Background
Nursing is a hands-on profession, and clinical practicum is a vital part of nursing education. By putting theory into practice, clinical training helps students to develop psychomotor, cognitive, and affective competencies, preparing them for success as professional caregivers [1, 2]. Although simulation offers valuable preparation for clinical experiences, it cannot fully replicate the complexities of real-world patient care within the clinical environment [3]. Interactions with patients aid students in acquiring professional skills for engaging with patients and navigating their diverse living circumstances. These learning opportunities foster the integration of theoretical knowledge with practical experience [2].
Creating a supportive clinical learning environment (CLE) is crucial for students to achieve their learning outcomes [4]. Four key aspects influence a student learning experiences in the CLE: the physical environment, psychosocial dynamics and interpersonal interactions, the overall culture of the organization, and the quality of teaching and learning methods used [5]. Studies and initiatives aimed at enhancing the CLE are essential not only for the students’ learning, their professional integration and welfare, but also for the quality of care they deliver throughout their careers post-graduation [3]. Prior to implementing any changes, it is essential to evaluate the CLE [1]. Therefore, measurement tools have been developed and validated to assess its effectiveness [1, 6‐8]. These tools pave the way for positive changes that will ultimately enhance the learning experience for students.
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An integrated review of studies utilizing the Clinical Learning Environment Inventory (CLEI) to assess the CLE revealed that, in general, students desire a more favorable environment compared to their actual experiences [4]. In line with this finding, a recent systematic review of research employing the Clinical Learning Environment, Supervision and nurse Teacher (CLES + T) scale concluded that despite students reported high satisfaction with the CLE, opportunities for improvement still exist [9]. The supervisory relationship was the most valued aspect of the CLE, while the nurse teacher’s clinical role received lower and inconsistent ratings [9].
The supervisory relationship is the key to foster student development as professional through role modeling [2]. In this approach, students learn by observing and evaluating the actions of experienced professionals. However, Effective clinicians may not inherently possess the qualities of effective supervisors [10]. Although preceptors claimed to have a high level of expertise and trust in their capacity to train student nurses, they also acknowledged the necessity for more assistance in fulfilling their teaching responsibilities [11]. To empower preceptors to fully guide students during their learning process, nurse teachers need to provide them sufficient support [12]. This can be achieved through developing, implementing and evaluating formal education program that equips preceptors with the necessary knowledge and attitude for successful supervision during clinical practicum [10‐12]. Research has revealed further issues including strained staff resources as a result of high patient demand, nurse shortages, and reduced remuneration [1].
Preceptorship model, in which students work under the supervision of experienced practitioners, proved to be very successful clinical teaching method for nursing and midwifery students [12]. The conventional approach for preceptorship was team supervision; however, there has been a growing focus on individual supervision due to its importance for student professional development [2]. Furthermore, studies show that students who receive individualized supervision tend to be more satisfied with the supervisory relationship [9, 13], which helps explain the growing popularity of this approach. Nevertheless, it’s crucial that the collaboration between the student and their preceptor is explicitly outlined in their mutual agreement, and that the preceptor specified in the agreement remains consistent throughout the student’s placement [2]. In such individual supervision, the term mentor is also used to designate the named personal preceptor [2].
In addition to clinical staff, nurse teachers, employed by educational institutions, play a vital role in student supervision within clinical settings. Beyond their academic responsibilities, these nurse teachers possess a crucial reservoir of knowledge essential for student learning [1]. While a teacher is adept at guiding the learning process, a preceptor serves as a practical expert and a key professional role model for students [2]. Therefore, collaboration between nurse teachers and preceptors is paramount for effective clinical experiences [1]. However, studies have shown a lack of appreciation for such collaboration, with nurse teachers often not being fully integrated as members of the nursing staff [14].
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Over the past decade in numerous European countries, the role of nurse teachers in clinical settings has shifted from being primarily a skilled clinical practitioner to acting as a liaison between educational institutions and healthcare providers [15]. This shift was largely due to the transition of healthcare education from diploma-level to bachelor-level programs within higher education institutions [2]. As a result, nurse teachers have needed to adapt their skill sets to prioritize teaching and research [15]. Certainly, approaches to collaboration can evolve and it’s not always necessary for a teacher to personally visit clinical settings [2]. Recent studies suggest that a digital educational tool can serve as an effective and advantageous supplementary approach to reinforce and promote the nurse teacher’s role in clinical nursing education [16, 17].
In Morocco, a comprehensive understanding of the CLE has been lacking until today. Research on CLE is scarce, with existing studies primarily intent on validating tools for evaluating the CLE quality [18, 19]. This study sets out to offer an initial insight into the CLE as seen by nursing and midwifery students and to propose enhancements for clinical education.
