STUDENT EVALUATION OF CLINICAL EDUCATION ENVIRONMENT

STUDENT EVALUATION OF CLINICAL EDUCATION ENVIRONMENT (SECEE):
INSTRUMENT DEVELOPMENT AND VALIDATION
By
Kari Sand-Jecklin
A DISSERTATION
Submitted to
The College of Human Resources and Education
at
West Virginia University
Doctoral Committee: Anne H. Nardi PhD, chair
Julie S. Vargas, PhD
Rayne S. Dennison, PhD
Karen E. Miles, EdD
Lynne Ostrow, EdD
in partial fulfillment of the requirements
for the degree of
Doctor of Education
In
Educational Psychology
Department of Advanced Educational Studies
Morgantown, West Virginia
September 29, 1998
Keywords: Student Evaluation of Clinical Education Environment
Copyright 1998, Kari Sand-Jecklin

ABSTRACT
STUDENT EVALUATION OF CLINICAL EDUCATION ENVIRONMENT (SECEE):
INSTRUMENT DEVELOPMENT AND VALIDATION
By Kari Sand-Jecklin
This paper describes the refinement and testing of the Student Evaluation of Clinical
Education Environment (SECEE) inventory, an instrument designed to measure nursing student
perceptions of the clinical learning environment. Although a quality student clinical experience
is considered critical to nursing education, no comprehensive instruments measuring the
clinical learning environment have been published.
The SECEE inventory contains 29 forced-choice items divided among four scales:
Communication and Feedback, Learning Opportunities, Learning Support, and Department
Atmosphere. Items were included based on nursing students and faculty input, a review of the
literature and sample clinical agency contracts, and data resulting from administration of the
original version of the SECEE instrument. Items requesting students to identify aspects of the
clinical setting that helped as well as hindered learning were also included.
A convenience sample of nursing students from two small liberal arts institutions (SMW
and SMA) and one large university (LMA) completed the SECEE inventory at the end of the
spring 1998 semester. A sub-sample of students completed the inventory twice during the
semester, for test-retest reliability determination.
Data analysis indicated that students responded consistently to the instrument as a whole
and to the four scales. Rearrangement of four items within scales resulted in further
improvements in reliability. Test-retest correlations for all scales were statistically significant.
Correlations between individual student evaluations of two distinct clinical sites were not
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significant for any of the four scales, indicating that students responded differently to the
instrument when evaluating different clinical sites.
Significant differences between scale scores were found between institutions for all
scale scores. Differences were also found between academic levels of students within each
institution, and between clinical site groups within institutions SMW and SMA. Student
narrative comments supported inclusion of the majority of forced-choice items and allowed
identification of items that may be beneficial to include in future inventory revisions.
Overall, the SECEE inventory appears to be a reasonably valid and reliable measure.
Minor revisions are suggested for future revisions.
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ACKNOWLEDGEMENTS
An endeavor such as this is not accomplished without the support and encouragement of
others. I am grateful to have had the opportunity to study with faculty and students who so
willingly have shared their knowledge and experience, and supported others in accomplishing
their goals. I am also grateful to the Swiger Foundation for providing me the opportunity to
focus solely on studies, without financial concerns.
My sincere thanks to my doctoral committee who supported this research endeavor and
made the process of dissertation completion as painless as possible. Thanks particularly to Dr.
Anne Nardi who has provided me with unwavering support and encouragement throughout the
last three years. Thanks to Dr. Rayne Sperling Dennison for hours of help with data analysis
and to Dr. Julie Vargas for helping me maintain a ”balanced perspective”. Also, my
appreciation to Dr. Karen Miles and Dr. Lynne Ostrow, who helped me to focus the application
of all that I have learned to the field of Nursing.
Without the assistance of others, data collection would have been nearly impossible. I
greatly appreciate the assistance of Dr. Donna Hartweg, Dr. Shari Metcalfe, Dr. Joan Clites and
Dr. Karen Miles for their assistance with data collection. Thanks also to the nursing faculty at
the three institutions used for data collection, for making time during class to gather data.
I am also very thankful for the support of my husband, Dave, and children Kallie and
Bryce during the past three years. The road has been long, but the end is in sight. Finally, I
thank God for providing me the opportunity to accomplish this longstanding goal and for
keeping my family intact during the process.
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Table of Contents
List of Tables vii
Chapter 1: Introduction 1
Definition of Terms 4
Chapter 2: Review of Literature 6
Theoretical Perspectives on the Learning Environment 6
Theoretical Perspectives on Evaluation of the Learning Environment 12
Empirical Investigations of the Applied Learning Environment in Nursing 13
Empirical Investigations of the Traditional Classroom Learning Environment 19
Statement of the Problem 31
Preliminary Investigation 32
Research Questions 37
Chapter 3: Methods 39
Instrument Revisions 39
Population 43
Procedure 44
Chapter 4: Results 46
Descriptive Analysis 47
Missing Data 48
Descriptive Statistics 49
Parametric Analyses 50
Institutional Differences in Student Response to SECEE Instrument 54
Instrument Reliability Determination 57
Test-Retest Reliability 60
Differences in Scale Scores According to Clinical Site Groups 67
Analysis of Narrative Inventory Data 75
Student Narrative Responses Reflecting SECEE Item Content 77
Student Narrative Responses not Addressed by Forced Choice Item Content82
Chapter 5: Discussion 85
Research Question 1 85
Brevity and Practicality of Use 85
Content Validity 86
Research Question 2 88
Inventory Reliability 88
Scale Reliability 88
Research Question 3 91
Construct Validity 91
Research Question 4 94
Removal of SECEE Items 94
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Table of Contents, Continued
Demonstration of Instrument Validity 95
Revisions to Improve Data Gathering and Analysis 96
Summary of Proposed Changes in the SECEE Inventory 100
Study Limitations 101
Research Implications 104
Related Research Issues 105
Conclusion 107
References 109
Appendices
A. Original SECEE Instrument 115
B. SECEE Inventory Items Categorized by Scales 118
C. Revised SECEE Instrument 121
D. Table of Specifications for SECEE Inventory 126
E. Statement to Participants 129
F. IRB Approval Letter 131
Curriculum Vita 133
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Tables
List of Tables
1. Identification and Frequency of Factors (Scales) contained in the LEI, CES,
ICEQ, MCI, CLUCEI and SLEI instruments 29
2 SECEE Inventory Forced Choice Item Means and Standard Deviations 51
3 Scale Means and Standard Deviations by Institutions 55
4 Statistical Results for Institution by Scale Score ANOVA 56
5 Significance Levels for Institutional Comparisons According to Scale Scores 58
6 Reliability Coefficients for SECEE Instrument and Individual Scales by Institution 59
7 Scale Score Correlations Between Pretest and End of Semester Inventories 62
8 ANOVA Results, Student Level by Scale Score 63
9 Significance Levels for Student Comparisons According to Scale Scores 64
10 Scale Score Means and Standard Deviations by Student Level 65
11 ANOVA Statistics, Clinical Site Group by Scale Score 70
12 Scale Score Means and Standard Deviations by Clinical Site Groups 71
13 Significance Levels for Post Hoc Differences Between Clinical Site Groups at SMW 74
14 Comparison of Number of Student Narrative Comments on Pretest and End of Semester
Inventories 76
15 Category of Student Comments to SECEE Open-Ended Questions 78
16 Frequencies of Student Responses to Request to Identify Aspects of the Clinical
Setting that Helped Learning—Issues Addressed by Scaled SECEE Items 80
17 Frequencies of Student Responses to Request to Identify Aspects of the Clinical
Setting that Hindered Learning—Issues Addressed by Scaled SECEE Items 81
18 Frequencies of Student Responses to Request to Identify Aspects of the Clinical
Setting that Helped Learning—Issues not addressed by Scaled SECEE Items 83
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List of Tables, Continued
19 Frequencies of Student Response to Request to Identify Aspects of the Clinical
Setting that Hindered Learning—Issues not addressed by Scaled SECEE Items 84
20 Reliability Coefficients for Scales by Institution (Revised Item Placement) 90
viii

Student Evaluation of Clinical Education Environment (SECEE):
Instrument Development and Validation
Chapter 1
Introduction
According to Dunn and Burnett (1995), the learning environment consists of all the
conditions and forces within a setting that impact learning. As Shuell (1996, p. 726) stated,
“Teachers and students work together in a rich psychological soup of a classroom, a soup
comprised of cognitive, social, cultural, affective, emotional, motivational and curricular
factors.” The learning environment provides the setting for learning and at the same time acts as
a “participant” in teaching and learning (Loughlin & Suina, 1982). It can support, impede, or
limit learning opportunities for students (Reilly & Oermann, 1992).
Several authors have identified the importance of the student learning environment and
have discussed various aspects of this environment. Loughlin and Suina (1982) authored an
entire text geared toward teacher construction of a physical environment conducive to student
learning, using student behavior as a basis for arranging the environment. Shuell (1996)
identified several characteristics of classroom learning environments: multidimensionality,
simultaneity, immediacy, unpredictability, publicness, and history. Earlier, Moos (1979) had
conceptualized the student learning environment in terms of three dimensions. The relationship
dimension includes the extent to which people are involved in the environment, how much they
help (support) each other, and the amount of open expression allowed. The personal growth
dimension includes the degree of task orientation, competition, independence, social orientation,
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and intellectuality of the environment. The system maintenance and system change dimension
includes organization, rule clarity, teacher control, and innovation in the environment.
Most formal education at elementary and secondary school levels takes place within the
traditional classroom setting. Aside from a few field trips and secondary school vocational
training programs or science lab classes, the learning environment consists of a traditional
classroom structure. In contrast, at the post secondary level, the learning environment may
include multiple experiences or even entire courses in applied learning settings. For instance, in
the area of nursing, students must complete a number of courses that involve experiences in the
clinical nursing environment. The same is true for most university students in professional or
technical programs.
Although the traditional classroom may include authentic activities that reflect activities
of real life and practice in the context in which learning will be put to use, there are several
differences between the applied or experiential learning environment and the traditional
classroom setting (Resnick, 1987). Traditional school learning generally revolves around
individual effort, pure thought activities (often without the support of references and tools),
symbolic rather than tangible manipulation of objects, and generalized competencies. In
contrast, learning outside the school setting involves shared cognition, tool use in cognition,
contextual reasoning, and situation specific competencies (Resnick, 1987). The traditional
classroom setting is self-contained and the instructor can monitor all students at one time.
Students generally work on similar tasks and the teacher has a significant amount of control over
the physical and social learning environment. Interactions occur between students and their
peers as well as between students and teacher. In contrast, the instructor has much less control
over the environment in the applied learning setting. Students may be working on the
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development of different skills and they are often not within direct view of the instructor. It is
also the case that instructor assistance may not be immediately available to the students. In the
applied learning setting, students interact with several other people in addition to their peers and
the instructor. Professionals in the applied setting often serve as mentors for students, but may
have little formal instruction in mentoring or in creating an environment conducive to student
learning. These additional variables inherent in an applied learning setting further highlight the
importance of assuring the adequacy of the environment in these learning situations.
The clinical nursing education context is a prime example of an applied learning setting.
Undergraduate education in nursing provides a foundation for nursing practice in a variety of
settings with clients in all stages of the lifespan. The clinical component of nursing education is
critical to the overall curriculum, as it provides realistic experiences and allows learners to
“apply knowledge to practice, to develop problem solving and decision making skills, and to
practice responsibility for their own actions” (Reilly & Oermann, 1992, p. 115). Although
typical baccalaureate nursing students spend between eight and sixteen hours per week in a
clinical learning environment (Polifroni, Packard, & Shah, 1995), the mere passage of time in the
clinical environment does not itself ensure clinical competence (Scheetz, 1989) or a positive
clinical experience. A number of variables, including student, faculty, resource staff, and clinical
environment factors interact to contribute to student learning outcomes. In order to ensure that
students experience a clinical education environment that supports learning, the factors
impacting learning in that context must be identified and evaluated. Standard III of The
American Association of Colleges of Nursing’s Standards for Accreditation of Baccalaureate and
Graduate Nursing Programs (1997) states that the environment for teaching, learning, and
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evaluation of student performance should foster achievement of expected outcomes and that
there should be clear congruence between the teaching-learning experience and expected results.
One means to demonstrate the effectiveness of the teaching-learning experience is to
evaluate the clinical educational environment through the students’ eyes—obtaining students’
perceptions about the adequacy of the clinical education environments that they have
experienced. Nursing instructors may informally request individual student feedback about the
quality of the clinical learning environment, or may include one or two questions about the
adequacy of this environment in the overall course evaluation tool. However, there is currently
no comprehensive instrument that has been demonstrated to accurately measure student
perceptions of their clinical education environment. The purpose of this investigation was to
develop and test the accuracy and efficiency of such an instrument: the Student Evaluation of
Clinical Education Environment (SECEE). Development of such an instrument is one of the first
steps in the empirical process of assessing and improving the student clinical learning
environment and positively impacting student learning in this environment.
Definition of Terms
Learning Environment: All the forces and conditions within a setting that impact student
learning (Dunn & Burnett, 1995). The forces include but are not limited to the physical setting,
instructional methods, interactions with others, and opportunities for growth.
Applied Learning Environment: A setting in which students apply information and skills to an
authentic situation, with exposure to all factors influencing performance in that setting.
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Examples of applied learning environments include laboratory settings, simulations, and practice
settings.
Traditional Classroom Environment: A setting composed of a traditional physical classroom,
a general absence of application tools, and traditional instructor-student relationships (One
instructor for a class of 20 or more students).
Clinical Learning Environment: For the purpose of this investigation, the clinical learning
environment includes any settings in which clinical nursing is practiced and nursing students
have applied learning experiences.
Preceptor: A staff nurse in the clinical setting who is generally paired with a nursing student for
the duration of the student’s clinical rotation. The preceptor instructs and coaches the student,
and may participate in student evaluation.
Resource Nurse: A staff nurse in the clinical setting who is generally paired with a particular
nursing student for only one or a few clinical experiences. The resource nurse may instruct and
coach the student, but generally the nursing faculty member is considered the primary instructor.
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Chapter 2
Review of the Literature
The perceived significance and contribution of the learning environment to student
learning is addressed by many learning theories and research investigations, although the
majority focus on the traditional classroom environment (Fraser, 1991; McGraw et al., 1996;
Resnick, 1987). Applied cognition and experiential learning theories, however, do focus on the
applied environment setting and also highlight the importance of the learning environment’s
influence on student learning. The behaviorological position also addresses the significance of
the educational environment in relation to student learning. Although this review of literature
focuses primarily on the applied cognition perspective, several aspects of the behaviorological
position are also presented, as the author feels that a synthesis of the two positions most
adequately describes the influence of the applied learning environment on student learning.
Theoretical Perspectives on the Learning Environment
According to the cognitive apprenticeship or situated cognition theory, learning and
cognition are fundamentally situated (Brown, Collins & Duguid, 1989). They are a product of
the learning activity, the context, and the culture in which they are developed and used (Brown,
Collins & Duguid, 1989; Goodenow, 1992). Brown, Collins and Duguid suggested considering
conceptual knowledge as a set of tools that can only be understood through use. Learning how to
use the knowledge tools requires more than memorizing a set of rules—students must also
understand the context for use and must practice using the tools (Greeno, Collins, & Resnick,
1996). Behaviorologists also hold this perspective, stating that students must not only read and
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hear about a topic, but must contact the situation directly and receive feedback related to the
behavior (Vargas, 1996). Knowing by acquaintance (through experience) generally results in
more efficient behavior (Skinner, 1989). For instance, nursing student proficiency in performing
an intravenous insertion generally does not occur as a result of only being told or shown the
anatomical location of veins and the procedure for inserting an intravenous line. Rather, the
student must practice the procedure, preferably in a simulated application setting first and then in
a real setting. By doing the task, the student is able to contact natural reinforcers of the drag of
the needle on the skin, the “pop” of the needle into the vein, and potentially the feedback of the
patient undergoing the procedure.
A cognitive apprenticeship can be described as a process by which learner gradually
acquires expertise through interaction with an expert who models appropriate behavior and
provides coaching to the learner (Brown, Collins & Duguid, 1989; Slavin, 1997). Students learn
by observation, imitation, and practice through both repetition and continued engagement in the
learning process. The behaviorological perspective also supports modeling as an effective
instructional method, but only when the student also performs the behavior and receives
feedback (Skinner, 1989).
Apprenticeship methods enculturate students into authentic practices through activities
and social interactions, in a way similar to craft apprenticeships. The expert, who is either an
adult or a more experienced peer, socializes the learner to the norms and expected behaviors for
the particular setting. The expert instructs initially by scaffolding (coaching and cueing) students
as they perform a task and then gradually fading (withdrawing) the supports (Slavin, 1997;
Greeno, Collins, & Resnick, 1996). Two instructional methods used by behaviorologists that
share the characteristics with scaffolding are shaping of responses by reinforcement of
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successive approximations to the desired behaviors, and prompting correct responses with fading
of prompts as responses are strengthened. Prompting is most effective when the student is
“primed” or cued just enough to go on, with prompts removed as soon as possible, while
maintaining the desired behavior (Skinner, 1989). These instructional methods help students
succeed by reducing errors during learning and increasing opportunities for obtaining the natural
reinforcement of success.
An apprenticeship begins with tasks embedded in a familiar activity, and moves to more
complex tasks and concept applications, according to a progressive and sequenced curriculum
(Resnick, 1987). Cognitive apprenticeships allow students to observe the whole of a trade or
profession and to begin performing small pieces of it. The ultimate goal of situated cognition
instruction is for the student to behave as a practitioner in the particular field. The paradigm of
behaviorology also holds that sequencing of instruction is important. Students must first know
the prerequisite skills for development of a new skill or behavior, and then instruction must be
arranged in sequences of related successive steps (Greeno, Collins & Resnick, 1996; Skinner,
1989). For instance, in the applied nursing education setting, students progress from observation
of experts performing skills and fulfilling professional roles, to practicing particular skills, and
finally, to fulfilling almost all professional nursing roles.
Cognitive apprenticeship concepts follow Vygotsky’s emphasis on the social nature of
learning, the zone of proximal development (the span between what a learner is able to do
independently and what the learner is able to do with assistance from an expert), and scaffolding
(Slavin, 1997). Instructors assign complex, realistic tasks and provide enough support/prompts
to allow the students to complete the tasks or solve identified problems that they would be unable
to complete alone at that time. Higher psychological processes are acquired through interaction
8

with others and participation in a social or professional community (Goodenow, 1992). Learning
is situated in both physical and social contexts, with the social contexts being constructed by the
teachers and students through interactions and around lessons. According to Marshall (1990), the
goals of the “learning centered” environment relate to the process of learning, with a focus on
determining how students learn and on socializing students to the role of learner rather than of
producer of a product (Marshall, 1990).
Experiential learning may be considered to be synonymous with situated cognition.
Carver (1996) described experiential learning as education using a combination of the senses,
emotions, physical conditions, and cognition that integrates conscious application of student
experiences into the curriculum. She identified four pedagogical principles of experiential
learning: (a) authenticity—instruction that is relevant to student lives, and that includes naturally
occurring rewards; (b) active learning—experiences that are physically and/or mentally
engaging; (c) drawing on student experience and encouraging students to reflect on their
experiences; and (d) connecting experiences to future learning opportunities. Teachers facilitate
processes in which students participate in the construction of knowledge and which lead to
student achievement of the sub-goals of learning: personal agency, belonging and competence.
Carver’s instructional principles may or may not be evident in an experiential setting, as they
depend primarily on instructor and mentor/expert instructional focus. Addressing the presence
or absence of the principles in a particular instructional setting may be beneficial in determining
the quality of the applied learning environment.
Carver (1996) also developed a general model for discussion and development of an
experiential learning environment. Student experience, including both process and product
factors, is at the center of a context of the learning environment, which is characterized by the
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nature of the student experience, the program characteristics, and the general characteristics of
the environment. This model was developed as a way to look at the whole experiential learning
experience, and to compare and contrast a variety of experiential student learning opportunities
(Carver, 1996). Although no application of this model to a specific experiential or applied
learning environment has been published to date, it would appear to be an adequate framework to
describe and compare clinical education environments in the area of nursing.
Warren (1993) identified the role of the teacher in the experiential learning process as
creating a safe learning atmosphere for students and encouraging them to recognize the
opportunities for growth in the environment. She likened the teacher in an experiential setting to
a midwife, stating that she assists in the birth of new ideas by guiding students in their learning
and guarding the intensity and safety of their engagement in the environment. The teacher
manages the logistics of the experience to allow students to concentrate fully on the learning that
is possible in the given environment. She serves as nurturer, establishes relationships with
students, assists students in acknowledging commonalties and differences, creates student-
centered learning experiences, and assists with closure of the experience, while remaining a
learner/participant in the experience.
Both the situated cognition theory and the behaviorological paradigm obviously
acknowledge the impact of the learning environment on student learning. These theories are
particularly appropriate in an applied educational setting, although the behaviorological
perspective does not differentiate between traditional and applied settings, because it views
learning as an active and applied process, regardless of the setting. Although generally viewed
as opposing theories, the behaviorological and applied cognition perspectives would describe the
10

