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Undergraduate nursing students' experience related to their clinical learning environment and factors aﬀecting to their clinical learning process
Burcu Arkana,∗, Yaprak Ordinb, Dilek Yılmazc a
Uludag University, Health Science Faculty, Psychiatric Nursing Department, Bursa, Turkey Dokuz Eylül University, Nursing Faculty, Department of Surgical Nursing, İzmir, Turkey c Uludag University, Health Science Faculty, Fundamentals of Nursing Department, Bursa, Turkey b
A R T I C L E I N F O
A B S T R A C T
Keywords: Nursing education Clinical learning Clinical learning environment Experience Qualitative research
Clinical education is an essential part of nursing education. The purpose of this study was to explore nurse students' experiences related to cinical learning environments, factors eﬀecting to clinical learning process. Descriptive qualitative design was used in this study, and data were collected from 2nd class nursing student (n = 14). The study took the form of in-depth interviews between August–October 2015. The qualitative interviews were analyzed by using simple content analysis. Data were analyzed manually. Experiences nurse students are described ﬁve themes. The themes of the study are (1) eﬀecting persons to clinical learning, (2) educational atmosphere, (3) students' personal charactering, (4) the impact of education in school, and (5) students' perceptions related to clinical learning. Participants stated that they experienced many diﬃculties during clinical learning process. All students importantly stated that nurse teacher is very eﬀecting to clinical learning. This study contributes to the literature by providing data on beginner nursing student' experiences about clinical learning process. The data of this present study show to Turkish nursing student is aﬀecting mostly from persons in clinical learning. The data of this present study will guide nurse teacher when they plan to interventions to be performed to support student during clinical learning process.
1. Introduction Nursing education consists of theory and practice. Clinical learning forms half of the educational experience of students in nursing education (Warne et al., 2010). Nursing students need to practice in an environment that will provide them with individual and professional development. Clinical education ensures delivering information and skills related to patient care for students. The objective of clinical education is to improve students' professional critical thinking and decision-making skills and increase their self-conﬁdence (Elçigil and Sarı, 2007). The clinical education environment is a social environment where there are individuals with diﬀerent expectations and requirements and control of the conditions that aﬀect learning is poor (Chan, 2002). These features of the clinical environment complicate providing appropriate learning conditions to students and result in stress among students and trainers (Rahmani et al., 2011; Karaöz, 2013; Elçigil and Sarı, 2007). In clinical learning, a positive learning environment, clinical trainer support (Chan and Ip, 2007; Serçekuş and Başkale, 2016; Warne et al., 2010), face-to-face communication with students
(Rahmani et al., 2011), long-term clinical learning experience (Warne et al., 2010), the peers a student has (Serçekuş and Başkale, 2016; Kelly, 2007; Peyrovi et al., 2005) and communication with patients (Rahmani et al., 2011; Serçekuş and Başkale, 2016; Suikkala et al., 2008; Warne and McAndrew, 2008) are all important. Nurse trainers mentor students during their clinical education and develop students' learning outcomes and competencies (Spitzer and Perrenoud, 2006). It has been pointed out that the communication between trainers and students in the clinical environment (Cilingir et al., 2011; Mlek, 2011; O'Mara et al., 2014; Shahsavari et al., 2013; Yaghoubinia et al., 2014) and the support of the trainer are of importance (Serçekuş and Başkale, 2016; Karaöz, 2013). Trainers' skills in providing feedback and clinical and educational experience aﬀect the students' learning process (Kelly, 2007; Cilingir et al., 2011; Elçigil and Sarı, 2007). When students spend a long period of time in the clinic this increases the quality of nursing care and students' professional satisfaction (Warne et al., 2010). Furthermore, it has been suggested that the support of peers and eﬀective communication in the clinical environment has positive eﬀects on students' learning (Serçekuş and Başkale, 2016; Roberts, 2009; Kelly, 2007; Peyrovi et al., 2005). In
Corresponding author. Tel.: +90 532 7764843/+90 224 2942477; fax: +90 224 2942451. E-mail addresses: [email protected]
(B. Arkan), yapraksa[email protected]
(Y. Ordin), [email protected]
https://doi.org/10.1016/j.nepr.2017.12.005 Received 11 July 2016; Received in revised form 12 December 2017; Accepted 14 December 2017 1471-5953/ © 2017 Elsevier Ltd. All rights reserved.
