ongoing
academic support was essential to the implementation of the CEU model. The main
ways in which this was provided included the provision of staff development workshops,
regular liaison with staff in the CEU wards and pre-briefing/de-briefing sessions in
conjunction with each clinical practicum. Perhaps the reason why the academic support
didn’t emerge as an issue was that it tended to be regarded by nursing staff as a ‘given’
and, thus, as more of a background rather than foreground issue. From an academic
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point of view, however, the support element was highly significant. The importance of
staff support was, without question, a high priority. However, from a practical point of
view, it is a potentially resource intensive activity particularly when conducted on-site in
health care facilities. Given the current challenges to the quality of clinical learning
environments (as discussed above), support for nurses in their provision of clinical
education will become an even bigger priority. It will essential to develop cost effective
strategies that enable this to happen.
8.2 Recommendations
In light of the context and findings from this study, several recommendations are
proposed. These are as follows:
1. Discussions with key partners with respect to the systematic integration of key
CEU principles within the clinical education component of the undergraduate
nursing curriculum, particularly the final year of the program. Importantly this
recommendation is predicated upon agreement from individual health care
facilities which includes their assessment of the advantages and disadvantages
of the core principles and structural elements of the CEU model vis-a-vis their
own particular contexts.
2. Development of strategies for supporting registered nurses in working with
students in the clinical area which effectively meet nurses’ needs whilst, at the
same time, are resource efficient for universities.
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3. Further research to investigate the pattern of relationships between the key
factors that emerged from this study and their impact on outcomes for students,
registered nursing staff and patient care.
4. Further research to investigate, in more detail, the nature of ‘drivers’ and barriers
regarding the involvement of nursing staff in students’ clinical education, and the
impact of current changes in the nursing workforce upon nurses’ day-to-day
experience with students.
5. Further research to investigate academic and clinical understandings of the
nature of ownership within the context of undergraduate clinical education and
strategies for its implementation by academic and clinical partners.
5. Further longitudinal research to investigate the longer term effects of the CEU
model on the transition of new graduates to the nursing workforce. Such
research would also have the potential to inform current discussions regarding
recruitment of nurses and their retention within the nursing workforce.
8.3 Conclusions
This study makes a unique contribution to nursing education, specifically the clinical
education of undergraduate nursing students. Through a collaborative process involving
academic and clinical nursing staff, an innovative model of clinical education, the Clinical
Education Unit or CEU model, was developed, implemented and evaluated through two
iterations/phases of an action research process. A particular strength of the study was
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the inclusion of both students and registered nursing staff from CEU and non-CEU
environments throughout both phases.
Overall, the results of this study indicate that the CEU model enhanced the prac
experience for students and registered nurses working in the wards where students were
placed for their clinical practicums. Students and registered nurses in wards where the
CEU model was being used evaluated the prac experience more positively than did
students and registered nurses in wards where non-CEU models were being used. This
result was consistent across both phases of the study. Key factors that were found to be
important in facilitating these outcomes included the collaborative nature of the CEU
model and a sense of ownership by nursing staff of students’ clinical education. These
factors provided an operating framework which enabled the development of positive
learning environments in the wards where students were placed for prac.
Equally important were arrangements for the supervision of students’ practice which
involved ‘local’ clinical facilitation and the explicit inclusion of other nursing staff in the
ward. Further, continued support from the university to allow the clinical facilitators to
take a supernumary role when facilitating students, to provide staff development for
clinical education and to support staff on a day-to-day basis during the prac was also
important, if not essential. These factors, acting in combination, promoted enhanced
access to learning opportunities for students and improved learning outcomes for
students and staff.
Clinical education is a vital component of undergraduate nursing courses. This study has
demonstrated the positive impact of an innovative model of clinical education on the
clinical experience of students and registered nurses. The study has also identified a
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range of factors that, arguably, play a key role in achieving quality outcomes for students
and nursing staff. The findings suggest that positive outcomes are more likely to be
achieved with a multi-focal approach that emanates from, and is underpinned by, a
genuine collaborative relationship between key stakeholders. The factors that were
identified in this study as influencing the outcomes for students and nursing staff
advance the understanding of what may constitute an ‘ideal’ model of clinical education
for undergraduate nursing students. According to Christine Tanner (2002, 52),
“revolutionising clinical education is no longer an option – we must”. The findings of this
study provide evidence that is fundamental to progressing this imperative.
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APPENDIX 1
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Overview of the key findings from the Evaluating the Quality and Effectiveness of
Selected Models Pre-registration Clinical Education project (Nash et al. 1999)
This section presents an overview of the key findings from the study that was
undertaken earlier to evaluate four models of clinical facilitation and investigate “best
practice” in clinical education for pre-registration nursing students. The study was carried
out by Nash and co-workers as a follow-on from the National Review of Nursing
Education in the Higher Education Sector: 1994 and Beyond (Reid 1994). With respect
to clinical education, the National Review found that, from the dearth of literature
available, the educational models that may be most effective in achieving the
competencies expected of beginning level nursing practitioners were still not identified. It
was recommended that further work be undertaken to investigate issues related to
clinical education and subsequently several projects were implemented nationally
through funding made available under the National Priority (Reserve) Fund Scheme.
The models targeted in the study undertaken by Nash et al (1999) were those that were
being used most commonly for the provision of clinical education, specifically (1) Full-
time academic staff facilitating on a 1:8 basis; (2) Sessional staff facilitating on a 1:8
basis; (3) Seconded staff facilitating on a 1:8 basis; and (4) Preceptors facilitating on a
1:1 basis. Data collection involved second and third year students enrolled in the
Bachelor of Nursing (Pre-registration) course at QUT, clinical facilitators and preceptors,
and health care facility representatives. The key data collection strategies were as
follows:
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Focus groups
Focus groups were held with all constituents to explore the concepts of interest to the
study. Discussions with second/third year students enrolled in the Bachelor of Nursing
(Pre-registration) course (n=21) focused on their perceptions of the selected models,
clinical facilitation more generally and their perception of an “ideal” model. Discussions
with facilitators (n=56) and health care facility representatives (n=15) explored the
advantages and disadvantages of the selected models, areas of satisfaction and/or
concern regarding the provision of clinical learning experiences for students, and their
perceptions of an “ideal” model.
Surveys
In the context of their most recent clinical practicum, second and third year students
(n=119) were invited to complete a structured survey questionnaire to investigate their
opinions about a range of issues regarding clinical education. The questionnaire
incorporated a modified version of the Clinical Learning Environment Scale (Dunn and
Burnett 1995), a series of questions designed to ascertain students’ perceptions of their
learning outcomes in the clinical setting and an open question asking for students’
comment on any issues relating to clinical education. Clinical facilitators (n=47) were
invited to complete a similar questionnaire asking their opinions about the facilitation
model with which they had most recently been involved and the notion of “best practice”
in clinical education for pre-registration nursing students.
2.7.1 What the students said
Data from the questionnaire and the focus group discussions indicated strongly that
students enjoyed their clinical placements – regardless of the model of facilitation that
was used - and valued the opportunity to “put their theory into practice”. In particular,
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they valued the input from their clinical facilitators and felt that these people had played
a key role in their clinical learning and development. This is exemplified in the following
comments:
“Our group could not have learned as much without our facilitator”
“I think we learn faster and better when we have more good people with good
knowledge who can show us”
A number of students commented that their learning was enhanced by facilitators who
provided guidance, support and encouragement as this promoted students’ confidence
to “expand their boundaries” and think more critically about “what they were doing”.
There was a strongly held view that facilitators were “there” for students and, when
needed, provided an important “buffer zone” between students and health care facility
personnel, eg.
“You need your facilitator to back you up – or be a backup when you can’t get
something explained by your RN”
“I just had an RN who wouldn’t let me do any medications – so the morning I was
there it was just making beds and taking people to the toilet. When I told the
