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Nursing students' satisfaction of the clinical learning environment: A

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Papastavrou et al. BMC Nursing (2016) 15:44
DOI 10.1186/s12912-016-0164-4

RESEARCH ARTICLE Open Access

Nursing students’ satisfaction of the clinical

learning environment: a research study
Evridiki Papastavrou1*, Maria Dimitriadou1, Haritini Tsangari2 and Christos Andreou1

Abstract
Background: The acquisition of quality clinical experience within a supportive and pedagogically adjusted clinical
learning environment is a significant concern for educational institutions. The quality of clinical learning usually
reflects the quality of the curriculum structure. The assessment of the clinical settings as learning environment is a
significant concern within the contemporary nursing education. The nursing students’ satisfaction is considered as
an important factor of such assessment, contributing to any potential reforms in order to optimize the learning
activities and achievements within clinical settings.
The aim of the study was to investigate nursing students’ satisfaction of the clinical settings as learning
environments.
Method: A quantitative descriptive, correlational design was used. A sample of 463 undergraduate nursing students
from the three universities in Cyprus were participated. Data were collected using the Clinical Learning
Environment, Supervision and Nurse Teacher (CLES + T).
Results: Nursing students were highly satisfied with the clinical learning environment and their satisfaction has
been positively related to all clinical learning environment constructs namely the pedagogical atmosphere, the
Ward Manager’s leadership style, the premises of Nursing in the ward, the supervisory relationship (mentor) and
the role of the Nurse Teacher (p < 0.001). Students who had a named mentor reported more satisfied with the
supervisory relationship. The frequency of meetings among the students and the mentors increased the students’
satisfaction with the clinical learning environment. It was also revealed that 1st year students were found to be
more satisfied than the students in other years.
Conclusion: The supervisory relationship was evaluated by the students as the most influential factor in
their satisfaction with the clinical learning environment. Student’s acceptance within the nursing team and a
well-documented individual nursing care is also related with students’ satisfaction. The pedagogical atmosphere
is considered pivotal, with reference to students’ learning activities and competent development within the
clinical setting. Therefore, satisfaction could be used as an important contributing factor towards the development
of clinical learning environments in order to satisfy the needs and expectations of students. The value of the
development of an organized mentorship system is illustrated in the study.
Keywords: Nursing education, Mentorship, Clinical environment, Nurse Teacher, Satisfaction

* Correspondence: [email protected]
1
Department of Nursing, School of Health Sciences, Cyprus University of
Technology, Limassol, Cyprus
Full list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Papastavrou et al. BMC Nursing (2016) 15:44 Page 2 of 10

