Nurse Education Today

Transcription

1 Nurse Education Today 33 (2013) Contents lists available at SciVerse ScienceDirect Nurse Education Today journal homepage: Development and psychometric testing of the Ascent to Competence Scale Michelle A. McCoy, Tracy Levett-Jones 1, Victoria Pitt 2 School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW 2308, Australia article info summary Article history: Accepted 2 November 2011 Keywords: Nursing students Clinical placements Competence Questionnaire Psychometrics Aim: This paper reports the development and psychometric testing of the Ascent to Competence Scale, an instrument designed to measure nursing students' perceptions of the quality of their clinical placement experience. Background: The key purpose of clinical placements is to facilitate students' learning and progress toward the attainment of competence. The attainment of competence requires personal commitment and active involvement of students; support and guidance of clinical and academic staff; and clinical environments that are welcoming and inclusive of students. Method: The items for the Ascent to Competence Scale were identified following a critical review of the literature. Content and face validity were established by an expert panel. During 2010 the instrument was tested with third year nursing students (n=88) from one Australian university. Exploratory factor analysis with promax oblique rotation was used to determine construct validity and Cronbach's coefficient alpha determined the scale's internal consistency reliability. Results: The final scale demonstrated satisfactory internal consistency (alpha 0.98). Exploratory factor analysis yielded a three-component structure termed Being welcomed ; Belongingness and Learning and competence. Each subscale demonstrated high internal consistency: 0.89; 0.96; and 0.95 respectively. Conclusion: The Ascent to Competence Scale provides a fresh perspective on clinical placements as it allows for the relationship between belongingness, learning and competence to be explored. The scale was reliable and valid for this cohort. Further research in different contexts would be valuable in extending upon this work. Relevance to clinical practice: The Ascent to Competence Scale profiled in this paper will be of benefit to both educational and healthcare institutions. The use of a quantified yardstick, such as the Ascent to Competence Scale, is important in evaluating the efficacy of programs, placements and partnerships between higher education and health services Elsevier Ltd. All rights reserved. Introduction The primary aim of undergraduate nursing education is the development of competent registered nurses (RNs). Clinical placements are fundamental to students' learning and preparation for practice. Thus, it is essential that the conditions that facilitate positive clinical learning experiences are fully understood. The Ascent to Competence Scale (ACS), profiled in this paper, provides a valid and reliable instrument for examining students' perceptions of the quality of their placements and the extent to which clinical environments are conducive to learning and the attainment of competence. DeVellis (2003) Corresponding author. Tel.: ; fax: addresses: michelle.mccoy@newcastle.edu.au (M.A. McCoy), Tracy.Levett-jones@newcastle.edu.au (T. Levett-Jones), Victoria.Pitt@newcastle.edu.au (V. Pitt). 1 Tel.: ; fax: Tel.: ; fax: proposed that scales must be informed by a theoretical framework. The model that guided the design of the ACS was the Ascent to Competence conceptual framework developed by Levett-Jones and Lathlean (2009a). This framework, based upon the work of Maslow (1987), provides a system of interrelated concepts arranged in a hierarchy with five levels that include: the need for safety and security, the need to belong and be accepted, the need for a healthy self-concept, the need to learn, and the need to attain competence. Background Most previous research exploring nursing students' clinical placement experiences has focused on a single aspect of clinical placements, for example orientation (Robinson et al., 2009); horizontal violence (Longo, 2007); professional self (Bjorkstrom et al., 2008); learning (Newton et al., 2009; Roberts, 2008); or competence (Edwards et al., 2004; Watson et al., 2002). A limited number of studies have explored clinical placement experiences more holistically /$ see front matter 2011 Elsevier Ltd. All rights reserved. doi: /j.nedt

2 16 M.A. McCoy et al. / Nurse Education Today 33 (2013) Dunn and Hansford (1997) used the Clinical Learning Environment Scale (CLES) to explore student's general perceptions of the clinical environment but failed to take into account key issues such as students' feelings of safety and security; learning; or attainment of competence. More recently, Chan (2002) developed the Clinical Learning Environment Inventory (CLEI) which explored intrinsic factors, for example, personalization, satisfaction, and task orientation. However, this scale had a somewhat narrow focus on the level of student's participation in patient care as an indicator of placement success. The aim of the current study was to extend upon Levett-Jones and Lathlean's previous work (2009a) by developing and testing the psychometric properties of a new scale, termed the Ascent to Competence Scale (ACS), which incorporates the five levels of the original Ascent to Competence framework. Level 1 Safety and Security Unless nursing students' basic need for physical and psychological safety and security (including freedom from anxiety and stress) are met, higher-level needs became less important, as survival becomes their primary motivation. Orientation/induction