facilitator she intervened – I told her not to worry as I was going to theatre
anyway, but she was ready to stand up for me”.
In addition, facilitators were seen to have a more educational, or student-oriented, focus
in comparison to the work-oriented focus of the registered nursing staff. This was
particularly true in the case of full-time academic staff and sessional facilitators. Given
the supernumary status of students whilst in the clinical setting, the educational focus
was seen to be particularly important in terms of “grounding” the experiences undertaken
by students within a teaching-learning rather than service/job related framework, eg.
“The facilitator is aware that you are a student!”
“My facilitator was really good – she would ask me questions, and ask me to
explain what I was doing. Say with medications – she would ask me what it was
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for and if I didn’t know she would explain like more in depth than just looking up
the MIMS. It wasn’t just about whether I had given it”
Notwithstanding the strongly positive view that was held by students with regard to
clinical facilitation, two key issues were raised as concerns: (1) facilitators “knowing” the
organisation and (2) relationships with registered nursing staff.
Students highlighted the importance of clinical facilitators “knowing” the organisation in
which they were facilitating students’ clinical experience. This included not only a good
working knowledge of the hospital’s policies and protocols but also, and perhaps more
importantly, a thorough understanding of the local culture, politics and mores. It was also
clear that “being known” was as important as “knowing the organisation” in terms of
access to clinical learning opportunities as this often depended on “who” the facilitator
knew and/or to what extent the facilitator was “known”, eg.
“If they (facilitators) know the people in the hospital they can get you into certain
things … I went to theatre because the facilitator knew the surgeon”
“It’s tremendously important that the facilitator knows the organisation …the last
one I had worked there part-time and it was great. It saved a lot of pussy footing
around. We just walked in and were accepted. It worked really well. It was a
much easier prac.”
Indeed the use of health care facility staff as clinical facilitators/preceptors was seen to
be advantageous in terms of their superior “insider knowledge” regarding local issues of
importance, policies and procedures and the availability of particular clinical experiences
within the facility, eg.
“the facilitator that we had also worked in the ICU at the hospital and it was just
fantastic, you know, I mean they know the run of the hospital and the wards and
it just makes such a big difference”
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Students also raised the issue of relationships between health care facility staff. There
were two perspectives within this: (1) not “being welcome”, and (2) the attitudes of
registered nurse “buddies” and their impact on students’ clinical experience. The
following comments highlight these perceptions:
“when we met the CNC she said ‘I don’t particularly like university trained nurses
and I won’t put you with anyone under 2 years out of uni. Therefore one of you
will be redundant every day and your facilitator will have to stay with that
redundant person.”
“the ward staff were unenthusiastic – they just didn’t want us to be attached to
them at all. It was awful.”
“we could have learned a lot more if we could have followed the staff around and
watched what they were doing. But they didn’t want us there – in fact they started
out by saying that we couldn’t even take blood pressures”.
These problems were compounded by health care facility staff “not knowing” the
students and having unrealistic expectations of their performance:
“they assume that you know things and ask you to go and do something. When
you say ‘I haven’t done that’ they say ‘Oh, but you’re in third year – you should
know that”
“on the ward I was on, a lot of the RNs were not aware of our level because they
thought we were first years. Then the one I was with, first up, didn’t let us do any
meds because she believed we were in the old system where first years didn’t do
injections or tablets”
Students also drew attention to the issue of conflict between university-based clinical
facilitators and health care facility staff with regard to students’ clinical education and the
potential impact of this on the quality of their clinical experience:
“she (facilitator) made demands that were not practical. I was doing my first
medication round. It took 3 hours just because she wanted to do it her way, and
I’m afraid it didn’t go down at all well with the staff because 8 o’clock tablets were
not done until nearly 11 o’clock. She insisted I look up every single tablet- which
was correct- but I think then I should have done only one room instead of twelve”.
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2.7.3 What the facilitators said
Similarly to the students, there was a commonly held view from clinical facilitators about
the importance and value of clinical facilitation with respect to students’ learning in the
clinical setting. Regardless of the model used, all participants were strongly supportive of
the facilitator role and felt that the facilitator played an essential role in students’ clinical
education, eg.
“well I think it’s important because it really does provide students with specific
direction. Students get out there and you really assist them to make those links
between what they’re learning and what’s happening out there. I think we really
help them to structure their experience in useful ways”.
Going on from this, participants highlighted the importance of “someone” having an
educational focus and that the facilitator was often in the best position to help students
bridge the theory-practice gap, eg.
“I think we are useful, although the staff might be more useful at teaching them
the tricks of the trade. I think we can make them think more in depth about what
they’re doing”.
“I think they “the RNs” think that we’re from the university and know the theory
behind things. I mean most RNs know the theory too but the students are more
comfortable if we do it, so they come to us rather than the RNs when there’s a
problem”.
The notion expressed in the above comments was especially true in the case of full-time
academic and sessional staff who both felt that they offered students the benefit of
working with facilitators who had a particular focus on teaching and learning, a good
understanding of the curriculum and, hence, the ability to more explicitly “make the links”
between theory and practice for students.
In the discussions regarding particular models of clinical facilitation the facilitators had a
range of comments about each model in particular. This was a little different to the
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students who, perhaps unsurprisingly, tended to comment rather more globally about
clinical facilitation in general. Comments made by the facilitators with respect to each of
the four models targeted in this study are summarised below:
Full-time academic staff
Particular advantages of using full-time academic staff for clinical facilitation were
perceived to include -
• enhanced synthesis of theoretical, conceptual and practical knowledge in the clinical
environment, and
• collaboration between the university and health care facilities
However, a major disadvantage associated with this model related to the pressure of
balancing a “prac” workload with other academic commitments. Full-time staff felt that
they were undertaking “two workloads” and had insufficient time to do either job
effectively.
Sessional staff
Particular advantages of using sessional staff for clinical facilitation were perceived to
include -
• a focus on assisting students’ integration of theory within the clinical setting. It was
felt that through their employment by the university, these facilitators had a close
relationship with the School and a good understanding of the theory and clinical
subjects in the curriculum.
• the provision of “independent” learning support in the clinical setting. Sessional staff
perceived that they were not “hampered“ by hospital politics or “internal intrigues”
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and thus were able to retain students as their primary focus throughout the
practicum.
There were, however, some important disadvantages associated with this model and
these included:
• not being able to give students “enough time” individually – this was related to having
students spread across different ward areas and trying to meet the individual needs
of eight students.
• feeling isolated when out on prac. Many of the sessional facilitators raised the issue
of support whilst out in the field, and expressed concern about feeling unsupported –
particularly when they were working on a sole facilitator basis within a health care
facility, ie. without any other facilitators working there at the same time.
• feeling a little in “no man’s land” in the clinical setting. Notwithstanding the perceived
value associated with being able to be somewhat “independent” in the provision of
learning support, there was a strong concern expressed about being “caught in the
middle of things” or “feeling neither a university nor health care facility person” and
quite stressed as a result.
Seconded staff
Similarly to the full-time and sessional staff, the seconded facilitators felt that they made
an important contribution to students’ clinical education. Particular advantages of using
sessional staff for clinical facilitation were perceived to include –
• “superior” knowledge of the health care facility and/or specific clinical area in which
students were placed for clinical experience
• their strong profile as experienced practitioners
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• motivation to participate in students’ clinical experience and share their knowledge
and expertise with the “nurses of the future”
• being better able - than university based facilitators - to help the students feel part of
the clinical team
Disadvantages perceived by this group with respect to their clinical facilitation role
included:
• feeling somewhat unprepared for “taking on” the role and “doing it justice” - this was
regardless of the orientation and pre-briefing sessions offered by the university
• perceived difficulties in communicating easily with staff in the university - leading to
feelings of frustration and “isolation”
• the pressure of role conflict between workplace needs and the students’ educational
needs. There was concern expressed over the “dual role” carried by these
facilitators. Because they were key personnel in their work areas they were not
infrequently called upon by staff to help them out with clinical duties. Balancing their