Background practice areas as more meaningful and educative because

Mobility of health care professionals is a growing they provide them with opportunities of clinical practice
phenomenon worldwide and in the case of Europe sev- and linking the theoretical aspect of their studies [11].
eral policies have been developed in order to harmonize This will provide important feedback for clinical education
nursing education in the European countries. Thus, the and potential curriculum revisions [11–13]. To this end,
duration and the content of both theoretical teaching the current study is intended to contribute empirical
and practice in the clinical areas is explicitly regulated evidence as to the existing evidence within the relevant,
by the European directive2013/55/EU [1] that recom- international literature thus allowing potential compa-
mends that 50 % of the total duration of the under- risons of the nursing students’ satisfaction nationally and
graduate nursing education need to include clinical across countries.
practice in order to get a registration as a nurse. All the “The attainment of certain outcomes of a clinical
educational and learning activities during the clinical placement may be enhanced by modifying the CLE in
placements of nursing students could be compound ways that make it more congruent with the environment
into a broader concept, the Clinical Learning Environ- preferred by students” [14]. For the present, there is a
ment (CLE). lack of a clear and commonly accepted definition of
The CLE is an interactive network of forces within the what contributes to nursing students’ satisfaction with
clinical setting that influences learning outcomes [2]. It the CLE. This may be due to different conceptual ap-
includes everything that surrounds students and affects proaches that occurred across the relevant studies and
their professional development in the clinical setting. due to the fact that the students’ satisfaction seems to
There is considerable evidence supporting the CLE as depend on various dimensions of teaching and learning
extremely beneficial in familiarizing students with clinical in clinical settings [15].
judgment and decision–making [3], in stimulating their Students’ satisfaction is a complex and multifactorial
critical thinking [4], in challenging students to recognize issue [16]. Relevant studies revealed positive links
the consequences of their mistakes [5], and in exposing between students’ satisfaction and the quality of nursing
them to various socio-cultural, biological, psychological care [10, 17], the ward’s pedagogical atmosphere and
and mental aspects of patients’ care [3]. The CLE is the leadership style [3, 12, 13] the sense of belonging [18],
place where the theoretical components of the curriculum the peer support [19] and the motivation level [20]. On
can be integrated with the practical and transformed into the other hand, students’ supervision and the relation-
professional skills and attitudes within an emotionally safe ship among the nursing students and mentor [8, 20] or
environment [6]. However, from the nursing students’ nurse teacher (NT) [3, 21] have been considered as the
point of view, CLE is “the most anxiety-provoking compo- most noteworthy elements for the effectiveness of the
nent of nursing education” [7] as they have to satisfy a CLE with reference to nursing students’ learning and
dual role, that of the learner and that of the worker. The professional development.
ongoing changes in health care needs together with the Previous studies [3, 22] highlighted the importance of
shift in nursing education to academic levels, have trans- the interpersonal relationships on the effectiveness of
formed students’ clinical experiences from “learning by the clinical experience and student satisfaction. Patients
doing” to evidential oriented learning. However, not all [23] peer [19] ward staff [22] mentor and clinical teacher
the clinical settings are conducive to students’ learning [21] are the major stakeholders involved in that
outcomes or contributing to their competencies’ deve- experience-rich, supportive relationship. Students’ posi-
lopment [8]. tive clinical experiences are more likely to be related to
Within this context, it is not surprising that the quality how valued and supported students feel than the phy-
of clinical preparation of students has been systematically sical aspects of a placement [24]. High levels of satis-
debated since 1980, in order to reach an optimal level of faction have been reported when students had someone
clinical learning achievements [9]. In many recent stu- to ensure that their learning needs were addressed, when
dies, students’ satisfaction has been consistently identified the clinical staff were well briefed [11] when the students
as an important factor of a “good” clinical learning envi- were treated with respect and appreciation [25] as well
ronment [10]. as being included as part of the health care team [26].
Although the CLE has been investigated in various Other issues on which students expressed satisfaction
educational respects, there is a scarcity of studies explo- concerned effective levels of mentor expertise and guid-
ring the nursing students’ point of view from the stand- ance [8, 25, 27], continuous feedback on their profes-
point of their satisfaction with the CLE on a worldwide sional performance [26], frequent clinical conferences
basis. This current study aims to explore Greek Cypriot with their mentor and NT [20, 22], and the concurrence
undergraduate nursing students’ level of satisfaction with of clinical practice with theory [10]. However, the degree
the CLE in hospital settings. Students view hospital of satisfaction appeared to be influenced by the unique
Papastavrou et al. BMC Nursing (2016) 15:44 Page 3 of 10