Nursing education in Morocco transitioned to higher education about ten years ago [18, 20], following a trend seen in European countries aligning with the Bologna process [21]. The undergraduate program spans three years, divided into six semesters, integrating theoretical and practical coursework totaling at least 2310 h. Clinical practicums, which make up more than half of the program, occur in various approved settings, including public health facilities. Both healthcare provider nurses and educational institute nurse teachers participate in clinical supervision. While the traditional team supervision approach remains common, research suggests more effective methods for fostering supportive learning environments.
This study aimed to evaluate nursing and midwifery students’ satisfaction with the CLE, and identify factors associated with their satisfaction in Morocco.
Methods
Study design, sample, and settings
Public nursing and midwifery education takes place in the Higher Institutes of Nursing Professions and Health Techniques (ISPITS), founded in 2013 following the implementation of the License-Master-Doctorate system. Managed by the Ministry of Health, these institutes provide high education curricula. The ISPITS network consists of ten primary institutes and related establishments situated throughout the country. This cross-sectional research involved undergraduate nursing and midwifery students from two ISPITS during the spring semester of the 2022–2023 academic year.
The study recruited participants based on convenience sampling methods, selecting eligible students who were easily accessible and inclined to participate at the time. Students were eligible if they: (1) were enrolled in their first, second, or third year of undergraduate studies; (2) had just finished a clinical practice placement in either a hospital ward or primary healthcare setting and (3) had given their informed consent. Students lacking previous experience in clinical practice or who chose not to take part were excluded from the study.
According to Cochran’s formula [22, 23], the sample size required for the study to be statistically reliable was 349. The assumptions were to get results with a 95% confidence level, a 5% margin of error, and a mean score and level of satisfaction of 3.26 (65.2%), based on previous research from Saoudi Arabia [24], similar to the Moroccan context. However, for better results and increased accuracy, the researchers decided to include all eligible students from both institutions involved.
Data collection instrument and procedure
To assess the CLE as perceived by nursing and midwifery students, the Clinical Learning Environment, Supervision and Nurse Teacher (CLES + T) scale [2] was selected. CLES + T was chosen over other potential instruments for several key reasons. First, it uniquely includes a dimension specifically dedicated to the role of the nurse teacher in the clinical setting [1], providing valuable insight into this crucial aspect of student learning. Second, the CLES + T is the most widely used and validated instrument [6, 7], demonstrating its robust psychometric properties across diverse populations and settings. Third, it offers a comprehensive and in-depth evaluation, covering the six key themes of the CLE identified by Hooven [1], thus providing a holistic perspective. Fourth, CLES + T has demonstrated adaptability to various clinical contexts, including primary healthcare settings [25], highlighting its flexibility and applicability.
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The Arabic version of the CLES + T scale (ar. CLES + T), previously validated for use in Morocco [18], was employed in this study. This prior validation confirmed the instrument’s reliability and validity for measuring students’ CLE perceptions in a similar cultural context. In the current study, the ar. CLES + T scale demonstrated satisfactory internal consistency, with a Cronbach’s alpha coefficient of 0.95 for all subscales. This version comprises 34 items distributed across five dimensions: pedagogical atmosphere on the ward, leadership style of the ward manager, premises of care on the ward, supervisory relationship, and role of the nurse teacher.
Additionally, a survey with six questions categorized the students’ supervision experiences into three groups [26, 27]. Unsuccessful supervision included: (1) The student did not have a named supervisor; (2) A personal supervisor was named, but the relationship with this person did not work or (3) The named supervisor changed during the placement. Group supervision involved: (4) The supervisor varied according to shift or place of work, or (5) The supervisor had several students and was a group supervisor rather than an individual supervisor. Successful supervision meant: (6) A personal supervisor was named and the relationship worked during the placement.
After completing their most recent clinical placement, students were provided with clear explanations regarding the study objectives, assurances of confidentiality and anonymity of their data. They signed the consent form and filled out a paper questionnaire at their institute. The questionnaire used a 5-point Likert scale for the 34 CLES + T items, along with additional questions about demographics and their educational background (age, gender, program, year of study, placement type, and practice duration).
Statistical analysis
The study used frequencies and percentages to describe the distribution of participants by demographic and educational backgrounds. To get an overall idea of participants’ experiences, the mean score of all item scores of the ar. CLES + T scale was determined. Likewise, mean scores for each dimension were determined by averaging the ratings of their respective items. Higher ratings reflect higher levels of satisfaction regarding the CLE.
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Prior to conducting inferential statistical analyses, the distribution of continuous variables was examined to assess normality. For this large sample (n = 1175), visual inspection of histograms and Q-Q plots was prioritized over formal normality tests. The latter, such as Shapiro-Wilk, are overly sensitive with large datasets [28, 29], often flagging minor departures from normality as statistically significant, even when they pose no practical threat to parametric analyses. Visual assessment provided a more nuanced evaluation of distributional shape, allowing us to focus on meaningful deviations [30]. Based on this, distributions were considered sufficiently normal for the selected parametric tests, which are robust to moderate non-normality in large samples due to the Central Limit Theorem [31].
