DEVELOPMENT OF STUDENT NURSE-DRIVEN TOOLS TO ASSESS LEARNING NEEDS AND CLINICAL LEARNING ENVIRONMENTS IN ORDER TO ESTABLISH GUIDING PRINCIPLES

FOR MAINTAINING HIGH QUALITY CLINICAL EDUCATION

by ARBY P. VILLANUEVA Nursing Department Calayan Educational Foundation, Inc . (CEFI) Lucena City, November 2010

ABSTRACT
This paper addresses two major factors of clinical education, namely: students determination of their own learning needs and their perceptions of the clinical learning environment, with the end in view of developing assessment tools to help establish and maintain high quality clinical learning environments in nursing education. Individual semi-structured interviews were conducted in a private setting with seven (7) undergraduate nursing students, in an attempt to gain a deep, interpretive and holistic understanding of the perceptions of these students with regard to their clinical learning experiences and felt educational needs. The study found agreement on 92 felt learning needs, and also noted differing opinions among student nurses on selection and ranking of learning needs. The elements of an ideal clinical learning environment identified by the students could be categorized under five headings: 1) Clarity of objectives, 2) High quality clinical education staff, 3) A welcoming environment, 4) A culture of learning, and 5) Appropriate learning opportunities.

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KEY WORDS:

Clinical placements, Learning environment, Learning needs assessment, Clinical education

1. Introduction Clinical education, usually delivered to undergraduate nursing students through clinical placements, is a vital component in the curricula of nursing programs because it provide students with an opportunity to integrate and apply knowledge, skills and attitudes taught in the classroom or laboratory in a clinical setting. However, although often described as the single most important resource in the development of knowledgeable and competent nursing professionals, it remains essential to take cognizance of the various factors operating in this multi-dimensional workplace context, and the impact of these on student learning (Quinn & Hughes, 2007). This paper addresses two major factors of clinical education, namely: students identification of their own learning needs and their perceptions of the learning environment, with the end in view of synthesizing a set of guiding principles for establishing and maintaining high quality clinical learning environments in nursing education. 1.1 Clinical Learning in the Context of Nursing Education Nursing education occurs in many different settings and formats. As in most other tertiary disciplines, lecture, tutorial, workshop, seminar, and laboratory are the most common variations of classroom environments student nurses encounter. Clinical field placement is another essential part of the nursing curriculum because it is a period of transition, which allows students to consolidate knowledge and practice skills acquired during fieldwork practice in a workplace situation. During clinical field placement, students are expected to develop competencies in the application of knowledge, skills, attitudes, and values inherent in the nursing profession.
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Massarveh (2005) described the clinical setting as the clinical classroom. In contrast to classroom teaching, clinical education occurs in a complex social context where a teacher monitors clients', students', and clinicians' needs. Unlike classroom learning in which student activities are structured, students in clinical classrooms frequently find themselves irvolved in unplanned activities with patients and other health care providers. 1.1.1 State of Nursing Education in the Philippines Before the 1950s, there were only 17 nursing schools in the Philippines which graduated 7,179 qualified nurses per year. The number of schools and nursing graduates increased consistently each year. A peak of 14,112 qualified nurses was reached in 1976, mostly due to a response to the demand for Filipino nurses abroad (Asutilla, 2008). During the late 70s however, the United States and West Germany (two countries where Filipino nurses were much in demand), closed its doors temporarily to foreign nurses. Because nursing schools were created as a response to world market demand, there was then an oversupply of nurses who could not find work in the Philippines. Nursing began to lose its attraction as a profession. By the early 1980s, there was an insignificant number of applicants to nursing schools. The Philippine Regulation Commission registered only 5,859 enrollees in 1983 compared to a peak of 14,563 in 1980 (Asutilla, 2008). In order to offset the decreasing enrollment of nurses in the early 1980s, nursing schools adopted a policy of 'open admission' which basically meant anybody could enroll. Since then, according to the Philippine Nurses Association (PNA), the quality of nursing education has started to decline
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(Valisno, 2006). The resurgence in the demand for nurses has not created any improvement in nursing education. In 1988, about half of the schools did not meet the standard set by the Department of Education, Culture, and Sports. Because of the continuing policies of open admission and unlimited enrolment, classes remained overcrowded. The massive demand for nurses abroad has led to the depletion of the supply of qualified nursing instructors who would rather work as nurses abroad than teach. In 2008, only 28,994 examinees passed out of 67,700 nursing students who took the board examinations in December. This passing rate of 43.38 percent was --- at that time--- the lowest in the history of the board exams Education officials blamed the low passing rate on poor quality education in many of the 460 nursing schools all over the country (Asutilla, 2008). Three factors were cited for the low performance quality of the faculty, the number of students' admitted in schools and the lack of tertiary training hospitals for clinical placements or the related learning experience (Asutilla, 2008). 1.1.2 Clinical Education and Learning Needs Assessment The need for a sound and relevant nursing education curriculum underscores the importance of the Related Learning Experience (RLE) or clinical placement, which has become an integral part of nursing education. Ideally, it is the exit evaluation process that should determine how successful a clinical placement has been. The results of such a process must also, on the whole, help to identify the assessed learning needs of student nurses so that beneficial amendments or modifications can be introduced by nursing educators.
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The Commission on Higher Education (CHED) has prescribed the following RLE standards in this regard in Memorandum Order No. 30, Series of 2001, thus:
Section 2. The Related Learning Experiences (RLE) are highly selected to develop competencies utilizing the nursing process in varying health situations. The following conditions must be observed: a. There should be close correlation of theoretical knowledge to

