Mpho N. MotsaanakapersName, Agnes MakhenepersName, Gugu NdawopersName (2022date). “Clinical learning opportunity in public academic hospitals: A concept analysis..” Health SA Gesondheidtitle·j.
Object of study — clinical learning opportunities for student nursesterm·key
Research question — what clinical learning opportunityterm·dom means, and what precedes and follows it
Contribution — a theoretical and operational definition of clinical learning opportunityterm·dom, with its defining attributes and empirical referentsterm·mth
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | student nurses receiving too few clinical learning opportunities — “The student nurses were not provided with sufficient CLOs and practical experiences to meet their clinical learning goals” | |
| claim-type | existence — “The defining attributes of CLO were identified, namely the context, antecedents, processes, consequences and outcomes” | |
| method — evidence | — “The eight steps of concept analysis by Walker and Avant were followed” | |
| object of study — evidence | — “The aim of the study was to explore and describe the conceptual meaning of CLO, have a clear understanding and insight into the concept and identify the antecedents and consequences for pragmatic purposes” | |
| research question — evidence | — “Concept analysis aimed to clarify the conceptual meaning of clinical learning opportunities within the context of the study, have a clear understanding and insight into the concept and identify the antecedents and consequences for pragmatic purposes in the clinical settings” | |
| contribution — evidence | — “A theoretical and operational definition of CLO was developed. The findings and results of concept analysis identified and specified the defining attributes of clinical learning opportunity” | |
| mechanism | overcrowding Too many students in one hospital leave each with too few learning opportunities, hurting skills and growth. — “The overcrowding leads to inadequate CLOs for the student nurses, with the resultant inability to integrate theory to practice, poor development of critical skills and clinical competencies, and a lack of professional growth” | mechanisms[0] |
| mechanism | clinical placement Suitable placement fosters interprofessional collaborative learning and varied learning opportunities. — “The appropriate clinical placement of student nurses fostered interprofessional collaborative learning, exposing them to diverse learning opportunities within the clinical practice environment” | mechanisms[1] |
| builds-on | Walker and Avant (2019), eight-step concept analysis — “The concept of clinical learning opportunity was analysed using the eight steps of concept analysis by Walker and Avant” | claim_relations[0] |
| sense | clinical learning opportunities (Musafiri and Daniels) - ways of engaging students in real-life clinical activities — “Musafiri and Daniels ( 2020 ) report that clinical learning opportunities (CLOs) are approaches for student nurses engaged in real-life clinical activities for meaningful experiences” | senses[0] |
| sense | novice to expert (Benner) - proficiency that grows over time through experiential learning — “The transition of student nurses’ proficiency from novice to expert develops over time from various forms of experiential learning and knowledge acquisition with an improved holistic understanding of the patient” | senses[1] |
| relation | HOTS —same-as→ higher-order thinking skills — Its ambiguous nature leads to uncertainties and poor development of the required clinical attributes of successful theory to practice integration, higher-order thinking skills (HOTS) — “Its ambiguous nature leads to uncertainties and poor development of the required clinical attributes of successful theory to practice integration, higher-order thinking skills (HOTS)” | concept_edges[0] |
| weight | HOTS —same-as→ higher-order thinking skills — 0.9 — “Its ambiguous nature leads to uncertainties and poor development of the required clinical attributes of successful theory to practice integration, higher-order thinking skills (HOTS)” | concept_edges[0] |
| relation | clinical learning opportunity —distinct-from→ theoretical studies — The clinical learning opportunity is not experimentation, laboratory, or theoretical studies and does not include assigning the students to patient care unaccompanied — “The clinical learning opportunity is not experimentation, laboratory, or theoretical studies and does not include assigning the students to patient care unaccompanied” | concept_edges[1] |
| weight | clinical learning opportunity —distinct-from→ theoretical studies — 0.75 — “The clinical learning opportunity is not experimentation, laboratory, or theoretical studies and does not include assigning the students to patient care unaccompanied” | concept_edges[1] |
| effect direction | problem-based learning —causes→ critical thinking skills — increases — “Engagement and active participation of student nurses in problem-based learning activities stimulate their critical thinking skills and enhance their ability to apply theory to practice” — “Engagement and active participation of student nurses in problem-based learning activities stimulate their critical thinking skills” | concept_edges[2] |
| relation | problem-based learning —causes→ critical thinking skills — Engagement and active participation of student nurses in problem-based learning activities stimulate their critical thinking skills and enhance their ability to apply theory to practice — “Engagement and active participation of student nurses in problem-based learning activities stimulate their critical thinking skills and enhance their ability to apply theory to practice” | concept_edges[2] |
| weight | problem-based learning —causes→ critical thinking skills — 0.65 — “Engagement and active participation of student nurses in problem-based learning activities stimulate their critical thinking skills and enhance their ability to apply theory to practice” | concept_edges[2] |
| relation | poor clinical judgement —causes→ adverse clinical events — Poor clinical judgement abilities result in more than half of adverse clinical events, delivery of poor and unsafe clinical practices and substandard patient care — “Poor clinical judgement abilities result in more than half of adverse clinical events, delivery of poor and unsafe clinical practices and substandard patient care” | concept_edges[3] |
| weight | poor clinical judgement —causes→ adverse clinical events — 0.6 — “Poor clinical judgement abilities result in more than half of adverse clinical events, delivery of poor and unsafe clinical practices and substandard patient care” | concept_edges[3] |
| replication | not-applicable | |
| limitation | Only a contrary case was built; borderline, related and invented cases were not. — “As a modification to Walker and Avant’s ( 2019 ) process of concept analysis, the additional cases of the borderline, related, invented and illegitimate cases were not constructed as the model case provided a clear understanding of the concept (Bourne, Smeltzer & Kelly 2021 ). In this study, only a contrary case was formulated” | limitations[0] |
| limitation | The study was set in a single public academic hospital. — “The study took place in a public academic hospital in Gauteng” | limitations[1] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | Saturation came after 117 articles, which with 15 dictionary definitions gave 132 items for analysis. — “The 117 articles were added to the 15 definitions of the concept from online dictionaries, encyclopaedias and thesauruses, resulting in the final list of 132 definitions, characteristics, nature and uses of clinical learning opportunities for review and critical analysis” | content_tags.findings[0] |
