YNEDT-03048; No of Pages 5

Nurse Education Today xxx (2015) xxxxxx

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Nurse Education Today

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A Survey on Turkish nursing students' perception of clinical learning

environment and its association with academic motivation and clinical
decision making
Yeim Yaman Akta a, Neziha Karabulut b,
a
b

Department of Surgical Nursing, The Faculty of Health Sciences, Giresun University, Giresun, Turkey
Department of Surgical Nursing, The Faculty of Health Sciences, Atatrk University, Erzurum,Turkey

a r t i c l e

i n f o

Article history:
Accepted 20 August 2015
Available online xxxx
Keywords:
Nursing students
Clinical practice
Academic motivation
Clinical decision making

s u m m a r y
Background: Nursing education is a process that includes theoretical and practical learning and requires the
acquisition of theoretical knowledge and skill. Nursing students need a good clinical practice environment in
order to apply their knowledge and skills due to the fact that the clinical practice settings play an important
role in the nursing profession.
Objectives: This study was carried out in an effort to explore nursing students' perception of the clinical learning
environment and its association with academic motivation and clinical decision making.
Design: A descriptive survey design was used.
Setting: This study was conducted in Giresun University in Turkey.
Participants: Participants were second-, third- and fourth-year undergraduate students (n = 222) in the Bachelor
of Nursing Science Degree in the academic spring term of 20142015.
Methods: The data was collected using the Clinical Learning Environment Scale, the Academic Motivation, and
the The Clinical Decision Making in Nursing Scale.
Results: Of the respondents in this study, 45% of the students were second class, 30.6% of the students were third
class and 24.3% of the students were fourth class. There was a statistically signicant positive correlation found
between the clinical learning environment and the nursing students' academic motivation (r = 0.182, p b .05).
However, there was no correlation between the clinical learning environment and clinical decision making
(r = 0.082, p N .05).
Conclusion: One of the prerequisites for the training of qualied students is to provide nursing students with a
qualied clinical environment. It was found that nursing students' academic motivation increased as the quality
of their clinical learning environment improved.
2015 Elsevier Ltd. All rights reserved.

Introduction
In nursing education, clinical context is recognized as an essential
arena for students to learn about practice in the real world (Egan
and Jaye, 2009). Clinical placement represents an integral part of the
nursing education curricula, so the place where practical work is carried
out becomes a fundamental part of the students' learning experience.
Clinical learning plays a crucial role in undergraduate nursing programs.
Not only does it provide opportunities for students to apply theories
learned in the classroom to the real world of clinical nursing, it also offers a socialization process through which students are introduced to

This research received no specic grant from any funding agency in the public,
commercial, or not-for-prot sectors.
Corresponding author. Tel.: +90 442 231 2360; fax: +90 442 2360984.
E-mail addresses: nezihekarabulut@hotmail.com, nezihek@mynet.com (N. Karabulut).

the practices, expectations and real-life working environment of the

nursing profession (Dunn et al., 2000; Papastavrou et al., 2010).
Although the clinical practicum is a large and essential component of
any undergraduate nursing degree (Henderson et al., 2012), the quality
of the clinical learning environment (CLE) is also considered an important factor when determining the quality of the clinical experience for
the student (Papp et al., 2003). According to Papp et al. (2003), a good
clinical learning environment is described by nursing students as a clinical setting in which there is cooperation among staff and a good atmosphere where they feel appreciated and are given opportunities to study
in order to achieve their objectives. A range of factors can positively inuence the CLE including: cooperation, attitude, morale and friendliness
of the staff, positive staff attitudes towards patient care, quality patientcentered care, and access to positive role models (Lfmark and Wikblad,
2001; Papp et al., 2003; Lewin, 2006). In contrast, rigid, hierarchical environments, lack of nursing practice guidelines, and lack of awareness of
students' learning needs contribute to an unsupportive CLE (Lfmark

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Please cite this article as: Akta, Y.Y., Karabulut, N., A Survey on Turkish nursing students' perception of clinical learning environment and its
association with academic motivation and..., Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.08.015

Y.Y. Akta, N. Karabulut / Nurse Education Today xxx (2015) xxxxxx

and Wikblad, 2001; Chan, 2002). While ward-based, hospital learning

environments remain fundamental, multidimensional milieus for nursing education, a study conducted by Chan (2002) has indicated that not
all practice settings are able to provide student nurses with positive
clinical learning environments.

with academic motivation and clinical decision making. Participants

were all second, third and fourth-year undergraduate students in the
Bachelor of Nursing Science Degree at the University of Giresun. Two
hundred twenty two (222) nursing students were enrolled in this
study. In this study, sampling was not used and the research population
was comprised of all students.

