Clinical learning environment of nursing and midwifery students in Ghana

Nursing care is pivotal in the health care services worldwide. Globally, nurses and midwives constitute 59% of the health workforce [1]. In Ghana, out of the 115, 650 health workers employed by the government, nurses and midwives account for 58% [2]. The axillary nurses (community and enrolled nurses; trained for 2 years) make up the majority (53%) of the total nursing and midwifery workforce whiles professional nurses (with at least 3 years of training resulting in the acquisition of diploma, undergraduate, postgraduate qualifications, or specific speciality areas of study) account for 47% [2, 3]. The nurse serves as the main vessel that convey most interventions and care necessary for individuals utilizing health care services. For nurses to efficiently perform the myriads of duties, it depends on their ability to apply theory to practice [4, 5]. Hence, nursing training involves both theory and practical training. Each aspect of the training carries important weight.

The clinical skills acquisition of nurses is so important that the Nursing and Midwifery Council (NMC) of Ghana, a body mandated to regulate the training of nurses increased the clinical contact hours of students to 432 h, 624 h and 576 h for the first, second and third year of training respectively [6]. According to Benner [7], skills acquisition is not an event but a process where individual nurses start as novice and gradually become experts. Whiles the acquisition of knowledge on the theory is done in the classroom, the skills acquisition is done in the skills laboratory and clinical learning environment or setting depending on one’s level of study.

The clinical learning environment (CLE) is a complex and constantly changing setting [8]. The CLE can be influenced by several factors such as the kind of supervisor, the quality of feedback received by students, the context and the students [9, 10]. Much of skills teaching are done by the nurses in clinical practice regardless of their level of education and expertise.

This implies that the quality of clinical teaching of students depends on the efficiency of the supervisor they meet in the clinical facility [11, 12]. In Ghana, it is regarded the responsibility of every registered nurse or midwife to provide teaching or guidance for students who work with them on their shift without any specific training for that purpose. The registered nurses supervise students and do not receive payments by any of the institutions for this service. Some of these supervisors may not be adequately prepared or motivated for the task of clinical teaching [9]. According to Chan and Ip [13], their relationship is very key and determines the kind of learning environment created. A positive learning clinical environment is a result of good relationship between the supervisor and the students. Nursing students will always be motivated to learn in environments where there is mutual respect and students are involved in the team and supported with their decision making [4].

Constructs of the clinical learning environment positively influence students’ satisfaction with their learning activities [14]. The pedagogical atmosphere, ward manager leadership style and supervisory relationship are important factors that contribute to satisfaction with the clinical environment. Students who have the chance to meet a supervisor on more regular basis tend to well appreciate the contribution of the clinical environment to their skills learning. Having access to a supervisor or mentor allows the student to learn more and improve the skills learning.

Despite the importance of clinical learning for nursing students, it comes with some challenges to students, faculty and supervisors. For students, depending on the level of study it can be demanding especially when students feel, they lack the right skills for a particular assigned task [15]. They worry about the probability of supervisors holding negative perceptions about them which could affect their grading and therefore may come under “pressure” to please their supervisors [9].

Crowding of students in the clinical setting is a major challenge to clinical teaching and learning [16, 17]. Overcrowding in the ward makes it difficult for both students and clinical supervisors to engage meaningfully. When student numbers are high it means student-preceptor ratios will be higher than required for effective clinical learning. When students are more than the physical space can accommodate it becomes very difficult for staff to even assist them to learn clinical skills [18]. In Ghana, the ration of a supervisor to student is approximately 1: 10 or more students in a shift [19]. This is because students are required to do their clinical placement only in the hospital setting. Therefore, the need to improve clinical nursing education is an important aspect of training of nurses. Thematic areas of importance in improving clinical nursing education include having positive clinical environment, effective clinical supervision, adequate assessment of students and clinical-academic collaborations [20]. However, there are no current studies reporting the student evaluation of their clinical placement experience in Ghana. We examined nursing and midwifery students’ evaluation of their clinical placement using the CLES+T.

Statistical analyses were done using SPSS version 21. Demographic characteristics of students are presented as frequencies and percentages. Internal consistency was checked for the overall scale and each of the five dimensions using Cronbach’s alpha. There was high internal consistency of the overall CLES +T (Cronbach’s alpha = 0.904). The five dimensions also showed high internal consistency with Cronbach’s alpha values ranging from 0.713 to 0.903 which showed the suitability of the use of this scale (Additional file 1). The method of supervision was categorised into three based on responses to six questions. Unsuccessful supervision was assigned based on a combination of three alternative questions: (i) the student did not have a named supervisor; (ii) a personal supervisor was named, but the relationship with this person did not work; and (iii) the named supervisor changed during the training course. Team supervision was assigned based on a combination of: (i) the supervisor varied according to shift or place and (ii) the supervisor had several students. Successful supervision was where students had a named mentor and the relationship worked in practice [23, 24].