| quantity | 363 000; 17 800; 1612 — — “From the 363 000 articles retrieved, 345 200 were not full-text articles; thus these were excluded, and 17 800 full-text articles remained for inclusion. Further, 16 188 articles were excluded as they had data already reported in other included articles, and 1612 full-text articles remained for inclusion” | content_tags.quantities[0] |
| quantity | 30 — — “The process of content analysis assisted in the compilation and creation of 30 meaningful statements from the available literature to provide new insight and understanding of the concept” | content_tags.quantities[1] |
| key-terms | clinical learning opportunity, student nurses, concept analysis, clinical competency, critical thinking, holistic patient care |
| concept | clinical learning opportunity — The clinical learning opportunity is an occasion that occurs in dynamic, multidimensional, real-life healthcare settings that requires planning of clinical placement, provision of clinical learning outcomes and consideration of the cognitive level of students — “The clinical learning opportunity is an occasion that occurs in dynamic, multidimensional, real-life healthcare settings that requires planning of clinical placement, provision of clinical learning outcomes and consideration of the cognitive level of students” | concepts[0] |
| concept | CLO — not defined in this paper's own words; clinical learning opportunity — “Clinical learning opportunities (CLO) are vital educational encounters occurring in various clinical areas to provide the student nurses with clinical knowledge and experiences to develop their competencies for professional practice” | concepts[1] |
| concept | higher-order thinking skills — not defined in this paper's own words; the reasoning and judgement students need for complex clinical problems — “Its ambiguous nature leads to uncertainties and poor development of the required clinical attributes of successful theory to practice integration, higher-order thinking skills (HOTS)” | concepts[2] |
| concept | HOTS — not defined in this paper's own words; higher-order thinking skills — “Its ambiguous nature leads to uncertainties and poor development of the required clinical attributes of successful theory to practice integration, higher-order thinking skills (HOTS)” | concepts[3] |
| concept | clinical placement — a strategic arrangement where student nurses would be allocated in a conducive and dynamic clinical setting practice environment that supports and enhances a positive interaction with learning experiences — “Planning clinical placement is a strategic arrangement where student nurses would be allocated in a conducive and dynamic clinical setting practice environment that supports and enhances a positive interaction with learning experiences” | concepts[4] |
| concept | collaborative learning — an innovative, instructional small group learning approach in which students are required or encouraged to work together to enhance learning and achieve common learning goals — “Collaborative learning is an innovative, instructional small group learning approach in which students are required or encouraged to work together to enhance learning and achieve common learning goals” | concepts[5] |
| concept | problem-based learning — not defined in this paper's own words; learning built around real-life health problems, led by the students rather than by lectures — “Engagement and active participation of student nurses in problem-based learning activities stimulate their critical thinking skills and enhance their ability to apply theory to practice” | concepts[6] |
| concept | critical thinking skills — Critical thinking skills are essential elements for student nurses, acquired during real-life experiences in a complex learning environment — “Critical thinking skills are essential elements for student nurses, acquired during real-life experiences in a complex learning environment” | concepts[7] |
| concept | holistic care — a comprehensive patient care model based on nurturing the wholeness and respect of patients’ uniqueness to physical, mental, emotional and environmental strengths and challenges, valuing their beliefs and health experiences — “Holistic care is a comprehensive patient care model based on nurturing the wholeness and respect of patients’ uniqueness to physical, mental, emotional and environmental strengths and challenges, valuing their beliefs and health experiences” | concepts[8] |
| concept | clinical judgement — It is related to critical thinking and clinical reasoning employed by healthcare professionals to conclude observations, analyse data and weigh evidence to make informed clinical decisions to improve patient care — “Clinical judgement is one of the vital attributes of professional practice. It is related to critical thinking and clinical reasoning employed by healthcare professionals to conclude observations, analyse data and weigh evidence to make informed clinical decisions to improve patient care” | concepts[9] |
| concept | poor clinical judgement — not defined in this paper's own words; weak clinical judgement, linked to unsafe practice and substandard care — “Poor clinical judgement abilities result in more than half of adverse clinical events, delivery of poor and unsafe clinical practices and substandard patient care” | concepts[10] |
| concept | adverse clinical events — not defined in this paper's own words; harmful events in patient care — “Poor clinical judgement abilities result in more than half of adverse clinical events, delivery of poor and unsafe clinical practices and substandard patient care” | concepts[11] |
| concept | theoretical studies — not defined in this paper's own words; classroom or laboratory study, named as what clinical learning is not — “The clinical learning opportunity is not experimentation, laboratory, or theoretical studies and does not include assigning the students to patient care unaccompanied” | concepts[12] |
| concept | data saturation — when other sources provided no added information, and a sense of closure is imminent — “Data saturation is when other sources provided no added information, and a sense of closure is imminent” | concepts[13] |
| concept | antecedents — events that precede the occurrence of the concept — “Antecedents are events that precede the occurrence of the concept” | concepts[14] |
| concept | consequences — the results of the occurrence of the concept — “Consequences are the results of the occurrence of the concept” | concepts[15] |
| concept | empirical referents — classifications or categories; their presence determines the existence of the concept — “Empirical referents are classifications or categories; their presence determines the existence of the concept” | concepts[16] |
| concept | contrary case — the direct opposite of a model case, which indicated a clear example of what the concept was not and thus lacked all the defining attributes — “A contrary case is the direct opposite of a model case, which indicated a clear example of what the concept was not and thus lacked all the defining attributes” | concepts[17] |
| concept | conceptual mapping — a graphic presentation that signifies and depicts the relationships between concepts and ideas — “Conceptual mapping is a graphic presentation that signifies and depicts the relationships between concepts and ideas” | concepts[18] |
| concept | theoretical validity — the extent to which a concept is described and interpreted accurately — “Theoretical validity is the extent to which a concept is described and interpreted accurately” | concepts[19] |
Full text — tagged
Clinical learning opportunityterm·dom in public academic hospitals: A concept analysisterm·key.