The student’s t-test or analysis of variance (ANOVA) were utilized to assess the level of student satisfaction with the quality of the CLE across student groups based on their characteristics. If the ANOVA result was significant, Tukey’s Post-Hoc analysis was utilized to identify the specific groups that exhibited differences. Linear regression was used to identify the factors associated with student satisfaction regarding the CLE, supervision, and the role of the nursing teacher. Initially, univariate analysis was performed, followed by multivariate analysis. To avoid the impact of confounding variables, only statistically significant variables (p-value < 0.05) were chosen for analysis in the multivariate model.
Jamovi (version 2.3.21.0) was selected for statistical analysis [32]. It’s a free and open-source statistical software platform built upon the R statistical language, a widely recognized and powerful environment for statistical computing [33]. Jamovi offers a user-friendly interface while providing access to a wide range of advanced statistical procedures, ensuring the rigor and validity of the analyses conducted in this study [34].
Results
Sample characteristics
A total of 1175 students returned their questionnaires, representing a 91% response rate. The demographic and clinical placement characteristics of the participants are summarized in Table 1. As shown in the table, 73.3% of them were aged 18 − 20, and 82.9% were women. Over 81% of the participants were undergraduate nursing and completing their practicums in hospital settings. 41.0% of the participants were in their first year, with second-year students representing 36.7% and third-year students making up 22.3%. Most respondents (82.1%) achieved a 160-hour clinical practicum, while the remaining 17.9% achieved 120 h. Team supervision is the most common approach used in clinical settings (96.3%). In 42.1% of cases, the occupational title of the supervisor was the ward manager, followed by the nurse (22.8%) and the specialist nurse (19.6%). Half of the students said they’d never had an unscheduled private meeting with their supervisor.
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Table 1
Characteristics of respondents and conditions of supervision (n = 1175)
Characteristics | No. (%) |
|---|---|
Age (year) | |
18–20 | 861 (73.3) |
21–24 | 312 (26.6) |
25–46 | 2 (0.2) |
Gender | |
Female | 974 (82.9) |
Male | 201 (17.1) |
Study program | |
Nursing | 953 (81.1) |
Midwifery | 222 (18.9) |
Student year | |
First | 482 (41.0) |
Second | 431 (36.7) |
Third | 262 (22.3) |
Clinical setting | |
Hospital | 959 (81.6) |
Primary healthcare | 216 (18.4) |
Clinical practicum duration | |
120 h | 210 (17.9) |
160 h | 965 (82.1) |
Occupational title of the supervisor Nurse | |
Nurse | 268 (22.8) |
Nurse specialist | 230 (19.6) |
Ward manager | 495 (42.1) |
Other | 182 (15.5) |
Occurrence of supervision | |
Unsuccessful supervision | 33 (2.8) |
Team supervision | 1131 (96.3) |
Successful supervision | 11 (0.9) |
Frequency of separate, unscheduled private meetings with the supervisor | |
Not at all | 599 (51.0) |
Once or twice during the course | 215 (18.3) |
Less than once a week | 105 (8.9) |
About once a week | 91 (7.7) |
More often | 165 (14.0) |
Students’ satisfaction with the CLE and its dimensions
Overall student satisfaction with the CLE was moderate. Table 2 presents the mean scores for the overall CLE and each of its five dimensions. Regarding specific dimensions, the “Leadership of the ward manager” dimension received the highest rating, with students expressing greater satisfaction that “The ward manager regarded the staff on her/his ward as a key resource” compared to whether “The ward manager was a team member.” The “Premises of care on the ward” dimension received a moderate rating, with highest satisfaction for “Documentation of nursing was clear” and lowest for “The ward’s nursing philosophy was clearly defined.” The “Pedagogical atmosphere” dimension was in the middle range of satisfaction. Notably, “There were sufficient meaningful learning situations on the ward” was particularly well-rated, while “During staff meetings, I felt comfortable taking part in the discussions” received the lowest rating within this dimension. The “Supervisory relationship” dimension received the lowest rating, with student disapproval for “I felt that I received individual supervision” and “I continuously received feedback from my supervisor.” In contrast, “Mutual respect and approval prevailed in the supervisory relationship” was the highest-rated item. Finally, the rating for the “Role of the nurse teacher” dimension was also low, with “Nurse teacher as enabling the integration of theory and practice” rated highest and “Relationship among student, mentor, and nurse teacher” rated lowest within this dimension.