ideal applied learning environment somewhat similarly (Berliner, 1983; Shuell, 1986). Both
would consider the following as important characteristics of the ideal learning environment.
1. A physical setting that approximates the ultimate practice or life setting as closely as
possible.
2. Adequate and accessible tools/equipment for skill development and practice.
3. Experts who are able to model appropriate skills and behaviors and to provide
constructive feedback to students regarding skill and knowledge development.
4. Instructor/expert scaffolding (shaping, prompting) of new skills and knowledge concepts.
5. Sequencing of learning from observation, to practice of “pieces” of the skill, to practice
of the whole skill or profession.
6. Adequate opportunities for practice.
7. Connection between current experiences and future practice (behavior opportunities).
Although constructive feedback for student behavior would be assumed to be present in
the learning environment, the applied cognition literature does not focus on this factor of the
environment. The behaviorological position holds that feedback, both naturally occurring and
instructor provided, is responsible for the learning or lack of learning that occurs (Vargas, 1996).
According to Sidman (1991), most contingencies in education are punitive—often resulting in
the transformation of eager young learners to older, less willing learners. Punishment is even
less effective when it is based on an absence of behavior such as “not doing” homework
(Skinner, 1989). When used effectively, positive reinforcement is potentially the most powerful
teaching tool available. Tangible rewards can be used initially to reinforce behavior, but they
must eventually be eliminated to establish learning as its own reward. Differential reinforcement
of student responses brings responding under appropriate stimulus control and results in student
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ehaviors of discrimination and generalization, which define the “understanding of concepts”
(Thomas, 1991).
Theoretical Perspectives on Evaluation of the Learning Environment
One of the main differences between these two frameworks lies in their focus for the
study of learning and of the learning environment. The situated cognition model focuses on the
process of learning as well as learning outcomes, whereas the behaviorological model is
concerned with the learning process primarily as it impacts the behavioral product of learning.
The situated cognition focus on process would support investigation of student thoughts and
feelings about the learning environment and about “coming to know” a particular skill or
concept. Student perceptions of the environment are considered by some to have even more
influence on student learning than does the “actual” environment, because the perceptions
influence the way a student approaches a task, and thus, ultimately determine the quality of
learning outcomes (Cust, 1996). If instruction is to be student centered (Marshall, 1990), it is
important to determine student perceptions of the environment and about how it might be
improved to benefit learning, since students may interpret the same environment differently. The
applied cognition perspective also focuses on the quality of relationship and communication
between students and peers, practitioners and instructors (Moos, 1979; Slavin, 1997).
Behaviorologists, however, would not be as concerned about student perceptions of the
learning environment as they would about the student behaviors that indicate a particular
"attitude", because verbal statements about satisfaction are viewed as often unreliable and
inconsistent (Skinner, 1953). A behaviorologist would be more likely to observe the
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contingencies present in the learning environment and the student’s behavior (or behavior
change) both during and after instruction (C. D. Cheney, 1991; D. Cheney, 1991).
Observation of the learning environment and students’ behaviors as they participate in the
environment together with gathering data about student perceptions of the environment may
result in the most comprehensive assessment of environmental impact on student learning.
Observation of several students in each learning environment would be necessary to gather
reliable observational data in each of the settings. Data collection through observation would be
possible in educational programs that use limited numbers of applied learning settings.
However, most nursing education programs use a large number of applied learning settings
(clinical sites) in order to expose students to a variety of practice environments. If the research
purpose is to evaluate the adequacy of all clinical learning environments used in a nursing
program, the costs of an observational study would most likely prohibit this type of data
collection. In contrast, student perceptions of multiple clinical environments may be obtained in
a more efficient manner through a survey instrument. Therefore, the focus of this investigation
is on student perceptions of the clinical learning environment.
Empirical Investigations of the Applied Learning Environment in Nursing
Relatively few research studies have investigated the impact of the applied learning
environment on student learning, as opposed to the many investigations that have been
conducted and tools that have been developed to measure the more traditional classroom
environment. More specifically, few authors have either proposed factors that may impact
learning in the clinical environment or have conducted investigations of the clinical nursing
education environment (Tanner, 1994). Of the few published studies focusing on the clinical
13

education environment, only a handful focus on evaluation of the environment, and the majority
of these studies have been descriptive in nature.
Reed and Price (1991) suggested criteria for an audit (assessment) of the clinical nursing
learning environment, including social climate, nursing climate, physical environment,
relationship between classroom and practice settings, and learning outcomes. However, they did
not identify specific criteria within these categories that should be addressed in such an
assessment. Clinical agency evaluation criteria were also suggested by Reilly & Oermann
(1992). They identified the importance of flexibility of the learning environment,
appropriateness of client population and adequate client numbers, range of learning
opportunities, current care practices at the agency, availability of records, student orientation,
and resource/space availability as important in determining clinical learning environment
adequacy.
Bevil and Gross (1981) identified several factors to be considered in selecting appropriate
clinical settings for nursing student learning experiences, and developed a tool for faculty use in
evaluating clinical settings. The forced-choice instrument addressed the issues of (a) availability
of staff to facilitate learning, (b) student opportunity to assess patients and give direct care, (c)
availability of records to students for review and documentation, and (d) an atmosphere
conducive to growth. No tool validity or reliability data was included in the publication and no
data collection was reported—only a plan for administering the tool and interpreting the results
was presented.
In contrast, Windsor (1987) used a student-centered approach in her study of the clinical
learning environment, conducting focused interviews to better understand the clinical experience
from the student perspective. Her detailed interviews of nine senior nursing students indicated
14

that many aspects of the clinical environment affected the quality of the student experience. A
variety of clinical assignments, opportunity for professional socialization, and staff approval
contributed to improved learning, while staff criticism contributed to a “bad” clinical day.
Windsor’s findings indicated that relationships of students with instructors, staff nurses, other
students, and patients were all important in the clinical experience.
Based on Windsor’s research, Peirce (1991) conducted a qualitative study investigating
preceptored students’ perceptions of their clinical experience. Twenty-nine first level and 15
second level undergraduate nursing students participated in the study. The open-ended
questionnaire data were analyzed for themes, with the variables identified as influencing the
clinical experience grouped into the categories of school/faculty factors, clinical site
organizational and personnel factors, and student factors. Within the clinical site factors,
variables mentioned by students included: assignments, staff feedback, preceptor’s availability
and interest in students, preceptor nursing skills, opportunity to perform skills, adequacy of
orientation, quality of nursing care, student participation in unit life, and staff willingness to
teach and to serve as role models. Faculty factors identified included direction and guidance,
availability to students, and follow-up to clinical experiences. Peirce stated that an unexpected
finding was the relative importance of the staff nurses to the quality of the student clinical
experience. This finding is supported by the research of Wilson (1994), who noted that students
perceived staff nurses as linked with the real world of clinical practice as opposed to the world of
theory to which the instructor was perceived to be linked.
Perese (1996) identified additional factors related to student perception of clinical
experiences in a descriptive study of 38 baccalaureate nursing students at the conclusion of a
psychiatric clinical rotation. The majority of factors identified as influencing the student clinical
15

experience involved nursing staff, including: role modeling, attitude, professionalism, staff
support of nursing students, and staff workload.
A review of the literature revealed only three recent studies aimed at developing and/or
testing an instrument to evaluate the clinical education environment. Robins, Gruppen,
Alexander, Fantone, and Davis (1996) developed an instrument to measure the medical school
learning environment as part of an effort to improve student perceptions of their medical school
experience. Although the authors did not specify whether their intent was to measure the
classroom or the clinical environment, the reader might assume that the instrument was intended
to measure the student learning environment in general, as no questions were addressed
specifically to either the classroom or the clinical education component. The 435 completed
instruments represented three years of data collection from medical students attending a large
Midwest university. Student respondents rated the overall learning environment as well as the
comfort of the environment for both men and women and for all races and ethnicities. The
quality and amount of feedback provided to students, faculty involvement and interest in student
education, and the program’s ability to promote critical thinking were also included in the
instrument. No information as to the format of the questionnaire, student response options, or
the reliability of the instrument was provided. Robins et al. (1996) did state that men and
Caucasian students perceived some aspects of the learning environment more favorably, and that
all medical students, regardless of gender or ethnicity valued a strong academic program and
faculty who are respectful and supportive. Promotion of critical thinking and timely feedback
were also identified by students as important. Regression analysis identified the strongest
predictor of satisfaction as student perception that faculty placed a high priority on student
education.
16

The second instrument-based clinical education evaluation study, conducted in Australia,
focused on development of an objective measure of nursing students’ clinical learning
environment in a psychiatric rotation. Farrell and Coombes (1994) developed the Student Nurse
Appraisal of Placement (SNAP) inventory with input from nursing faculty, agency staff, and
students. The inventory consisted of nine semantic differential items as well as an area for
student comments and an open-ended question about student experiences. Items addressed
physical resources, learning opportunities, availability of staff, opportunities to practice
interpersonal and technical skills, and overall student perceptions. Analysis was conducted
based on right and left deviation from the analogue center. No support for validity or reliability
of the instrument was presented in the article, and the size of the sample used in this
investigation was not identified. However, Farrell and Coombes did state that data were used in
curriculum review and decisions related to clinical site use. Data analysis revealed evaluation
differences between clinical sites; authors stated the items were in keeping with professionally
agreed upon criteria related to adequate learning environments for students.
The final instrument-based clinical evaluation study was based on the authors’ perception
that there was a lack of well-tested instruments to measure clinical learning environment. Dunn
and Burnett (1995) developed the Clinical Learning Environment Scale to measure the applied
component of nursing education. The instrument was based on Orten’s Ward Learning Climate
Survey (as cited by Dunn & Burnett, 1995) and was intended for use in the Australian nursing
system. Authors extracted and revised 55 items from Orten’s survey and administered the items
to 423 nursing students and faculty at an Australian university. Exploratory factor analysis
combined with a literature review led to further revision of the instrument. Confirmatory factor
analysis followed with further revision of factors. Their final instrument included 23 items with
17

five sub-scales measuring student-staff relationships, nurse manager commitment, patient
relationships, interpersonal relationships, and student satisfaction. Factors within the sub-scales
included: interpersonal relations, attitudes, physical structure, patient factors, staff workload,
student allocation, role clarity, staff supervision of students, and ward atmosphere. The authors
claimed construct validity of the instrument as determined by the confirmatory factor analysis.
Reported reliability alpha coefficients for the final four factors were .63 to .85. Although several
items in Dunn and Burnett’s tool might be appropriate for an instrument designed to assess the
clinical learning environment in the United States, others, such as (a) the amount of ritual on the
ward, (b) whether this was a happy ward, and (c) whether this was a good ward for learning
seemed either too general or unrelated to the current clinical nursing environment in the United
States. It would be difficult to use this instrument as a basis for any type of action aimed at
improving the clinical learning environment, as items containing broad statements about the
environment provide little information about what specific factors within the environment make
it supportive or not supportive of student learning.
It was apparent after review of the literature that although the clinical education
environment was acknowledged to be a critical component of nursing education, there was no
comprehensive tool that concisely measured student perceptions of the clinical learning
environment in nursing. Therefore, the literature search was broadened to include instruments
that have been developed to measure the learning environment in the more traditional classroom
setting.
18

Empirical Investigations of the Traditional Classroom Learning Environment
A number of instruments have been developed to measure the traditional classroom
learning environment. However, the majority have focused on elementary and secondary school
environments. In the last 25 years, the majority of published instruments addressing the
traditional classroom environment have been quantitative assessments of student perceptions of
the environment. However, one recently published instrument was designed to evaluate the
learning environment from an observer’s perspective. Recently, McNamara and Jolly (1994)
developed the Classroom Situation Checklist as part of a more extensive assessment tool to
investigate inappropriate student behavior in elementary school classrooms. The checklist was
developed in response to the authors’ observation that classroom environment factors often
contribute to student behavior problems. Three categories of factors compose the checklist:
1. Organizational factors: student entry/exit, seating and social grouping,
distractions / interruptions, equipment, lesson activities and transitions, and material
distribution,
2. Teaching interaction factors: classroom rules, personal comments, use of questions
and rhetorical questions, reprimanding, and supervision,
3. Pupil/curriculum factors: pupils unclear about tasks, pupils uninterested, unfairness,
pupils unable to complete an assigned task, pupils waiting.
An outside observer completes the checklist after one or more classroom observations.
The observer provides evidence (description) of the effects of the above factors on the classroom
environment and the possible impact on a particular student’s behavior. This information as well
as suggestions for managing the environment is then provided to the instructor. No information
related to tool validity or reliability or to the effectiveness of the Classroom Situation Checklist
19

in identification and modification of environmental factors impacting student behavior was
presented by authors.
One of the first quantitative inventories developed to measure student perceptions of the
classroom learning environment, the Learning Environment Inventory (LEI), was initially
developed in the late 1960’s by the Harvard Project Physics (Fraser, Anderson & Walberg,
1982). The final form of the instrument contains 105 items divided equally among 15 scales
(cohesiveness, diversity, formality, speed, material environment, friction, goal direction,
favoritism, difficulty, apathy, democracy, cliqueness, satisfaction, disorganization, and
competitiveness). Secondary level students report their level of agreement with the stated items
according to a four point Likert scale. Statistical testing of the instrument was reported by
Fraser, Anderson and Walberg (1982). Reported scale consistency (alpha reliability coefficients)
for inventory scales varied from .56 - .85. Within class correlations per scale were .31 - .92.
Test retest reliability ranged from .51 - .73, and correlations among the 15 scales varied from
.08 - .40.
Fraser and Fisher (1982) developed a modified version of the LEI, called the My Class
Inventory (MCI), for use with younger children, 8-12 years old. This instrument contains five
scales (cohesiveness, friction, difficulty, satisfaction, and competitiveness), rather than the
original fifteen. The MCI consists of 38 questions with yes/no response options. The inventory
was initially tested with 2305 seventh grade science students in Tasmania, Australia. The scale
consistency (Crohnbach’s alpha) scores ranged from .73 - .88. Correlation of each scale with all
others ranged from .13 - .30. ANOVA testing demonstrated that each scale was able to
differentiate between classrooms (p< .01). An eta squared value of .18 - .31 indicated that
20

etween 18 and 31% of variance in scale scores was attributable to class membership (Fraser &
Fisher, 1983).
The MCI instrument has been used in several studies as a dependent measure for
classroom improvement initiatives, although the majority of studies have been conducted in
other countries. Studies by Fraser and O’Brien (1985) and Diamantes (1994) demonstrated that
teacher interventions to improve the learning environment based on analysis of pre-intervention
MCI data resulted in significant improvement in student perceptions of the targeted dimensions
(scales) of the learning environment.
Fraser also developed an abbreviated version of the MCI, consisting of 25 questions
divided into five scales. Reliability testing with 758 third grade Australian students resulted in
findings similar to the long form, with the instrument being able to differentiate between
classrooms (p< .001), and the scales accounting for significant variance in student cognitive
outcomes (post-test scores), when controlling for prior knowledge and general ability (Fisher &
Fraser, 1981).
Another inventory designed to measure student perceptions of the classroom learning
environment, the Classroom Environment Scale (CES), was developed by Trickett and Moos
(1973). It was the result of literature review, interviews with students and faculty, and classroom
observations. The final version of CES consists of 90 items divided equally among 10 scales
(involvement, affiliation, support, task orientation, competition, order/organization, rule clarity,
teacher control and innovation). Student responses are limited to true and false. Initial
instrument testing with American junior high and senior high school students resulted in scale
consistency (alpha reliability) scores of .67 - .85, with correlation of individual scales with all
other scales ranging from .10 - .31 (Trickett & Moos, 1973). The amount of variance in CES
21

scale scores attributed to class membership varied from 21 - 48%. Test-retest stability over a
two-week interval varied from .91 to .98. Fraser and Fisher (1983) repeated reliability testing of
the instrument, finding similar results. They also developed and tested a preferred form of the
instrument, to measure the type of learning environments that students consider ideal. The
instrument was tested with junior high Australian students and faculty. Preferred scale reliability
alphas ranged from .60 - .86. Correlation of individual scales with all other scales varied from
.16 - .43 for the preferred form. Each scale was able to differentiate between classrooms (p<
.001) with the amount of variance in the CES scales attributable to class membership varying
from 18 - 43%.
Fraser (Fraser, 1983; Fraser & Fisher, 1983) developed yet another instrument, the
Individualized Classroom Environment Questionnaire (ICEQ), for use in more individualized
classroom settings. The ICEQ was based on review of literature related to classroom learning
characteristics, interviews with teachers and students, and the identified need for a time and cost-
efficient instrument to measure the learning environment of secondary students. It consists of 50
questions divided among five scales (personalization, participation, independence, investigation,
and differentiation). Student response options range from “almost never” to “almost always”.
Two forms of the instrument are available: one in which students or teachers respond to the
actual classroom environment, and one in which students and/or teachers respond according to
their preferred or ideal classroom environment. Reliability and validity testing was conducted
with seventh through ninth grade students in 116 Australian classes (Fraser & Fisher, 1983).
Scale internal consistency values for each scale ranged from .77 - .91 for the class actual form,
and from .75 - .92 for the class preferred form. Correlations between each individual scale of the
instrument and the other four scales were very similar across the two inventory forms, being .16 -
22

