Nursing Students Perspectives of an Effective Clinical Learning Environment – A Qualitative Study


Mrs. Devakirubai E., Dr. Mrs. Juliet Sylvia, Ms. Lynn Antoinette Bentick

Professors in Nursing, Sacred Heart Nursing College, Madurai, Tamil Nadu

IV year B.Sc (N) Student, Sacred Heart Nursing College, Madurai, Tamil Nadu

*Corresponding Author Email:




Background: All nurse educators unanimously agree that clinical competence is essential to fulfil the role of a professional nurse. Nursing student’s perspectives on their clinical experience would provide greater insight in promoting a positive clinical learning environment. So the current aimed to explore the perspectives of nursing students regarding effective clinical learning environment.

Methods: Three focus group interviews were conducted among 15 students who were selected purposely from second, third and fourth year Nursing students. A qualitative data analysis technique was followed to arrive at the final themes. Results: Six themes emerged from the qualitative analysis and they were ‘inadequate clinical facilities’, ‘ anxiety towards clinical experience’, ‘attitude of nursing staff towards students learning’, ‘theory-practice gap’, ‘lack of mentors’ and ‘professional role ambiguity’ which hindered their effective clinical learning.

Conclusion: The study finding highlights the obstacles encountered by the students in clinical areas. This necessitates the nurse educators to re-examine and to use innovative clinical teaching strategies to promote an effective learning environment.


KEY WORDS: Effective clinical learning   environment, Nursing Students , Perspectives)




The clinical setting is fundamental to the nursing students learning because it offers opportunities for them to work with real clients with real problems. It is only in the clinical setting that student nurses can use knowledge in practice, develop competency in psychomotor skills and become socialized in their future roles1.  Clinical practice is fundamental to the nursing students learning, however, many experience problems and difficulties during their clinical practicum. There is an extensive amount of literature highlighting the problems that affect the student’s clinical learning. Stress, anxiety, the initial clinical experience and the theory-practice gap are some of the problems discussed.

Moreover, problems and difficulties experienced by nursing students in the clinical setting may lead to their failure to learn and rejection of the nursing profession1.



Although nursing care has changed significantly over the past 30 years, methods to clinically train nursing students have not. The traditional model of clinical nursing education, where a faculty member oversees a group of six to eight students on an acute care unit for a four to eight hour shift, provides a haphazard approach to learning. A need exists to find innovative ways to effectively train nursing students to better prepare them for today’s health care environment2.


To meet the needs of today’s graduates, nursing education must re-examine the academic and clinical preparation of nurses. Four case studies sought to identify the perceptions of recent baccalaureate nursing graduates regarding their clinical experiences and if they felt prepared to enter the practice arena. Qualitative and quantitative methods were used to obtain data in the form of a mailed self-administered questionnaire developed by the researcher. Statistical analysis indicated that, although the academic clinical experiences wee generally positive, there were significant differences in what actually occurred and what graduates deemed important for their preparation for practice. Faculty must be aware of effective teaching practices and be supported in that role. A preceptor type of experience was noted to be the most effective clinical experience in preparing students for the reality of independent practice. Nursing education must re-examine current approaches to clinical teaching and seek methods to better prepare future nurses3.


The clinical learning environment is recognized as a complex entity with direct impact on learning outcomes, providing student nurses with opportunities to combine cognitive, psychomotor and affective skills, and problem solving abilities. Fretwell and Ogier identified the following factors that promote and hinder clinical student learning 4




Adequate levels of qualified staff and the accessibility of mentors with appropriate educational preparation

Poor clinical knowledgebase of mentors

Effective two-way communication

Lack of enthusiasm in learners or mentors

Effective leadership

Heavy workload of mentors

Staff confidence and responsibility

Mentors and team leader’s attitude to the need for teaching

Practical demonstration of skills

Low staff-student ratio

Students feeling they can take their time over performing clinical skills

Lack of organized teaching programs

Teaching on a one-on-one basis

Poor leadership qualities

Full explanation of procedures

Mentor ill-prepared for student through insufficient communication between university tutor and mentor regarding learning outcomes

