Learning in clinical practice: Factors, outcomes, and challenges in clinical nursing education - A scoping review.

This section includes detailed findings from the second set of visits (2015–2017) of the Clinical Learning Environment Review (CLER) Program. The findings in the 6 CLER Focus Areas1 are based on site visits to the major participating clinical sites (ie, hospitals and medical centers) for 287 Accreditation Council for Graduate Medical Education (ACGME)-accredited Sponsoring Institutions (SIs) with 3 or more core residency programs.23 These clinical sites serve as clinical learning environments (CLEs) for the SIs.Collectively, the 287 SIs oversee 9167 ACGME-accredited residency and fellowship programs, with a median of 20 programs per SI. These larger SIs account for 87.1% of all residents and fellows in ACGME-accredited programs—with a range of 17 to 2156 trainees per SI (median = 246).Approximately 28% of the CLEs were located in the Northeast region of the United States, 30.3% in the South, 26.5% in the Midwest, and 14.6% in the West. The sites ranged in size from 107 to 2654 acute care beds (median = 528). The majority (67.2%) were nongovernment, not-for-profit organizations; 23.3% were government, nonfederal; 5.9% were investor-owned, for-profit; and 3.5% were government, federal. Although the CLER teams spent the majority of their time at inpatient settings, they also sometimes visited affiliated ambulatory care practices in close proximity.In total, the CLER teams interviewed more than 1600 members of executive leadership (including chief executive officers), 9262 residents and fellows, 8164 core faculty members, and 6034 program directors of ACGME-accredited programs in group meetings. Additionally, the CLER teams interviewed the CLEs' leadership in patient safety and health care quality and thousands of residents, fellows, faculty members, nurses, pharmacists, social workers, and other health care professionals while on walking rounds in the clinical areas.As previously described in the CLER National Report of Findings 2016,4 these findings are based on a mixed methods approach to data gathering and analysis to improve the accuracy of the findings by combining quantitative, descriptive, and qualitative evidence in a complementary manner. As such, some of the findings are represented quantitatively while others are described qualitatively.The combination of methodologies and varied representation of findings should be considered when interpreting the results, making comparisons, or drawing conclusions. Both supporting and conflicting evidence may be presented to explain or qualify findings. For example, results from the group interviews may appear more positive than information gathered on walking rounds. Alternatively, practices reported during group interviews may have been verified on walking rounds.During the group interviews with residents and fellows, faculty members, and program directors, an electronic audience response system (ARS; Keypoint Interactive version 2.6.6, Innovision Inc, Commerce Township, MI) was used to collect anonymous responses to closed-ended questions. The results from the ARS were analyzed at both the individual (eg, residents and fellows) and the CLE levels.At the individual level of analysis, results are presented as percentages of the total number of individuals surveyed. For example:At the CLE level of analysis, individual responses were aggregated at the CLE level and results are presented as median and interquartile range (IQR) percentages. For example:Statistically significant differences (ie, P ≤ .05) in responses due to resident and fellow characteristics (eg, residency year) and CLE characteristics (eg, bed size) are also reported. Of note, statistical significance does not always imply practical significance. For example, differences in responses by residency year may be statistically significant but the differences may not be meaningful or large enough to have practical relevance or implications.As described in the Methodology section,5 this report contains a specific set of descriptive terms that summarize quantitative results from both the ARS and specific findings that were quantified from the site visit reports. These terms and their corresponding quantitative ranges are as follows:Besides the quantitative data, this report contains qualitative data from a number of open-ended questions that CLER Site Visitors asked during group interviews and walking rounds. This information, by design, was not intended to be enumerated. For these questions, the site visit teams made an assessment of the relative magnitude of observations at each individual site. To prevent confusion, these results are presented in the report using a set of descriptive terms different from the previously described terms used for quantitative data. The qualitative descriptive terms, which are intended to approximate the quantitative terms above, are as follows:Finally, this section follows approximately the same structure as the individual CLER Site Visit reports received by participating institutions. This structure is intended to facilitate easy comparison between data from an individual site and that of this report, which aggregates results from all 287 SIs. Those who seek additional detail may consult the Appendices (p. 81–124). Appendix A contains additional information on the SIs, sites visited, and groups interviewed, Appendix B contains selected aggregated quantitative results from the group interviews with residents and fellows, and Appendix C contains qualitative information from the group interviews and walking rounds.The CLER Program explored several aspects of resident and fellow engagement in patient safety with emphasis on 5 major topics: culture of safety, use of the patient safety event reporting system, knowledge of patient safety principles and methods, inclusion in patient safety event investigations, and disclosure of patient safety events. Generally across CLEs, members of the executive leadership team identified patient safety as their highest priority area for improvement.The patient safety and quality leaders in many CLEs indicated that they periodically conduct a culture of safety survey that includes residents, fellows, and faculty members. Overall, 97.7% of the residents and fellows in the group interviews reported that their CLE provides a safe and nonpunitive environment for reporting errors.Across CLEs, physicians and other staff members also reported use of the patient safety event reporting system to report on individual behaviors. This use included reporting on behaviors in a retaliatory fashion or in a manner that could be perceived as punitive.Given this and based on the collective findings from the site visits, it is unclear as to whether residents, fellows, and other staff members perceived a safe and nonpunitive culture for reporting patient safety events.Overall, CLEs had 1 or more mechanisms for reporting patient safety events, including an online or paper-based patient safety event reporting system, a chain-of-command system that allowed events to be reported to an immediate supervisor (eg, a more senior resident or faculty member), and a mechanism to verbally report events to the patient safety staff (eg, hotline).In general, residents and fellows appeared to be aware of their CLE's process for reporting patient safety events such as adverse events, near misses/close calls, and unsafe conditions. During walking rounds, the CLER Site Visit teams also asked nurses about their CLE's patient safety event reporting system. Across nearly all CLEs (97.2%), nurses appeared to be familiar with their CLE's system for reporting patient safety events.Approximately 78% of CLEs were able to provide information on the number of patient safety event reports submitted by residents and fellows (see Appendix C1), and 70.7% were able to provide the number of patient safety event reports submitted by attending physicians. The remaining CLEs indicated that their system did not track such information. Whereas CLEs occasionally provided the Graduate Medical Education Committee and their governing body with information on the number or percentage of patient safety event reports submitted by residents and fellows, it was less common for them to routinely report the number or percentage of patient safety event reports submitted by faculty members to these same groups.Generally across CLEs, the residents and fellows interviewed on walking rounds appeared to lack understanding and awareness of the range of reportable patient safety events, including what defines a near miss/close call. In most CLEs (83.6%), nurses' understanding of reportable patient safety events also varied (see Appendix C2).Across CLEs, residents, fellows, and nurses appeared to focus on reporting sentinel events, medication errors, patient falls, and other events with harm; they did not appear to recognize near misses/close calls, unsafe conditions, events without harm, unexpected deteriorations, or known procedural complications as reportable patient safety events. Residents, fellows, and nurses appeared to have little awareness of the importance of reporting these events and how such reporting can provide valuable information for identifying system failures, addressing vulnerabilities in the system, reducing risks, and improving patient safety.Overall, 72.7% of the residents and fellows in the group interviews indicated that they had experienced an adverse event, near miss/close call, or unsafe condition while at their CLE. This experience varied by gender, year of training, and specialty grouping (see Appendix B1).Of the residents and fellows who reported that they had experienced an adverse event, near miss/close call, or unsafe condition, 49.8% indicated that they had personally reported the patient safety event using the CLE's patient safety event reporting system. Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was 50.0% (37.5%–66.7%) and varied by region, CLE bed size, and type of ownership (see Appendix B2). For those who did not personally enter the patient safety event into the system, 13.6% indicated that they relied on a nurse to submit the patient safety event report, 24.4% indicated that they relied on a physician supervisor, and 12.1% indicated that they cared for the patient and chose not to submit a report.When faculty members and program directors in the group interviews were asked what process residents and fellows most frequently followed when reporting a patient safety event, 57.9% of the faculty members and 53.7% of the program directors indicated that they believed residents and fellows most often reported the event themselves using the CLE's patient safety event reporting system.In a separate query, 23.6% of the residents and fellows in the group interviews indicated that they had reported a near miss/close call event while at the CLE; responses varied by gender, year of training, and specialty grouping (FIGURE 1). Across CLEs, this finding ranged from 0% to 100%, with a median (IQR) of 23.1% (15.2%–33.3%); responses varied by region and type of ownership (see Appendix B3).On walking rounds, residents and fellows in many CLEs mentioned that they often report patient safety events locally or through their chain of command while also indicating familiarity with the patient safety event reporting system and its use. When they delegated or relied on others to report, it was unclear if these reports were formally captured in the CLE's centralized patient safety event reporting system. Residents and fellows mentioned the cumbersome process of submitting a report, the time needed to enter a report, fears of repercussion, and the uncertainty of receiving feedback as reasons for not reporting. The collective information from the site visits indicated that in 70.6% of the CLEs, resident and fellow reporting of patient safety events into the CLE's patient safety event reporting system was varied or infrequent (see Appendix C3).In the group interviews, the CLER teams also explored faculty members' and program directors' use of the CLE's patient safety event reporting system. Approximately 36% of the faculty members reported that they had personally reported an adverse event, near miss/close call, or unsafe condition in the past year (median [IQR], 35.7% [26.0%–46.6%] across CLEs). Among the program directors, 35.9% reported that they had personally reported an adverse event, near miss/close call, or unsafe condition in the past year (5.5% had no clinical responsibilities at the site). Across CLEs, the median (IQR) finding was 36.0% (27.3%–50.0%). In both groups, responses varied by CLE bed size and type of ownership.In the group interviews, the CLER teams asked residents and fellows whether they received feedback on patient safety event reports. Of those who had experienced an adverse event, near miss/close call, or unsafe condition and who had personally submitted a patient safety event report or relied on a nurse or supervisor to submit the report, 46.1% reported that they received feedback on the outcome of the report. Responses varied by gender, specialty grouping, and year of training (FIGURE 2; see also Appendix B4).Residents and fellows often mentioned receiving an e-mail acknowledging receipt of the patient safety event report. They also noted receiving requests for additional information as part of a formal patient safety event investigation. It was uncommon for residents to mention receiving information on the outcome of the investigation, including recommended actions to address vulnerabilities in the system and to improve patient safety. Across CLEs, residents, fellows, nurses, and other clinical staff expressed a strong desire to receive feedback in response to submitting a patient safety event report.Overall, CLEs varied in their processes for reviewing and prioritizing patient safety events. Residents and fellows also varied in their knowledge of these processes and often used the term "black box," indicating that these processes were unclear. Many residents and fellows appeared to be unaware of how their CLEs use the reporting of adverse events, near misses/close calls, or unsafe conditions to improve care both broadly and at the individual departmental level. Residents and fellows were rarely involved in their CLE's process for reviewing and prioritizing patient safety events that required further investigation.On walking rounds, the CLER teams explored resident and fellow participation in the time-out process as part of patient safety practices (eg, ambulatory and bedside procedures). Across many CLEs, residents, fellows, nurses, and other health care professionals interviewed on walking rounds indicated that residents and fellows do not consistently conduct standardized time-outs before performing bedside procedures.Across most CLEs (91.6%), residents and fellows appeared to have limited knowledge of fundamental patient safety principles and methods (eg, Swiss cheese model of system failure, root cause analysis, fishbone diagrams; see Appendix C4).When asked to identify their skills in applying patient safety principles, the majority of the faculty members indicated that they were either proficient or expert (62.7% and 25.1%, respectively) in applying these skills. Similarly, most of the program directors reported themselves as proficient or expert (63.6% and 21.9%, respectively).Of the residents and fellows in the group interviews, 36.3% reported that they had participated in a structured interprofessional simulation activity related to patient safety. Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was 37.1% (26.3%–50.0%), with responses varying by region and type of ownership.In many CLEs, the patient safety and quality leaders indicated that they did not track resident and fellow participation in patient safety event investigations (eg, root cause analysis). A limited number of CLEs provided the Graduate Medical Education Committee and the governing body with information regarding the number of residents and fellows who had participated in formal patient safety event investigations.The CLER teams also asked the program directors in the group interviews if they measured resident and fellow participation in patient safety event investigations. Approximately 42% of the program directors reported tracking resident and fellow involvement (median [IQR], 44.4% [30.0%–66.7%] across CLEs). Responses varied by region, CLE bed size, and type of ownership.In the group interviews, 37.6% of the residents and fellows who were postgraduate year 3 (PGY-3) and higher indicated that they had participated in an interprofessional investigation of a patient safety event that included components such as analysis of system issues, development and implementation of an action plan, and monitoring for continuous improvement. Reponses varied by specialty grouping (FIGURE 3). Across CLEs, the median (IQR) finding was 37.6% (28.6%–50.0%), with responses varying by region, CLE bed size, and type of ownership (see Appendix B5).The CLER teams also asked faculty members about their involvement in interprofessional patient safety event investigations. Approximately 64% of the faculty members in the group interviews reported that they had participated in an investigation of a patient safety event that involved physicians, nurses, administrators, and other health care professionals (median [IQR], 63.3% [53.0%–73.2%] across CLEs).Overall, the format and process of investigating patient safety events varied both across and within CLEs. It was uncommon for residents and fellows to describe involvement in comprehensive systems-based approaches to patient safety event investigations aimed at preventing future adverse events and sustaining improvements in patient safety. In general, residents and fellows described experiences that lacked the attributes of a formal patient safety event investigation with very little or no interprofessional or interdisciplinary engagement. Residents and fellows varied widely in their perceptions of what constituted a formal investigation of a patient safety event. Across many CLEs, case conferences, morbidity and mortality conferences, and grand rounds continued to be the major approach to patient safety event investigations.Faculty members and program directors indicated that departmental mortality conferences, case conferences, and online modules were other informal approaches to model elements of a patient safety event investigation.In the group interviews, 66.0% of the residents and fellows indicated that they had received training on disclosing medical errors to patients and/or families (4.5% reported that such training was not applicable). Responses varied by year of training. Across CLEs, the median (IQR) finding was 68.2% (57.1%–79.3%), with responses varying by region and CLE bed size. Of those who received training, 10.1% indicated that the training was primarily simulation based; 69.8%, didactic and/or online; 15.1%, informal; and 5.0%, other.Approximately 82% of the residents and fellows in the group interviews indicated that they knew of CLE resources to assist them in coping with a major patient safety event that resulted in a patient death (median [IQR], 85.8% [74.7%–93.0%] across CLEs; see Appendix B6 for information on variability). Of those familiar with the resources, most indicated that they would be somewhat (39.8%) or very comfortable (44.7%) in using these resources.The CLER Program explored resident and fellow engagement in improving health care quality within the context of 6 major areas: involvement in developing and implementing the CLE's strategies for health care quality, awareness of the CLE's health care quality priorities, knowledge of health care quality terminology and methods, engagement in quality improvement (QI) projects, access to quality metrics data, and engagement in CLE efforts to address health care disparities.As part of understanding the CLE's approach to improving health care quality, the CLER Site Visit teams reviewed the organization's strategic plan for quality and interviewed both executive and patient safety and quality leaders. Overall, a limited number of CLEs appeared to integrate QI within the organization as part of a system-wide, comprehensive approach to promote experiential learning and to improve quality and safety across the organization.Across CLEs, resident and fellow involvement in strategic planning for QI was uncommon. Residents and fellows often served as implementers of CLE-wide QI activities (eg, hand hygiene, reducing hospital-acquired infections, reducing 30-day readmissions).A limited number of CLEs had instituted resident and fellow committees aimed at increasing resident and fellow engagement in QI; few of these committees were integrated into the CLE's formal QI processes. In many CLEs, resident and fellow participation in institutional QI committees was uncommon; often, roles and expectations for participation were undefined or unclear. The clinical sites also appeared to have insufficient structure to allow residents and fellows to attend committee meetings regularly and to participate in meaningful ways. Additionally, residents and fellows in many CLEs were not included in the governing body's patient safety and quality committees.In general, priorities for improving health care quality varied across CLEs. However, some common themes included alignment with broad national priorities such as Centers for Medicare & Medicaid Services value-based purchasing, Core Measures, or publicly reported performance measures. Many were also highly focused on meeting specific criteria such as reducing 30-day readmissions or improving performance on metrics related to pneumonia, chronic heart failure, and surgical care improvement project measures.In the group interviews, 78.8% of the residents and fellows (PGY-2 and above) reported knowing their CLE's priorities for improving health care quality (see Appendix B7 for additional information on variability). When asked the same question, 84.4% of the faculty members and 86.7% of the program directors reported knowing the priorities. Often, the physician groups focused on departmental activities and did not describe priorities that aligned with those identified by the CLE's executive leadership or the patient safety and quality leaders. When the physicians identified priorities aligned with those of executive leadership, they were most commonly around nationally recognized measures, especially those related to programs with financial incentives such as measures from the Centers for Medicare & Medicaid Services.In 55.1% of the CLEs, the residents and fellows appeared to have limited knowledge or understanding of basic QI terminology and methods such as Lean, Plan-Do-Study-Act, and Six Sigma (FIGURE 4, see also Appendix C5). A limited number of residents and fellows could articulate the QI approach employed by their CLE in designing and implementing QI activities to improve patient care.In general, the approach to educating residents and fellows about health care QI varied both within and between CLEs. Although some type of education was common as part of new resident and fellow orientation, a limited number of CLEs aimed to provide ongoing training for all residents and in health care QI appeared to primarily within or medical education programs, and the methods, and appeared to of the CLEs, the patient safety and quality leaders indicated that they resident and fellow QI the group interviews with residents and fellows (PGY-2 and reported they had participated in a QI project of their design, or by their program or Of this reported that their QI project was to 1 or more of the CLE's 23.3% were Of those who reported their QI were to the CLE's reported their involved interprofessional Appendices and provide detailed information on the group interviews and on walking rounds, the CLER teams asked residents and fellows to describe their QI Overall, residents and fellows varied in their of these It was uncommon for residents and fellows to describe that aligned with their CLE's priorities. In most CLEs few described that included the components of a QI (ie, (FIGURE see also Appendix Often, resident and fellow participation was limited to planning and implementing a QI For many residents and fellows, their QI did not formally and designing actions to and ongoing QI was also uncommon for residents and fellows to describe involvement in interprofessional QI During the interviews on walking rounds, a limited number of nurses and other health care professionals indicated that they were involved in interprofessional QI that included residents and the CLER teams faculty members in the group interviews about their engagement in interprofessional QI projects, 72.7% reported that they had participated in a QI project with nurses, pharmacists, and other members of the health care team (median [IQR], across the group interviews, of the program directors reported that their residents and fellows have access to for and data for the of health clinical and or national quality were often reported as common of QI data. Residents and fellows often mentioned the (eg, in specific reports from these data Many faculty members noted that residents and fellows had limited for data When it was often a departmental The type and of to residents and fellows varied both within and across of the residents and fellows in the group interviews reported receiving aggregated or QI data on their Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was with responses varying by region, CLE bed size, and type of ownership (FIGURE see also Appendix the patient safety and quality leaders indicated that residents and fellows receive QI data to the care of their patients with others served by their clinical many CLEs, executive leaders were aware of of health their Many described to improve access to care and or care and for the often by residents and fellows from a few core (eg, and A limited number of residents and fellows from other specialty and programs reported in these limited number of executive leaders to health care within their or medical Overall, less than of executive leaders described a specific set of strategies or a approach to and in the care provided to or the clinical of their patient at for health care In approximately of the CLEs, the executive faculty members, or program directors indicated that some were data or related to health care specific patient many of these efforts were reported as the group interviews, 55.1% of the residents and fellows reported that they knew their CLE's priorities in addressing in health responses varied by year of training and specialty grouping. Across CLEs, this finding ranged from to (median [IQR], Responses varied by region, CLE bed size, and type of ownership (see Appendix In of the faculty members and of the program directors reported that they knew their CLE's priorities with to health care residents, fellows, faculty members, and program directors interviewed in the group interviews were able to describe at for health care at their clinical the group interviews, of the residents and fellows reported that they had received training that was specific to at for health care at their clinical reported receiving training that was not specific to the CLE's patient reported receiving training that was primarily informal while clinical and indicated that they had not received training at their CLEs, a median (IQR) of of the residents and fellows indicated that they had received training that was specific to at for health care at their clinical site. Responses varied by region, CLE bed size, and type of ownership (FIGURE see also Appendix interviews on walking rounds, many residents and fellows described education and training in that was and not specific to the