.32 for the student actual form and .17 - .35 for the student preferred form. Test-retest reliability
was reported to vary from .67 - .83 for a group of 105 students. Each scale of the instrument was
determined to differentiate between classrooms (by means of ANOVA results), with 20 - 43% of
the variance in scale scores being attributable to class membership (Fraser, 1983).
Fraser (1983) investigated application of the ICEQ in a classroom study aimed at
improving the student learning environment in a private secondary school class of 31 seventh
grade boys. Students completed both actual and preferred forms of the ICEQ instrument. The
teacher was provided the student means for each scale and developed interventions directed at
improving perceived personalization and participation scale scores. After one month of teacher
interventions, reassessment with the actual ICEQ inventory demonstrated significant change in
student perceptions of the environment related to the two scales targeted for intervention by the
teacher.
Fraser and Fisher (1982) also demonstrated a significant association between student
cognitive outcomes and their perception of the classroom psychosocial environment, using the
ICEQ and CES instruments. The magnitude of relationships was larger for the class than for the
individual student.
Fraser has also developed short forms of the ICEQ and CES, due to the perception that
time and cost constraints may prevent teachers from using the longer forms to assess the learning
environment and to measure improvements in the environment post-intervention (Fraser &
Fisher, 1986). The goal for the development of the shortened tools was to increase efficiency of
testing and scoring, while maintaining an accurate representation of mean class perceptions. The
shortened inventories were developed as a result of several item analyses of the long form data
from administration of these two tools, as well as from an attempt to achieve a balance of
23

positive and negatively worded items, with a goal of maintaining face validity of the instrument
(Fraser, 1982). The short version of the ICEQ consists of five scales with five questions each.
The shortened CES contains 24 questions divided evenly between six scales. The correlation
between the long and short forms for the ICEQ was reported to vary from .84 to .97. Reported
alpha reliability for the short form scales was .69 - .85. The correlation between long and short
forms of the CES was .78 - .92 and the alpha reliability for the CES short form scales ranged
from .78 - .92.
In addition, Fraser and his colleagues reported case studies using the shortened versions
of both the CES and MCI to assess and measure improvements in the learning environment of
Australian elementary school students (Fraser & O’Brien, 1985; Fraser & Fisher, 1986).
Teachers were informed of student perceptions of the environment and targeted specific areas for
intervention, based on inventory results. Post intervention scale scores for each inventory were
significantly different from initial scores, particularly in the areas targeted for intervention.
Yet another instrument was developed by Fraser, Treagust, and Dennis (1986), based on
an identified need for instruments to measure the learning environment in higher education
classrooms. The College and University Classroom Environment Inventory (CUCEI) was
designed to be used for smaller lecture or seminar-type university classes. The inventory
contains seven scales (personalization, involvement, cohesiveness, satisfaction, task orientation,
innovation, and individualization), with seven questions in each scale. Students respond to the
instrument according to a four level agree to disagree Likert scale; half of the items are reverse-
scored. Testing with 307 Australian post graduate and undergraduate students and 65 U.S. post
graduate and undergraduate students resulted in class reliability coefficient alphas for the scales
of .81 - .96, and correlation of individual scales with all other scales of .36 - .56. Each scale
24

significantly differentiated between classrooms (p< .001), with 32 - 42% of the variance in scale
scores being due to class membership (Fraser, Treagust, & Dennis, 1986).
Fraser, Williamson, and Tobin (1987) used the CUCEI instrument to compare
environmental perceptions of Australian students enrolled in an alternative high school geared
toward the adult learner with the perceptions of students enrolled in more traditional education
settings (evening technical school, traditional high school for adolescents only, and traditional
setting including both older learners and adolescents). They found differences between school
types on all seven scales of the CUCEI instrument. Overall, the evening technical school was
rated most favorably, followed by the alternative high school, the conventional adolescent high
school, and the high school integrating adolescents with adult learners.
Recently, Fraser, Giddings, and McRobbie (1991) have developed a new questionnaire,
called the Science Laboratory Environment Inventory (SLEI), to measure the unique
environment of science laboratory classes in secondary or tertiary level classes. The
questionnaire has five scales (student cohesiveness, open-endedness, integration, rule clarity and
material management). Students respond to questions on a five-point frequency Likert scale.
The instrument was field tested simultaneously in six countries with over 6,000 students (Fraser,
1991). Scale alpha reliabilities by class were reported to vary from .75 - .83, with the mean
correlation of individual scales with all other scales ranging from .07 - .37. Repeat investigation
resulted in somewhat higher correlations (.18 - .57) between individual scales and all remaining
scales (Henderson, Fisher, & Fraser, 1995). The researchers have also developed a “personal”
form of the SLEI instrument, to obtain student perceptions of his/her own role within the
classroom rather than perceptions of the class as a whole.
25

Due to an identified need to assess the degree to which a classroom’s environment is
consistent with a more constructivist philosophy, Taylor and Fraser (1991) developed the
Constructivist Learning Environment Survey (CLES). The inventory items are divided among
the four scales of autonomy, prior knowledge, negotiation, and student-centeredness. Reported
scale reliability scores for the actual version of this instrument ranged from .61 - .79.
Idiris and Fraser slightly modified the original CLES instrument to measure the perceived
learning environment of 1175 agricultural science students in 20 different Nigerian secondary
schools. They added the Investigation and Differentiation scales contained in the ICEQ to the
original CLES scales, and dropped the Prior Knowledge scale. Within-scale reliability scores
varied from .71 to .96 with the school mean as the unit of analysis and from .55 - .82 with the
individual as the unit of analysis. Correlation of each individual scale with all other scales varied
from .33 - .49 for group data, somewhat higher than scale correlations reported for the MCI,
CES, ICEQ, and SLEI, but comparable to those reported for the CUCEI. Between scale
correlations using individual data were slightly lower at .24 - .39. The actual form was found to
differentiate significantly (p< .001) between perceptions of students in different schools, with 14
- 45% of the variance in scale scores accounted for by school membership (Idiris & Fraser,
1994).
Very recently, Cannon (1997) administered both the preferred and the actual forms of the
original CLES instrument to 108 American students enrolled in college science courses (biology,
chemistry and physics). He reported within-scale reliability scores ranging from .63 - .89 for the
actual (perceived) inventory form and from .35 - .91 for the preferred form. Chemistry students’
scale reliability scores for the Prior Knowledge and Autonomy scales were noticeably lower than
other reliability scores, at .35 and .57 respectively. Cannon found that student perceived scores
26

were lower than preferred scores for all scales, indicating that the learning environments in all
three types of science classes fell short of what students preferred for these environments.
Generally, all of the instruments described above have been demonstrated to be
sufficiently reliable for use in assessment of classroom learning environments (Fraser, 1991).
Within-scale reliabilities indicated that students respond consistently to each of the scales within
the inventories. Correlations of individual scales with the other scales in an inventory indicated
the concepts measured by each of the instruments are distinct but somewhat overlapping. All
inventories have been shown to discriminate between the learning environments of students in
different classes. Each of the inventories measures somewhat different factors, as evidenced by
the different scales in the instruments.
Fraser (1991) created a matrix of the scales included in six of the above instruments (LEI,
CES, ICEQ, MCI, CUCEI, and SLEI), categorizing each instrument’s scales according to the
three dimensions of the human environment (Relationship, Personal Development, and System
Maintenance and Change) identified by Moos (1979). It was evident from review of this matrix
that several of the instruments contain some of the same or very similar scales, but that none
contain exactly the same scales. This author has further summarized Fraser’s matrix, focusing
on the scales included in the six instruments and frequency of identification of each scale among
the instruments. In addition, the scales identified in the more recent CLES inventory have been
included in the matrix summary. Table 1 identifies each scale (factor) measured by the seven
previously identified instruments and the frequency of scale identification across the instruments.
It is apparent that student cohesiveness or affiliations, involvement or participation, satisfaction,
competitiveness, and diversity or individualization are considered important factors in the
27

traditional classroom learning environment, as evidenced by their inclusion in at least three of
the seven learning environment inventories.
The most recently developed instrument measuring student perceptions of the classroom
learning environment, the Perceptions of Learning Environments Questionnaire (PLEQ), was
published by Clark (1995). This semi-structured inventory containing open-ended questions was
developed in response to the author’s perception that the previously cited instruments are limited
by scales developed a priori and forced-choice student response options. On the PLEQ, students
identify a learning environment and then describe up to 10 behaviors and activities that help as
well as hinder their learning. The author tested the instrument with 1249 students at Queensland
University of Technology in Australia. The categorized statements and reasons of 100 randomly
selected students were analyzed to determine 55 categories of statements and 47 categories of
reasons for use in classifying the remaining data. The most frequently identified
activities/behaviors that helped students to learn were (a) practical application, (b) clear
presentation/explanation, (c) lecturer supports student learning (d)
28

Table 1.
Identification and Frequency of Factors (Scales) Contained in LEI, CES, ICEQ, MCI, CUCEI,
and SLEI Instruments According to Moos’ Dimensions of the Educational Environment
Relationship
Dimension
Student cohesiveness or
affiliation (5)
Involvement or
participation (3)
Satisfaction (3)
Friction (2)
Personalization (2)
Favoritism (1)
Cliqueness (1)
Apathy (1)
Teacher support (1)
Personal Development
Dimension
Competitiveness (3)
Difficulty (2)
Task orientation (2)
Speed (1)
Independence (1)
Investigation (1)
Open-endedness (1)
Integration (1)
29
System Maintenance /Change
Dimension
Diversity, differentiation or
individualization (3)
Rule clarity (2)
Material environment (2)
Organization or
disorganization (2)
Teacher control vs.
democracy (2)
Innovation (2)
Formality (1)
Goal direction (1)

lecturer asks questions, and (e) discussion occurs. The most frequently identified
activities/behaviors that hindered student learning were (a) class not disciplined, (b)
inappropriate pacing of instruction, (c) unclear presentation/explanation, (d) inappropriate class
size, and (e) no variety in presentations/activities. Clark noted that an interesting finding of the
research was that students did not refer to either constructing their own knowledge or to
autonomy in learning as contributing to or hindering learning.
The PLEQ instrument is descriptive in nature, and no reliability or validity testing was
reported. Its purpose is also somewhat different from the previously described instruments, as
students are not evaluating an actual environment, but are making statements about a general
type of learning environment. It does, however, support inclusion of items related to student
interaction, application of knowledge, instructor support, discussion, clear presentations,
variety/innovation, and appropriate discipline in an instrument designed to measure student
perceptions of an actual learning environment.
Research consistently demonstrates that students' perceptions of their environment
account for an appreciable amount of variance in student outcomes (Henderson, Fisher, & Fraser,
1995; Moos & Moos, 1978), even when student background characteristics (prior knowledge and
general ability) were controlled (Fraser, Williamson, & Tobin, 1987). In addition, teachers tend
to perceive the environment more positively than students do (Fraser, 1991), although both
groups generally agree about characteristics of an ideal learning environment (Fraser, 1995;
Fraser & Fisher, 1982; Raviv, Raviv, & Reisel, 1990). Classroom environment research has also
shown that person-environment fit, as measured by congruence between student perceived and
preferred or ideal learning environment, is important in student achievement (Fraser, 1991).
30

Although the above-mentioned learning environment inventories are valid and useful
instruments to measure the traditional classroom environment, they do not address several
variables present in applied learning settings, such as the clinical nursing education environment.
The physical environment layout and resources, the adequacy of learning opportunities within
the environment, the influence of other student groups on the nursing student learning
experience, and the impact of professional staff or expert practitioners on student learning are not
addressed by the traditional classroom inventories. As noted previously, there are currently no
published instruments that comprehensively address the factors present in the applied learning
environment.
Statement of the Problem
Student and faculty variables that influence learning in the clinical setting may be
evaluated using a variety of tools and processes. The adequacy of the clinical environment,
however, often is assessed with one or two evaluative questions imbedded in an overall nursing
course evaluation. Analysis of one or two global questions related to the clinical setting can
hardly result in reliable information about the adequacy of the setting for students of a particular
ability level. The clinical education environment includes many forces and conditions within the
setting that impact student learning (Dunn & Burnett, 1995). The wide variety of clinical
settings used for undergraduate nursing education, the increased focus on clinical competence,
and the frequent use of clinical agency preceptors for nursing students highlight the need for a
comprehensive evaluation of the clinical sites used in undergraduate nursing education.
However, it was apparent after review of the literature that although the clinical education
environment was considered a critical component of nursing education, there was no
31

comprehensive tool that concisely measured student perceptions of the clinical learning
environment in nursing. Multiple inventories exist to assess student perceptions of the traditional
classroom environment, but most are designed for use with elementary and secondary level
students, and none address the factors identified in the nursing literature as critical to an
assessment of the applied clinical environment. The purpose of this research endeavor was to
develop and test an instrument that measures student perceptions of the clinical learning
environment in the variety of agencies and sites used in nursing education.
Preliminary Investigation
The initial Student Evaluation of Clinical Education Environment (SECEE) instrument
was developed as a tool for student evaluation of their clinical environments (Sand-Jecklin,
1997). Attention to the validity of content was addressed from the initial steps in inventory
development. Items were selected based on a review of the literature, nursing faculty and senior
nursing student perceptions of important aspects of the clinical environment, and a review of
sample university–agency contracts and unpublished course evaluations. Senior nursing student
and nursing faculty at a large mid-Atlantic university were requested to identify characteristics of
the clinical education environment that they felt should be addressed by an evaluation instrument
via group discussion with researcher facilitation. A table of specifications was developed,
including criteria identified through each of these sources. Item content was taken directly from
the table, with particular attention to criteria identified by several sources, supporting validity of
instrument content. An additional criterion considered in tool development was the need for a
brief survey that could be completed by students in a short time frame. Instrument revisions
were made based on review of the instrument by evaluation and nursing experts.
32

The original two-page SECEE instrument consisted of thirteen forced-choice items
relating to the clinical learning environment, of which eleven were presented in a four point
Likert format (a copy of the instrument appears in Appendix A). Content of the forced-choice
items included issues related to (a) student orientation; (b) nursing staff/preceptor availability,
communication, role modeling, and workload; (c) resource availability including patients,
equipment, and references; and (d) student opportunity for hands on care (Peirce, 1991; Perese,
1996). In addition, two questions contained dichotomous (yes/no) choices related to staff
preparation to serve as a resource and the presence of other students at the site during clinical
time.
Four open-ended items requested students to describe both the strengths and limitations
of the clinical experience at a particular agency, to describe the impact of other health
professional students at the clinical site on the student’s experience, and to comment further on
either the clinical experience or the evaluation tool.
Data were collected at the end of the 1996 spring semester. All students enrolled in the
undergraduate nursing program at the main campus of a large mid-Atlantic university were
included in data collection. Nursing faculty at the university distributed and collected the
inventories during the last two weeks of the semester. From the group of 218 sophomore, junior
and senior nursing students at the main university campus, 148 questionnaires were completed,
representing a 68% response rate. Response rates were similar across the three levels of
students. A total of 41 specific clinical learning environments were evaluated by students, with
each student evaluating only one site experienced during the spring semester. The number of
clinical sites was rather large due to senior level students participating in a precepted clinical
33

experience in a wide variety of clinical agencies, with only one to three senior students placed at
each site.
Student response consistency (Cronbach alpha coefficient) for the forced-choice
inventory items was .897, with question two removed from analysis as it contained nominal data.
According to Burns and Grove, (1993), alpha levels of .8 to .9 demonstrate response consistency
for the instrument. The range of correlations of individual items with the total ranged from .468
to.789, except for the single item related to the adequacy of orientation, which had a correlation
of .161 with the total.
Factor analysis was also used to determine reliability of the evaluation instrument.
Analysis with varimax rotation resulted in two factors with eigenvalues over 1.0. The reliability
coefficient alpha for factor 1 (learning environment) was .831 and the alpha for factor 2 (agency
or department atmosphere) was .774. Within factor 1, however, there appeared to be two sub-
scales. The coefficient alpha for sub-scale 1 (learning opportunities) was .799 and the alpha for
sub-scale 2 (staff/preceptor issues) was .790. Five of the eleven items included in the factor
analysis loaded above .35 on both identified factors, although they generally loaded somewhat
higher on one factor.
Several steps were taken to demonstrate validity of the SECEE instrument. Review of
the tool by both nursing education faculty and experts in evaluation contributed to the validity of
content. In addition, analysis of variance was performed to discern the discrimination ability of
the instrument. In order to conduct the ANOVA procedure, agency sites identified by fewer than
six respondents were combined into site categories or groups, according to similarity of the type
of nursing care provided at the sites. The resulting ten site groups varied in number of
respondents from seven to twenty-seven, with the majority including thirteen to eighteen student
34

espondents. Analysis of item responses by site groups demonstrated significant differences
between groups for all scaled items (p < .05). Follow-up testing with the Duncan test confirmed
significant differences between several site groups within each item. Some general trends were
evident across items, with two clinical areas being generally rated more favorably and three sites
being rated least favorably.
Student responses to the open-ended questions appeared to corroborate the ANOVA
results. Sites rated significantly lower than others in the comparative analysis also received
fewer positive comments in response to the open-ended item that requested students to identify
the strengths of having a clinical experience at the agency and were the only sites mentioned as
having “no strengths”.
As mentioned previously, the open-ended questions were included in the SECEE
instrument in order to provide support for existing forced-choice items and to determine whether
students would identify any significant clinical environment issues that were not addressed by
the forced-choice portion of the instrument. One item asked students to describe the impact of
other health professional students being present at the clinical agency on their experience.
Generally, the comments were global in nature and either positive (e.g., enhanced the student
experience) or neutral. Information about the impact of other students in the setting on the
nursing student learning experience could be more efficiently gained through a forced-choice
question.
Students were also asked to describe the strengths and limitations of having a clinical
experience at the identified agency. The most frequently identified strengths and limitations had
already been addressed in the forced-choice portion of the SECEE instrument, supporting
content validity of the instrument. The issues of variety of patients in the setting and time
35

constraints experienced by students were the only strengths or limitations not specifically
addressed by the scaled-response portion of the instrument.
Finally, students were asked to make any further comments they wished to communicate,
related either to their clinical experience or to the evaluation instrument. Most comments were
general in nature and related to either preceptor or staff issues (both positive and negative
comments) or to general perceptions about the agency environment.
Three study limitations became evident during data analysis, with the physical layout of
the demographic section contributing to two of the limitations. The semester identification item
was found to have 57 missing responses. This did not affect data analysis, as data collection
occurred during only one semester. However, it might affect analysis, if data were to be
collected over the span of several semesters. In addition, the item that requested students to
identify the clinical site being evaluated was found to be problematic. Twenty-six students
identified clinical sites only by institution (hospital) or clinical rotation (psychiatric), rather than
by specific unit or department, even though instructions requested inclusion of the unit or
department. This resulted in the need to create two general agency clinical site groups for
ANOVA analysis, potentially impacting analysis results. However, the majority of missing data
was from students evaluating one specific rotation in psychiatry, so validity testing of the
instrument was assumed to be minimally affected.
The third study limitation that became apparent during data analysis related to the
unequal numbers of students evaluating the variety of clinical sites. Due to senior students
having precepted clinical experiences in a wide variety of community and hospital settings, the
number of students evaluating some sites was very small. Thus, it was necessary to group
individual sites prior to ANOVA analysis. This grouping may have masked extreme scores for
36

sites having few respondents. If individual site data were needed for settings having very few
students, it would be necessary to review inventories rating these settings individually, or to
combine data for two or more semesters in order to achieve a larger sample size per site for
quantitative analysis.
Research Questions
The original SECEE inventory appeared to adequately reflect nursing students’
perceptions of some aspects of the clinical learning environment, based on data from students
enrolled in one nursing education program. However, the inventory did not reflect the full range
of factors impacting the clinical learning environment. As there continued to be no other
published instruments addressing student perceptions of the clinical education environment, the
investigator chose to continue refinement and testing of the SECEE inventory. The goals of
inventory revision were to produce an instrument that was a valid and reliable measure of student
perceptions, that reflected more fully the range of environmental impacts on student learning,
and that was practically useful to nursing educators. Based on the results from administration of
the original SECEE inventory and on further review of the applied learning environment
literature, the following questions were posed for continued research.
1. Is it possible to revise the original SECEE instrument to include all issues critical to the
nursing clinical education environment, while maintaining brevity and practicality of use
by nursing educators?
2. Is the revised SECEE inventory a reliable instrument for measuring student perceptions
of their clinical (applied) learning environment?
37

3. Is the revised SECEE inventory able to differentiate between various student populations
through the evaluation of their clinical education environment?
4. Are further revisions recommended to improve the validity, reliability, or ease of
administration and analysis of the SECEE inventory?
38