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these models are ‘preceptorship’, the ‘mentorship system’ and the ‘faculty nurse educator’. In many higher education institutions providing nursing education in Turkey, the faculty nurse educator model is applied. The very ﬁrst clinical practical course in nursing undergraduate programs is generally given in the spring semester of the ﬁrst year, in Turkey. In the second year of education, students make medical visits as a part of the Internal Medicine and Surgical Nursing course. In the institute where this research was conducted, “Faculty Nurse Educator” model was in use and beginning of the second semester of the ﬁrst educational year the clinical practice experience was provided. The faculty member works together with the nursing student in the clinical environment. In the clinical application, the faculty member leads the way in planning and carrying out the students' nursing care and their communication with the patient. Nurses working in the clinic do not bear a direct responsibility for the clinical learning of students. Students observe the care-giving activities of nurses and their communication with the patient in the clinical environment. In the institution where this study was conducted, this faculty member training model is applied. In clinical application, the trainer to student ratio is one to 35.
previous studies, it has been reported that students' emotional interaction with patients is highly eﬀective in promoting learning. Students improve their communication skills and nursing practices during their communication with the patient. Simultaneously, students become aware of their own professional improvement through the feedback they receive from the patient in this process (Suikkala et al., 2008; Warne and McAndrew, 2008). Other factors eﬀective in clinical learning are the clinical environment which arises from features of the clinical environment, the attitude of clinical personnel, the number and characteristics of patients. Students are aﬀected negatively by physical inadequacies such as a lack of equipment and the absence of a common room in the clinical environment (Serçekuş and Başkale, 2016). Poor communication with personnel in clinical environment is an element also negatively affecting students' learning (Serçekuş and Başkale, 2016; Dadgaran et al., 2013; Madhavanpraphakaran et al., 2014; Zadvinskis et al., 2011; Isaacson and Stacy, 2009). Students require the support of nurses working in the clinic (Luanaigh, 2015). Students are stressed when they do not feel like a member of the team (Mlek, 2011; Isaacson and Stacy, 2009). The failure to relate theoretical knowledge to practice is also a signiﬁcant problem in terms of clinical learning. In many studies, it is pointed out that the gap between theory and practice aﬀects students' learning negatively (Khater et al., 2014; Peyrovi et al., 2005; Sharif and Masoumi, 2005; Elçigil and Sarı, 2007; Serçekuş and Başkale, 2016). In clinical learning, the number of patients that students provide care for and the characteristics of the patients also aﬀects learning (Walsh and Seldomridge, 2005; Rahmani et al., 2011; Isaacson and Stacy, 2009). Another problem is when the activity of caring for patients and the expectations of the trainer cause exhaustion in students (Elçigil and Sarı, 2007). Clinical evaluation is another element creating stress in students in clinical education. Clinical evaluation is actually a part of clinical education. However, sometimes the evaluation process creates stress in students because of the trainers, a lack of clinical practice time, an excessive number of students or students' perceptions of their role as only something to be evaluated (Karaöz, 2013). Previous studies state that students experience particular anxiety about being evaluated (Mlek, 2011; Elçigil and Sarı, 2007; Cilingir et al., 2011; Serçekuş and Başkale, 2016). In all studies examining nursing students' clinical learning experience, an eﬀort is made to explain the eﬀects of the clinical environment. In two qualitative studies carried out in Turkey, it is stated that clinical environment has an eﬀect on students' learning (Elçigil and Sarı, 2007; Serçekuş and Başkale, 2016). As can be seen, the clinical learning environment is a signiﬁcant element in nursing students' clinical education. The nature of qualitative research is that the research results reﬂect the experience of the research sample. With this research, a diﬀerent group of students' experiences regarding clinical learning environment in Turkey will be reﬂected. Moreover, the speciﬁc experience of the clinical learning environment for nursing students within the Turkish culture, which has a diﬀerent socioeconomic structure, will be explained. Therefore, the present study aims to describe the experience of undergraduate nursing students related to their clinical learning environment and factors aﬀecting their clinical learning process.