Background
The main objective of clinical education is to develop the nursing
students' professional skills and knowledge needed in life-long learning
and critical thinking, to create self-condence as a nurse, and to ensure
that the nurse is able to make his or her clinical decisions and be independent (Lfmark and Wikblad, 2001; Papp et al., 2003). Clinical education provides the student with the opportunity to apply the knowledge,
skills and concepts learned in the classroom to the actual care of the patient (Elcigil and Sar, 2007). The quality of the clinical learning environment (i.e. physical environment, teaching staff, nurses and other health
professionals) is important for the nursing students' learning, clinical
decision making and academic motivation during their clinical education (Papastavrou et al., 2010; Salminen et al., 2010).
The factors that inuence academic success are different for every
student; however one of the major predictors for academic achievement for both male and female students is academic motivation
(Kaufmann et al., 2008; Olani, 2009; Rose, 2011). Academic motivation
is a key determinant of academic achievement. Intelligence is not the
only predictor of academic achievement and retention for nursing students. To reach specic goals in nursing education and achieve qualied
education, academic motivation is important. A student who is not
highly motivated is not ready for learning. Additionally, if there is not
important catalyst to promote learning, the student does not improve
the interest for learning (Vallerand et al., 2008; Bacanl and Sahinkaya,
2011). Motivation is classied as intrinsic motivation, extrinsic motivation, and amotivation based on the self-determination theory that was
developed by Deci and Ryan in 1985 (Deci and Ryan, 2000). Generally,
studies have found that highly academically motivated students engaged in learning are more likely to achieve better grades and exhibit
lower dropout rates (van den Berg and Coetzee, 2014; Khalaila, 2015).
However, each type of motivation (intrinsic and extrinsic) separately
may not have the exact same effect on students' performance. The
most important thing that causes a person to perform a work or action
is intrinsic motivation. In order to perform better, the motivation should
be turned into intrinsic motivation (Bacanl and Sahinkaya, 2011).
The education provided during clinical practice helps nursing students acquire professional skills, including knowledge, critical thinking
and clinical decision making that will be necessary for them throughout
their lives, and helps them to make independent nursing decisions
(Papp et al., 2003; Elcigil and Sar, 2007). Decision making is an integral
part of nursing practice (Lauri and Salantera, 2002). Nurses with limited
clinical experience make decisions based on theoretical learning and
may not recognize deviations from unambiguous clinical presentations
found in nursing textbooks (Benner et al., 2009). One study showed that
only 30% of new nursing graduates consistently demonstrated the ability to recognize and safely manage commonly occurring problems in
their patients (Del Bueno, 2005). In a study conducted by Jeffries and
Rizzolo (2006) it was reported that clinical decision making perceptions
of nursing students were similar due to the fact that all students had
clinical practice experience, comprehended the clinical environment,
undertook the care of a real patient, and adapted to the new
environment.
Materials and Methods
Design and Sample
A descriptive survey design was used to explore nursing students'
perceptions of the clinical learning environment and its association