programs help students become accustomed to and feel safe in the clinical environment (Beskine, 2009). Robinson, et al. (2009) report that students who have a comprehensive orientation feel supported [and] welcomed by staff (p.356). The provision of an orientation depends on ward culture, university expectations and facility policies. Myall et al (2008) commented that only half the students in their study received an orientation. Many students experience stress and anxiety during clinical placements (Chesser-Smyth, 2005). This impacts on the extent to which they feel secure in the clinical environment. First year students are noted to have the highest anxiety levels, taking at least two weeks to adjust to the clinical environment (Andrew et al., 2009). Students' level of stress and anxiety tends to decrease when they felt accepted and welcomed by the nursing team (Chesser-Smyth, 2005). Students' feelings of safety and security are negatively impacted by workplace bullying and horizontal violence. This phenomenon is defined as a collection of negative actions or behaviors toward an individual and can include verbal remarks, sarcasm, negative gestures or body language, aggression, or exclusion (Curtis et al., 2007). Evidence suggests that student's witness or experience high incidences of horizontal violence and bullying and that it has a negative impact on their placement experiences and clinical progress (Curtis et al., 2007; Longo, 2007). Level 2 Belongingness Once the students' need for workplace safety and security has been met they are able to move to the next level of the hierarchy where fitting in and becoming an integral member of the nursing team take precedence. Belongingness evolves in response to the degree to which the individual feels (a) secure, accepted, included, valued and respected by a defined group, (b) connected with or integral to the group, and (c) that their professional and/or personal values are in harmony with those of the group (Levett-Jones and Lathlean, 2008). Students' sense of belonging is influenced by the quality of the interpersonal relationships forged with their nursing colleagues and by the receptiveness, acceptance, support and interest demonstrated by those nurses (Edgecombe and Bowden, 2009; Levett-Jones et al., 2009). Registered nurses who value and are welcoming of students facilitate their sense of belonging and acceptance (Newton et al., 2009). The degree of belongingness students experience influences how motivated they are and the degree of satisfaction they gain from the placement (Levett-Jones and Lathlean, 2009b). Level 3 Self-concept Self-concept incorporates self-esteem, confidence and professional self-worth (Bradbury-Jones et al., 2007; Chesser-Smyth, 2005). Students' with high self-esteem are more confident and motivated to learn (Karagozoglu et al., 2008) as well as being more self directed (Lo, 2002). Confidence, like self-concept, has been described as a vital human need (Lundberg, 2008). Nash, et al. (2009) suggested that positive self concept is linked to competence, and is a important for becoming a successful RN. Students with lower levels of self-concept often have poorer clinical placement experiences (Lundberg, 2008). Level 4 Learning In the fourth stage of the hierarchy, the development of clinical knowledge and skills through immersion in patient care and working beside effective role models is students' primary motivation. A positive clinical placement experience allows students to become increasingly self-directed in their learning (Papp et al., 2003). Levett-Jones and Lathlean (2008) identified that a strong sense of belonging allows students to feel more comfortable asking questions and negotiating their own learning opportunities. Students also report that their learning is impeded by staff who are not supportive or interested in their learning (Hartigan-Rogers et al., 2007). Furthermore, feelings of alienation, the antithesis of belonging, impede students' motivation to learn (Levett-Jones and Lathlean, 2008). Level 5 Competence When the other needs in the hierarchy have been addressed, students move toward a realization of their full potential and the attainment of a beginning level of competence becomes possible (Levett-Jones and Lathlean, 2009a). Competence is defined as the combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a profession/ occupational area (Australian Nursing and Midwifery Council 2005). The Ascent to Competence conceptual framework (Fig. 1) describes the conditions that facilitate the attainment of nursing competence (Levett-Jones and Lathlean, 2009a): The structure of the Ascent to Competence conceptual framework provides a useful way of conceptualizing students placement experiences. However, what is needed is a valid and reliable instrument for examining how the quality of the clinical setting influences students' clinical placement experiences. The ACS addresses this need by extending upon the concepts that underpin that framework in a way that allows students to report on their experiences and for their responses to be quantified. Research Design The aims of this study were to: 1. Develop a scale that represents the key concepts of the Ascent to Competence framework using DeVellis's (2003) method for scale development; and 2. Conduct a study to evaluate the psychometric properties of the ACS. Phase 1: Development of the Ascent to Competence Scale DeVellis' (2003) method of scale development include: Ascertaining what is to be measured Production of an item pool Determining the method of measurement Review of the item pool by an expert panel Pilot testing with a small sample Reevaluation of items for inclusion in the scale.

