ISSN: 2581-4265
Archives of Nursing Practice and Care
Research Article       Open Access      Peer-Reviewed

The degree of preparedness and experience of student nurses participating in the generic program during their first clinical experience

Yardena Kol* and Marina Vexler

Academic School of Nursing, Meir Medical Center affiliated with Tel Aviv University, Israel
*Corresponding author: Yardena Kol, RN, PhD, Academic School of Nursing, Meir Medical Center affiliated with Tel Aviv University, Israel, Tel: 972-50-6263121; Fax: 972-9-7472281; E-mail: yardenako@clalit.org.il
Received: 05 January, 2021 | Accepted: 11 January, 2021 | Published: 12 January, 2021
Keywords: Clinical experience; Student nurses; Preparedness

Cite this as

Kol Y, Vexler M (2021) The degree of preparedness and experience of student nurses participating in the generic program during their first clinical experience. Arch Nurs Pract Care 7(1): 001-007. DOI: 10.17352/2581-4265.000053

Objective: To examine the first clinical experience of student nurses from their perspective and determine the factors that influence it.

Method: Sample: 103 student nurses whose first clinical experience was in internal medicine and surgical departments. Tool: a questionnaire that included demographic details, questions on the clinical training experience, and questions about factors that may affect the training experience.

Results: The factor analysis found 4 factors that explained up to 33.82% of the variance in the experience: (1) the clinical instructor’s attitude toward the student, (2) the student’s self-confidence in his or her abilities, (3) the department staff’s attitude toward the student, and (4) a sense of calmness and familiarity with the work environment. The students’ experience in each of the factors was above 4.33 on average (on a scale of 1-5). A strong, positive correlation was found between the support and guidance of the preceptor and between the clinical instructor’s approach toward the student; between the support and guidance of the preceptor, a sense of confidence and ability to provide care; and between a positive relationship with staff and colleagues and the student’s confidence in his or her personal ability.

Conclusion: The human factor in the training: the clinical instructor, staff, and colleagues are of the utmost importance in students’ having a positive experience in their first clinical training.

Highlights

• Student nurses’ experience in first clinical experience

• Experience of student nurses in generic program

• First experience of student nurses.

Introduction

The generic curriculum in nursing includes theoretical studies and clinical experience. The curriculum is based on lessons in humanity, critical thinking, and reflective learning for managing various health conditions.

The teaching methods prepare student nurses in Israel and around the world to manage the nursing care ethically, professionally, and based on an informed decision-making process and integrating methodologies. The goal is to prepare the student for a therapeutic encounter with patients and their families in the best way possible [1,2].

In Israel, the initial clinical experience is at the end of the first academic year in adult nursing. A clinical instructor accompanies the clinical experience closely and provides follow-up.

Clinical experience is an essential part of the nursing curriculum and plays a crucial role in shaping the student nurses’ basic skills and professional abilities [3,4]. The students’ experience during the first clinical placement is a critical juncture in their educational and professional journey [5].

Based on our experience in classroom discussions, focus groups, and feedback from students after experiencing their first clinical placement, supported by findings in the research literature, many students report great difficulty, stress, and strain during the first clinical experience. These experiences impair the level of attention required during this stage of learning.

According to these reports, the questions arose:

• What do the students in Israel experience during their first clinical placement?

• What factors can influence a positive or negative outcome during the first clinical experience?

Background

A review of the literature found a broad consensus that a student’s first placement in a clinic has an important and crucial role in the training process of student nurses in the general nursing program.

Student nurses express a wide range of feelings regarding the quality of their first clinical experience and learning experience. They express feelings ranging from excitement, revelation, enjoyment, and pride to confusion, anxiety, fear, apprehension, and distress [5].

Many papers indicate that students experience a high level of anxiety regarding their first clinical placement, which may adversely affect the clinical learning process.

Anxiety is an emotion characterized by feelings of stress and worry among student nurses [6,7].

López-Cruz and colleagues [8] reported that initial clinical experience involves particularly high pressures, resulting from lack of knowledge and skills required of the student; fear of making mistakes and causing harm to the patient; communication with the patient and family; exposure to human suffering, disability, and death; heavy workload; and interaction with the clinical instructor and with a multidisciplinary team in the department.