To analyse nursing students' perceptions of the clinical learning environment and supervision and the connection between their satisfaction and intention of staying in their placement hospitals. Global nursing shortage necessitates strategies for the recruitment and retention of nurses. It is believed that nursing students' clinical placement experiences can affect their learning outcomes, as well as influence their choice of future workplace. Cross-sectional, correlational study. One hundred and eighty nursing students participated in the study. The data were collected in person using The Clinical Learning Environment, Supervision and Nurse Teacher scale tool. Students' satisfaction with the clinical learning environment and learning process was measured using a 4-point Likert scale developed by the researchers. The STROBE checklist was used in this paper. Nursing students perceived a favourable clinical learning environment and supervision in the hospitals where they undertook clinical placements, recording high levels of satisfaction and high levels of intention to stay and work there. The clinical learning environment and supervision established positive correlations with student satisfaction. This study promotes the development of knowledge and understanding of how student satisfaction and intention to stay and work in their placement hospitals relates to the quality of the clinical learning environment and supervision, which could be helpful to the management of healthcare facilities and faculties in improving nursing education and retention/recruitment strategies. Nursing students represent the future of the nursing workforce, so managers of healthcare facilities and faculties should move towards promoting a clinical learning and supervisory environment where supervisors, tutors and staff are aware of their commitment to student education and promote optimal learning and positive experiences in order for students to feel satisfied and motivated to work in their placement hospitals.