3 M.A. McCoy et al. / Nurse Education Today 33 (2013) Fig. 1. Ascent to Competence conceptual framework (Levett-Jones and Lathlean, 2009b). Item Pool A critical review of the literature informed the development of the 119 items that comprised the initial item pool for the ACS. The item pool reflected the key themes and constructs of the Ascent to Competence framework. Method of Measurement Answer choices for the ACS were based on a five-point Likert scale with 0 = strongly disagree; 1 = disagree; 2 = neither agree nor disagree; 3 = agree and 4 = strongly agree. Items were worded both positively and negatively to minimize response bias. Likert-scales measure direction and intensity of attitudes or perceptions (devaus, 2004). The disadvantages of rating scales relate to the development of the scale as items that are poorly worded can be misinterpreted and will produce poor results. This may also impact on the response rate as participants are likely to lose interest (devaus, 2004). These issues can be addressed through the use of expert panel review. Expert Panel Ten expert judges reviewed and evaluated the item pool for the ACS. The group consisted of two nursing professors, two directors of clinical education, four nursing lecturers and two second year nursing students. One reviewer was of non-english speaking background. This was important to determine the cultural and linguistic appropriateness of the scale. The panel was asked to review the item pool for clarity, conciseness, relevance, ambiguity and unnecessary repetition. DeVellis (2003) suggests that this process increases the scale's construct and face validity. Forty-eight items were reworded or rephrased based on the feedback from the panel and 40 items were removed resulting in a scale with 79 items. Phase 2: Study Study Sites and Participants The study took place in a school of nursing and midwifery at a large regional university in Australia. Convenience sampling was considered an appropriate method (devaus, 2004) and third year nursing students (n=364) were invited to participate. Ethics approval for this study was provided by the university's ethics committee. Participants were recruited through the advertisements on the web based platform Blackboard TM. An information statement was provided and electronic submission of the anonymous questionnaire was taken as implied consent. Each questionnaire was numerically coded for data entry and all indentifying information removed prior to access by the researcher. One hundred students submitted the questionnaire, however, only 88 were complete and used in analysis The majority were aged years (44%, n =39). Eighty nine percent (n=78) of participants were female. Eighty-eight percent (n=78) of participants were born in Australia; the others were born in Asia, Africa, United Kingdom or New Zealand. English was the first language for the majority of participants (88%, n =79). The majority (64%, n=56) had 1 5 years previous nursing experience as either endorsed enrolled nurses (14%, n=12), or assistants in nursing (28%, n=25). The participants' clinical placement settings were varied and included mental health units (14.8%, n=9); medical/surgical wards (24%, n=21); operating theaters (22%, n=19), and medical rehabilitation wards (13%, n=11). Analysis and Results Prior to analysis, data were checked for missing values. Of the 100 questionnaires submitted only 88 were accepted for analysis as 12 had 20% or more incomplete responses. In questionnaires with less than 20% of incomplete responses the median value of 2 was imputed for the missing values (Fink, 2003). Results were processed using PASW Version 18 (formerly known as SPSS). Descriptive Statistics Mean and standard deviation for ACS scores for each item are provided in Table 1 as ranked scores. The highest scoring item was: I actively involved myself with patient care activities (B6, M=3.59). The lowest scoring item was: The harder I worked the more the staff accepted me (B21r, M=1.09). This item was reversed scored indicating that most students viewed working hard as important to a successful placement experience and their acceptance by ward staff. Scores for a number of the items, such as: I felt like I was just an extra pair of hands (B20r, M=2.15); and Getting the work done was more important than learning (L11r, M=2.31) seem to support this contention. As the primary goal of clinical placements is for students to engage in learning, the fact that for a number of students working hard appeared to take precedence, warrants careful consideration. Analysis of the ACS scores also shed light on students' perceptions of the need to fit in. While the results indicate that they Tried to fit in (B2, M=3.16); their sense of inclusion and connectedness was not strong (B5, M=2.98; B3, M=2.91). The results indicated that

4 18 M.A. McCoy et al. / Nurse Education Today 33 (2013) Table 1 Ascent to Competence Scale (means ranked). n=88 Item M SD B6 I actively involved myself in patient care activities L2 My mentor(s) willingly answered my questions L7 I made the most of all learning opportunities B22 My mentor encouraged me to participate in patient care activities during placement SC5 I felt that my mentor trusted me with patient care responsibilities C1 My mentor(s) thought that I was competent L6 The nursing staff were receptive to my questions L10 I was motivated to learn during the placement SS8r During the placement there were times that I did not feel physically safe SS12r I was bullied during the clinical placement B17r I felt discriminated against by nursing staff during the placement B10 I developed a good working relationship with my mentor(s) L9 During the placement I felt confident enough to work in an increasingly independent way B2 I tried to fit in during the placement SC6 I made a valuable contribution to patient care C5 As a result of the placement I am more committed to patient-centered care B18 I felt supported by staff during the placement C2 I felt more capable at the end of my placement SS2 The nursing staff made me feel welcome when I commenced the placement SC3 My mentor(s) thanked me for my help at the end of each shift SS5 I was introduced to the nursing staff in the