organizational atmosphere of each nursing ward [28], Methods

the duration of clinical placement [13], the years of Aim and research questions
study [17] and educational supervision [22]. The study aimed to investigate nursing students’ satisfac-
Efforts at producing a high quality of CLE have recently tion with the clinical learning environment. With this in
been focused on creating a pedagogical atmosphere, and mind, the following research questions were posed:
strengthening the connection between university class-
work and placement experience by means of adoptive 1. What is the level of Cypriot nursing students’
supervision models [21, 22]. The two models primarily satisfaction with the CLE?
used in European countries involve: a) the mentor or 2. If any, what is the relationship between the students’
preceptor (these terms are used interchangeably) and satisfaction and some of their personal data (e.g.,
represent an experienced clinical nurse affiliated in the year of study, type and frequency of supervision)?
university, focused on translating knowledge in skillfulness 3. If any, what is the relationship between the students’
and b) the NT who is employed by the educational institu- satisfaction and the five dimensions of the clinical
tion acting as a liaison, confirming theory –practice learning environment, as defined within the
continuum. CLES + T?
These clinical learning models were also adopted by
the nursing programs of all the Universities in the Research instrument
Republic of Cyprus. Usually they include clinical skills of The CLES + T scale was developed and validated by
about 90 ECTS (European Credit Transfer System) Saarikoski et al. [31] and adapted in many languages as a
according to the European and National standards [29] self-report questionnaire designed to measure the nurs-
and the duration of clinical practice increases according ing students’ perceptions of their satisfaction of the CLE.
to the year of study and the different learning objectives The questionnaire consists of 34 items classified into 5
that have to be achieved. The supervisory role in the dimensions: pedagogical atmosphere on the ward; super-
clinical settings is undertaken mainly by named mentors visory relationship; leadership style of the ward manager;
who are supported by members of the academic staff of premises of nursing on the ward; role of the NT in
each University. Mentors’ work is considered very impor- clinical practice [31]. Respondents are asked to score
tant in supporting the professional development of the their perception of each item on a 5-point Likert-type
nurse students and the assessment of their “competencies” scale ranging from “very dissatisfied” to “very satisfied”.
[30]. For this reason, the chosen mentors attend a The instrument has been adapted to the Greek language
mandatory two days seminar in order to understand [13, 17] reporting reliable and valid measures with
nursing curriculum and help students to get the best from scales’ Cronbach’s alpha values ranging 0,82–0.96 [20].
practice placement. The mentor\student ratio is 1:5, both For the purpose of the current study, the CLES + T
are supernumerary and this gives the mentor the oppor- Greek version was used alongside a questionnaire on
tunity to be more student-oriented and devote his\her demographic data referring to the university, the gender,
time exclusively to the needs of the students. the age and the participants’ educational level. Demo-
Although there is a lack of a conceptual and theo- graphics also included learning-teaching characteristics
retical background describing the nursing students’ such as the hospital and the ward type, the clinical
satisfaction, there is evidence that it could be concep- placement length, the frequency of the weekly meetings
tually clarified and measured within the context of an with the NT, the use of e-contact with the NT during
internationally accepted tool, specifically the Clinical clinical placement and the motivational level of the
Learning Environment, Supervision and Nurse Teacher clinical setting. The satisfaction with the CLE was exa-
(CLES + T) [31]. In this context, the nursing students’ mined by one general question in a 5-point Likert-scale.
satisfaction was described within five distinctive con-
structs. The ward’s pedagogical atmosphere includes Sampling and data collection
the teamwork and the personnel’s interest in students’ In the Cyprus Republic there are four universities lead-
learning needs. The supervisory relationship constructs ing to a bachelor’s degree in nursing, one state and three
that stands for the sense of trust, student/mentor private institutions. One private university refused to
equality and continual feedback. The third construct participate in the study, so only three universities were
reflects the ward’s leadership style representing the included. The total nursing student population of the 3
relationships between the ward managers, the staff universities were 664 individuals. The inclusion criteria
and the students. The premises of nursing on the ward for students’ participation were: (1) the students’ in-
refer to the organization of the nursing care and the formed consent and (2) practicing in hospitals and not
NT’s role in clinical practice is defined as the nurse in community settings. The questionnaires were person-
teacher’s ability to minimize the theory-practice gap. ally administered to the students during the last nursing
Papastavrou et al. BMC Nursing (2016) 15:44 Page 4 of 10

laboratory lesson towards the end of the academic year Table 1 Demographic data (n = 463)
2012–13. Nursing students were provided with infor- Variable f f/n (%)
mation with regard to the purpose of the study, the Type of University
anonymity of the collected data and the voluntary nature Private university 149 32.2
of their participation. From the total population, 463
Government university 314 67.8
questionnaires were returned, giving a response rate of
70.3 %. Four of the questionnaires were removed from the Gender
data analysis as they were not properly completed and so Male 179 38.7
the final sample consisted of 463 nursing students. Female 284 61.3
The research proposal was approved by the National Year of study
Bio-Ethics Committee and permissions to access partici- 1st year 111 24.0
pants granted from the universities’ authorities. Permis-
2nd year 110 23.8
sion to use the CLES + T was obtained by the authors.
3rd year 121 26.1
4th year 121 26.1
Data analysis
Type of nursing ward of last clinical placement
Descriptive statistics were used to calculate frequencies,
means and standard deviations from the demographic Geriatrics 2 0.4
data. The reliability of the data was estimated with Surgical 81 17.5
Cronbach’s alpha. Taking into account the data deviation Gynecology 6 1.3
from normality, non-parametric inferential statistics were medical 88 19.0
selected. The correlation analyzes between the students’ Pediatrics 65 14.1
satisfaction and the five constructs of the CLE were
Psychiatric 40 8.7
performed with Spearman’s rho correlation coefficient.
Chi-square tests were also used to examine the relation- Other 180 39.0
ship between the nominal scales of students’ satisfaction Did any changes take place during your placement
and their demographic data as well as regarding students’ No 266 58.3
relationship with their mentors. In order to examine the Yes 79 17.3
relationship between the ordinal scale of students’ satis- I can’t evaluate 111 24.3
faction with students’ demographic data and relationship
Type of the hospital in which clinical placement was held
with their mentors, multinomial logistic regression was
used. The simultaneous entering of all the independent General Hospital 427 92.2
variables in the model has the advantage of reducing Type Specialized care center 7 1.5
I errors. However, individual Chi-square tests were also Outpatient department 13 2.8
performed for additional insight into the relationships. Other 16 3.5
How many times did you meet NT during the latest clinical placement
Results Never 32 6.9
The results showed high internal consistency for the 1–2 times 82 17.7
total CLES + T (Cronbach’s alpha = 0.95) and for each of 3 times 32 6.9
the five dimensions, ranging from 0.81 (“premises of
Often 316 68.4
nursing care in the ward”) to 0.97 (“supervisory relation-
ship”). Regarding the sample’s demographics, 38.7 % Did you use e- communication tools with your NT during placement
were males and 61.3 % females, with age ranging from I have never used 274 59.4
18 to 34 years, with a mean of 21.08 years and standard 1–3 times 114 24.7
deviation 2.23 years. 149 participants studied in private 4–6 times 30 6.5
universities and 318 at the public university (Table 1). Moreoften 43 9.3
The mean score for the total sample of nursing students’
satisfaction was estimated at 4.1, supporting the conten-
tion that students perceived the CLE as “very good”. The the overall students’ satisfaction was positively correlated
relationship between the five CLES + T dimensions and with all the items (p < 0.001) (Table 3).
the question that measured the general satisfaction of Multinomial logistic regression showed significant re-
student was examined. Spearman’s rho correlation coeffi- lations between students’ satisfaction and demographics,
cient was significant between the overall satisfaction and as well as with the student’s relationships with their
all of the five dimensions (p < 0.001) (Table 2). Similarly, mentors (Table 4). The results showed that significant
Papastavrou et al. BMC Nursing (2016) 15:44 Page 5 of 10

