18 Ag4m3

Xi'an Shiyou Daxue Xuebao (Ziran Kexue Ban)/
Journal of Xi'an Shiyou University, Natural Sciences Edition

ISSN: 1673-064X
E-Publication: Online Open Access
Vol: 66 Issue 01 | 2023
DOI 10.17605/OSF.IO/AG4M3
PERCEPTIONS OF NURSING STUDENTS REGARDING THEIR CLINICAL

LEARNING ENVIRONMENT: A SYSTEMATIC REVIEW
NIHAD BSHARAT
PhD in Nursing, Candidate, Arab American University Palestine.
Corresponding Author Email: [email protected]
LILA DE TANTILLO
PhD, MS, APRN, FNP-BC, Jacksonville University, USA. Email: [email protected]
IMAD FASHAFSHEH
Assistant Prof, Arab American University Palestine AAUP, PhD in Nursing. Email:[email protected]
IBRAHIM AQTAM
Assistant Prof, Ibn Sina College for Health Sciences Palestine, PhD in Nursing, Palestine.
Email: [email protected]
Abstract:
Perception of undergraduate nursing students regarding clinical environment is essential to improve the
clinical training. Aim of the Study: This study was conducted to assessing the perceptions of nursing
students regarding their clinical learning environment. Methods: Peer reviewed research articles related to
perception of undergraduate nursing students about CLE were searched using Boolean operators and
validated MeSH terms including "perception" AND " nursing student" OR " nursing students" AND " clinical
learning environment" in Pub-Med, CINAHL, and Science Direct data bases. Results: A total of 941 articles
were found, 14 research articles with a total sample size of 2875 participants met the inclusion criteria.
There was a discrepancy of the highest and lowest mean value for different domains of learning environment,
also the relationship between satisfaction and clinical learning was significantly different for various
dimensions; the highest correlation value was for the role of the lecturer nurse (r = 0.544). Conclusion:
Despite the satisfactory results from different studies of nursing students' perception concerning their CLE,
there is still a space for obtaining more information about nursing students' perspectives in various contexts
because each has its own characteristics and circumstances.
Index Terms: Nursing Students, Clinical Learning Environment.
INTRODUCTION:
Nursing education contains two parts: theoretical and clinical. The clinical nursing learning
plays a major role in nursing education; it forms more than half of the nursing curriculum,
[1]. Many studies had shown that the learning environment is significant with respect to
clinical learning and its outcomes; also it is a powerful educational component for
acquiring nursing knowledge and skills, [2].
Nursing students' perception about clinical learning environment plays an essential role
in providing care to patients, [2]. The quality of learning environment is essential to
discover how nursing students perceive clinical environment, [1]. From the nursing
students' viewpoint, CLE is an anxiety provoking part in nursing education because it has
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to satisfy the learner and the worker, [3]. Student satisfaction is defined as "meeting or
exceeding the student’s expectations of campus reality", [4].
Student’s satisfaction can be a good quality indicator for nursing teaching and learning
which eventually has a positive effect on delivering nursing care to patients because
satisfied students are more effective and committed to accomplish their goals than
unsatisfied students,[5]. The lack of consensus and the discrepancy among the published
studies concerning the perception of nursing students about their clinical learning
environment makes this topic a global concern, which justifies this review that inclines to
answer the question: How do nursing students in different contexts perceive their clinical
learning environment?
the quality of nursing learning environments is crucial to discovering how nursing
students perceive their clinical learning environments (CLEs) he quality of nursing
learning environments is crucial to discovering how nursing students perceive their
clinical learning environments (CLEs) he quality of nursing learning environments is
crucial to discovering how nursing students perceive their clinical learning environments
(CLEs) he quality of nursing learning environments is crucial to discovering how
nursing students perceive their clinical learning environments (CLEs).
Aim of the work:
This study is aimed to assessing the Perceptions of Nursing Students Regarding their
Clinical Learning Environment.
METHODS:
1- Technical design:
Three databases for searching were used: CINAHL, Pub-Med, and Science Direct.