Abstract Clinical learning opportunities (CLOterm·dom) are vital educational encounters occurring in various clinical areas to provide the student nursesterm·key with clinical knowledge and experiences to develop their competencies for professional practice. However, CLOterm·dom is a broad concept with varied characteristics that allow ambiguity, limiting its understanding and use. Its ambiguous nature leads to uncertainties and poor development of the required clinical attributes of successful theory to practice integration, higher-order thinking skillsterm·dom (HOTSterm·dom) and clinical competencies.
The aim of the study was to explore and describe the conceptual meaning of CLOterm·dom, have a clear understanding and insight into the concept and identify the antecedentsterm·mth and consequencesterm·mth for pragmatic purposes.
The study took place in a public academic hospital in Gauteng.
The eight steps of concept analysisterm·key by Walker and Avant were followed. Multiple data sources not limited to nursing were explored and critically analysed for the definitions, characteristics, nature and uses of CLOterm·dom from different fields of study.
The defining attributes of CLOterm·dom were identified, namely the context, antecedentsterm·mth, processes, consequencesterm·mth and outcomes. The context within which CLOterm·dom occurs was dynamic, multidimensional, real-life healthcare settings; antecedentsterm·mth included planning of clinical placementterm·dom, provision of learning outcomes and consideration of the cognitive level of the students. Engagement and active participation in collaborative, problem-based learningterm·dom activities, community-based research and the use of emerging technologies were the processes identified. The outcomes were autonomous, confident, competent professional nurses with critical thinkingterm·key, clinical reasoning, judgement, critical decision making and problem-solving skills.
A theoretical and operational definition of CLOterm·dom was developed. The findings and results of concept analysisterm·key identified and specified the defining attributes of clinical learning opportunityterm·dom. The findings can assist nurse educators, Clinical Education and Teaching Unit (CETU) personnel and operational managers to enhance CLOterm·dom for student nursesterm·key to achieve their clinical learning goals and outcomes. The evaluation tools that may be adopted to assess the acquired clinical skills were also identified.
An increase in the existing body of knowledge in nursing education, considering that enhancing the CLOterm·dom exposes students to various clinical experiences contributing to their development of clinical competencies to solve complex problems. The strategies to enhance the CLOterm·dom will be developed, which may also provide vital information for policy development. Conceptualisation of the findings to nursing practice and quality patient care will be integrated into relevant literature.
Keywords: concept analysisterm·key, clinical learning opportunityterm·dom, defining attributes, antecedentsterm·mth, consequencesterm·mth, student nursesterm·key Introduction Nursing is a practice-based profession that requires adequate clinical learning and positive practical experiences to prepare the student nursesterm·key for their professional roles. Musafiri and Daniels ( 2020 ) report that clinical learning opportunities (CLOsterm·dom) are approaches for student nursesterm·key engaged in real-life clinical activities for meaningful experiences. Salifu, Heymans and Christmals ( 2022 ) added that the clinical placementterm·dom of student nursesterm·key is vital because it provides them with adequate exposure and CLOsterm·dom in real-life practice settings, as well as motivation to achieve their clinical learning outcomes. However, there is overcrowding of students in the public academic hospital under study, caused by the placement of students from different nursing education institutions as well as students from other health disciplines (MotsaanakapersName, MakhenepersName & Ally 2020 ). The overcrowding leads to inadequate CLOsterm·dom for the student nursesterm·key, with the resultant inability to integrate theory to practice, poor development of critical skills and clinical competencies, and a lack of professional growth (Mbakaya et al. 2020 ). Furthermore, student nursesterm·key became despondent and demotivated, leading to frustration, increased absenteeism and prolonged length of study due to inadequate CLOsterm·dom (Berhe & Gebretensaye 2021 ; MotsaanakapersName et al. 2020 ). Exposure to real-life practice settings, experiences and clinical activities provides opportunities that will facilitate clinical learning to bridge the gap between theory and practice and prepare the student nursesterm·key to develop the qualifications of a clinically competent, independent, professional nurse practitioner (Taylor et al. 2021 ; Zulu, Du Plessis & Koen 2021 ). MotsaanakapersName et al. ( 2020 ) also report that clinical exposure to learning opportunities will develop the student nursesterm·key’ clinical competencies in higher-order thinking skillsterm·dom (HOTSterm·dom). They will also help them with clinical preparedness as they undergo role transition into the nursing profession. It is also a learning period where student nursesterm·key demonstrate applied competency in integrating foundational, practical and reflexive competencies in real-life healthcare settings, as stipulated by the South African Qualifications Act (No. 58 of 1995) (Republic of South Africa [RSA] 1995 ). Mothiba, Bopape and Mbombi ( 2020 ) suggest that nursing education institutions need to design and implement clinical learning activities that will provide the student nursesterm·key with opportunities to develop the required professional skills and clinical competence. The student nursesterm·key will have confidence in their ability to provide and achieve quality health care for the patients (Al-Harahsheh et al. 2020 ) Implementing CLOsterm·dom and activities will also improve the quality of clinical education for the student nursesterm·key and prepare them to practise in the 21st century (Modarres et al. 2021 ).
Despite the critical discussions on the importance and various applications of CLOsterm·dom in literature, there is a lack of clarity in its definition and understanding as a concept (Stoffels et al. 2021 ; Walker & Avant 2019 ). A lack of clear definition and misunderstanding of the concept created challenges for nursing educators, clinical education and training unit (CETU) personnel, and operational managers in providing student nursesterm·key with adequate exposure to clinical teaching, learning and positive practical experiences (Taylor et al. 2021 ). The ambiguous and abstract nature of the concept of CLOsterm·dom was defined and clarified to capture its contextual intricacies and to help improve the global standards of professional clinical education in the practice-based profession (Baker, Cary & Bento 2021 ; Shaterjalali et al. 2018 ; WHO 2020 ).