Table 2 Bivariate Correlations between the “total satisfaction” items with the CLES + T dimensions(n = 463)
Totalsatisfaction Scale Pedagogical Leadership style of Premises of Nursing Supervisory Nurse Teacher
Atmosphere Ward Manager in ward Relationship role
Spearman’s Corr.coefficient 0.610** 0.521** 0.388** 0.385** 0.550** 0.432**
p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
**Correlation is significant at α = 0.01

differences existed in terms of year of study (p = 0.01), subcategory (so called successful supervision) included
the frequency of meetings with NT (p = 0.02), the students who had a named mentor and their relationship
frequency of supervision with mentor (p = 0.05), the was effective. Taking eight degrees of freedom and p-
method of supervision (p = 0.01), mentor or NT (p < value smaller than 0.001, significant differences were re-
0.001) and the motivation (p < 0.001). Specifically, the vealed across the satisfaction level and the supervision
first year students had the highest satisfaction level method. Further examination of data showed that the
compared to the other years (2nd to 4th). Those stu- highest satisfaction level was found for those with suc-
dents who reported that they met with their NT at least cessful supervision (mean satisfaction = 4.11), followed by
three times per week had a higher level of satisfaction in those with group supervision (mean satisfaction = 3.86),
comparison to those that met only once or twice a week. and the least satisfied were students with unsuccessful
The highest satisfaction was found among those students supervision (mean satisfaction = 2.61).
who had a named mentor with whom their relationship
was effective, while the lowest was reported by those who Discussion
did not have a named supervisor. Students who had The positive learning experiences revealed in the current
frequent meetings with their mentor had a higher level of study correspond to the supervisory relationship in
satisfaction compared to those who did not have any combination with the frequency of individual meetings,
meetings at all, or had very rare meetings (e.g., once or the presence and support of the NT and the sense of
twice in total per week). Those who answered that the “team spirit” in a well-organized nursing care environ-
most important person was the NT had the lowest satis- ment. These findings are in agreement with previous find-
faction, compared to those who placed emphasis for their ings of the Cypriot studies [13, 17, 20] as well as other
supervision on “mentors” or “both” the NT and a mentor. relevant studies [11, 12, 22]. The current results generally
Students who had no motivation had the lowest satis- showed that nursing students’ satisfaction with their prac-
faction, followed by those who had some motivation. The tice environment was significantly related to all of the five
most satisfied nursing students were those who had high CLES + T dimensions: pedagogical atmosphere, ward
levels of perceived motivation by the CLE. It should be manager leadership style, premises of nursing on the ward,
noted that individual Chi-square tests showed the same supervisory relationship and the role of the nurse teacher
significant relations, (notice that the relation with fre- (p < 0.001). The students’ satisfaction was also found to be
quency of supervision with mentor was highly significant, positively related to all the individual items of the factors
with p-value = 0.01), while two additional variables were comprising the learning environment in clinical settings.
found to be significant, namely University (p = 0.04) and Although the evidence on student satisfaction from learn-
type of nursing ward (p = 0.02), where the results revealed ing in the practice environment is limited, efforts have
that nursing students from the private universities were been made to improve the quality of clinical placements
found to be less satisfied than those from the state uni- in Cyprus and elsewhere [19]. Therefore our results can
versity, and students practicing in paediatrics units had be partly explained by the NT involvement through regu-
the lowest satisfaction compared to other nursing wards. lar visits and collaboration with the mentors. The NT also
In the examination of the relationship between the acts as a supporter to the mentor and together they
method of supervision and the satisfaction, the six organize students’ clinical learning, so that each has the
method levels were grouped into three subcategories to opportunity to participate in the learning situation.
facilitate presentation and interpretation. The first subca- The mentorship relationship was evaluated by the stu-
tegory (so called unsuccessful supervision) included the dents as the most influential factor for their satisfaction,
following characteristics: the student did not have a a similarity that was echoed across earlier studies using
named supervisor, a personal supervisor was named, but the CLES + T [12, 13, 20, 22]. Students with a named
the relationship did not work or the named supervisor mentor (successful supervision) reported themselves as
changed during the course of training. The second more satisfied with the dimensions concerning the men-
subcategory (so called group supervision) referred to torship relationship, suggesting the idea that students’
cases where the supervisor had several students and satis- experiences of their relationships and of being treated as
faction varied according to shift or location. The third unique individuals are supporting agents for their
Papastavrou et al. BMC Nursing (2016) 15:44 Page 6 of 10