Chapter 3
Methods
The following section describes revisions to the original SECEE inventory and the
research procedure used in testing the revised inventory version. Nursing students at three
institutions were participants in data collection, in order to allow increased instrument testing and
potential generalizability for use with other nursing student populations.
Instrument Revisions
The focus of the present investigation was on continued refinement and testing of the
SECEE instrument. Several changes were made to the 13 forced-choice and 4 open-response
items of the original instrument, based on analysis of student data as well as on a more extensive
review of both theoretical literature and instruments that have been used to assess both the
traditional classroom and the applied learning environment (see Appendix D for Table of
Specifications). All revisions were made with consideration for validity of content, with
emphasis on data from student and faculty focus groups.
Forced-choice questions were formatted to fit the same scale, to improve the ease of
reading and scoring. In addition, the response options were changed from a four point frequency
Likert scale (very seldom to almost always) to a five point agreement scale (strongly agree to
strongly disagree), to increase the discrimination ability of the instrument. A sixth option of
“can’t answer” was also added, along with a request for students to provide an explanation for
questions to which they responded “can’t answer”. It was hoped that the addition of the “can’t
answer” response option would reduce the incidence of items left blank, provide information as
39

to why students were unable to respond to an item, and perhaps point to the need for further
inventory modifications.
The inventory contained four items for which a low score reflects a negative, rather than
positive, characteristic of the environment. These items were reverse-coded prior to data
analysis. The two demographic items (semester and clinical site being evaluated) on the initial
instrument that were found to have missing or incomplete student responses in the initial data
collection were altered to guard against recurrence of missing data.
An additional objective in revision of the inventory was to encompass more fully the
wide range of environmental influences on learning that had been identified through previous
research investigations (Peirce, 1991; Windsor, 1987). In order to accomplish this objective, four
items addressing student opportunities for learning and success, the impact of both instructor and
resource staff behaviors on the student experience, and relationships with other students were
added to the inventory.
The initial instrument did not address the impact of the instructor on the learning
environment. Based on research literature support for inclusion of instructor variables in a
comprehensive educational environment evaluation (Fraser, Treagust, & Dennis, 1986;
Henderson, Fisher, & Fraser, 1995; Robins et al., 1996; Trickett & Moos, 1973), the issues of
instructor feedback to students, instructor serving as a role model for professional nursing,
adequate instructor guidance, instructor encouragement of students helping each other, and
instructor availability for questions or assistance were addressed through the addition of one
inventory item for each issue. Two inventory items related to adequate preceptor/resource nurse
guidance in learning new skills and preceptor/resource nurse feedback to students were also
40

added, based on the applied cognition literature (Bevil & Gross, 1982; Peirce, 1991; Slavin,
1997).
An item addressing the range of learning opportunities at the site was also added, as a
result of multiple student comments about learning opportunities on the open-ended items of the
initial instrument as well as from further literature review (Farrell & Coombes, 1994; Reilly &
Oermann, 1992). In addition, eight items asking about clear communication of student
responsibilities, whether students are encouraged to identify and pursue learning opportunities,
whether students were allowed increased independence as their skills improved, if they
experienced difficulty obtaining assistance when needed, whether adequate support was provided
during attempts at a new skill, whether the student found responsibilities overwhelming, if
nursing students helped each other, and whether the atmosphere was conducive to learning were
added, based on review of both the applied and traditional classroom learning literature (Cust,
1996; Fraser & Fisher, 1983; Slavin, 1997).
Two questions were removed from the instrument, due to the perception that not all
nursing students would have adequate prior knowledge and experience to make reliable
judgements about the items. The forced-choice items asking whether students felt their
preceptor/resource nurse was prepared to serve as a resource to students and requesting student
recommendation about future use of the agency as a clinical education site were removed during
instrument revision. If either of these issues were critically important to a particular student s/he
could comment on them via the open-ended questions.
The forced-choice instrument items encompass four predetermined factors or scales:
communication and feedback, learning opportunities, learning support and assistance, and
department atmosphere (see appendix B for a list of items within each scale). The four scales are
41

epresentative of all three of Moos’ (1979) dimensions of educational environments. The
Communication and Feedback scale represents Moos’ relationship dimension; the learning
support and assistance and learning opportunity scales fall under the personal development
dimension; and the department atmosphere scale represents the system maintenance and change
dimension. The SECEE instrument has fewer scales than some of the previously cited traditional
classroom inventories (Fraser & Fisher, 1983), but it was believed that the items within the
scales measure the primary components of the clinical education environment and that the scales
would be shown through data analysis to measure distinct factors of the environment. A copy of
the complete SECEE instrument appears in Appendix C.
The majority of forced-choice items as well as the open-ended questions are written from
an individual rather than from a group perspective. As Fraser (1991) mentioned, students may
perceive the environment somewhat differently from a personal or from a class perspective.
Students generally work independently in the clinical nursing setting, and so may not be able to
comment on the learning environment for the clinical group as a whole. Thus, the inventory was
designed to gather perceptions about the individual’s experience within the environment.
Open-ended items asking students to identify aspects of the clinical setting that promoted
learning and the aspects that hindered learning, as well as an item providing space for additional
student comments remained in the instrument. It was felt that analysis of these items would
provide support for the validity of inclusion of the forced-choice items as well as identify issues
that may still not be addressed by the forced-choice items.
In addition to the six demographic questions, the SECEE inventory contains 29 scaled
items, plus three open response items. Questionnaire brevity was an issue identified by Fraser
(1991) in his development of the shortened versions of the MCI, CES and ICEQ inventories.
42

Limiting the number of items while maintaining the discrimination ability and consistency of an
instrument allows for improved efficiency of administration and scoring, and may promote use
of the instrument as a tool in the process of improving the student learning environment. It was
anticipated that students would need approximately ten minutes to complete the inventory, so
that students could easily complete the instrument at the end of a clinical session or during a
session of a theory based course.
Population
The study population for this investigation consisted of nursing students enrolled in
clinical nursing courses in baccalaureate nursing programs. The sample population was taken
from one large mid-Atlantic university (LMA) and two small liberal arts colleges, (one college in
the Mid-Atlantic States [SMA] and one small university in the Midwest [SMW]). The potential
number of student respondents from all institutions was approximately 380. Permission to
conduct the investigation was obtained from each institution prior to administration of the
instrument.
A description of the general nature of student clinical experiences at each university was
obtained from the dean of each school of nursing. Nursing students at all three institutions have
clinical sessions twice per week. The number of hours per week in the clinical setting varied
from 12 to 18, varying more with student level than with institution. Generally, sophomores had
the fewest clinical hours per week (8 – 12) and seniors had the highest number of clinical hours
per week (16 – 18). Nursing programs at LMA and SMW included a staff-precepted student
clinical experience at the senior level in both the community and leadership clinical rotations.
The program at LMA did not include any formally arranged precepted clinical experience for
43

students. Students attending LMA and SMW had two distinct clinical rotations per semester,
except senior students at LMA, who were placed in a rural site rotation for an entire semester.
At SMA, only junior students had two clinical rotations per semester; sophomores and seniors
remained at one primary clinical site throughout the semester.
Procedure
The SECEE instrument was administered to all classes of nursing students who were
enrolled in a clinical nursing experience at each institution. The instruments were distributed
during classroom sessions of nursing courses, for the sake of convenience in data gathering.
Students were asked to evaluate the primary clinical site that they were currently experiencing.
If students had concurrent clinical experiences at more than one site, they were assigned to
evaluate the first clinical setting they experienced during the school week. Only primary clinical
rotation sites were evaluated—observational and single day experiences at clinical sites were not
included in data collection. Although these experiences are also important to student learning,
inclusion of observational or single session sites in data collection would require students to
complete multiple inventories (one for each site experienced) within a short time frame,
potentially impacting the quality of student responses. To the investigator’s knowledge, all
students had at least three clinical sessions at the site being evaluated prior to data collection.
Data were collected during the 1998 spring semester. A sub-sample of sophomore and
junior students at institution LMA completed the instrument twice during the semester, during
two different clinical rotations. These data allowed comparison of individual student evaluations
of distinct clinical sites during the same semester. The junior students at SMW and the senior
students at SMA completed the inventory twice during the semester, but evaluated the same
44

clinical sites, for the purposes of test-retest reliability determination. The second administration
of the inventory to the above groups of students was between three and four weeks after the first
administration, following guidelines for test-retest reliability determination (Burns & Grove,
1993). All other students at the three institutions completed the SECEE inventory only once
toward the end of the semester.
Nursing instructors at institutions LMA, SMW, and SMA who distributed and collected
the instruments read the “Statement to Participants” prior to instrument distribution, assuring
students of confidentiality and anonymity as well as the voluntary nature of participation in the
study. The investigator read the “Statement to Participants” as well as distributed and collected
the SECEE inventories only for the sophomore and junior classes of students at LMA. All
students were requested to identify their inventories with the first two letters of their mother’s
first name and the last two digits of their social security number. Identification of student
inventories was necessary for comparisons of students’ pretest and end of semester inventories.
To the investigator’s knowledge, no time limitations were imposed for student completion of the
inventory. Upon completion, the SMW and SMA student inventories were forwarded to the
researcher by the deans of the nursing departments. LMA sophomore and junior student
inventories were collected directly by the investigator and senior student inventories at LMA
were forwarded to the investigator by nursing faculty.
45

Chapter 4
Results
The following chapter presents analysis of the data resulting from administration of the SECEE
inventory to the previously described nursing student population as well as brief discussion of
results. Data resulting from the end of semester SECEE inventory administration were the
primary focus for analysis, with analysis of the pretest data primarily for the purposes of
reliability determination. Tables reflect analysis of the primary end of semester data, with
inclusion of pretest data analysis when appropriate. Descriptive analysis of the forced-choice
portion of the inventory is followed by comparison of results by institution, reliability
calculations, and comparative analysis of scale scores by student level and by clinical site.
Finally, student narrative responses to the open-ended questions are presented.
Three hundred nineteen nursing students at the three identified institutions (LMA, SMW,
and SMA) completed the end of semester SECEE inventory. Of the selected sub-sample, 126
students completed pretest inventories. Student response rates across institutions were somewhat
different, with SMA and SMW students having higher response rates (92.3% and 90.8%
respectively) than LMA students (67.2%). This trend was also evident in the pretest data. The
low LMA response rate was primarily due to several students being out of class for a nursing
conference on the date of pretest inventory administration, and to half of the senior students
being off campus for the entire spring clinical rotation, returning only on the last day of class
during the semester to complete paperwork and evaluations.
46

Descriptive Analysis
Data from the forced-choice inventory items were entered according to the coded
responses (1-5) with responses of 6 (can’t answer) coded as “99” and removed from the data set
prior to parametric analysis. Student explanations as to why they could not answer a particular
forced-choice item were reviewed for thematic content, in order to determine if instrument
revisions would address the situations identified.
Prior to data entry, scores for items 9, 11, 21, and 25 were reverse-coded, as they
reflected negative characteristics of the learning environment. Prior to analysis, respondents’
“scale scores” were calculated by adding the scores for the items within each scale (see
Appendix B for a list of items within each scale). Data analysis was focused on determination of
SECEE inventory validity and reliability.
The 319 end of semester study participants fairly evenly represented the three student
levels, with 100 sophomore students, 94 juniors, and 122 seniors. Fifty sophomores, 40 juniors
and 37 seniors completed the pretest inventory. The vast majority of participants in both the
pretest and end of semester inventory (N = 297 and 120, respectively) were generic BSN
students. Only 15 students (4 students in the pretest group) reported being enrolled in RN to
BSN programs.
As expected, the majority of participants in both the pretest and end of semester
inventory reported being assigned a staff nurse at the clinical site (N = 63 and 159, respectively).
Fewer students (N = 21 and 59) reported being assigned an RN preceptor for the clinical rotation.
An unexpected finding was the number of students (N = 37 for pretest inventory and 86 for end
of semester inventory) who reported working only with their instructor at the clinical site, not
47

having been assigned any resource person. Only two respondents reported being assigned a
non-nurse resource person.
Missing data. Only two of the demographic items contained a frequency of missing data
worthy of concern. The first was the student ID number. Thirty-five students did not identify
their inventories with the first two letters of their mother’s first name and the last two digits of
their social security number. This presented a problem only when attempting to match pretest
and end of semester inventories for test-retest reliability determination. The second demographic
item with a frequency of missing data worthy of concern was clinical site identification. Sixty-
six respondents to the end of semester inventory and 22 respondents to the pretest inventory did
not identify the clinical site they were evaluating. Missing data were not evenly distributed
across institutions. All students at SMW institution completed the site identification item for
both the pretest and end of semester inventories. There were 40 cases of missing site
identification data from the end of semester inventories at LMA and 9 cases from the pretest
inventories. At SMA, 26 students completing the end of semester inventory and 9 students
completing the pretest inventory failed to identify the clinical site they were evaluating. The
missing site identifications resulted in exclusion of these inventories from any analysis using
clinical site as a study variable.
Data from the forced-choice portion of the inventory contained few occurrences of
missing data (items left blank by respondents). Of the 319 completed end of semester
inventories, only 17 “open” cells were identified. No more than three respondents left any
particular item blank. The pre-test data contained only six open cells, with no more than one
respondent leaving any item blank.
48

Study participants responded “can’t answer” to inventory items with a higher frequency
than that of leaving items blank. Of the 319 completed end of semester inventories, there were
183 occurrences of response number “6” (can’t answer). These occurrences were not evenly
distributed. Of the seven items with a frequency of ten or more can’t answer responses (numbers
2, 5, 8, 9, 21, 22, and 28), four dealt with preceptor or resource nurse issues and three contained
issues related to other students in the clinical learning environment. Thirty-nine explanations for
“can’t answer” responses were provided by students, accounting for 21.3% of the “can’t answer”
responses. Student explanations for the four preceptor/resource nurse items with highest
frequency of “can’t answer” responses were all similar, stating that there had been no preceptor
or resource nurse assigned to the student. Student explanations for “can’t answer” responses to
items related to other students at the clinical site were also similar, citing the absence of other
students at the particular clinical site.
Overall, the total number of student responses that were either open or entered as “can’t
answer” was relatively low, representing less than two percent of total possible responses to the
instrument. Therefore, the impact on data analysis was assumed to be negligible.
The pretest inventory data contained only six open cells among the 127 completed
instruments and 61 “can’t answer” cells. Again less than two percent of total possible data was
either missing or coded as “can’t answer”.
Descriptive Statistics
Descriptive analysis of forced-choice items revealed that overall item means varied from
1.70 to 2.62 on the end of semester inventory administration, indicating that respondents
evaluated the clinical sites positively to some degree (bear in mind that a lower item or scale
score indicates a positive evaluation of that aspect of the clinical learning environment).
49

Standard deviations ranged from 0.86 to 1.22. Pretest data means and standard deviations were
similar. All items except numbers 9 (negative impact of high preceptor/resource nurse
workload) and 25 (difficult to find help when needed) were somewhat positively skewed upon
visual inspection of histograms. The calculated means and standard deviations for forced-choice
items appear in Table 2.
Parametric Analyses
Prior to further analysis, scale scores were calculated for each respondent, by adding the
scores for all items contained in each of the four predetermined scales. Open data cells and cells
coded as “can’t answer” were replaced with the individual participant’s mean scale score, which
was calculated from the individual’s response to the remainder of the items in the scale. No
cases contained more than two “calculated” item scores per scale. Visual inspection of scale
score histograms revealed a more normal distribution than was apparent with individual items.
A slightly positive skew was visible on the Communication / Feedback and Learning Support
Scales. Following are the analysis results for the SECEE inventory data collected during the
spring semester, 1998. An alpha level of .05 was used for all statistical tests.
50

Table 2
SECEE Inventory Forced-choice Item Means and Standard Deviations.
End of Semester Inventory Pretest Inventory
Item 1. Adequacy of orientation M = 1.78
M = 2.17
SD = 0.93
SD = 0.82
n = 319
n = 127
Item 2. Preceptor/resource nurse available M = 1.78
SD = 0.86
n = 295
Item 3. Range of learning opportunities
available
Item 4. Responsibilities clearly
communicated
51
M = 1.86
SD = 0.88
n = 319
M = 1.90
SD = 0.91
n = 317
Item 5. RN maintained pt. responsibility M = 1.81
SD = 0.92
n = 299
Item 6. Instructor available M = 1.89
SD = 1.11
n =317
Item 7. Encouraged to identify / pursue
learning opportunities
Item 8. Preceptor/resource RN
communication about patient.
Item 9. Impact of high RN workload on
student experience (reverse coded)
M = 1.74
SD = 0.86
n = 319
M = 1.82
SD = 0.89
n = 307
M = 2.67
SD = 0.89
n = 295
Item 10. Adequate instructor guidance M = 1.80
SD = 0.95
n = 314
M = 1.85
SD = 0.84
n = 117
M = 1.87
SD = 0.83
n = 127
M = 1.82
SD = 0.77
n =127
M = 2.19
SD = 1.05
n = 116
M = 1.73
SD = 0.83
n = 127
M = 1.66
SD = 0.74
n = 127
M = 1.88
SD = 0.85
n = 121
M = 2.62
SD = 1.17
n = 114
M = 1.83
SD = 0.91
n = 127

Item 11. Overwhelmed by responsibilities
of role (reverse coded)
Item 12. Instructor provided adequate
feedback
Item 13. Adequate number and variety of
patients appropriate for abilities
Item 14. Adequate preceptor / resource
nurse guidance
Item 15. Allowed more independence as
skills increased
Item 16. RN’s served as positive role
models
Item 17. Equipment, supplies and
resources available
Item 18. Felt supported in attempts at new
skills
Item 19. RN’s informed students of
learning opportunities
Item 20. Instructor served as positive role
model
Item 21. Negative impact from competition
with other students (reverse coded)
52
M = 2.32
SD = 1.12
n = 316
M = 1.91
SD = 1.01
n = 317
M = 1.97
SD = 0.92
n = 318
M = 2.15
SD = 1.03
n = 312
M = 1.76
SD = 0.89
n = 316
M = 2.21
SD = 1.02
n = 315
M = 1.86
SD = 0.90
n = 317
M = 1.89
SD = 0.87
n = 318
M = 2.21
SD = 1.08
n = 314
M = 1.68
SD = 0.91
n = 316
M = 2.40
SD = 1.22
n = 308
M = 2.15
SD = 0.96
n = 127
M = 1.83
SD = 0.77
n = 127
M = 2.05
SD = 0.85
n = 127
M = 2.13
SD = 0.79
n = 124
M = 1.92
SD = 0.77
n = 126
M = 2.34
SD = 0.94
n = 127
M = 2.16
SD = 0.95
n = 126
M = 1.93
SD = 0.75
n = 126
M = 2.30
SD = 0.97
n = 126
M = 1.69
SD = 0.85
n = 127
M = 2.35
SD = 1.13
n = 123

Item 22. Students helped each other M = 1.75
SD = 0.84
n = 291
Item 23. Site provided an atmosphere
conducive to learning
Item 24. Nursing staff positive about
serving as a resource
Item 25. Was difficult to find help when
needed (reverse coded)
Item 26. Was able to do “hands on” to
level of ability
Item 27. RN staff provided constructive
feedback
Item 28. Instructor encouraged students to
help each other
Item 29. Was successful in meeting
learning goals
53
M = 1.92
SD = 0.86
n = 318
M = 2.21
SD = 1.02
n = 315
M = 2.42
SD = 1.17
n = 314
M = 1.74
SD = 0.96
n = 314
M = 2.27
SD = 1.11
n = 311
M = 1.85
SD = 0.96
n = 300
M = 1.83
SD = 0.89
n = 319
M = 1.88
SD = 0.91
n = 120
M = 1.90
SD = 0.80
n = 127
M = 2.33
SD = 0.96
n =126
M = 2.31
SD = 0.99
n =127
M = 1.73
SD = 0.76
n = 127
M = 2.39
SD = 0.88
n = 126
M = 1.91
SD = 0.94
n = 122
M = 1.80
SD = 0.65
n = 125

Institutional Differences in Student Response to the SECEE Instrument. Prior to
reliability determination for both the SECEE instrument as a whole and for the four
predetermined scales, it was necessary to determine whether there were differences between the
institutions in terms of respondent scale scores. Calculations of four ANOVAs were completed,
using the institution as the independent variable and the four calculated scale scores as the
dependent variables. A random sample of 35 completed inventories from each institution was
used for analysis. No violation of the homogeneity of variance assumption was detected via the
Levene’s Statistic method (Norusis, 1997). Institution specific and overall scale score means and
standard deviations are reported in Table 3. Significant differences in scale scores were found
between institutions for all four scales: Communication / Feedback F (2, 102) = 8.17, p < .01;
Learning Opportunities F (2, 102) = 4.49, p < .05; Learning Support F (2, 102) = 8.40, p < .01;
and Department Atmosphere F (2, 102) = 4.70, p < .05. Results of the ANOVA analysis are
presented in Table 4.
Multiple comparisons were calculated using the Dunnett T3 method (Lomax, 1992) and a
significance level of p < .05. These results revealed that for the Communication and Feedback
scale, students attending SMW rated their clinical sites more positively (M = 11.06) than did
students attending both LMA (M = 14.99) and SMA (M = 13.78). Students attending SMW
institution also rated the Learning Opportunities at their clinical sites more positively (M =
13.11) than did students at LMA did (M = 16.47). Learning Support at the clinical site was rated
higher by students at SMA (M = 13.33) and students at SMW (M = 14.68) than by students at
LMA (M = 17.13). Finally, students at SMA rated the department atmosphere at their clinical
54