Research method and design The concept of clinical learning opportunityterm·dom was analysed using the eight steps of concept analysisterm·key by Walker and Avant ( 2019 ). Extensive literature and multiple data sources, not limited to nursing, were consulted to explore and critically analyse the definitions, characteristics, nature and uses of clinical learning opportunities from different fields of study. Online dictionaries, encyclopaedias and thesauruses, as well as databases of Cumulative Index of Nursing and Allied Health Literature (CINAHL), Elton B. Stephens Company (EBSCOhost), PubMed Central (PMC), ScienceDirect and other online sources were searched to analyse and capture the meanings of the concept. The Google Scholar search engine was also consulted for relevant and related articles on the concept. Data saturationterm·mth was reached after a total sample of 132 definitions, characteristics, nature and uses for critical analysis. Walker and Avant’s eight steps of concept analysisterm·key followed were (1) selecting a concept, (2) determining the aims of concept analysisterm·key, (3) identifying all uses of the concept, (4) determining the defining attributes, (5) identifying antecedentsterm·mth and consequencesterm·mth, (6) defining empirical referentsterm·mth, (7) identifying a model case and (8) additional cases.
Step 1: Select a concept When selecting the concept, the researcher began by identifying the nature of the problem to be addressed by the study (Rodgers, Jacelon & Kanafl 2018 ). The problem that drove the research study was the ambiguous and unclear meaning of clinical learning opportunityterm·dom that created challenges and uncertainties for nurse educators, CETU personnel and operational managers in the clinical areas. The student nursesterm·key were not provided with sufficient CLOsterm·dom and practical experiences to meet their clinical learning goals (Mothiba et al. 2020 ; MotsaanakapersName et al. 2020 ; Taylor et al. 2021 ). The uncertainties and challenges led to the poor professional development of the student nursesterm·key (Berhe & Gebretensaye 2021 ). The inadequate operational understanding and uncertainties of clinical learning opportunityterm·dom directed the focus of the study for concept analysisterm·key and to address the research problem.
Step 2: Determine the aims of concept analysisterm·key Concept analysisterm·key aimed to clarify the conceptual meaning of clinical learning opportunities within the context of the study, have a clear understanding and insight into the concept and identify the antecedentsterm·mth and consequencesterm·mth for pragmatic purposes in the clinical settings (Walker & Avant 2019 ).
Step 3: Identify the uses of the concept (sample and sampling method) Extensive literature and multiple data sources (not limited to nursing) were consulted to explore and critically analyse the definitions, characteristics, nature and uses of clinical learning opportunities from different fields of study. The aim was not to limit the literature search but to avoid a biased understanding of the true nature and meaning of the concept (Walker & Avant 2019 ). The keywords used to explore the definitions of the concept were derived from the selected concept of ‘clinical learning opportunityterm·dom’, which were ‘clinical’, ‘learning’ and ‘opportunity’. Online dictionaries, encyclopaedias and thesauruses were explored, as these sources do not describe clinical learning opportunityterm·dom as a whole concept, and 15 definitions of the keywords were identified. The researcher continued to explore the databases of CINAHL, EBSCOhost, PMC, ScienceDirect, and other online sources using the keyword ‘clinical learning opportunityterm·dom’ for critical analysis and capturing the meaning of the selected concept. A total number of 363 000 articles were found eligible for the definitions, characteristics, nature and uses of clinical learning opportunityterm·dom. The resulting literature was initially searched and screened by reviewing titles and abstracts for relevance. The aim was to capture all the related meanings of the concept and increase the validity of the results. Literature searched was not limited to the years of publication.
From the 363 000 articles retrieved, 345 200 were not full-text articles; thus these were excluded, and 17 800 full-text articles remained for inclusion. Further, 16 188 articles were excluded as they had data already reported in other included articles, and 1612 full-text articles remained for inclusion. The redundancy of exploring the data sources occurred when the researcher had read 117 articles and reached data saturationterm·mth. These articles were managed and authenticated via the Mendeley reference manager system. Data saturationterm·mth is when other sources provided no added information, and a sense of closure is imminent (Polit & Beck 2019 ). The 117 articles were added to the 15 definitions of the concept from online dictionaries, encyclopaedias and thesauruses, resulting in the final list of 132 definitions, characteristics, nature and uses of clinical learning opportunities for review and critical analysis.
Figure 1 is a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram adopted to show the steps of identification, screening, eligibility, inclusions and exclusions of the literature in the study. The aim was to map the existing literature in the field of interest in terms of the volume, nature and characteristics of the primary research. It also ensured rigorous, transparent and complete reporting of the literature reviewed (Zhang et al. 2019 ). The flow diagram summarises all the empirical evidence that addressed the processes embarked on for the search of definitions, characteristics, nature and uses of the concept, thus minimising biases.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.
Step 4: Determine the defining attributes (data collection method) Determining the defining attributes of a concept is regarded as fundamental to describing its characteristics, as they contribute to a clear and in-depth understanding of the concept (Walker & Avant 2019 ). A three-columned table was used to identify the defining attributes. The first column displayed all the definitions, characteristics, nature and uses of the concept from various data sources. The researcher then manually and repetitively browsed through each literature to identify and underline similar and contrary patterns and phrases that appeared repeatedly. Similar and contrary patterns related closely to each other were clustered and classified together to formulate new and meaningful statements of clinical learning opportunities (content analysis). The process of content analysis assisted in the compilation and creation of 30 meaningful statements from the available literature to provide new insight and understanding of the concept (Roller 2019 ; Walker & Avant 2019 ). The formulated statements were transposed, redefined and categorised into the defining attributes of the concept, namely the context, antecedentsterm·mth, process, consequencesterm·mth and outcomes of CLOterm·dom.
Step 5: Identify antecedentsterm·mth and consequencesterm·mth (data analysis) Antecedentsterm·mth are events that precede the occurrence of the concept (Walker & Avant 2019 ). Not revealing the antecedentsterm·mth could prevent the activity of clinical learning opportunityterm·dom from occurring. The antecedentsterm·mth that must be in place were identified as planning of clinical placementterm·dom, provision of clinical learning outcomes and consideration of the cognitive level of students. Consequencesterm·mth are the results of the occurrence of the concept (Walker & Avant 2019 ). The consequencesterm·mth of clinical learning opportunityterm·dom were the development of HOTSterm·dom and clinical competencyterm·key, integration of theory and practice, provision of holistic patient careterm·key and the transition from novice to expert healthcare practitioners. The description of the defining attributes is presented under the findings and discussion to provide the importance of each.