Boolean operators (OR, AND) are used separately to combine and expand the search
first, then to narrow down and make the search more focused to have productive results,
also validated MeSH terms search is considered. Finally, the following form is used in
searching ("perception" AND "nursing student" OR "nursing students" AND "clinical
learning environment"). The years included are from January 2017- May 2022. The titles
and abstracts of the relevant articles were skimmed carefully; (941) results from all
databases (CINAHL= 448, PubMed = 22, Science Direct = 471) were obtained.
The inclusion criteria determined as follows: English language, nursing students: (2nd,
3rd, & 4th year), five years limit, research articles, peer reviewed, and the focus is on
articles that talk about perceptions & views of nursing students.
The exclusion criteria: involved the articles of systemic review, simulation, and
perception of other health professionals, the first year nursing students, and the articles
more than five years. Finally, there are 14 articles included; six of them are shared with
the three databases as illustrated in figure 1 (PRISMA), the selected studies were
relevant and met the inclusion criteria. These studies were reviewed extensively; ten of
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them used quantitative methodology, [3, 6-14].Three used qualitative methodology, [15-
17]. Two of them used the phenomenological approach, [15, and 17]. Finally, one study
used a mixed research methodology, [18].
RESULTS:
There were,[12]studies that either talked about , recommended, or encouraged further studies
to go deep or explore more about the perceptions and the experiences of nursing students
regarding their CLE. One study,[6] recommended that the nursing educators at Sohag
University should collaborate with the clinical learning administrations to pay more attention to
the obstacles in clinical environment and to take an assertive action to overcome the
challenges and problems in order to have a more comfortable CLE, also they urged to conduct
further studies later on to see the alteration in the students' perception,[18] in their study
recommended the challenges in CLE with the curriculum design be addressed well. Another
study recommended the problems experienced by nursing students should be identified
through regular meetings and proper communications among nursing lecturers, nursing
students, and staff members in order to improve the working environment and to support and
address the concerns of the students, [9]. Two further studies focused on the collaboration and
partnership with different stakeholders (nursing institutions, nursing educators, clinical sites,
clinical administrators) in order to enhance positive sense towards the students, to have an
organized orientation program, and to hold regular meetings to discuss the challenges related
to the clinical learning environment, [7,11]. In their study, [10] they called for further qualitative
studies to collect more data to explain more the factors and causes related to the students'
clinical experiences and to replicate their study on larger population from different nursing
institutions to examine the different experiences of nursing students to understand the factors
related to clinical environment better and to have a more representative view to improve the
learning environment. One study emphasized the characteristics of the nursing team, nurse
tutor, and nursing students involved in ward activities concluded that the results should prompt
a deeper reflection on the components of the supervisory process and the CLE, [17]. Three
studies discussed the dimensions or sub dimensions related to the clinical learning
environment; the findings of one study recommended that the CLE be evaluated through the
assessment of its sub-dimensions (pedagogical atmosphere & relationship with supervisors)
and showed that the results of this study can be used for further research to assess the nursing
schools, the hospitals, and the clinical environment, [8]. Moreover, the perceptions of the
nursing students regarding the content of the role of the nurse teacher, the supervisory
relations, and the pedagogical atmosphere subsidize the creation of a conducive clinical
learning environment greatly, [12]. Furthermore; it should be considered that different nursing
students from different universities have different clinical experiences and so different themes
will emerge, [15].
Fifty six point seven (56.7%) of the students reported that there was a good relationship
between nurses and physicians, and they rated this as the highest factor of positive clinical
environment,[14] while there was poor relationship between nurses and students which caused
a barrier for an effective and meaningful learning in the clinical environment,[18]. One study
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showed that resources' adequacy and staffing were rated as the lowest factor,[14] but another
study showed 97.3% of students reported that they were absent from the clinical training
because they covered the shortage of staff,[9]. Also the unwilling of staff nurses to teach and
help the nursing students and the shortage of resources were considered as factors that made
the clinical environment not optimal for learning, [18].