The Overarching Themes From the CLER National Report of Findings 2018.

Background: Feedback from students regarding their clinical learning environment and clinicians teaching attributes should be evaluated regularly to monitor students' learning experiences which can affect learning outcomes, the readiness for professional practice, and the level of satisfaction with the profession. Differences may exist in this feedback from students based on their institution, level of study, and characteristics of the clinicians. Aim: To evaluate physiotherapy students’ perception of their clinical learning environment and clinicians’ teaching attributes. Methods: This cross-sectional study utilised 258 participants from two academic institutions, which offer physiotherapy training in southeast Nigeria. A self-structured questionnaire, the McGill Clinical Teacher Evaluation tool (MCGill CTE) and the Dundee Ready Educational Environment Measure (DREEM) were used to collect the data. Descriptive statistics of mean and standard deviation were used to present the mean scores obtained on the DREEM questionnaire and McGill CTE tool. The Mann-Whitney U test was used to determine the difference in the students’ perception of their clinical learning environment and clinicians' teaching attributes based on their institution of learning and level of study. In addition, the Mann-Whitney U test also determined the difference in the students' perception of their clinicians teaching attributes based on the clinicians' gender, while the Kruskal Wallis test determined the difference in the students' perception of their clinician's teaching attributes based on their last clinical posting unit and the highest educational level of the clinicians. Results: The students perceived their learning environment to be “more positive than negative”. The highest-rated domain in the DREEM questionnaire was "perception of learning", while the lowest was "social perception". The highest-rated attribute for clinicians in the McGill CTE tool was "clinical interest in helping students to learn", while the lowest was "emphasises concept rather than factual recall". A significant difference was observed in the students rating of their clinical learning environment based on their institution and level of study. Conclusion: There is a need for regular evaluation of students' perception of their clinicians’ teaching attributes and the clinical learning environment to ensure the desired learning outcomes are attained and that students are ready for professional practice after training.

Background: It is thought that students’ perceptions of educational and clinical learning environments improve the effectiveness of curricula and professional standards. It is essential to examine the educational and clinical learning environments in which nursing students learn, as well as how nursing students evaluate particular factors of these environments. Objectives: The objectives of this study were to (1) identify nursing students’ perceptions on professional competence and learning environments in the classroom and clinical settings and (2) test a hypothetical model of variables that influence and predict students’ perceptions of learning environments and professional competencies. Methods: The study employed a descriptive cross-sectional methodological design. Five hundred and eighteen undergraduate nursing students were recruited from three Saudi Arabian universities using a convenient sampling technique. Using valid and reliable self-reported questionnaires, including the Dundee Ready Educational Environment Measure (DREEM), the modified Clinical Learning Environment Inventory (CLEI), and the Nurse Professional Competence Scale-Short (NPCS-SF), data were collected. Results: Perceptions of professional competence and learning environments were positive among nursing students. With satisfactory fit indices, the final model found that students’ perceptions of clinical competence were significantly predicted by their perceptions of the clinical environment (B = 0.43, p < 0.001), students’ perceptions of university environments (B = 0.29, p < 0.001), ward type (B = 0.12, p < 0.001), and students’ year of study (B = 0.11, p < 0.001). The students’ perceptions of clinical environments were significantly predicted by their perceptions of the university environment (B = 0.31, p < 0.001), gender (B = 0.13, p < 0.001), students’ year of study (B = 0.12, p < 0.001), and ward type (B = 0.11, p < 0.001). Moreover, the students’ perceptions of the university environment were significantly predicted by gender (B = 0.11, p < 0.001) and length of training (B = 0.12, p < 0.001). Conclusions: A range of factors might influence students’ perceptions of their professional competence and learning environments. Improving the learning environments and clinical experiences of students could enhance their clinical competence. This study’s findings provide evidence for how to enhance the learning environments in the classroom and clinical settings in order to improve students’ clinical competence, which will ultimately result in better patient outcomes. It is a top priority for nursing educators all around the world to improve classroom and clinical learning settings that foster students’ learning and professional competencies.