ward/unit when I commenced the placement SS9r During the placement there were times when I felt frightened L8 I felt empowered to negotiate my own learning opportunities L13 I was encouraged to learn new skills B1 I felt like I fitted in with others during the placement L1 Nursing staff were supportive of my learning L17r My anxiety impeded my ability to embrace learning opportunities provided B5 I felt included in ward activities B19 I found the placement experience distressing SC8 I felt that the nursing staff recognized my contribution to the work of the team B4 I felt like part of the team during the placement C9r I did not feel competent following placement SS3 The nurse unit manager made me feel welcome when I commenced the placement B3 I felt a sense of connectedness with nursing staff during the placement L4 I achieved my learning objectives SC2 I was provided with patient care responsibilities that matched my knowledge and skills C4 I am a more confident nurse as a consequence of the placement C8 The placement helped me prepare to work as an RN SS4r I was ignored by nursing staff when I started the placement SS7 My mentor explained the ward routine to me when I commenced the placement SC7 I was provided with opportunities to work with increasing levels of independence L21 My clinical placement motivated me to extend my learning B13r I felt disappointed by the quality of the patient care that I observed during the placement L5 Nursing staff willingly took the time to teach me during the placement L18r My anxiety prevented me from performing at my best B11 My professional values were similar to those of the nursing team with whom I worked during the placement SC1 I felt valued by the nursing staff during the placement L22 My mentor(s) challenged me to extend my skills L16r I did not feel confident enough to make the most of learning opportunities provided C7 I am more able to integrate theory and practice as a result of the placement C10 I believe that I have the makings of a competent beginning RN as a result of the placement SC10r I felt unable to perform well during the placement SC12r During the placement I spent a lot of time worrying about what the staff thought of my performance L20r I was not supported to extend my learning L14 The nursing staff were committed to my professional development B12 My personal values were similar to those of the nursing team with whom I worked during the placement L3 I was provided with many opportunities to practice my clinical skills L12 The nursing staff were interested in my progress during the placement SS11r I witnessed workplace bullying during the placement B7r I felt like an outsider C6 During the placement I was able to improve my time management skills SC4 I felt like an important member of the nursing team SC9r I felt like a burden to my mentor(s) C3 The placement experience enabled me to reach my full potential L19r I did not feel challenged to learn new skills L15 The nurse unit manager was committed to my learning SC11r I felt inferior to the nursing staff L11r Getting the work done was more important than learning B8 The nurse unit manager helped me to fit into the placement environment B15 I felt confident speaking up when patient care was not provided in accordance with what I had learnt at university B16 I felt confident speaking up when I disagreed with the patient care provided B20r I felt like I was just an extra pair of hands during placement SS10r I felt anxious during the placement SS6 A structured orientation session was provided for me

5 M.A. McCoy et al. / Nurse Education Today 33 (2013) Table 1 (continued) n=88 Item M SD B14r I felt that conformity was essential to fitting in during the placement B9 I had the same mentor throughout the placement SS13r I was worried about making mistakes during the placement SS1r I felt apprehensive and uncertain when I commenced the placement B21r The harder I worked the more the staff accepted me during the placement r denotes items reversed scored. fitting in was related to the quality of the relationships between nursing staff and students. Scores for item The nursing staff made me feel welcome when I commenced the placement (SS2, M=3.08) and I developed a good working relationship with my mentor (B10, M=3.19) indicate that most students experienced a positive relationship with nursing staff. Interestingly, this was despite the fact that the majority of students did not have the same mentor throughout the placement (B9, M=1.48). With respect to learning and competence, the majority of students reported that nursing staff were supportive of their learning (L1, M=3.00); willingly answered questions (L2, M=3.49); and took the time to teach them (L5, M=2.86). Nevertheless, students recognized that they had to take responsibility for their own learning and most felt empowered to negotiate their own learning opportunities (L8, M=3.02); and were motivated to learn during the placement (L10, M=3.23). Despite this the items for confidence and perception of competence did not score highly. Encouragingly students did indicate that As a result of the placement they were more committed to patient-centered care (C5, M=3.10). Psychometric Testing of the ACS Internal Consistency Reliability The internal consistency of the items within the ACS was measured using Cronbach's alpha (α) i. Cronbach's alpha coefficient (Cronbach's alpha) is a commonly used indicator of scale reliability and in particular internal consistency (DeVellis, 2006). The alpha coefficient measures the correlations among the items (of a scale) (DeVellis, 2006). If there are high correlations between each of the items (i.e. they measure the same variable) the alpha coefficient will be high, that is, the items within the scale measure the same core subject (DeVellis, 2006). For the purpose of this study an alpha coefficient of greater than 0.8 was considered satisfactory (DeVellis, 2003, 2006). The alpha coefficient was used to measure each subscale and the entire scale in this study. The initial 79 items had an alpha of α=0.98. The Cronbach's alpha of the subscales is provided in Table 2. Analysis indicated that the removal of following items would result in better Cronbach's alpha