related learning experience. Classroom and RLE activities must be congruent. b. Classroom and RLE is a continuous process. Faculty teaching in

the classroom must continue to teach the students in their RLE. c. Related learning experiences are organized around the objectives

and competencies set for the course and all students must be able to achieve such. d. Faculty compensation is based on the computation of one (1)

hour RLE is equivalent to one (1) lecture hour. e. Effectiveness and efficiency of the related learning experience,

must consider the following factors: a) b) c) d) e) f) Background knowledge and capacity of the learner. Size and nature of the learning resources both in Adequate number and variety of clientele. Adequate number of qualified nursing and other personnel. Evidence of quality nursing care services. Compliance with the required equivalence of fifty one (51)

institutions and communities.

hours to one (1) unit RLE ratio of student to clientele depends upon the objectives and the capacity of the student. g) Utilization of varied teaching-learning methods or
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strategies appropriate to the situation. f. Evaluation is an integral part of the teaching-learning process and

must utilize appropriate feedback mechanism.

Determination of learning needs through the clinical placement, and particularly, through exit evaluation is, therefore, an important aspect of nursing education. Only after a comprehensive learning needs assessment occurs can effective continuing education programs with relevant offerings be planned and presented. Assessment of student learning and knowledge needs is a contentious topic in education. In higher education, a considerable amount of students activity is focused on assessment because nurses learning needs are continuous and dynamic. Educators must continuously seek the perceptions of the learning needs of nurses so that educational programs can be developed to significantly influence nurse competency and promote available resources (Rath et al, 2006). The assessment continuously need for a comprehensive ideally exit and integrated educational strategies. learning In the needs to current

process improve

should their

compel

institutions

evaluation

educational and economic climate, an increasingly important role of an education professional is to accurately identify what learners do not know, to determine instructional priorities, and within the constraints of available resources, to provide opportunities to effectively meet those needs. A learning needs assessment is the essential first step in planning any educational program. 2004). While needs assessment has long been valued in nursing education, it has often been documented informally (Moore & Short,

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And while exit evaluation holds the potential to meet the learning needs assessment challenge, most educational institutions either do not recognize this potential, often mistakenly viewing the exit evaluation process as avenues for teachers to lecture down on students rather than as opportunities to listen up to students. 1.1.3 The New Nursing Curriculum In response to widespread concern over the declining state of nursing education in the country, the CHED issued Memorandum Order (MO) No. 5 in 2008 transforming the Bachelor of Science in Nursing (BSN) program from a four to a five-year course. The new Nursing Curriculum in the Philippines has changed thus: a) Instead of the usual 79 units taken up by first year nursing students, the new guidelines will require students to take up 93 units in 2,632 hours. b) Additional 357 hours for clinical training or Related Learning Experiences (RLEs) from the previous 2,142 hours to 2,499 hours c) 28 additional units or about three summers of schooling Despite these dramatic changes in the curriculum, however, the quality of nursing education in the Philippines continues to decline. The 39.73 passing percentage in the latest 2010 Nursing Licensure Examinations is the lowest ever in history, while the total of 94,462 who took that exam is the highest number on record. Thus, higher learning institutions are currently under significant pressure in respect to delivering clinical education to undergraduate nurses. This situation is likely to worsen due to a range of factors, including workforce