Table 3
Scale Means and Standard Deviations by Institution
LMA Instit.
n = 35
SMW Instit.
n = 35
SMA Instit.
n = 35
All Institutions n
= 319
Comm. /
Feedback
M = 14.99
SD = 5.27
M = 13.78
SD = 3.66
M = 11.06
SD = 3.32
M = 13.99
SD = 5.02
Learning
Opportunities
M = 16.47
SD = 5.82
M = 15.19
SD = 3.85
M = 13.11
SD = 4.27
M = 15.37
SD = 5.25
55
Learning
Support
M = 17.13
SD = 4.40
M = 14.68
SD = 3.40
M = 13.33
SD = 3.92
M = 15.52
SD = 5.05
Department
Atmosphere
M = 14.63
SD = 5.88
M = 11.81
SD = 2.94
M = 12.10
SD = 3.24
M = 12.59
SD = 3.59

Table 4
Statistical Results for Institution by Scale Score ANOVA
df 1 df 2 F ratio p
Communication/ Feedback 2 102 8.17 .001
Learning Opportunities 2 102 4.49 .013
Learning Support 2 102 8.41 .000
Department Atmosphere 2 102 4.70 .011
56

sites more favorably (M = 11.81) than students at LMA did (M = 14.63). The p values for the
significant findings in post hoc comparisons are provided in Table 5.
In addition to comparisons of scale scores by institution, item specific ANOVAs were
completed using institution as the independent variable. Results indicated that institution effect
on individual item scores was significant for 20 of the 29 forced-choice items at p < .05,
although the data for 4 of the items violated the homogeneity of variance assumption according
to the Levene Statistic. There did not appear to be a pattern in terms of the significant and non-
significant items. The nine items for which no significant institutional differences were found
were evenly distributed across all four scales, with each scale having either two or three items for
which no institutional differences were found. Post hoc testing using the Dunnett T3 method
(controlling for violation of the homogeneity of variance assumption) produced results consistent
with the results of the scale score analysis, with students attending the smaller institutions rating
their clinical experience more positively than students attending the larger institution.
Instrument Reliability Determination. As there were significant differences in inventory
scale scores between the three institutions used in this investigation, calculations for reliability of
the scales and for the instrument as a whole were conducted separately for each institution as
well as for all institutions together (see Table 6). Reported internal reliability figures represent
standardized coefficient alphas (Anastasi, 1988). Correlations were found to be similar among
institutions, although SMA results were slightly lower than the other two institutions.
57

Table 5
Significance Levels for Institutional Comparisons According to Scale Scores
Comm /
Feedback
Learning
Opportunities
58
Learning
Support
Department
Atmosphere
LMA vs. SMW .033 -- .001 .002
LMA vs. SMA .000 .003 .001 --
SMW vs. SMA -- -- -- --
Note. Dashes indicate non-significant comparison results (p > .05)

Table 6
Reliability Coefficients for SECEE Instrument and Individual Scales by Institution
LMA Instit.
n = 126
SMW Instit.
n = 69
SMA Instit.
n = 122
All Instit.
n = 318
Entire
Instrument
Comm. /
Feedback
Scale
Learning
Support
Scale
59
Learning
Opportunity
Scale
Department
Atmosphere
Scale
.94 .87 .87 .82 .64
.89 .74 .74 .74 .59
.94 .86 .87 .81 .65
.94 .85 .81 .86 .63

Review of the analyses indicated that the overall alpha for the entire instrument was quite
high--.94 for both LMA and SMA institutions and .89 for SMA. The reliability of the instrument
as a whole was highest with all items included. Review of scale reliabilities by institution
indicated that reliability for the Learning Opportunities Scale might be slightly higher with the
item “I felt overwhelmed by the demands of my role in this environment”
taken out of the scale. Removal of this item results in reliabilities of .02 to .03 higher for all
institutions. Otherwise, reliability alphas were highest with all items included in each of the four
scales. There were only two items for which correlations of individual items with the scale were
below .35 for more than one institution: (1) the previously mentioned “felt overwhelmed” item
in the Learning Opportunities Scale, and (2) the “Competition with other health professional
students negatively impacted the student experience” item from the Department Atmosphere
scale.
Test-Retest Reliability. In order to determine test-retest reliability for the instrument,
pretest and end of semester scale scores were compared for the sub-sample of SMW and SMA
students who evaluated the same clinical site on the pretest and end of semester inventories
(n = 66). The lack of student identification of their completed inventories resulted in the loss of
20 cases from the test-retest reliability determination. Significant correlations were found
between the pretest and end of semester scores for each inventory scale (p < .001) for those
students who evaluated the same clinical sites on both inventories (n = 46). Correlations ranged
from .50 to .61 (see Table 7 for all correlation results).
In addition, a sub-sample of LMA students completed two SECEE inventories,
evaluating different clinical sites on the pretest and end of semester inventory. According to
Richards (1996), comparison of the same participants’ evaluations of discrete environments
60

assists in reducing the confounding person-environment sources of variance. If differences in
individual student evaluations of discrete sites are found, the differences are most likely due to
the discrimination ability of the instrument. For student participants evaluating different clinical
sites on the pretest and end of semester inventories (n = 60), no significant correlations were
found between pretest and end of semester scale scores (p > .05). This result indicates that there
was no relationship between the evaluations of different clinical sites, when the same students
evaluated two different sites. Correlations between inventory scale scores ranged from -.01 to
.20. These correlations also appear in Table 7.
Differences in Scale Scores According to Student Academic Level. As the SECEE
Inventory was able to detect differences between institutions in terms of student evaluation of
sites, the researcher wondered whether it might also detect differences between student
evaluation of sites according to student academic level (sophomore, junior, senior). Thus,
comparative ANOVAs were computed for differences in scale scores (dependent variable) by
student level (independent variable), after sorting data by institution. ANOVA results are
presented in Table 8 and significance levels for post hoc tests are shown in Table 9. Cell means
and standard deviations for the scale scores according to student level can be found in Table 10.
The Dunnett T3 method was used for all post hoc tests, as there was violation of the
homogeneity of variance assumption for some of the ANOVAs (violations will be identified in
discussion of each analysis). Results indicated that for institution SMW, differences between
scale scores were only significant for the Department Atmosphere scale [F (2, 66) = 4.70, p <
.05]. However, according to the Levene Statistic, the assumption of homogeneity of variance
was violated for the test [F (2, 66) = 3.93, p = .025]. Multiple comparisons
61

Table 7
Scale Score Correlations Between Pretest and End of Semester Inventories
Same Sites
Evaluated
Different Sites
Evaluated
Communication
/ Feedback
r = .55*
n = 46
r = .17
n = 60
Learning
Opportunities
r = .52*
n = 46
r = -.01
n = 60
Note. * Indicates correlation is significant at p < .001
62
Learning
Support
r = .50*
n = 45
r = .20
n = 58
Department
Atmosphere
r = .61*
n = 46
r = .19
n = 60

Table 8
ANOVA Results, Student Level by Scale Score
df 1 df 2 F ratio p
LMA Instit. Comm. / Feedback 2 123 5.95 .003
Learning Opportunities 2 123 3.89 .023
Learning Support 2 123 3.50 .033
Dept. Atmosphere 2 123 5.00 .008*
SMW Instit. Comm. / Feedback 2 66 0.98 .38
Learning Opportunities 2 66 1.03 .36
Learning Support 2 66 1.08 .35
Dept. Atmosphere 2 66 4.70 .012*
SMA Instit. Comm. / Feedback 2 117 3.85 .024
Learning Opportunities 2 117 2.94 .057
Learning Support 2 117 6.68 .002*
Dept. Atmosphere 2 117 5.69 .004
* Note: violation of Homogeneity of Variance assumption according to Levene’s
Statistic at p < .05
63

Table 9
Significance Levels for Student Comparisons According to Scale Scores
Comm /
Feedback
64
Learning
Opportunity
Learning
Support
Dept.
Atmosphere
LMA Instit. Jr vs Soph -- -- -- --
Jr vs Sr .004 .023 .045 .011
Soph vs Sr -- -- -- .021
SMW Instit. Jr vs Soph -- -- -- .003
Jr vs Sr -- -- -- --
Soph vs Sr -- -- -- --
SMA Instit. Jr vs Soph .013 -- .002 .023
Jr vs Sr -- -- -- --
Soph vs Sr -- -- .002 .002
Note. Dashes represent non-significant comparisons (p > .05).

Table 10
Scale Score Means and Standard Deviations by Student Level
LMA
Institution
SMW
Institution
SMA
Institution
Student
Level
Sophomore
n = 49
Junior
n = 46
Senior
n = 31
Sophomore
n = 25
Junior
n = 16
Senior
n = 28
Sophomore
n = 25
Junior
n = 32
Senior
n = 47
Comm. /
Feedback
M = 15.33
SD = 4.48
M = 17.26
SD = 6.51
M = 12.94
SD = 4.90
M = 13.44
SD = 4.17
M = 14.81
SD = 3.27
M = 13.17
SD = 3.88
M = 11.16
SD = 3.41
M = 14.42
SD = 4.85
M = 12.57
SD = 4.65
Learning
Opportunity
M = 17.05
SD = 5.47
M = 17.83
SD = 6.66
M = 14.17
SD = 4.91
M = 14.06
SD = 4.00
M = 15.25
SD = 3.44
M = 15.60
SD = 4.29
M = 12.30
SD = 3.27
M = 14.73
SD = 5.04
M = 15.00
SD = 5.17
65
Learning
Support
M = 17.07
SD = 5.47
M = 18.29
SD = 6.64
M = 14.95
SD = 5.02
M = 13.72
SD = 4.32
M = 15.50
SD = 2.63
M = 14.61
SD = 3.95
M = 11.85
SD = 3.38
M = 16.22
SD = 5.61
M = 14.97
SD = 4.43
Department
Atmosphere
M = 13.62
SD = 3.30
M = 14.07
SD = 4.05
M = 11.54
SD = 3.26
M = 10.34
SD = 2.45
M = 13.24
SD = 2.48
M = 11.48
SD = 3.54
M = 10.63
SD = 2.96
M = 12.90
SD = 3.20
M = 13.33
SD = 3.69

according to the Dunnett T3 test demonstrated that sophomore students rated the Department
Atmosphere of their sites (M = 10.63) significantly more positively (p < .01) than juniors did (M
= 12.90).
At LMA institution, there were significant differences in student evaluations of the
clinical learning environment according to student level for all four scales. Differences between
student levels on the Communication / Feedback scale were significant F (2, 123) = 5.95, p <
.01, with senior students at LMA institution having rated their clinical environments significantly
more positively (M = 12.94) than junior students did (M = 17.26), p < .01. Student level also
accounted for significant differences in student perception of clinical site Learning Opportunities
F (2, 123) = 3.89, p < .05. Senior students rated Learning Opportunities more positively (M =
14.17) than junior students did (M = 17.83), p < .05. ANOVA results also indicated differences
between student academic levels for the Learning Support scale F (2, 123) = 3.50, p < .05.
Again, seniors evaluated their sites more positively (M = 14.95) than did juniors (M = 17.07), p
< .05. Differences between student levels were also identified for the Department Atmosphere
scale F (2, 123) = 5.00, p < .01. Seniors students at LMA rated the Department Atmosphere of
their clinical education environments (M = 11.54) higher than did both juniors (M = 14.07) and
sophomores (M = 13.62). The Homogeneity of variance assumption was violated only for the
Department Atmosphere Scale ANOVA [F (2,123) = 3.35, p = .038].
Differences on three of the four scale scores were found for SMA students. Differences
between academic levels of students were found for the Communication and Feedback scale F
(2, 117) = 3.85, p < .05, with sophomore SMA students having evaluated their clinical
environments more positively (M = 11.16) than did junior students (M = 14.42). Differences
between student levels were also found for the Learning Support scale F (2, 117) = 6.68, p < .01.
66

Sophomore SMA students rated the Learning Support at their clinical sites significantly more
positively (M = 11.85) than both junior (M = 16.22) and senior students (M = 14.97) on the
Learning Support scale, p < .01. Students of different academic levels also evaluated the
Department Atmosphere of their learning environments differently F (2, 117) = 5.69, p < .01,
with sophomore students having evaluated their sites more positively (M = 10.63) than both
junior students (M = 12.90) and senior students (M = 13.33), p < .01. The Levene Statistic for
homogeneity of variance was significant only for the Learning Support scale [F (2, 117) = 5.71,
p = .004].
Differences in Scale Scores According to Clinical Site Groups. One means to support the
validity of an environmental measure is to compare student responses to the inventory across a
variety of settings, in order to determine whether the instrument is able to distinguish between
distinct environmental settings (Richards, 1996). The investigation of whether there were
differences between SECEE inventory scale scores based on the clinical site being evaluated was
conducted via ANOVA testing. Prior to this analysis, it was necessary to group some clinical
sites together, as several sites were evaluated by only one or two students. Site grouping was
based upon the type of nursing care provided at the site, and the dean or faculty at the schools of
nursing at each institution confirmed appropriateness of the grouping. Site grouping reduced the
number of clinical groups from 56 to 25. The degree of grouping required was not similar across
institutions. Only one site identified by SMW students was grouped with another site within the
same hospital. Six sites evaluated by SMA students were grouped together with other sites, with
the grouped sites representing primarily specialty care units (intensive care units, labor and
delivery, and other units with only one respondent). In contrast, 24 identified clinical sites at
LMA were consolidated into 10 site groups. The grouped sites represented community
67

healthcare programs, school nursing, clinic or physician offices, home health / hospice, and
specialty care units in the hospital environment. Even after grouping the cell sizes were not
equivalent, with the number of respondents in each site group varying from 4 to 26. The median
number of respondents per site group cells was 8.
Initial analysis consisted of four ANOVAs with site group as the independent variable
and scale score as the dependent variable. Although all F ratios were significant at p < .01,
indicating that scale scores differed according to clinical group, the Levene Statistic for
Homogeneity of Variance was violated for tests on two of the four scales (Communication /
Feedback and Learning Opportunities). Therefore, the additional grouping variable of institution
was used, and separate ANOVAs were run for each institution, resulting in 12 separate analyses.
The MANOVA procedure was not used for testing as the dependent variables (scale scores) were
found to be fairly highly correlated. The Dunnett T3 test was used for all post hoc analyses, as
some ANOVA tests violated the Homogeneity of Variance assumption. ANOVA statistics are
presented in Table 11 and scale means and standard deviations by clinical site group appear in
Table 12.
Results indicated that there were significant differences in scale scores according to
clinical site groups. For the SMW institution, ANOVA results were significant for all but one
scale score (Learning Opportunities). Significant differences between student evaluations of
clinical sites were found for the Communication and Feedback Scale F (6. 54) = 3.41, p < .01.
Post Hoc comparisons of SMW data indicated that students rated the Communication / Feedback
of clinical site group 5 more positively (M = 9.00) than site group 1 (M = 15.89), site group 2 (M
= 15.20), and site group 7(M = 15.29), p < .05. Differences between site groups were also found
for the Learning Support scale F (6, 54) = 3.46, p < .01. SMW students rated the Learning
68

Support at site group 5 more positively (M = 9.86) than site groups 1 (M = 16.92), 2 (M =
15.60), and 7 (M = 15.51), p < .05. ANOVA analysis also detected differences in scale scores
according to clinical site group for the Department Atmosphere scale F (6, 54) = 4.83, p < .01.
Again, SMW students at site group 5 rated the Department Atmosphere more positively (M =
8.43) than students at site 2 (M = 12.78). In addition, students at site 4 (M = 9.58) perceived the
Department Atmosphere to be more positive than students at site 2 (M = 12.78), p < .05. Levels
of significance for the differences found between site groups at SMW appear in Table 13.
At SMA, two of the four scales were found to have significant differences according to site
groups. Students evaluated the Learning Support F (11, 83) = 1.92, p < .05 and the Department
Atmosphere F (11, 83) = 1.95, p < .05 differently according to clinical site group. However
multiple comparisons using the Dunnett T3 test did not reveal significant differences between
individual site groups (p > .05). LMA institution data differed from the other institutions in that
no significant differences between clinical site groups were found for any of the four scales.
69

Table 11
ANOVA Statistics, Clinical Site Group by Scale Score
df 1 df 2 F ratio p
LMA Instit. Comm/ Feedback 10 73 1.21 .30 *
Learning Opportunity 10 73 1.00 .46
Learning Support 10 73 1.44 .18
Department Atmosphere 10 73 1.87 .064
SMW Instit. Comm/ Feedback 6 54 3.41 .006
Learning Opportunity 6 54 1.74 .13
Learning Support 6 54 3.46 .006
Department Atmosphere 6 54 4.83 .001
SMA Instit. Comm/ Feedback 11 83 1.44 .17
Learning Opportunity 11 83 1.77 .073 *
Learning Support 11 83 1.92 .048
Department Atmosphere 11 83 1.95 .045
* Note: violation of Homogeneity of Variance assumption according to Levene’s Statistic at p <
.05
70

Table 12
Scale Score Means and Standard Deviations by Clinical Site Groups
LMA 11
n = 11
Site Group Comm. /
12
n = 5
13
n = 6
14
n = 16
17
n = 5
19
n = 5
33
n = 4
39
n = 4
51
n = 9
54
n = 9
Feedback
M = 14.45
SD = 3.96
M = 12.40
SD = 1.82
M =17.75
SD = 2.72
M = 16.95
SD = 6.99
M = 19.00
SD = 6.36
M = 12.60
SD = 2.70
M = 16.29
SD = 5.12
M = 14.0
SD = 6.98
M = 15.15
SD = 7.99
M = 12.33
SD = 3.08
Learning
Opportunity
M = 13.27
SD = 3.35
M = 13.60
SD = 3.51
M = 15.83
SD = 2.48
M = 17.39
SD = 6.25
M = 19.80
SD = 7.19
M = 12.40
SD = 3.44
M = 16.07
SD = 4.66
M = 18.50
SD = 10.47
M = 18.11
SD = 7.93
M = 16.11
SD = 7.52
71
Learning
Support
M = 15.35
SD = 3.72
M = 12.40
SD = 2.41
M = 20.00
SD = 1.90
M = 18.53
SD = 6.85
M = 19.40
SD = 6.34
M = 16.21
SD = 5.89
M = 14.29
SD = 5.19
M = 13.25
SD = 7.54
M = 17.21
SD = 6.19
M = 14.47
SD = 4.18
Dept.
Atmosphere
M = 12.00
SD = 3.26
M = 10.92
SD = 2.83
M = 15.00
SD = 1.41
M = 14.72
SD = 4.20
M = 14.20
SD = 4.20
M = 9.40
SD = 0.89
M = 12.25
SD = 0.96
M = 9.25
SD = 3.95
M = 12.98
SD = 4.78
M = 11.89
SD = 4.29

SMW 1
n = 9
Site Group Comm. /
2
n = 10
3
n = 6
4
n = 17
5
n = 7
7
n = 7
10
n = 5
Feedback
M = 15.89
SD = 4.20
M = 15.20
SD = 3.85
M = 14.17
SD = 2.14
M = 12.34
SD = 3.73
M = 9.00
SD = 3.21
M = 15.29
SD = 2.98
M = 14.25
SD = 4.51
Learning
Opportunity
M = 16.22
SD = 5.31
M = 14.80
SD = 3.49
M = 16.00
SD = 3.52
M = 13.59
SD = 4.37
M = 12.14
SD = 4.22
M = 17.67
SD = 2.35
M = 13.50
SD = 2.32
72
Learning
Support
M = 16.92
SD = 3.27
M = 15.60
SD = 2.41
M = 15.33
SD = 3.20
M = 13.15
SD = 4.87
M = 9.86
SD = 2.61
M = 15.51
SD = 2.54
M = 14.07
SD = 2.09
Dept.
Atmosphere
M = 12.78
SD = 4.24
M = 12.78
SD = 2.12
M = 14.00
SD = 3.03
M = 9.58
SD = 2.42
M = 8.43
SD = 2.37
M = 13.17
SD = 2.50
M = 12.32
SD = 1.95