2. Method 2.1. Study design Descriptive qualitative design (Sandelowski, 2000) was used in this study, and data were collected from 2nd year nursing students in individual interviews. Qualitative researches are supposed to make a choice regarding how the researcher will deﬁne the data acquired, no matter what type of data they are. The researcher should deﬁne the experiences of participants in an accurate order and realistic way so that their meaning will reveal. In qualitative researches, real-life meanings of events should be presented in everyday language. Phenomenological, theoretical, ethnographic and narrative descriptive researches help telling the events from diﬀerent perspectives. The researcher is required to give a greater meaning to the information she/he obtains apart from her/his interpretations and reveal the events accurately with all their reality. This tendency is provided through the methodology being selected. Descriptive qualitative research design is a research design that has the most limited number of theoretical approaches in terms of qualitative researches and where the researcher has no theoretical philosophical foresights. This research design allows us to deﬁne real-life experiences in detail without any theoretical or philosophical foresights in the natural course of events (Sandelowski, 2000). 2.2. Participants Participants were recruited from Nursing Department of a Health Science Faculty in western Turkey. Eligibility criteria were as follows: (a) volunteered to attend the study, (b) age of 18 years or more, (c) 2nd year baccalaureate degree nursing student, (c) being able to speak and understand Turkish. Maximum variation sampling was used. According to this sampling, when the students to be taken into sampling are determined, their gender, age, place of residence, income and satisfaction with the institution are taken into consideration. The Nursing Department of the Health Science Faculty is where the study was performed. There were a total of 150 students attending 2nd year baccalaureate degree nursing program meeting the inclusion criteria. Out of 150 students, 14 volunteered to join the study (Table 1).
1.1. Clinical nursing education in Turkey The Turkish nurse training curriculum follows the European Union Standards for Nursing and consists of a total of 4600 h. In Turkey, the nursing education program takes four academic years, including theory and clinical practice. Students in the Bachelor of Science Nursing (BSN) program fulﬁl 2300 clinical and 2300 theoretical hours during their studies. Around the world, diﬀerent models are applied in clinical education. The most commonly found models in the literature from among
2.3. Data collection The study was performed on 2nd class students between August and September 2015. In-depth semi-structured interviews were conducted, audiotaped and transcribed verbatim. In addition, the researcher took 128
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2.6. Ethical consideration
Table 1 Demographic characteristics (n = 14). Variables
Written consent was obtained from all participants prior to data collection. The study protocol was approved by the University NonInvasive Clinical Research Ethical Committee. Approval was given by the administration of the Health Science Faculty where the study was conducted.
Students Mean (SD)
Mean age (year) Min-Max (year) Gender Male Female Accommodation Dormitory Shared home with friends Working status Not working Working Satisfaction related to faculty Yes No Hesitant
21.85 (1.83) 20–27
7 (50%) 7 (50%)
3.1. Demographic characteristics
4 (28.6%) 10 (71.4%)
The distribution of the characteristics of the nursing students who participated in the study is presented in Table 1. According to the research, it was found that, the students agreed to participate in the study had an average age of 21.25 ± 1.83; where 50% of them were females, 71.4% of the participants had housemates, 78.6% were unoccupied and lastly, 42.8% were stated that they were satisﬁed with the education they were receiving.
11 (78.6%) 3 (21.4%) 6 (42.8%) 4 (28.6%) 4 (28.6%)
notes related to body language and verbal information. The interviews lasted for 30–40 min, with a mean duration of 32 min. All the interviews were performed by the ﬁrst author of the study. The interview included open-ended questions inquiring about nursing students' experience relating to their clinical learning environment and factors affecting their clinical learning process.