Table 2
Mean scores of the overall ar. CLES + T scale, dimensions and items (n = 1175)
CLES + T scale | Mean ± SD |
|---|---|
Overall ar. CLES + T | 3.21 ± 0.73 |
Dimensions | |
1. Pedagogical atmosphere on the ward | 3.27 ± 0.83 |
Item 1: The staffs were easy to approach | 3.42 ± 1.18 |
Item 2: I felt comfortable going to the ward at the start of my shift | 3.06 ± 1.40 |
Item 3: During staff meetings (e.g. before shifts) I felt comfortable taking part in the discussions | 2.89 ± 1.37 |
Item 4: There was a positive atmosphere on the ward | 3.16 ± 1.31 |
Item 5: The staffs were generally interested in student supervision | 3.03 ± 1.30 |
Item 6: The staff learned to know the student by their personal names | 3.07 ± 1.51 |
Item 7: There were sufficient meaningful learning situations on the ward | 3.99 ± 1.11 |
Item 8: The learning situations were multi-dimensional in terms of content | 3.42 ± 1.17 |
Item 9: The ward can be regarded as a good learning environment | 3.42 ± 1.30 |
2. Leadership style of the unit/ward manager (WM) | 3.32 ± 0.99 |
Item10: The WM regarded the staff on her/his ward as a key resource | 3.62 ± 1.22 |
Item 11: The WM was a team member | 3.08 ± 1.46 |
Item 12: Feedback from the WM could easily be considered as a learning situation | 3.24 ± 1.37 |
Item 13: The effort of individual employees was appreciated | 3.33 ± 1.25 |
3. Premises of care on the ward | 3.21 ± 0.95 |
Item 14: The wards nursing philosophy was clearly defined | 2.96 ± 1.28 |
Item 15: Patients received individual nursing care | 3.28 ± 1.29 |
Item 16: There were no problems in the information flow related to patients’ care | 3.11 ± 1.27 |
Item 17: Documentation of nursing (e.g. nursing plans, daily recording of nursing procedures etc.) was clear | 3.48 ± 1.31 |
4. The supervisory relationship | 3.14 ± 1.03 |
Item 18: My supervisor showed a positive attitude towards supervision | 3.34 ± 1.30 |
Item 19: I felt that I received individual supervision | 2.23 ± 1.29 |
Item 20: I continuously received feedback from my supervisor | 2.83 ± 1.34 |
Item 21: Overall, I am satisfied with the supervision I received | 3.04 ± 1.39 |
Item 22: The supervision was based on a relationship of equality and promoted my learning | 3.20 ± 1.41 |
Item 23: There was a mutual interaction in the supervisory relationship | 3.22 ± 1.33 |
Item 24: Mutual respect and approval prevailed in the supervisory relationship | 3.83 ± 1.29 |
Item 25: The supervisory relationship was characterized by a sense of trust | 3.39 ± 1.35 |
5. Role of the (clinical) nurse teacher | 3.16 ± 0.99 |
5.1. Nurse teacher as enabling the integration of theory and practice | 3.41 ± 1.11 |
Item 26: In my opinion, the nurse teacher was capable to integrate theoretical knowledge and everyday practice of nursing | 3.45 ± 1.25 |
Item 27: The teacher was capable of operationalizing the learning goals of this clinical placement | 3.35 ± 1.21 |
Item 28: The nurse teacher helped me to reduce the theory-practice gap | 3.42 ± 1.25 |
5.2. Cooperation between placement staff and nurse teacher | 3.12 ± 1.14 |
Item 29: The nurse teacher was like a member of the nursing team | 2.99 ± 1.34 |
Item 30: The nurse teacher was able to give his or her pedagogical expertise to the clinical team | 3.25 ± 1.27 |
Item 31: The nurse teacher and the clinical team worked together in supporting my learning | 3.12 ± 1.30 |
5.3. Relationship among student, mentor and nurse teacher | 2.95 ± 1.17 |
Item 32: The common meetings between myself, mentor and nurse teacher were comfortable experience | 3.03 ± 1.31 |
Item 33: In our common meetings I felt that we are colleagues | 2.85 ± 1.33 |
Item 34: Focus on the meetings was in my learning needs | 2.96 ± 1.34 |
Students’ satisfaction with the CLE according to their background
The study revealed several significant differences in student satisfaction based on various factors. As indicated in Table 3, male and nursing students were more satisfied with the “Pedagogical atmosphere” than their female and midwifery counterparts, respectively. Early-year students were generally more satisfied with all CLE dimensions than final-year students. Both “Supervisory relationship” and the “Role of the nurse teacher» were better rated in primary care settings versus hospitals. More extensive practicums correlated with higher satisfaction regarding the “Pedagogical atmosphere”, “Leadership style of the ward manager”, and “Premises of care”. Supervision by the ward manager was also linked to higher satisfaction across those same dimensions. Notably, “Successful supervision” was associated with greater satisfaction in “Pedagogical atmosphere”, “Supervisory relationship,” and “Role of the nurse teacher”. Finally, frequent supervisor meetings correlated with higher satisfaction across all CLE dimensions.