In the end, two studies discussed the strengths and weaknesses of the clinical environments
of nursing practice and the factors that would enhance or impede the nursing students learning
and showed that studying and understanding the perceptions of the students provide accurate
and detailed information for the nursing managers. Besides, the future studies should focus on
evaluating the learning environment in order to identify the challenges and the factors that ease
or impede the students' learning during their clinical training, [13-14].
Characteristics
Sampl Students' Response
Author /Year Country Clinical placement
e size course level Rate %
( Alammar et al., Saudi 90 Final year Hospital 89.1%
2020) Arabia
(Ali et al., 2017) Egypt 183 2nd year Nursing college NA
( Doyle et al., Australia 150 Final year Private & public hospitals NA
2017)
(Khan et al., 2020) Pakistan 259 2nd, 3rd, 4th Nursing college NA
( Magobolo et al., South 152 2nd, 3rd, 4th Nursing college 93%
2019) Africa
(Ming & Wenjie, Singapore 301 3rd Polytechnic/ nursing NA
2020) students
(Mosia et al., South 160 3rd year Nursing school 91.25%
2020) Africa
(Nahariani et al., Indonesia 164 Final year Three different nursing 84.1%
2018) schools
(Ramsbotham et Australia & 891 2nd, 3rd, 4th Four different universities / 97%
al., 2019) Vietnam nursing students
( Rodríguez et al., Spain 180 3rd, 4th University hospital NA
2021)
(Cengiz et al., Turkey 30 4th year University nursing students 100%
2021)
(Raghavan et al., Oman 30 2nd , 3rd Public University/ nursing 100%
2021) students
(Vizcaya-Moreno Spain 48 1st, 2nd, 3rd University/ nursing students 100%
et al., 2018)
(Kamphinda & Malawi 219 3rd , 4th year Nursing College 96%
Chilemba, 2019)
2875
Note. NA represents not available
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Figure 1: PRISMA
Studies' characteristics:
The revised studies were conducted in various settings where each population had its unique
experiences and lived in different circumstances; this supported the generalization of those
shared or had similar characteristics. A brief description of the characteristics of the included
studies is illustrated in table1.The overall purposes of the studies were to assess, analyze,
explore, describe, investigate, and evaluate the perception and views of nursing students about
the clinical environment where they practiced their training and to determine the factors,
challenges, obstacles and problems that eased or hindered the nursing clinical education
except for one study that described the perceived personal and clinical related area and
reasons for nursing students' absenteeism,[9]. The majority of the quantitative studies used
the cross-sectional research designs while the phenomenological methodology was used in
two of the qualitative studies, so all the studies lay within the third level of evidence according
to the Johns Hopkins Nursing Evidence-Based Practice Rating Scale (JHNEBP, 2005). The
participants in all studies were nursing students from either public or private universities or
nursing schools and from different study levels: the 2nd, 3rd, and 4th years; except for one
study which included the first year with the second and the third year students,[17]. The
students training period ranged from 4 – 24 weeks at different clinical sites such as medical,
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surgical, maternity, psychiatry, and primary health care centers where they trained either in
governmental or private hospitals; in addition, to one study included overseas students,[7]. The
sample size of the studies ranged from 30-48 participants in the qualitative studies and from
90-891 in the quantitative studies to have a total of 2875 participants in all reviewed studies.
The sample selection was either convenient in quantitative or purposeful in qualitative studies.
The age groups of the participants ranged from 18–46 years old,[8-9]respectively. The
percentage of female nursing students was more in all studies except for,[15] study which was
equal with the male students and for,[8] study where the percentage of male nursing students
was higher than the females' percentage. With regard to the difference between the males and
females perception of the CLE, the females had higher mean scores of leaning environment
domains than the males,[6] and they perceived more opportunities for career
advancement,[14] while the male students rated the clinical environment more than
females,[13] but they were the least satisfied,[8].