strong work team ethic with a keenly felt responsibility to the students put them in a
position of “divided loyalties”. The feeling that they were “abandoning” their work
colleagues in favour of the students was a source of great stress amongst these
facilitators.
Preceptors
The preceptors believed strongly that they, and the students, benefited from the
continuity of the preceptor/student relationship over the course of the clinical placement.
Working collaboratively on a 1:1 basis offered the preceptor and student time to develop
mutual understanding, confidence and trust with each other. As a result, the preceptors
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felt that students were more likely to ask questions and seek advice on patient care and
matters of policy/procedure. Other advantages of using preceptors for clinical
facilitation were perceived to include -
• closer exposure, than other models, of students to the reality of the workplace. By
undertaking a full range of shifts and sharing a full caseload, preceptors felt that students
had gained a greater understanding of the “real world” of nursing practice.
• students being part of the team. Preceptors commented that they were able to involve
their students “completely” in all levels of patient care. In most instances this
involvement resulted in students being “ready” to accept responsibility for a patient load.
There were, however, several important disadvantages perceived by this group with
respect to their clinical facilitation role and these included:
• the additional workload required. Consistent with the structure of this model the
preceptors continued to carry their normal caseloads. The precepted students were
directly involved in the provision of that care, but the preceptors commented strongly
about the additional demands on their time - especially in the early part of the practicum.
• The need for “time out” from students. The close 1:1 working relationship associated
with this model not infrequently led to feelings of interpersonal “burnout” and the need to
be “student free” for a period of time. This was particularly true in the case of preceptors
who undertook this role on a regular basis.
• lack of recognition for their contribution to students’ clinical education. The lower
“visibility” of preceptorship vis-à-vis other models of facilitation coupled with the relative
lack of tangible rewards caused some preceptors to comment about feeling undervalued
for the time and energy that they put in the “doing a good job”.
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2.7.3 What the health care facility representatives said
Similarly to the students and clinical facilitators, there was a strongly held view from
health care facility representatives about the importance and value of students’
experience in the clinical setting. However, they expressed a deal of concern with
respect to the perceived effectiveness of three facilitation models, specifically the usage
full-time staff, sessional staff and seconded staff. Their concerns centred around (1) the
unfamiliarity of full-time academics and sessional staff with organisational policies and
procedures, (2) the “unavailability” of clinical facilitators, (3) issues related to students’
acculturation to the “real world” of nursing, and (4) the importance of the clinical nurse
“buddies”.
In the opinion of health care facility representatives, full-time academics and sessional
staff were not always familiar with hospitals’ administration and were perceived to
provide information to students that could be in conflict with a particular hospital’s
policies. This was felt to be confusing for students and a major concern for hospital
administration. It was also a source of significant frustration in that the time spent in
trying to bring full-time and sessional staff “up to speed” was perceived to be an
unnecessary and, sometimes, unacceptable impost on health care facility staff.
Another issue that was keenly felt by this group was the perceived “unavailability” or lack
of visibility of clinical facilitator working on a 1:8 basis, ie. full-time academics, sessional
staff and seconded staff. With a ratio of 8 students to 1 facilitator, the facilitator was
restricted in the amount he/she could spend with each student individually. This was
magnified by the placement of “sub groups” of students in geographically distant
wards/clinical areas. The impact of this was on clinical staff in the areas where students
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were placed, with students left reliant on these registered nurses to supervise and
supplement their learning needs. This issue is captured in the following comments:
“a facilitator can’t give them the education that they need – they’ve got eight
students spread over two different wards”
“I seldom see the facilitator – everyone tells me he/she is in the other ward”
“the facilitator doesn’t spend much time actually providing clinica instruction – this
is left to the ward staff to do”
The issue of students’ acculturation to the “real world” of nursing was also raised as a
concern by this group of participants. There was a very strong, and commonly held view
about the importance of students being able to “fit in” to the culture of an organisation.
Being a part of the nursing team was perceived to be one of the keys to achieving this.
Consequently, one of the concerns with the usage of university based models of
facilitation and, to some extent, the seconded model was that these models tended to
keep the students ”separate” from the mainstream of the wards, not readily identifiable
as part of the team and, consequently, not integrated effectively into the culture of the
organisation.
In addition to the foregoing, the health care facility representatives drew particular
attention to the major contribution made by clinical nurses in the ward areas to students’
clinical education. Whether students were “buddied” with different registered nurses, or
preceptored in a more formal way with one particular nurse, it was felt that students
benefited significantly from the opportunity to work alongside a practicing clinician, eg.
“working alongside someone they (students) get that constant role modelling –
constant reinforcement from a practising professional”
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However they also felt that there was little incentive for nurses to take on the extra
responsibility associated with a preceptorship role and were concerned about the
additional impact it could have on staff’s workload.
2.7.4 The “ideal” model?
All participant groups in this study were asked about their opinions regarding what might
be called an “ideal” model of clinical facilitation. Given the range of views expressed
about clinical facilitation it was, perhaps, not surprising that there was not a clear
consensus on this issue. However, a number of themes emerged from participants’
comments and these included:
• the importance of clinical facilitation - generally - for achieving learning outcomes;
• a positive learning environment ;
• familiarity of clinical facilitators with and within the clinical learning environment;
• the role of clinical nurses or “buddies” in students’ learning;
• adequate preparation, and ongoing support for facilitators to enable students’
integration of theory and practice, appropriate assessment of their performance and
enhancement of learning opportunities;
• continuity in the placement of students to reduce the time spent in “settling in“ to new
organizations thus maximizing the time available for them to meet their clinical
objectives and develop the required professional competencies; and
• the importance of students feeling part of the clinical team.
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APPENDIX 2
205
MODELS OF CLINICAL EDUCATION PROJECT
PHASE 1
FOCUS GROUP SCHEDULE CEU PARTICIPANTS
Preamble:
As part of evaluating the use of particular models of clinical education for the
undergraduate nursing students, your input to this discussion is highly valued. In
particular we are seeking your comments about the Clinical Education Unit (CEU)
model of clinical education that you have experienced during the recent practicum.
Trigger questions:
Thinking back over the most recent practicum:
1. In general, what are your comments about the CEU model of clinical education
that was used?
2. What are the reasons for your comments?
3. How does your most recent experience compare with previous experiences?
What are the similarities and/or differences?
4. What suggestions do you have for improving the CEU model of clinical
education? What are the reasons for your suggestions?
5. How would you describe an ‘ideal’ model of clinical education?
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PHASE 1
FOCUS GROUP SCHEDULE NON-CEU PARTICIPANTS
Preamble:
As part of evaluating the use of particular models of clinical education for the
undergraduate nursing students, your input to this discussion is highly valued. In
particular we are seeking your comments about the sessional and/or secondment
models of clinical education that you have experienced during the recent practicum.
The sessional model is one where the facilitator is employed by QUT, whereas the
secondment model is one where the facilitator is a registered nurse who is seconded to
QUT from the health care facility in which he/she is employed.
Trigger questions:
Thinking back over the most recent practicum:
4. In general, what are your comments about the CEU model of clinical education
that was used?
5. What are the reasons for your comments?
6. How does your most recent experience compare with previous experiences?
What are the similarities and/or differences?
4. What suggestions do you have for improving the CEU model of clinical
education? What are the reasons for your suggestions?
4. How would you describe an ‘ideal’ model of clinical education?
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APPENDIX 3
208
PHASE 2
FOCUS GROUP SCHEDULE CEU PARTICIPANTS
Preamble
This focus group discussion is part of a quality improvement project that is focussing on
the clinical education of pre-registration nursing students. It is being undertaken jointly
by staff from the School of Nursing, QUT, and the Royal Brisbane Hospital.
The project aims to further improve the clinical education/facilitation arrangements for
pre-registration nursing students, enhance the learning outcomes achieved by students
and facilitate the transition of new graduate nurses into the workforce.
In this discussion we are particularly interested in your views about the CEU model of
clinical education. Your input to the discussion is invaluable, and we appreciate you
taking the time to participate.
Schedule
Thinking about the (QUT) clinical practicum that has just been completed, ie. Clinical
Practice 4, what are your comments about:
1. The overall effectiveness of the CEU model of clinical education/