SMA 14
n = 7
Site Group Comm. /
17
n = 6
19
n = 17
29
n = 16
33
n = 4
74
n = 12
75
n = 9
77
n = 5
79
n = 5
80
n = 5
82
n = 5
84
n = 4
Feedback
M = 17.71
SD = 5.85
M = 12.00
SD = 3.35
M = 11.97
SD = 3.99
M = 12.81
SD = 4.12
M = 11.50
SD = 5.92
M = 12.17
SD = 3.90
M = 15.11
SD = 6.70
M = 14.20
SD = 6.38
M = 12.03
SD = 5.40
M = 9.60
SD = 3.43
M = 13.40
SD = 2.70
M = 10.00
SD = 2.94
Learning
Opportunity
M = 20.14
SD = 3.72
M = 14.00
SD = 4.34
M = 12.29
SD = 4.62
M = 14.50
SD = 5.56
M = 14.00
SD = 7.44
M = 14.00
SD = 2.66
M = 16.21
SD = 4.55
M = 15.60
SD = 9.10
M = 11.20
SD = 3.27
M = 12.60
SD = 2.88
M = 14.80
SD = 3.70
M = 11.75
SD = 3.10
73
Learning
Support
M = 19.29
SD = 4.75
M = 15.67
SD = 1.97
M = 14.55
SD = 5.89
M = 14.22
SD = 4.57
M = 13.75
SD = 6.45
M = 13.85
SD = 3.95
M = 18.67
SD = 5.43
M = 14.20
SD = 5.54
M = 16.00
SD = 3.87
M = 11.00
SD = 2.74
M = 11.40
SD = 2.07
M = 12.25
SD = 3.86
Dept.
Atmosphere
M = 16.20
SD = 3.87
M = 13.33
SD = 3.98
M = 11.00
SD = 3.30
M = 13.81
SD = 3.64
M = 9.45
SD = 2.97
M = 11.52
SD = 3.21
M = 14.22
SD = 2.44
M = 13.64
SD = 5.60
M = 12.80
SD = 4.44
M = 12.16
SD = 2.41
M = 12.00
SD = 2.65
M = 10.50
SD = 3.70

Table 13
Significance Levels for Post Hoc Differences between Clinical Site Groups at SMW
Comm. / Feedback Learning Support Dept. Atmosphere
SMW Site 5 vs. 1 .007 .004 .042
SMW Site 5 Vs 2 .018 .026 .035
SMW Site 5 Vs 3 -- -- .010
SMW Site 5 Vs 7 .032 -- .034
74

Analysis of Narrative Inventory Data
As noted in the Methods section, students were asked to respond in narrative form to
three SECEE Inventory questions. They were asked to identify aspects of the clinical setting that
promoted learning, aspects of the clinical setting that hindered learning, and asked whether there
was anything else they would like to mention on the inventory. Prior to analysis of these data,
student comments were written on a separate card, along with the student’s demographic data.
Each comment was noted individually. For example, if a student noted three separate issues or
comments in response to one question, three data cards were created.
Students made a total of 358 comments about aspects of the clinical environment that
promoted learning, 226 comments about aspects of the environment that hindered learning, and
60 comments in response to the “anything else you would like to mention” item. An interesting
but somewhat expected finding was that those students who completed both the pretest and the
end of semester inventory made fewer comments overall upon repeat exposure to the instrument.
The overall numbers of student comments on the pretest and end of semester inventories, for the
sub-population of students completing both inventories are presented in Table 14.
75

Table 14
Comparison of Numbers of Student Narrative Comments on Pretest and End of Semester
Inventories
Number of Student Comments on
Pretest
76
Number of Student Comments on
Final Inventory
LMA 130 87
SMW 44 20
SMA 96 36

Analysis of the narrative student comments to the two specific clinical environment
questions revealed that relatively few were too broad in nature to be helpful in determining the
adequacy of the clinical learning environment (i.e., great experience, good instructor, disliked the
unit). The majority of student comments (both positive and negative) directly reflected issues
addressed by the forced-choice portion of the SECEE Inventory, lending support to the validity
of inventory content. The frequencies of student comments that were broad in nature, the
comments that had already been addressed by items contained in the inventory, and comments
that raised issues which were not addressed by the forced-choice portion of the instrument are
noted in Table 15.
Student Narrative Responses Reflecting SECEE Item Content. Of the student responses
mirroring the forced-choice portion of the inventory about environmental conditions which
helped learning, there was not even distribution across issues or items. Three statements had
frequencies of 30 or more and two additional statements had frequencies of 19. Of the five most
frequent statements about positive aspects of the learning environment, two were related to
nursing staff providing learning support, two involved the availability of learning opportunities,
and one identified the benefit of independence and autonomy. The frequencies of student
comments about aspects of the clinical setting that helped learning, which were directly related
to SECEE items are listed in Table 16.
77

Table 15
Categorization of Student Responses to SECEE Open-Ended Questions
Aspects of
Environment that
Helped Learning
78
Aspects of
Environment that
Hindered Learning
Additional
Comments
Broad, non-specific
Statements 52 2 8
Statements Reflected
Item content
199 116 4
Statements not
Addressed by Item
Content 107 108 56
Total Statements 358 226 60

Student comments reflecting scaled item content about environmental conditions that hindered
learning were also unequally distributed. Of the four statements with frequency over 10, two
related to staff being unwilling to help or unreceptive to students (Learning Support), and two
identified a lack of learning opportunities related to “hands on” learning and variety of patients.
A listing of the most frequent student comments about aspects of the environment that hindered
learning appears in table 17.
Only six items on the scaled portion of the inventory were not specifically addressed by
students in their narrative comments: numbers 4, 11, 22, 23, 28, and 29. Item numbers 23 (“The
environment provided an atmosphere conducive to learning”) and 29 (“I was successful in
meeting most of my learning goals”) were fairly broad in nature. In the open-ended questions,
students were asked to identify aspects of the clinical setting that helped and hindered learning,
and so would be expected to identify specific characteristics of the environment, rather than
broad statements.
Item numbers 22 and 28 addressed students helping each other in the clinical setting and
the instructor encouraging students to help each other and share experiences. It is interesting that
respondents made very few comments about fellow students at the clinical site. Only two
students responded “other students” in respect to the question about aspects of the environment
that helped learning. No students identified feeling overwhelmed by the demands of their role
(item 4) or the presence or absence of clear communication of patient care responsibilities (item
11) as impacting their learning in the clinical environment in response to the open ended
questions.
79

Table 16
Frequencies of Student Responses to the Request to Identify Aspects of the Clinical Setting that
Helped Learning—Issues Addressed by Scaled SECEE Items
Staff were helpful
“Hands on” and skill opportunities
Variety of patients and care needs
Staff took time to teach and explain
Independence / autonomy
Instructor available for help and questions
Staff / preceptor open to working with students
Nurses informed us of learning opportunities
Instructor taught and encouraged students
Resources / equipment available
Statement Response Frequency
Instructor encouraged us to take advantage of learning opportunities
Instructor encouraged independence
80
36
34
31
19
19
8
8
7
6
5
3
3

Table 17
Frequencies of Student Responses to Request to Identify Aspects of the Clinical Setting that
Hindered Learning—Issues Addressed by Scaled SECEE Items
Staff unwilling or unavailable to help
Staff not receptive to students (bad attitude)
Lack of patient variety
Lack of “hands on
Instructor unavailable
Staff refused to help us learn
Nurses too busy
Unprofessional staff
Unprofessional instructor
Lack of help (general comment)
Statement Response Frequency
81
27
25
16
12
9
6
5
4
3
3

Student Narrative Responses Not Addressed by Forced-choice Item Content. Of the
issues students raised in responding to the question “What aspects of this clinical setting
helped/promoted your learning” that were not addressed by the forced-choice portion of the
inventory, none were mentioned by more than six students. Student comments that had
frequencies of three or greater are listed in Table 18. The remainder of the comments had
frequencies of two or less. A few of the statements identified particular individuals who were
helpful in learning or specific situations. Others were isolated comments about the particular
learning environment.
Student comments about aspects of the learning environment hindering learning that were
not addressed specifically by the inventory were also fairly spread out among a variety of issues,
with one exception. Nineteen students identified a too high student to instructor ratio as
hindering their learning, a much higher frequency than any other student comments. Student
comments with a frequency of three or higher about aspects of the environment that hindered
learning are presented in Table 19.
Generally, student comments provided support for the validity of inclusion of the forced-
choice portion of the SECEE inventory. In addition, the narrative data provided valuable
information about what may need to be included in future revisions of the SECEE inventory.
82

Table 18
Frequencies of Student Responses to Request to Identify Aspects of the Clinical Setting that
Helped Learning—Issues not Addressed by Scaled SECEE Items
Statement Frequency
Opportunities for development of a particular skill 6
Teaching hospital environment 5
Knowledge / competence of instructor 5
One-on-one with client 4
Instructor supportive of students 4
Observation Opportunities 3
Not looked down upon for asking questions 3
Learned time management 3
83

Table 19
Frequencies of Student Responses to Request to Identify Aspects of the Clinical Setting that
Hindered Learning—Issues not Addressed by Scaled SECEE Items
Statement Frequency
Too high student / instructor ratio 19
Not enough clinical time 7
Too many people (staff, students) on unit 6
Didn’t feel comfortable asking questions 5
Treated like beginning students or aids 4
Unit/floor too busy 4
Long drive to clinical 3
Not seeing own clients 3
Not connecting with clients on home visits 3
Must rely only on self for learning 3
Nurses ignored us 3
84

Chapter 5
Discussion and Conclusions
The purpose of the described research was to continue development and testing of the
Student Evaluation of Clinical Education Environment (SECEE) inventory. This inventory was
developed in response to the identified absence of any instrument that concisely and
comprehensively measures nursing student perceptions of their clinical learning environment.
The SECEE inventory appears to be able to accurately and reliably reflect student perceptions of
their learning environments, although minor revisions may make the instrument even more
comprehensive and reliable. In the discussion section the research findings are related to the
questions posed at the beginning of the study.
Research Question 1
Is it possible to revise the original SECEE instrument to include all issues critical to the nursing
student clinical education environment, while maintaining brevity and practicality of use by
nursing educators?
Brevity and Practicality of Use. As described in the review of literature, the original
SECEE instrument was revised extensively both to increase the scope of measurement of the
learning environment, and to reflect findings of current literature and analysis results from initial
administration of the inventory. The “revised” SECEE inventory is brief in comparison to many
learning environment inventories (Fraser, 1991). It also appears to be practical for use, as data
for this study were collected with ease by both the researcher and nursing faculty at three
different institutions. After being given brief instructions as to administration of the instrument
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and reading of the “Statement to Participants”, faculty had no difficulties in instrument
administration and collection at any of the institutions.
Content Validity. The SECEE inventory addresses all clinical learning environment
issues that were identified in the Table of Specifications (Appendix D), indicating that it reflects
the critical aspects of the learning environment identified by nursing students, faculty, and the
literature, as well as the reviewed samples of Nursing School - Agency contracts. Although
administrative and faculty issues raised by the above-named sources also appear in the Table of
Specifications, they are not addressed by the inventory, as the purpose was to develop an
instrument that focuses on measuring student perceptions of their clinical learning environments.
Inclusion of all clinical learning environment issues identified in the Table of Specifications
within inventory items supports the content validity of SECEE instrument.
Content validity of the scaled portion of the inventory is also supported by student
narrative responses to the open-ended inventory items (requests to identify aspects of the clinical
setting that helped and hindered learning). The forced-choice portion of the inventory had
addressed the majority of student comments. Of the issues students raised that were not
addressed by the current items, a few may be of benefit to include in future instrument revisions.
An item about student/faculty ratio may be beneficial to include, as 19 students identified that
too high a student/faculty ratio hindered their learning. Narrative data would also support adding
a scaled item addressing student comfort with asking questions of both instructor and staff, as
five students stated they felt uncomfortable asking questions in the clinical environment, and
three students stated that feeling comfortable asking questions helped their learning. Several
students raised another issue in response to the open-ended inventory items. Four students noted
that one-on-one interactions with patients were beneficial, and three students cited not seeing
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their own clients as a hindrance to learning. Adding an item addressing interaction with patients
may also be helpful during instrument revision.
It may be beneficial to split item number 18 (“I felt supported in attempts at applying new
knowledge or learning new skills”) into two items--one addressing instructor support and one
addressing support from staff. Four students specifically identified instructor support as a
beneficial aspect of the learning environment, and three students noted that relying on
themselves only for learning was a hindrance. Another issue raised by students was the
perception of not having enough clinical time during rotations. Seven students identified
insufficient clinical time as a hindrance to learning. This may be another issue worth addressing
in inventory revision.
As one of the goals of SECEE instrument development was to have an inventory that was
brief in nature, it would not be possible to address all issues raised by students in the narrative
comments within the forced-choice portion of the inventory. Some issues were raised by only
two or three students, while others were related only to specific clinical settings. Although these
comments would be helpful for clinical faculty supervising students at the particular sites, they
do not seem appropriate to address individually in the scaled portion of the inventory at this time.
If all of the above-mentioned issues were addressed within the forced-choice portion of
the SECEE inventory, the result would be the addition of 6 questions to the 29 that are in
currently included in the instrument. Further testing of the instrument after these additions
would confirm whether they indeed add valuable information about student perceptions of the
clinical education environment.
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Research Question 2
Is the revised SECEE inventory a reliable instrument for measuring student perceptions of their
clinical (applied) learning environment?
Inventory Reliability. Reliability of the SECEE inventory was determined through a
variety of methods. Overall instrument reliability was determined for each institution's nursing
student population. Institutional data were analyzed separately, as significant differences were
found between institution scale score means. Internal consistency for the entire instrument was
high, with the coefficient alpha for LMA and SMA institutions being .94 and the alpha for SMW
institution being .89. Reliability findings indicate that students responded consistently to the
entire instrument (Anastasi, 1988).
Scale Reliability. Reliability for each of the four scale scores was determined using
correlation coefficients. Using data from all institutions together, coefficient alphas for both the
Communication / Feedback scale and Learning Opportunities scale were .85 and .86,
respectively. The alpha for the Learning Support scale was .81 and the Department Atmosphere
scale alpha was .63. Reliabilities appear acceptably high for all scales except the Department
Atmosphere scale. This scale has the fewest items (six) and covers a fairly broad range of issues.
A review of item placement for thematic content and the correlation of each item with
other items within a scale lead the researcher to consider changing the placement of four items
within the scales. Item 4 (“My responsibilities were clearly communicated”) was temporarily
moved from the Communication / Feedback scale to the Department Atmosphere scale. Item 11
("felt overwhelmed by the responsibilities of my role”) was moved from the Learning
Opportunities to the Learning Support scale. Item 21 (“competing with other students for skills
and resources had a negative impact”) was repositioned to the Learning Opportunities scale from
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the Department Atmosphere scale, and item 23 (“site provided an atmosphere conducive to
learning”) was moved from the Learning Opportunities scale to the Department Atmosphere
scale. This temporary moving of items within-scales left all scales with between six and nine
items.
After changing the placement of these four items, correlation coefficients were
recalculated. The result was standardized alpha levels for all scales of above .75 (see Table 20
for revised scale correlation coefficients). The revision of item placement increased the
Department Atmosphere reliability by .14. However, the change resulted in a decrease of .05 in
the Learning Opportunities scale reliability. The Learning Support and Communication /
Feedback scales were almost unchanged, being calculated at .01 and .02 lower than with the
original item placement. Overall, reliabilities were higher with the revised item placements. It
may be beneficial to consider using the revised item placements for further investigations using
the SECEE inventory. In addition, expanding the inventory to include some of the issues that
students raised in discussion of the aspects of the clinical environment that helped and hindered
learning may further improve reliability of the four scales.
The additional reliability measure of test-retest scale score correlations was calculated for a
sample of 46 students from SMA and SMW institutions. Test-retest correlations were found to
be significant at p < .001. Although not as high as might be expected (r value varied from .50 to
.61 for the four scales), the reader must bear in mind that the student respondents had
experienced several additional clinical sessions at the clinical site between the pretest and end of
semester inventory. These additional experiences may have significantly impacted the
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Table 20
Reliability Coefficients for Scales by Institution (Revised Item Placement)
LMA Instit.
n = 126
SMW Instit.
n = 69
SMA Instit.
n = 122
All Instit.
n = 317
Comm. /
Feedback
Learning
Opportunity
90
Learning
Support
Department
Atmosphere
.84 .84 .82 .78
.75 .72 .73 .67
.85 .80 .80 .77
.83 .81 .80 .77