Step 6: Define the empirical referentsterm·mth (data analysis) Empirical referentsterm·mth are classifications or categories; their presence determines the existence of the concept (Walker & Avant 2019 ). The empirical referentsterm·mth of clinical learning opportunityterm·dom were recognised as higher-order skills such as critical thinkingterm·key, clinical reasoning, judgement, critical decision-making and problem-solving skills.
Various authentic assessment tools are available to measure and evaluate the empirical referentsterm·mth and to verify the occurrence of clinical learning opportunityterm·dom for the student nursesterm·key. The most common assessment tools explored, described and applied for all the identified empirical referentsterm·mth and within the context of the entire study are listed in Table 1 . The assessment tools can be adopted to evaluate the occurrence of the empirical referentsterm·mth of clinical learning opportunities for student nursesterm·key.
Empirical referentsterm·mth of clinical learning opportunityterm·dom and their assessment.
Step 7: Identify a model case The researcher formulated a practical model case ( Box 1 ) to demonstrate the use of all the identified defining attributes of clinical learning opportunityterm·dom within nursing education and clinical learning for better understanding (Walker & Avant 2019 ).
A model case.
Students from nursing, physiotherapy, pharmacy and medicine, as well as different educators and clinical experts from two countries, took part in interprofessional learning (IPL) and collaboration. The learning activities occurred in dynamic, multidimensional, real-life healthcare settings (context) . Relevant stakeholders engaged in discussions and decision-making on the detailed plan of IPL (planning of clinical placementterm·dom) . They held multiple virtual sessions to identify and clarify inter-related professional roles and discussed common clinical learning goals (provision of clinical learning outcomes) . In collaboration, they formulated two groups of second-year student nursesterm·key, second-year physiotherapy, final-year pharmacy and fourth-year medical students (students’ cognitive level) .
All students engaged and actively participated in various learning activities, which involved interactive, cooperative and collective efforts (c ollaborative activities) . They worked together on complex real-life health problems in the clinical area, searching for solutions to address the problem (problem-based learningterm·dom [PBL]) . Students also engaged with the community in scientific investigations to address their health and social issues (community-based research) . They used smartphones, electronic health records, health information networks and patients’ portals to impact learning and healthcare in the 21st century (emerging innovative technology) .
The students learned to apply the acquired theoretical knowledge with rationales to guide their actions in various real-life clinical situations (integration of theory and practice) . They displayed different levels of insight through creative, critical, reflective and innovative thinking capabilities to make decisions and solve complex health problems ( HOTSterm·dom ). Students demonstrated the integration of foundational, practical and reflexive skills (clinical competencyterm·key) . They delivered comprehensive care to the patients based on a mutual understanding of their physical, psychological, emotional and spiritual dimensions (provision of holistic patient careterm·key) . The students built a substantial scientific knowledge base, clinical expertise and experience to excel in their professional domains (transition from novice to expert) .
Students engaged in argumentation, dialogue and debate to analyse, make inferences and evaluate the data to reach in-depth understanding and insight (critical thinking skillsterm·dom) . They applied thinking strategies, knowledge and scientific evidence to deliberate, argue and justify their views and practices (clinical reasoning skills) . Students used their thought processes and clinical reasoning skills to prioritise decisions based on subjective and objective data (clinical judgementterm·dom) . They integrated the acquired knowledge with scientifically evidence-based practices to decide on relevant interventions to solve patients’ complex health problems (critical decision-making) . They performed analysis to identify and define the patients’ health problems, implement practical solutions and evaluate outcomes (problem-solving skills) .
They developed the authority to assess and provide quality patient care based on competence, professional expertise and knowledge consistent with professional standards (autonomous) . They can independently care for and collaborate with other healthcare team members to effectively prioritise and coordinate patients’ daily care activities (confident) . Students practised ethically and fulfilled their professional responsibility by integrating the knowledge, skills, values, beliefs and acquired experience to provide effective patient care to cope with various clinical situations (competent) .
Step 8: Identify additional cases As a modification to Walker and Avant’s ( 2019 ) process of concept analysisterm·key, the additional cases of the borderline, related, invented and illegitimate cases were not constructed as the model case provided a clear understanding of the concept (Bourne, Smeltzer & Kelly 2021 ). In this study, only a contrary caseterm·mth was formulated to fully articulate, clarify and make a better judgement about the concept within the context of this study. A contrary caseterm·mth is the direct opposite of a model case, which indicated a clear example of what the concept was not and thus lacked all the defining attributes (Walker & Avant 2019 ).
A contrary caseterm·mth The clinical learning opportunityterm·dom is not experimentation, laboratory, or theoretical studiesterm·dom and does not include assigning the students to patient care unaccompanied.
Ethical considerations As stipulated in the National Health Act (No. 61 of 2003) (Republic of South Africa, 2003 ), ethical approval was obtained from the Research Ethics Committee (REC) and Higher Degree Committee (HDC) of the University of Johannesburg (reference number: REC-01-149-2019). Permission from the National Health Research Database (NHRD) and the Department of Health and the Research Approval Committee (RAC) to conduct the study in the public academic hospital in Gauteng was also granted. This article is a concept analysisterm·key.
Discussion The defining attributes of clinical learning opportunityterm·dom discovered during the concept analysisterm·key were categorised as the context, antecedentsterm·mth, process, consequencesterm·mth and outcomes. Each defining attribute was explained, followed by the conceptual map and the theoretical definition of clinical learning opportunityterm·dom.