supervision?
Important: probe the reasons for participants’ statements, eg.
Why does it work/not work?
What is it that makes it work/not work?
How is this different to other models of clinical education?
2. The key strengths/advantages of the CEU model?

What specifically works, if anything?
209
3. The key weaknesses/disadvantages of the CEU model?
What specifically doesn’t work, if anything?
4. The overall effectiveness of the clinical supervision/education given by

nursing staff during the practicum?
Important: probe participants’ perceptions here, eg.

What made this easy? hard? why?
Particular things that made it easy?
Particular difficulties encountered?
How is this different – if at all – to other models?
5. The overall effectiveness of student interaction with nursing staff during

the practicum?
Important: probe participants’ responses here, eg.

What are the reasons for their statements?
6. The overall effectiveness of the assessment of students’ performance

during the practicum?

7. Suggestions for further improvement?
210
PHASE 2
FOCUS GROUP SCHEDULE NON- CEU PARTICIPANTS
Preamble
This focus group discussion is part of a quality improvement project that is focussing on
the clinical education of pre-registration nursing students. It is being undertaken jointly
by staff from the School of Nursing, QUT, and the Royal Brisbane Hospital.
In this discussion we are particularly interested in your views about the sessional and
seconded models of clinical education. Your input to the discussion is invaluable, and we
appreciate you taking the time to participate.
Schedule
Thinking about the (QUT) clinical practicum that has just been completed, ie. Clinical
Practice 4, what are your comments about:
7. The overall effectiveness of the sessional/seconded (as relevant) model of

clinical education/ supervision?
Why does it work/not work?
What is it that makes it work/not work?
How is this different to other models of clinical education?
8. The key strengths/advantages of the sessional/seconded (as relevant)

model?
What specifically works, if anything?
211
9. The key weaknesses/disadvantages of the sessional/seconded (as
relevant) model?
What specifically doesn’t work, if anything?
10. The overall effectiveness of the clinical supervision/education given by

nursing staff during the practicum?
Important: probe participants’ perceptions here, eg.

What made this easy? hard? why?
Particular things that made it easy?
Particular difficulties encountered?
11. The overall effectiveness of student interaction with nursing staff during
the practicum?

12. The overall effectiveness of the assessment of students’ performance

during the practicum?