end of semester perception of the learning environment. In addition, test-retest reliability results
are generally somewhat lower than internal consistency measures (Kubiszyn & Borich, 1987).
The investigator believes that the level and significance of the test-retest correlations are
sufficiently high, given the potential effect of additional exposure to the environment between
testing occasions.
Research Question 3
Is the revised SECEE inventory able to differentiate between various student populations through
evaluations of their clinical learning environments?
Construct Validity. As was presented in the Results section, significant differences
between student sub-populations were found for all scale scores, using institution as the
independent variable. Generally, students attending the two smaller institutions evaluated their
clinical education environments more positively than did students attending the larger institution.
If the SECEE inventory was focused on evaluating the classroom environment, one might expect
these findings, with larger classrooms being generally noted to be less personal and perhaps less
positively perceived. However, as the clinical setting was the focus of the SECEE instrument
and the clinical groups at the three institutions were similar in size, the differences found were
most likely not due to the impersonal nature of the larger institution. This finding would be
interesting to investigate further, to determine whether some aspect of the clinical environments
at the smaller institutions has a more positive effect on students’ perceptions of the learning
environment.
In addition, differences in scale scores were found between academic levels of students.
At LMA, significant differences were found for all of the scale scores, and there were significant
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differences between academic ranks of students in all but one scale score at SMA. However, at
SMW institution, only one scale score (Department Atmosphere) was found to have significant
differences according to student academic level. The ANOVA results indicate that the SECEE
instrument did detect differences between student levels, but that the differences found were not
consistent across institutions. This finding was not unexpected, as the nursing programs at
LMA, SMA, and SMW have institution-specific programs of study and clinical foci for each
academic level. An interesting sidelight is that when differences were detected between levels of
students, the junior students appeared to perceive their clinical education environments less
positively than did the sophomore or senior students (see Table 10 in the Results section). These
findings present another possible topic for research, beyond that of instrument validation. It may
be of interest to find out why students at one level perceive their environments more or less
positively than students at other levels.
Scale score differences were also found between students evaluating different clinical site
groups at the two small institutions (SMA and SMW). The clinical sites at the smaller
institutions required much less grouping prior to ANOVA analysis, and thus clinical groups were
most likely more homogeneous. No scale score differences were found between site groups at
LMA institution; however, the 35 different clinical sites evaluated by LMA students were
collapsed into 10 site groups, prior to analysis. This forced grouping meant that as many as
seven distinct clinical learning sites were grouped together for analysis. Although the sites were
grouped according to the type of nursing care provided at the facility, the nature of the learning
environment (facilities, equipment, staff, and patient population) may have been very different.
Thus, student evaluations may have varied greatly within one site group. It is encouraging to
note that differences between clinical site groups were found for the institutions for which
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minimal grouping of sites was required. In the future, it would be beneficial to limit grouping of
clinical sites as much as possible. Those sites with only one or two students could be analyzed
over a period of several semesters, allowing collection of data from several students experiencing
the same clinical learning site, without having to group sites together for analysis.
In addition to detecting differences in inventory scale scores between student sub-
populations, the instrument was able to differentiate between the same students’ evaluations of
different clinical sites. For those students at LMA who evaluated two different clinical sites on
the pretest and end of semester inventories (n = 60), there were no significant correlations
between the scale scores for the two inventories. This result indicates that individual students do
evaluate distinct clinical sites differently when using the SECEE inventory.
The above results appear to support construct validity of the SECEE instrument. One
would expect different student populations (i.e. different academic levels of students) to evaluate
clinical learning environments differently. One would also expect individual students to evaluate
distinct clinical sites somewhat differently, and to evaluate the same clinical site similarly on two
separate occasions within a limited time frame. Finally, an instrument would be expected to
identify differences between distinct clinical sites, in terms of student perceptions of the learning
environments. The SECEE inventory was found to meet all of these construct validity
expectations. The lack of differentiation between clinical site groups at LMA may have been
largely due to the extensive grouping of distinct sites having only one or two student
respondents, prior to analysis.
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Research Question 4
Are further revisions needed to improve the validity, reliability, or ease of administration and
analysis of the SECEE inventory?
Removal of SECEE Items. Discussion of the previous three research questions has
included several potential areas for improving the comprehensive nature of the inventory—
adding items to improve scale reliability and addressing student-raised clinical learning
environment issues. In addition, the inventory may be improved by removing or rewording a
few items that either had low item-scale correlations or were not supported through student
narrative comments. Items number 23 and 29, “the environment provided an atmosphere
conducive to learning” and “I was successful in meeting most of my learning goals”, seemed to
be rather broad in comparison with the specificity of other inventory items, and were not
specifically mentioned in student narrative comments. It may be beneficial to replace these two
items with more specific items such as those identified by students in their narrative comments.
Two additional inventory items that were not directly identified by students in their
narrative comments related to feeling overwhelmed with the responsibilities of the student role,
and the presence of clear communication of the student’s patient care responsibilities. The
“overwhelmed” item did not appear to fit well in any of the scales. Perhaps these items should
be removed from the inventory during the next revision, or reworded into a statement such as “I
felt prepared (or unprepared) for my role in this clinical setting”.
The last two inventory items that were not directly addressed by student narrative responses
related to students helping each other in the clinical environment and to the instructor
encouraging students to help each other and share their learning experiences. Although student
narrative responses did not support inclusion of these two items in the forced-choice portion of
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the instrument, the investigator feels that these two items should remain in the inventory (at least
for the near future). Peer interactions and sharing of experiences with other students may
significantly impact the student learning environment (Goodenow, 1992). It may be that faculty
and nursing staff at the sites under study did not emphasize the learning benefit of peer
interactions and support, and thus students did not identify these factors as aspects of the
environment that either helped or hindered learning.
Demonstration of Instrument Validity. Issues related to content validity of the SECEE
inventory were addressed in discussion of Research Question 1 and criterion validity issues were
presented in discussion of Research Question 3. Instrument criterion validity is not currently
possible to measure, as there are no other published instruments with the stated purpose of
measuring student perceptions of the clinical education environment. Some nursing course
evaluations include one or two questions related to the clinical environment, but there is no
evidence that these global questions are valid measures of student perceptions of the
environment. It might be possible in the future to conduct observational studies of selected
clinical sites using items addressed by the SECEE inventory as observational components. If
this type of study were done, comparisons could be made between observer data and student-
reported SECEE inventory data. However, observational research would consume a significant
amount of researcher time, as it would require that several students be observed interacting with
the clinical learning environment over a period of several sessions in order to achieve an overall
perspective of the environment.
Recent publications that contain information related to instrument validity (Hambleton,
1996; Goodwin, 1997) state that the consequences of instrument use, including both intended
and unintended effects, must be considered during instrument validation and use. The intended
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consequences of use of data resulting from the SECEE instrument are: (a) identification of
clinical sites perceived by students as providing a positive learning experience, and sites
perceived as providing a less positive experience; (b) provision of feedback to clinical agency
facilitators related to student perception of their experiences at the site; and (c) revision,
adaptation, or alteration of clinical sites and instruction practices used for the undergraduate
nursing program. Unintended, but possible consequences of data use include: (a) conflict
between students or faculty and clinical agency staff as a result of negative student evaluation
and (b) discipline of agency staff or nursing faculty who are evaluated unfavorably by students.
It is the investigator’s opinion that the use of data resulting from instrument administration
should not result in negative consequences, if consideration is given to assure constructive
communication of results to students, faculty, and clinical agencies.
Revisions to Improve Data Gathering and Analysis. A question which arose during
revision of the scaled items of the original SECEE inventory related to the benefit of inclusion of
response option number “6” (can’t answer). The option was included in instrument revision,
with the hope that the analysis of data gathered would either confirm that the option provided
helpful information or demonstrate that it was unnecessary. Results of the analysis supported
inclusion of the “can’t answer” response as an option for the forced-choice items. Student
explanations for the “can’t answer” response indicated that being unable to answer was related to
a lack of exposure to the particular issue they were asked to evaluate within the identified clinical
site, rather than to lack of clarity of the inventory item as it was written. Students provided
logical reasons for the inability to answer particular items, such as there being no other students
at the clinical site, or not having been assigned a resource nurse at the site. The inclusion of the
sixth response option provided additional valuable information about student experiences and
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also may have averted a higher incidence of items left blank by respondents. There was a very
low incidence of missing data for the scaled inventory items—only 17 missing responses to the
forced-choice items were found for the 319 completed end of semester inventories. It should be
of benefit to continue to provide the “can’t answer” response option in instrument revisions, at
least until trends can be determined for items having frequent responses of “can’t answer” and
for items left blank. Eventually this option might be changed to “no opportunity to experience”
or “not applicable”
A few issues of concern were noted in review of the data resulting from the demographic
items within the inventory. Student identification of their completed inventories was missing in
35 cases. The missing data may have been the result of student fear for loss of anonymity,
particularly when there were few students evaluating a particular clinical site. The method of
inventory identification (first two letters of mother’s first name and last two digits of the
student’s social security number) was chosen in order to protect student anonymity, so a lower
incidence of missing data was expected. However, the only analysis affected by missing
identification was the correlation of individual student responses to the pretest and end of
semester inventories. This issue may continue to be a problem if further instrument testing
involves comparison of student responses at different points in time.
Missing data and incomplete responses were also a problem for the clinical site
identification item. Twenty percent of the end of semester inventories and seventeen percent of
the pretest inventories were missing clinical site identification. This resulted in the exclusion of
these inventories from the comparative analysis of scale scores according to clinical sites. It was
interesting to note that in the analysis of the original SECEE inventory there was not a problem
with missing clinical site identification. However, the original instrument did not request student
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identification of their completed inventories. Perhaps students were hesitant to provide both
inventory identification information and identification of the clinical site they were evaluating
for fear of loss of anonymity, particularly if there were a limited number of students at the
particular site.
Student lack of specificity in identification of clinical sites also presented a problem for
data analysis and interpretation. Although they were requested to identify the particular clinical
area or department within a facility to which they were assigned, 54 student respondents
identified their clinical learning sites with only a hospital name. This incomplete identification
of clinical sites resulted in the grouping of all inventories identified only with the facility name
into one site group for clinical site comparisons, potentially masking differences between distinct
(but unidentified) clinical sites within the facility. Five of the 25 clinical site groups used in the
comparative analysis included an unknown number of clinical sites within a particular hospital,
potentially impacting the ANOVA results, particularly for LMA and SMW institutions. This
incomplete clinical site identification may also have been a purposeful student act to protect
anonymity. It may be that the request for identification of inventories will need to be removed in
order to prompt students to accurately identify clinical sites. Perhaps in the future, separate
student populations should be used to gather test-retest reliability data and to conduct clinical site
comparisons, eliminating the need to gather student identification data for the site comparisons.
Student identification of their inventories would only be necessary for those students completing
evaluations of the same or different clinical sites over a period of time, for the purpose of
comparison of individual student scores.
Student data from one other demographic item were somewhat disconcerting to the
researcher. In response to the item addressing assignment of a student resource person, the
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number of students reporting that no resource person was assigned them was higher than
expected. In addition, same-level students from the same institution did not always respond
consistently to this item, when there most likely should have been consistency in student
experience with a resource person. Students may have been somewhat confused about whether
the item was addressing formal assignment to a resource person, or informal identification of the
staff person who was assigned the same patient(s) as a possible resource for the student. In
future instrument revisions, an additional response option could be included, indicating that no
formal assignment to a preceptor / resource person was made, but that the student worked
informally with the staff assigned to provide care for the patient to whom the student was
assigned.
During data analysis, a minor inconvenience was identified related to layout of the scaled
portion of the inventory. The point value assigned to the Likert agree to disagree scale made
data somewhat more difficult to interpret, as a lower point value represented a more positive
perception of the learning environment. Generally, a higher point value represents a more
positive or desired state. In the future, the point values for the scale could be reversed, so that
the “strongly agree” response is assigned a point value of “5” rather than “1”. The result would
be a higher point value indicating a more positive student perception of the learning
environment, which seems a bit more logical.
Four reverse-coded items were included in the forced-choice portion of the inventory, for
the purpose of minimizing response bias. These items did not seem to present a problem to
respondents and mean scores indicate that students responded appropriately to the items (see
Table 2 in the results section). Some degree of reverse coding of items will be maintained in
future inventory revisions.
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Summary of Proposed Changes in the SECEE Inventory
Following is a listing of the proposed SECEE inventory changes resulting from this research
investigation. All changes have been previously discussed.
1. Addition of items covering student identified issues
A. Student/Faculty ratio allowed adequate faculty supervision and assistance
B. Student comfort in asking questions of faculty
C. Student comfort in asking questions of staff
D. Benefit of one-to-one interaction with own patients
E. Adequate amount of clinical time during rotation to meet learning goals
2. Split item “I felt supported in attempts at applying new knowledge or learning new skills”
into two items: “Instructor supported me in my attempts at applying knowledge or
learning skills ” and “staff supported me in my attempts at applying knowledge or
learning skills”.
3. Combine items “felt overwhelmed by demands of role” and “responsibilities were clearly
communicated” into “I felt adequately prepared for my responsibilities in providing
patient care in this clinical setting”.
4. Remove two items “The environment provided an atmosphere conducive to learning” and
“I was successful in meeting my learning goals in this environment” due to their broad
nature in comparison to other SECEE items.
5. Reverse the scoring values for the scaled response items, so that a higher point value
reflects a more positive perception of the clinical education environment.
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6. Add a fifth response item to the demographic item related to identification of the staff
resource person at the clinical site, indicating that the student was not formally assigned a
resource person, but the RN assigned to the same patient as the student served as an
informal student resource.
7. Use different student populations for data collection in repeated measure comparisons
and single administration clinical site comparisons, to reduce the need for student
identification of their inventories and hopefully improve accurate identification of clinical
education sites.
The above changes would result in a net effect of the addition of 3 items to the current 29
forced-choice items. The only foreseeable difficulty with the addition of three items to the
inventory is that it would require a three rather than a two-page format, which may result in
student perception that the instrument will take a lengthy time to complete. However, if the
administrator of the inventory mentions that students should be able to complete the instrument
in about 10 minutes, there should not be any significant negative effects from item expansion.
Study Limitations
During the research process a few issues were recognized that either limit ability to draw
conclusions based on the data or to generalize results to other nursing student populations.
Group (pooled) data constituted the unit of analysis for most of the quantitative testing. The
grouping of students from distinct clinical sites for the purposes of ANOVA testing most likely
masked individual extremes in responses.
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The SECEE inventory contains primarily a priori determined items and scales, as well as
limited choice responses. The data indicated that some student perceptions about the clinical
education environment were unaddressed by the forced-choice portion of the instrument.
However, the inclusion of the open-ended items did assist in identifying potentially significant
issues that were overlooked in instrument development. These issues will be addressed in
further SECEE inventory revisions.
The SECEE instrument reflects only student perceptions of their clinical education
environment. No data have been gathered through observation of students as they interact with
these environments. There is no absolute assurance that students are accurately reporting their
internal state or perceptions about the environment or that student perceptions accurately depict
the clinical learning environment (Luce & Krumhansl, 1988). Future instrument validation
research might include initial data collection through the SECEE inventory with follow-up
observation of students interacting with learning environments that have been perceived
positively and those that have been perceived less positively. Similarities between observer data
and student evaluations would further support instrument validity.
At least one environmental factor that may significantly impact student learning in the
clinical nursing environment is not addressed by the SECEE inventory. This instrument does not
directly address the impact of the student-patient interaction on student learning, although the
investigator recognizes that this interaction may have a significant impact on student perceptions
of the learning environment. Student interactions with patients who are unreceptive to attempts
to provide care or patient teaching, patients who are confused or angry, and patients who are
eager to participate in their plan of care will most likely impact the overall student perception of
the clinical experience. However, in many clinical sites students have only short-term contact
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with individual patients, and are assigned a number of different patients throughout the course of
a clinical rotation. Thus, although interaction with patients may impact the student experience
either positively or negatively, this factor may vary greatly over the length of a four to six week
clinical rotation.
In order to fully address the impact of patient interactions on the learning environment,
some type of measurement would need to be completed after each discrete clinical experience.
However, the SECEE inventory is intended to measure overall student perceptions of the clinical
environment, rather than student perceptions of a particular clinical day. Thus, the decision was
made not to address patient interaction factors within the instrument. It might be more
appropriate for nursing faculty to address this factor informally through conversations with
students during the clinical experience, and to take appropriate action (i.e.: alter patient
assignments) to reduce any negative impact on learning resulting from patient factors. Another
option might be to include a general question about whether patient interactions were perceived
positively, or an open-ended question asking students to identify how characteristics of student-
patient interactions assisted or hindered their learning.
Other limitations of this particular study have been previously discussed: missing or
incomplete respondent data, the lower student response rate at LMA institution, and the grouping
of large numbers of clinical sites for comparative analysis. Suggestions have also been made to
avoid these limiting factors in future research. A final limitation involves current inability to
generalize the support for validity and reliability of the instrument to all nursing student
populations. Although nursing students from three different institutions were included in this
study, further research with other nursing student populations would be necessary before the
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instrument could be presented as an accurate and valid measure of nursing student perceptions of
their learning environments.
Research Implications
The SECEE inventory appears to have reasonable reliability and validity levels with the
nursing student populations under study. Incorporation of the recommended revisions should
result in even higher reliability and validity figures. After revision, the instrument should again
be tested with various student populations. Instrument and scale internal consistency should be
determined as well as differences between scale scores according to student sub-populations.
Factor analysis to explore other potential scale divisions may also be helpful.
After inventory revision and testing, it would be also be helpful to conduct an observation
study of students interacting with clinical education sites that were evaluated both more
positively and more negatively than the average. If observational data supported the inventory
findings, validity of the SECEE instrument would be strengthened.
Further consideration of the potential uses for the SECEE instrument in the process of
assessment and improvement of the clinical education environment resulted in another
suggestion for future investigation. Current inventory scale divisions reflect important constructs
in the clinical education environment (Communication / Feedback, Learning Opportunities,
Learning Support, and Department Atmosphere). However, as both faculty and clinical staff
issues are included in the Communication / Feedback and Learning Support scales, it is not
possible to use scale scores to determine overall student perceptions of the impact of either
faculty or clinical staff on learning. A nursing program administrator who may wish to use the
SECEE tool to gain information about the clinical education environment would have to look
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separately at each item pertaining to instructor and Preceptor / Resource RN to determine student
perceptions of these two important figures in the learning environment. In the future, it may be
more practical to consider reorganizing the items within the Communication / Feedback and
Learning Support scales to create two new scales: Instructor Facilitation scale and Preceptor /
Nursing Staff Facilitation scale. These two scales would reflect both the relationship and the
personal development dimensions of Moos’s dimensions of educational environments (Moos,
1979). The inventory would contain the same items and the same number of scales, but scale
scores may be more immediately useful to faculty and administrators of schools after
reorganization. Future investigations should determine the benefit of reorganization, based on
both student data and conversations with nursing faculty and administrators about which scale
divisions would result in the most useful information.
Related Research Issues
The current investigation has pointed to the potential difference in academic levels of
students in terms of their perceptions of the clinical education environment. It may be of benefit
to further investigate whether there is indeed a difference in how students perceive their learning
environments based on academic level. Perhaps students expect different learning experiences
or different degrees of learning support than are being provided. Further investigation of this
issue may result in identification of issues that must be addressed in order to maximize student
learning in the clinical setting.
Another area for study related to the current investigation involves the relationship of
student perceptions of the clinical education environment to student learning outcomes. Student
perceptions of the learning environment have been shown to be related to student learning
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outcomes in the traditional classroom setting (Henderson, Fisher, & Fraser, 1995), but this
relationship has not been demonstrated in the applied learning (clinical) setting. Often, expected
clinical learning outcomes are not operationally defined and are difficult to measure. Detailed
clinical learning objectives would be necessary for each clinical rotation within a nursing
program, in order to make objective determinations about whether individual students have met
learning outcomes, and prior to making any comparisons between learning outcomes and student
perceptions of the clinical education environment. This area of research would demand
considerable time and energy, but the results would certainly make a contribution to knowledge
about the applied learning environment.
Another factor in the applied learning environment that has not been directly addressed
through the current research relates to how the students themselves impact learning in the clinical
environment. Student variables such as motivation, preparation for clinical sessions, and
assertiveness in gaining opportunities for skill development undoubtedly impact learning
outcomes, but these factors have not been studied in the applied setting. In order to achieve a
full picture of learning in the clinical setting, these variables will also have to be considered.
It may also be beneficial to compare student perceptions of the clinical education
environment with faculty perceptions of the same environment. The SECEE inventory could be
written in a third person format for use with nursing faculty. Research has indicated that faculty
often perceive the traditional classroom environment more positively than do students (Fraser &
Fisher, 1982; Raviv, Raviv, & Reisel, 1990). However, these comparisons have not been made
in the applied clinical education setting.
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Conclusion
The applied learning aspect of nursing education is a critical component of the overall
nursing program as the development of competent nursing practitioners depends to a great
degree upon the quality of the clinical learning environment (Jacka & Lewin, 1986). Research
has demonstrated that student perceptions of the learning environment account for an appreciable
variance in student learning outcomes (Fraser, Williamson, & Tobin, 1987). The wide variety of
clinical sites used for applied learning experiences may provide vastly different qualities of
learning environments for nursing students. Thus, assessment of the quality of these sites is
critical. Yet, to date, there has been a lack of a means to comprehensively evaluate the clinical
learning environment and its impact on student learning. Accurate identification of the factors
influencing student learning in the applied (clinical) environment is necessary, in order for
nursing faculty and administrators to be able to assess the current status of these factors within
the clinical settings used by a nursing program, to implement changes to improve the clinical
learning environment, and to evaluate the benefit of changes that are made.
The SECEE inventory provides an efficient means to begin to assess the quality of the
clinical learning environment through the students’ eyes. The instrument is efficient to
administer and analyze. Students in the sample population responded consistently to the
instrument as a whole and to the scales within the inventory. Test-retest reliability was
sufficiently high, given the additional student clinical experiences between initial and repeat
testing. Data also indicated that students responded differently to the instrument when
evaluating two discrete clinical environments.
The SECEE inventory was demonstrated to detect differences between student sub-
populations. Students responded differently to the instrument according to the institution in
107

which they were enrolled, according to their academic level, and according to clinical site group.
The majority of issues raised by students in response to open-ended questions had already been
addressed by the forced-choice portion of the inventory. Recommendations were made for
revision of the instrument to include other issues raised by students as well as to remove items
that were either too general or that did not correlate well with other items in the inventory.
Recommendations were also made to reduce the incidence of missing demographic data and to
improve the ease of scoring the inventory. Implementation of these recommendations together
with those for repositioning some items within-scales should improve both the reliability of the
instrument and the ease of scoring and interpretation of data. Following revisions and testing, the
instrument will even more closely reflect student perceptions of their clinical learning
environment.
The goal for the development of an instrument to measure student perceptions of their
clinical learning environments is to provide accurate information to nursing faculty and
administrators about the quality of the learning environment at all clinical sites used by a nursing
program. Data from the SECEE inventory could be used together with other information to
make decisions about taking action to improve the clinical learning environment and to monitor
the success of actions taken, in terms of both the quality of the learning environment and student
learning outcomes.
108