Measures:
Five studies used the CLE supervision and teacher role (CLES+T) instrument, [3,7-8,12,18]
this scale is a well- known questionnaire scale with five domains; pedagogical atmosphere,
leadership style, nursing care premises, supervisory relationship, and the nurse teacher role)
and 34 items. The CLES+T instrument uses a five-point Likert scale. The Cronbach alpha for
the original tool ranged from 0.77 to 0.96, [19]. The English version of the instrument was used
in the five studies. One study used the modified form of CLES+T, which is the clinical learning
environment inventory (CLEI), [10]. Two studies used the CLEI with other instruments such as
the Vietnamese versions of the Dundee Ready Education Environment Measure (V- DREEM),
[13] and the Obstacles to Learning Clinical Skills Tool (OLCS), [6]. One study used the PES-
NWI questionnaire,[14] and four studies used structured self-administration and focus
group,[11,17]semi-structured,[16]and face to face interviews,[15]. Still one study used the
Simelane and Thobakgale, which is related to factors contributing to absenteeism of student
nurses, [9].
RESULTS:
The data were analyzed by different methods such as the Statistical Package for Social
Sciences (SPPS) in which nine studies used different versions, [6-10, 12-14, and 18]. One
study used the Statistical Analysis Software (SAS), [11]. The Qualitative data were analyzed
using the content analysis approach, and NVivo10 program was used for coding, [15].
Frequencies and percentages were used for categorical data. Descriptive statistics
summarized students' demography namely means, medians and percentiles to calculate the
continuous data, standard deviation, t. test for comparison (eg. males & females), Chi square,
and Fisher Exact Test. Spearman's rank correlation coefficient as well as multiple linear
regression were used to examine the relationship between the constructs. Also, Mann Whitney
U-test were also carried out to compare the scores of the means of PES-NWI subscales by an
academic year and unit type, [14].
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Domains and sub-dimensions:

One study revealed that leadership style of the ward manger reported the highest mean (M =
3.80, SD = 0.86), [3] while another study showed that nursing care in the ward had the highest
mean (M =3.87 ± 0.77), [8]. A third study indicated that the role of the lecturer nurse had the
highest correlation value (r = 0.544), [12]. The lowest mean value was given to the role of the
teacher and the supervisory relationship (M = 3.57, SD=0.80) and (M = 3.71 ± 0.84)
respectively, [3, 8]. In addition, one study indicated that the role of the nurse tutor was not well
defined as the students stated, [17]. Finally, in the CLEI constructs, the personalization and
task orientation got the highest scores while individualization and innovation got the lowest
scores, [10]. There were many studies addressing the factors, obstacles and challenges that
the nursing students might face during their clinical training and had negative impact on their
clinical learning; among these factors were the lack of cooperation between the clinical
departments in hospitals and the nursing educators, [3]poor quality of CLE represented by lack
of appropriate educational facilities, unsuitability of clinical climates, crowding numbers of
students in clinical sites,[6] and the students not receiving feedback,[18]. While having four
weeks of training led to a better quality learning environment, the interpersonal relationship
between the instructors and the staff had key factors influencing the students' learning,[13].
Besides, how the ward staff behaved toward the undergraduate nursing students was reported
as the second strongest factor that made the learning environment more comfortable,[7].
Satisfaction:
Eight studies reported a relationship between the CLE and the students' satisfaction with
different percentages, [3, 6-7, 10, 12-14, 18]. The majority of nursing students were satisfied,
[3]. 72.2% of the students were moderately satisfied, [6]; 90% of nursing students were highly
satisfied and the culture of the nursing unit had the most effect on satisfaction rates by making
the nursing students feel comfortable, [7]. While the students were dissatisfied with clinical
support and supervision, [18]. A significant relationship was between the students' satisfaction
and the CLE, [3, 12, and 14]. The majority of the students showed moderate satisfaction and
positive views toward their CLE,[6,10].The highest correlation was for the role of the nurse
teacher (r = 0.544), the coefficient of β adjusted highest to 2.075,[12];the nurse teacher role
had the highest impact of nursing students satisfaction,[12]and 62.8% of (n = 113) were
satisfied with the learning practice environment,[14]; other students perceived their CLE as
somewhat satisfied or favorable, [13-14].
