A Pre-Post Survey Study

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Contents lists available atScienceDirect

Nurse Education Today

journal homepage:www.elsevier.com/locate/nedt

The relationship between the undergraduate clinical learning environment and work readiness in new graduate nurses: A pre-post survey study

Mietta Dudley

^a,b

, Damien Khaw

^b,c,^⁎

, Mari Botti

^b,c

, Anastasia F. Hutchinson

^b,c

aEpworth HealthCare, Victoria, Australia

bSchool of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia

cCentre for Quality & Patient Safety Research Epworth HealthCare Partnership, Melbourne, Victoria, Australia

A R T I C L E I N F O Keywords:

Nursing education research Graduate nursing education Health workforce

Clinical learning environment Work readiness

Work preparedness Follow-up studies Self report

A B S T R A C T

Background:Due to projected nurse shortages, it is necessary that undergraduate programs optimise work readiness outcomes in new graduate nurses. Research that quantitatively evaluates characteristics of clinical nursing programs that predict increased work readiness is required.

Objectives:To explore the relationship between the undergraduate clinical learning environment and nurse perceptions of work readiness prior to and following, commencement as a new graduate nurse.

Design:A pre-post follow-up study. Undergraduates were surveyed at the end of their Bachelor's degree (baseline) and at 8–10 weeks after commencement as a graduate nurse (Time 1).

Setting:A multi-site, metropolitan private hospital in Victoria, Australia.

Participants:Nursing graduates who completed a university fellowship program (n= 26), or were undertaking their graduate year and had completed placement blocks within (n= 18) or outside (n= 31) the healthcare organisation.

Methods:Participants self-completed the Clinical Learning Environment Inventory (CLEI) and Work Readiness Scale for Graduate Nurses (WRS-GN) at baseline and Time 1. Multiple regression analyses were performed.

Results:CLEI scores significantly predicted work readiness outcomes (all p-values < .05), accounting for 16–36% and 17–28% of the variance of WRS-GN scores at baseline and Time 1, respectively. After adjusting for clustering due to clinical placement groups, CLEI Individualisation (p = .023) and Valuing Nurses Work (p= .01) predicted improved Time 1 WRS-GN Organisational Acumen. CLEI Innovative and Adaptive Culture scores predicted poorer Time 1 Organisational Acumen (p= .001).

Conclusions:Learning environments that offered high levels of individualised attention and valued nurses' work appeared to facilitate post-graduation engagement and identification with nursing practice. However, highly innovative and adaptive education may detract from optimal work readiness. Findings revealed that while important, the clinical learning environment only accounted for a small-to-moderate degree of nursing graduates' work readiness. To facilitate robust evidence-based improvement of clinical nursing education, future research should attempt to empirically establish the value of additional facilitators of work readiness.

1. Introduction

A fundamental objective of undergraduate nursing education is to cultivate a workforce capable of delivering high-quality, skilled patient care (Australian Nursing and Midwifery Accreditation Council, 2019;

Nursing and Midwifery Council, 2018a). However, due to the aging population and increasing demand for health services within Australia and internationally, a substantial shortage in the nursing labour force is expected to emerge within the current decade (e.g.,Health Workforce

Australia, 2014; Snavely, 2016). To help mitigate the effects of this projected shortfall, there is a need to maximise training efficiency in undergraduates, to ensure new nurses have an optimum degree of work readiness.

In the absence of consensus concerning approaches to undergraduate clinical placements, universities and health services have ex- perimented with various clinical placement models that aim to enhance students' work readiness upon graduation (Berndtsson et al., 2020;

Franklin, 2013). It is commonly recognised that a high quality

https://doi.org/10.1016/j.nedt.2020.104587

Received 29 January 2020; Received in revised form 22 July 2020; Accepted 25 August 2020

⁎Corresponding author at: Centre for Quality & Patient Safety Research Epworth HealthCare Partnership, 185-187 Hoddle Street, Richmond, Victoria 3121, Australia.

E-mail address:[email protected](D. Khaw).

