SATISFACTION ON CLINICAL LEARNING ENVIRONMENT AMONG NURSING STUDENTS OF SELECTED MEDICAL COLLEGES OF CHITWAN, NEPAL

Background: Clinical learning environment includes everything that surrounds students and is extremely beneficial in stimulating their critical thinking and affects their professional development via focus on clinical judgment and decision–making in the clinical setting. This study aims to assess the level of satisfaction on clinical learning environment among nursing students of selected medical colleges of Chitwan, Nepal.


INTRODUCTION
Clinical Learning Environment (CLE) is a workplace for the staff and a learning place for the student helping students with clinical judgment and decision-making, [1][2][3][4] in motivating their critical thinking 5 and identifying the consequences of their mistakes. 6 Nursing students' satisfaction is considered as an important factor of contemporary nursing education 7 that enhances students' professional responsibility and desire to choose specific specialties to be subsequently employed within. [8][9][10][11] Researches show strong positive correlation between CLE and student satisfaction, 12 and even higher at government hospitals than those at private hospitals. 13 The challenges faced by nurses in today's health care settings have highlighted the necessity for graduating nursing students to feel both competent and prepared for practice. 14 Since, limited studies are found done in Nepal, this study was aimed to assess the satisfaction on clinical learning environment among Nursing Students of Selected Medical Colleges of Chitwan.

METHODS
Descriptive, cross sectional study design was used to assess the satisfaction on clinical placement among nursing students of selected medical colleges of Chitwan. There are four medical colleges affiliated to three different universities (each university has single college except one which has two colleges) running B.Sc Nursing program. Since, one college refused to participate in our study, other three colleges were included (each from three different universities). All the students studying B.Sc. Nursing in 2 nd year, 3 rd year and 4 th year of three different colleges willing to participate were taken for the study (B.Sc. Nursing 1 st year were excluded as they did not have at least 6 months of clinical exposure). Among 253 students, only 242 students were available during the period of data collection. Standard tool CLES + T scale developed and validated by Saarikoski et al. was used which consisted of two parts. 15 Part I included demographic and academic information and part II included CLES+T scale (total of 34 items) that measures the satisfaction of students regarding different components of clinical learning environment viz. pedagogical atmosphere(PA), leadership style of the ward manager (WM), premises of nursing on the ward (NC), supervisory relationship (SR) and role of nurse teacher (NT).
Satisfaction regarding each item of this scale was scored on a 5-point Likert-type scale ranging from "very dissatisfied" to "very satisfied" (total score of 34 items be 170) and the level of satisfaction was categorized as: High level of satisfaction ≥ means score and Low level of satisfaction < mean score. Data were collected from 2 nd of May to 14 th of May 2019. Prior to data collection, ethical clearance was obtained from Chitwan Medical College Institutional Review Committee (CMC-IRC) after presenting the proposal to the board. Data collection permission was taken from the authorities of respective colleges. Verbal informed consent was taken from each student. Confidentiality and anonymity were assured by not disclosing the information given by them and code number was given instead of students' name while collecting and entering data in the computer program. The dignity of students was secured by giving right to reject or discontinue from the research study at any time. Data collection took place in a classroom of respective colleges where researcher themselves distributed and immediately collected the tool giving 20-30 minutes to each to complete the questionnaire on the same day. As the colleges are at distance apart, there was minimal chance of mixing of the students from different colleges. Data collection was done within two weeks duration.
Field and Central editing done and the organized data was entered by using IBM Statistical Package for Social Science (SPSS) version 20.0. The data was further analyzed by using descriptive statistics and inferential statistics was used to measure the association between the variables. The findings of the study were presented in different tables.