Stunden and colleagues [9] conducted a review of tools and methods for reducing anxiety among student nurses in the first placement and how this intervention affected the student experience. They reviewed 8 articles dealing with the subject. The findings raised several key themes, one of which was related to anxiety. Student anxiety in the first placement was affected positively when the clinical instructor provided tools for students to manage stressful situations. Another theme related to the process of preparing students for their first placement used simulations. Zupiria and colleagues [10] developed a bilingual questionnaire (KEZKAK) to measure stressors among student nurses in clinical practice. A total of 287 students answered the questionnaire. The factor analysis revealed 9 factors (stressors) that explained 64.4% of the variance. In the student’s clinical environment: lack of competence, contact with suffering, relationship with the instructor and group members, lack of necessity and importance, lack of control over the relationship with the patient, emotional involvement, feeling vulnerable due to relationship with the patient, the patient seeking a relationship, and workload. The KEZKAK questionnaire was found to be an effective tool for measuring stressors among student nurses in clinical practice [1].

Other sources of stress reported in the literature among student nurses include: a) academic studies (workload, lack of knowledge, exam load, teaching style), (b) clinical practice (fear of making a mistake, lack of skill, fear of responsibility with patients, caring for a dying patient, dealing with death, and lack of free time), c) Relationships with others (clients, colleagues, teachers, or other health professionals), and d) Personal factors (gender, age, new environment away from home, family structure, and financial burden) [11].

Alshahrani, et al. [12] examined factors that would support a positive experience in the first clinical field placement of 154 student nurses in Australia. The questionnaire included questions on anxiety level and coping tactics. The findings revealed that most of the subjects had a moderate level of anxiety, of which the main concerns were the initial encounter with the patient and fear of making a mistake that could cause harm.

To summarize, according to the literature, student nurses in their first clinical placement need a supportive environment and a better sense of readiness and capability. The preparation should be tailored to the experiences and feelings the students express.

The purposes of this study were to examine the first clinical experience from the students’ point of view and to determine the factors that affect it.

Materials and methods

Type of study: A research – survey

The sample includes all 103 nursing students in the academic retraining program and the academic nursing program at the university, who had their first clinical experience in adult nursing, participated in the study in 2019 (There are no exclusion criteria).

Ethical approval

The Meir Medical Center Ethics Committee approved the study (25.07.2019). Informed consent was not required.

The research tool was based mainly on studies on this subject and included central categories taken from Boostel and colleagues, 2018 [1]; López-Cruz and colleagues [8]; and Zupiria and colleagues [10]. Following a review of the relevant literature, a questionnaire appropriate for the studied population was constructed and underwent tests of reliability and validity, as described in the section on Statistical Methods below.

The final research tool included a structured questionnaire that included demographic details, 30 questions regarding the clinical experience, 41 questions about factors that might influence the clinical experience, and three open-ended questions. Participants were asked to rate each item on a Likert scale from 0 (do not agree at all) to 5 (strongly agree).

Statistical methods

A pre-study test was conducted to evaluate the questionnaire’s reliability. The questionnaire was found reliable with a Cronbach’s alpha of 0.962 in estimating the students’ first clinical experience, and a Cronbach’s alpha of 0.899 in detecting factors promoting or inhibiting their first clinical experience, based on their opinions.

Content validity was tested among 11 judges (nursing school instructors) to check the relevance of the questions. A Pearson correlation was found between each question and the questions that were the main objectives of the study. The Cronbach’s alpha was similar to that found in the pre-study.

Clinical experience: a questionnaire detailing the first clinical experience in the adult nursing ward stage A. The respondents were requested to rank their responses on a Likert scale between 0 (completely disagree) and 5 (completely agree). Cronbach’s alpha = 0.97.

Factors that might influence the clinical experience: a questionnaire describing factors that might influence the clinical experience. The respondents were requested to rank their responses on a Likert scale between 0 (completely disagree) and 5 (completely agree). Cronbach’s alpha = 0.88.

In order to examine sub-factors of the questionnaire in the current study, we conducted a factor analysis for each questionnaire using a Varimax rotation. The factors freely gathered according to an Eigenvalue higher than 1. Data were collected approximately two weeks after the first clinical field work ended, anonymously.