T

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undergraduate clinical learning environment is fundamental to equip nurses for clinical work, by allowing students to bridge the gap between theory and practice and consolidate clinical skills (e.g., Flott and Linden, 2015; Walker and Campbell, 2013). However, few empirical studies have examined facilitators of work readiness in nursing clinical education – except for studies evaluating outcomes of local clinical placement models (Nash et al., 2009;Patterson et al., 2017), the extant research has typically explored transitioning to clinical work qualita- tively (e.g., Connor, 2019; Hatzenbuhler and Klein, 2019; Milton- Wildey et al., 2014;Newton et al., 2011;Walker et al., 2013a;Watt and Pascoe, 2013). Despite requirements for extensive clinical placements (Australian Nursing and Midwifery Accreditation Council, 2019;

Nursing and Midwifery Council, 2018b), nursing graduates (Hatzenbuhler and Klein, 2019;Milton-Wildey et al., 2014), commen- tators (Bisholt et al., 2014), educators and managers (El Haddad et al., 2017) report a substantial difference between students' work readiness at the end of their undergraduate program and the expectations of healthcare organisations. To optimise student outcomes, additional quantitative research is needed to understand the elements of clinical placement programs that are likely to be associated with increased work readiness upon entry into the nursing workforce.

Some authors have suggested that acculturation into the social contexts of nursing work is critical to graduates' ability to smoothly transition into professional practice (Connor, 2019; Walker and Campbell, 2013). Entry into the workforce by novice nurses has been associated with ‘transition shock’, acute stress related to navigating new professional relationships, roles, responsibilities and work-life balance, and adjusting to the physical demands of shift work (Duchscher, 2009;

Duchscher and Windey, 2018).

In 2005, our healthcare institution, a large multi-site, metropolitan private hospital located in Victoria, Australia, developed a collaborative model of clinical education (the ‘Fellowship Model’) that combines theoretical education and clinical placements at the health service and aims to socialise undergraduate nurses into the values, behaviours and expectations of the organisation. As nursing students enrolled in a range of traditional clinical placement programs are also part of the health service, we had an opportunity to explore the relationship between nurses' clinical learning environment and graduate work readiness across varied nurse education programs. We were also able to evaluate a fellowship clinical placement model that seeks to acculturate and retain graduates within a specific organisational environment. This paper reports a pre-post survey study that aimed to explore the relationship between nursing students' attitudes toward the undergraduate clinical learning environment and perceptions of their work readiness prior to and following, their employment as a graduate nurse.

Secondary aims of the study were to: describe their trajectory of perceived work readiness; comparatively evaluate the quality of the clinical learning environment and perceived work readiness associated with the Fellowship Model and other undergraduate education programs at the healthcare organisation.

2. Methods 2.1. Design

In this single-institution, pre-post study, we surveyed nursing graduates at the end of their undergraduate training (baseline) and during the first 8–10 weeks following commencement of their graduate year (Time 1). Students' perceptions of their clinical learning environment were evaluated at baseline. To investigate the possible effect of undergraduate clinical education programs, we measured change in self-reported work readiness between baseline and Time 1. Analyses were adjusted for relative differences in clinical education programs.

Three groups of undergraduate clinical education programs were identified: (1) the academic/health service ‘Fellowship Model’; (2) clinical education models that included placement blocks within the

healthcare organisation (‘internal clinical placements’) and (3) undergraduate education models in which nursing students undertook clinical placements in a broad range of public and private health services that did not include the healthcare organisation (‘external clinical placements’). Nurses in the Fellowship Model group completed their Bachelor of Nursing at the affiliated university. Nurses who completed internal or external clinical placements completed their Bachelor of Nursing through different universities and had experienced various models of clinical education during their undergraduate education.

2.2. Participants

Participants were third-year Bachelor of Nursing students recruited at the end of their preregistration nursing training program who completed the Fellowship Model program, or were undertaking a graduate year program at the healthcare organisation. Criteria for inclusion in the study were: (1) successful completion of the third year of a Bachelor of Nursing; and (2) completion of the fellowship clinical education program in November/December 2015, or commencement of a graduate nurse year in the beginning of 2016 at one of three hospital sites that had hosted the Fellowship Model program.

Human Research Ethics Committee (HREC) approval was gained from the healthcare institution and affiliated university via a low risk application process. We obtained written informed from all participants prior to data collection. Individually identifying information was stored separately from de-identified study data to enhance data security and minimise risks to participant privacy and confidentiality.

2.3. Measures

2.3.1. Clinical Leaning Environment Inventory (CLEI)

The CLEI is a multi-dimensional measure of student nurses' perceptions of their clinical learning environment (Chan, 2002). We employed the 40-item revised version of the CLEI, validated byNewton et al. (2010), in a longitudinal study of 513 Australian nursing students.