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shortages, large increases in the numbers of students, more education providers entering the arena, significant variability in course structures and educational models, changing models of patient care, and limited funding. In this context, student nurses perception of the clinical learning environment during clinical placements may provide a roadmap for improving the quality of clinical placements and the efficiency of resource usage within the constraints of the system. 1.2 Objectives Over the past decade there has been a paradigm shift in education from a focus on teaching to a focus on student learning (Havnes, 2005). There has been recognition that the preparation for practice requires a more complex interplay of different ways of knowing for students to begin to develop connoisseurship in nursing practice (Higgs et al., 2004). Nursing is a practice based discipline and is dependent on its practitioners demonstrating competence in clinical practice. The clinical learning environment represents an essential element of nurse education that needs to be measurable from the students perspective and warrants further investigation. The aim of this study was to promote an awareness of the possible impact of various aspects of the clinical learning environment and students perceptions thereof, on their learning experiences; and to develop student nurse-driven tools to assess learning needs and clinical learning environments in order to create guiding principles for establishing and maintaining high quality clinical learning environments in nursing education. 1.3 Relevant Literature From the students' perspective, all educational environments provide
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important opportunities for learning. On the other hand, the educational environment can be a powerful teaching instrument at the disposal of the teacher. Fraser (2005) suggested that educational environments can be considered the social-psychological contexts or determinants of learning. Therefore, in the process of teaching and learning, the classroom environment has two functions. It provides the setting for learning and at the same time acts as a part of the teaching-learning process. Fraser and Fisher (2006) stated that the strongest tradition in past classroom environment research has involved investigation into the predictability of students' cognitive and attitudinal outcomes, based on their perceptions of the classroom learning environment. Student learning was found to be positively related to levels of cohesiveness, satisfaction, and task orientation in the classroom, and negatively related to levels of friction and disorganization (Fraser & Fisher, 2006). This suggests that student outcomes may be improved by adjusting classroom environments. This is supported by Byrne, Hattie, and Fraser (2006) who indicated that the ideal classroom or school environment is one that is conducive to maximum learning and achievement. Furthermore, past research into classroom environments has shown that student perception accounts for appreciable amounts of variance in learning outcomes (Fraser & Walberg, 2007). In addition to the time spent in the formal classroom, student nurses spend a great deal of time in clinical practice. Arguably, the clinical environment is equivalent to a classroom for student nurses during their clinical field placement. In accordance with Fraser and Fisher's (2006) suggestions, student outcomes during their clinical field experience may be improved by adjusting the clinical environment. Therefore, there is a need to assess students' learning needs as well as their perceptions of the clinical
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learning environment to facilitate and maximize their field placement. 1.4 Significance of the Study There is evidence of an insufficient skilled nursing workforce, which may have been exacerbated by the apparent decline of the uality of nursing education in the country. In addition, the introduction of new technology and changes in the provision of health care demands will require new skills (Lindner, 2008). It is absolutely essential, therefore, to plan the right type of education for registered nurses (RNs) in order to meet todays health care demands. This is the rationale behind Memorandum Order No. 30, Series of 2001, issued by the Philippine Commission on Higher Education (CHED), entitled UPDATED POLICIES AND STANDARDS FOR NURSING EDUCATION, which acknowledges the need of rationalizing Nursing Education in the country with the end in view of meeting the health needs of the people through quality health services and keeping it relevant and apace with the demands of global competitiveness. Consequently, it is critical that educational offerings be based on the assessed learning needs of each student as well as on student assessments of the learning environment, and not on the preference, intuition, or convenience of the planners. The completion of a systematic learning needs and learning environment assessment is one means to develop necessary and relevant educational experiences for nurses and other health care workers (Burchell & Jenner, 2006). Through this study, the researchers aim to benefit nursing students, educators, educational planners and the nursing profssion as a whole through the development of learner-driven tools for objective learning needs and learning environment assessments distinguishing, in the process, the areas where they need instruction the most.
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Ultimately, it is hoped that the results of this study can generate interest in further related research work to meet the demands of a dynamic and constantly expanding nursing profession. 1.5 Scope and Delimitation A qualitative, interpretive study, investigating seven (7) individual undergraduate nursing students, was undertaken in an attempt to gain a deep, interpretive and holistic understanding of the perceptions of these students with regard to their clinical learning experiences and self-assessed learning needs. 2. Methodology Individual semi-structured interviews were conducted in a private setting during students clinical rotations. The same guiding questions were asked in each interview, and interesting answers were further explored or clarified. Data saturation was made possible by the broad range of qualitative data provided by participants. Students were allowed to speak in the language in which they were most comfortable. No interpreter was required. Interviews were transcribed and verified. Member checking did not result in any changes to transcripts. Thematic analysis of interview transcripts was undertaken. All necessary measures were taken to ensure the removal of identifying information as soon as it was no longer necessary. 2.1 Development of Student Nurse-Driven Assessment Tools The assessment tools shall be developed using all of the data collected in the literature review and study, although most emphasis should be placed on the interviews with student nurses. The findings from each interview were tabulated and compared.
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Themes that were common were identified for further interrogation. From this analysis, a number of elements that appear to contribute to a quality clinical learning environment were identified. Those supported by the literature and/or data collected via the learner surveys shall be included in the initial drafts of the tools. These drafts shall further be developed to include a set of indicators that might assist in monitoring the implementation and use of the tools (including structural, process and outcome measures). 3. Results and Discussion The qualitative data analysis provided insight into students perceptions and interpretations of their clinical learning experiences, as impacted upon by various facets of the clinical learning environment. Several predominant themes emerged. 3.1 Learning Needs Assessment One hundred fifty (150) learning topics were presented to the student nurses. Respondents were asked to rate their perception of their learning needs on a three-point scale: 1 = low priority for me, 2 = medium priority for me, and 3 = high priority for me. The study found agreement on 92 felt learning needs (see Annex A) and also noted differing opinions among student ranking of learning needs. An additional benefit of this study was that the learning needs can eventually be separated by category, which included clinical problems, leadership skills, nursing interactions, the nursing process and professional issues. This categorization has implications for practice, as identification of
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nurses on selection and