Table 3 Correlations between all the CLES + T items and nursing students’ satisfaction (n = 463)
CLES + T items Corr. Coefficient p-value
Pedagogical atmosphere (PA)
PA1 The staff was easy to approach .429 < 0.001
PA2 I felt comfortable going to the ward at the start of my shift .265 < 0.001
PA3 During staff meetings (e.g., before shifts) I felt comfortable taking part in the discussions .447 < 0.001
PA4 There was a positive atmosphere on the ward .471 < 0.001
PA5 The staffs were generally interested in student supervision .368 < 0.001
PA6 The staff learned to know the students by their personal names .194 < 0.001
PA7 There were sufficient meaningful learning situations on the ward .372 < 0.001
PA8 The learning situations were multi-dimensional in terms of content .371 < 0.001
PA9 The ward can be regarded as a good learning environment .476 < 0.001
Leadership style of the ward manager (WM), Premises of Nursing on the ward (NC)
WM10 The WM regarded the staff on his/her ward as a key resource person* .344 < 0.001
WM11 The WM was a team member* .279 < 0.001
WM12 Feedback from the WM could easy be consider a learning situation* .352 < 0.001
WM13 The effort on individual employee was appreciated* .302 < 0.001
NC14 The ward nursing philosophy was clearly defined* .316 < 0.001
NC15 Patients received individual nursing care* .317 < 0.001
NC16 There were no problem in the information flow related to patients’ care* .244 < 0.001
NC17 Nursing Documentation (e.g., nursing plans, daily procedures etc.) was clear* .363 < 0.001
Supervisory relationship (SR)
SR18 My supervisor showed a positive attitude towards supervision* .440 < 0.001
SR19 I felt that I received individual supervision * .469 < 0.001
SR20 I continuously received feedback from supervisor* .500 < 0.001
SR21 Overall I am satisfied with the supervision I received* .568 < 0.001
SR22 The supervision was based on a relationship of equality and promoted my learning* .505 < 0.001
SR23 There was a mutual interaction in the supervisory relationship* .495 < 0.001
SR24 Mutual respect and approval prevailed in the supervisory relationship* .508 < 0.001
SR25 The supervisory relationship was characterized by a sense of trust* .509 < 0.001
Role of the nurse teacher (NT)
NT26 The NT was capable of integrating theoretical knowledge and everyday practice* .333 < 0.001
NT27 The NT was capable of operational sing the learning goals of this placement* .323 < 0.001
NT28 The NT helped me to reduce the theory-practice cap* .317 < 0.001
NT29 The NT was like a member of the nursing team* .309 < 0.001
NT30 The NT was able to give his or her expertise to the clinical team* .352 < 0.001
NT31 The NT and the clinical team worked in supporting my learning* .362 < 0.001
NT32 The meetings between myself mentor and NT were comfortable experience* .418 < 0.001
NT33 In our common meetings I felt that we are colleagues* .416 < 0.001
NT34 Focus on meetings was in my learning needs* .349 < 0.001
*Correlation is significant at p = 0.01

learning and increase their sensitivity to the patients’ long accepted axiom of adult learning. In accordance with
needs [32]. This finding supports what was reported by the study of Dobrowolska et al. [33] in comparing the
one European study [32] and confirms the nursing stu- mentor’s role in 11 EU and non- EU countries, the type of
dents’ preference towards one-to-one supervision. This mentor who are staff nurse working in the clinical area
could also be considered a further argument supporting focus mainly on developing clinical competences in the
the individual learning approach of the nursing students, a students, although is accused of lacking teaching
Papastavrou et al. BMC Nursing (2016) 15:44 Page 7 of 10

