Factors associated to clinical learning in nursing students in primary health care: an analytical cross-sectional study

ABSTRACT Objective: to identify the students' perception about the quality of clinical placements and asses the influence of the different tutoring processes in clinical learning. Methods: analytical cross-sectional study on second and third year nursing students (n=122) about clinical learning in primary health care. The Clinical Placement Evaluation Tool and a synthetic index of attitudes and skills were computed to give scores to the clinical learning (scale 0-10). Univariate, bivariate and multivariate (multiple linear regression) analyses were performed. Results: the response rate was 91.8%. The most commonly identified tutoring process was "preceptor-professor" (45.2%). The clinical placement was assessed as "optimal" by 55.1%, relationship with team-preceptor was considered good by 80.4% of the cases and the average grade for clinical learning was 7.89. The multiple linear regression model with more explanatory capacity included the variables "Academic year" (beta coefficient = 1.042 for third-year students), "Primary Health Care Area (PHC)" (beta coefficient = 0.308 for Area B) and "Clinical placement perception" (beta coefficient = - 0.204 for a suboptimal perception). Conclusions: timeframe within the academic program, location and clinical placement perception were associated with students' clinical learning. Students' perceptions of setting quality were positive and a good team-preceptor relationship is a matter of relevance.


Introduction
The European Union (EU) policy on nursing education has been changing procedures in nursing schools around Europe, aiming to unify the educational structure and guarantee equality in professional qualification. According to EU recommendations, at least 50% of the total hours from nursing studies has to be completed with clinical practicum experiences (77/453/ CEE), and students must be supervised by a professional nurse in these practice sessions (1).
New learning models also emphasize the importance of practicum settings with the purpose of achieving an adequate competence development by the student (2).
The clinical placement, or clinical location, has been defined as the interactive network of forces within the clinic that has an influence on the clinical results of students' learning (3). It is known that not every clinical placement can provide nursing students with a positive learning environment(4), and, considering that students spend a significant part of their training in these settings, an evaluation of this scenario and the feedback of students about the quality of their learning, should be a priority for those involved with nursing education (5).
The literature shows that the quality of the learning environment is dependent on a variety of factors, including characteristics of clinical placement, the degree of compatibility to the learning objectives and the capacity to provide opportunities for students to learn, as well as the relationship among students, health professionals and university faculty(6). The feeling of recognition/attachment in the clinical learning placements and an authentic relationship of students with the tutors and health team members are considered as key elements to stimulate students´ self-confidence and reliability, which favors the learning process (7).
Factors that students identify as learning facilitators include the promotion of responsibility and autonomy, provision of opportunities to perform different tasks, provision of support, as well as feedback of students´ performance from preceptors and professors (8).
Variables considered to hinder the learning process include lack of trust in nursing students shown by preceptors, discontinuity in supervision, scarcity of opportunities to perform practical procedures, and feelings of inadequacy and low self-confidence among students(9).
The students' perceptions about the learning setting quality and the tutoring model can provide valuable information to educators related to the learning process in the clinical practicum environment. However, it should be pointed out that few assessment tools have been developed to investigate such perceptions (10).
In addition, tutoring models can influence the learning process within clinical placement. Among the many different tutoring model definitions found in the literature, the preceptorship model, in which a student is under the supervision of a registered nurse, is one of the most frequent for nursing education (11). The outcomes of the tutoring models for clinical learning are also an issue that needs further investigation, especially when it come to Primary Health Care (PHC) practicum experiences (12) .
The aim of the present study was to assess students´ perceptions on the quality of clinical placements in PHC and to evaluate the influence of different tutoring processes on student learning. Each student had a preceptor who was responsible for his/her supervision during clinical learning. The preceptor was a registered nurse working in PHC services, who "assumed voluntarily the responsibility of clinical and practical learning of students within his/her working place during his/her working hours; by planning, coordinating and evaluating the learning process" (13) .