7. Suggestions for further improvement?
212
APPENDIX 4
213
CONFIDENTIAL CEU - STUDENTS
Quality of Prac Experience Questionnaire

Phase 1
The purpose of the following questionnaire is to find out your opinions of selected
models of clinical education. You are asked to consider your most recent clinical
practicum and base your responses on that practicum. Please complete each question
by circling the one number which best describes your opinion. There are no right or
wrong answers - we are interested in your opinions regarding each statement.
Please be assured that the findings from this questionnaire will contain no reference to
identifiable clinical groups. All participants will remain anonymous and information
received will be STRICTLY CONFIDENTIAL.
SECTION 1
Thinking about your most recent clinical practicum (Clinical Practice 5), please
answer questions 1-23 by choosing the response that most accurately reflects
your view.
Strongly Strongly
Agree Disagree
1. All nurses on the unit, from the CNC to the newest

1 2 3 4 5
student, felt part of the nursing team
2. In general, ward staff helped nursing students to gain the 1 2 3 4 5

widest possible experience
3. The Clinical Associate (CA) put a lot of effort into teaching 1 2 3 4 5

nursing students
4. This was a good unit for nursing students to learn about 1 2 3 4 5

clinical-practice
5. It was always easy to know the standard of performance 1 2 3 4 5

6. The CA made a real effort to understand difficulties 1 2 3 4 5

students' might be having with their work
7. In general, undertaking "prac" on this unit motivated 1 2 3 4 5

students to do their best work
8. The Clinical Partners/buddy nurses attached a great deal 1 2 3 4 5

of importance to the learning needs of nursing students
9. It was often hard to discover what the ward staff expected

1 2 3 4 5
of students during this practicum
10. This experience has made me more eager to become a 1 2 3 4 5

Registered Nurse
214
Strongly Strongly
Agree Disagree
11. I felt that I was able to make a useful contribution to the 1 2 3 4 5

nursing team on the unit
12. I usually had a clear idea of where I was going and what 1 2 3 4 5
was expected from me during this practicum
13. This practicum helped me to further develop my problem- 1 2 3 4 5

solving skills
14. The ward staff put a lot of effort into commenting on my 1 2 3 4 5

performance
15. This practicum helped me to further develop my 1 2 3 4 5

communication skills
16. I generally received constructive feedback on how I was 1 2 3 4 5

going
17. This practicum helped me to further develop my technical 1 2 3 4 5

kills
18. On the whole, I was clear about what I was doing well and 1 2 3 4 5
what I needed to improve
19. This practicum helped me to further develop my reflective 1 2 3 4 5

skills
20. My performance was assessed in an open, consultative 1 2 3 4 5

way

understanding of concepts and principles of nursing
practice
22. This "prac" helped me to further develop my 1 2 3 4 5

organisation/time management skills
23. Overall, I feel that this practicum was a worthwhile 1 2 3 4 5

learning experience
ANY SPECIFIC COMMENTS YOU WOULD LIKE TO MAKE?
215
SECTION 2:
Please respond to the following questions regarding your most recent clinical
practicum (ie. Clinical Practice 5)
29. What do you think are the best aspects of the CEU model of clinical education?
30. What aspects of the CEU model are most in need of improvement?
31. How did this practicum compare to your previous clinical experiences?
32. What are your suggestions for improving the CEU model of clinical education?
216
33. In your opinion, what are the key components of a high quality model of clinical education?
SECTION 3:
Please complete the following questions which ask for some details about
yourself (circle the appropriate response).
34. What is your gender? Male

Female
35. What is your age? 17-20 yrs

21-25 yrs
26-30 yrs
31-40 yrs
40+ yrs
36. What is your study mode? Full-time

Part-time
37. Year level in the course? Year 2

Year 3
THANK YOU FOR YOUR PARTICIPATION
217
CONFIDENTIAL Non CEU - STUDENTS

Phase 1
models of clinical education. You are asked to consider your most recent clinical
practicum and base your responses on that practicum. Please complete each question
by circling the one number which best describes your opinion. There are no right or
wrong answers - we are interested in your opinions regarding each statement.
The clinical facilitation during your most recent practicum was provided by (please circle one):
1. A Registered Nurse who normally works in the hospital where you did your "prac" (ie. a
seconded facilitator)
2. A QUT Clinical Facilitator
SECTION 1
Thinking about your most recent clinical practicum (Clinical Practice 5),
please answer questions 1-23 by choosing the response that most accurately
reflects your view.
Strongly Strongly
Agree Disagree
1. All nurses on the unit, from the CNC to the newest student,
1 2 3 4 5
felt part of the nursing team

3. The clinical facilitator put a lot of effort into teaching 1 2 3 4 5

nursing students

clinical-practice
5. It was always easy to know the standard of performance 1 2 3 4 5

6. The clinical facilitator made a real effort to understand 1 2 3 4 5

difficulties students' might be having with their work
7. In general, undertaking "prac" on this unit motivated 1 2 3 4 5
students to do their best work
8. The registered nurse “buddies” attached a great deal of 1 2 3 4 5

importance to the learning needs of nursing students
218
Strongly Strongly
Agree Disagree
9. It was often hard to discover what the ward staff expected

1 2 3 4 5
of students during this practicum
10. This experience has made me more eager to become a 1 2 3 4 5

Registered Nurse
11. I felt that I was able to make a useful contribution to the 1 2 3 4 5

nursing team on the unit
12. I usually had a clear idea of where I was going and what 1 2 3 4 5
was expected from me during this practicum
13. This practicum helped me to further develop my problem- 1 2 3 4 5
solving skills
14. The ward staff put a lot of effort into commenting on my 1 2 3 4 5

performance

communication skills
16. I generally received constructive feedback on how I was 1 2 3 4 5

going
17. This practicum helped me to further develop my technical 1 2 3 4 5

kills
18. On the whole, I was clear about what I was doing well and 1 2 3 4 5
what I needed to improve
19. This practicum helped me to further develop my reflective 1 2 3 4 5

skills
20. My performance was assessed in an open, consultative way 1 2 3 4 5

understanding of concepts and principles of nursing
practice
22. This "prac" helped me to further develop my 1 2 3 4 5

organisation/time management skills
23. Overall, I feel that this practicum was a worthwhile learning 1 2 3 4 5

experience
219
SECTION 2:
Please respond to the following questions regarding your most recent clinical
practicum (ie. Clinical Practice 5).
29. What do you think are the best aspects of the model of clinical facilitation that you
experienced in CP5?
30. What aspects of this facilitation model are most in need of improvement?
31. How did your CP5 practicum compare to your previous clinical experiences?
32. What are your suggestions for improving the model of clinical facilitation that you
experienced in CP5?
220
33. In your opinion, what are the key components of a high quality model of clinical
education?
SECTION 3:

Female

21-25 yrs
26-30 yrs
31-40 yrs
40+ yrs
36. What is your study mode? Full-time

Part-time
37. Year level in the course? Year 2

Year 3
221
APPENDIX 5
222
CONFIDENTIAL CEU - REGISTERED NURSES

Phase 1
models of clinical education. You are asked to consider the most recent clinical
practicum in your ward and base your responses on that practicum. Please complete
each question by circling the one number which best describes your opinion. There are
no right or wrong answers - we are interested in your opinions regarding each
statement.
SECTION 1
Thinking about the most recent clinical practicum in your ward, please
answer questions 1-19 by choosing the response that most accurately reflects
your view.
Strongly Strongly
Agree Disagree
1 2 3 4 5

3. The Clinical Associate put a lot of effort into teaching 1 2 3 4 5

nursing students
4. There was a great deal of importance attached to the 1 2 3 4 5

learning needs of nursing students
5. Nursing students were regarded as workers rather than as 1 2 3 4 5

learners

clinical-practice
7. It was always easy to know what was expected of students 1 2 3 4 5
8. I felt adequately prepared to partner/“buddy” a student 1 2 3 4 5
9. I knew who to talk to if I needed help in working with a 1 2 3 4 5

student
10. I enjoy working with students 1 2 3 4 5
223
Strongly Strongly
Agree Disagree
11. There was a lot of effort put in to commenting on students’ 1 2 3 4 5

performance
12. I knew what students needed to do when they were in the

1 2 3 4 5
ward
13. Working with students is a positive experience 1 2 3 4 5
14. Students are there to work rather than learn 1 2 3 4 5
15. Students getting the most out of prac requires commitment 1 2 3 4 5

from them
16. I understand the model of clinical facilitation being used on 1 2 3 4 5

my ward
17. Working with students is too time consuming 1 2 3 4 5
18. On the whole, I felt that this practicum was a good 1 2 3 4 5

experience
SECTION 2:
Please respond to the following questions regarding the most recent clinical
practicum in your ward.
20. What do you think are the best aspects of the model of clinical facilitation that was
used?
224
22. How did this most recent experience compare with previous clinical practicums?
23. What are your suggestions for improving the model of clinical facilitation that was
used?
24. In your opinion, what are the key components of an “ideal” model of clinical
education?
225
SECTION 3:

Female

21-25 yrs
26-30 yrs
31-40 yrs
40+ yrs
27. Years of clinical experience? < 5 yrs

5-10 yrs
> 10 yrs
226
CONFIDENTIAL Non-CEU REGISTERED NURSES

Phase 1
models of clinical education. You are asked to consider the most recent clinical
practicum in your ward and base your responses on that practicum. Please complete
each question by circling the one number which best describes your opinion. There are
no right or wrong answers - we are interested in your opinions regarding each
statement.
The clinical facilitation during your most recent practicum was provided by (please circle one):
3. A Registered Nurse who is employed in your organisation, ie. a seconded facilitator
4. A QUT Clinical Facilitator, eg. a sessional facilitator
SECTION 1
Thinking about the most recent clinical practicum in your ward, please answer
questions 1-19 by choosing the response that most accurately reflects your view.
Strongly Strongly
Agree Disagree
1 2 3 4 5

3. The facilitator put a lot of effort into teaching nursing 1 2 3 4 5

students
4. There was a great deal of importance attached to the 1 2 3 4 5

learning needs of nursing students
5. Nursing students were regarded as workers rather than as 1 2 3 4 5

learners

clinical-practice
7. It was always easy to know what was expected of students 1 2 3 4 5
8. I felt adequately prepared to “buddy” a student 1 2 3 4 5
9. I knew who to talk to if I needed help in working with a 1 2 3 4 5

student
227
Strongly Strongly
Agree Disagree
10. I enjoy working with students 1 2 3 4 5
11. There was a lot of effort put in to commenting on students’ 1 2 3 4 5

performance
12. I knew what students needed to do when they were in the

1 2 3 4 5
ward
13. Working with students is a positive experience 1 2 3 4 5
14. Students are there to work rather than learn 1 2 3 4 5
15. Students getting the most out of prac requires commitment 1 2 3 4 5

from them
16. I understand the model of clinical facilitation being used on 1 2 3 4 5

my ward
17. Working with students is too time consuming 1 2 3 4 5
18. On the whole, I felt that this practicum was a good 1 2 3 4 5

experience
SECTION 2:
Please respond to the following questions regarding the most recent clinical
practicum in your ward.
20. What do you think are the best aspects of the model of clinical facilitation that was
used?
228
22. How did this most recent experience compare with previous clinical practicums?
23. What are your suggestions for improving the model of clinical facilitation that was
used?
24. In your opinion, what are the key components of an “ideal” model of clinical
education?
229
SECTION 3:
Female

21-25 yrs
26-30 yrs
31-40 yrs
40+ yrs
27. Years of clinical experience? < 5 yrs

5-10 yrs
> 10 yrs
230
APPENDIX 6
231
CEU students
School of Nursing
Centre for Nursing Research

Phase 2
Information for participants
About the project

This project is being undertaken as part of the School of Nursing’s ongoing quality
improvement program (teaching and learning) for the Bachelor of Nursing course. The
project focuses on the implementation and evaluation of models of clinical
education/supervision for pre-registration nursing students.
Purpose of the project

Participant involvement
Your participation in this part of the project will involve completion of the attached
questionnaire. Return of a completed questionnaire will be taken as an indication of your
consent to participate in the survey. All participants will remain anonymous and
information received will remain strictly confidential.
Questions or concerns
You are welcome to contact the Chief Investigator (see details below) regarding any
concerns or questions you may have about this project. Should you have any concerns
relating to the ethical conduct of this project, please feel free to contact the Queensland
University of Technology’s Registrar on Ph 3863 1056.
Project Leader
Robyn Nash
Director of Undergraduate Studies
School of Nursing, QUT
Ph 3864 3843 or email r.nash@qut.edu.au
232
Section 1
Please indicate your responses to the following statements by circling the one number
that best represents your opinion. There are no right or wrong answers - we are
interested in your general opinions about the issues.
Strongly Agree Disagree Strongly