Clear objectives for the placement

Mentors not updated on revised preregistration curricula

Students feeling valued as team members

Unavailability of mentor to integrate theory and practice

Students being treated with respect and their supernumerary status honoured



The nursing student’s lived experience of clinical practice was studied qualitatively by Chapman and Orb. The major themes identified in the study were those of clinical practice enhancement, clinical practice: the real world, and hindrance. It was concluded that participants provided the students with the opportunity to link theory with the practice of caring for clients. Participants considered that there were many factors that enhanced the student’s clinical experience. It is not surprising that one of these factors was the positive relationship with their clinical teachers and agency staff. Hindrance was viewed in terms of what made clinical practice harder and that which hindered their learning. Hindrance was associated with personal difficulties, feeling frustrated, being tired and feeling angry when student’s needs were not recognised1.



Qualitative approach using focus group discussion technique was used to elicit the perception of nursing students on an effective clinical learning environment.  The purpose of using focus group is to obtain information of a qualitative nature from a predetermined and a limited number of people.  The study was conducted in a selected College of Nursing of Madurai District.  A total of 15 nursing students (5 students each from II year III year & IV year) were recruited for the study using intensity sampling strategy of purposive sampling technique.  A focus group guide was used to collect the data. The purpose of the study was explained to the participants and an informed consent was obtained.  A total of 3 focus group discussions were held, with each discussion lasting for an hour.  The investigator moderated the sessions.  Simultaneously the discussion was tape recorded and debriefing notes were taken by a recorder.



The flow of events in the data analysis is depicted as below:


Interpretation of findings and discussion:

The group consisted of 60% girls and 40% boys aged between 18-22 years. The qualitative analysis led to the emergence of six themes and they were as follows:

Theme 1:    Lack of clinical facilities

Theme 2:    Anxiety towards clinical experience

Theme 3:    Attitude of nursing staff towards student     learning

Theme 4:    Theory - practice gap

Theme 5:    Lack of clinical mentors

Theme 6:    Professional role ambiguity


Theme 1: lack of clinical facilities:

All the participants expressed their difficulties experienced with regard to clinical infrastructure. Students felt that the hospital infrastructure should facilitate both patient care and student learning which is highlighted in the following verbatim.


One of the students expressed:

“A separate clinical teaching room with facilities to use all type of AV aids like projectors, LCD’s etc, a rest room and library-including internet facilities on each floor would be nice to have.


Another student expressed:

“Most of the time hospital infrastructure is designed only to provide patient care and students find it inconvenient when there is no provision to keep their bags and note books”.


Theme 2: Anxiety towards clinical experience:

Almost all the students felt anxious when they are moved from theory to clinical postings and from one clinical area to an unfamiliar clinical area.  The intensity of anxiety was higher for second year students when compared to fourth year students.


One of the students felt:

“On the first day I was so anxious about even going near the patient, I remember when I was posted in a new area I avoided doing new procedures;  Kept running away when called me for assistance.


Another student expressed: 

“Once a doctor and a staff nurse scolded me in front of a patient and his relatives for a simple mistake, I felt really embarrassed and thereafter hesitated to even perform a simple procedure.


Theme 3: Attitude of nursing staff towards student learning:

Almost every student mentioned that the number of nursing staff was inadequate and hence were unable to contribute towards student learning.


One of the students reported:

“The ward staff is so busy with their work that they are unable to guide us with the care of the patient. Without this guidance we students loose our thirst to learn leading us to failure”.


One of the participants expressed:

“All staff consider us as beginners and believe that we do not possess adequate skill to perform procedures”.


About half of the students mentioned that if there were adequate staff nurses they could teach the student nurses efficiently.


Theme 4: Theory -practice gap:

This theme emerged from 2 focus group discussions.


One of the students expressed:

“We go to the clinical area without learning many disease conditions, then about a month or so later we learn them in theory.  This does not allow us to gain a complete understanding of the particular disease.


Yet another participant felt:

“We learn all our procedures on the dummy n our theory class but in the hospital we realize that a dummy and a patient are totally different it would therefore be good if the teaches demonstrate the procedures once again on the real patient so that we gain confidence in performing those procedures on the patient”.


All the students clearly portrayed that there is a gap between theory and practice.


Theme 5: Lack of clinical mentors:

The study findings brought to light that there is a lack of clinical supervisors.


One of the students reflected:

“There should be adequate number of teaching staff in the clinical area to supervise us in performing procedures; this could enable us to complete our requirements”.