RESULTS
In this study, most of the students (86.8%) were in the age group of 20 to 25 years with Median (IQR)= 21(22-20). Majority (95%) followed Hindu religion and more than half (54.5%) were Brahmin. Regarding socioeconomic status, most (95.5%) were from middle class family.
Most (39.7%) of the students were from Tribhuwan University followed by Purbanchal University (34.7%) and Kathmandu University (25.6%) affiliated colleges. More than one third (39.3%) were from B. Sc. Nursing second year. More than three fourth (76.4%) of the students were posted in private hospital in their latest clinical placement and 79 (32.6%) were posted in medical ward. Almost two third (65.3%) students have clinical placement in private hospital most of the time. Most (62%) of the students often have meeting with nurse teacher in the last posting (Table 1).
Among the five sub-dimensions of evaluation scale measuring satisfaction on clinical learning environment (with five point Likert scale), the mean score of respondent's satisfaction towards supervisory relationship was highest (3.69 ± 0.68) followed by satisfaction towards role of nurse teacher (3.61 ± 0.21), satisfaction towards leadership style of ward manager (3.45 ± 0.56), satisfaction towards pedagogical atmosphere (3.34 ± 0.56) and premises of nursing on the ward (3.18 ± 0.75). Among the total nursing students, nearly half of them 124 (51.2) were highly satisfied with the CLE provided to them. The level of association was categorized into two, low (<118) and high (≥118) based on the mean score (Table 2).  The level of satisfaction was highly significant with the year of study with p value <0.01. Third year students (75%) were more satisfied with the CLE than second (43.2%) and fourth year (32.3%) students. Type of ward of latest clinical placement was statistically significant with the level of satisfaction among nursing students with p value <0.05 (Table 3).

DISCUSSION
The current study was conducted to measure satisfaction towards clinical learning environment among the undergraduate nursing students from different universities using standard CLES+T tool. The result shows that more than half of the students are highly satisfied with their practice environment which is supported by the findings of the study done in Cyprus and nine countries in 2007-2008. 16 However, nearly half of them were still found to be poorly satisfied with their clinical learning environment.
Among the five dimensions of CLES+T tool, satisfaction was highest with supervisory relationship (3.69 ± 0.68) which is relatively similar to the findings of other studies. 7,17 This finding may be because of constant supervision of nurse teachers in the ward during their clinical placement shift providing conducive environment for learning. Students might feel confident in the presence of supervisor during their clinical placement. However, a similar study in Nepal revealed pedagogical atmosphere was one of the most common factors for dissatisfaction with clinical placement. 13 Nursing students need to learn from the situation without prior situational experience in the clinical placement where the role of nursing staff is critical to enhance learning. 13 However, due to the workload and huge responsibilities it may be impossible for nursing staff to create conducive learning environment in clinical. 13 The study findings showed no any significant difference between the total satisfaction and the different universities. There are some significant differences between university attended and satisfaction with the level of clinical placement support. 11 This study does not show any association with the type of hospital as with the other study. 7 However, a study from Nepal revealed that students' practicum satisfaction level at government hospital was significantly higher than those at private hospitals (t (260) = 4.50, p < 0.0001). 13 These might be because of insecure job service, stress in private hospitals which may lead to provision of poor ward environment for clinical placement. 13 The frequency of meeting NT with the student has no association with satisfaction on clinical learning. In contrast, the frequency of meeting with NT and mentor with satisfaction was demonstrated in a study conducted in Cyprus. 7 Further, this study showed student who had their latest placement in Gynae/Obstetric ward were highly satisfied with CLE. This might be due to the continuous presence of NT in the ward to facilitate learning. In addition, direct involvement of students in assisting birth and care of women and baby might have made them more satisfied.
A similar study in Rwanda revealed that despite the level of satisfaction with CLE, system is still having a big room for improvement which is needed to respond to quality education corresponding to the fourth sustainable development goal. 17 This may show a conflict of tasks and priorities between the health care needs and objective of universities' personnel. However, the presence of NT in the clinical posting has an influence on the nursing staff to involve them in the students' learning process. 19 The results of our study show only the satisfaction with the CLE. This does not offer comparison with the satisfaction and academic performance. Only three nursing colleges with only one nursing programme were included in this study which may not represent whole nursing students from different streams and self-administered nature of the instrument may contribute to bias. Qualitative aspects of the study could provide better understandings regarding the students' perceptions towards the CLE.

CONCLUSION
The CLES+T scale could be very useful to assess the satisfaction on CLE among nursing students providing adequate information to nurse educators regarding best clinical practices for improving the CLE of bachelor level nursing colleges of developing countries. In the long run, satisfaction level could be used as an important contributing factor towards changing the CLE to satisfy the expectations of the students in today's student's centered learning concept. Satisfaction towards supervisory relationship and role of NT were found highest than other three domains of CLE which clearly shows that improvement in this field would certainly yield positive learning environment for the nursing students. Further investigation is needed to identify the other factors that has important role in the satisfaction of the student on clinical learning area as well as adequate exploration on student's and teacher's interpretation of these concepts are required prior any implications for educational practice.

ACKNOWLEDGEMENT
Thanks to Mikko Saarikoski for the permission given for using CLES+T. We would also like to thank all the students for their valuable contribution.