Instruments
The data was collected by the researchers using the demographic
form for students, Clinical Learning Environment Scale, Academic Motivation Scale and The Clinical Decision Making in Nursing Scale. The
demographic form included the socio-demographic characteristics of
the students. The Clinical Learning Environment Scale was developed by
Dunn and Burnett (1995) and its validity and reliability in a Turkish setting were tested by Sar (2001). Cronbach's alpha value of the scale is
0.82. This scale consists of 20 items (i.e. item 2: Learning aids such as
books/articles are available to nursing students on this unit, item 8: In
planning the shift, allowance is made for nursing students to gain the
widest possible experience, item 14: Nursing care individualized for
each patient on this unit, item 18: This experience has made me more
eager to become a Registered Nurse). The scale is a 5-point Likert-type
(1 = strongly disagree to 5 = strongly agree). The highest possible
score is 110 and the lowest possibly score is 22 in this scale. The increase
in the total number of points indicates that students have found the
clinical learning environment to be appropriate (Sar, 2001).
The Academic Motivation Scale was developed in Turkey by
Bozanoglu (2004). Cronbach's alpha value of the scale is 0.87. This
scale consists of 20 items (i.e. item 2: Everything I learned causes
more curiosity, item 7: When I have a choice I usually choose homework
that is bother for me, item 12: I always liked to work in new and different issues, item 15: I would like to help others with something I learned,
item 17: I try so much to learn something even though course grade will
not been given). The scale is a 5-point Likert-type (1 = strongly inappropriate to 5 = strongly appropriate). The highest possible score is
100 and the lowest possible score is 20 in the scale. The score increase
indicates that academic motivation is higher (Bozanoglu, 2004).
The Clinical Decision Making in Nursing Scale (CDMNS) was developed
by Jenkins in 1983 (Jenkins, 2001). The scale consists of 40 items and
four subscales. The CDMNS is a ve-point Likert-type scale (1 = never
to 5 = always), and 18 items of the scale are reversed and the options
range from never to always. The total scale score varies between 40
and 200. There is no cut point. A high score from the scale indicates a
high decision making perception while a low score demonstrates a
low and negative decision making perception. Cronbach's alpha value
of the original scale was 0.83 (Jenkins, 2001). In Turkey, a reliability
and validity study of the CDMNS was carried out by Durmaz and Dicle
in 2012 (Dicle and Durmaz-Edeer, 2013).
Data Collection
The data was collected during, Surgical Nursing, Children's Health and
Illness Nursing, Public Health Nursing, and Management in Nursing clinical
practices of nursing students during the 2014 and 2015 academic period
in this study. Nursing students were trained in two government hospitals in conjunction with their theoretical courses in the academic spring
term. After written consent was obtained from the director of institution, the questionnaires were administered to each of the classes one
by one during their clinical training in spring semester. First year students have been excluded from the study because they had minimal
clinical contact during clinical practice of the rst year course. Before
it was applied, verbal permission was obtained from the responsible lecturer of the lesson. At the end of each lesson, required statements for the
study were posed to the students, special permission was obtained,
adequate time was given and they were asked to respond to the

Please cite this article as: Akta, Y.Y., Karabulut, N., A Survey on Turkish nursing students' perception of clinical learning environment and its
association with academic motivation and..., Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.08.015

Y.Y. Akta, N. Karabulut / Nurse Education Today xxx (2015) xxxxxx

questionnaire. Nursing students completed the forms within approximately 2030 min.
Data Analysis
The Statistical Package for Social Sciences (SPSS, Chicago, IL) for
Windows version 16.0 was used for data entry and analysis. Nursing
students' demographic variables, clinical learning environment and academic motivation were evaluated using the percentage distribution
and mean. To make a comparison of the means of the clinical learning
environment and academic motivation or clinical decision making, the
Pearson correlation test was used. Variance analysis is used to evaluate
the difference of the average points of the classes between scales. The
statistical signicance level was set at p b 0.05.
Ethical Considerations
The study was conducted according to the ethics guidelines set out
in the Declaration of Helsinki, and written consent was obtained from
the director of the faculty. The aim of the study was explained to the students and participation in the study was voluntary. Condentiality and
anonymity were offered to respondents and guaranteed by the absence
of identifying marks or numbers on the questionnaires.
Results
The nursing students' socio-demographic characteristics are shown
in Table 1. Two hundred twenty two (222) undergraduate students
completed the questionnaire. The mean age of the students was 21.08
years, with a standard deviation of 1.17 years. Approximately 81.5%
(181) of the sample were female. Of the respondents in this study,
100 (45%) were second-year students, 68 (30.6%) were third-year
Table 1
Socio-demographic characteristics of nursing students (n = 222).
Age (mean SD)

21.08 1.17
n

Gender
Female
Male

181
41

81.5
18.5

Class
Second class
Third class
Fourth class

100
68
54

45
30.6
24.3

Have information about the profession before deciding to be a nurse

Yes
No

156
66

70.3
29.7

Reason of choosing the nursing profession

Easier to nd a job after graduation
Take interest in the profession
Family wish
Sufciency of the university entrance exam
Random