The revised CLEI comprises six subscales derived from principle com- ponents analysis: (1) Student-centeredness [Cronbach's α = 0.88]; (2) Affordances and engagement [α = 0.88]; (3) Individualisation [α = 0.65]; (4) Fostering workplace learning [α = 0.67]; (5) Valuing nurses work [α = 0.57]; and (6) Innovative and adaptive culture [α = 0.50]. Except for scales measuring Valuing nurses work and In- novative and adaptive culture, the internal consistency of instrument subscales, measured by Cronbach's alpha, was satisfactory (> 0.60;

Nunnally and Berstein, 1994). Items are scored on a four-point Likert scale ranging from strongly disagree to strongly agree (score: 1–4).

Negatively worded items were reverse scored so that higher subscale scores denote a more positive clinical learning environment.

2.3.2. Work Readiness Scale for Graduate Nurses (WRS-GN)

The WRS-GN is a 46-item measure of the perceived work readiness of graduate nurses (Walker et al., 2015). It is derived from the Work Readiness Scale (WRS), originally developed as a generic measure of work readiness in college graduates (Caballero et al., 2011). Four WRS- GN subscales were derived from exploratory factor analysis: (1) Work Competence [Cronbach's α = 0.88]; (2) Social Intelligence [α = 0.87];

(3) Organisational Acumen [α = 0.85]; and (4) Personal Work Char- acteristics [α = 0.84]. Total internal consistency of the WRS-GN is excellent (α = 0.92), and the internal consistency of individual subscales is high (α ≥ 0.8). Higher WRS-GN Personal Work Characteristics scores denote lower levels of perceived work readiness. Higher scores on other WRS-GN scales denote greater levels of perceived work readiness. WRS-GN scale scores were presented as the sum of con- tributing items.

In the present study, we employed a provisional version on the WRS-GN provided to us by the authors prior to its final development and psychometric testing in 2015 (Walker et al., 2015). Item wording

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was equivalent between instrument versions. However, to ensure compatibility with the final, published version of the WRS-GN, item responses on the provisional instrument were rescaled from a 5-point, to 10-point Likert scale. Social Intelligence scores were not measured in the present study as these items were not included in the provisional instrument.

2.4. Procedures

All final year nursing students completing the Fellowship program in 2015, or commencing their graduate year program at the healthcare organisation in 2016, were invited to participate. To minimise the risk of undue influence over students' decisions to participate, an independent researcher with no prior relationship with students (AH) contacted prospective participants by email or in person. Students' email contacts were provided by clinical education coordinators at the three study sites. A study information session was held on staff or- ientation days prior to commencing employment. Interested students were given a participant information and consent form, and written informed consent was obtained prior to completing the study surveys.

Participants were allocated a study ID number and were provided with paper copies of baseline and Time 1 surveys. Records of participants' names and study ID numbers were stored separately. Participants self- completed surveys and returned them to the research centre. To maximise rates of baseline data collection, the Fellowship group was also given the option of completing the baseline surveys at a scheduled group meeting at the study sites. Participants' study ID numbers were recorded on all returned surveys to coordinate data collection across time-points. To minimise rates of loss-to-follow-up, we sent participants a reminder email regarding follow-up surveys.

2.5. Analysis

Statistical analyses and data summaries were performed in Stata version 16 and SPSS version 25. Group comparisons were performed using parametric statistics and categorical variables were analysed with Chi-square Tests of Independence and Fisher's Exact Test. There was a small proportion of missing data in outcome variables (range: 0% - 5.3%), which was determined to be Missing Completely at Random (Little's MCAR test, p = .901). We imputed missing values using

Expectation-Maximisation (EM) (Enders, 2001).

2.5.1. Primary analyses: relationship between clinical learning environment and work readiness

Multiple regression was performed on CLEI subscales to predict self- reported work readiness at baseline and Time 1. Robust standard errors (SE) were used to adjust for clustering due to clinical placement group (StataCorp, 2019). To ensure adequate statistical power, only five of the six CLEI subscales were entered into regression models (n = 75 required; Stevens, 1996). CLEI Individualisation and Affordances and Engagement scores were removed from Baseline and Time 1 analyses, respectively, on the basis of hierarchical regression, and poor correlations with WRS-GN outcomes (r < 0.02). Pearson's r indicated no multicollinearity at Baseline (rrange [0.23, 0.72]) or Time 1 (rrange [0.03, 0.72]). Multivariate normality, linearity and homoscedasticity of residuals were assessed according to visual examination of residual scatterplots (Tabachnick and Fidell, 2013). Responses related to one multivariate outlier were removed from analyses of Time 1 Work Competence and Organisational Acumen.

