Validation of a questionnaire designed to measure nursing student satisfaction with practical training

Objective: to validate an instrument designed to assess practical training and measure nursing student satisfaction with clinical practice modules. Method: cross-sectional study (academic year 2014-2015). Validation of the self-administered, anonymous, 17-item Nursing Student Satisfaction with Practical Training Questionnaire, developed by consensus by eight practical training experts in three nominal group sessions. Exploratory and confirmatory factor analyses were performed to assess internal consistency and validity. Student satisfaction was measured in relation to each module and all modules as a whole. Results: 174 responses. High item-test correlation (≥0.90); Cronbach’s alpha = 0.91; Káiser-Meyer-Olkin index =0.86; the results of the Bartlett sphericity test were statistically significant (p<0.001); S-stress=0.17; R2=0.81. Exploratory factor analyses identified 4 factors: simulation, teacher tutoring, care facility selected for the placement, and clinician tutoring. Total explained variance was 66.6%. Confirmatory factor analysis obtained a chi-squared value of 285.275 (p= 0.000). Student satisfaction increases proportionately with each academic year. Conclusion: the questionnaire was shown to have good validity and is therefore a reliable instrument for measuring level of nursing student satisfaction with practical training in both clinical and simulated environments.


Introduction
One of the main challenges facing teachers and students in the field of health sciences is combining theoretical and practical knowledge, given the importance of the latter in the design of academic disciplines. Nursing science should incorporate practical nursing knowledge based on a rationale that draws on that which is already known and that which is acquired from practical experience. This requires a dialectic that combines reflection in action, with action, and for action played out in practical contexts marked by continuous decision-making to promote the development of judicious, critical, and reflective professionals (1) .
As other authors suggest, this reflection should be the bridge that unites what is set out in the academic curriculum and that which later constitutes professional development (2)(3) . This learning, framed within a critically reflective perspective developed by the subjects who take part in the teaching and learning process, constitutes the central objective of new pedagogical approaches and a challenge that enables professionals to create, change, redo, take risks, experiment, succeed, and fail (3) . Directive (5)(6)(7) .
The clinical learning process should enable students to develop reflective practice competencies that integrate the application of knowledge with skills and attitudes in real-life clinical situations and encourage them to reflect, internalize, and socialize professional values. At the same time, it should help students to identify components of the so-called "hidden curriculum" (meanings, characteristics and, in some cases, power relations) (8) . By caring for people during their practical training, students make sense of the theory learned in the classroom, contextualizing it in the time spent in care facilities and in the time spent studying and reflecting (9) .
Tutoring by clinicians is key to student learning.
Tutors should be capable of taking students on a reflective journey through theoretical and practical knowledge (9)(10) . They should also promote reflective debate in the classroom on students' perceptions and problem-solving with the teachers responsible for the modules, encouraging reflective dialogue on actions undertaken in the care facilities. It is about stimulating students to investigate, search, and reflect on the practices learned.
There is no doubt that students undergo a process of evolution during the learning process which can often lead to stress; however, at the same time this process contributes to the transition that takes place between uncertainty in the first clinical practice modules and the sense of security students acquire towards the end of the course. A study with nursing students from a Spanish university showed that the greatest impact occurs in the realm of interpersonal relationships and behavior (11) .
In Spain, there are few validated instruments for measuring nursing student satisfaction with practical clinical training. We were unable to find an instrument that measures overall satisfaction with practical training in both real-life and simulated environments.
A study that translated and validated the Clinical Learning Environment, Supervision and Nurse Teacher Evaluation Scale for use with Spanish students at the University of Alicante showed that the instrument had satisfactory psychometric properties for measuring student satisfaction in clinical environments, rather than simulated environments (12) . In terms of student satisfaction with practical training in simulated environments, we found a study conducted in Portugal that validated a questionnaire developed by the authors showing that the instrument had good validity and reliability (13) .
Given the importance of clinical practice modules for the student learning process and the lack of instruments for measuring student satisfaction, this study sought to develop and validate a questionnaire for measuring students' opinions on practical training in both real-life and simulated environments. The main objective of the study was to assess the content and construct validity and reliability of the questionnaire, while the secondary objective was to determine the level of student satisfaction with the teaching methods implemented after the application of the Bologna agreements.  Each module consists of face-to-face study (80%) and non-face-to-face (autonomous learning) study (20%). Face-to-face study includes stays in health facilities, attendance at workshops, seminars, and learning activities tutored by teachers and clinicians (5) .