The context: Dynamic, multidimensional, real-life healthcare settings Student nursesterm·key need clinical experiences from various healthcare settings that offer opportunities for successful learning. Such a learning environment needs to be stimulating, self-motivating and supportive with a diverse range of healthcare professionals, real-life patients and a complex psychosocial setting rich in learning resources (Van Rossem et al. 2019 ). A context with an interactive network of forces, complexity and exposure increases their clinical opportunities for interprofessional learning (IPL) enhances challenging experiences and helps students to develop various higher-order skills (Van Diggele et al. 2020 ). Moreover, it develops clinical competencies and the best scientific practices to solve complex problems within varied clinical healthcare settings. According to Nair, Thomas and Prem ( 2020 ), learning in a dynamic environment with a complex real-life health problem can be adapted with creativity and innovation, providing and promoting learning opportunities for interprofessional interactions, with the development of critical thinkingterm·key, problem-solving and communication skills.
The antecedentterm·mth Planning of clinical placementterm·dom Planning clinical placementterm·dom is a strategic arrangement where student nursesterm·key would be allocated in a conducive and dynamic clinical setting practice environment that supports and enhances a positive interaction with learning experiences. Bøe and Debesay ( 2021 ) support the planning of clinical placementterm·dom of student nursesterm·key to provide a supportive environment that ensures authentic experiences, adequate exposure and practice opportunities to achieve varying levels of proficiencies and the ability to respond to complex health problems. The appropriate clinical placementterm·dom of student nursesterm·key fostered interprofessional collaborative learningterm·dom, exposing them to diverse learning opportunities within the clinical practice environment (Aggar et al. 2020 ). Furthermore, it assisted student nursesterm·key to develop the knowledge, clinical skills and attributes to prepare them to become safe, competent and independent healthcare professionals (Atakro et al. 2020).
Provision of clinical learning outcomes Providing clinical learning outcomes highlights clear and shared expectations between student nursesterm·key and clinical facilitators on professional abilities, skills and values that need to be achieved at the end of the student’s clinical learning experiences and practice (Hustad et al. 2019 ; Masilaca, Kumar & Balekiwai 2018 ). Clinical learning outcomes aligned with the qualification level registered on the National Qualifications Framework (NQF) ensured communication of course expectations to the student nursesterm·key in order to supply a seamless success and progression (SANC 2013 ). Providing clinical learning outcomes is beneficial to motivating students’ clinical learning associated with practice opportunities for a transparent, focused and successful pathway to achieving their goals.
Consideration of cognitive level of student nursesterm·key Consideration of the cognitive level of student nursesterm·key is vital as it promotes building upon and combining their prior knowledge with the latest information to process new understanding that will develop their critical thinkingterm·key, analysis and evaluation (Mi & Ok-Hee 2021 ; Nascimento et al. 2021 ). Taking into consideration their cognitive level can be used to support and apply constructive learning to know how best to assist and guide student nursesterm·key to develop intellectually and build their skills needed for effective learning. The more developed students are at higher-order skills, the better they are at learning and constructing new knowledge to apply in clinical practice. Upahi and Ramnarain ( 2020 ) highlighted the changing professional standards and health complexities that require nurse educators to create and provide student nursesterm·key with learning opportunities to develop higher-order cognitive skills through problem solving activities. Creative strategies and learning opportunities need to be tailored to students’ needs and progressively build their knowledge to perform the tasks in practice and further facilitate their progression from dependence to independence (Den Hertog & Boshuizen 2022 ).
The process Engagement and active participation in collaborative activities Collaborative learningterm·dom is an innovative, instructional small group learning approach in which students are required or encouraged to work together to enhance learning and achieve common learning goals (Markowski et al. 2021 ). Encouraging such activities will further allow shared information from different professional backgrounds, creating professional role clarity and an opportunity to cooperatively participate in constructing patient care plans to address their complex health needs (Chetty, Bangalee & Brysiewicz 2020 ; WHO 2020 ). Furthermore, students’ engagement and active participation in collaborative activities create an authentic learning experience that develops their understanding as they relate, synthesise, discuss, communicate and justify their ideas and thoughts within an IPL context (Chabeli, Nolte & NdawopersName 2021 ). Interprofessional collaborative activities can enhance the students’ learning opportunities. They will acquire the necessary knowledge and transferable skills to become global health professionals with critical thinkingterm·key, decision-making and problem-solving skills (Joseph 2018 ; Kim et al. 2019 ).
Engagement and active participation in problem-based learningterm·dom activities Engagement and active participation of student nursesterm·key in problem-based learningterm·dom activities stimulate their critical thinking skillsterm·dom and enhance their ability to apply theory to practice (Wosinskic et al. 2018 ). The student nursesterm·key will develop problem-solving, leadership and teamwork skills. Seibert ( 2021 ) added that students learn to construct their knowledge, become creative and analytical, applying reasoning and problem-solving skills with opportunities to implement practical solutions to improve patients’ health and well-being. Problem-based learningterm·dom activities aim to address complex health problems and challenges experienced and encountered in real-life situations, with a shift from a traditional teaching paradigm of teacher-directed and traditional lecture format to a learning paradigm of self-directed, interactive learning (Jensen, Srentoft & Ravn 2019 ).
Engagement and active participation in community-based research Ghasemi, Moonaghi, and Heydari ( 2020 ) and Jacobs ( 2020 ) support the engagement and active participation of student nursesterm·key in community-based research as it promotes the collaborative development of community health projects, solving various and complex health conditions and morbidities. Community-based research removes the various social, cultural and logistical barriers that confound the well-intentioned efforts of public healthcare services (Chabeli et al. 2021 ; Tremblay et al. 2018 ). The intention is to provide learning opportunities for student nursesterm·key to develop a deeper understanding of global health issues and promote access to primary care, disease prevention and health-promoting behaviours, sustainable scientific evidence-based health practices and professional maturity (Vera 2020 ).
Engagement and active participation in emerging innovative technologies Technology has transformed learning for student nursesterm·key into a more blended, interactive, and enhanced collaborative learningterm·dom opportunities (Howlett & Waemusa 2019 ; Wittmann-Price, Wilson & Gittings 2020 ). The understanding and use of emerging technology will allow them to serve on the front lines of applying the latest advancements in scientific evidence-based research, allowing communication with their colleagues in real time and helping their patients with increased efficiency and effectiveness (Broughel & Thierer 2019 ; Carroll 2020 ). The educational goal of using technology facilitates and promotes CLOterm·dom, improving clinical and psychomotor skills, especially on critical and rare skills.