2.5.2. Secondary analyses: comparative evaluation of clinical placement groups

Baseline CLEI scores were compared between groups using multivariate analysis of variance (MANOVA). Data were confirmed to meet the assumptions of MANOVA according to the procedures indicated by Tabachnick and Fidell (2013). The effects of a univariate (n= 1) and multivariate (n= 1) outlier were mitigated via trimming/winsorising and deletion, respectively. The CLEI Affordances and Engagement scale was multicollinear with the Student Centeredness scale (r= 0.72) and was heteroscedastic (Levene's Test,p= .043). Consequently, we analysed CLEI Affordances and Engagement with one-way Welch's ANOVA.

We investigated whether change in perceptions of work readiness after commencing the graduate year depended upon nurses' degree of baseline work readiness, defined as tertiles of WRS-GN work competence, organisational acumen and personal work characteristics scores.

Pre-post WRS-GN data were analysed using repeated-measures MANOVA. Due to significant skew (zskew = −4.23), Organisational Acumen scores were transformed using a power transformation.

Pearson's correlations indicated an absence of multicollinearity/singu- larity (r [0.08, 0.58]). All pairwise comparisons in MANOVA were Table 1

Baseline characteristics of all graduate nurse participants (n= 75).

Fellowship model

(n= 26) Internal clinical placements

(n= 18)^# External clinical placements

(n= 31)^# p-Value

Nurse characteristics

Female,n(%) 25 (96.2) 16 (88.9) 31 (100) .110^a

Age,Mdn(IQR) 24.1 (3.4) 22.9 (3.3) 23.5 (4.4) .635^b,c

Clinical learning environment (CLEI)

Affordances and engagement,M(SD) 37.3 (3.0) 35.7 (5.0) 33.9 (4.6) .007^d

Student centeredness,M(95%CI)^$ 40.9 (39.5, 42.4) 40 (38.2, 41.8) 38.0 (36.6, 39.4) .015^e

Individualisation,M(95%CI)^$ 9.7 (9.1, 10.2) 8.5 (7.8, 9.2) 8.0 (7.5, 8.5) < .001^e

Fostering workplace learning,M(95%CI)^$ 18.2 (17.2, 19.3) 18.1 (16.9, 19.4) 17.5 (16.5, 18.5) .567^e

Valuing nursing work,M(95%CI)^$ 13.9 (13.4, 14.5) 12.9 (12.3, 13.6) 13.2 (12.7, 13.7) .049^e

Innovative and adaptive culture,M(95%CI)^$ 8.5 (8.0, 9.1) 7.8 (7.2, 8.5) 7.4 (6.9, 7.9) .008^e

Baseline work readiness (WRS-GN)

Work competence,M(95%CI)^$ 107.3 (102.8, 111.8) 107.5 (102.2, 112.9) 109.7 (105.7, 113.8) .679^e

Organisational acumen,M(95%CI)^$ 150.8 (146.9, 154.6) 150.6 (145.9, 155.3) 147.5 (144.0, 151.1) .395^e

Personal work characteristics,M(95%CI)^$ 36.4 (32.1, 40.7) 35.9 (30.8, 41.1) 34.6 (30.7, 38.5) .819^e

Note. CLEI Clinical Learning Environment Inventory, WRS-GN Work Readiness Scale for Graduate Nurses.

# Internal and external clinical placement groups denote clinical placement models that included or did not include, prior organisational exposure, respectively.

$1 multivariate outlier removed, totaln= 74.

a Fisher's Exact Test.

b One-way ANOVA.

c Reciprocal transformation applied.

dOne-way Welch's ANOVA.

e One-way MANOVA, between-subjects effects.

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performed using the Sidak correction.

3. Results

3.1. Baseline participant characteristics and survey results

Characteristics of study participants are described inTable 1. Par- ticipants were predominately female (n= 72, 96%), and had a median age of 22 years (IQR= 4). There was no significant association between placement program group (Fellowship, Internal or External clinical placements) and distributions of sex or age.