Results

Characteristics of the study population

Most of the 103 study participants were women (80.2%), at an average age of 29.3±7.5 years. About half were Muslims (50.5%) and the rest were Jewish (43.4%), Christian (1.0%), or other (5.1%). More than half were married (52.0%), with an average of 2.8±1.6 children. The rest of the participants were single (46.0%) or divorced (2.0%).

The participants were evenly divided between adult nursing in Internal Medicine Departments (48.9%) and Surgical Wards (51.1%).

In addition to their academic studies, about half of the participants worked (51.0%) about 21.3±10.6 hours per week and the remaining 49% were not employed outside of school.

Of the participants in the academic retraining program, 49% had a bachelor’s degree and 51% had a graduate degree. Most participants (62.5%) had attended an academic college and 37.5% had graduated from a university.

Research variables

The dependent variable was student nurses’ experience during their first clinical experience.

The factor analysis included 4 factors that explained 33.82% and 20.11%, 9.38% and 6.58% of the variance in the experience: (1) the clinical instructor’s attitude to the student, (2) the student’s confidence in her/his personal ability, (3) the department staff’s attitude to the student, and (4) feeling calm and familiar in the work environment. The students’ experience in each of the factors was above 4.33 (on a scale of 1-5).

The independent variables - factors that influence the feelings regarding the clinical experience.

An analysis of the influencing factors found 8 factors that explained 13.07%, 9.78%, of the variance in the factors influencing the clinical experience:

1. Assistance, support, and guidance from the instructor – 13.07% (Cronbach’s alpha = .92).

2. A sense of security and capability in providing care – 9.787% (Cronbach’s alpha =.60).

3. Success in contact with the patient and his environment – 7.77% (Cronbach’s alpha =.78).

4. School work load – 6.85% (Cronbach’s alpha = .79).

5. Meeting professional expectations – 6.55% (Cronbach’s alpha =.66).

6. Relations with staff and colleagues – 5.65% (Cronbach’s alpha =.69).

7. Adapting to the atmosphere of the department – 6.64% (Cronbach’s alpha =.54).

8. Degree of fear of harming the patient – 5.28% (Cronbach’s alpha =.40).

Most of the factors were found to have direct, positive relationships with each other, except for the factors “adapting to the atmosphere of the department” and the “degree of fear of harming the patient”, which had less of a direct relation with the other factors.

Differences between the research groups - It was found that the students in the April cycle rated the relation of the clinical instructor to the student, the relation of the department staff to the student, and the support and guidance of the instructor, as better than those in the September cycle did, and reported less school workload.

The Jewish students felt less success in connecting with the patient and her/his environment than the Arab students did.

Students who studied at a university prior to nursing studies felt calmer and more familiar with the work environment and reported better contact with staff and colleagues than students who attended an academic college.

Multivariate model for predicting each of the components of the student experience from the first clinical experience

A. Predicting the clinical instructor’s relationship to the student

In the linear regression analysis, the explanatory variables were the support and guidance of the instructor, a sense of security and ability to provide care, academic workload, meeting professional expectations, and a positive relationship with staff and colleagues. The explanatory variable was the clinical instructor’s attitude toward the student.

The regression model showed that the five independent variables in the model explained about 81.3% of the total variance in the relation of the clinical instructor to the student (F(5, 95)=82.39, p<.001).

The regression showed that there is a strong positive correlation between the support and guidance of the instructor and the attitude of the clinical instructor to the student (β=.89, p<.01). That is, the more assistance, support, and guidance from the instructor, the greater the positive attitude of the clinical counselor toward the students (Table 1). No other significant correlations were found Table 2.

B. Predicting the student’s confidence in her/his personal ability

In the linear regression analysis, the explanatory variables were the support and guidance of the instructor, a sense of security and ability to provide care, success in contact with the patient and his environment, meeting professional expectations, positive contact with staff and colleagues, and adapting to the atmosphere of the department.

The regression model showed that the six independent variables in the model explained about 66.9% of the total variance in the student’s confidence in his/her personal ability (F(6, 94)=31.66, p<.001).

The regression findings showed that there are significant strong positive correlations between support and guidance of the instructor (β = .41, p <.01), sense of security and ability to provide care (β = .22, p <.01), a positive relationship with the staff and colleagues (β = .30, p <.01), and the student’s confidence in his/her personal ability. That is, the more assistance, support, and guidance from the instructor, the more the student has a sense of security and ability to provide care, and the better relationship with the staff and colleagues, the greater the student’s sense of confidence in his/her personal capabilities.

