Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12052 Clinical achievement improvement through experiential learning-based training Fitri Chandra Kuspita,1 Tintin Sukartini,1 Ahsan Ahsan,2 Nursalam Nursalam,1 Apriyani Puji Hastuti3 1Faculty of Nursing, Universitas Airlangga, Surabaya; 2Faculty of Health Science, Universitas Brawijaya, Malang; 3Department of Nursing, Faculty of Health Science, Institut Teknologi Sains dan Kesehatan RS dr Soepraoen, Malang, Indonesia Abstract This study aimed to enhance clinical educators’ competence through experiential learning-based preceptorship training. Many clinical educators struggle with implementing effective clinical education, providing guidance, and having limited time for new nurses. The research employed a quasi-experimental design with a pre-posttest control group involving 60 clinical educators. The intervention group received a five-day training module using experiential learning-based preceptorship, while the control group received standard intervention. Data analysis used the Wilcoxon Signed Rank Test to analyse differences before and after interven- tion, and used Mann-Whitney to analyse differences between the two groups. Analysis revealed significant improvements in critical thinking, patient safety, leadership, communication, research- based practice, and professional development among the interven- tion group compared to the control group (p=0.000). The findings highlight the effectiveness of this training model in enhancing clinical educators’ learning outcomes. The study suggests that incorporating experiential learning into clinical education can be a valuable strategy for improving the competence of clinical edu- cators and subsequently achieving better clinical achievements. Introduction Learning outcomes for clinical educators are designed to ensure the competence of new nurses can be attained. However, many clinical educators still lack an understanding of how to effectively implement clinical education practices.1 Additional identified problems include clinical educators struggling with pro- viding guidance, having limited time to meet new nurses, and a lack of evaluation to measure the performance of new nurses. 2 The concept of learning theory highlights components that need further exploration, including the characteristics of new nurses, clinical educators, and learning media facilities. This is in addition to assessing the learning achievements of clinical educa- tors themselves.3–5 Factors contributing to enhanced competence among clinical educators involve improvements in their quality as role models.6–8 The qualities of clinical educators as role models encompass being caring, engaging in positive interactions, show- ing empathy, earning respect from colleagues, possessing reliable communication skills, and fulfilling a strong advocacy function. Meanwhile, the qualities of a clinical educator as a role model include being an expert practitioner, an enthusiastic resource per- son, a knowledge sharer, a respecter of human dignity, a critical thinker, and an honest and accountable individual.9,10 Enhanced learning outcomes for clinical educators, in terms of quality, will improve critical thinking, patient safety, leadership, communica- tion, research-based practice, and professional development.2,3 The Experimental Learning Theory (ELT) is a combination of understanding and transforming experiences that can assist clini- cal educators in guiding new nurses to enhance their clinical com- petence in attitudes, knowledge, and skills. To operationalise an appropriate learning system for forming competent clinical educa- tors, the experiential learning system is proposed.11–15 The stages in Experiential Learning consist of Concrete Experience (CE), Reflective Observation (RO), Abstract Conceptualization (AC), and Active Experimentation (AE). These four phases of Experiential Learning cannot be applied with just one method; there needs to be a combination of learning theory and andragogy Correspondence: Tintin Sukartini, Faculty of Nursing, Universitas Airlangga, Surabaya, East Java, Indonesia. E-mail: tintin-s@fkp.unair.ac.id Key words: clinical education, experiential-learning, learning outcome, nursing, preceptorship. Contributions: FC, conceptualization, data curation, formal analysis, methodology, validation, visualisation, writing – original draft, review and editing; TS, AA, NN conceptualization, investigation, methodology, validation, conceptualization, formal analysis, validation, and analysis; AP, writing – original draft, review & editing. Funding: none. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: this research was approved by ethical permission from the Health Research Ethics Commission (KEPK) Faculty of Nursing, Universitas Airlangga number 2540- KEPK dated June 20 2022. Patient consent for publication: written informed consent was obtained for anonymised patient information to be published in this article. Availability of data and materials: all data generated or analysed during this study are included in this published article. Received: 5 November 2023. Accepted: 19 December 2023. Early access: 26 January 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12052 doi:10.4081/hls.2024.12052 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:12052] [page 207] Non -co mmerc ial us e o nly theory. The combined focus of these two theories is on adult learn- ing, particularly in the context of new nurses (nursing center learn- ing). Andragogy learning theory includes self-concept and motiva- tion to learn, experience, readiness to learn, and orientation to learn.9,16,17 The concept of learning theory highlights components that need further exploration, including the characteristics of new nurs- es, clinical educators, and learning media facilities, in addition to the learning achievements of clinical educators themselves.10,18–21 The aim of this study was to analysed clinical education training based on experiential learning to improve clinical achievement. Materials and Methods The research conducted in three hospitals that have achieved Plenary Accreditation for Hospital Accreditation Standards issued by the Ministry of Health (STARKES), aimed to investigate the impact of implementing a clinical nursing education model based on experiential learning using a preceptorship method. Employing a robust quasi-experimental design with a pre-posttest control group approach, the study provided a comprehensive framework for assessing the learning outcomes of clinical educators. The study involved a total of 338 clinical educators within the selected hospitals. After rigorous application of inclusion criteria, 200 clinical educators were deemed eligible for participation, while 138 were excluded based on predefined research criteria. The purposive sampling method ensured a deliberate selection of qualified participants, resulting in a final cohort of 60 clinical nurse educators evenly distributed between the control and exper- imental groups. To ensure the study’s relevance and representative- ness, the target population consisted of clinical educators from var- ious hospitals in East Java, Indonesia. Strict inclusion criteria for this population included nurses working in hospitals, possessing a minimum of five years of experience with permanent employee status, holding a Bachelor’s Degree in Nursing, and being certified preceptors. Exclusion criteria were meticulously established to maintain the study’s integrity, excluding nurses on maternity leave, those undergoing training, and those on permission or study assignments. The independent variable in this research was the implementa- tion of clinical nursing education using a preceptorship method based on experiential learning, while the dependent variable was the learning outcomes of clinical educators, measured through crit- ical thinking, patient safety, leadership, communication, research- based practice, and professional development. The implementation of clinical nursing education using a preceptorship method based on experiential learning was aimed at increasing the learning out- comes of clinical educators, supported through clinical educators with module training and its subsequent implementation directly with new nurses. The influence of developing a clinical education model with a preceptorship method based on experiential learning to increase the learning outcomes of clinical educators for new nurses was a key focus. The research instrument used a question- naire developed by the researcher. The intervention group received training in clinical nursing education modules using a preceptor- ship method based on experiential learning for five days, while the control group received standard intervention. Data analysis employed the Wilcoxon Signed Rank Test for pretest and posttest comparisons and the Mann-Whitney test for assessing differences between the control and intervention groups with a significance level of 5%. The research findings, summarised in the analysis table, provide a detailed overview of the outcomes observed in both groups. Both groups were measured for learning outcomes before and after intervention using the questionnaire. Ethical considerations were paramount throughout the research process. The study received ethical approval from the Health Research Ethics Commission (KEPK) at the Faculty of Nursing, Universitas Airlangga, under protocol number 2540- KEPK, dated June 20, 2022, ensuring that the research adhered to the highest standards of ethical conduct. All participants approved and signed the informed consent after receiving an explanation of the study