Consequencesterm·mth Higher-order thinking skillsterm·dom and clinical competencyterm·key Developing and stimulating HOTSterm·dom and clinical competencyterm·key in student nursesterm·key is crucial to everyday practice, as they equip them with the required skills to respond to and solve varied and complex real-life health problems within dynamic healthcare settings (Boso, Van Der Merwe & Gross 2021 ; Fukada 2018 ). Factors such as effective clinical learning environment, clinical experience, learning opportunities, motivation and theoretical knowledge are among the most important factors affecting clinical competencyterm·key of nurses (Karami, Farokhzadian & Foroughameri 2017 ). Student nursesterm·key with HOTSterm·dom can make clinical judgementsterm·dom and critical decisions in providing quality patient care in a complex, dynamic healthcare environment with various challenges and demands.
Integration of theory and practice Student nursesterm·key need to learn and apply the theoretical framework into practice effectively and confidently to become competent healthcare professionals. Integrating theory and practice is vital as it shows student nursesterm·key’ ability to apply theoretical evidence to practice and make arguments and justifications for their clinical decisions that inform skill practices (Berndtsson, Dahlborg & Pennbrant 2020 ; Diery, Knogler & Seidel 2021 ). Younas and Quennell ( 2019 ) support nursing theory-guided practice as it assists to improve the quality of patient care, allowing students to articulate what they do for patients with clinical reasoning and judgement in applying evidence-based practice.
The provision of holistic patient careterm·key Holistic careterm·dom is a comprehensive patient care model based on nurturing the wholeness and respect of patients’ uniqueness to physical, mental, emotional and environmental strengths and challenges, valuing their beliefs and health experiences (Rasweswe et al. 2021 ). When student nursesterm·key are engaged in a holistic approach to patient care, it enables them to incorporate a comprehensive and interprofessional sustainability that increases health outcomes. It further reduces medical errors and increases one’s purpose as a competent and caring professional. The provision of holistic patient careterm·key further leads to professional growth and builds the self-confidence of student nursesterm·key.
The transition from novice to expert practitioners The transition of student nursesterm·key’ proficiency from novice to expert develops over time from various forms of experiential learning and knowledge acquisition with an improved holistic understanding of the patient (Benner 1982 ; Ozdemir 2019 ; Gonzalez, Nielsen & Lasater 2021 ). Experiential learning and adequate exposure to various CLOsterm·dom promote the students’ professional growth to make better clinical judgementsterm·dom and rational decisions, improving their practice over time to be confident in excellent patient care. Student nursesterm·key will practise competently, providing safe and quality patient care.
The outcomes Autonomous professional practitioner Student nursesterm·key begin exercising their professional autonomy as their knowledge and skills improve through clinical experiences and interactions within the interprofessional team approaches to quality care. To gain independence in professional practice, student nursesterm·key require adequate CLOsterm·dom to develop and improve their clinical competencies and have the expertise and authority to make decisions following their professional knowledge base (Hara, Asakura & Asakura 2020 ; Labrague, McEnroe-Petitte & Tsaras 2019 ; Rouhi-Balasi et al. 2020 ). Autonomous healthcare professionals are also competent in critical thinkingterm·key, with abilities to make discretionary decisions within their scope of practice and professional accountability for their actions and confidence (Oshodi et al. 2019 ).
Confident professional practitioner Student nursesterm·key gain professional confidence over time during their clinical experiential and interactive learning practices. The benefit of developing confident student nursesterm·key is to foster their belief in the ability to deliver safe and effective care while performing a complex role competently and skilfully within an interprofessional collaborative environment (Makarem et al. 2019 ; Owens & Keller 2018 ).
Competent professional practitioner The need to develop competent healthcare practitioners is vital to integrate the professional attributes that include knowledge, psychomotor skills, clinical judgementterm·dom, values and beliefs required to perform in a variety of clinical settings and to fulfil their professional responsibility through practice (Allvin et al. 2020 ; Fukada 2018 ; SANC 2013 ). Having professional competency is crucial as it leads to quality improvement of patient care, which is the ethical and professional responsibility of healthcare professionals. Competent healthcare practitioners can integrate theory into practice and engage in interprofessional collaboration and cooperative problem-solving of complex health problems in dynamic healthcare settings (Saifan 2021 ).
Critical thinking skillsterm·dom Critical thinking skillsterm·dom are essential elements for student nursesterm·key, acquired during real-life experiences in a complex learning environment, to develop the knowledge and make critical decisions in solving the health problems of the patients in safe, efficient and skilful interventions (Carter, Creedy & Sidebotham 2018 ). Such skills serve as crucial guide to apply diagnostic and clinical reasoning skills to solve complex and challenging health problems (Diamond-Fox & Bone 2021 ). Student nursesterm·key with critical thinking skillsterm·dom can apply their acquired knowledge and experience to identify patient’s health problems in order to make logical and reasonable decisions to ascertain possible solutions to solve health complexities impacting patient’s outcomes. Poor critical thinking skillsterm·dom lead to student nursesterm·key’ poor interpretations of findings, inaccurate clinical judgementterm·dom associated with incompetency and unsafe health practices (Antonova, Pletyago & Ostapenko 2020 ) Clinical reasoning skills With adequate exposure to collaborative CLOsterm·dom and problem-based activities, student nursesterm·key will learn and apply the acquired clinical knowledge, balance evidence and draw from their experiences to reach a definitive diagnosis of patients’ conditions (Wosinskic et al. 2018 ). The need of student nursesterm·key to develop sound clinical reasoning is to make the correct timeous diagnosis, apply critical thinkingterm·key to determine interventions to reduce medical errors and ultimately improve the patient’s health outcomes (Barratt 2018 ; Kavanagh & Sharpnack 2021 ).