Qualitative studies:
Three studies extracted different categories and themes; one of them emphasized the nurse
tutor and student nurse relationship, [17]. Another one considered the clinical instructor central
for clinical training, [16]. While two of them reassured the interpersonal skills and
communication, [15-16].
The bias:
One study talked about the response bias; in which the participants in self- administered
surveys may answer in an acceptable social manner rather than reflecting their real own
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experiences, [10]; this also may be applied to other studies that had a self- administered
questionnaire, which may affect the quality of these studies.
Quality assessment:
Referring to the (JHNEBP, 2005) Rating Scale the reviewed studies lie between good and high
levels as several studies used appropriate methodologies, valid and reliable measures, and
adequate sample size and reported the response rate. Besides, their findings and
recommendations were consistent with the literature.
DISCUSSION:
The reviewed studies show that the nursing students from various settings perceive their CLE
differently; this means that there are different points of views about the dimensions or domains
of CLE among the nursing students in different contexts, which mostly affect the nursing
students' clinical learning. Three studies indicate that the highest mean values for different
domains is the leadership style, nursing care, and the supervisory relationship, respectively,
[3, 8, 12]. This also applies to the dimensions with the lowest mean values. One study shows
that the role of the teacher has the lowest mean value, [3]. While another study reveals that
the role of the tutor nurse is not clearly defined, [17]. The findings of another study are different,
in which the supervisory relationship has the least mean value, [8]; this contradicts with the
results of, [12] study which indicates that the supervisory relationship has the highest mean
value.
Regarding the gender differences, a study at sohag university in Egypt reveals that the mean
scores for CLE domains are higher in female students than in male students; these findings
differ from the results of a study done on a large sample at four different universities in both
Australia and Veitnames, which shows that the environment domains for the male nursing
students rated higher rates than female nursing students, [6,1].
The current evidence shows that nursing students' satisfaction is another important indicator
in the CLE that affects the students' attitudes toward learning as many studies confirm this
relationship with varied percentages; this also emphasizes the satisfaction variable in further
studies as an indicator of delivered quality care. The findings of a study in Indonesia shows
that the role of the nursing teachers has the highest correlation with satisfaction. Another
study's findings in Australia indicate that the nursing unit culture has the most impact on comfort
and satisfation for nursing students while another study done in Turkey reveals that effective
communication has the highest impact on the students' satisfaction,[7,15]. An additional study
in Malawi shows that the nursing students are not satisfied with the clinical support and
supervision and this makes the clinical environment not optimal for learning, [18]. This is
different from the findings of, [12] study which indicates that the role of the lecturer has the
highest correlation value of satisfaction. Concerning the satisfaction among male and female
nursing sutdents, the findings of a study in Pakistan point out those female nursing students
are more satisfied than male nursing students, [8].
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Regarding the level of years for nursing students' perception, one study conducted in singapore
shows that the final year nursing students have moderate positive views of their clinical
environment while the findings of two other studies-- one in Spain and the other in Australia &
Veitnam-- are simillar claiming that as the students’ progress, they become more able to
compare and more critical, but their perception and satisfaction trend down, [10, 13-14].
The results of the thematic analysis of two qualitative studies conducted recently in Turkey and
Oman show communication as a theme; one of these studies also encourages further research
on different students at other universities as new themes might emerge, [15]. This review
suggests that the qualitative studies should be encouraged in the future research because
many of these studies may extract different categories of themes related to the challenges,
problems, and factors facing nursing students during their clinical training. It is also
recommended that further mixed studies be done as they may strengthen the evidence,
produce new themes and add an additional input to the literature.
Most of this evidence draws our attention to the obstacles facing the nursing students during
their training in clinical sites and focuses more on their perception and experiences in the CLE
which must be studied in other contexts with larger population in order to clarify more these
experiences and perceptions ; there is also a focus on the collaboration and partnership
between the nursing schools and the clinical settings; this review apparently promotes future
studies in these aspects to highlight these issues and encourage to explore more about making
the CLE and the nursing students training more comfortable as the administrators of both
academic institutions and clinical settings will be more involved and become aware of the
circumstances of nursing students training which will enable them to work and to solve the
related problems and make the students' trainings more satisfactory. One can conclude that
future studies, more investigation and indepth research in other contexts regarding the nursing
students perceptions may reveal different results.
