Each year, hundreds of nurses, paramedics, midwives, dieticians, speech therapists, optometrists, occupational therapists, podiatrists, pharmacists, and many other professional students graduate from tertiary institutions and enter positions involving significant responsibility within the healthcare sector. As they do so, the quality of their academic education and clinical training is of the utmost importance to their future clients and the broader community (Bierer & Hull, 2007).
Previous studies have been undertaken to evaluate the quality of health professional education and how the students themselves perceive the various aspects of their course environment (Lizzio et al., 2002; Spencer, 2003; Bosch, 2006). It is often argued that a positive learning environment can lead to increased satisfaction, achievement, and success as a practitioner (Papp et al., 2003; Till, 2004). Indeed, it is for this reason that many academic institutions have been motivated to evaluate the learning environments within their own courses, both in terms of the practice education (also referred to as clinical education and fieldwork education) and traditional coursework settings (Roff, 2005; Smedley & Morey, 2010; Henderson et al., 2012).
While many studies have investigated health professional education from the perspective of the students' self-reported perceptions of the clinical and practice education learning environments, (Gordon et al., 2000; Till, 2004; Roff, 2005), others have focused specifically on the performance of health professionals who provide clinical education (Copeland & Hewson, 2000; van der Hem-Stokroos et al., 2005). The Clinical Teaching Effectiveness Instrument (CTEI) (Copeland & Hewson, 2000), for example, was designed to provide medical and health faculties, schools, and institutions with a reliable indicator of clinical educator performance that is easy to administer, collate, interpret, and compare with other departments or courses. The CTEI was initially used to evaluate the performance of the individual clinical educator (also referred to as a fieldwork supervisor, clinical instructor, facilitator, or clinical preceptor).
Subsequent studies have shown that it can also be used effectively to evaluate clinical educators at a group level (van der Hem-Stokroos et al., 2005), and attempts have been made to determine if it can provide a valid evaluation of a whole course (Bierer & Hull, 2007). Still, it has largely remained a tool to help administrators allocate teaching responsibilities, reward or promote proficient clinical educators, and provide feedback so that clinical educators can focus on their weaknesses.
Clinical educators play a key role in the education of healthcare professional students, because they supervise students while they are completing practice education placements. They are directly linked to the learning environments where students apply their emerging professional skills. That is, they are experienced, qualified professionals who share their knowledge and skills with students. It is recognized within the field of health professional education that clinical teachers and instructors can foster a positive practice education learning environment (Doll et al., 2004; Hue & Li, 2008; OECD, 2010; Jones, 2011; Haydn, 2012).
In the education literature, albeit non-specific to tertiary health professional learning, the educational environment is referred to as something to be maintained, if not nurtured, or even created by an instructor (Doll et al., 2004; Bosch, 2006). That is, the clinical instructor is not just part of the practice education learning environment, but largely responsible for cultivating and facilitating it. Skilled clinical educators are able to teach effectively, provide constructive feedback, motivate students, adjust their instructional style, facilitate appropriate questions, foster a positive atmosphere in a clinical setting, or scaffold a learning task for the “just-right” level of challenge; all factors that contribute affirmatively to students feeling comfortable, confident, competent, capable, listened to, supported, and engaged (Hummell, 1997; Buchel & Edwards, 2005).
Unlike the majority of secondary school-level and some tertiary teaching, health professional education does not typically all revolve around the traditional classroom setting or academic environment (May & Veitch, 1998; Gordon et al., 2000). Rather, contemporary health professional coursework usually includes practical skills sessions that are underpinned by related theoretical models and content material. As well, professional skills are usually underpinned by foundation bodies of knowledge (including the biomedical and social sciences). Another fundamental component of health professional student education is clinical (also referred to as fieldwork or practice) education placements, where they apply the skills and knowledge they have been exposed to in the academic settings in “real-life” professional contexts. Often health professional students have to demonstrate core skill competencies in order to be deemed “practice ready” (Spielman et al., 2005; Frank et al., 2010).
It should be noted that even though a proportion of health professional education is conducted outside traditional tertiary settings, this does not mean that academic educators have no impact on students' learning environments. Indeed, tools used to evaluate the learning environment in both clinical fieldwork and academic coursework aspects of health professional programs suggest that a link between educator performance and the students' learning environment exists. The Clinical Learning Environment Inventory (CLEI), which has been used to evaluate the overall clinical fieldwork/practice education learning environment among nursing students, is one such example. Its developer argued that the clinical learning environment is a multidimensional entity with a complex social context (Chan, 2003), and the CLEI's various subscales reflect this. Student responses produce scores across six different aspects of the clinical learning environment, namely: personalization, task orientation, individualization, innovation, involvement, and satisfaction (Chan, 2001).