Clinical judgementterm·dom Clinical judgementterm·dom is one of the vital attributes of professional practice. It is related to critical thinkingterm·key and clinical reasoning employed by healthcare professionals to conclude observations, analyse data and weigh evidence to make informed clinical decisions to improve patient care (Manetti 2018 ; Wosinskic et al. 2018 ). Engaging student nursesterm·key in complex real-life problem activities and research during their clinical learning helps them to apply their knowledge, develop critical thinking skillsterm·dom and practise evidence-based care that influences their independent clinical judgementterm·dom.
Poor clinical judgementterm·dom abilities result in more than half of adverse clinical eventsterm·dom, delivery of poor and unsafe clinical practices and substandard patient care (Alfaro-LeFevre 2020 ). Hence, the need to enhance CLOterm·dom for the student nursesterm·key to develop their good clinical judgementterm·dom skills in applying their knowledge, experience, evidence and critical thinking skillsterm·dom in their daily practices.
Critical decision-making skills As the provision of care is becoming increasingly complex and challenging in the ever-changing health environment, the need to develop student nursesterm·key with critical decision-making skills during clinical learning and experiences is vital for their effectiveness in clinical practice and profession. Adequate exposure and engaging student nursesterm·key in complex real-life problem activities will enhance their ability to respond to changing circumstances, apply their knowledge and skills in different clinical situations to diagnose health problems and solve them accurately (Ahmady & Shahbazi 2020 ; Nibbelink & Brewer 2018 ).
Problem-solving skills Student nursesterm·key rely on CLOsterm·dom to develop expertise and experiences in various situations to be equipped with problem-solving skills to solve complex health problems much more effectively and efficiently (Ahmady & Shahbazi 2020 ; Fatma, Sehrinaz & Tennur 2020 ). The varied and ever-changing healthcare environment requires healthcare professionals who are competent and able to identify real-life health problems and think creatively and collaboratively to integrate their knowledge to find possible health solutions to improve patients’ health.
Conceptual map Conceptual mappingterm·mth is a graphic presentation that signifies and depicts the relationships between concepts and ideas (Kunberger 2018 ). The lines and arrows in between explain the connections and relationships among the concepts. Figure 2 illustrates the conceptual mappingterm·mth of concept analysisterm·key of clinical learning opportunityterm·dom.
Conceptual map of clinical learning opportunityterm·dom (CLOterm·dom).
Theoretical definition of clinical learning opportunityterm·dom The result of concept analysisterm·key was the identification of the defining attributes of clinical learning opportunityterm·dom, which were used to develop and provide an operational definition with a clear theoretical base. The aim was to provide a clear understanding and consistency in the use of the concept within the study (Gray, Grove & Sutherland 2020 ; Walker & Avant 2019 ).
Theoretical definition The clinical learning opportunityterm·dom is an occasion that occurs in dynamic, multidimensional, real-life healthcare settings that requires planning of clinical placementterm·dom, provision of clinical learning outcomes and consideration of the cognitive level of students. There is engagement and active participation in collaborative, problem-based, community-based research activities and the use of emerging innovative technologies. It enhances the integration of theory and practice and develops HOTSterm·dom and clinical competencyterm·key to provide holistic patient careterm·key. It also supports the transition from novice to independent, confident practitioners with critical thinkingterm·key, clinical reasoning and judgement, critical decision-making and problem-solving skills.
Theoretical validityterm·mth Theoretical validityterm·mth is the extent to which a concept is described and interpreted accurately. It further addresses the explicit theoretical construction that the researcher brings to the study (Hayashi, Abid & Hoppen 2019 ). The researcher consulted literature and multiple data sources (not limited to nursing) over an extended period to avoid a biased understanding of the true nature and meaning of the concept. Extensive literature was explored and critically analysed until data saturationterm·mth. Similar and contrary patterns and phrases related to the concept were identified and clustered together to gain a better understanding of the concept.
Meaningful statements of clinical learning opportunityterm·dom were objectively synthesised, transposed, redefined and classified within the context of the study. A theoretical and operational definition that consists of all the defining attributes was formulated to provide an accurate description of the concept. A model case was constructed to highlight the significance and practicality of the defining attributes within real-life clinical contexts. A contrary caseterm·mth was also formulated to avoid conflicting and contradictory understanding of the concept.
Implications Theoretical definition of clinical learning opportunityterm·dom was developed to add to the existing knowledge in nursing education, practice and research. Without a well-constructed conceptual definition, the progression from conceptual understanding to a well-developed operational definition cannot take place. The article highlights the fundamental need for a concept analysisterm·key process that promotes a scientific approach in research to develop strategies to enhance positive clinical learning and professional development of student nursesterm·key within the healthcare learning environment and nursing education.
Conclusion The strategies to enhance the CLOsterm·dom for student nursesterm·key in a public academic hospital will be developed, implemented and evaluated using the identified defining attributes and empirical referentsterm·mth of the concept. It is also recommended that the same defining attributes and empirical referentsterm·mth may be standardised and measured across nursing education by prospective researchers. The development of a conceptual definition could lead other researchers to develop and confirm an instrument to quantify the phenomenon and to compare data accurately and consistently across populations and over time. The results of concept analysisterm·key may further provide evidence to inform policymakers in the development of policies and guidelines for nursing education and clinical learning of student nursesterm·key.
Acknowledgements The researcher (UJ student: Mpho N. MotsaanakapersName) would like to thank Prof. MakhenepersName and Dr NdawopersName employed at the University of Johannesburg, Faculty of Health Sciences, for their expert advice, supervision and encouragement throughout the process.
Competing interests The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions M.N.M. is a PhD student for the research study who was responsible for conceptualisation, methodology, formal analysis, investigation, visualisation as well as writing of the initial draft of the manuscript. A.M. was the supervisor with G.N. as the co-supervisor for this study, who both contributed in funding acquisition.
Funding information This research was supported by self-funding and the University of Johannesburg supervisor-linked bursary.
Data availability The data that supports the findings will be made available upon request.
Disclaimer The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.
Footnotes References Associated Data Data Availability Statement The data that supports the findings will be made available upon request.