The purpose of this study was to identify the possible correlations of ‘satisfaction with clinical practice (SA)’ with ‘clinical learning environment (EN)’ and ‘clinical practice stress (ST).’ We searched for the mediating effect of ‘clinical practice stress’ on ‘satisfaction with clinical practice’ when the clinical learning environment influences ‘satisfaction with clinical practice.’
This research investigated 208 medical and nursing students attending the school of medicine and nursing in Korea. The total number of nursing students was 135 (64.9%); 73 medical students participated (35.1%). We used the Korean-Undergraduate Clinical Education Environment in 24 questions for EN, ST scale in 24 questions, and SA scale in 10 questions. We performed measurement structural equation model analysis to identify a path of the model.
Medical students had significantly higher levels of ST. EN had a significant negative correlation with ST and a significant positive correlation with SA. The ST had a significant negative correlation with SA. The results of the goodness of fit index have fulfilled the criteria of goodness of fit. There was a significant mediating effect of ST on SA when EN influences SA.
The clinical learning environment affected satisfaction with the clinical practice directly or indirectly mediated by clinical practice stress. Therefore, educational institutes should try to increase satisfaction with clinical practice by continuously monitoring and improving the clinical learning environment in addition to taking measures for decreasing the clinical practice stress.
In general, the teacher, student, curriculum, and educational environment are considered significant education components. In clinical practice, students and supervisors, clinical practice programs, and clinical learning environments are the main factors for successful learning. For nursing students with a high level of satisfaction with clinical clerkship, autonomous and responsible learning occurred more [
The clinical learning environment affects learning, learners’ well-being, and satisfaction [
However, the measurement tools had limitations in measuring some critical educational phenomena since many of them lack a theoretical basis, consider the clinical learning environment as a mere educational arena, and fail to acknowledge that it is a workplace as well [
The factors that influenced one’s satisfaction with the clinical practice were practice workload, stress, emotional intelligence, and communication skills. The inter-professional relationships with fellow students, faculties, patients, and co-workers affected professional self-concept formation [
The purpose of this study was to identify the level of ‘satisfaction with clinical practice’ in nursing and medical students who were doing their clinical practice in the one teaching hospital. Through this, we tried to find out the educational climate. We examined the possible correlations between ‘satisfaction with clinical practice (SA)’ and ‘clinical learning environments, (EN)’ and ‘clinical practice stress, (ST),’ respectively. Furthermore, we examined whether ST has a mediating effect on SA when the EN influences SA. Through this study, we would like to discuss what efforts are required by nursing and medical schools to improve learners’ satisfaction during clinical practice.
Two hundred and twenty-nine medical and nursing students attending the school of medicine and nursing, Konyang University, Daejeon, South Korea responded to the questionnaire, of which 208 were included in this study. The total number of nursing students was 135 (64.9%), of which the number of third-year students was 100 (48.1%), and fourth-year students were 35 (16.8%). The number of female students was 124 (91.85%), and male students were 11 (8.15%). Seventy-three medical students participated (35.1%), of which 29 (13.9%) were third-year students, 44 (21.2%) were a fourth-year students; with 24 (32.88%) female students and 49 (67.12%) male students. Nursing students had at least 3 to 8 weeks of clinical practice experience in a teaching hospital and should participate in orientation, ward round, core fundamental nursing skill learning, and case conference. Nursing professionals with a master’s degree or higher were in charge of clinical practice, and full-time faculty of a nursing college must direct at least 30% of the training course. Medical students had at least 24 to 56 weeks of clinical practice experience in a teaching hospital and must practice at least 36 hours per week. Faculties of medical college and residents as teachers were in charge of clinical practice. The subjects were nursing and medical students who participated in clinical practice in 2018–2019, and they agreed to participate after receiving information about the research contents before the survey. The Institutional Review Board of Tongmyung University approved this study (ethics consent no., TUIRB-2020-009).