Table 3
Comparison of the mean scores of the overall ar. CLES + T scale and dimensions between student groups (n = 1175)
Factor | Overall Ar.CLES + T | Pedagogical atmosphere of the ward | Leadership style of the ward manager | Premises of care on the ward | Supervisory relationship | Role of the nurse teacher |
|---|---|---|---|---|---|---|
Age (year) | ||||||
18–20 | 3.24 ± 0.72 | 3.30 ± 0.81 | 3.33 ± 0.99 | 3.24 ± 0.93 | 3.18 ± 1.02 | 3.18 ± 0.97 |
21–24 | 3.13 ± 0.77 | 3.19 ± 0.87 | 3.29 ± 0.98 | 3.10 ± 0.99 | 3.02 ± 1.03 | 3.11 ± 1.02 |
25–46 | 3.29 ± 1.41 | 3.11 ± 1.10 | 3.88 ± 0.88 | 3.13 ± 1.23 | 3.00 ± 1.41 | 3.56 ± 2.04 |
P value | 0.089 | 0.092 | 0.601 | 0.082 | 0.079 | 0.486 |
Gender | ||||||
Male | 3.28 ± 0.73 | 3.41 ± 0.80 | 3.27 ± 0.99 | 3.24 ± 0.89 | 3.24 ± 1.00 | 3.20 ± 0.95 |
Female | 3.19 ± 0.74 | 3.24 ± 0.83 | 3.33 ± 0.99 | 3.20 ± 0.96 | 3.11 ± 1.03 | 3.15 ± 1.00 |
p value | 0.134 | 0.008 | 0.477 | 0.618 | 0.128 | 0.491 |
Study program | ||||||
Nursing | 3.23 ± 0.73 | 3.32 ± 0.83 | 3.34 ± 0.99 | 3.23 ± 0.95 | 3.16 ± 1.02 | 3.16 ± 0.99 |
Midwifery | 3.10 ± 0.74 | 3.08 ± 0.82 | 3.21 ± 0.95 | 3.11 ± 0.92 | 3.04 ± 1.01 | 3.13 ± 1.00 |
p value | 0.017 | < 0.001 | 0.068 | 0.101 | 0.110 | 0.627 |
Student year | ||||||
First | 3.34 ± 0.70*** | 3.37 ± 0.80*** | 3.42 ± 0.99*** | 3.31 ± 0.92*** | 3.30 ± 1.00*** | 3.33 ± 0.91*** |
Second | 3.18 ± 0.75** | 3.27 ± 0.81* | 3.33 ± 0.99* | 3.21 ± 0.95* | 3.09 ± 1.02* | 3.10 ± 1.05** |
Third | 3.00 ± 0.74 | 3.09 ± 0.88 | 3.11 ± 0.93 | 3.00 ± 0.98 | 2.90 ± 1.01 | 2.93 ± 0.97 |
p value | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 |
Clinical setting | ||||||
Hospital | 3.18 ± 0.73 | 3.25 ± 0.84 | 3.30 ± 0.99 | 3.20 ± 0.94 | 3.10 ± 1.02 | 3.12 ± 0.98 |
Primary healthcare | 3.33 ± 0.73 | 3.36 ± 0.79 | 3.41 ± 0.97 | 3.26 ± 0.96 | 3.29 ± 1.03 | 3.32 ± 0.99 |
p value | 0.009 | 0.106 | 0.117 | 0.394 | 0.016 | 0.006 |
Practicum duration | ||||||
120 h | 3.18 ± 0.75 | 3.08 ± 0.75 | 3.18 ± 0.96 | 2.98 ± 0.83 | 3.09 ± 0.92 | 3.17 ± 0.96 |
160 h | 3.31 ± 0.84 | 3.31 ± 0.84 | 3.35 ± 0.99 | 3.26 ± 0.96 | 3.15 ± 1.04 | 3.16 ± 0.99 |
p value | < 0.001 | < 0.001 | 0.031 | < 0.001 | 0.416 | 0.873 |
Title of the supervisor | ||||||
Nurse | 3.17 ± 0.76 | 3.18 ± 0.84* | 3.23 ± 1.03* | 3.16 ± 0.98 | 3.14 ± 1.03 | 3.15 ± 1.01 |
Nurse specialist | 3.18 ± 0.69 | 3.29 ± 0.81 | 3.25 ± 0.96 | 3.13 ± 0.90 | 3.14 ± 1.03 | 3.11 ± 0.97 |
Ward manager | 3.28 ± 0.73* | 3.37 ± 0.83** | 3.43 ± 0.96 | 3.32 ± 0.96* | 3.16 ± 1.04 | 3.20 ± 0.97 |
Other | 3.11 ± 0.73 | 3.11 ± 0.80 | 3.23 ± 0.98 | 3.06 ± 0.89 | 3.06 ± 0.97 | 3.11 ± 1.04 |
p value | 0.031 | < 0.001 | 0.011 | 0.005 | 0.771 | 0.576 |
Occurrence of supervision | ||||||
Unsuccessful supervision | 2.62 ± 0.69*** | 2.75 ± 1.00*** | 3.10 ± 1.19 | 3.03 ± 1.12 | 2.10 ± 1.01*** | 2.56 ± 1.03** |
Team supervision | 3.22 ± 0.73* | 3.28 ± 0.82*** | 3.32 ± 0.98 | 3.21 ± 0.94 | 3.16 ± 1.01*** | 3.17 ± 0.98** |
Successful supervision | 3.84 ± 0.56 | 3.87 ± 0.63 | 3.55 ± 1.01 | 3.21 ± 0.94 | 4.10 ± 1.01*** | 3.74 ± 0.98** |
P value | < 0.001 | < 0.001 | 0.330 | 0.094 | < 0.001 | < 0.001 |
Frequency of separate, unscheduled private meetings with the supervisor | ||||||
Not at all | 3.03 ± 0.72 | 3.16 ± 0.82 | 3.19 ± 1.00 | 3.09 ± 0.96 | 2.83 ± 1.01 | 2.99 ± 0.99 |
Once or twice during the course | 3.29 ± 0.75 | 3.27 ± 0.86 | 3.37 ± 1.04 | 3.23 ± 0.93 | 3.27 ± 0.98 | 3.32 ± 1.00 |
Less than once a week | 3.19 ± 0.63 | 3.22 ± 0.80 | 3.26 ± 0.78 | 3.15 ± 0.89 | 3.20 ± 0.86 | 3.14 ± 0.85 |
About once a week | 3.35 ± 0.61 | 3.34 ± 0.73 | 3.39 ± 0.88 | 3.19 ± 0.87 | 3.45 ± 0.86 | 3.32 ± 0.89 |
More often | 3.68 ± 0.66 | 3.69 ± 0.76 | 3.71 ± 0.92 | 3.66 ± 0.86 | 3.87 ± 0.83 | 3.49 ± 0.97 |
p value | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 |
Factors associated with students’ satisfaction with the CLE