No other significant correlations were found Table 3.

C. Predicting the attitude of the department staff to the student

In the linear regression analysis, the explanatory variables were the support and guidance of the counselor, a sense of security and ability to provide care, success in contact with the patient and his environment, meeting professional expectations, positive contact with staff and colleagues, and adapting to the ward atmosphere.

The regression model showed that the six independent variables in the model explained approximately 51.6% of the total variance in the relation of the department staff to the student (F(6, 94)=16.67, p<.001).

The regression findings showed that there are significant strong positive correlations between assistance, support and guidance of the instructor (β = .34, p <.01), a positive relationship with the staff and colleagues (β = .55, p <.01), and the relation of the department staff to the student. That is, the more assistance, support, and guidance from the instructor and a good relationship with the staff and colleagues, the greater the sense of a positive relation from the department staff to the student. No other significant correlations were found Table 4.

D. Predicting a feeling of calm and familiarity with the work environment

In linear regression analysis, the explanatory variables were the help, support, and guidance of the instructor, a sense of security and ability to provide care, success in contact with the patient and her/his environment, meeting professional expectations, and positive relations with staff and colleagues. The explanatory variable was a sense of calm and familiarity in the work environment.

The regression model showed that the five independent variables in the model explained approximately 61.3% of the variance, a feeling of calm and familiarity in the work environment (F(5, 95)=30.04, p<.001).

The regression findings showed significant strong positive correlations between help, support, and guidance from the instructor (β = .38, p <.01), a sense of security and ability in providing care (β = .21, p <.02), a positive relationship with the staff and colleagues (β = .31, p <.01), and the relation of the department staff with the student. That is, the more assistance, support, and guidance provided by the instructor, the more positive the contact with the staff and colleagues, and the better contact with the staff and colleagues, the greater the sense of calm and familiarity in the work environment. No other significant correlations were found Table 5.

Summary of findings of the open-ended questions (97% response rate)

To the question: What were the most helpful factors in your first clinical experience?

The leading areas were the character of the instructor (88%), and the department in which the experience took place (41%).

To the question: What were the most inhibiting factors in your first clinical experience?

The leading areas were: the field of study (65%), and the load of theoretical studies combined with tests and the assignments of the experience during the clinical experience made it difficult for them to focus on the clinical experience (58%).

To the question: What would make it easier for students in their first clinical experience?

The students reported that a clinical instructor who is supportive, inclusive, directing, not stressful, coordinates expectations, and works systematically, would be the most significant factor.

Summary of findings

The outcomes of the student nurses’ clinical experience were based on 4 factors: the attitude of the clinical instructor to the student, the student’s confidence in his/her personal ability, the attitude of the department staff to the student, and a feeling of calm and familiarity with the work environment.

Eight factors were found to influence the clinical experience: assistance, support, and guidance from the instructor, a sense of security in ability to provide care, success in contact with the patient and his/her environment, no academic workload, meeting professional expectations, positive relations with staff and colleagues, adapting to the ward atmosphere, and the amount of fear of harming the patient.

Most of the factors had positive direct relationships with each other, except for the factors of adapting to the atmosphere of the ward and the degree of fear of harming the patient, which had less of a direct relation with the other variables.

Regarding the differences between the study subgroups, it was found that the students in the spring semester rated the relation of the clinical instructor to the student, the relation of the department staff to the student, and help, support, and guidance from the counselor better than those in the fall semester did. In addition, they reported a lighter academic work load. The Jewish students felt less success in connecting with the patients and their environment than the Arab students did. Also, students who studied at a university prior to nursing school felt calmer and more familiar with the work environment and reported better relations with the staff and fellow student than those who had studied at an academic college did.

For predicting the students’ experiences, based on the questionnaire, the regression findings showed that the more assistance, support, and guidance provided by the instructor, the greater the perception of a positive attitude from the clinical instructor toward the students. The more assistance, support, and guidance provided by the instructor, the greater the sense of security and ability to provide care, and the better communication with the staff and colleagues, the greater the student’s sense of confidence in his or her personal ability. The more assistance, support, and guidance from the instructor and the better the relationship with the staff and colleagues, the greater the perception of a positive attitude from the staff to the student. And the more assistance, support, and guidance from the instructor, the more positive the contact with the staff and colleagues and the better contact with the staff and colleagues, so was the perception of a greater sense of calm and familiarity in the work environment.