and the potential risks involved, along with an under- standing that their identities would be kept confidential for the pur- pose of publishing the study results. Results Table 1 shows that the highest proportion of ages in both groups is 45-49 years (50% and 57%, respectively). The largest proportion of respondents in both the intervention group and the control group were female (50% and 57%). Regarding religious characteristics, all respondents in both the control group and the intervention group belonged to the Islamic religion (100%). In terms of ethnic characteristics, in the intervention group, 100% of respondents had this characteristic, while in the control group, 50% were from the Javanese tribe, and 50% were from the Madurese tribe. Concerning work experience, most of them had 11-20 years of work experience in the intervention (50%) and in the control group (53%). Regarding structural position characteris- tics, 67% of the respondents in the intervention group held the position of Team Heads, while in the control group, most of them, there is 50%, held the position of Team Leaders. Regarding expe- rience as a clinical educator, both groups have more than 5 years of experience (73% for the intervention and 67% for the control group). Table 2 reveals a notable impact or disparity between the inter- vention and control groups resulting from the implementation of clinical education module training utilising the experiential learn- ing-based preceptorship method. This initiative aimed to enhance the learning outcomes of clinical educators for new nurses in the intervention group, as indicated by the results of both pre-test and post-test assessments. Furthermore, the Mann-Whitney test results for other variables in this study demonstrated significant differ- ences between the intervention and control groups, encompassing critical thinking (p=0.000), patient safety (p=0.000), leadership (p=0.000), communication (p=0.000), research-based practice (p=0.000), and professional development (p=0.000). Discussion The conducted study revealed findings explaining that indica- tors such as critical thinking, patient safety, leadership, communi- cation, research-based practice, and professional development strongly influenced the increased learning outcomes of clinical nursing educators using experiential learning-based preceptorship methods. The research also demonstrated significant differences in the competency of clinical educators in clinical nursing education, particularly when employing the experiential learning-based pre- ceptorship method to enhance their learning outcomes. The research-based practice factors within the infrastructure and human resources category were found to be in the deficient cate- Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 208] [Healthcare in Low-resource Settings 2024;12:12052] Non -co mmerc ial us e o nly gory. Additionally, based on the description of the characteristics of professional development in the implementation category, the final results were still categorised as poor. Changes and advancements in the nursing clinical education process exert an influence on the demand for heightened sensitivi- ty and selective service quality segmentation. This segmentation is based on the value of diversity among individuals, patients, and clinical educators.22–24 Therefore, there is a need to enhance the professional competence of clinical educators, facilitating improved services through the adaptation of experiential values, competence, and procedures. This adaptation occurs through the interactive engagement of clinical educators in the learning pro- cess of clinical nursing education. This perspective aligns with the notion that individuals continuously develop knowledge across cognitive, affective, and psychomotor factors.25,26 The role of clinical educators extends beyond being merely teachers who introduce knowledge; it encompasses being guides, developers, and managers of learning activities. Clinical educators play a vital role in facilitating the learning activities of new nurses, ensuring the achievement of set goals.26,27 Characteristics of clini- cal educators that can influence the learning process, serving as indicators for selecting clinical educators in this research, include Teacher Formative Experience, Teacher Training Experience, and Teacher Properties. Teacher Formative Experience pertains to educators’ charac- teristics such as age, gender, religion, social and cultural back- ground, and past experiences related to loss, grief, and bereave- ment. Teacher Training Experience includes activities and educa- tional background/level of education, along with training experi- ence related to palliative care proposed.15 Teacher Properties encompass everything related to the characteristics possessed by clinical