3.2. The themes of the study
2.4. Data analysis
3.3. Eﬀecting persons to clinical learning
The tape-recorded interviews were transcribed verbatim, and destroyed following transcription. The qualitative interviews were analysed by using content analysis (Sandelowski, 2000). Data were analysed manually. To ensure credibility of the ﬁndings and interpretations, the initial coding was collaborative: the ﬁrst author and the second author coded the transcripts and met at regular intervals to discuss emerging categories. In the ﬁrst step, each transcript was read several times by the ﬁrst author and an independent researcher to obtain an overall understanding. In the second step, signiﬁcant statements that pertained to the participants' experiences of the transition process were extracted from all transcripts. In the third step, the extracted signiﬁcant statements were condensed in to abstract statements. In the fourth step, the abstract statements were sorted into themes and sub-themes. Finally, the ﬁndings were contrasted and reviewed by two researchers independently to determine themes and sub-themes of the study. Then second author reviewed all the obtained themes and sub-themes.
Students pointed out that instructors, nurses, doctors, clinical personnel, patients, patient relatives and peers are eﬀective in clinical learning processes. All students expressed their instructor are highly eﬀective in their self-learning processes. Students stated that especially their instructors' ways of communication, clinical adequacy and communication with clinical nurses positively aﬀect their learning. Students expressed that instructors' asking too many questions, asking questions in front of patient and not providing eﬃcient feedback in clinical practice process negatively aﬀect students' learning. Many of students expressed that instructors' controllership is signiﬁcant in practice environment. Students expressed that in clinics with less supervision they do not pay attention to clinical practice hours and fulﬁl their learning responsibilities:
Students believe that instructors seek their deﬁciencies and have high expectations from them. They express their feel exhaustion and a great decrease of motivation for this reason. In meetings with students, it is observed that all the students experiences anxiety of evaluation many times:
The themes of the study are (1) eﬀecting persons to clinical learning, (2) educational atmosphere, (3) students' personal charactering, (4) the impact of education in school, and (5) students' perceptions related to clinical learning.
“Instructors cannot visit some clinics often since there are few instructors. We are quite free in these situations. Everyone leaves practice and go to drink coﬀee and the instructor do not notice whatsoever” (6th Student, Female, age 20)
Criteria for transparency and systematicity per quality guidelines for qualitative research were met (Meyrick, 2006). Multiple techniques to ensure rigor, including repeated in-depth review of the protocol by experienced qualitative researchers (BA, YO), iterative questioning, and investigator triangulation were employed (Başkale, 2016). The ﬁrst author who conducted interviews (BA) has worked as nursing educator for 12 years and has had training for qualitative methods. These condand third authors had expertise in qualitative methodology and have worked as nursing educator for above 10 years. Credibility was established by three authors who have considerable nurse educator experience with nursing students. To address potential bias, weusedopenended questions and tried to maintain objective attitudes throughout the interviews and analysis. The researcher took notes on the participants' responses during interviews. Two authors (ﬁrst and second author) analysed the data independently identiﬁed the main themes, and then compared their analyses. Also, it was made to a meeting for reached an agreement on the ﬁndings with all member of the study.
“Our instructors make visit with us and scold us a lot when we cannot answer a question during these visits. In this situation, we feel a great fear of getting a low score.” (5th Student, Female, age 20) All students expressed that nurses' positive and negative approaches directly aﬀect their clinical learning. Students stated that they learn more eﬃciently and become more motivated when nurses involve them into practices. Many students pointed out that they seldom see this positive attitude during clinical practice and are generally ignored by nurses. They stated this situation negatively aﬀects both learning process and their self-conﬁdence: “Nurses have a high impact on us because when they involve us into treatment and answer our question, we feel more encouraged” (1st 129
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Student, Male, age 20) Students stated that doctors make contribution to them and communicate with them. Only two of the students stated that doctors support their learning. All of the students pointed out that patients and patient relatives who do not have experience of hospital before are not willing to answer questions. Students stated that this situation blocks data collection stage in patient care process. Students expressed that patient relatives' overprotective attitudes restrict their opportunity to communicate with the patient and carry out practice. Students stated that patient relatives who stay in hospital for a long time performs nursing interventions other than drug administration. Therefore, students stated that these patient relatives are highly interfering and controlling when they are performing nursing practices:
3.5. Students' personal charactering Students expressed that being of the same gender with patient's companion facilitates communication and this is reﬂected on their interaction with patient. Some students stated that choosing the nursing department eagerly aﬀect their adaptation and success in clinical practices. Students pointed out that they have more positive view of practices and feel less stress as they proceed in terms of grades: “We had a good communication with patient's companion and he was helpful. I think this resulted from being of the same gender” (3rd Student, Male, age 20)
“Patient relatives' attitude towards me changes sometimes when they realise I am a student. They become more controlling over me since they stayed in the hospital for a long time.” (3rd Student, Male, age 20)
“I chose the department of nursing on my family's will not mine and that is why there was an adaptation period in the ﬁrst years. I experienced problems in my ﬁrst practices. Now I feel better and devote myself to the practice” (2nd Student, Male, age 20)
“Patients who are hospitalised for the ﬁrst time refrain from us. They do not answer our questions and patient relative supports that. Obviously, this is a big problem for us.” (4th Student, Male, age 27)
3.6. The impact of education in school
Students stated that their positive and negative interactions and cooperation with their friends aﬀect their learning. They expressed that attitudes of their friends and their academic success is a motivating factors in learning environment. Students pointed out the fact that when an erroneous practice they make during nursing practices they perform for the ﬁrst time, their willingness to try new practices is affected negatively. Students stated that presence of competition among some student groups creates a pressure over students:
Students stated excess number of students in laboratory practices in school and limited facilities negatively aﬀect their learning. Students expressed that practices learnt in laboratory shortly before clinical practice are more lasting. Furthermore, students pointed out that the practice they are shown in school and the one performed in the clinic are diﬀerent and this situation creates doubtfulness during a practice: “It would be better if we had more practice areas in our school. It is certain that a practice lectured on a model is much more diﬀerent than a practice lectured on board.” (7th Student, Male, age 21)
“We always work together with my friends and help each other to make up for each other. Sometimes we visit patient together and support each other during practices” (13th Student, Male, age 20)
“The practices taught us and the ones performed by nurses are diﬀerent. So I start thinking how I am going to do this” (14th Student, Female, age 21)
“Friend is a great element because it is the one that jokes about and creates a huge pressure on us when we make a mistake. They also follow what we can and cannot do. They think that an instructor favours me when teaches me something. All these situations are highly demotivating for me”. (11th Student, Female, age 20)
3.7. Students' perceptions related to clinical learning While referring to clinical practice processes, student stated that they pay great importance to medication. It is observed that they attach high importance to their drug administration while they are evaluating their own clinical learning. Furthermore, basing on students' statements it is understood that students perceive nursing care process as an assignment given by their instructors and they do not internalise clinical practices during performance:
3.4. Educational atmosphere All of the students stated that clinics are crowded in terms of the number of student. Students expressed that patient features and clinical culture in the clinic they perform practices aﬀect their learning. They pointed out that nurses' attitudes in some clinics are highly supportive and in some other clinics nurses are not supportive although the workload is the same. Students stated that number of patients, nursing care requirement and patient circulation in clinics where they perform practice aﬀect variety of nursing practices:
“Sometimes nurses do not perform treatment with us. In this case, our learning process takes a serious damage … and in this case a whole day of internship is wasted.” (7th Student, Male, age 21) “I cannot decide whether I should make a care plan or provide care to patient. I try to prioritise making a care plan since the instructor will demand the plan when he comes.” (8th Student, Female, age 20)
“We served our internship in the same clinic for a school term. This affected my highly negatively since I saw routine treatments, routine patients and diseases and similar patients and diseases every week” (3rd Student, Male, age 20)