All the hypotheses were partially confirmed except for the second hypothesis, which was refuted in the statistical analysis, but was cited as a negative factor in the students’ clinical experience, in the open-ended question.

Discussion

A review of the literature found that there is broad agreement regarding students’ feelings regarding their first clinical experience. However, the quality of their first clinical experience and the learning experience spans a wide range of feelings and statements of students, such as enjoyment, excitement, confusion, anxiety, etc [5].

One goal of this study was to examine what constitutes the first clinical experience from the student’s point of view. The findings suggested that the experience includes 4 components.

Examining the factors influencing each of the components of the outcomes of the first experience, 8 factors were found. Similar factors have been described in the literature. Assistance and support from the instructor, a sense of readiness, success in contact with the patient, the degree of fear of harming the patient, academic workload, meeting expectations, adapting to the atmosphere of the department, and positive contact with staff and colleagues [6-8].

In the analysis of the correlations between the factors influencing the first clinical experience and the components of the experience, positive correlations were found with only 5 factors.

In contrast to the literature, no correlation was found with academic workload, adapting to the atmosphere of the department, and fear of harming the patient.

The explanation regarding adapting to the atmosphere of the department and fear of harming the patient, should note that the first experience is 7 weeks and gradual learning is done on very basic skills such as data collection and measurement of vital signs. Each student receives one patient one which to perform basic skills only and does not receive a patient with serious health issues.

Regarding the academic workload: The variable was composed of the burden of tasks, seminars, study days with words for the experience and load testing. Surprisingly, no correlation was found. However, in the open question that related to inhibiting factors, 58% of students indicated that the burden of theoretical studies combined with tests and assignments during the experience made it harder for them to concentrate on the experience. In addition, during the internship the students felt pressure “due to the load of tests and assignments during the internship”. Study load may be a mediating factor influencing the experience, as reported in most of the studies reviewed [6,11,13].

The most prominent factor having a positive or negative relationship with the first clinical experience on each component was the help, support, and guidance of the clinical instructor. The clinical instructor is also referenced in the literature as being a central figure in the outcomes of the student’s clinical experience.

The clinical instructor has a major impact on the general interaction of the clinical experience [6,7,9]. There is no doubt that the clinical instructor has a significant impact on the students’ clinical experience, because every clinical experience is led and guided by the knowledge that begins with the orientation to the department and setting expectations, and not providing feedback and formative assessment. At the end of the first clinical experience, the instructor’s evaluation has an important weight in the student’s grade and in shaping his or her ability for the continuing clinical experience.

Cooper and colleagues [14] examined which factors have a positive or negative effect on the first clinical experience, among 361 students. The questions were divided into 3 categories: (a) how much the students felt wanted in the department, (b) the individual approach versus the staff approach, and (c) the students’ expectations of supervision by the department nurses. The findings suggested that methodology for preparing the students for the clinical training, and preparing the environment for the students’ clinical experience need to be improved. Building professional trust and encouraging learning will support achieving positive learning in the first clinical experience.

Cantrell and colleagues [6] in their review, found that students report that the common causes of stress are the academic requirements during the experience, the relationship in the clinical environment, and the care of the patient and family. Clinical placement, tests, exercises, and the student’s level of competence were found to engender high levels of stress.

Reference was also made to the clinical instructor in the open-ended question in which the students were asked to indicate what are the factors that contribute to a positive experience from the clinical experience. 88% of the students answered that the clinical instructor is the most helpful factor. Regarding the question “what can make it easier for the student in their first clinical experience?”, the students indicated that the figure of the clinical instructor is the most significant factor for them:

The students indicated that the clinical instructor as a very significant factor for them: supportive, inclusive, directing, not stressful, coordinates expectations, and works systematically. In addition, students were asked to consider how they would ease the demands of the clinical experience.

With the help of the instructor, his or her support and guidance, a significant positive connection was also found to the other components of the first clinical experience: the student’s confidence in his or her ability, the attitude of the department staff, and the sense of calm in the work environment. In addition to the instructor’s assistance, a positive relationship with the staff and colleagues also had a positive impact on these factors.