specific categories of needs could assist educators in developing a comprehensive framework for a continuing education plan. 3.2. Assessment of Clinical Learning Environment Research into the clinical learning environment has been conducted for the purpose of identifying factors (or issues) that contribute to and shape the clinical learning environment. A simple checklist was used for this purpose (see Annex B). Issues that were commonly found to be associated with negative perceptions of the environment include: 1. Lack of clear objectives 2. Unrealistic expectations 3. Inadequate planning 4. Passive observation rather than active participation by learners 5. Inadequate supervision 6. Lack of feedback 7. Lack of formal training in teaching skills (of educators) Many of these issues relate to communication, suggesting

communication is a key factor in effective clinical education. Nursing students were most satisfied with environments that respected them and where they were considered part of the team. Students also become less anxious soon after becoming involved or occupied with ward activities. Hence, a good practice model would encourage students to become involved as soon as possible, resulting in reduced anxiety and improved performance. The elements of an ideal clinical learning environment identified by the
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student could be categorized under the following five headings: 1. Clarity of objectives, where clinical educators have ample knowledge of clinical procedures and assessment is understood and factored into the clinical education. 2. High quality clinical education staff, who have experience and confidence; are adequately prepared; are reflective, flexible and good at handling problems; are committed to education and their profession; and provide a good role model for students. 3. A welcoming environment, where students receive an appropriate orientation/induction; are included in activities; feel valued; and there are facilities and amenities provided for the students. 4. A culture of learning, which values lifelong learning and evidencebased practice; and where learners feel it is safe to ask questions and participate; a non-judgemental environment. 5. Appropriate learning opportunities, mainly with respect of clinical activities students. There was also agreement on the role of educational institutions creating positive learning environments in clinical settings, which principally: a) Adequate preparation of students. b) Appropriate allocation of students to sites, done with the involvement of the site.
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but

also

including

non-clinical

areas

such

as

staff

administrative duties, which provide challenging, active learning for

in is

4. Conclusion and Directions for Future Use The challenge remains to best prepare students for the complexities and dynamics of the workplace learning environment, while at the same time modifying this environment to effectively meet students learning needs. It is therefore essential that we as educators make the effort to listen to and learn from our students, as it is only through knowing what our students truly need that we will be able to implement positive change and facilitate powerful learning experiences (Ramsden, 2005). These preliminary findings suggest that the knowledge and learning experience needed to support a student nurse in contemporary tims combines theoretical, tacit and personal knowledge. Therefore, the assessment of the earning environment and knowledge attainment by students of nursing should be consistent with the complexity of this broad knowledge base. The nursing profession shoud strive for an understanding and practice of assessment in nursing which provides confidence to the graduate and the communities in which they will work. We argue there is a need for developed tools of assessment of learning needs and of the clinical learning environment to assure quality in nursing education for practice.