An overall mean score of the questionnaire was calculated for each student by calculating the mean score of all questions. Scores on the five sub-dimensions were also calculated for each student using scores of the questions that make up those dimensions. Higher scores indicate more agreement with the statements.

The association between student demographic characteristics and clinical placement experience and mean scores was determined using t-test or ANOVA as appropriate. We determined associations of the overall mean score on CLES+T and the sub-dimensions using the mean scores (continuous) as dependent variable and demographic characteristics (binary/categorical) and clinical experience (binary/categorical) as independent variables.

In this cross-sectional study among undergraduate nursing and midwifery students in the Tamale metropolis of Ghana, we assessed students’ evaluation of their clinical experience in health facilities using the Clinical Learning Environment and Supervision + Nurse Teacher (CLES +T) evaluation scale. The main findings are that; more students received supervision from nurses during clinical placement and team supervision was the most common supervisory type. Nursing students were more likely to rate their clinical experience better than midwifery students and students who had increased contacts with private supervisors were more likely to rate their experience higher. Clinical experience was also evaluated better by students who received successful supervision compared to those who had other forms of supervision.

The higher likelihood of nurses than other health professionals such as midwives to provide supervision to students on clinical placement in this setting may be explained by the type of skills and competencies students are placed to acquire. This is because many basic skills for both nursing and midwifery as well as advanced skills are taught by nurses as most of those skills are general until students, such as the midwifery students move on to perform specific midwifery skills. The higher rating of clinical placement by nursing students than midwifery students in the present study could mean that midwifery students were expecting that since they are midwives they needed to have been supervised by only midwives; there is also the tendency to view midwifery practice totally separate from nursing practice, which in fact, should not be the case because most basic skills performed in midwifery practice also occur in nursing practice. This is a perception that needs more exploration to inform students’ experience and appreciation of their practice and skills acquisition. It is, therefore, useful for students to be made aware of this ahead of their clinical placement to avoid being unsatisfied with the initial nurse dominant supervision they receive.

We find that frequency of contact with private supervisor was associated with high evaluation of clinical experience by both nursing and midwifery students. These findings are consistent with the results from Cyprus [14], Slovakia [25], northern Italy [26] and Sweden [27] where nursing students evaluated their clinical experience better with private supervision. As team supervision was higher and likely to be poor among students, it is reasonable that contact with private supervisors with a high tendency for tailored training to receive high rating. There is high need for private supervision as revealed in the study and calls for students to make more efforts and make good use of this opportunity whenever available to gain the needed skills. We recommend that clinic or ward staff also endeavour to provide private supervision to increase the quality of clinical experience of students.

Consistent with previous findings [14, 23, 26], successful supervision was associated with higher evaluation of student clinical experience. However, this has not always been the case in all studies [28]. Successful supervision constitutes having a named mentor and a perception of the relationship having worked out. Therefore, it is understandable that students who had successful supervision rated their overall clinical experience better. For improved clinical experience of students, mentors and students should work together to achieve a successful supervision.

To the best of our knowledge, this is the first attempt to report nursing and midwifery students’ evaluation of their clinical placement in Ghana. The findings could be useful to health institutions and providers such as hospitals and clinics involved in the training of nursing and midwifery students to achieve better clinical experience and skills acquisition. However, the results of the study should be interpreted keeping some limitations in mind. First, our sample consisted of more nursing students than midwifery students, so the generalizability of the findings may be less applicable to midwifery students. Second, most supervisors at the ward level were often of a lower educational level than the students which could affect the quality of supervision and supervisory relationship. While this is not a typical limitation of the study, it may have influenced the evaluation of student experience of their clinical placement. Third, the CLES+T questionnaire has not been validated in this setting. However, we do not think this would have affected our results greatly, as the questionnaires were administered in the original English language not translated into a different Ghanaian language. The tests for reliability of the CLES+T using Cronbach’s alpha were also within acceptable ranges indicating its suitability. In spite of these limitations, our results provide important insights into the experiences of nursing and midwifery students during clinical placement in Ghana.

Team supervision is high in health facilities where students undertake clinical placement in Ghana; nursing students are more likely to rate their clinical experience better than midwifery students and students with increased contacts with private supervisors were more likely to rate their experience better. Frequent contact with private supervisor and successful supervision are associated with better rating of clinical experience among Ghanaian undergraduate nursing and midwifery students.