The Accreditation Council for Graduate Medical Education (ACGME) established the Clinical Learning Environment Review (CLER) Program12 to provide graduate medical education (GME) leaders and executive leaders of hospitals, medical centers, and other clinical settings with formative feedback in the 6 CLER Focus Areas.3 This feedback is aimed at improving patient care while optimizing the clinical learning environment (CLE). This report details findings from the second set of CLER Site Visits, which the CLER Program conducted from March 31, 2015, to June 10, 2017.The aggregated findings in this report reflect a mixed methods approach (ie, both quantitative and qualitative information gathering and analysis), which was used by the CLER Program to form a comprehensive base of evidence on how the nation's CLEs engage residents and fellows in the CLER Focus Areas.In addition to findings from the second set of CLER visits, this report includes an initial look at changes on a selected set of measures in each of the CLER Focus Areas since the first set of CLER visits (2012–2015). This 2-point analysis highlights both progress and challenges in CLEs. These findings can enhance and extend understandings of the complex and dynamic nature of CLEs and help inform conversations on how to continually improve physician training to ensure high-quality patient care within these learning environments.In 2015, there were 725 ACGME-accredited Sponsoring Institutions (SIs) and nearly 1800 major participating sites, which are the hospitals, medical centers, ambulatory units, and other clinical settings where residents and fellows train. This report contains findings from 287 CLEs that had 3 or more ACGME-accredited core residency programs. These CLEs were affiliated with 287 SIs that collectively oversaw 9167 residency and fellowship programs (89.1% of all ACGME programs) and 111 455 residents and fellows (87.1% of all residents and fellows in ACGME-accredited programs).a Appendix A provides additional information on the general characteristics of these SIs (eg, type of SI, number of programs) compared to all ACGME-accredited SIs.For SIs with 2 or more clinical sites that served as participating sites, the CLER Program visited 1 site due to resource limitations. This selection was based on 2 factors: (1) which CLE served the largest possible number of programs for that SI, and (2) whether that CLE had the availability of both the designated institutional official (DIO) and the chief executive officer (CEO) for the opening and exit interviews.The CLER Site Visit protocol included a structured schedule of events for each visit (FIGURE 1).CLER Program staff notified clinical sites of their CLER Site Visit at least 10 days in advance. This relatively short notice was intended to maximize the likelihood of gathering real-time information from interviewees.The number of site visitors and visit length varied according to the number of programs and residents and fellows at the site, with teams comprising 2 to 4 CLER Site Visitors and visits lasting 2 to 3 days. A full- or part-time salaried employee of the ACGME led each CLER Site Visit team. Additional team members included other CLER Site Visitors, ACGME staff, or trained volunteers from the GME community.For each site visit, the CLER Site Visitors conducted group interviews in the same order: (1) an interview with the DIOb; (2) an initial group interview with the CEO, members of the executive team (eg, chief medical officer, chief nursing officer), the DIO, and a resident representative; (3) a short interview with patient safety and quality leaders; (4) a group interview with residents and fellows; (5) a group interview with faculty members; (6) a group interview with program directors; (7) a second interview with patient safety and quality leaders; and (8) an exit meeting with the CEO, members of the executive team, the DIO, and a resident representative. Following specific guidelines, each clinical site provided the site visitors with a list of all individuals attending the group interviews before the site visit. The CLER team conducted all interviews in a quiet location without interruption and ensured that the interviews did not exceed 90 minutes.The purpose of the initial meetings with executive and patient safety and quality leaders was to allow the CLER team to become familiar with the basic language and culture of the CLE's current activities in the 6 CLER Focus Areas. This information helped inform subsequent interviews and observations during the CLER visit.The resident and fellow group interviews comprised 6 to 32 peer-selected participants per session. Specifically, residents and fellows at the SI, excluding chief residents, voted for their peers to attend the group interviews. The participants broadly represented ACGME-accredited programs at the clinical site with proportionally more individuals from larger programs. The CLER team primarily interviewed residents and fellows who were in their postgraduate year 2 (PGY-2) or higher to ensure that interviewees had sufficient clinical experience to assess the learning environment. PGY-1 residents in a transitional year residency program were permitted to attend.For the group interviews with faculty members and program directors, the CLER Program instructed the DIO to invite participants to attend the group interviews. In the faculty member group interviews, each session comprised 5 to 32 clinical faculty members who broadly represented the residency and fellowship programs at the CLE. Program directors were not permitted to attend the faculty member meetings. Group interviews with program directors comprised 3 to 32 leaders of ACGME-accredited core residency programs at each clinical site; sessions included associate program directors when program directors were not available.For CLEs with more than 30 programs, 2 separate sets of interviews were conducted with residents and fellows, faculty members, and program directors, with no more than 32 participants attending an individual session.Additionally, the CLER Site Visit team conducted a set of walking rounds, escorted by senior or chief residents and fellows, to observe various patient floors, units, and service areas. The CLER Program asked the DIO to select residents and fellows, preferably from a range of different specialties, to guide each CLER Site Visitor. Residents and fellows who participated in the resident and fellow group meetings or who served as the resident representative in the executive leadership meeting were not permitted to serves as escorts for the walking rounds.The walking rounds enabled the CLER Site Visit team to gather feedback from physicians, nurses, and other health care professionals (eg, pharmacists, radiology technicians, social workers) in the clinical setting. Each CLER Site Visitor conducted at least 3 sets of walking rounds per clinical site, with each walking round lasting 90 minutes. For larger CLEs, site visitors conducted an additional fourth walking round lasting 60 minutes.Throughout each visit, the CLER team conducted huddles to discuss the information they had gathered. Later during the visit, they held a team meeting to synthesize their findings, reach consensus, and prepare both an oral report and a draft of a written narrative report. At the exit meeting, the CLER team shared its oral report with executive leadership, which covered initial feedback on the 6 CLER Focus Areas. The written report, delivered approximately 6 to 8 weeks after the visit, reflected the same topics but with a more comprehensive and detailed set of observations. The intention of both the oral and written reports was to provide formative information that would help executive leadership assess their practices in the 6 CLER Focus Areas, inform resident and fellow training, and guide improvements in the CLE to ensure high-quality patient care.Survey instruments. To conduct the group interviews, the CLER Site Visitors used a structured questionnaire developed under the guidance of experts in GME and/or the 6 CLER Focus Areas. The questionnaires contained both closed- and open-ended questions. After the questionnaires were initially content validated by expert review, the CLER Program field tested the instruments on 4 CLER Site Visits. At the conclusion of each of these visits, the items were refined as part of an iterative design process; with each iteration, the CLER Program reviewed and revised the items as necessary based on feedback from interviewees and interviewers.Walking rounds. The CLER Program designed the walking rounds to facilitate random, impromptu interviews with residents, fellows, nurses, and other health care professionals across a number of clinical areas (eg, inpatient and outpatient areas, emergency departments) where residents and fellows were trained based on the SI's ACGME-accredited specialty and subspecialty programs.The aims of the walking rounds were to (1) triangulate, confirm, and cross-check findings from the group interviews and (2) glean new information on residents' and fellows' experiences across the 6 CLER Focus Areas. The walking rounds provided important information that could either confirm or conflict with the information gathered in group interviews.CLER Site Visit reports. The CLER Site Visitors synthesized findings from each visit in a written report, working from a formal template developed and refined in the early stages of the CLER Program. The template assisted the CLER Site Visit team in ensuring that each of the 6 CLER Focus Areas was fully