112
61
28
16
5

50.5
27.5
12.6
7.2
2.3

190
150
142

85.6
67.6
64.0

159
137

71.6
61.7

160
127
95
80
62

72.1
57.2
42.8
36.0
27.9

The purpose of clinical practice*

Theory learned in the classroom integrated with clinical practice
See the hospital environment and working conditions
Observe communications among health professionals
(patient-nurse or patient-physician)
Learn about diseases, drugs and new applications
Communicate with the patient and learn to empathize
Teaching methods and techniques*
Case presentation
Individual teaching
Observation
Nursing process
Group teaching
*Marked more than one option.

students and 54 (24.3%) were fourth-year students. Around 70% of the

students had knowledge about the nursing profession and 50.5% of
the students indicated that they preferred the nursing profession due
to the fact that they were able to nd work easily after graduation. In
the study 85.6% of the students reported that they thought the purpose
of clinical practice was that theory learned in the classroom integrated
with clinical practice and 40% of the students indicated that theory integrated with clinical practice moderately. As shown in Table 1, 72.1% of
the students reported that they wanted to use case presentation,
57.2% individual teaching, 42.8% observation, 36% nursing process, and
27.9% group teaching in the clinical practices (Table 1).
The comparison of the mean of the scales is presented in Table 2. The
mean scores of the clinical learning environment, academic motivation,
and clinical decision making scales were 62.3 9.6, 70.9 11.2, and
147 13.2, respectively. A positive correlation was found to be statistically signicant between the clinical learning environment and nursing
students' academic motivation (r = 0.182, p b .05), although there was
no correlation between clinical learning environment and clinical decision making (r = 0.082, p N .05). It was found that nursing academic
motivation scores increased if the scores of their clinical learning environment were higher in the study (Table 2).
Statistical analysis showed that there was no signicant difference
statistically between classes (p N .05). In spite of that lack of difference,
it was found that the clinical learning environment, academic motivation and clinical decision making scores were similar in 2nd and 3rd
year students, and decreased in 4th year students (Table 3). When the
scales were compared within classes, the difference between the clinical
learning environment, academic motivation and clinical decision making scores between classes was found not to be statistically signicant
(p N .05) (Tables 45).
Discussion
Clinical training sessions also play a key role for nursing students and
a positive assessment keeps them motivated to study nursing education
(Dante et al., 2011). Therefore, although nursing students theoretically
learned all necessary skills during education period, they graduated
without enough experience and with an insufciency of practice. This
may contribute to the lack or decrease of academic motivation and clinical decision making in nursing students during their education.
Half of the students (50.5%) who were involved in the study had
chosen nursing due to the fact that it is easier to nd a job after graduation with a nursing degree (Table 1). In a study by Kosgeroglu et al.
(2009), it was reported that nursing students had chosen the nursing
profession by chance (n = 409), voluntarily (n = 815) and family preference (n = 300) in Turkey. It was also found that 85.6% of the students
would like to integrate theory with clinical practice. In a study by
Peyrovi et al. (2005) which examined Iranian nursing students' experiences in clinical practice, it was stated that the students thought that
going to a clinical site after receiving theoretical education was very effective in transferring theoretical information into practical knowledge,
and that their experiences in the clinical setting would be benecial to
them in their future interactions, as well as outside the work environment. For many years, however, the theorypractice gap has been a
problem in nursing students' clinical education, as indicated by many
Table 2
The comparison of the Clinical Learning Environment Scale, the Academic Motivation
Scale, and the The Clinical Decision Making in Nursing Scale.
Clinical Learning Environment

Academic motivation
Clinical decision making

0.182*
0.082*

0.006**
0.226

*Pearson correlation, **p b .05.