Participant ratings of their baseline clinical learning environment significantly varied according to placement program, favouring the Fellowship model (MultivariateF[10, 134] = 3.66,p < .001; Wilks' Lambda = 0.617, partialη²= 0.21; seeTable 1). Fellowship students had significantly higher CLEI Affordances and Engagement (p= .004), Student Centeredness (p= .015), Individualisation (p < .001), and Innovative and Adaptive Culture (p= .006) scale scores than students placed externally to the healthcare organisation. Fellowship participants also had significantly higher Individualisation (p= .038) scores than students in the internal clinical placement group. Despite the finding of a significant univariate effect (Table 1), pairwise comparisons failed to identify significant between-group differences on the Valuing Nurses Work scale (p > .05).

MANOVA indicated no statistically significant effect of placement group on baseline work readiness scores: Multivariate F(6, 140) = 0.589,p= .739, Wilks' Lambda = 0.951.

3.2. Relationship between clinical learning environment and perceived work readiness

3.2.1. Prior to commencing graduate year employment

Regression models showed that CLEI subscale scores predicted baseline WRS-GN Work Competence (p = .035), Organisational Acumen (p < .00001) and Personal Work Characteristics (p= .0003) scores and explained 16%, 36% and 28% of the variance, respectively.

After adjusting for clustering due to placement group, ratings of CLEI Innovative and Adaptive Culture were predictive of poorer baseline scores on the ‘Work Competence’ subscale of the WRS-GN (Table 2). In

addition, ratings of CLEI Student Centredness were predictive of positive ratings on the ‘Personal Work Characteristics’ subscale of the WRS- GN, while ratings of Innovative and Adaptive Culture were predictive of poorer ratings on the ‘Personal Work Characteristics’ subscale. The same pattern of predictors were obtained in unadjusted analyses of WRS-GN ‘Work Competence’ and ‘Personal Work Characteristics’ subscales. No CLEI variables significantly predicted baseline WRS-GN

‘Organisational Acumen’ scores in adjusted analyses. However, in unadjusted analyses, CLEI Affordances and Engagement scores (B = 1.19, 95%CI [0.54, 1.84];p= .001) and Fostering Workplace Learning scores (B = −0.98, 95%CI [−1.84, −0.11];p= .028) predicted baseline

‘Organisational Acumen’ scores on the WRS-GN.

3.2.2. Following 8–10 weeks of graduate year employment

Regression models for baseline CLEI scores predicting ‘Work Competence’ (p = .0004), ‘Organisational Acumen’ (p= .025) and

‘Personal Work Characteristics’ (p= .024) at Time 1 were statistically significant. CLEI predictors accounted for 28% of the variance of ‘Work Competence’ scores, and 17% of the variance of ‘Organisational Acumen’ and ‘Personal Work Characteristics’ scores. After adjusting for clustering, CLEI Individualisation and Valuing Nurses work scores were significantly predictive of improved ‘Organisational Acumen’, while Innovative and Adaptive culture scores were significantly predictive of poorer ‘Organisational Acumen’ (Table 3). CLEI subscales were not significantly predictive of self-reported ‘Work Competence’ and ‘Per- sonal Work Characteristics’ following clustering. However, in unadjusted analyses, Individualisation (B = 1.47, 95%CI[0.004, 2.94];

p= .049) and Innovative and Adaptive Culture (B = -2.49, 95%CI [−4.01, −0.97];p= .002) predicted perceived ‘Work Competence’ at 8–10 weeks. Student centredness predicted ‘Personal Work Character- istics’ scores at 8–10 weeks (B = -0.89, 95%CI[−1.71, −0.08];

p= .033). The change in work readiness scores between baseline and Time 1 are described inFig. 1.

3.3. Trajectories of perceived work readiness

There was a significant effect of baseline ‘Work Competence’ and

‘Organisational Acumen’ subscale scores on change in these scores between baseline and follow-up (Table 4). Post-hoc testing indicated that Table 2

Predictors of perceived work readiness at the end of the undergraduate year (Baseline) - adjusted for placement group.

Predictor B 95%CI Robust SE^# t p

WRS-GN work competence (r²= 0.16)

(Constant) 82.43 [42.81, 122.10] 9.21 8.95 .012

CLEI student centredness 0.22 [−1.64, 2.08] 0.43 0.51 .658

CLEI affordances & engagement −0.18 [1.63, 1.26] 0.34 −0.55 .640

CLEI foster workplace learning 1.06 [−2.63, 4.75] 0.85 1.24 .342

CLEI valuing nurses work 1.41 [−0.7, 2.88] 0.34 4.11 .055

CLEI innovative & adaptive culture −1.82 [.-2.68, −0.97] 0.20 −9.20 .012^a,b

WRS-GN organisational acumen (r²= 0.36)