Table 4 Multinomial Logistic regression for the examination of Henderson et al. [36], have explicated that third year
the relation between nursing students’ satisfaction and personal students’ satisfaction is associated with involvement,
data (n = 463) personalization, greater motivation and commitment
Item Chi Square df p-value towards their learning needs and the patient care.
Q1: University 1.315 4 0.85 Also, the frequency of meetings with the NT and
Q2: Age 44.751 44 0.44 mentor in relation to the satisfaction level was demon-
Q3:Sex 1.340 4 0.85
strated. Even though the two models of supervision had
different perspectives, the nursing students expressed
Q4: Year of study* 27.917 12 0.01
their satisfaction from the meetings with both the NT
Q5: Type of nursing ward of the 3.854 16 0.99 and the mentor. Students’ satisfaction is also shown in
clinical placement
the statement declaring that “The common meetings
Q6: Changes in the ward during 5.201 8 0.73
the clinical placement
between myself mentor and NT were a comfortable
experience”, suggesting that NT presence in clinical area,
Q7: Hospital type 14.369 12 0.27
as a member of academic staff, is useful in order to
Q10: How many times did you meet the 25.011 12 0.02 monitor and guide through the medium of the mentor–
NT during the last clinical placement*
student relationship and to act as a learning advocator
Q11: Use of e-communication tools with 11.488 12 0.48
the NT during placement
[37]. The NT is considered to be the person who is
responsible for the careful planning of the clinical place-
Q12: Occupational title of the mentor 8.552 12 0.74
ment, and therefore regular visits enhanced students’
Q13: Methodof supervision (with mentor)* 21.493 8 0.01 clinical experience because those visits ensured that
Q14: Frequency of separate private 25.764 16 0.05 student educational goals were successfully achieved in a
supervision with mentor *
timely fashion [25, 37]. In contrast, students may feel
Q15: Mentor orNT * 28.277 8 < 0.001 abandoned when they have no or few visits, especially
Q16: Motivation * 71.561 8 < 0.001 when they were placed in new environments [37]. In
*Relation is significant at α = 5 % terms of unfamiliar nursing team and organizational
philosophies, they appreciated the presence of the NT in
experience and pedagogical education. However, having a order to give ongoing guidance to the ward staff with re-
named mentor during the clinical placement might be dis- gard to the anticipated performance level at the student’s
advantageous if the mentorship relationship “doesn’t particular stage of learning [38]. Besides, the NT’s role
work”, as student would then have to deal with issues of as educator with a clinical background and working as a
negativity and prejudice [34]. liaison between the university and clinical settings has
In addition to this concern, it was also argued that a been documented by several relevant studies as effective,
successful mentorship might be depended on student especially in stressful situations [22]. However, the weak
preparedness, readiness and willingness to learn [35]. correlation (r = 0.381 p < 0.001) between students’ satis-
Finally, in line with other relevant studies, satisfaction faction and both of the CLE dimensions Role of the NT
from mentorship supervision was found to be differenti- and leadership style of the ward manager, showed that
ated according to the clinical settings [12], the method the supervision models of ward placements may have
of supervision and the frequency of meetings [13, 20]. led ward managers not to place students’ education
Regarding the academic year, the first year students within the priorities of the ward [35]. This may indicate
reported the highest satisfaction compared to other, later a conflict of tasks and priorities between the needs of
years. This was reported likewise within other relevant healthcare and the goals of the universities’ personnel.
studies [10], which showed satisfaction to decline as However, the fact remains that the NT’s presence is
students progressed through the program. A probable influential on the nursing staff to involve themselves in
explanation for that finding might be the fact that the the students’ learning process [37].
learning objectives and activities differed in the academic Another finding that is congruent with previous
progress [19]. The first year students felt high levels of studies [20] is the lower satisfaction reported by those
physical and mental stress due to their limited capacities participants who answered that the most important
in terms of fundamental clinical skills [19]. Therefore, person to understand nursing practice was the NT com-
mentoring was recommended as a teaching strategy to pared to those who said “mentor” or “both”; suggesting
minimize anxiety and to help novice students to deal that students evaluate both roles positively. However,
with the feelings of unpreparedness [7]. On the other the mentor’s role seemed to prevail in the fulfillment of
hand, there is evidence that the third year students prerequisite clinical competencies and advance the
expressed higher confidence in clinical knowledge and socialization process in clinical settings [12, 24]. The men-
skills, and tend to focus on leadership and guidance [19]. tor was perceived to be essential for ensuring clinical
Papastavrou et al. BMC Nursing (2016) 15:44 Page 8 of 10