Method
The study population was all students in the Degree in Nursing taking practice modules in the second, third, and fourth years during the study period. Sample size was calculated based on a minimum of 100 respondents (14)(15) and a minimum of 10 respondents per scale item (16) . The questionnaire was distributed to all students taking practice modules in a hospital setting. The data was analyzed using descriptive statistics (frequencies and percentages) using the variables academic year and module. Mean and standard deviation was then calculated for each item.
Internal consistency was measured using the itemtest correlation, calculating Cronbach's alpha for each deleted item and the 17 items as a whole using methodologies previously used by other authors (17)(18)(19) .
Exploratory factor analysis was preformed to identify the latent variables of the questionnaire, of the exploratory factor analysis. This type of analysis provides more specificity for hypothesis testing.
Confirmatory factor analysis was used to determine the validity of each item and identify common factors, verifying the contrast statistic of the hypothesis, as well as the analysis of covariance instead of correlation. The results of the nonparametric method used for multidimensional scaling using the alternating least squares algorithm were as follows: for the matrix: S-stress = 0.1675; and coefficient of determination Principal component analysis was followed by the application of varimax rotation to reduce the number of variables with high factor loadings. Four factors were selected and total variance and the percentage of variance explained by each factor was calculated. Factor 1 (simulation), comprising 6 items (12,13,14,15,16,17) related to the dimension practice in "simulation", explained 41.6% of total variance; factor 2, consisting of 4 items (1,3,4,10) related to "teacher tutoring process", explained 10.1% of total variance; factor 3, composed of 4 items (7,8,9,11) related to the "selected health facility", explained 8.3% of total variance; and factor 4, made up of 3 items (2,5,6) related to the "clinician tutoring process", explained 6.6% of total variance (Table 2).
Total explained variance was 66.6%. Based on the recommendations of several authors (15,(23)(24) , for the model to be accepted the p-value should be > 0.05, since the null hypothesis states that the model is not significant (Figure 1).
K-means clustering was used to measure satisfaction for each dimension of the questionnaire.       Overall level of satisfaction with the practice modules A A

10
Practice module monitoring and evaluation process was adequate A

11
Level of previous knowledge prior to doing the practice module A

12
Information received (theoretical/practical-laboratory content, simulation…) A B

13
Methods used by teachers in the weekly clinical sessions (presentation, audiovisual media, review of care plan, material…) A B

14
Teacher's knowledge of the topics and clarity of explanation A B

15
Duration of clinical sessions (presentations and practices) was adequate A B

16
Organization and planning of clinical sessions/module monitoring and control A B

17
Usefulness of the skills acquired during practical training, laboratory, simulation, problem-based learning, etc. for clinical practice A A properties. The fact that it is possible to measure both learning environments using a single instrument is one of the strengths of this study.
Student growth and development promotes progress and the transition to professional practice and therefore strategies designed to teach practical skills should be developed as a single, natural, progressive, and inseparable process. As such, these strategies should be measured as a whole, since it is student progress that enables the development of both the formal and the so-called hidden curriculum (8) . fourth and final year, when student practice most closely resembles professional practice. These findings are in line with those of a previous study (11) , confirming that nursing student learning is progressive, involving a gradual transition from uncertainty in the first practice modules to a sense of security in the final stages of the course, which supports our consideration regarding the evolution of student satisfaction.
The findings also show that the level of satisfaction was high for all dimensions, most notably for the health facility assigned for acquisition of clinical competencies.
Satisfaction percentages of over 59% show that the majority of students are satisfied, both overall and for each dimension of the questionnaire. It is interesting to note that, although relatively high (59.8%), the dimension that obtained the lowest level of satisfaction was clinician tutoring.
This dimension shows room for improvement, given that other authors have reported that students view tutoring by clinicians as a vital component of their training (9,12,(26)(27) .
The main contribution of this study to the body of knowledge in this area is that it provides a validated tool for evaluating clinical learning processes in dual environments (real-life and simulated), thus filling a current gap, given the lack of validated instruments adapted to evaluate practice modules in courses in mixed environments in the field of health sciences.
One of the limitations of this study is that our findings do not confirm the validity and robustness of the CSPEE for measuring satisfaction with practical training in other health facilities and other disciplines in the field of health sciences. In this respect, further research is needed to assess the validity of this instrument for courses in areas such as medicine, physical therapy, chiropody, and dentistry.

Conclusion
The main contribution of this study is that it was able to integrate the measurement of student satisfaction