(Constant) 98.37 [74.84, 121.91] 5.47 17.98 .003

CLEI affordances & engagement 1.19 [−1.16, 3.54] 0.55 2.18 .161^b

CLEI foster workplace learning −0.98 [−3.62, 1.67] 0.61 −1.59 .253^b

CLEI innovative & adaptive culture −0.78 [−3.77, 2.21] 0.69 −1.13 .377

WRS-GN personal work characteristics (r²= 0.28)

(Constant) 75.02 [40.80, 109.24] 7.95 9.43 .011

CLEI student centredness −1.43 [−1.84, −1.03] 0.09 −15.12 .004^a,b

CLEI affordances & engagement 0.72 [−0.31, 1.75] 0.24 3.00 .095

CLEI foster workplace learning −0.51 [−2.65, 1.63] 0.50 −1.02 .415

CLEI valuing nurses work −1.41 [−2.83, 0.12] 0.33 −4.27 .051

CLEI innovative & adaptive culture 2.52 [0.95, 4.09] 0.37 6.89 .020^a,b

SE standard error.

# Adjusted for placement group in 3 clusters.

a Predictor statistically significant in analyses adjusted for clustering due to clinical placement group,p < .05.

b Predictor statistically significant in unadjusted analyses,p < .05.

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participants with high self-perceived baseline ‘Work Competence’ reported a significantly greater decline in scores at follow-up relative to students with moderate (p= .003) or low (p < .001) baseline ‘Work Competence’. Participants with high scores for self-rated ‘Personal Work Characteristics’ scores had significantly greater decline in scores relative to students with moderate (p= .016) or low (p= .004) scores at baseline. Conversely, participants with low levels of self-reported

‘Organisational Acumen’ at baseline had a significantly greater increase in ‘Organisational Acumen’ scores relative to students with moderate (p= .003) or high (p < .001) baseline ‘Organisational Acumen’.

Repeated measures MANOVA indicated no significant changes in mean WRS-GN scores between the three clinical placement groups (Fig. 1). Specifically, there was no significant interaction effect of clinical placement group on change in WRS-GN scores, multivariateF Table 3

Predictors of perceived work readiness 8–10 weeks following the start of graduate year employment (Time 1) - adjusted for placement group.

Predictor B 95%CI Robust SE^# t p

WRS-GN work competence (r²= 0.28)^$

(Constant) 80.91 [47.84, 113.98] 7.69 10.53 .009

CLEI individualisation 1.47 [−2.17, 5.11] 0.85 1.74 .224^b

CLEI innovative & adaptive culture −2.49 [−5.21, 0.23] 0.63 −3.94 .059^b

WRS-GN organisational acumen (r²= 0.17)^$

(Constant) 141.11 [133.57, 148.65] 1.75 80.53 < .001

CLEI student centredness −0.16 [−0.64, 0.33] 0.11 −1.39 .300

CLEI individualisation 0.61 [0.21, 1.02] 0.09 6.52 .023^a

CLEI valuing nurses work 1.26 [0.71, 1.81] 0.13 9.78 .010^a

CLEI innovative & adaptive culture −2.02 [−2.27, −1.77] 0.58 −34.77 .001^a,b

WRS-GN personal work characteristics (r²= 0.17)

(Constant) 85.43 [−35.46, 206.31] 28.09 3.04 .093

CLEI student centredness −0.89 [−2.44, 0.66] 0.36 −2.47 .132^b

CLEI individualisation 0.14 [−2.72, 3.00] 0066 0.20 .857

CLEI foster workplace learning −0.30 [−1.30, 0.69] 0.23 −1.30 .322

CLEI valuing nurses work −1.16 [−5.52, 3.20] 1.01 −1.15 .370

CLEI innovative & adaptive culture 0.82 [−0.34, 1.98] 0.27 3.04 .093

SE standard error.

# Adjusted for placement group in 3 clusters.

$Multivariate outlier removed (n= 1).

a Predictor statistically significant in analyses adjusted for clustering due to clinical placement group,p < .05.

b Predictor statistically significant in unadjusted analyses,p < .05.

Fig. 1.Change in Work Readiness Scale (WRS-GN) subscale scores between the end of the undergraduate year and the beginning of the graduate year.

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(6, 110) = 1.37, p = .234. Furthermore, there were no significant differences in overall WRS-GN subscale scores between clinical placement groups,F(6, 110) = 1.25,p= .289, and subscale scores did not significantly change over time,F(6, 110) = 1.58,p= .205.