safety while students developed their scope of practice experience as older students. Of course a mix method-
[39]. However, the mentor has the dual role of an educa- ology similar to other relevant studies [11, 22] could
tional supervisor and an assessor. He was therefore per- provide further insights of the students’ qualitative
ceived to violate his educational expectations as well as responses as regard their views and/or perceptions of
those of the students. As noted in Price et al. [37] study, the CLE. However students’ satisfaction could not be
NT’s clinical visits have to be encouraged so as to develop considered as the only measurement to assess the CLE’s
well-informed and confident mentors, ensuring continuity impact on students’ learning and development. Within
between the idealized class world and the practice reality. such mix methodology there might emerge other inter-
Finally, the strong and significant correlation found esting and unknown variables. Yet despite the limitations
between the pedagogical atmosphere and premises of nurs- of the current study, our results are much in accordance
ing care indicated that students’ satisfaction is higher when with recent relevant studies conducted across EU coun-
they are actively involved in individual patient care with tries. Nevertheless, addressing the lack of a relevant
clear information flow and clear documentation of nursing grounded theoretical or conceptual model for this field
care within a welcoming and educationally structured would be of value. Nursing students represent the future
environment. This is in line with the findings of previous nursing workforce, thus nursing education is an impor-
studies [20, 34], confirming that the CLE is related to the tant investment for the quality of the provided clinical
quality of nursing care and patient contact [17]. It is nursing care. During a pre-registration program students
accepted, though, and confirmed by other European are systematically prepared to reach the minimum
studies that a task-oriented approach to nursing care is standards of ‘competencies’ on knowledge, skills and
considered a barrier to students’ learning [35]. In the Papp attitudes, during their clinical learning in order to be certi-
et al. [25] study, students associated the quality of clinical fied for their professional capability.
practice with the quality of mentorship and the quality of
patient care. The feeling of being welcome as students Conclusions
was manifested by the way the nursing staff approached The need for evaluating students’ satisfaction with their
them. Specifically, a notable observation of the current practice environment is associated with two important
study, which concurs with a previous Cypriot study [20] is issues of nursing workforce: the competency of graduates
that the significantly lower satisfaction with item six “The and students’ retention. In the context of the current
staff learned to know the students by their personal study, Cypriot nursing students were found to be highly
names”, which compromised the students dignity as adult satisfied with the CLE and this was related to the level of
learners and implied their status to be “just a pair of motivation and the nursing care delivery, the supervisory
hands” [8]. According to the students’ written comments, relationship with the mentor and NT’s role in clinical
their dissatisfaction might be attributed to the barriers in practice. However, students’ satisfaction was found to
accomplishing their learning objectives [11], the constant change according to the level of study, indicating that
hurry of staff [26] and the weakness to assert their dual learning needs and expectations differentiate as student
status as supernumerary and as students [35]. coming up the“ladder of competence” indicating that
Conclusively, the CLES + T scale could be considered clinical supervision and support need to be tailored
useful in exploring nursing students’ satisfaction with their according to the their individual needs.
clinical experiences and the supervision with which they The current study illustrated the value of the develop-
are provided. In future studies, satisfaction level could be ment of an organized mentorship system. This was
used as an important contributing factor towards the devel- viewed by the participant nursing students as one of the
opment and/or reforms of clinical learning environments in most important variables in their clinical learning and
order to satisfy the needs and expectations of students. their satisfaction with the CLE. Student’s acceptance
within the nursing team and the organization of nursing
Limitations care impact students’ satisfaction.
Some limitations should be noted when drawing firm Under current economic distress, there is a need to
inferences from the findings of this study due to the re-clarify the potential roles of all parties involved in
relatively short periods of time spent in specific ward students’ clinical learning so that adequate preparation
environments, specifically from two to three days per will be made to meet educational objectives. Also, find-
week during a period of seven to eight weeks as “short ings support the need to encourage both the nursing
clinical rotations”. These may not provide sufficient time staff and the mentors in order for theoretical knowledge
to build mutual understanding and familiarity within the to be effectively transferred into clinical practice, thus
specific CLE. A longitudinal approach will be very help- minimizing the gap between the theoretical ideal and
ful in assessing students’ satisfaction with the CLE from the reality of the clinical world. However, the findings
the standpoint of the novice as younger students to across relevant studies presented an ensemble of factors
Papastavrou et al. BMC Nursing (2016) 15:44 Page 9 of 10