addressed in the oral and written reports for each clinical site. The reports also included a brief description of the clinical site and any of its notable aspects. All members of the CLER Site Visit team reviewed and edited each report for accuracy and to achieve consensus on the findings.Other sources of data. Several other sources of data were used to augment the site visit data, including the ACGME annual data reportsc and the 2015 American Hospital Association (AHA) Annual Survey Database.d The ACGME reports provided information on the SIs, programs, and physicians in GME, including the number of ACGME-accredited programs, number of residents and fellows matriculated, and university affiliation. The AHA data offered CLE information, including type of ownership (eg, nongovernment, not-for-profit versus investor-owned, for-profit) and size, as measured by the number of staffed acute care beds.Group interviews with an audience response system (ARS). CLER Site Visitors conducted group interviews with residents and fellows, faculty members, and program directors using a computerized ARS (Keypoint Interactive version 2.6.6, Innovision Inc, Commerce, MI) that allowed for anonymous answers to closed-ended questions. The ARS data were exported into a Microsoft Excel spreadsheet and then into a software package for statistical analysis. Site visitors documented responses to open-ended questions qualitatively. The 3 surveys—1 each for residents and fellows, faculty members, and program directors—consisted of 45, 35, and 36 closed-ended questions and 25, 25, and 27 open-ended questions, respectively.Group interviews with no ARS. CLER Site Visitors documented all responses qualitatively for group interviews with the DIO (39 questions); with the CEO, members of the executive team, the DIO, and the resident representative (38 questions); and with patient safety and quality leadership (70 questions).Descriptive statistics. Descriptive statistics were used to summarize and describe distribution and general characteristics of SIs, CLEs, and physician groups interviewed. For SIs, characteristics included SI type (eg, teaching hospital, medical school) and the number of ACGME-accredited residency and fellowship programs per institution. CLE characteristics included type of ownership (eg, nongovernment, not-for-profit), number of licensed beds, and total staff count. Demographic information included gender and medical specialty of physicians who participated in the group interviews.Analysis of ARS data. Analyses were conducted at both the individual (eg, resident and fellow) and the CLE level. For the individual-level analyses, results are based on the total sample of individuals surveyed, presented as percentages. For CLE-level analyses, results show differences between CLEs after individual responses were aggregated at the CLE level and are presented as medians and interquartile ranges. These 2 levels of analysis provided a national overview of the state of CLE engagement in the 6 CLER Focus Areas and revealed how CLEs compared on these outcomes.Chi-square analysis was used to compare resident and fellow responses and to identify any relationships in responses by (1) gender; (2) residency year; and (3) specialty grouping. Chi-square analysis was also used to explore if differences were associated with the following CLE characteristics: (1) regional location; (2) bed size; and (3) type of ownership. Categories in the annual AHA survey informed grouping of CLE-specific variables (eg, bed size). P values of .05 or less were considered statistically significant. All statistical analyses were conducted using SPSS Statistics version 22.0 (IBM Corp, Armonk, NY).Analysis of CLER Site Visit reports. Specific findings based on responses to non-ARS questions and interviews on walking rounds were systematically coded in NVivo qualitative data analysis software version 11 (QSR International Pty Ltd, Doncaster, Victoria, Australia) following the principles of content analysis. Three members of the CLER Program staff, trained in qualitative data analysis, generated a master codebook through an iterative process by (1) independently applying codes to the data; (2) peer-reviewing coding; (3) discussing coding discrepancies; and (4) reaching agreement on the codes through consensus. The results were recorded as frequency counts for further descriptive analysis. Overall percentages and percentages stratified by CLE region, bed size, and type of ownership are reported.Two-point analysis of selected measures in the CLER Focus Areas. For this report, a selected set of measures in each of the CLER Focus Areas was examined to explore change over time for matched observations (ie, the same CLEs in both sets of visits). The final data set for this 2-point analysis comprised 242 CLEs; reasons for exclusion included health care system consolidations, changes in accreditation status (eg, voluntary withdrawal), changes in the number of core residency programs (eg, fewer than 3 core programs), and incomplete or missing data (see FIGURE 2). The measures examined for this section were the same in both sets of visits (eg, the questions remained constant between Cycle 1 and Cycle 2 of CLER visits).The Kolmogorov-Smirnov test was used to test for normality in the data. Based on the results of the Kolmogorov-Smirnov test and tests of symmetry, nonparametric tests were employed in the 2-point analysis. The Wilcoxon signed rank test (and the sign test when the data were nonsymmetrical) was conducted to compare changes in median percentage based on responses to closed-ended questions (ie, ARS data) that were aggregated at the CLE level. Based on coded extractions from the CLER Site Visit reports, the McNemar and marginal homogeneity tests were conducted to compare changes in the qualitative findings.P values of .05 or less were considered statistically significant. SPSS Statistics version 22.0 was used to conduct statistical analyses.Development of overarching themes and findings in the CLER Focus Areas. The overarching themes and findings by CLER Focus Areas were determined in 3 stages. First, the CLER Program staff asked each CLER Site Visitor to identify the overarching themes (ie, broad, high-level observations) and the challenges and opportunities in each of the CLER Focus Areas based on their summative experiences and observations through a key informant survey. The CLER Program staff systematically analyzed the content of all responses to discern common themes and note salient concepts. The approach to analysis was inductive in that the themes emerged from the content of the responses.Next, the CLER Site Visitors reviewed and commented on the results and offered additional findings by consensus. Based on feedback from the site visitors, the CLER Program staff revised the summary of results and presented them to the CLER Evaluation Committee. Lastly, the members of the CLER Evaluation Committee reviewed the results and developed a set of commentaries on the importance of the findings and their impact on patient care and physician training. The work of the committee was achieved by consensus.Use of terms to summarize quantitative and qualitative results. For the purposes of this report, a specific set of descriptive terms is used to summarize quantitative results from both the ARS and the site visit reports: few (< 10%), some (10%–49%), most (50%–90%), and nearly all (> 90%).The summary of qualitative data (ie, responses to open-ended questions during group interviews and conversations on walking rounds) is based on the site visitors' assessment of the relative magnitude of responses. The following set of terms is intended to approximate the quantitative terms above: uncommon or limited, occasionally, many, and generally.Triangulation of the findings enhanced overall accuracy in the conclusions. The findings were cross validated for consistency and corroboration using multiple sources of complementary evidence and analytic techniques. For example, the ARS results were more meaningful when supplemented by critical qualitative information and vice versa. Multiple sources of data provided greater insight and minimized inadequacies of individual data sources when a finding was supported in multiple places. This mixed methods approach provided a richer, more balanced, and comprehensive perspective by allowing for deeper dimensions of the data to emerge.As with any formative learning process, limitations to the CLER Program warrant consideration in using the information in this report. Perhaps most important, these findings do not suggest cause and effect.Second, although this aggregated set of findings is designed to be highly representative, it is based on a series of sampled populations and thus may not be generalizable to all CLEs. As previously mentioned, the CLER teams interviewed a sample of residents, fellows, faculty members, program directors, and other clinical and administrative staff for each visit—with the aim of broad representation across all programs (eg, proportionally more individuals from larger programs). Although the goal was to achieve a broad degree of representativeness, the sample may or may not reflect the entire population. Given that the CLER Program is a formative assessment, this approach to sampling allowed for a broad and in-depth understanding of socially complex systems such as CLEs. The CLEs that were not included in this sample may represent different experiences and consequently could yield different conclusions as CLER goes on to consider them in the future.