4. Discussion

Findings from this single-institution, pre-post survey study confirmed the presence of a significant interrelationship between student perceptions of their undergraduate clinical learning environment and self-reported work readiness at graduation and 8–10 weeks following commencement as a new graduate nurse. In this sample of nursing graduates at a large, private sector Australian hospital, elements of the undergraduate clinical learning environment accounted for at least one- fifth to one third of participants' perceptions that they were competent to perform their role, had organisational acumen, that is, the ability to engage and identify with the profession and the organisation (Walker et al., 2013b), and possessed other positive work characteristics in- cluding attributes of adaptability, self-awareness, personal skills, and personal resilience. Findings therefore indicated the importance of the clinical learning environment in preparing undergraduates for work in the clinical setting. Moreover, they suggest empirical support for the position emerging from the qualitative literature (Milton-Wildey et al., 2014;Newton et al., 2011;Watt and Pascoe, 2013) and widely held by nursing educators (e.g.,Bourgeois et al., 2011;Flott and Linden, 2015;

Newton et al., 2009), that optimisation of the content and structure of clinical nursing education may be efficacious for the facilitation of work readiness in nursing graduates.

Given the importance of rapidly securing a skilled nursing workforce in the current context of high demand for health services (Health Workforce Australia, 2014), undergraduate nursing education programs could be configured, on the basis evidence-based principles, to maximise work readiness outcomes. This study identified several elements of the clinical learning environment that appeared to significantly influence perceived work readiness in graduates: the extent to which the learning environment was student-focussed (student-centredness); receiving individualised education (individualisation); valuing nurses work; and having an innovative and adaptive learning culture. Student centred teaching was associated with greater perceptions of work competence and more positive work characteristics immediately following graduation. However, this relationship was not sustained at 8–10 weeks following the transition into professional

practice. In contrast, the degree to which undergraduate education was perceived to offer individualised learning and value nurses work was unrelated to baseline outcomes, but significantly corresponded with reports of organisation acumen at 8–10 weeks. Finally, although education providers value innovation, and innovative undergraduate nursing programs have been are associated with increased student satisfaction (Papathanasiou et al., 2014), in this study, innovative teaching was associated with lower perceived work readiness (baseline Work Competence and Personal Work Characteristics, Time 1 Organi- sational Acumen). This appears to indicate that while undergraduates may enjoy newer educational approaches, they may result in lower work preparedness relative to traditional teaching methods. Future research should be undertaken to identify the elements of innovative education programs that contribute to, and detract from, overall work readiness in nurses.

The pattern of scale interrelationships identified by study analyses indicated an apparent shift in the significance of the undergraduate clinical learning environment to perceived work readiness prior to and following commencement as a new graduate nurse. In adjusted analysis that accounted for clustering due to variation in clinical placement programs, CLEI subscales were predictive of WRS-GN Work Competence and Personal Work Characteristics immediately after graduation. However, 8–10 weeks after starting as a new graduate nurse, CLEI subscales were predictive of Organisational Acumen only. This suggested the diminishing importance of the clinical learning environment in determining self-perceived capacity to perform work tasks proficiently and its increased importance in determining perceived organisational acumen, following the transition to professional practice.

In the early stages of new employment, nursing graduates may be preoccupied with successful acculturation and socialisation to the work environment (Phillips et al., 2015) and present data suggest that the undergraduate clinical learning environment may critically impact nurses' perceived ability to make this transition.

Although we identified the undergraduate clinical learning environment to be an important predictor of perceived work readiness in new graduate nurses, the small amount of total variance explained by regression models indicated that work readiness is largely determined by other factors. Despite the finding of a more positive clinical learning environment in the Fellowship program, in the present sample, clinical placement selection was not a key driver of work readiness outcomes prior to or following, commencement as a graduate nurse. Research has identified personality traits (e.g.,Fisher et al., 2001), emotional support and self-efficacy (e.g.,Collard et al., 2020;Gibbons et al., 2011), and emotional intelligence (Hurley et al., 2020) as potentially critical facilitators of work readiness in graduate nurses. However, in order to identify the full range and extent of modifiable factors capable of being efficiently leveraged to maximise graduate work readiness, the scope of future research in this field should be expanded to quantify the influence of relevant demographic, psychological, social and contextual facilitators.