It is possible to argue that, to varying degrees, each of the six aspects of the learning environment covered by the CLEI could be affected by the performance of the clinical fieldwork educator. For instance, the innovation subscale was initially described as representing the “extent to which clinical teacher/clinician plans new, interesting and productive ward experiences, teaching techniques, learning activities and patient allocation” (Chan, 2001, p. 450). While some parts of this description are likely restricted by course structure and other external factors, proficient fieldwork educators should still be able to positively impact aspects that this CLEI scale covers. This is illustrated by CLEI item 17, which states: “The facilitator thinks up innovative activities for students” (Chan, 1999, p. 114). If a student decides to strongly agree with this statement, it contributes positively to the innovation subscale, yet this is surely also a credit to the fieldwork educator's performance.
The Dundee Ready Education Environment Measure (DREEM) (Roff et al., 1997; Roff, 2005) is another widely-used self-report scale used to evaluate the learning environments in medical and health professional education settings (Roff et al., 2001; Ostapczuk et al., 2012); however, it involves the structured academic side of the curriculum (e.g. education that occurs within the classroom at the university). When completing the DREEM, students answer items that contribute to subscale scores across five aspects of the overall learning environment, namely their perceptions of learning, teaching, atmosphere, their academic self-perception, and their social self-perception (Roff et al., 1997).
Notwithstanding that the DREEM focuses on the academic side of the curriculum, logic dictates that educator performance, even in a clinical practice fieldwork setting, could impact on each of these constructs to varying degrees. For instance, proficient clinical practice educators could enhance the student perception of teaching across both clinical and academic aspects of the course; that is, the teaching across the entire course could be perceived more positively. In addition, if clinical practice educators are able to effectively relate their teaching sessions to academic material taught in classroom settings, this could have a positive impact on the academic self-perception or the academic learning experience of the students (Lambert & Glacken, 2005). There are many possible links.
Until an empirical link is demonstrated between clinical educator performance and academic and clinical education learning environments in health professional courses, any inferences drawn between these constructs can only be at best speculative. However, if a credible link can be demonstrated, this would add insights when considering these factors. This study investigates the link between health professional students' perceptions of their clinical fieldwork educators' performance and their perceptions of their clinical fieldwork education and academic learning environments.
A prospective, cross-sectional survey design using a standardized self-report scale was conducted.
Participants included 548 students (response rate: 54.5%) enrolled in undergraduate health professional programs offered at Monash University, Australia, in 2008–2009, whose courses consisted of academic education classes and clinical fieldwork placements. This included students from bachelor degrees in occupational therapy (76), physiotherapy (33), emergency health (paramedics) (60), midwifery (37), nutrition and dietetics (31), pharmacy (116), social work (78) and radiography and medical imaging (114). Three students did not indicate what course they were enrolled in. Courses are four years in length, with the exception of midwifery and emergency health (three years in length) and social work (two years of social work courses plus two years of related tertiary studies in length). Nursing students from Monash University were not included as participants because they were involved in another study.
Convenience sampling was used to source participants from each discipline. Inclusion criteria for participants were: (i) being enrolled at Monash University in a health professional program; (ii) providing consent to take part in the study; and (iii) having completed at least one fieldwork education clinical placement/practicum.
The DREEM is a 50-item self-report questionnaire designed to assess students' perspectives of the educational environment within health professional and medical schools. The DREEM is a validated and reliable inventory (Roff et al., 1997; 2001) and has been used in many studies of healthcare education throughout the world (Roff, 2005). High internal consistency has been reported independently, with Cronbach's alpha levels of 0.91 (Roff et al., 1997) and 0.93 (de Oliveria Filho et al., 2005), respectively. Evidence of the DREEM's construct validity was demonstrated via the initial factor analysis results when it was created (Roff et al., 1997). Convincing convergent validity evidence has recently been demonstrated (r = 0.66) when correlated with the Düsseldorf Mission Statement Questionnaire (Ostapczuk et al., 2012).
The DREEM items are in the form of statements relating to the respondent's course environment (e.g. I am encouraged to participate in class), which are rated via a five-point Likert scale, where 4 = strongly agree and 0 = strongly disagree. Several items are worded negatively (e.g. Cheating is a problem in this school), and are reversed scored before tallying subscale totals. Item scores count toward an overall environment score, as well as one of five subscales or domains (maximum subscale scores are in parenthesis): students' perceptions of learning (48), students' perceptions of teaching (44), students' academic self-perception (32), students' perception of atmosphere (48), and students' social self-perception (28). The overall DREEM score is out of 200.