Enduring shortages in the gerontology nursing workforce are projected to increase as demand for services for older persons grows. Recruitment of Registered Nurses in gerontology is further hindered by negative perceptions held by students towards nursing older people. To determine whether a professional development activity designed to assist clinical supervisors to build the mentorship capacity of care staff in residential aged care facilities could positively improve their clinical learning environment and improve student attitudes towards working with older adults. A quasi-experimental, non-equivalent pretest-posttest control group design. Clinical settings in which participants were undertaking an older person-focused clinical placement. A purposive sample of 466 first-year undergraduate nursing students. Forty-seven students responded to both the pre- and post-placement surveys. The intervention comprised four professional development sessions delivered to clinical supervisors supervising nursing students during clinical placement across three residential aged care facilities. Pre- and post-placement surveys measured Student Perceptions of Working with Older People (SPWOP). The modified Clinical Learning Environment Inventory (CLEI) was included in the post-placement survey to measure student perceptions of the clinical placement learning environment. Control group participants reported higher pre-placement SPWOP scores yet showed no significant improvement in score post-placement; however, the intervention group reported a statistically significant increase in SPWOP score post-placement. Modified CLEI results revealed the control group reported higher levels of engagement in the learning environment, yet the intervention group reported greater motivation to learn. An intervention designed to build staff mentorship capacity in gerontology care settings can positively influence student perceptions of working in gerontology. Despite these positive gains, results indicated that students who undertook placement at the intervention sites were less engaged. This disparity illuminates the need for continued efforts to build staff mentorship capacity in older person-focused clinical learning environments to improve student experiences and perceptions of gerontology nursing. Further research that engages directly with unregulated healthcare workers in geronotological care settings could provide new insights into what this cohort need to become effective mentors and shift student nurse attitudes towards caring for older adults.