for the subscales: SS1, SS6, B2, B9 and B21. Table 2 Cronbach's alpha Ascent to Competence Scale. Number of items Cronbach's alpha a (α) The Ascent to Competence Scale Subscales Safety and security Belongingness Self-concept Learning Competence a Unless otherwise specified, α=.05 for all statistical analysis in the study and all test assumptions are satisfactory. Exploratory Factor Analysis Sampling adequacy tests were conducted to ensure that factor analysis was appropriate (Field, 2009). The Kaiser Meyer Olkin (KMO) coefficient was and Bartlett's test results (x 2 = ; df=3081, pb0.001). This demonstrates that factor analysis was an appropriate approach for this study (Field, 2009). To understand the underlying dimensions of the ACS and to ascertain its construct validity, exploratory factor analysis was employed. Factor analysis is a statistical process that restructures the items within a scale into a smaller number of factors (DeVellis, 2003, 2006). DeVellis (2006) refers to this process as assessing the dimensionality of the scale. This means the scale and subscales are assessed to determine whether the items are measuring the same thing or a number of different things. Exploratory factor analysis was used as this was the first testing of the ACS (DeVellis, 2006). Exploratory Factor Analysis Safety and Security The correlation matrix for the 11 item Safety and security subscale had no high correlations. Using exploratory factor analysis three factors with eigenvalues greater than one were extracted. Each of the three factors extracted accounted for 67.3% of the variance within this subscale. The rotated component matrix confirmed the extraction of three factors. Most items loaded strongly on just one factor; however, the item I witnessed workplace bullying during the placement (SS11) loaded equally on two factors. Consequently, this item was removed prior to further analysis. The scree plot confirmed the extraction of the three factors. Exploratory Factor Analysis Belongingness The correlation matrix of the 22 item Belongingness subscale confirmed that items B15 and B16 correlated too highly, subsequently B15 was removed. The exploratory factor analysis showed the three factors accounted for 62% of the variance. The rotated component matrix showed six items cross loading among factors which were removed at this stage, these included: B11, B12, B13, B16 and B19. The scree plot confirmed the extraction of three factors. Exploratory Factor Analysis Self-concept The correlation matrix of the 12 item Self-concept subscale showed no items with high correlations. The exploratory factor analysis identified two factors with eigenvalues greater than one and a total variance of 67%. The rotated component matrix also demonstrated the extraction of two factors; and two items cross load significantly and were removed: SC9 and SC10. The scree plot confirmed the extraction of two factors. Exploratory Factor Analysis Learning The correlation matrix of the 22 item Learning subscale showed four pairs of items with high correlations (L1:L14; L5;L12; L12:L14; L17:L18). Three of these items were removed: L12, L14 and L17. The exploratory factor analysis of the learning subscale showed that four factors accounted for a total of 69% of the variance. The rotated component matrix had four factors. The scree plot confirmed that four factors should be extracted. Six items cross loaded and were removed: L10, L11, L15, L18, L19 and L21.

6 20 M.A. McCoy et al. / Nurse Education Today 33 (2013) Exploratory Factor Analysis Competence The correlation matrix of the 10 item Competence subscale identified two pairs of highly correlated items; however, both pairs include the item I am a more confident nurse as a consequence of the placement (C4) so this item was removed. The exploratory factor analysis of the Competence subscale extracted only one factor which explained 63% of the variance. As only one factor was extracted it was not possible for a rotated component matrix to be produced. The unrotated component matrix shows all the items loading well on the one factor. The scree plot confirmed a single factor for extraction. Exploratory Factor Analysis Ascent to Competence Scale Following exploratory factor analysis of the subscales 55 items were retained and subjected to factor analysis as one scale. This process identified 10 factors with eigenvalues greater than one accounting for 76% of the variance (refer to Table 3). However, from factor four onwards there was significant cross loading between items on a number of factors. Examination of the scree plot suggested that only three of the 10 factors should be extracted. Nineteen items were identified as being potentially removed from the questionnaire: SS8, SS9, SS10, SS11, SS13, B6, B7, B14, B17, B20, SC2, SC6, SC7, SC12, L7, L8, L16, C5 and C9. The final ACS had three factors with 36 items. In respect to the key themes evidence in the three factors they were subsequently named: Being welcomed; Belongingness; and Learning and Competence. The Cronbach's alpha for the 36-item ACS was (very good). The Cronbach's alpha of each of the subscales was also calculated (refer to Table 4). Table 3 Rotated component matrix Ascent to Competence Scale. Component My mentor(s) willingly answered my questions.804 The nursing staff were receptive to my questions.710 I developed a good working relationship with my mentor(s).687 I felt that my mentor trusted me with patient care responsibilities Nursing staff were supportive of my learning My mentor(s) challenged me to extend my skills.651 My mentor(s) thanked me for my help at the end of each shift.649 Nursing staff willingly took the time to teach me during the placement.626 I felt like part of the team during the placement.615 I felt like I fitted in with others during the placement.592 I felt a sense of connectedness with nursing staff during the placement I was not supported to extend my learning My mentor thought that I was competent I felt included in ward activities I felt that the nursing staff recognized my contribution to the work of the team I felt like an important member of the nursing team I am more able to integrate theory and practice as a result of the placement.761 During