Methods
Besides the preceptor, the professor was also involved with the clinical practicum experience. The professor was a faculty member who coordinated and supervised the clinical learning process in its entirety, ensured communication between student and preceptor, and acted as a learning facilitator.
A synthetic Score (14) , from 0 to 10, was calculated to grade the clinical learning. By using a structured questionnaire, preceptors evaluated students' attitudes and skills in the clinical placement, during home visits and related to nursing procedures (comprising 40% of the synthetic score) and the student conducted a selfassessment (comprising 15% of the synthetic score).
Two written assignments were graded by the responsible professor, one focused on a clinic case (25% of the score) Serrano-Gallardo P, Martínez-Marcos M, Espejo-Matorrales F, Arakawa T, Magnabosco GT, Pinto IC. and the other focused on a health situation analysis in the health area (20% of the score). This synthetic score was applied and validated in a previous study (14) . We also considered the final grade of "Community Nursing" subjects, which consisted of a written test scored from 0 to 10 to describe students' performance.
The tutoring model was defined as the supportive process provided during clinical learning, characterized by evaluation meetings, the use of active teaching strategies, and active communication among students, preceptors and professors (2) . In order to define an operational definition of tutoring model, we used a the original tool was adapted and validated (14) for Spanish language and culture; presenting a Cronbach's alpha value of 0.89 (15) . In this CPET version, a lower score means a better setting perception. An optimal perception of the clinical placement was considered for those scores below the 50th percentile value, and a suboptimal perception was considered for those scores above the 50th percentile value (16) .
The CPET questionnaire was provided to students at the last day of the clinical learning period. Students were oriented to fill out the questionnaire within 48 hours and delivered it to the professor who coordinated the clinical learning. The dummy variables were considered significant even if some categories had not presented a p-value of £ 0.05 (17) . Confidence intervals (95%) were estimated.
The SPSS v.17 software was used.
The study was conducted according to the ethical guidelines of the Declaration of Helsinki. To carry out the study, institutional permissions were obtained. The study objectives and procedures were previously explained to the students and ethical procedures with data management were followed strictly. As students may be considered a vulnerable population, the participation was voluntary and informed consent was obtained from all subjects who agreed to participate.

Results
The response rate was 91.8% (n=112). The  Table 1).   Regarding the CPET items, a higher level of agreement was identified in the following items: "There was a good relationship between the team and me" (80.4%; n=90), "I had a good working relationship with the preceptor" (77.7%; n=87) and "I was motivated and eager to learn" (77.5%; n=86). A lower level of agreement was identified in the items: "The team explained the procedures to me" (52.7%; n=59), "Nurses informed me about their patients' cares" (52.7%; n=59), and "The team encouraged me to ask questions" (38.4%; n=43) ( Table 2).
The highest grades in clinical learning in the bivariate analysis are related to women, third-year students, PHC Area B, tutoring process "professorstudent" and clinical placement perceived as optimal.
However, statistical significance was found only for the "academic year" (7.17 in second year and 8.36 in third year, p<.001) and "PHC Area" (7.44 in area A; 8.01 in area B and 7.86 in area C, p=0.03) ( Table 3).
Other authors have noted that communication and cooperation are the basis of adequate supervisory relationships (11) . Further, Bisholt et al. Higher clinical learning showed by third-year students could be explained by the fact that those students had been using a reflective methodology based on self-assessment for two years (during the second and third year) as opposed to second-year students who had only used it for a year. This coincides with the conclusions obtained in a literature review (22) showing that reflective activities provide opportunities to students for critical thinking development and tools for self-learning. In addition, Brugnolli and colleagues point out that an effective preceptorship is the one that includes a reflective work process, highlighting the active role of students guiding their own learning process (23) .
Regarding the PHC Area where clinical learning was performed, this study does not allow us to clarify why the area influences clinical learning in a relevant and independent way. It is important to mention that there were no significant differences among those PHC Areas included in the study related to the academic year, the tutoring process they performed, and the student perception about the clinical placement they had. Some other factors described in the literature but not included in this research, such as an appropriate