Please cite this article as: Akta, Y.Y., Karabulut, N., A Survey on Turkish nursing students' perception of clinical learning environment and its
association with academic motivation and..., Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.08.015

Y.Y. Akta, N. Karabulut / Nurse Education Today xxx (2015) xxxxxx

Table 3
The comparison of the scales between classes.
Mean SD
Second class
Clinical Learning
Environment
Academic
Motivation
Clinical Decision
Making

Third class

Fourth class

61.5 9.22

62.5 9.92

60.2 8.18

70.0 11.35

70.6 11.16

69.2 11.03

145.64 13.09

146.7 12.56

144.2 13.71

Statistical
evaluation
F = 1.891
p N .05
F = 1.265
p N .05
F = 1.995
p N .05

studies (Corlett, 2000; Dadgaran et al., 2012). Although nursing students indicate that they want to integrate theory and practice in this
study, Elcigil and Sar (2007) indicated that nursing students experienced difculty in integrating theory learned in the classroom with clinical practice. Nursing students also reported that some clinical skills
learned in the skills laboratory were not practiced quite in the same
way in the hospital. Students are confronted with real cases during clinical practices and are prepared for their new role as a nurse. If these
practices are structured well, they can help to bridge the gap between
theoretical courses and practice (Andrews and Roberts, 2003; Sharif
and Masoumi, 2005). In a study conducted by Corlett (2000) on the perceptions of nursing instructors and student nurses, the theorypractice
gap could be viewed positively as a means of developing students'
problem-solving skills, and attempts should be made to minimize its
impact.
Clinical educators need to identify creative ways to meaningfully
streamline workloads, decrease stress and promote effective learning
strategies (Killam and Heerschap, 2013). In this study, the nursing students reported that 72.1% wanted to use case presentation, 57.2% individual teaching, 42.8% observation, 36% nursing process, and 27.9%
group teaching in the clinical practices. Similar to our ndings, a study
by Aygin and Cnar (1999) stated that 38.9% wanted the nursing process, 24.2% observation and 13.9% individual training as the top desired
methods to be used in clinical practices. It is thought that these ndings
are linked to the students' perception that case presentation in clinical
practices is a uniquely systematic and scientic approach to the nursing
profession. Deciding the needs of the patients and other educational
methods, such as group teaching, is not specic to the nursing profession since they are used in several courses.
As shown in Table 2, it was found that there was a statistically significant and positive correlation between the scores taken by the students
from the clinical learning environment scale and their academic motivation level (r = 0.182, p b .05). However, the scores between clinical
learning environment and clinical decision making were not signicantly different (r = 0.082, p N .05). It is observed that the students do not
think the clinical practice setting is sufcient, and accordingly, their academic motivation level is low. However, the motivation level of nursing students in the profession makes the professional success and
goals in their occupation higher. Also, motivated students invest more

Table 4
The comparison of the Clinical Learning Environment Scale and the Academic Motivation
Scale within classes.
Mean SD
Clinical Learning
Environment

Academic
Motivation

Second class

61.5 9.22

70.0 11.35

Third class

62.5 9.92

70.6 11.16

Fourth class

60.2 8.18

69.2 11.03

*Pearson correlation.

Statistical
evaluation

r = 0.071*
p N .05
r = 0.169*
p N .05
r = 0.107*
p N .05

Table 5
The comparison of the Clinical Learning Environment Scale and the The Clinical Decision
Making in Nursing Scale within classes.
Mean SD
Clinical Learning
Environment

Clinical Decision
Making

Second class

61.5 9.22

145.64 13.09

Third class

62.5 9.92

146.7 12.56

Fourth class

60.2 8.18

144.2 13.71

Statistical
evaluation

r = 0.047*
p N .05
r = 0.136*
p N .05
r = 0.104*
p N .05

*Pearson correlation.