educators.28 In this study, Teacher Properties will be assessed based on the professional abilities of clinical educators, interpersonal relationships with new nurses, and the personal qual- ities exhibited by clinical educators during the learning process.29 The perceived lack of role modelling by clinical educators reflects their low proficiency in indicators of professional ability and the development of interpersonal relationships.17 Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristic of respondents (N=60). Variable Category Group Intervention Group Control Group Frequency (f) Percentage (%) Frequency (f) Percentage (%) Age 30-34 years old 0 0 0 0 35-39 years old 2 6 8 27 40-44 years old 8 27 3 10 45-49 years old 15 50 17 57 50-54 years old 5 17 2 6 Gender Man 15 50 13 43 Woman 15 50 17 57 Religion Islamic 30 100 30 100 Christian 0 Ethnic group Javanese 30 100 15 50 Maduranese 0 0 15 50 Length of work 5-10 years 5 17 4 13 11-20 years 15 50 16 53 21-30 years 5 17 6 20 31-40 years 3 10 2 7 41-50 years 2 6 2 7 Structural position Head of nurse 10 33 10 33 Primary nurse 20 67 15 50 Associate nurse 0 0 5 17 Clinical educator experience Under 5 years 8 27 10 33 Above 5 years 22 73 20 67 Table 2. Impact of experiential learning-based preceptorship on clinical educator learning achievements in new nurses (N=60). Variable Intervention Group (n=30) Control Group (n=30) Pre-test Post-test ΔMean p Pre-test Post-test Δ Mean p Mean±SD Mean±SD Mean±SD Mean±SD Critical thinking 13.5±0.013 14.8±0.000 0.4 0.000 12.8±0.183 14.0±0.000 1.9 0.000 Patient safety 18.3±0.093 57.8±0.047 1.7 0.000 19.0±0.691 57.9±0.000 2.7 0.000 Leadership 12.8±0.007 39.9±0.000 0.3 0.000 12.4±0.40 39.0±0.000 1.6 0.000 Communication 11.4±0.151 35.0±0.000 0.0 0.000 11.6±0.28 35.0±0.000 2.0 0.000 Evidence based practice 12.5±0.589 40.0±0.000 0.2 0.000 13.1±0.036 39.0±0.000 1.7 0.000 Professional practice 12.8±0.013 39.8±0.000 0.5 0.000 12.8±0.024 39.0±0.000 1.7 0.000 [Healthcare in Low-resource Settings 2024;12:12052] [page 209] Non -co mmerc ial us e o nly Consequently, the quality of nurses may suffer, and from a scien- tific perspective, their skills and competencies might not meet the standards, risking the safety of patients during practical activi- ties.15,22 Moreover, the low ability of clinical educators in fulfilling mentoring functions for new nurses during the orientation period has led to a relatively high turnover rate of 16% among new nurs- es. This condition can induce discomfort in the learning process of clinical nursing education, resulting in a decline in the quality of clinical educators and the application of practical knowledge.16 Improving the learning outcomes of clinical educators in terms of quality, including critical thinking, patient safety, leadership, com- munication, research-based practice, and professional develop- ment, is crucial.2 The Experiential Learning Theory (ELT), formulated by David Kolb, is a dynamic framework guiding clinical educators in shap- ing the clinical competence of new nurses. ELT posits that learning involves active engagement with experiences, reflection, concep- tualisation, and practical application.10 By orchestrating hands-on experiences and reflective discussions, clinical educators expose new nurses to a holistic learning environment, fostering not only technical skills but also critical thinking and professional attitudes.30,31 The theory underscores the importance of tailoring teaching methods to individual learning styles, emphasising a cyclical process of concrete experiences, reflective observation, abstract conceptualisation, and active experimentation.31 ELT thus provides a comprehensive foundation for optimising the develop- ment of new nurses, ensuring a personalised and effective educa- tional experience within clinical settings. Conclusions The implementation of training clinical nursing education using the experiential learning method has demonstrated its effec- tiveness in significantly enhancing the learning outcomes of clini- cal educators. By incorporating an ELT-based learning model, which integrates practical experiences with theoretical foundations in clinical nursing education, alongside the preceptorship method, this approach ensures a comprehensive development of clinical educators’ learning outcomes. The training focuses on not only increasing knowledge and skills related to clinical nursing educa- tion but also fostering a positive attitude towards the preceptorship method. This multifaceted approach recognises the importance of not only imparting theoretical knowledge but also providing hands-on experiences that contribute to a more profound under- standing of clinical education, ultimately shaping well-rounded and proficient clinical educators. References 1. 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