To measure the clinical learning environment (EN), we used Korean-UCEEM developed by Strand et al. [
To measure the clinical practice stress (ST), we used the scale developed by Beck and Sriavastava [
To measure the satisfaction with clinical practice (SA), we used four questions of Maastricht Clinical Teaching Questionnaire developed by Stalmeijer et al. [
Data were analyzed using IBM SPSS ver. 21.0 (IBM Corp., Armonk, USA), AMOS ver. 22.0 (IBM Corp.), and frequency analysis to evaluate participants’ demographics. We calculated Cronbach’s α for reliability evaluation. Additionally, the relationships between variables were determined by using Pearson’s correlation coefficient analysis. We examined whether the observable variables in this study were appropriate for explaining the latent variables using structural equation modeling (SEM), then we performed “measurement model” analysis and “structural equation model” analysis to identify the path of the model. We used the bootstrapping method to analyze the mediation effect, sufficient for indirect effect analysis [
Results of correlation analysis between EN, ST, and SA were as follows. First, EN had a significant negative correlation with ST (r=0.322, p<0.01) and a significant positive correlation with SA (r=0.807, p<0.01). The ST had a significant negative correlation with SA (r=0.270, p<0.01). The results of correlation analysis among sub-factors of EN, ST, and SA are shown in
For the SEM analysis, we performed exploratory factor analysis to ensure that the observable variables used to measure the EN, ST, and SA could explain the latent variables. For parameter estimation, we used the maximum likelihood method. The results of goodness of fit index were as follows: χ2=133.841 (p<0.001, degrees of freedom [df]=59), χ2/df=2.268, RMR=0.037, GFI= 0.909, TLI=0.927, CFI=0.945, and RMSEA=0.078. The χ2 value was sensitive to sample size, that other GFI were considered together, then GFI, TLI, CFI were more than 0.90 [
The goodness of fit index results were CMIN/DF=2.297 (p<0.001), RMR=0.039, GFI=0.914, TLI=0.925, CFI=0.946, and RMSEA=0.079, which showed appropriate goodness of fit (
This study examined EN, ST, and SA perceived by nursing and medical students and investigated EN and ST’s effects on SA. Also, the mediating effect of ST in EN affecting SA was verified.
Despite having practiced in the same hospital, nursing students had significantly lower SA than medical students and experienced more clinical practice stress. Such differences can be attributed to contents and methods of training and the leadership style of educators, and the type of coaching [
EN was positively correlated with SA from correlation analysis between EN, ST, and SA. And there were negative correlations between EN and ST, and ST and SA. These results were consistent with that of previous studies [
Additionally, they need to provide counseling and systematic support services to help the students reduce their stress and deal with interpersonal conflicts or conflicts with patients. Most of all, the learning environment factors identified in this study, such as workplace interaction, equal treatment, quality of learning and supervision, preparedness for students, and learning opportunities, should be improved. Moreover, the stress from inappropriate role modeling and practice workload should be reduced by means of the curriculum improvement and the faculty development programs. The consistent efforts to reduce the students’ stress include decreasing the discrepancies between students’ expectations and the real educational environments and solving the inconsistencies between the pre-clerkship education and the clinical practice [
In conclusion, with the current study on the differences in SA between nursing and medical students, and the relationship between EN and ST affecting the SA, we identified environmental improvement and stress reduction for improving students’ satisfaction with their clinical practice. The EN affected SA directly or indirectly mediated by ST. Because the current study was performed on clinical practice in a single teaching hospital, validation of multicenter follow-up study results is necessary. Furthermore, we suggest some research subjects identifying the reasons for the difference in satisfaction with clinical practice according to gender and the effects of consistent monitoring and measures for environmental education improvement on learners. We hope this study be useful in improving the quality of clinical clerkship.
None.
None.
No potential conflict of interest relevant to this article was reported.
KHC: conception or design of the work and critical revision of the article; YSP: data analysis and drafting the article; MHK: first revision of the article; and all authors: final approval of the version to be published.
EN1: Workplace interaction, EN2: Equal treatment, EN3: Quality of learning & supervision, EN4: Preparedness for students, EN5: Learning opportunities, ST1: Clinical environment, ST2: Undesirable role models, ST3: Assignments and workload, ST4: Interpersonal relationships, ST5: Conflict with patients, SA1: Satisfaction with the learning environment, SA2: Coaching satisfaction, SA3: Overall satisfaction. **p<0.01. ***p<0.001.
Differences in EN, ST, and SA between Nursing and Medical Students
Variable | Nursing student (n=135) | Medical student (n=73) | Total (n=208) | t-value |
---|---|---|---|---|
EN | ||||
Workplace interaction | 3.29±0.72 | 3.59±0.86 | 3.39±0.79 | 7.427 |
Equal treatment | 3.16±0.94 | 3.59±0.83 | 3.31±0.93 | 10.448 |
Quality of learning & supervision | 3.71±0.55 | 3.72±0.65 | 3.71±0.59 | 0.025 |
Preparedness for students | 2.96±0.78 | 3.40±0.76 | 3.12±0.80 | 15.689 |
Opportunities to learning | 3.66±0.59 | 3.65±0.73 | 3.66±0.64 | 0.024 |
ST | ||||
Clinical environment | 3.67±0.60 | 3.17±0.80 | 3.50±0.71 | 26.159 |
Undesirable role models | 3.35±0.67 | 2.56±0.78 | 3.07±0.80 | 58.337 |
Assignments and workload | 3.68±0.61 | 3.15±0.76 | 3.50±0.71 | 30.170 |
Interpersonal relationships | 2.71±0.83 | 2.83±0.72 | 2.75±0.80 | 1.199 |
Conflict with patients | 2.54±0.80 | 2.69±0.81 | 2.59±0.80 | 1.734 |
SA | ||||
Satisfaction with the learning environment | 3.71±0.83 | 4.37±0.91 | 3.94±0.91 | 27.617 |
Coaching satisfaction | 3.34±0.79 | 3.71±0.68 | 3.47±0.77 | 11.351 |
Overall satisfaction | 6.38±1.79 | 7.56±1.50 | 6.79±1.78 | 23.119 |
Data are presented as mean±standard deviation.