Thinking about your most recent clinical practicum: agree disagree
1. It was easy to feel part of the nursing team 1 2 3 4
2. In general, students were taken seriously by staff in the 1 2 3 4

ward/area
3. There were plenty of opportunities to practise different 1 2 3 4

skills
4. During this prac it as easy to know where I was going and 1 2 3 4

what was expected
5. There was a strong sense of camaraderie between 1 2 3 4

students and staff in the ward/area
6. I could ask as many questions as I wanted to 1 2 3 4
7. It was easy to feel like a burden on staff in this ward/area 1 2 3 4
8. In general, I felt well supported by staff during this prac 1 2 3 4
9. During this prac I found it hard to get enough practice on 1 2 3 4

different skills
10. I was given opportunities to be involved in making 1 2 3 4

decisions about patient care
11. As a result of this prac I am confident about my ability to 1 2 3 4

reflect critically on nursing care
12. It was hard to get feedback on progress during this prac 1 2 3 4
13. I was encouraged to reflect on issues that arose during 1 2 3 4

the prac
14. It was easy to get assistance in dealing with/undertaking 1 2 3 4

with new situations
15. I was given opportunities to take some responsibility for 1 2 3 4

patient care in this ward/area
16. My critical thinking skills really improved during this prac 1 2 3 4
17. During this prac I felt well supported in undertaking new 1 2 3 4

skills
233
agree disagree
18. This prac has made me keener than ever to become a 1 2 3 4

registered nurse
19. It was hard to discover what was expected of me during 1 2 3 4

this prac
20. This prac has really sharpened my time management 1 2 3 4

skills
20. During this prac staff put a lot of time in commenting on 1 2 3 4

my work
21. As a result of this prac, I am confident about my ability to 1 2 3 4

plan patient care
22. My problem solving skills really improved during this prac 1 2 3 4
23. Overall, I am satisfied with the quality of this prac 1 2 3 4
Section 2 - About you
What is your gender? What do you identify as your ethnic background?
• Female 1
• Male 2
What is your age? Previous experience in nursing? Yes

(If yes, please specify)
No
• < 20 years 1
• 21-29 years 2 Type of experience ……………………….
• 30-39 yrs 3
• 40-49 years 4
• > 50 years 5 Years of experience ………………………
In what clinical area were you placed for CP4?

(please specify ward and health care facility)
Section 3 – Other comments

Are there any comments that you would like to make?
THANK YOU FOR YOUR TIME IN COMPLETING THIS QUESTIONNAIRE
234
NON-CEU STUDENTS
School of Nursing

Phase 2
Information for participants
About the project
You are welcome to contact the Chief Investigator (see details below) regarding any
relating to the ethical conduct of this project, please feel free to contact the Queensland
University of Technology’s Registrar on Ph 3863 1056.
Project Leader
Robyn Nash
235
Section 1
Please indicate your responses to the following statements by circling the one number
that best represents your opinion. There are no right or wrong answers - we are
interested in your general opinions about the issues.

Thinking about your most recent clinical practicum: agree disagree
1. It was easy to feel part of the nursing team 1 2 3 4
2. In general, students were taken seriously by staff in the 1 2 3 4

ward/area
3. There were plenty of opportunities to practise different 1 2 3 4

skills
4. During this prac it as easy to know where I was going and 1 2 3 4

what was expected
5. There was a strong sense of camaraderie between 1 2 3 4

students and staff in the ward/area
6. I could ask as many questions as I wanted to 1 2 3 4
7. It was easy to feel like a burden on staff in this ward/area 1 2 3 4
8. In general, I felt well supported by staff during this prac 1 2 3 4
9. During this prac I found it hard to get enough practice on 1 2 3 4

different skills
10. I was given opportunities to be involved in making 1 2 3 4

decisions about patient care
11. As a result of this prac I am confident about my ability to 1 2 3 4

reflect critically on nursing care
12. It was hard to get feedback on progress during this prac 1 2 3 4
13. I was encouraged to reflect on issues that arose during 1 2 3 4

the prac
14. It was easy to get assistance in dealing with/undertaking 1 2 3 4

with new situations
15. I was given opportunities to take some responsibility for 1 2 3 4

patient care in this ward/area
16. My critical thinking skills really improved during this prac 1 2 3 4
17. During this prac I felt well supported in undertaking new 1 2 3 4

skills
236
agree disagree
18. This prac has made me keener than ever to become a 1 2 3 4

registered nurse
19. It was hard to discover what was expected of me during 1 2 3 4

this prac
20. This prac has really sharpened my time management 1 2 3 4

skills
20. During this prac staff put a lot of time in commenting on 1 2 3 4

my work
21. As a result of this prac, I am confident about my ability to 1 2 3 4

plan patient care
22. My problem solving skills really improved during this prac 1 2 3 4
23. Overall, I am satisfied with the quality of this prac 1 2 3 4
Section 2 - About you

What is your gender? What do you identify as your ethnic background?
• Female 1
• Male 2
What is your age? Previous experience in nursing? Yes

(If yes, please specify)
No
• < 20 years 1
• 21-29 years 2 Type of experience ……………………….
• 30-39 yrs 3
• 40-49 years 4
• > 50 years 5 Years of experience ………………………
In what clinical area were you placed for CP4?

(please specify ward and health care facility)
Section 3 – Other comments
Are there any comments that you would like to make?
237
APPENDIX 7
238
CEU REGISTERED NURSES
School of Nursing

Phase 2
INFORMATION FOR PARTICIPANTS
About the project


You are welcome to contact the Project Leader (see details below) regarding any
relating to the ethical conduct of this project, please feel free to contact the Secretary of
the University Human Research Ethics Committee on Ph 3864 2902.
Project Leader
Robyn Nash
239
Section 1
Please indicate your responses to the following statements by circling the one number that best represents
your opinion. There are no right or wrong answers - we are interested in your general opinions about current
arrangements (or models) for the supervision of pre-registration students on clinical “prac”.
Thinking about the most recent (QUT) clinical practicum Strongly Agree Disagree Strongly
in your ward/clinical area (3rd year students): agree disagree
1. Staff in this area found it easy to include students as 1 2 3 4

2. In general, staff knew what was expected of them 1 2 3 4

during the prac
3. There were plenty of opportunities for students to 1 2 3 4

practise different skills
4. Staff in this ward/clinical area felt well prepared for 1 2 3 4

their role in supporting students during this prac
5. There was a real sense of camaraderie between 1 2 3 4

students and staff in this ward/area
6. In general, staff in this ward/clinical area were clear 1 2 3 4

about students’ learning needs
7. Staff in this ward/clinical area really value having 1 2 3 4

students on clinical practicum
8. Giving students feedback on their progress was a 1 2 3 4

priority in this ward/clinical area
9. It was easy to know what students were aiming to 1 2 3 4

achieve during the prac
10. In general, staff in this ward/clinical area felt well 1 2 3 4

supported in working with students during this prac
11. Staff felt like they were “on their own” in assisting 1 2 3 4
students during this prac
12. It was hard to know what students were “there for” 1 2 3 4

during this prac
13. Commenting on students’ work takes too much time 1 2 3 4

for staff
14. Staff felt valued for their contribution to students’ 1 2 3 4

learning
15. Overall, I am satisfied with the clinical supervision 1 2 3 4

arrangements that operated during this prac
240
Section 2
To help us better understand your views about clinical supervision for pre-registration
students, we also ask for your responses to the following questions.
In thinking about the arrangements (or model) of clinical supervision in your ward/clinical
area, ie. CEU (Clinical Education Unit):
1. What do you think works well about this model?
2. What do you think doesn’t work well about this model?
3. What suggestions would you like to make for further improving the arrangements
for clinical supervision in your area?
4. Any further comments?
5. What is your gender? Male Female
6. What is your age? 17-20 yrs 21-25 yrs 26-30 yrs