the placement I was able to improve my time management skills.760 The placement helped me prepare to work as an RN.740 I believe that I have the makings of a competent beginning RN as a result of the placement.719 I was provided with many opportunities to practice my clinical skills.661 The placement experience enabled me to reach my full potential I felt more capable at the end of my placement.653 I achieved my learning objectives I was encouraged to learn new skills During the placement I felt confident enough to work in an increasingly independent way The nurse unit manager made me feel welcome when I commenced the placement.850 The nurse unit manager helped me to fit into the placement environment.759 I was introduced to the nursing staff in the ward/unit when I commenced the placement.703 The nursing staff made me feel welcome when I commenced the placement.617 I was ignored by nursing staff when I started the placement.564 My mentor explained the ward routine to me when I commenced the placement I made a valuable contribution to patient care I was provided with opportunities to work with increasing levels of independence I was provided with patient care responsibilities that matched my knowledge and skills I actively involved myself in patient care activities.434 I was worried about making mistakes during the placement.802 I felt anxious during the placement.762 During the placement I spent a lot of time worrying about what the staff thought of my performance.754 I made the most of all learning opportunities.800 I felt empowered to negotiate my own learning opportunities provided.619 As a result of the placement I am more committed to patient-centered care.613 I did not feel confident enough to make the most of learning opportunities provided I did not feel competent following placement.579 I felt that conformity was essential to fitting in during the placement.763 I felt inferior to the nursing staff.522 I felt like I was just an extra pair of hands during placement.479 I felt like an outsider During the placement there were times when I felt frightened.837 During the placement there were times that I did not feel physically safe.800 I felt discriminated against by nursing staff during the placement.828 Extraction method: principal component analysis. Rotation method: Varimax with Kaiser normalization. a. Rotation converged in 11 iterations.

7 M.A. McCoy et al. / Nurse Education Today 33 (2013) Table 4 Cronbach's alpha Revised Ascent to Competence Scale. Number of items Cronbach's alpha (α) The Ascent to Competence Scale Subscales Being welcomed Belongingness Learning and competence Discussion The current study extends Levett-Jones's previous research by developing and testing the ACS. The underlying constructs that comprise this scale emerged from Levett-Jones (2005) work but were reexamined with respect to the current literature. The scale, its structure and each of the items were also reviewed by an expert panel review. The psychometric testing in this study resulted in a 36-item ACS. The final scale contains three subscales that, although not entirely consistent with Levett-Jones and Lathlean's Ascent to Competence conceptual framework, do nonetheless reflect the core concepts within the framework. The first subscale Being welcomed highlights the importance of the nurse unit manager in welcoming and supporting students as they commence their clinical placement. This is supported by Andrews, Brodie, Andrews et al. (2005) whose research also acknowledged the importance of the manager in helping students settle into the clinical environment. Other items in this subscale reflect the value students place on being introduced to nursing staff and the importance of their relationship with their mentor, the person who was seen to be most responsible for explaining the ward routine during the settling-in period. These results align with those of Elcock, Curtis and Sharples (2007), Levett-Jones, et al. (2009) and Myall, Levett- Jones and Lathlean (2008) who also reiterate the importance of mentors in helping students' settle into the clinical environment and find their place amid the complexity of contemporary practice. The second subscale Belongingness demonstrates that mentors and other nursing staff are essential to students' feelings of acceptance and inclusion by the nursing team. Levett-Jones, et al. (2009) suggests that student staff relationships are the key to a student's sense of belonging. Nursing students need to feel as if they fit in and are part of the team. Feeling connected to the nursing staff and being treated like part of the team is pivotal to belonging (Levett- Jones et al., 2007; Nolan, 1998). The third subscale, Learning and Competence, identifies the conditions that promote learning and the subsequent attainment of competence. This includes, for example, clinical teaching that allows students to bridge the theory practice gap and fulfill their potential as contributing members of the team. Chapman and Orb (2000) report that when the theory taught at university aligns with what students experience in the clinical environment anxiety is decreased and student learning increased. Bradbury-Jones, et al. (2007) reported that students who felt they had a legitimate place in the team had more productive learning experiences than those who did not. Newton, et al. (2009) also reinforced that mentors and nursing staff are pivotal to students' learning and need to actively create learning opportunities for students to ensure positive learning experiences. The combination of learning and competence together in one subscale suggests that these needs are interlinked. Levett-Jones and Lathlean (2009a) highlight that competence should not be viewed as an endpoint but that students should attain a novice level of competence prior to registration as a nurse and that clinical environments should be facilitative of this process. An important note of interest is that although self-concept was one of the levels in the Ascent to Competence framework it was not a strong feature of the revised 36-item ACS. This may because of item construction of the ACS. More items that focus on student selfconcept, self-esteem, self-efficacy, and confidence