Vietnamese Nursing Students’ Perspectives on Learning Environments: A Multisite Benchmarking Study to Inform Future Initiatives

Over the last three decades Vietnam has experienced rapid economic growth and social change following the shift from a socialist state to a market economy. Similarly, the Vietnamese health sector has been challenged by population growth and shifts from traditional to western lifestyle practices. The disease profile of the population has also changed with greater prevalence of lifestyle related chronic diseases (WHO, 2017). Health care provision, however, remains largely hospital based as there is little focus on preventative or family/community care. Consequently, there is severe over-crowding in hospitals, often more than two patients to a bed, extended lengths of stay, and for nurses, a very heavy workload (1 nurse: 25-30 patients is the norm). The Vietnamese health sector is attempting to address these challenges through development of the health workforce and, in particular, nursing is being transitioned toward an autonomous, university educated profession with nursing-specific benchmarks. However, what remains unknown is how current factors within nursing education environments in both Vietnamese universities and health settings facilitate or are a barrier to nursing students’ learning, and the subsequent impact on development of competence. Within the context of this study the learning environment is defined as a combination of forces and interactions that impact negatively or positively on students’ learning outcomes, in either the university or health care setting.

This study aimed to investigate undergraduate Bachelor of Nursing students’ perceptions of the education environment at both university and clinical experiences in health, within new competency-based curriculum contexts in four universities across Vietnam.

Literature

Learning environments in health disciplines typically comprise both on-campus university based learning and off-campus work integrated learning. Within the on-campus theoretical environment, nursing students commonly develop relevant knowledge and skills that prepare them for experiences during off-campus clinical practice where they integrate learning and develop competence through participation in real health care (Flott & Linden, 2016; Kristofferzon et al., 2013). Nursing practice is the cornerstone of developing future nurses and students learn most effectively in clinical environments that support and encourage learning (Bisholt et al., 2014; Dale et al., 2013) yet issues concerning quality in nursing placements persist internationally. In relation to nursing in Vietnam, where bachelor level programmes have been in place for about 15 years (Chapman et al., 2012), the issues affecting on-campus and clinical environments are considerable. For example in on-campus contexts, nursing is taught largely by medicine and superficial recall-based assessment strategies such as multi-choice questions and rote learning dominate curricula. In clinical practice anecdotal evidence from nurse teachers indicates growing levels of student overcrowding, lack of opportunities to implement prior on-campus learning in the clinical situation; and a lack of consistency between university teaching and hospital care practices. There is a paucity of research examining the quality of the university and clinical learning environment in Vietnam upon which recommendations for improvement might be based.

Methods

During 2016 a cross-sectional multi-site study was conducted at four Vietnamese universities providing undergraduate nurse education to investigate nursing students’ perceptions of on-campus and off-campus learning environment experiences. Following ethical approval, students (n=891) completed two self-report instruments, previously translated into Vietnamese in separate studies using a forward and backward translation process (Sousa & Rojjanasrirat, 2011). The Vietnamese language version of the Dundee Ready Education Environment Measure (V-DREEM) measures students’ perspectives of their university learning environment (four-point Likert scale; five subscales and 47 items) (Roff, 2005; Huong, 2013). The Clinical Learning Environment Inventory (V-CLEI), also in Vietnamese language, measures students’ perspectives of their clinical learning environment (four-point Likert scale; six subscales, 42 items) (Newton et al., 2010; Troung 2015). Additionally, two open-ended items sought information about barriers and facilitators of learning in the clinical environment.

Results

Results showed students were predominately female (84%) and enrolled in 2^nd, 3^rd and 4^th year (60%, 27% and 13%) respectively. Statistical modelling showed that that university environments were different between universities (p < 0.001) and year of course (p < 0.001) but not between gender (p = 0.35). V-DREEM scores were similar between year 3 (M=126.7, SD=16.5) and year 4 (M=125.8, SD=12.8) students, while year 2 students (M=128.7, SD=16.4) rated the university environment significantly higher (p<0.001) than students in year 3 or 4. Students’ rated the Perception of Teaching and Learning subscale highest reflecting satisfaction with this element of the university environment. Overall the V-CLEI mean score was in the low range (M=138.7, SD 14.7, possible range 42-168). Modelling indicated that students’ experience in clinical environments was statistically different between universities (p< 0.001) and length of clinical placement (p< 0.001). Year 2 (M=140.4, SD=14.9) and year 3 (M=138.7, SD=13.5) students scored the clinical environment higher than year 4 students (M=131.6, SD= 14.5, p< 0.001) but there was no difference between male and female students (p = 0.66) and type of clinical wards (p = 0.46). Interactions with clinical staff were the most frequently reported facilitating factor or barrier to student learning.

Discussion

Vietnamese students in this study are largely satisfied with new active methods of teaching and learning within their university experience. The clinical environment score in this study was relatively low confirming anecdotal evidence and reflecting a clinical environment not supportive of student learning. Ideally students rate their clinical environment and experiences highly as clinical practice is popular and students usually engage enthusiastically (Bisholt et al., 2014; Dale et al., 2013). Consistent with patterns found globally, partnerships between universities and hospitals in clinical nurse education, and use of supporting processes such as effective preceptorship are crucial to facilitating students’ learning. This study provides benchmarks from which priorities for change were identified for the participating universities. Other universities and colleges across Vietnam will be able to conduct similar evaluations.