The CLEI is a self-report scale where students rate various aspects of their clinical learning environment (referred to as the actual version of the CLEI), and provide equivalent ratings for what would be their ideal environment (referred to as the ideal version of the CLEI). The CLEI actual and ideal versions are separated into two parts (Chan, 2001; 2002). Each part includes the same 44 items (e.g. Staff are often punctual), which students are asked to rate on a four-point Likert scale, from “strongly agree” to “strongly disagree”. Some items (e.g. This is a disorganized clinical fieldwork placement) are worded negatively and are reverse scored accordingly by the researcher. The CLEI has demonstrated satisfactory scale reliability, with Cronbach's alpha ranging from 0.73 to 0.84 for the actual subscales, and 0.66 to 0.80 for the preferred subscales (Chan, 2003). Evidence of the CLEI's validity has been reported (Chan, 1999; 2001).
The CTEI is a 15-item self-report measure through which medical, nursing, and allied health students can rate aspects of their clinical fieldwork placement. Items relate to the behavior and performance of their clinical educators. This provides insights from the students' perspectives on factors about the clinical educators that facilitate or inhibit their learning experiences. Authors have claimed that the CTEI is reliable after noting that inter-trainee ratings for the same educator correlated strongly (between 0.74 and 0.95) (Chan, 1999; 2001; 2002; 2003). Bierer & Hull, 2007 Internal consistency has also been shown to be high, indicated by a Cronbach's alpha of 0.97 (Copeland & Hewson, 2000; Bierer & Hull, 2007). Construct validity has also been reported for the CTEI (Bierer & Hull, 2007).
Statements relating to the educator (e.g. Gives clear explanations/reasons for opinions, advice, actions etc.) are rated on a five-point Likert scale, from “never/poor” to “always/superb”. A “don't know/not applicable” option is also available. The CTEI scores for each participant are calculated as their mean rating for all 15 items.
Ethics approval for the study was granted by the Monash University Standing Committee on Ethics in Research Involving Humans. Participants received an explanatory statement detailing the study, and were informed that all data collected would be de-identified. Participants' consent to take part in the study was inferred by their completion of the questionnaire.
At the conclusion of a lecture during semester period, the DREEM, CLEI, CTEI, and a brief demographic questionnaire were distributed to students in each health professional course. For the CTEI, instructions were provided to answer the questions in relation to all of their clinical placements for that year to date, as opposed to a specific clinical educator, setting, or interaction. A non-teaching member of staff facilitated the process and collected the completed surveys. No follow ups were undertaken.
Raw data from all three scales were entered into IBM SPSS Statistics 20 (IBM, Armonk, NY, USA), and variables were created for each relevant subscale score. A standard multiple regression analysis was used to assess the ability of the five DREEM subscales and the six CLEI actual subscales (e.g. independent variables) to predict the CTEI score (e.g. dependent variable) among undergraduate students from a range of health professional courses. Preliminary analyses were conducted to ensure that no violation of the assumptions of normality, linearity, multicolinearity, and homoscedasticity was present (Weisberg, 2005).
This study investigated the extent of any predictive relationships between clinical fieldwork educator performance within health professional courses, as measured by the CTEI (the dependent variable), and the clinical fieldwork education and academic learning environments, as perceived by the same students and measured by the CLEI actual and DREEM (the independent variables). The findings indicated that student-rated clinical fieldwork educator performance explained 40% of the variance in students' perception of clinical fieldwork education and academic learning environments. However, the extent of the relationship varied across the various components of these two learning environments.
DREEM versus CLEI actual subscales as predictors of the CTEI
Across the DREEM and CLEI actual instruments, nine of the 11 subscales correlated positively with the CTEI scores; however, most of these coefficients were very low. All were represented by R2 coefficients of below 0.25, and only five were statistically significant to P < 0.05 (3 were significant to P < 0.01). Generally, the CLEI actual subscales correlated more strongly with the CTEI score, with four of the five significant correlations involving a CLEI actual subscale.
The findings indicated that clinical fieldwork educator performance was only slightly associated with a few aspects of health professional students' learning environments. It also appeared that the predictive relationship was stronger for aspects of the learning environment within the clinical fieldwork education setting in particular. This was perhaps not surprising, that the performance of clinical fieldwork educators would be more strongly related to the setting in which they teach and where students complete their practice education placements.
DREEM subscales as predictors of the CTEI
Despite a general trend of positive correlations, only one DREEM subscale correlated significantly with the CTEI score; that was academic self-perception, which explained 1.1% of the variance in the CTEI score.