Conclusion and limitation

The current study conducted a regression to predict the main factor in the students’ experience among the factors found in the literature to influence the first clinical experience.

In conclusion, the human factor that accompanies the training: (clinical instructor, staff, and colleagues) is of the utmost importance for a positive experience for the student in the first clinical experience. The academic work load that is not directly related to the clinical experience should be reduced as much as possible and should focus on the learning tasks that are relevant to the clinical experience.

However, further studies are necessary to support this finding as the most significant predictor of the students’ experience, in light of the range of factors found in the literature to influence the students’ first clinical experience. Another limitation of the current study is the need to establish the results using a control group.

  1. Boostel R, Felix JVC, Bortolato-Major C, Pedrolo E, Vayego SA, et al. (2018) Stress of nursing students in clinical simulation: a randomized clinical trial. Rev Bras Enferm 71: 967-974. Link: http://bit.ly/3qbwTdt
  2. Courtney‐Pratt H, Fitzgerald M, Ford K, Johnson C, Wills K (2014) Development and reliability testing of the quality clinical placement evaluation tool. J Clin Nurs 23: 504-514. Link: http://bit.ly/2Xz5DJC
  3. Chan CK, So WK, Fong DY (2009) Hong Kong baccalaureate nursing students' stress and their coping strategies in clinical practice. Journal of Professional Nursing 25: 307–313. Link: http://bit.ly/2Ls42Ts
  4. Moridi G, Khaledi S, Valiee S (2014) Clinical training stress-inducing factors from the students' viewpoint: A questionnaire-based study. Nurse Education in Practice 14: 160-163. Link: http://bit.ly/3btmZzN
  5. Levett-Jones T, Pitt V, Courtney-Pratt H, Harbrow G, Rossiter R (2015) What are the primary concerns of nursing students as they prepare for and contemplate their first clinical placement experience?. Nurse Education Practice 15: 304-309. Link: https://bit.ly/2K5aK16
  6. Cantrell ML, Meyer SL, Mosack V (2017) Effects of simulation on nursing student stress: An integrative review. Journal of nursing Education 56: 139-144. Link: https://bit.ly/35zbC5H
  7. Shearer JN (2016) Anxiety, nursing students, and simulation: State of the science. Journal of Nursing Education 55: 551–554. Link: https://bit.ly/2LfbWjf
  8. López-Cruz V, Hernández-Castañón MA, Mendoza-Zamora A, Villarreal-Ríos E, Gasca-Ramírez MA (2016) Support to nursing students in their first clinical practice in stressful situations. Revista de Enfermería del Instituto Mexicano del Seguro Social 24: 165-170.
  9. Stunden A, Halcomb E, Jefferies D (2015) Tools to reduce first year nursing students' anxiety levels prior to undergoing objective structured clinical assessment (OSCA) and how this impacts on the student's experience of their first clinical placement. Nurse Education Today 35: 987-991. Link: http://bit.ly/39q9HBw
  10. Zupiria XG, Uranga MI, Alberdi ME, Barandiaran ML (2003) KEZKAK: A new bilingual questionnaire to measure nursing students' stressors in clinical practice. Gaceta sanitaria 17: 37-51. Link: http://bit.ly/3nDu8jz
  11. Liu M, Gu K, Wong TK, Luo MZ, Chan MY (2015) Perceived stress among Macao nursing students in the clinical learning environment. International Journal of Nursing Sciences 2: 128-133. Link: http://bit.ly/3qfZ3nB
  12. Alshahrani Y, Cusack L, Rasmussen P (2018) Undergraduate nursing students' strategies for coping with their first clinical placement: descriptive survey study. Nurse Education Today 69: 104–108. Link: http://bit.ly/3qcJv42
  13. Rafati F, Nouhi E, Sabzehvari S, Dehghan-Nayyeri N (2017) Iranian nursing students' experience of stressors in their first clinical experience. Journal of Professional Nursing 33: 250–257. Link: http://bit.ly/3sfGTUY
  14. Cooper J, Courtney-Pratt H, Fitzgerald M (2015) Key influences identified by first year undergraduate nursing students as impacting on the quality of clinical placement: A qualitative study. Nurse Education Ttoday 35: 1004-1008. Link: http://bit.ly/35xjhBq
© 2020 Kol Y, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.