may prove worthy in future testing of the ACS. The primary purpose of this study was to develop and test the psychometric properties of the ACS. It is acknowledged that the sample size for the study was relatively small (n=88) which limits generalizability. The KMO coefficient for this study demonstrates that factor analysis was appropriate but also reflects the need for a larger sample size in future testing. However, the results of this study are still valid as demonstrated by Bartlett's test (Field, 2009). The key descriptive results from the survey are now discussed. The majority of participants in this study reported feelings of apprehension, uncertainty and anxiety at the commencement of their placements and were often worried about making mistakes. Timmins and Kaliszer (2002) found that clinical placements are a source of significant stress and anxiety for nursing students. The unfamiliar nature of the clinical environment and problematic staff student relationships are the two main stressors that contribute to this anxiety. In this study few participants reported feeling frightened or unsafe within the clinical environment. This result is surprising but somewhat encouraging that few students witnessed workplace bullying or were subjected to bullying themselves. However, this contrasts with previous research such as that of Hinchberger's (2009) which reported that all students (100%) witnessed or were subjected to workplace violence while on clinical placements. The findings from this study indicate that student staff relationships are central to belongingness. Levett-Jones et al. (2009) conveyed that students' sense of belonging and feeling like part of the team are pivotal before nursing students can shift their focus to learning. Levett-Jones et al. also assert that mentors have the greatest influence on students' sense of belonging. Participants in the current study reported a relatively a moderate to high degree of belongingness, felt that they fitted into the clinical environment, were connected to and supported by nursing staff, and a developed good working relationships with mentors. Participants identified a number of proactive strategies that they used to fit in, not all of positive behaviors. For example, a number of students conformed to the practice norms of the clinical environment and did not feel comfortable speaking up when they disagreed with the type of patient care provided. Levett-Jones and Lathlean (2009b) found that students' commitment to providing safe patient care was often subsumed within their need to belong; and they often followed the directions of their mentors without question in order to be accepted. Many students in the current study saw themselves as an extra pair of hands and viewed working hard as a way of gaining acceptance from staff. Bradbury-Jones, et al. (2007) and Elcock, et al. (2007) suggest that students who forsake their supernumerary status and allow themselves to become a part of the workforce often miss out on valuable learning experiences. Levett-Jones and Lathlean (2009b) also described how some students worked hard in an attempt to gain acceptance from the nursing staff. The participants believed that they made a valuable contribution to patient care and their responses indicated that, in general, they felt valued and appreciated by mentors and nursing staff; nevertheless most did not feel like an important member of the nursing team. Brodie, et al. (2005) described the importance that nursing students place on being valued and appreciated for their contribution to the work of the team and how this influenced their future employment decisions. Bjorkstrom, et al. (2008) found that when students felt valued for their contribution to practice their self-esteem increased. While most participants in the current study reported that nursing staff trusted them with patient care responsibilities they did not feel that they were provided with opportunities to work with increasing levels of independence. Bradbury-Jones et al. (2007)state that mentors were less inclined to allow students to

8 22 M.A. McCoy et al. / Nurse Education Today 33 (2013) work independently until they had first established the student's capabilities. However, Newton et al. (2009) found that students' confidence increases as they gain independence in practice. Participants' responses to the survey indicated that mentors and nursing staff were somewhat facilitative of their leaning and usually willing to answer questions. Levett-Jones and Lathlean (2008) found that students needed a sense of belongingness and a degree of confidence before they felt comfortable enough to ask questions. Hartigan- Rogers et al. (2007) also reported that supportive relationships are needed to ensure students are enabled to embrace learning opportunities. In the current study opportunities to practice clinical skills were not always provided and participants felt that they did not always achieve their clinical placement objectives. There were relatively low levels of agreement with statements related to staff (including nurse unit managers and mentors) being committed to students' professional development or challenging them to learn new skills. This is in contrast to Newton et al. (2009) who found that nursing staff were prepared to challenge and create learning opportunities for students to ensure that they experienced a range of practical skills. The participants' responses in the current study indicated that they made the most of the learning opportunities provided and often felt empowered to negotiate their own learning opportunities. Bradbury-Jones et al. (2007) specified that student empowerment is crucial to student self-directedness in seeking out learning opportunities. Papp et al. (2003) found that students who were supported by mentors had greater access to learning opportunities and were able to meet their learning objectives. Most participants did not feel that their placement experience enabled them to reach their full potential. Interestingly while most participants felt that their mentors thought they were competent by the end of the placement, they reported relatively low levels of selfconfidence and competence, and did