The results of the multivariate linear regression analysis, presented in Table 4, identified several factors significantly associated with student satisfaction with the CLE. Study program was a factor, with midwifery students reporting lower satisfaction with the “Pedagogical atmosphere” compared to nursing students. Student year also played a role; third-year students were less satisfied across the overall CLE and its dimensions compared to first-year students. Clinical settings significantly impacted satisfaction, with hospital placements linked to lower satisfaction regarding “Supervisory relationships” and “The role of the nurse teacher” compared to primary health care settings. Shorter practicum duration was associated with decreased satisfaction in “Pedagogical atmosphere” and “Premises of care”. The supervisor title was relevant; having a nurse as supervisor, compared to a ward manager, correlated with lower satisfaction in “Pedagogical atmosphere”, “Ward manager leadership”, and “Premises of care”. Experiencing unsuccessful supervision was a strong negative predictor of satisfaction across “Pedagogical atmosphere”, “Supervisory relationships”, and “The role of the nurse teacher” compared to successful supervision. Finally, infrequent meetings with supervisors were associated with lower satisfaction across the overall CLE and its dimensions compared to frequent meetings.
Table 4
Factors associated with students’ satisfaction of the clinical learning environment using multiple linear regression analysis
Factor | Overall Ar.CLES + T | Pedagogical atmosphere of the ward | Leadership style of the ward manager | Premises of care on the ward | Supervisory relationship | Role of the nurse teacher | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
β | P value | β | P value | β | P value | β | P value | β | P value | β | P value | |
Age | ||||||||||||
(21–24) − (18–20) | 0.10 | 0.065 | 0.01 | 0.800 | 0.00 | 0.930 | 0.07 | 0.346 | ||||
(25–46) − (18–20) | 0.49 | 0.310 | 0.09 | 0.871 | 0.08 | 0.894 | 0.36 | 0.578 | ||||
Gender | ||||||||||||
Male − Female | 0.11 | 0.086 | ||||||||||
Study program | ||||||||||||
Midwifery − Nursing | -0.08 | 0.169 | -0.16 | 0.022 | ||||||||
Student year | ||||||||||||
Second – First year | -0.21 | < 0.001 | -0.04 | 0.468 | -0.06 | 0.343 | -0.07 | 0.249 | -0.26 | < 0.001 | -0.30 | < 0.001 |
Third – First year | -0.42 | < 0.001 | -0.24 | 0.002 | -0.29 | < 0.001 | -0.29 | < 0.001 | -0.48 | < 0.001 | -0.44 | < 0.001 |
Clinical setting | ||||||||||||
Hospital – Primary healthcare | -0.19 | < 0.001 | -0.20 | 0.007 | -0.27 | < 0.001 | ||||||
Practicum duration | ||||||||||||
120–160 H | -0.07 | 0.161 | -0.14 | 0.027 | 0.10 | 0.153 | -0.21 | 0.003 | ||||
Title of the supervisor | ||||||||||||
Nurse − WM | -0.09 | 0.059 | -0.18 | 0.002 | -0.19 | 0.010 | -0.14 | 0.034 | ||||
Nurse specialist − WM | 0.02 | 0.620 | 0.02 | 0.695 | -0.12 | 0.135 | -0.10 | 0.182 | ||||
Other − WM | -0.06 | 0.298 | -0.15 | 0.033 | -0.12 | 0.155 | -0.15 | 0.056 | ||||
Occurrence of supervision | ||||||||||||
Team supervision − successful supervision | -0.44 | 0.035 | -0.52 | 0.030 | -0.47 | 0.097 | -0.62 | 0.029 | -0.39 | 0.182 | ||
Unsuccessful supervision − Successful supervision | -0.88 | < 0.001 | -0.97 | < 0.001 | -0.55 | 0.087 | -1.44 | < 0.001 | -0.83 | 0.014 | ||
Frequency of meeting with the supervisor | ||||||||||||
Not at all – more often | -0.62 | < 0.001 | -0.51 | < 0.001 | -0.53 | < 0.001 | -0.56 | < 0.001 | -1.00 | < 0.001 | -0.47 | < 0.001 |
Once or twice during the course – more often | -0.38 | < 0.001 | -0.40 | < 0.001 | -0.34 | < 0.001 | -0.41 | < 0.001 | -0.60 | < 0.001 | -0.17 | 0.071 |
Less than once a week – more often | -0.45 | < 0.001 | -0.44 | < 0.001 | -0.47 | < 0.001 | -0.50 | < 0.001 | -0.63 | < 0.001 | -0.31 | 0.009 |
About once a week – more often | -0.35 | < 0.001 | -0.38 | < 0.001 | -0.36 | 0.004 | -0.51 | < 0.001 | -0.44 | < 0.001 | -0.19 | 0.117 |
Discussion
Nursing and midwifery students in Morocco reported modest CLE satisfaction, similar to other Arab countries [35‐37], indicating a need for improvement. Although European studies also point to areas for enhancement, satisfaction tends to be higher [9, 38]. This discrepancy likely reflects contextual differences between Morocco and Europe, such as disparities in healthcare resources, infrastructure, and the organization of nursing education programs [39].