Notwithstanding the fact that the DREEM and CTEI focus on different components of the education setting (e.g. academic and clinical fieldwork), a greater degree of cross-over and generalization between the two environments might have been anticipated. That is, a proficient clinical fieldwork educator's capacity to contribute towards a positive learning environment might be expected to carry over to the academic classroom setting. In addition, a positive learning environment within the academic setting could help facilitate a positive perception of clinical instructors' performance.
Ideally, clinical fieldwork educators would be familiar with the academic curriculum that students they supervise are completing, and would assist the students to make links between what they observe and experience in the clinical fieldwork setting and what they have studied in the academic classroom context. As noted by Kirke et al. (2007, p. S17), “Competent fieldwork educators acknowledge that competent practitioners are not ‘one size fits all’ but exemplify a diversity of styles and therapeutic approaches”.
A contrasting view is that students could, to a degree, juxtapose their clinical fieldwork experience with their academic one. That is, a positive clinical fieldwork learning environment could make the academic learning environment appear less positive by comparison, or vice versa. If such a phenomenon was true, we might have seen a trend of negative relationships between the CTEI score and DREEM subscale scores, at least if this phenomenon outweighed any positive relationship due to the cross-over or generalization between academic and clinical education settings.
CLEI actual subscales as predictors of the CTEI
Four of the six CLEI actual subscales positively correlated with the CTEI score at a significant level, and three of these were significant at P < 0.001. R2 coefficients indicated that clinical educator performance explained 6.2% of the variance in innovation, 5.1% in task orientation, 1.7% in satisfaction, and 1.1% in personalization.
These results indicate that clinical educator performance is related to several aspects of the perceived learning environment of clinical placements within health professional courses. While the reported effect sizes were generally low by conventional standards, it is worth remembering that the CTEI evaluates overall clinical fieldwork educator performance, not just fieldwork educators' performance with regard to facilitating students' levels of innovation, for example. Given that the six CLEI actual subscales purport to represent different constructs, the very fact that the CTEI is related to a given CLEI subscale limits the potential strength of relationship that it might have with another CLEI actual subscale. That is, specific CTEI items that might have strengthened the relationship between this scale and the innovation subscale might have diluted the relationship between the CTEI and the satisfaction subscale.
It is noteworthy that four of the six CLEI actual subscales are significant positive predictors of the CTEI. This demonstrates that clinical fieldwork educators in the health-related professions, through their actions, feedback, supervision, and performance, contribute significantly towards their students' perceptions of most aspects of their clinical fieldwork learning environment. As noted by Bonello (2001, p. 95), “Within the context of both traditional and innovative models of supervision, the fieldwork educator plays a critical role in developing an optimal learning environment”. Further, in light of literary evidence that a positive learning environment can lead to increased satisfaction, achievement, and success as a practitioner (Till, 2004), it could be inferred that the performance of clinical fieldwork educators contributes, in part, to the outcomes of future health science practitioners.
Dunn and Hansford (1997) used the Clinical Learning Environment Scale (CLES) to investigate 229 student nurses' perceptions of their clinical learning environment. Five factors were identified using the CLES: staff–student relationships, nurse manager commitment to teaching, patient relationships, hierarchy, and ritual. Smedley and Morey (2010) used the CLEI to collect data from 55 senior Bachelor of Nursing students about perceptions of their clinical learning environment. The findings indicated that the nursing students identified the CLEI actual personalization and student involvement areas as the most significant in generating suitable clinical education environments. Similar to Smedley and Morey (2010), nursing students from Australia (Chan, 2002) and Hong Kong (Ip & Chan, 2005), who completed the CLEI, both rated its actual personalization and student involvement scales the highest in relation to clinical education environments.
Personalization indicates that opportunities for individual students to interact with clinical teachers are emphasized, and that fieldwork supervisors have a genuine concern for students' personal welfare (Chan, 2002). Using a qualitative methodology Hummell (1997) investigated what the perceptions of Australian occupational therapy students were of effective clinical fieldwork supervisors: “The two major characteristics of effective fieldwork supervisors identified by the students were well-developed interpersonal skills and the use of collaborative and facilitatory teaching/learning strategies” (Hummell, 1997, p. 147). Similarly, interpersonal relationships were identified as being a very significant factor in the clinical learning environment by Dunn and Hansford (1997). This could potentially have an impact on students' experience of personalization while completing fieldwork placements. In their review of effective clinical teaching, Irby et al. (1987) listed accessibility, enthusiasm, clarity, knowledge of the discipline, role-modelling, demonstrating clinical skills, and taking the time for teaching as key traits of effective clinical fieldwork educators. Again, these traits would promote personalization of students' learning experience in clinical and practice education settings.
