Nursing students’ clinical learning: Combining simulation training with nursing home practice

Abstract

Background: The traditional clinical practice model for first-year nursing students in Norwegian nursing education is placement in nursing homes for six to eight weeks supervised by on-site registered nurses. In nursing homes, increased care complexity, high workloads, and a limited number of registered nurses serving as student supervisors can pose significant challenges to students’ clinical learning. Simulation training may provide an evidence-based learning alternative during students’ clinical practice period. However, research on clinical practice models that combine simulation training with clinical practice in nursing homes for first-year nursing students is limited internationally and unexplored in a Norwegian context. Aim: The overall aim of this thesis is to gain knowledge by investigating firstyear students’ experiences with and relevant outcomes of simulation training combined with clinical practice in nursing homes in a Norwegian context. To achieve the overall aim, we initially identified elements in simulation training (based on the National League for Nursing (NLN) Jeffries Simulation Theory) associated with student outcomes of satisfaction and self-confidence (Paper I). Second, student experiences of multiple simulation training as a supplement during the students’ clinical practice period were investigated (Paper II). The Clinical Learning Environment Comparison Survey (CLECS) was then translated and tested for its psychometric properties (Paper III). The CLECS was used in the final investigation, in which student outcomes regarding knowledge acquisition, self-efficacy, and fulfilment of clinical learning needs were examined after integrating the simulation training as a partial replacement for clinical hours during the students’ clinical practice period (Paper IV). Methods: A multimethod design was employed. First, a study with a cross-sectional design using the NLN questionnaire (n = 187) was conducted to identify associations. Data were analysed using descriptive and correlation statistics (Paper I). The second study, which investigated student experiences (n = 27) had a qualitative descriptive study design with focus group interviews. Data were analysed using systematic text condensation (Paper II). The third study had a cross-sectional design with a longitudinal component (n = 122), and the CLECS’ psychometric properties were investigated using validity and reliability statistics (Paper III). The fourth study had an experimental design with pre- and post-test comparisons of an intervention group (n = 52) versus a control group (n = 48) to examine student outcomes using a knowledge test and the General Self-Efficacy Scale. Furthermore, a descriptive, survey-based comparison was used to examine the fulfilment of clinical learning needs in the intervention group using the CLECS. Data in the fourth study were analysed using descriptive and inferential statistics (Paper IV). Results: Active learning was significantly associated with satisfaction, while active learning and clear objectives were associated with self-confidence (Paper I). Three categories of student experiences were identified: enhancing the reasoning behind care, transferring knowledge and experiences between learning environments, and enhancing the sense of mastery (Paper II). The CLECS had acceptable construct validity and internal consistency, and most subscales displayed moderate to good test-retest reliability (Paper III). The mean improvement in knowledge acquisition from the pre- to post-test was higher in the intervention group than in the control group, and the difference was statistically significant, with a moderate to high effect size. No significant difference in self-efficacy improvement was observed. The intervention group scored the simulation training significantly higher on meeting their clinical learning needs compared with the nursing homes. Learning needs within the nursing process, self-efficacy, and the teaching–learning dyad especially excelled, showing moderate to high effect sizes (Paper IV). Conclusions: This thesis suggests that simulation training (based on a theoretical framework), either as a supplement to or as a partial replacement for clinical hours, combined with clinical practice in nursing homes, might be of great benefit for Norwegian first-year nursing students. Active student engagement in simulation training may increase both student satisfaction and self-confidence, and the first-year students experienced enhanced knowledge, confidence, and mastery due to the simulation training after attending simulation training combined with clinical practice. Active student engagement, collective reflections, and feedback from facilitators and peers in the simulation training seemed pivotal for promoting the students’ clinical learning during the practice period. The CLECS (Norwegian version) was proven adequate for evaluating clinical learning to meet students’ learning needs and; combining simulation training with clinical practice in nursing homes was positively associated with knowledge acquisition and with meeting the clinical learning needs of first-year students, especially within the areas of the nursing process, self-efficacy, and the teaching-learning dyad.