Ward manager leadership style emerged as a key driver of satisfaction, aligning with previous research [40, 41]. Students supervised by ward managers reported higher satisfaction across multiple dimensions, particularly pedagogical atmosphere and ward facilities. This finding underscores the manager’s indirect yet crucial role in shaping a positive learning environment [42]. This suggests focusing on empowering ward managers to further enhance student learning experience through their leadership.
Student satisfaction with the supervisory relationship, however, was lower, contrasting with higher satisfaction reported in European studies [9, 38, 43] where individualized supervision is more prevalent [42]. While team supervision remains the norm in Morocco, as confirmed by our study, students expressed lower satisfaction with this model, preferring individualized supervision which allows for more personalized feedback and reflection [42]. Further impacting satisfaction is the perceived lack of preceptors preparedness for teaching roles [44], a concern also observed in the Moroccan context. Formal training programs for preceptors are crucial to improve supervisory quality [45‐48], benefiting both students and preceptors by fostering a more supportive and effective learning environment [46].
Crucially, meeting frequency with preceptors was a strong predictor of satisfaction across all CLE dimensions, especially the supervisory relationship, echoing previous research [24, 27, 49]. Regular individual meetings facilitate student reflection and professional development [42]. The concerning lack of unplanned meetings, potentially due to workload and student numbers, warrants further investigation to understand and address barriers to regular preceptor-student interaction.
As expected, successful supervision experiences, characterized by positive preceptor relationships, strongly correlated with higher satisfaction, reaffirming findings from numerous studies [27, 43, 49, 50]. The supervisory relationship was particularly sensitive to supervision success. While team supervision is dominant, satisfaction with the supervisory relationship was higher among students experiencing successful supervision, even in team settings. This reinforces the potential benefits of individualized supervision, particularly in Morocco where the supervisory relationship is a weaker area [9, 38, 51].
Therefore, the study advocates for a shift towards individualized supervision in Morocco and the implementation of structured educational programs to better prepare preceptors and enhance the supervisory relationship. However, it’s important to acknowledge potential barriers to this shift. These include a shortage of qualified preceptors available for one-on-one mentoring. Increased preceptor workload is another significant concern [52]. Furthermore, substantial investment in training programs would be required, and these resources may be limited.
Low satisfaction was also reported regarding the nurse teacher role, consistent with findings of infrequent contact in clinical settings [9, 35, 53]. The historical shift of nurse education to higher education may have inadvertently shifted nurse teacher focus towards academic setting [54]. While this emphasis on academic rigor is important, it may have reduced opportunities for essential role modeling, and direct supervision. However, recent trends toward hybrid teaching models offer a potential solution for bridging this gap. Increasingly utilized in undergraduate nursing education, these approaches blend traditional face-to-face instruction with technology-mediated methods, providing flexibility, accessibility, and valuable in-person clinical guidance [55‐57]. Even with limited clinical engagement, students in our study appreciated nurse teachers’ assistance in theory-practice integration. Modern e-communication methods [58, 59], integrated within a well-designed hybrid framework incorporating active-learning techniques, could supplement physical contact and enhance nurse teacher accessibility, especially given students’ positive experiences with online learning during the pandemic [60].