Yet another student added:

“Teachers should be friendly, approachable with positive criticism rather than being judgmental”.


The clinical instructor or mentors play an important role in student nurses’ self confidence, promote role socialization, and encourage independence which leads to clinical competency.


Theme 6: Professional role ambiguity:

One of the views that was frequently expressed by student nurses in the focus group sessions was that students often thought that their work was not really professional nursing. They were confused by what they had learned in the theory and what they saw in reality. The student nurses were unable to see & experience profession nursing roles taught in theory being practiced in the clinical settings.



One of the students opined:

“In the class room we learn so many procedures, ethics, values and various advanced roles of a nurse; but in reality we are not able to carry out the same.  Most of the time we do very basic nursing procedures. Though we spend four years studying a lot, we don’t feel we are able to do a professional job.


The following study findings were in line with the above themes. Nursing students’ experiences of clinical practice was investigated qualitatively. Four themes emerged from the data and they were: i) Initial clinical anxiety ii) Theory-practice gap iii) Clinical supervision iv) Professional role5.  A qualitative study that described the nursing students’ expectations regarding effective clinical education led to the emergence of three themes: i)appropriate communication and interaction between instructors and students ii) incorporation of both theory and practice gap between theory and practice in clinical education iii) Having specialised instructors with the specific emphasis on the instructors’ knowledge and motivation6 .



·        The views expressed by the participants were limited to one single setting

·        The views of the participants collected through focus group interview technique could not be strengthened by field observations.



·        There should be provision for a class room for conducting ward teachings.

·        In affiliated hospitals, there should be provision to keep the equipments of nursing students.

·        Permission should be sought for the use of hospital library by the college authority.

·        A strong collaboration between the academic faculty and health professionals in the clinical environment will facilitate positive attitude towards the fulfillment of the clinical learning objectives.

·        Apart from simulations in the demonstration room, clinical demonstration could promote confidence among nursing students.

·        During initial clinical postings to overcome reality shock, adequate orientation, support from clinical instructors and the length of clinical postings to be increased gradually in a phased manner are to be implemented.

·        Regular continuing nursing education that would prepare clinical instructors to serve as mentors rather than evaluator needs attention.



Clinical practice deals with real life, face-to-face contact with clients and health care professionals that exposes the students to a variety of health care settings. The art of caring for real clients cannot be practiced only in the laboratories but by exposing them to quality clinical experience. The current study revealed theory-practice gap, inadequacies in the clinical environment towards student learning, and lack of mentors. From this perspective, nurse educators must recommit themselves to ensure quality clinical learning for the future practice of professional nursing.



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2.       Niederhauser V, Schoessler M, Gubrud-Howe PM, Magnussen L, and Codier E. Creating Innovative Models of  Clinical Nursing Education. Journal of Nursing Education 2012, 51(x). Doi:10.3928/01484834-20121011-02.[Accessed on 28th October, 2013].

3.       Hickey MT. Baccalaureate Nursing Graduates’ Perceptions of Their Clinical Instructional Experiences and Preparation for Practice. Journal of Professional Nursing 2010, 26(1): 35-41. Doi:10.1016/j.profnurs.2009.03.001. [Accessed on 28th October, 2013].

4.       Kirkham SR, Harwood CH, Terblanche L, and Hofwegen LV. The Use of Clinical Placements in Nursing Education: A National Survey. Western Region Canadian Association of Schools of Nursing., Trinity Western University.   [Accessed on 28th Oct, 2013].

5.       Sharif F and Masoumi S. A Qualitative of Nursing Students Experiences of Clinical Practice. BMCNursing 2005, 4(6): doi:10.1186/1472-6955-4-6 [Accessed on 28th October, 2013].

6.       Esmaeili M, Cheraghi MA, Salsali M and Ghiyasvandian S. Nursing Students’ Expectations Regarding Effective Clinical Education: A Qualitative Study. International Journal of Nursing Practice 2013, doi: 10.1111/ijn.12159.[Accessed on 28th October, 2013].







Received on 04.11.2013           Modified on 28.11.2013

Accepted on 03.12.2013           © A&V Publication all right reserved

Int. J. Adv. Nur. Management 1(1): Oct.- Dec., 2013; Page 18-21