Participants stated the fact that the clinic does not possess a computer which students can use to access patient data and make research and a break room where they can rest and share information negatively aﬀect their learning. They pointed out that since they live in a big city, they experience diﬃculties in terms of getting to clinic in time due to traﬃc and they do not have time to eat outside of the hospital in short lunch breaks since the hospital does not provide facilities to eat in the hospital:
Qualities of instructor and instructor's relationship with the student are signiﬁcant factors in clinical learning (Serçekuş and Başkale, 2016; Karaöz, 2013; Cilingir et al., 2011; Elçigil and Sarı, 2007). In this study, students stated that their learning is aﬀected negatively since instructors ask too many questions, ask questions bedside and do not provide feedback with appropriate communication method. In previous studies, it was stated that instructors' eﬀective relationship with students (Cilingir et al., 2011; Mlek, 2011; O'Mara et al., 2014; Shahsavari et al., 2013; Yaghoubinia et al., 2014) and their skills to provide feedback (Kelly, 2007; Cilingir et al., 2011; Elçigil and Sarı, 2007) are
“There is either a doctor or a nurse on the computer. There is always someone on the computer. We have to wait thirty minutes to one hour even to check a blood test result” (14th Student, Female, age 21) 130
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clinical learning and might cause competition among peers. The fact that instructor pays attention to provide similar learning opportunities to all students and perceives clinical evaluation as only a part of clinical learning is signiﬁcant (Isaacson and Stacy, 2009). As a result of this research; some of the students indicated that choosing nursing department voluntarily aﬀect their adjustment and success in clinical practices. Furthermore, students stated that their perspective grows more positive and they became less stressed as their grade levels move up. Choice of profession is individual's canalization towards the one that is suitable for itself among the occupational options (Karadağ et al., 2013). However, this canalization is aﬀected by many factors such as status of profession, employment opportunities, skills, interest, occupational values, gender, family's educational and income level (Karadağ et al., 2013; Özpancar et al., 2008). In a study conducted in Turkey, Köşgeroğlu et al. (2009) pointed out that majority of nursing students voluntarily chose nursing profession. In another study, students reﬂected that they chose nursing profession because of its convenience in employment after graduation (Aktaş and Karabulut, 2016). It is thought the fact that students choose nursing profession voluntarily might increase their desire to learn and positively aﬀect their success in clinical practices. Moreover, in some of the studies, similar to our study, it is emphasized that students are under stress especially in the ﬁrst years of their training (Elçigil and Sarı, 2007). This situation shows that students' level of stress in clinical area decreases as their grade level increases. Students who participated in the study pointed out that being of the same sex with companion facilitates their communication and this is reﬂected on their interaction with patient. In literature; it is stressed that male nurses have trouble in professions that are identiﬁed with women by the society because of sexist roles (Clow et al., 2014; Liminana-Gras et al., 2013; Rajaich et al., 2013; Zamanzadeh et al., 2013). It is observed that male students in this study sometimes might have trouble in clinical practice and make communication easier with patients and companions of the same sex. In this study, students indicated the fact that the number of students is too high in clinical practices and restricted resources negatively aﬀect their learning and the practice displayed in the laboratory in school and the one in clinic are diﬀerent from each other which creates nervousness during practice. In literature, it is indicated that the diﬀerences and gap between theory and practice create a considerable level of stress during clinical practices (Evans and Kelly, 2004). In a study conducted in Turkey, students stated that they have diﬃculty in transferring the knowledge they obtained in theoretical class to clinical environment and the clinical skills they learnt in skills laboratories in school are not applied in the same way in the hospital (Elçigil and Sarı, 2007). Similar results were found in other studies on this subject (Khater et al., 2014; Peyrovi et al., 2005; Serçekuş and Başkale, 2016; Sharif and Masoumi, 2005). It was observed that students who participated in this study attach great importance to medication while they are evaluating their own clinical learning. It is deduced from these results that students do not adopt functions such as providing care; patient training and patient diagnose which are other signiﬁcant functions of nursing during clinical evaluation process. Students see nurses working in clinic as role models in clinical learning. The fact that students attach great importance to medication might be related to the fact that nurses primarily implement medication practices and cannot allocate adequate time to other cares because of limited number of nurses in Turkey.