time in their courses (Wijnia et al., 2011) and are more likely to complete their study programs, whereas unmotivated students are more
prone to drop out (van den Berg and Coetzee, 2014; Khalaila, 2015).
The social context of a learning environment can inuence the motivation and clinical decision making of nursing students (Black and Deci,
2000). Therefore, clinical educators play an important role in the clinical
experiences of the nursing students. An important function of the educator during clinical practice is to give support to the nursing students
(Andrews and Roberts, 2003; Dante et al., 2011). If the clinical education
does not provide the student with the support needed for the planning
and fulllment of the student's tasks, the clinical learning and motivation period may be ineffective (Papp et al., 2003).
There was no correlation between the clinical learning environment
and clinical decision making in the present study. Clinical educators
often struggle with knowing how to effectively support nursing students in developing their clinical decision making capacity. Del Bueno
(2005) notes that only 35% of new registered nurse graduates, regardless of educational preparation and credentials, meet entry expectations
for clinical judgment. Consolidation of practical decision making skills
takes place in the classroom (Garrett, 2005). However, it is argued
that this rarely happens, because decision making is not a skill that is
easily explained in a classroom (Croskerry, 2005). Instead, critical thinking skills are generally developed in the workplace with the guidance of
a mentor (Garrett, 2005). Our study ndings may be related to these results. However, due to constraints related to clinical placements and
limited availability within clinical simulation laboratories, the focus is
on nurse educators to provide innovative, interactive teaching, learning
and assessment strategies to develop students' clinical decision making
(Standing, 2007).
When the scales were compared within classes, the difference
between the clinical learning environment, academic motivation and
clinical decision making scores between classes was found not to be statistically signicant (p N .05) (Tables 45). In this study, the average of
the total points awarded by 2nd year students to the Clinical Learning
Environment Scale was 61.5, 3rd year students 62.5, and 4th year students 60.2. It was discovered by variance analysis that this difference
was not statistically signicant (F = 1.891, p N .05) (Table 3). As the
students progress to senior year, the clinical component of their
coursework gradually increases. IP and Chan (2005) reported that
there were signicant differences (p b 0.001) in all mean scores of
year two students with year three and four students, while the difference between the mean scores of 3rd year and 4th year students was insignicant. It was found that nursing students found the clinical
learning environment to be inappropriate as the students progressed
to senior years, and the senior nursing students' academic motivation
and clinical decision making scores were lower than those of 2nd and
3rd year students. This situation can be linked to the fact that clinical
practice settings cannot meet the increasing needs of the students. As
shown in Tables 4 and 5, the comparison of the scales between and
within classes was not statistically signicant (p N .05). Similarly, in a
study by Dicle and Durmaz-Edeer (2013) clinical decision making
scores of juniors were found to be higher than the other classes. In a

Please cite this article as: Akta, Y.Y., Karabulut, N., A Survey on Turkish nursing students' perception of clinical learning environment and its
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Y.Y. Akta, N. Karabulut / Nurse Education Today xxx (2015) xxxxxx

study conducted by Krumwiede (2010), clinical decision making scores

of senior nursing students were found to be 147.99 10.19. In a comparison of the clinical decision making scores of nurses and nursing students in England, Girot (2000) stated that the clinical decision making
scores of seniors were 147.21 11.05. The scores of the senior nursing
students participating in this study (144.22 13.71) were lower than
those of the senior nursing students participating in the studies mentioned. It is thought that senior nursing students nd the clinical learning environment inadequate and lack the skill set necessary to follow
the correct critical thinking process in order to determine effective interventions for patient problems. However, it is seen that the juniors
gain experience in providing care to several patients in clinical practice
and perceive themselves as stronger and more competent in making
correct decisions for problems of patients.
Study Limitations
Due to the small sample drawn from one university in Turkey, the
ndings may not be generalizable to other settings. For future studies,
consideration can be given to the use of a combination of quantitative
and qualitative methods, in addition to a larger sample size. Future researchers specically addressing the impact of clinical learning environment on nursing students' academic motivation or clinical decision
making may be carried out. It also would be interesting to follow up
this study with a longitudinal study to determine whether students'
perceptions change over time.
Conclusion
The clinical learning environment is an essential component of students' education and it cannot be substituted. This study shows that
nursing students prefer individual teaching as a training method and
want to use case presentation in clinical practices. Furthermore, it is observed that as the scores they gained from the clinical learning environment increase, their academic motivation also increases.
Clinical education is a major component of the nursing curriculum.
This study shows that the students found clinical practice settings to
be inadequate. Therefore, it is proposed that the physical environment
of clinical practice be improved and research opportunities given to
the nursing students. To achieve a good learning environment within
each clinical placement requires close cooperation between nursing education staff, clinical staff and the ward manager. The student is a part of
the nursing team, and the other members of the team need to be aware
that the student is in need not only of academic learning but also of
practical learning.
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Please cite this article as: Akta, Y.Y., Karabulut, N., A Survey on Turkish nursing students' perception of clinical learning environment and its
association with academic motivation and..., Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.08.015