This study had several limitations. First, graduates' work readiness was only assessed with respect to self-reports on the WRS-GN, which may differ from the perceptions of work readiness in supervisors and colleagues. Second, because of the need to maximise the robustness of regression models due to sample size restrictions, only five out of six CLEI subscales were entered as predictors. However, CLEI subscales were excluded according to empirical considerations and excluded subscales were poorly related to WRS-GN outcomes and were thus unlikely to substantively impact results. Third, we used a provisional version of the WRS-GN that employed a 5-point scale and required item-response rescaling to match the current, 10-point scale instrument.

However, research has found that scores from rescaled 5-point scales are largely comparable to responses on 10-point scales (Dawes, 2008).

Furthermore, our analyses merely explored associations between the CLEI and WRS-GN and comparedrelativedifferences in WRS-GN scores over time and between clinical placement groups. Finally, as with other Table 4

Degree of change in categories of Work Readiness Scale scores (WRS-GN) between the end of the undergraduate year and the beginning of the graduate year.

Baseline work readiness n Mean change in score at

grad year (SD) p-Value

Work competence score^#

Low 25 +3.09 (8.21) < .001^a

Moderate 25 +0.34 (6.25)

High 25 −6.40 (6.56)

Organisational acumen score^#

Low 25 +5.91 (13.79) < .001^b

Moderate 23 −4.70 (5.37)

High 27 −8.15 (6.84)

Personal work characteristics score^#

Low 25 +4.30 (6.97) .002^a

Moderate 25 +3.10 (9.31)

High 25 −3.65 (8.66)

Note.

# Low, moderate, and high work readiness scores denoted by WRS-GN tertiles.

a One-way ANOVA.

b One-way Welch's ANOVA.

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studies published to-date, we did not account for the possible effect of student characteristics, such as personality and self-efficacy in determining clinical placement choices and subsequent work readiness outcomes. Given our finding that the clinical learning environment only accounts for a portion of work readiness, future research in this area would do well to additionally explore the role of student characteristics on educational outcomes, and to examine data for possible interactions between student characteristics and the various types of clinical placement models.

5. Conclusion

Maximising work preparedness and the training efficiency of nursing clinical education is likely to have considerable importance given the high and ever increasing demands on health services. In conclusion, this study quantified the influence of the undergraduate clinical learning environment in determining self-perceptions of work readiness prior to, and following, commencement as a new graduate nurse. By highlighting the importance of the clinical learning environment, this study provided some empirical support for the idea that undergraduate programs could be effectively configured to optimise nurses' post-graduation work readiness. On the basis of present findings, we would expect programs that provide students with high levels of individualised attention and have a culture in which nursing work was valued to significantly promote self-perceived organisational acumen following transition to professional practice. In contrast, programs with highly innovative and adaptive learning environments may not opti- mally prepare nursing graduates for clinical work. Additional studies are required to identify the precise aspects of innovative programs that perform less well than traditional educational approaches with respect to work readiness. Finally, our analyses suggested that factors other than the clinical learning environment likely account for the bulk of nurses' post-graduation work readiness. Further research is required to identify the nature of these factors and thereby initiate the possibility of exploring and implementing a robust and comprehensive program for the evidence-based optimisation of undergraduate nursing education.

CRediT authorship contribtion statement

MD: Conceptualisation, methodology, investigation, project ad- ministration, data curation (data entry), and writing – original draft.

DK: Data curation (data cleaning), formal analysis, visualisation, writing – original draft, writing – review & editing. MB:

Conceptualisation, methodology, supervision. AH: Conceptualisation, methodology, investigation, supervision, writing – review & editing.

Funding source

This research was undertaken as part of a Master of Nursing Practice degree (Deakin University) and did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethics approval and consent to participate

Ethical approval to undertake this research was obtained from the Deakin University Human Research Ethics Committee (DU 2015-283) and the low risk sub-committee of the Human Research and Ethics Committee of the affiliated healthcare service. Participants were informed that participation was voluntary and that they could choose not to participate, or withdraw from the study at any time without penalty.

All participants provided written informed consent prior to data collection.

Declaration of competing interest

The first author (MD) is a clinical education coordinator at the study institution. To avoid potential conflict, independent researchers informed prospective participants of the study (AH), and analysed (DK) and interpreted (DK, AH) study data. No other competing interests are declared by the authors.

Acknowledgements

We wish to acknowledge Jennifer Newton who gave us permission to use the Clinical Learning Environment Inventory, and Arlene Walker who gave us permission to use, and provided us with, the Work Readiness Scale for Graduate Nurses. We would also like to thank the graduate nurses who participated in this study.

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