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114

Appendix A
Original SECEE Instrument
115

WEST VIRGINIA UNIVERSITY SCHOOL OF NURSING
STUDENT EVALUATION OF CLINICAL AGENCIES: 1996
Please circle or check the best answer to each question and provide written answers in the
blanks provided.
WVU Campus: Morgantown Potomac State Semester: Spring
Charleston Glenville Fall
Are you a: Generic BSN student RN to BSN student
Year in program: Sophomore Junior Senior
Clinical site being evaluated (include unit or dept)_____________________________________
1. What was the adequacy of your orientation to this agency / department?
no orientation given inadequate minimally adequate complete
2 Which of the following best describes your assignment to a preceptor or staff nurse
familiar with your assigned patients during your time at this agency / department?
____RN Preceptor assigned--same preceptor throughout the experience.
____Staff resource RN assigned--changed on a daily basis.
____Non-RN preceptor or resource person assigned.
____No resource person or preceptor was assigned to me at this agency.
3. To what degree did your assigned preceptor or resource nurse communicate with you
during your agency experience?
____little/no communication ____through report only
____through report and occasionally at other times ____frequently throughout the day
Please indicate in the right margin the number that best represents your answer to the
following questions.
Key: 1 = very seldom 2 = sometimes 3 = frequently 4 = almost always
4. How often was the preceptor or resource nurse available to answer
your questions or provide assistance with patient care? 1 2 3 4
5. How often did your preceptor or resource nurse maintain ultimate
responsibility for patients to which you were assigned? 1 2 3 4
6. How often did the agency nursing staff serve as role models for
professional nursing? 1 2 3 4
7. How often did preceptor or resource nurse workload impact your
experience at this agency / department? 1 2 3 4
116

Key: 1 = very seldom 2 = sometimes 3 = frequently 4 = almost always
8. How often did agency nursing staff point out potential learning
experiences for students? 1 2 3 4
9. How often were there adequate numbers of patients whose acuity of
nursing needs were appropriate for your clinical nursing abilities? 1 2 3 4
10. How often did the agency and agency staff permit you to perform
"hands on" care to the level of your clinical ability? 1 2 3 4
11. How often were equipment, supplies and material resources needed to
provide patient care and teaching available in this agency/department? 1 2 3 4
12. What was the attitude of nursing staff toward serving as a resource to nursing students?
very negative somewhat negative somewhat positive very positive
13. Do you believe nursing staff were prepared to serve as a resource to nursing students?
no yes
14. Were other health professional students using this agency or department for clinical
experience?
no yes (if yes, please name the students and describe the impact on your
experience)
______________________________________________________________________________
______________________________________________________________________________
15. What were the strengths of having a clinical experinece at this agency / department?
______________________________________________________________________________
______________________________________________________________________________
16. What were the limitations of having a clinical experience at this agency / department?
______________________________________________________________________________
______________________________________________________________________________
17. Please note your recommendations for the future use of this agency or department as a
clinical site in the future.
____Do not recommend for use at any student level
____Do not recommend for use of this level, but may be appropriate at a different level
____Recommend for use at this level with minor modifications
____Recommend for use at this level without modification
Any other comments about either your experience at this agency or about this questionnaire?
______________________________________________________________________________
117

Appendix B
118

Inventory Scale Item
Number
Communication/Feedback 4
8
12
16
20
24
27
Learning Opportunities 3
7
11
15
19
23
26
29
Learning
Support/Assistance
2
6
10
14
18
22
25
28
SECEE Inventory Items Categorized by Scales
Abbreviated Content Item in original
Inventory? (Y/N)
Responsibilities clearly communicated
N
Preceptor/resource nurse communication re: pt. care
Y
Instructor provided constructive feedback
N
Nursing staff served as positive role models
Y
Instructor served as positive role model
N
Nursing staff positive about serving as student resource
Y
Nursing staff provided constructive feedback
N
Wide range of learning opportunities available at site
Encouraged to identify/pursue learning opportunities
Felt overwhelmed by demands of role (reverse coded)
Allowed more independence with increased skills
Nursing staff informed students of learning opportunities
Atmosphere conducive to learning
Allowed hands on to level of abilities
Was Successful in meeting most learning goals
Preceptor/resource nurse available
Instructor available
Instructor provided adequate guidance with new skills
Nursing staff provided adequate guidance with new skills
Felt supported in attempts at learning new skills
Nursing students helped each other
Difficult to find help when needed (reverse coded)
Instructor encouraged students to help each other
119
N
N
N
N
Y
N
Y
N
Y
N
N
N
N
N
N
N

Scale Item
Number
Department Atmosphere 1
5
9
13
17
21
Abbreviated Content Item in Original
Inventory? (Y/N)
Adequately oriented to department
Y
RN maintained responsibility for student assigned pt.
Y
High RN workload negatively impacted exp. (reverse coded) Y
Adequate number and variety of patients available at agency Y
Needed equipment, supplies and resources were available Y
Competing for skills and resources negatively impacted exp.
(reverse coded)
Y
120

Appendix C
Revised SECEE Instrument
121

STUDENT EVALUATION OF CLINICAL EDUCATION ENVIRONMENT
Please circle or check the best answer to each question and provide written answers in the
blanks provided.
University and Campus ______________________________________________________
Semester/Yr: Spring Fall 19____
Program type: Generic BSN RN to BSN
Year in program: Freshman Sophomore Junior Senior
Clinical site you are evaluating (include both the name of facility and the department or
unit)_______________________________________________________________________
This evaluation is being used to evaluate a variety of clinical education environments. In some
agencies or departments, students are assigned resource nurses or preceptors in addition to the
supervision of their clinical instructor. In other settings, the instructor is the only student
resource. Which of the following best describes your experience with a preceptor or staff
resource nurse during your time at this agency/department (choose only one).
____I was assigned an RN preceptor (same preceptor throughout the experience).
____I was assigned a staff resource RN (the RN assigned changed on a daily basis).
____I was assigned a non-RN preceptor or resource person.
____I worked only with my instructor at this agency (no resource person or preceptor was
assigned to me).
Circle the number that best represents your answer to the following questions. Please
provide an explanation for any questions to which you respond “can’t answer” (number 6)
in the space directly below the question.
Key: 1 = Strongly Agree 2 = Agree 3 = Neutral 4 = Disagree
5 = Strongly Disagree 6 = Can’t Answer
1. I was adequately oriented to the agency or department. 1 2 3 4 5 6
2. My preceptor/resource nurse was available to answer questions
and to help with patient care. 1 2 3 4 5 6
3. A wide range of learning opportunities was available at this
agency/department. 1 2 3 4 5 6
122

Key: 1 = Strongly Agree 2 = Agree 3 = Neutral 4 = Disagree
5 = Strongly Disagree 6 = Can’t Answer
Remember to explain any questions to which you responded “can’t answer” (6)
immediately below the question.
4. My responsibilities in providing patient care were clearly
communicated to me. 1 2 3 4 5 6
5. My preceptor/resource nurse maintained ultimate
responsibility for the patients to which I was assigned. 1 2 3 4 5 6
6. My instructor was available to answer questions and to
help with patient care. 1 2 3 4 5 6
7. I was encouraged to identify and pursue opportunities
for learning in this environment. 1 2 3 4 5 6
8. My preceptor/resource nurse or instructor talked with me
about new information and developments related to my
patients’ care. 1 2 3 4 5 6
9. High preceptor/resource nurse workload negatively
impacted my experience at this agency/department. 1 2 3 4 5 6
10. The instructor provided me with adequate guidance as I
learned to perform new skills. 1 2 3 4 5 6
11. I felt overwhelmed by the demands of my role in
this environment. 1 2 3 4 5 6
12. My instructor provided constructive feedback about my
nursing actions in this setting. 1 2 3 4 5 6
13. This agency/department had an adequate number and
variety of patients appropriate for my clinical
nursing abilities. 1 2 3 4 5 6
14. The nursing staff provided me with adequate guidance
as I learned to perform new skills. 1 2 3 4 5 6
15. As my skills and knowledge increased, I was allowed to
do more skills independently. 1 2 3 4 5 6
123

Key: 1 = Strongly Agree 2 = Agree 3 = Neutral 4 = Disagree
5 = Strongly Disagree 6 = Can’t Answer
Remember to explain any questions to which you responded “can’t answer” (6)
immediately below the question.
16. The nursing staff in this department served as positive
role models for professional nursing. 1 2 3 4 5 6
17. Equipment, supplies, and material resources needed to
provide patient care and teaching were available in
this agency/department. 1 2 3 4 5 6
18. I felt supported in my attempts at applying new knowledge
or learning new skills. 1 2 3 4 5 6
19. Nursing staff in this department informed students of
potential learning experiences. 1 2 3 4 5 6
20. My instructor served as a positive role model for
professional nursing. 1 2 3 4 5 6
21. Competing with other health professional students using
this agency for skills/procedures, patient assignments,
or resources negatively impacted my clinical experience. 1 2 3 4 5 6
22. Nursing students helped each other with patient care and
problem solving in this setting. 1 2 3 4 5 6
23. This environment provided an atmosphere conducive
to learning. 1 2 3 4 5 6
24. The nursing staff were positive about serving as a
resource to nursing students. 1 2 3 4 5 6
25. When I needed assistance with a situation or skill, it was
difficult to find someone to help. 1 2 3 4 5 6
26. I was allowed to perform "hands on" care at the level
of my clinical abilities. 1 2 3 4 5 6
27. The nursing staff provided constructive feedback about
my nursing actions in this setting. 1 2 3 4 5 6
124

Key: 1 = Strongly Agree 2 = Agree 3 = Neutral 4 = Disagree
5 = Strongly Disagree 6 = Can’t Answer
Remember to explain any questions to which you responded “can’t answer” (6)
immediately below the question.
28. The instructor encouraged students to assist each other
with patient care and to share their learning experiences. 1 2 3 4 5 6
29. I was successful in meeting most of my learning goals
in this environment. 1 2 3 4 5 6
What aspects of this clinical setting helped/promoted your learning?
___________________________________________________________________________
___________________________________________________________________________
What aspects of this clinical setting hindered your learning?
___________________________________________________________________________
___________________________________________________________________________
Is there anything else you wish to mention?
______________________________________________________________________________
________________________________________________________________________
125

Appendix D
126

Table of Specifications for Student Evaluation of Clinical Education Environment (SECEE) Inventory
Issue Identified Identified by
Agency Literature Nursing Nursing Trad.Classrm.
Contracts * Faculty * Students * Instruments
Facility
Adequate supplies / equipment for providing care X X X
Adequate reference sources X X
Student access to records / documentation X
Atmosphere conducive to growth X
Contact person assigned and available ** X
Agency contact person meets with faculty each sem. ** X
Private area for conferences and belongings ** X X X
Agency Experience
Adequate orientation - student X X X X
Adequate number and acuity of patients X
Degree of competition for pts / skills with other students X X
Students allowed adequate "hands on" care X X
Range/variety of learning opportunities X
Student role clarity X
Adequate orientation - faculty ** X X
Agency agrees to provide certain experiences ** X
Agency experience provides for meeting course obj. ** X X
Agency Staff/Preceptor
Preceptor / resource is identified for students X X X
Preceptor available as resource X X X
Staff adjusts work to accommodate student experience X X
127

Issue Identified Identified by
Agency Staff/Preceptor (continued)
Agency Literature Nursing Nursing Trad. Classrm.
Contracts * Faculty * Students * Instruments
Staff workload allows time to work with students X X
Staff communicate with/provide feedback to students X X X
Attitude of staff toward working with students X X X X
Staff are skillful and serve as role models for students X X
Agency/staff remain ultimately responsible for patients X X
Staff prepared to work with students ** X X
Staff education level (AD, diploma, BSN) ** X X
Recommendations related to continued affiliation ** X
Changes recommended related to agency experience ** X X
Agency keeps faculty informed of student progress ** X X X
Assist in determining student assignments ** X X
Note. (*) indicates information gathered prior to development of the original version of the SECEE inventory.
Note. (**) indicates issues that are important in determining the full nature of the clinical environment but that are outside the
realm of the current focus of instrument development: measurement of student perceptions of their clinical education environments.
128

Appendix E
129

STATEMENT TO PARTICIPANTS
This research investigation is being conducted by Kari Sand-Jecklin, an adjunct
faculty member at West Virginia University and a doctoral student. The purpose of the study
is to test a newly developed instrument that measures student perceptions of their clinical
learning experiences. The study involves completing an inventory (survey) which requests
your opinions about the clinical setting that you are currently experiencing.
Your participation in this study is strictly voluntary. You may choose not to respond
to any or all portions of the inventory. Your decision about participating will have no bearing
on your success in this course or in the nursing program. Your privacy will be protected, as
no names are requested on the inventory. The only identifying mark will be the first two
letters of your mother’s first name and the last two digits of your social security number. This
identification is necessary, as some students will be completing more than one inventory
during the study period.
Analysis of the inventory should be completed by fall, 1998. Your school of nursing
will be provided with summarized results of instrument analysis as well as group data about
perceptions of clinical sites.
130

Appendix F
131

College of Human Resources and Education, West Virginia University
Office of the Dean
February 27, 1998
TO: Kari Sand-Jecklin
FROM: Ernest R. Goeres Associate Dean
RE: Human Resources & Education H.S.#98-029
Title: "Student Evaluation of Clinical Education Environment (SECEE):
Instrument Development and Testing"
Your Application for Exemption for your above-captioned research project has been
reviewed under the Human Subjects Policies and has been approved.
This exemption will remain in effect on the condition that the research is carried out exactly
as described in the application.
Best wishes for the success of your research.
Attachment
cc: Deans Office
Student Advising and Records
Anne Nardi, Advisor
304 293-5703 0 802 Allen Hall 11 P.O. Box 6122 0 Morgantown, WV 26506-6122
Equal Opportunity / Affirmative Action Institution
132

KARI SAND-JECKLIN
2003 White Oak Dr.
Morgantown, WV 26505
(304) 598-2673
West Virginia RN License #: 051382
EDUCATION
Bachelor of Science in Nursing, completed at Illinois Wesleyan University in May, 1982.
Graduated Magna Cum Laude.
Master of Science in Adult Health Nursing, completed at the University of Illinois in August,
1987. Emphasis in self-care. Completed teaching internship in the area of Medical-
Surgical Nursing.
Doctor of Education from the Department of Educational Psychology at West Virginia
University, 1998. Awarded the Swiger Fellowship for doctoral study.
ADDITIONAL EDUCATION
Cardiac dysrhythmia Course: 6 hour course completed at Mennonite Hospital in
Bloomington, IL.
Critical Care Course: 80 hour course completed at Mennonite Hospital.
Physical Assessment Course: 48 hour course completed in 1982. Additional physical
assessment course completed in 1994. Both courses taught by Certified Nurse
Practitioners.
Leadership/Management: various courses related to health care management, administration,
change and situational leadership.
Continuing Education: Topics of seminars/conferences attended include: health care reform,
diabetes management, other clinical issues, staff development/nursing education,
patient education, risk management, discharge planning, quality improvement, and
nursing research.
NURSING EXPERIENCE
Visiting Instructor at the School of Nursing, West Virginia University, from August 1998 to
present. Responsibilities include instruction in both classroom and clinical settings.
Adjunct Faculty at the School of Nursing, West Virginia University, from August, 1996 to
May, 1998. Conducted research, assisted with course revision, and instructed nursing
students during this time.
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Clinical Instructor in the undergraduate department of the School of Nursing at West Virginia
University from February to May, 1996. Responsibilities included instructing and
supervising students in a medical-surgical clinical area.
Nurse Educator for the Center for Healthy Lifestyles at St. Joseph Medical Center,
Bloomington, IL from June 1994 to August 1995. Responsibilities included health
education needs assessment; program planning, development, presentation, and
evaluation. Also provided individual outpatient education related to illness
management and health promotion, coordinated monthly public seminar series, and
spoke to groups/organizations on health related topics. Served as on-site supervisor
for nursing and health education interns. Authored and received a United Way grant
to provide diabetic education and follow-up care for low income diabetic population.
Director, Nursing Education at Frederick Memorial Hospital, Frederick, MD from July 1993
to May 1994. Responsibilities included supervising 5.1 FTE staff; maintaining
department budget; and facilitating plan, implementation and evaluation of Nursing
education activities for over 600 nursing service employees. Obtained CEU provider
status for the hospital through the Maryland Nurses Association. Administered FMH
Nursing Scholarship program, based on yearly grants from HSCRC. Chairperson of
Patient Education committee, and member of several interdepartmental committees.
Director, Progressive Care Nursing at Frederick Memorial Hospital, Frederick, MD from
November 1990 to July 1993. Responsibilities included staffing, budget
administration, and supervision of 56 FTE staff, and 24 hour accountability for the 38
bed telemetry step-down unit. Implemented pilot RN/NA partnership. Concurrently
functioned as Chair for Nursing Quality Improvement Council and member of hospital
Quality Assurance Committee.
Director of Medical and Oncology unit at St. Joseph Medical Center, Bloomington, IL from
July to October 1990. Responsibilities included 24 hour accountability for the 38 bed
unit, supervision of 30 FTE employees, budget administration, staffing, and
policy/procedure development. Member of Service Excellence Steering committee.
Director of Education/Professional Development at St. Joseph Medical Center, Bloomington,
IL from February 1988 to July 1990. Responsibilities included coordinating nursing
orientation, nursing staff development, inpatient and outpatient education programs
and community health promotion activities. Developed and presented education
programs related to a variety of clinical and professional issues.
Patient Education Coordinator at St. Joseph Medical Center in Bloomington, IL from July
1987 to February 1988. Responsibilities included developing and coordinating
inpatient, outpatient, and diabetic education as well as community health promotion
activities.
Staff Nurse: employed full-time and part-time at Brokaw Hospital in Normal, IL from
November 1983 to May 1987 in the Maternal-child Health Department.
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Staff Nurse: employed part-time at Galena Stauss Hospital from June 1983 to November
1983. Provided care for medical, surgical, obstetric, pediatric, emergency and
intensive care patients.
Staff Nurse: employed full-time at Mennonite Hospital from June 1982 to June 1983 in the
Intensive Care/Post Intensive Care Unit.
RELATED EXPERIENCE
Adjunct Specialist in Nursing at Illinois Wesleyan University, Bloomington, IL (1994-95).
Chair, Nursing Quality Improvement Council and consult for nursing or clinically-related
quality issues at Frederick Memorial Hospital (1992-94).
Member, Service Excellence at St. Joseph Medical Center, Bloomington, IL (1988-90).
Transcultural Experience: member of a medical mission team, staffing a small clinical on a
seminary compound in Haiti in 1984.
Prenatal Exercise instructor: developed and instructed exercise programs for prenatal and
postnatal women at Brokaw Hospital (1984-87).
Exercise Instructor for BroMenn Wellness Center: taught an adapted aerobic exercise class
for individuals who had physical fitness limitations or were just beginning exercise
(1986).
PRESENTATIONS, PUBLICATIONS AND CONSULTATIONS
Member of panel of experts on "Health for Herself" television program produced by PBS
(WILL TV) on October 27, 1994. Topic: Women and Nutrition.
Regularly presented programs on topics such as stress management, self-care, alternative
therapies, eating disorders, breast health and diabetes management to both lay and
health professional groups (1994-95).
"Incorporating Patient Classification Measures into a Volume-Based Nursing Productivity
System": storyboard presentation at Innovations '93, sponsored by the Maryland
Hospital Education Institute, November 1993.
"Quality Improvement - It's Up to You" presentation to professional nurses, July and
December 1993.
"Becoming a Wise Healthcare Consumer": community lecture, September 1993.
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Contributor to Health at Work section of the Business to Business magazine in
Bloomington, IL (1988-90).
"Educating Yourself and Your Patients": presentation to senior level BSN students at Illinois
Wesleyan University (1988 - 1990).
"Stress: You Can Cope": presentations to a variety of community and business groups in
1988.
"Have a Healthy Retirement": presentation to retiring industrial employees, November 1988.
"Identifying Self-Care Behaviors in Response to Minor Illness": unpublished thesis submitted
as partial fulfillment of requirements for the Master of Science Degree at the
University of Illinois at Chicago (1987).
"Pregnancy and Exercise - A Safe Combination?": seminar presented to local exercise
instructors, September 27, 1986.
"Women's Health in Haiti": presentation at Linking Research to Practice Seminar in Urbana,
IL, November 1985.
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