The program of study was significant. Nursing students were more satisfied with the pedagogical atmosphere than midwifery students. This may be linked to less supportive learning environments in obstetrics/gynecology settings and warrants further investigation into CLE quality across different clinical placements. The prevalence of nurse preceptors, rather than midwife preceptors, might also contribute to midwifery students’ lower satisfaction [27, 61], suggesting the importance of matching preceptor expertise to student specialization.
Interestingly, satisfaction decreased with each year of study, contrasting with some studies [62] but aligning with others [36, 63, 64]. This may reflect evolving student perspectives and increasing criticality as they gain experience [36, 63]. Alternatively, supervision might be less robust for senior students [64]. Consistent, strong supervision is crucial across all academic years.
Satisfaction levels varied across clinical settings. Students in primary healthcare settings reported greater satisfaction with the supervisory relationship and the nurse teacher role compared to hospital wards, aligning with studies in primary care [47, 65]. Increased preceptor involvement fosters a constructive learning environment [47]. Hospital protocols and workload may limit nurse support, highlighting the need for dedicated time and space for preceptor-student interaction [11].
Consistent with European studies [13, 66], longer clinical placements correlated with increased student satisfaction. Longer placements allow students to build relationships, refine skills, and foster teamwork [26], with a minimum of 7 weeks suggested [66]. Extending practicum length in Morocco could be advantageous.
Strengths and limitations
While this study possesses notable strengths, it’s crucial to interpret these findings with consideration for certain limitations. A primary advantage is the unique assessment CLE satisfaction among nursing and midwifery students in Morocco, using the ar. CLES + T scale. The international use of the CLES + T scale allows for broad comparisons across diverse contexts and cultures, and its validation in the Moroccan setting strengthens the credibility of our findings.
However, several limitations warrant careful interpretation of our findings. First and foremost, it is important to acknowledge the cross-sectional nature of this study. This design inherently limits our ability to establish causality. We can only identify associations between CLE satisfaction and the variables examined but not determine cause-and-effect relationships. Further longitudinal or interventional studies are needed to explore potential causal pathways.
Secondly, our sample had a larger proportion of nursing students compared to midwifery students, which might limit the generalizability of the results to the wider population of nursing and midwifery students in Morocco. Furthermore, the predominantly female composition of the sample raises the possibility that CLE satisfaction levels may differ between genders. Future studies should aim for more balanced gender representation to address this potential bias and enhance the generalizability of the findings.
Conclusions
This study revealed moderate satisfaction with the CLE among nursing and midwifery students in Morocco, underscoring the critical need for targeted improvements. While ward manager leadership was recognized for fostering a positive learning atmosphere, student satisfaction with supervision and the nurse teacher’s clinical role requires enhancement. To address these findings, policymakers, in collaboration with educational institutions and healthcare providers, should develop national guidelines and standards promoting individualized supervision and standardized preceptor training to equip preceptors with effective supervision techniques, feedback strategies, and assessment skills. To further strengthen the CLE and support nurse teachers, future policy should consider investing in digital learning infrastructure and providing training for nurse teachers to effectively utilize online communication tools for mentorship, feedback, and theory-practice integration.
Several factors influenced CLE satisfaction, including program of study, academic year, clinical setting, placement duration, supervision quality and frequency. Lower satisfaction was observed among midwifery students, final-year students, those in hospital settings with shorter placements, and those experiencing infrequent or ineffective supervision. These findings highlight the need for policymakers and healthcare institutions to develop comprehensive, differentiated strategies to address these specific vulnerabilities. This could involve tailoring placement durations and supervision intensity based on student cohort and clinical setting characteristics.
These findings provide valuable, actionable insights for policymakers and healthcare institutions in Morocco seeking to optimize the clinical learning experience for nursing and midwifery students. Future research should indeed explore the perspectives of preceptors and nurse teachers to achieve a holistic understanding of the CLE, further informing evidence-based policy and practice adjustments. Furthermore, future research should specifically investigate how institutions can effectively implement digital learning tools, such as virtual platforms and mobile applications, to directly support the role of the nurse teacher in clinical settings. This multi-faceted approach, combining policy reform, practical implementation, and ongoing research, will be crucial for creating a truly supportive and effective clinical learning environment for future generations of nurses and midwives in Morocco.
Acknowledgements
We extend our sincere thanks to the administrators of the educational institutions for granting us permission to carry out our investigation on their premises. Additionally, we express our appreciation to all the students who took part in the study.
Declarations
Ethical approval and consent to participate
The study was conducted in accordance with the principles of the Declaration of Helsinki and obtained ethical approval from the Institutional Review Board of Mohammed V University of Rabat. Rigorous measures were implemented to ensure the protection of participants, including the provision of clear explanations regarding the study objectives, assurances of confidentiality and anonymity of their data, and the option to withdraw at any time. All students formalized their informed consent by signing the consent form, completing the questionnaire, and returning it.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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