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REFERENCES Asutilla, Carine M. (2008). Poor quality nursing schools blamed. Cebu Daily News. Retrieved October 30, 2010 from http://www. INQUIRER.net.htm. Burchell, H. & Jenner, E. A. (2006). The role of the nurse in patientfocused care: Models of competence and implications for education and training. International Journal of Nursing Studies, 33(2), 67-75. Fraser, B. I. (2005). Research on classroom and school climate. In D. Gabel (Ed.), Handbook of research on science teaching and learning (pp. 492541). New York: Macmillan. Fraser, B.J., & Fisher, D.L. (2006). Assessment of classroom psychological environment. (Monograph). Perth, Australia: Curtin University of Technology. Fraser, B.J., & Walberg, H.J. (Eds.). (2007). Educational environments: Evaluation, antecedents and consequences. Oxford, England: Pergamton Press. Havnes, A. (2005). Examination and learning: an activity-theoretical analysis of the relationship between assessment and educational practice. Assessment & Evaluation in Higher Education 29 (2), 159176. Lindner, R. (2008). A framework to identify learning needs for continuing nurse education using information technology. Journal of Advanced Nursing, 27(5), 1017-1020. Massarweh, I.-J. (2005). Promoting a positive clinical experience. Nurse Educator, 24(3), 44-47. Moore, P. V. & Short, J. (1994). Planning a continuing education program: The model for health education planning. American Association of Occupational Health Nurses Journal, 42(9), 430-4. Quinn, F.M., Hughes, S.J. 2007. Quinns Principles and Practice of Nurse Education. 5th Ed. London: Nelson Thornes Ltd. Ramsden, P. 2005. Learning to Teach in Higher Education. 2nd Ed. London: Routhledge Falmer. Rath, D., Boblin-Cummings, S., Baumann, A., Parrott, E., & Parsons, M. (2006). Individualized enhancement programs for nurses that promote competency. The Journal of Continuing Education in Nursing, 27(1), 12-6.
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Valisno, Mona. Technical Workshop on Education and Globalization. July 31, 2006.

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Annex A FELT EDUCATIONAL NEEDS IDENTIFIED BY RESPONDENTS

1. Sterilizing packing instruments 2. Preparation of OR packs 3. Surgical aseptic technique 4. Drug Administration 5. Medications (Discharge) 6. Physical preparation (surgery) 7. Handling of instruments 8. Psychological preparation (pre-operative) 9. Counting of sponges 10.Patient rights 11.Laboratory procedures 12.Evaluate nursing process 13.Carrying out Physicians Order 14.Health teaching (Clinical Care) 15.Prolonging life 16.Thoracostomy care 17.Activities (Discharge Planning)

18. Documenting nursing plan

19.Standards of care 20.Tracheotomy care 21.Assessment of vital signs 22.Comfort measures 23.Charting
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24.Handling performance problems 25.Post-mortem care 26.When giving medication (Communication Skills/ Values/Attitudes) 27.Diet (Discharge Planning)

28. Assessing physical status

29.I & O measurement 30.Suctioning 31.Computation of rate IV flow

32. Follow-up (Discharge Planning)

33.Participation in care 34.When giving health teachings(Communication Skills/Values & Attitudes) 35.Postural drainage 36.Urinary catheterization

37. Specimen collection (Communicable Disease)

38.Neurological assessment 39.Receiving/Giving endorsement

40. Managing problems

41.Psychosocial assessment 42.Regulatory requirements 43.Motivating peers 44.Nurse-client-relative conference 45.Rehabilitation measures 46.Reality orientation 47.Functional assessment 48.Preparation for gyne exam
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49.Collection of specimen (Reproductive Problems) 50.Gastric lavage 51.Documentation (Leadership Skills) 52.Outlining performance standards 53.Team member functions 54.During admission (Communication Skills/Values/Attitudes) 55.Psychological preparation (Nursing Interactions) 56.Eye, ear and nose care 57.Steam inhalation