Objective: To assess the clinical learning environment and clinical training for students' in maternal and childhealth nursing.Methodology: A descriptive study was conducted on non probability sample (purposive) of (175) students' inNursing College/ University of Baghdad for the period of June 19th to July 18th 2013. A questionnaire was used as atool of data collection to fulfill with objective of the study and consisted of three parts, including demographic,clinical learning environment and clinical training for students' in maternal and child health nursing. Descriptivestatistical analyses were used to analyze the data.Results: The results of the study revealed that the 65.1% of student at age which ranged between (19-23) yearsand 56% were male student, 66.9% were third year nursing students, and 59.4% were morning study. The studyrevealed that there were high mean score response among study sample except item (11) the response was (No)in which as (The learning environment in the hospital with a homogeneous environment college) at student'sattitude's regarding clinical learning environment. And the study revealed that there were high mean scoreresponse among study sample at the clinical training.Recommendations: The study recommended to need to conduct other the researches to evaluate the actualclinical learning environment for nurse's skills and practices performance in the hospital. And to determine factorsinfluence student's during clinical learning environment and clinical training

BackgroundMedical students view clinical workplace placements as an inspiring and motivating learning environment where active student participation is pivotal to development of students’ identity. The progress from pre-clerkship to clerkship education harbors many challenges which consist of experiential learning, adjusting to the clinical environment, and understanding roles & responsibilities. Workplace learning is underpinned by various adult learning theories including social theories,constructivism, supported participation and legitimate peripheral participation. Workplace learning course was recently initiated for pre-clerkship students at a medical university in UAE, which will enable their smooth entry into the clerkship phase of the curriculum.ObjectivesThe research aims to explore students’ perceptions of various domains of their clinical learning environment (CLE), highlight the challenges they face, and extract valuable feedback to improve their environment.MethodsThis study was conducted qualitatively by using focus groups method in order to explore students’ perceptions of the clinical learning environment. Two focus group discussions were conducted (n = 8 +/-10) to determine the common challenges of workplace learning and its potential solutions. Data were analyzed using thematic analysis. The approach used to carry out this study was phenomenology, as it helps to understand the learning and behavior of these students who are undergoing this pre-clerkship training in order to transition smoothly to the clerkship phase.ResultThe focus groups helped to deeply explore the perceptions of students about their clinical learning environment. It helped to reveal the challenges encountered by the students including the significance of proper orientation of staff and students, language barrier, availability of learning opportunities, and supervision quality. The focus groups provided worthwhile suggestions to improve the learning opportunities in the clinical learning environment which include orientation of the staff and students what to expect, improved supervision, mentoring and providing learning opportunities to encourage participation.ConclusionThis study attempted to identify the pre-clerkship students’ perception of their clinical learning environment and the challenges they face over there. Possible suggestions by the students included a formal orientation for the staff and students to be carried out at the beginning. Efforts should be made by clerkship directors to provide students with learning opportunities by increasing patient exposure, encouraging participation, and providing high-quality supervision.

Purpose: This study evaluates the clinical placement learning environment from the standpoint of Year 3 and Year 4 healthcare students in the UAE. Methods: The perspectives of healthcare students on clinical learning environments were studied using the validated Undergraduate Clinical Education Environment Measure (UCEEM). Third- and fourth-year (fifth-year pharmacy students inclusive) undergraduate healthcare students (radiography and medical imaging, emergency health, midwifery, nursing, pharmacy, physiotherapy, and psychology) (n=647) at a United Arab Emirates university were invited to participate in the study. The UCEEM contains 25 items under two overarching aspects, experiential learning and social engagement, with four subscales: learning opportunities at and through work and quality of supervision, preparing for entering students, patterns of workplace interaction and student engagement, and equal treatment. Results: The study recorded a response rate of 80.97%. The mean UCEEM score was 95.254±25.9753 (optimal range: 90-125). Patterns of workplace interaction and student engagement were recorded (22.783 ± 5.9105). (optimal range: 22-30) A—Learning opportunities at and through work and quality of supervision (42.1644 ± 10.7101). (Optimal range: 41-55) “Equal treatment” and “opportunity to put theory into practice” were ranked amongst the highest. Clinical supervision-related items were ranked high. Conclusion: High UCEEM scores indicate healthcare students have an optimistic view of their clinical learning environments, especially for equality and experiential learning. Most participants from different programs showed high satisfaction levels. However, the emergency health program showed a moderate satisfaction level.

Views and perceptions of nursing students on their clinical learning environment: Teaching and learning

Practice education learning environments: The mismatch between perceived and preferred expectations of undergraduate health science students

Increased attention to improving a culture of belonging in clinical learning environments has led to various approaches to addressing microaggressions. However, most approaches in the literature focus on responding or reacting to microaggressions with insufficient attention to building trust before microaggressions might occur. Research on microaggressions in clinical learning environments suggests anticipatory or pre-emptive conversations about microaggressions may foster greater trust. In this study, the authors explored how diverse participants perceived the experience of anticipatory conversations about potential microaggressions. Overall, the authors sought to gain a deeper understanding of how pre-emptive and anticipatory conversations may influence an organization's approach to addressing microaggressions in clinical learning environments. The authors utilized constructivist grounded theory methodology and conducted individual qualitative interviews with 21 participants in an academic department within a larger health sciences center in the United States. Findings suggest that anticipatory conversations about microaggressions were challenging due to existing norms in dynamic clinical learning and working environments. Participants shared that the idea of anticipating microaggressions elicited dissonance. Conversations about microaggressions could potentially be facilitated through leaders who role model vulnerability, organizational supports, and an individualized approach for each team member and their role within a complex hierarchical organization. Anticipating and addressing microaggressions in clinical learning environments holds tremendous potential, however, any conversations about personal identity remain challenging in medical and healthcare environments. This study suggests that any attempts to address microaggressions requires attention to cultural norms within healthcare environments and the ways that hierarchical organizations can constrain individual agency.

The transition of nursing education from traditional methods to more advanced approaches is crucial for adequately preparing students to deliver competent care in tertiary care centers. Moreover, clinical faculty in nursing plays a key role in guiding nursing students through their clinical training in various healthcare settings. This study aims to describe the perceptions of undergraduate nursing students regarding the effectiveness of the learning environment and clinical teaching in clinical areas across various countries. The study, conducted using a descriptive, cross-sectional research design, gathered data from 215 nursing students using the Clinical Learning Environment Inventory and Clinical Teaching Effectiveness Instrument. Data analysis included frequencies, percentages, mean, standard deviation, t-tests, analysis of variance, and correlation assessments to comprehend the impact of clinical teaching and learning environments. Nursing students' perceptions of the clinical learning environment produced mean scores between 2.03 and 3.38 on a scale from 1 to 4, resulting in an overall mean score of 2.72 across 42 items. This indicates a general satisfaction with their clinical learning experiences. Regarding effective clinical teaching, the mean student responses varied from 3.02 to 3.40 out of a possible 5 points, with a total mean of 3.22. The study revealed notable correlations in the context of effective clinical teaching, particularly with demographic variables and the clinical learning environment. Specifically, a significant correlation with age (r = .177, p = .009) and the clinical learning environment (r = .572, p < .001) was identified. The study concludes that students expressed overall satisfaction with their clinical learning experiences. They recognized the importance of participating in clinical training, fulfilling clinical responsibilities for assigned patients, exerting extra effort for learning, receiving support from preceptors in clinical settings, and being attentive to communications from staff. The collaboration between clinical preceptors and academic nursing lecturers is crucial in providing a positive learning environment for students to complete clinical tasks effectively.

CLER Pursuing Excellence: Faculty Development Innovations in Quality, Safety, Equity, and Value.