eﬀective in clinical learning. Students are negatively aﬀected since they are afraid of losing trust of patients in case of their failure in answering questions when instructors ask questions bedside (Cilingir et al., 2011; Elçigil and Sarı, 2007; Serçekuş and Başkale, 2016; Yaghoubinia et al., 2014). For this reason, it is recommended to not ask questions to students bedside (Serçekuş and Başkale, 2016). Instructors' experience in clinical teaching positively aﬀects clinical learning (Kelly, 2007; Cilingir et al., 2011; Elçigil and Sarı, 2007). Therefore, it is signiﬁcant that instructors who do not have experience in clinical teaching receive training on clinical learning and gain experience by working with an experienced instructor. In this study, students speciﬁed that they suﬀer from exhaustion and lose motivation to learn because of high expectations of their instructors. In previous studies, students pointed out that preparing a nursing care plan during clinical practice takes up a great portion of their time, they have considerable diﬃculty in preparation and are under a lot of stress for these reasons (Elçigil and Sarı, 2007; Altıok and Üstün, 2013). In the institution where this study was conducted, students are expected to prepare a care plan and this situation might have created stress in them. Another important factor causing such feelings in students is students' fear of low evaluation by their instructors (Karaöz, 2013; Mlek, 2011; Cilingir et al., 2011; Elçigil and Sarı, 2007). In Turkey, instructors are responsible from guiding and evaluating students in clinical practice. Therefore, instructors' expectations from students create an evaluation stress on students (Serçekuş and Başkale, 2016). Instructors' primary role in clinical learning is to facilitate learning process but sometimes due to diﬀerent reasons, instructors might perceive their role as grading students (Isaacson and Stacy, 2009). The number of students per lecturer and instructor in Turkey is 74 for 2015 (OSYM, Statistics Guidelines) and this rate (NEPAB, 2013; Texas BON, 2013) (minimum, 1 lecturer for 10–20 students) is highly over the universal standards determined for nursing education which is an applied profession. High number of students might cause clinical instructors to not be able to allocate adequate time to student and have concerns of failure in evaluating students correctly (Karaöz, 2013). Guidance nurse practice is becoming popular in clinical education because of lack of instructor. In clinical training, nurses' interaction with students and being a role model for students is a signiﬁcant chance of learning (Serçekuş and Başkale, 2016). However, nurses' exclusion of students from the team, not supporting them and not making eﬀective communication with them negatively aﬀect students' learning (Mlek, 2011; Kelly, 2007; Serçekuş and Başkale, 2016). While the number of nurses per 100.000 patients is 252 in Turkey, this number is 882 for WHO European Area (TR. Ministry of Health, 2014). Therefore, nurses cannot allocate time for training of students since the number of patients they are responsible for is too high. Some of instructors' responsibilities in nurses and other personnel's not embracing students are to pay attention to students' period of adaptation into service, maintain communication with the team and to minimize possible communication problems (Isaacson and Stacy, 2009). In this research, it is a signiﬁcant subject that students' learning processes are negatively aﬀected because of patient relatives' overprotective attitudes. Patient relatives are by the patient 24 h a day and can pursue interventions about self-care of the patient due to inadequate number of nurses. While students are implementing self-care interventions to the patient they are providing care for, they might be subjected to supervisory behaviors of patient relatives. Furthermore, students might have problem in making communication with the patient because of overprotective attitudes of patient relatives. Peer interaction is a signiﬁcant element in learning. In this study, students reﬂected that academic success of their peers and their positive interactions with their peers positively aﬀect their learning. In previous studies, it was indicated that interaction and support of peers are effective in clinical learning (Serçekuş and Başkale, 2016; Roberts, 2009; Kelly, 2007; Peyrovi et al., 2005). Clinical evaluation is a process within
5. Conclusion and recommendations As a result of ﬁndings obtained in the research, the elements affecting students' clinical learning environment are; eﬀecting persons to clinical learning, (2) educational atmosphere, (3) students' personal charactering, (4) the impact of education in school, and (5) students' perceptions related to clinical learning. It was determined that students 131
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are highly aﬀected by instructor's qualities and approaches in clinical learning environment. Furthermore, it is observed that students are negatively aﬀected by excessive number of students in professional skills laboratories in clinical learning environment. In line with these results, it is recommended to;
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• Develop clinical training nursing training strategies in major group • •
because of high number of students both in clinical environment and theoretical classes (case study, simulation training etc.) Evaluate curriculum again and reorganize clinical learning and theoretical training environment Fill the gap between theoretical and clinical practice and develop activities aimed at improving cooperation between school and hospital in every institution providing nursing training in order that this reﬂects on students' training positively.
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