58. O2 administration
59.Gastric gavage 60.Handling complaints

61. Assessing mental status

62.Research on illness 63.Oral hygiene 64.Teaching peers new skills

65. Assessing environment

66.Implement plan 67.Enema 68.Managing a crisis 69.Delegating to peers 70.Peer evaluations 71.Supervising peers 72.Spiritual assessment 73.Vaginal douche

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74.Bedside Care 75.Discharge planning (Nursing Interactions) 76.Collection of specimen (oxygenation)

77. H2O-sealed bottle

78.Collection of stool specimen 79.Collection of urine specimen 80.Fluid & electrolyte therapy 81.Care of the skin 82.Perineal preparation & washing 83.Insertion of suppository 84.Vaginal suppository insertion 85.Active & passive exercises 86.Bathing the patient 87.Care of the feet 88.Offering bed pan 89.Ambulating patient 90.Peer review ( Profl Issues) 91.Care of the hair 92.Breast care

Annex B

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CHECKLIST OF INDICATORS IN THE CLINICAL LEARNING ENVIRONMENT PRESENTED TO RESPONDENTS

1. 2. 3. 4. The orientation I received to the workplace for this placement was adequate The atmosphere during the ward teaching was conducive to learning This clinical placement was well timetabled Clinical instructors favored some students over others 5. I was introduced to relevant members of the team (e.g., nursing supervisor) 6. The atmosphere during lectures/tutorials was conducive to learning 7. I felt my ideas and opinions were respected by the clinical instructors 8. There were opportunities for me to develop interpersonal skills 9. I felt comfortable socially in teaching sessions 10.I felt able to ask the questions I want 11.I found the clinical placement experience disappointing 12.The good aspects outweighed the bad aspects of the placement 13.The atmosphere motivated me as a learner 14.I would be keen to return to that hospital for further placements or to work there 15.The learning facilities provided for students (e.g. desk space, computers, library access) were adequate 16.The learning aids provided for students (e.g. simulation, models, specialised equipment were adequate) 17.The learning spaces provided for students (e.g. tutorial rooms, breakout rooms, etc.) were adequate 18.Other facilities provided for students (e.g. lounge, etc) were adequate 19. I was encouraged to participate in clinical activities ] 20.The teaching was well focused 21.I was encouraged to participate in tutorials 22.The teaching was often stimulating 23.The teaching was student-centred 24.The placement helped to develop my competence 25.The teaching helped to develop my confidence 26.The placement time was put to good use 27.The teaching during the placement over-emphasised rote learning of facts 28. I was taught by a number of different clinical instructors 29. The school and the clinical placement provider/hospital were well coordinated 30.The students were treated as learners, not workers 31.The placement gave me the opportunity to learn with students from other disciplines 32.The teaching and learning activities provided me with the opportunity to fulfil the objectives of the placement 33.I was exposed to a number of different health professional disciplines during the course of this placement
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34.I was clear about the learning objectives of the placement 35.The teaching encouraged me to be an active learner 36.The amount of supervision I received was about right 37.The school adequately prepared me for this clinical placement 38.There was someone to contact at the school in relation to this clinical placement 39. The lectures and practical sessions I had undertaken prior to this placement adequately prepared me for this placement 40. I was/am confident about passing the assessment relevant to this placement 41.I felt I was being well prepared for my profession 42. I learned about the role of empathy in my profession during this placement 43.The placement helped me to further develop clinical reasoning skills 44.Much of what I learned seems relevant to a career in healthcare 45.There was a good support system for students who encountered difficulties in relation to the placement 46.I have encountered age bias during this placement 47. There was adequate school support during this placement 48.I was rarely bored on this placement 49.I have encountered sexual discrimination during this placement 50.If I had problems with my clinical placement, I could discuss these with someone at the hospital during the placement 51. If I had problems with my clinical placement, I could discuss these with someone at my school during the placement 52. The clinical instructors were knowledgeable 53. The clinical instructors demonstrated good communication skills with patients

54. The clinical instructors had good bedside manner 55. The clinical instructors ridiculed the students 56. The clinical instructors were authoritarian 57. The clinical instructors were good at providing feedback to students 58. The clinical instructors provided constructive criticism 59. The students irritated the clinical instructors 60. The clinical instructors were well prepared for their teaching sessions

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