Satisfaction is viewed as the extent of enjoyment that a student experiences while completing a clinical fieldwork placement (Chan, 2002). Hummell noted that students' perceived effective clinical fieldwork supervisors as being “active listeners, empathetic, supportive, flexible and exhibited enthusiasm about the supervisory role” (1997, p. 154). No doubt a clinical fieldwork supervisor possessing these traits would have an impact on satisfaction with the clinical teaching and fieldwork experience of health professional students. Smedley and Morey (2009) applied the term “community of practice” (originally coined by Wenger, 1998) to describe the integration of students into a clinical/professional fieldwork setting, and “infers a place of co-operation, kinship, caring, support, understanding, unity and inclusiveness” (p. 76). Fostering a community-of-practice approach to student clinical education could potentially promote a sense of satisfaction for students.
It is perhaps not surprising that the CLEI innovation subscale was among the strongest predictors of CTEI scores, as this construct is described as representing the teaching techniques and the clinician's planning of new, interesting, and productive experiences at the clinical site (Chan, 2002). These could be considered features of proficient clinical fieldwork educator performance. According to Hummell (1997), effective clinical teachers were seen as collaborators who shared their practical knowledge, gave clear explanations, and encouraged students to explain their clinical reasoning and problem solving: “They were perceived as skilled clinicians who behaved in a professional manner and provided clear, accurate and constructive feedback and evaluation in a supportive manner” (Hummell, 1997, p. 154). Clinical fieldwork educators who exhibited these traits could be viewed as innovative in their supervisor approach.
The subscale with a similar predictive strength was task orientation, which represents how clear and well organized the learning activities are for students at the facility or agency providing the clinical fieldwork placement (Chan, 2002). While it is not necessarily the case that individual clinical fieldwork educators have control over the organization of teaching activities at the health facility, it is possible that this is often viewed by the students in this way. That is, proficient clinical fieldwork educators have the capacity to, and do, organize teaching activities at the health facility well. Hummell (1997) reported that effective supervisors generate a learning environment where students felt at ease to ask questions, as well as to develop, practise, and refine abilities and roles that were important for clinical and professional practice.
It should be noted that one challenge that clinical fieldwork educators face is balancing the dual role of being an educator and continuing to be a service provider. Clinical fieldwork educators have to provide optimal learning opportunities for students, plus maintain the professional service requirements of their job. Other challenges include competing demands, opportunistic teaching, increasing numbers of students, lack of time for student supervision due to heavy clinical caseloads, and under-resourcing (Lambert & Glacken, 2005). Another issue noted by Papp et al. (2003, p. 267) was that the “clinical environment is constantly changing and sometimes very unpredictable, which makes it hard to plan an optimal clinical learning environment for students”. These factors might potentially impact on students' perceptions of task orientation.
Limitations and recommendations
While this study has provided a valuable insight into the relationship between clinical educator fieldwork performance and aspects of the perceived learning environment within a range of health professional courses, there are a number of ways in which this investigation could be taken further. First, it would be useful to explore some of the DREEM and CLEI subscales in more detail to address the following questions: Can some of the stronger relationships found in the present study be replicated? Do these subscales represent constructs that should logically be more closely related to educator performance than others? Are there other factors besides clinical fieldwork instructor performance (e.g. lecturer performance, curriculum or class size) that relate more closely to the other subscales?
Second, it would be worthwhile exploring if the strength of the relationships found is consistent across the various health professional disciplines and different institutions. It is possible that some courses or universities, more than others, lend themselves to a situation where the clinical fieldwork educators have more impact on the clinical and/or academic learning environments. Third, this study could be extended to nursing, optometry, podiatry, speech therapy, dental, and medical students, as these courses constitute a similar combination of academic and clinical fieldwork education settings.
A final consideration is that, for ethical reasons, convenience sampling was used to recruit participants. This might have inflated scores, as those who were present at the time of administration might have felt more positively towards their course and/or their clinical educator's performance than those who were absent. Alternatively, it might have deflated the scores, as those with less satisfaction might have been keener to take part in order to voice their grievances. While convenience sampling is the norm for studies using these instruments, it is difficult to gauge the impact this has on subscale and total scores, and subsequently the relationships between them.
Conclusion and summary
Clinical fieldwork educators play a key role in the education of health professional students by contributing to the positive learning experience of students, and subsequently, the outcomes of future health practitioners. This study provides evidence that the performance of clinical fieldwork educators in health professional courses is positively related to students' perceptions of most aspects of their clinical fieldwork learning environment and some aspects of their academic learning environment. This study provides empirical evidence of this significant link, and it is recommended that further research be completed on this topic.