31-40 yrs 40+ yrs
7. Years of clinical experience? <5 yrs 5-10 yrs >10 yrs
241
NON-CEU REGISTERED NURSES
School of Nursing

Phase 2
INFORMATION FOR PARTICIPANTS
About the project


You are welcome to contact the Project Leader (see details below) regarding any
relating to the ethical conduct of this project, please feel free to contact the Secretary of
the University Human Research Ethics Committee on Ph 3864 2902.
Project Leader
Robyn Nash
242
Section 1
Please indicate your responses to the following statements by circling the one number that best represents
your opinion. There are no right or wrong answers - we are interested in your general opinions about current
arrangements (or models) for the supervision of pre-registration students on clinical “prac”.
Thinking about the most recent (QUT) clinical practicum Strongly Agree Disagree Strongly
in your ward/clinical area (3rd year students): agree disagree
1. Staff in this area found it easy to include students as 1 2 3 4

2. In general, staff knew what was expected of them 1 2 3 4

during the prac
3. There were plenty of opportunities for students to 1 2 3 4

practise different skills
4. Staff in this ward/clinical area felt well prepared for 1 2 3 4

their role in supporting students during this prac
5. There was a real sense of camaraderie between 1 2 3 4

students and staff in this ward/area
6. In general, staff in this ward/clinical area were clear 1 2 3 4

about students’ learning needs
7. Staff in this ward/clinical area really value having 1 2 3 4

students on clinical practicum
8. Giving students feedback on their progress was a 1 2 3 4

priority in this ward/clinical area
9. It was easy to know what students were aiming to 1 2 3 4

achieve during the prac
10. In general, staff in this ward/clinical area felt well 1 2 3 4

supported in working with students during this prac
11. Staff felt like they were “on their own” in assisting 1 2 3 4
students during this prac
12. It was hard to know what students were “there for” 1 2 3 4

during this prac
13. Commenting on students’ work takes too much time 1 2 3 4

for staff
14. Staff felt valued for their contribution to students’ 1 2 3 4

learning
15. Overall, I am satisfied with the clinical supervision 1 2 3 4

arrangements that operated during this prac
243
Section 2
To help us better understand your views about clinical supervision for pre-registration
students, we also ask for your responses to the following questions.
In thinking about the arrangements (or model) of clinical supervision in your ward/clinical
area, eg. sessional/casual facilitator, seconded facilitator:
5. What do you think works well about this model?
6. What do you think doesn’t work well about this model?
7. What suggestions would you like to make for further improving the arrangements
for clinical supervision in your area?
8. Any further comments?
5. What is your gender? Male Female
6. What is your age? 17-20 yrs 21-25 yrs 26-30 yrs

31-40 yrs 40+ yrs
7. Years of clinical experience? <5 yrs 5-10 yrs >10 yrs
244
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Queensland University of Technology

‘Collaboration in clinical education: Development, implementation and

Models of clinical education

Clinical learning environment

Clinical learning outcomes

Quality of clinical experience and undergraduate students

Background to the study

Clinical education is a vital component of the undergraduate nursing curriculum. ‘Real

commitment of universities to produce competent graduates, there has continued debate

2002). Hence, as recommended in the recent National Review of Nurse Education

education, is clearly warranted.

Education Unit (CEU) on the quality of clinical prac as experienced by undergraduate

– Development, implementation and initial evaluation of an innovative model of clinical

used for comparison.

nursing staff ownership of students’ clinical education. These factors provided an

operating framework which enabled the development of positive learning environments

these factors, acting synergistically, promoted enhanced access to learning opportunities

an important contribution to nursing education by providing evidence that can inform

future developments in the area of undergraduate clinical education. It has potential

STATEMENT OF ORIGINAL AUTHORSHIP xiii

DECLARATION OF ENROLMENT xiv

CHAPTER 1: Introduction and Summary 1

1.1 Background and Significance 1

CHAPTER 2: Literature Review 8

CHAPTER 4: Change intervention 76

CHAPTER 6: Results – Phase 2 126

6.1 Introduction 126

CHAPTER 7: Discussion 154

7.1 Introduction 154

CHAPTER 8: Implications and Recommendations 183

7.7 Implications 183

Table 2.1 Most commonly identified characteristics of ‘good’ clinical 35

Figure 2.1 Trigonal model of clinical education 18

Buddy / buddy RN A registered nurse working in a particular health care

Clinical Associate A registered nurse working in a CEU unit who is formally

Clinical facilitator A registered nurse who is formally appointed to a

Clinical Partner A registered nurse working in a CEU unit who is informally

Grads A common colloquial term for graduate nurses

Prac A common colloquial term for clinical practice that is used

Sessional facilitator A registered nurse employed directly by the university to act

Seconded facilitator A registered nurse employed in a health care facility who is

Out on prac A common colloquial term used by students to denote the

Preceptor A registered nurse employed in a health care facility who

Uni A common colloquial term for University that is used by

University’s Research Degrees Committee.

I also express my appreciation and thanks to my supervisors Professor Helen Edwards

INTRODUCTION AND SUMMARY

1.1 Background and Significance

Nursing is a practice-based discipline that requires a minimum level of competence for

Competencies and the organisational abilities needed to function effectively as a

commitment of universities to produce competent graduates, there has been a growing

is a key element in the preparation of pre-registration students for professional practice.

teaching practice in light of changes in nursing practice, research on learning and

broader developments in professional and para-professional preparation” (p. 24). Thus,

ability to function as newly graduated registered nurses.

1.2 Problem statement

Currently there is a relative absence of knowledge and understanding about the

differential impact of various models of facilitation on students’ clinical education

their relationship to students’ perceptions, and/or the sustainability of stakeholder

perceptions over time.

Therefore the challenge is to be able to maximise the identified strengths of various

of students. Given the importance of clinical education within pre-registration

undergraduate courses, and continued tensions surrounding the preparedness of