EN: Clinical learning environment, ST: Clinical practice stress, SA: Satisfaction with clinical practice.
p<0.01.
p<0.001.
Correlation of Variables
EN1 | EN2 | EN3 | EN4 | EN5 | ST1 | ST2 | ST3 | ST4 | ST5 | SA1 | SA2 | SA3 | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EN1 | - | ||||||||||||
EN2 | 0.564 |
- | |||||||||||
EN3 | 0.648 |
0.444 |
- | ||||||||||
EN4 | 0.665 |
0.500 |
0.578 |
- | |||||||||
EN5 | 0.703 |
0.431 |
0.767 |
0.562 |
- | ||||||||
ST1 | -0.270 |
-0.268 |
-0.133 | -0.417 |
-0.153 |
- | |||||||
ST2 | -0.320 |
-0.294 |
-0.202 |
-0.336 |
-0.243 |
0.493 |
- | ||||||
ST3 | -0.200 |
-0.214 |
-0.065 | -0.315 |
-0.097 | 0.511 |
0.586 |
- | |||||
ST4 | -0.136 | -0.140 |
-0.196 |
-0.099 | -0.237 |
0.172 |
0.343 |
0.301 |
- | ||||
ST5 | -0.056 | 0.079 | -0.165 |
0.040 | -0.180 |
0.083 | 0.297 |
0.121 | 0.575 |
- | |||
SA1 | 0.650 |
0.513 |
0.638 |
0.632 |
0.628 |
-0.234 |
-0.394 |
-0.244 |
-0.133 | -0.010 | - | ||
SA2 | 0.585 |
0.389 |
0.561 |
0.586 |
0.617 |
-0.190 |
-0.266 |
-0.226 |
-0.199 |
-0.093 | 0.581 |
- | |
SA3 | 0.582 |
0.403 |
0.587 |
0.578 |
0.556 |
-0.283 |
-0.333 |
-0.205 |
-0.206 |
-0.101 | 0.581 |
0.595 |
- |
EN1: Workplace interaction, EN2: Equal treatment, EN3: Quality of learning & supervision, EN4: Preparedness for students, EN5: Learning opportunities, ST1: Clinical environment, ST2: Undesirable role models, ST3: Assignments and workload, ST4: Interpersonal relationships, ST5: Conflict with patients, SA1: Satisfaction with the learning environment, SA2: Coaching satisfaction, SA3: Overall satisfaction.
p<0.5.
p<0.01.
p<0.001.
Factor Loading of the Measurement Model
Variable | B | β | SE | CR | |
---|---|---|---|---|---|
EN | |||||
Learning opportunities | 1.00 | 0.76 | |||
Preparedness for students | 1.28 | 0.79 | 0.111 | 11.588 |
|
Quality of learning & supervision | 0.92 | 0.77 | 0.061 | 14.934 |
|
Equal treatment | 1.16 | 0.67 | 0.132 | 8.802 |
|
Workplace interaction | 1.34 | 0.83 | 0.098 | 13.596 |
|
ST | |||||
Conflict with patients | 1.00 | 0.30 | |||
Interpersonal relationships | 1.54 | 0.40 | 0.385 | 3.994 |
|
Assignments and workload | 2.54 | 0.73 | 0.777 | 3.268 |
|
Undesirable role models | 3.18 | 0.81 | 0.966 | 3.286 |
|
Clinical environment | 2.20 | 0.63 | 0.685 | 3.210 |
|
SA | |||||
Overall satisfaction | 1.00 | 0.74 | |||
Coaching satisfaction | 0.43 | 0.73 | 0.041 | 10.458 |
|
Satisfaction with the learning environment | 0.56 | 0.81 | 0.049 | 11.544 |
SE: Standard error, CR: Critical ratio, EN: Clinical learning environment, ST: Clinical practice stress, SA: Satisfaction with clinical practice.
p<0.01.
p<0.001.
Direct, Indirect, and Total Effects of Model
Path | Total effect | Direct effect | Indirect effect |
---|---|---|---|
EN→T | -0.379 |
-0.379 |
0.000 |
ST→A | -0.151 |
-0.151 |
0.000 |
EN→A | 0.937 |
0.880 |
0.057 |
EN: Clinical learning environment, ST: Clinical practice stress, SA: Satisfaction with clinical practice.
p<0.5.
p<0.01.
p<0.001.