Implications:
The implication of this review can be employed in nursing education to develop baccalaureate
nursing curriculums, assist in decision making and implementation of successful programs,
improve different learning modalities, and initiate alternative teaching methods in clinical
education , also it can be employed in clinical settings to do assessments and evaluation of
the sub- dimensions of the clinical learning environment and act on improving them, , enhance
more collaboration between nursing instructors and nurses in the clinical sites, and promote
partnerships between nursing institutions and clinical learning sites.
Recommendations:
It is recommended that further future quantitative and qualitative studies be conducted at
students' levels representing various nursing schools from varied countries, increasing the
sample size and involving both the academic institutions and the clinical learning settings to
explore more various challenges and obstacles to minimize the related problems and to
improve the quality of the delivered care. In addition, there must be an emphasis on further
studies to explore other variables and to focus on the perception of the nursing students
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concerning the pedagogical atmosphere and the relationship with supervisors among both
sexes and different levels of nursing students. Furthermore, studying and understanding the
perceptions of the nursing students may reveal important, accurate, and detailed information
to the nursing managers and nursing academics about the challenges that face nursing
students and hinder their learning during their clinical training.
Limitations:
The limitations in this review can be categorized as follows. First, some studies deal with one
cohort of students at one campus or one university. Second, other studies talked about
studying homogenous participants with small sample size, which makes results difficult to
generalize, as they are not representative. Third, there is low ranking in the hierarchy of the
research evidence as most of the studies are cross sectional and qualitative; many of them
have high response rate though. Fourth, there is also a social desirability bias because most
of the studies use self-administered questionnaires, which restrict collecting profound and
pertinent information. Fifth, cultural differences may affect the comparisons among different
studies. Finally, the majority of the studies conducted in countries with limited resources;
however, if other high resource countries are involved, different results might be obtained
Strengths:
The strength of this review is that the students are from 12 different countries, 16 different
public, private, and polytechnic universities and nursing colleges, and three different public,
private, and university hospitals, which aids in collecting varied perspectives.
CONCLUSION:
Perception of nursing students about their CLE plays a major role in understanding how the
nursing students deliver competent and high quality nursing care to their patients, and help the
managers of the clinical settings and the nursing educators to better facilitate the training
conditions for the nursing students as they become more aware of these conditions. More
future mixed studies that focus on different dimensions of the clinical environment in various
contexts with more involvement of stakeholders will improve nursing students' performance
and make them more satisfied.
Abbreviation:
CLE: Clinical Learning Environment
SAS: Statistical Analysis Software
SD: Standard Deviation
M: Mean
SPPS: Statistical Package for Social Sciences
OLCS: Obstacles to Learning Clinical Skills Tool
CLEI: clinical learning environment inventory
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Financial Disclosure: The authors declared that this study received no financial support.
Conflict of interest: The authors declare no conflicts of interest. This manuscript is not under
consideration by another journal and has not been published or presented elsewhere in part
or in its entirety except Research Square of a preprint.
Ethical Approval: Approval was granted from the Institutional Review Board of Arab
American University & Nablus University for Vocational and Technical Education, at Palestine.
Prior to the translation and survey. The purpose and process of this study were explained by
the researchers to the participants. The study participants were guaranteed confidentiality and
voluntary participation and provided their written informed consent. Informed consent was
obtained from all individual participants included in the study.
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Xi'an Shiyou Daxue Xuebao (Ziran Kexue Ban)/

Journal of Xi'an Shiyou University, Natural Sciences Edition

PERCEPTIONS OF NURSING STUDENTS REGARDING THEIR CLINICAL

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Note. NA represents not available

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Domains and sub-dimensions:

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