that impact nursing students’ satisfaction of the CLE. Fur- 6. Steven A, Magnusson C, Smith P, Pearson PH. Patient safety in nursing
ther investigation of the field is therefore recommended. education: contexts, tensions and feeling safe to learn. Nurse Educ Today.
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7. Moscaritolo LM. Interventional strategies to decrease nursing student
Abbreviations
anxiety in the clinical learning environment. J Nurs Educ. 2009;48:17–23.
CLE, Clinical Learning Environment; CLES + T, Clinical Learning Environment,
8. Hamshire C, Willgoss TG, Wibberley C. “The placement was probably the
Supervision and Nurse Teacher; NT, Nurse Teacher
tipping point” - the narratives of recently discontinued students. Nurse Educ
Pract. 2012;12:182–6.
Acknowledgments 9. Pollard C, Ellis L, Stringer E, Cockayne D. Clinical education: a review of the
The authors would like to thank Mikko Saarikoski for the permission given for literature. Nurse Educ Pract. 2007;7:315–22.
using CLES + T, the nursing students that participated in the study and Mr. 10. Lee CY, White B, Hong YM. Comparison of the clinical practice satisfaction
Gerry Barrett for the language editing. of nursing students in Korea and the USA. Nurs Heal Sci. 2009;11:10–6.
11. Bisholt B, Ohlsson U, Engström AK, Johansson AS, Gustafsson M. Nursing
Funding students’ assessment of the learning environment in different clinical
The research was funded by Cyprus University of Technology. settings. Nurse Educ Pract. 2014;14:304–10.
12. Skaalvik MW, Normann HK, Henriksen N. Clinical learning environment and
Availability of data and materials supervision: experiences of Norwegian nursing students - a questionnaire
Please note that identifying/confidential patient data should not be shared. survey. J Clin Nurs. 2011;20:2294–304.
13. Warne T, Johansson U-B, Papastavrou E, Tichelaar E, Tomietto M, Van den
Bossche K, Moreno MFV, Saarikoski M. An exploration of the clinical learning
Authors’ contributions
experience of nursing students in nine European countries. Nurse Educ
Conception and Study Design: EP, MD. Data Collection and Analysis: MD, HT.
Today. 2010;30:809–15.
Manuscript Writing: EP, MD, HT, CA. All the authors approved the final
version. 14. Chan DS. Combining qualitative and quantitative methods in assessing
hospital learning environments. Int J Nurs Stud. 2001;38:447–59.
15. El Ansari W, Oskrochi R. What “really” affects health professions students’
Competing interests satisfaction with their educational experience? Implications for practice
None of the authors have personal or financial relationships that influence and research. Nurse Educ Today. 2004;24:644–55.
the study. 16. Papathanasiou IV, Tsaras K, Sarafis P. Views and perceptions of nursing
students on their clinical learning environment: teaching and learning.
Consent for publication Nurse Educ Today. 2014;34:57–60.
Not applicable. 17. Papastavrou E, Lambrinou E, Tsangari H, Saarikoski M, Leino-Kilpi H. Student
nurses experience of learning in the clinical environment. Nurse Educ Pract.
Ethics approval and consent to participate 2010;10:176–82.
The research protocol has been approved by the Cyprus National Bioethics 18. Levett-Jones T, Lathlean J, Higgins I, McMillan M. Development and psychometric
Committee and additional approvals to conduct the study and access the testing of the belongingness scale-clinical placement experience: an international
students gained from the relevant Universities’ Boards. Permission to use the comparative study 1497. Collegian. 2009;16:153–62.
research instrument obtained from its developer Dr Saarikoski (personal 19. Brynildsen G, Bjørk IT, Berntsen K, Hestetun M. Improving the quality of
contact) as well as its adaptors to Greek language (Dr Papastavrou and Dr nursing students’ clinical placements in nursing homes: an evaluation study.
Lambrinou). The aims of and the rationale for the study, and assurances that Nurse Educ Pract. 2014;14:722–8.
the data would be processed anonymously were outlined verbally. The 20. Dimitriadou M, Papastavrou E, Efstathiou G, Theodorou M. Baccalaureate
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they had completed their clinical placement, during a nursing laboratory environment. Nurs Health Sci. 2015;17:236–42.
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Author details 22. Sundler AJ, Björk M, Bisholt B, Ohlsson U, Engström AK, Gustafsson M.
1
Department of Nursing, School of Health Sciences, Cyprus University of Student nurses’ experiences of the clinical learning environment in relation
Technology, Limassol, Cyprus. 2Statistician, Department of Economics and to the organization of supervision: a questionnaire survey. Nurse Educ
Finance, School of Business, University of Nicosia, Nicosia, Cyprus. Today. 2014;34:661–6.
23. Christiansen A, Prescott T, Ball J. Learning in action: developing safety
Received: 7 December 2015 Accepted: 7 July 2016 improvement capabilities through action learning. Nurse Educ Today.
2014;34:243–7.
24. Hartigan-Rogers JA, Cobbett SL, Amirault MA, Muise-Davis ME. Nursing
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