not feel they had the making of a competent RN. Similar results were evident in regards to the ability to integrate theory and practice. Chapman and Orb (2000) found that when students could bridge the theory practice gap they had better clinical placement outcomes, for example, increased learning and acquisition of competence. In a study by Lauder et al. (2008) students had high levels of self-reported competence; however, this perception was not commensurate with their actual level of competence when measured objectively. It is important to note that most participants were more committed to patient-centered care as a result of the placement. Papp et al. (2003) also reported that students directly involved patient-centered care had a better quality clinical placement and were more capable as a result of the placement. Limitations The main limitations of this study included the small sample size, the localized nature of the study and that most of the participants were Australian females. An additional limitation is that survey data were based on self-report. Responses obtained in this manner may be subject to social desirability that may bias answers toward more acceptable norms. However, it was anticipated that the anonymity provided by online submission of questionnaires would improve the likelihood of participants responding candidly to the survey. Recommendations for Future Research This study indicated that the quality of nursing students' clinical placements is an important and measurable construct. As scale development is an iterative process replication studies with larger cohorts and in other contexts are needed. While in this study participant demographics were used only to describe the sample, further studies incorporating a larger sample size and confirmatory factor analysis would benefit from examining the relationships between participant demographics and ACS results. Conclusion The ultimate goal of clinical education is the development of nurses who are confident and competent beginning practitioners. A positive and productive clinical placement experience is pivotal to their success (Levett-Jones and Bourgeois, 2011). However, the challenge for those with a vested interested in students' clinical learning experiences is determining the factors conducive to learning and measuring the extent to which clinical contexts are facilitative of learning. In 2009, commenting on Levett-Jones and Lathlean's Ascent to Competence Conceptual Framework, Watson (2009) stated that The beauty of hierarchical models is that they are testable what would be required would be the development of an appropriate set of questions related to the pyramid of competence. Following on from Watson's suggestion the study profiled in this paper developed and psychometrically tested an instrument based upon Levett-Jones and Lathlean's Framework. The ACS quantifies the perceptions of nursing students in regards to the conditions that impact upon their learning and attainment of competence. The ACS is different from other scales in that it is holistic and encompasses the clinical placement experience in its entirety. This scale has proven to be both reliable and valid. Further use of the ACS in different contexts would be valuable in extending upon this work and in providing further evidence of its psychometric integrity. The author(s) declare that they have no conflict of interests. Acknowledgments The authors wish to acknowledge the advice received from Patrick McElduff (Senior Statistician, The University of Newcastle). References Andrew, N., McGuinness, C., Reid, G., Corcoran, T., Greater than the sum of its parts: transition into the first year of undergraduate nursing. Nurse Education in Practice 9 (1), Andrews, G.J., Brodie, D.A., Andrews, J.P., Wong, J., Thomas, B.G., Place(ment) matters: students' clinical experiences and their preferences for first employers. International Nursing Review 52, Australian, Nursing, Midwifery, Council, National Competency Standards for the Registered Nurse. (Retrieved April 28, 2009, from) userfiles/file/competency_standards/competency_standards_rn.pdf. Beskine, D., Mentoring students: establishing effective working relationships. Nursing Standard 23 (30), Bjorkstrom, M.E., Athlin, E.E., Johansson, I.S., Nurses' development of professional self from being a nursing student in a baccalaureate programme to an experiences nurse. Journal of Clinical Nursing 17, Bradbury-Jones, C., Sambrook, S., Irvine, F., The meaning of empowerment for nursing students: a critical incident study. Journal of Advanced Nursing 59 (4), Brodie, D.A., Andrews, G.J., Andrews, J.P., Thomas, B.G., Wong, J., Rixon, L., Working in London hospitals: perceptions of place in nursing students' employment considerations. Social Science & Medicine 61, Chan, D., Development of the clinical learning environment inventory: using the theoretical framework of learning environment studies to assess nursing students' perceptions of the hospital as a learning environment. The Journal of Nursing Education 41 (2), Chapman, R., Orb, A., The nursing students' lived experience of clinical practice. The Australian Electronic Journal of Nursing Education 5 (2) (electronic version). Chesser-Smyth, P.A., The lived experiences of general student nurses on their first clinical placement: a phenomenological study. Nurse Education in Practice 5, Curtis, J., Bowen, I., Reid, A., You have no credibility here: nursing students' experiences of horizontal violence. Nurse Education in Practice 7, devaus, D., Structured questionnaires and interviews. In: Minichello, V., Sullivan, G., Greenwood, K., Axford, R. (Eds.), Research Methods for Nursing and Health Science. Pearson, Frenchs Forest. DeVellis, R.F., Scale Development: Theory and Applications. Sage Publications, Thousand Oaks. DeVellis, R.F., Classical test theory. Medical Care 44 (11), S50 S59. Dunn, S.V., Hansford, B., Undergraduate nursing perceptions of their clinical learning environment. Journal of Advanced Nursing 25, Edgecombe, K., Bowden, M., The ongoing search for the best practice in clinical teaching and learning: a model of nursing students' evolution to proficient novice registered nurses. Nurse Education in Practice 9,