of Chitwan Medical ORIGINAL RESEARCH ARTICLE LEVEL OF SATISFACTION ON CLINICAL LEARNING ENVIRONMENT AMONG NURSING STUDENTS OF HAMRO SCHOOL OF NURSING AT BIRATNAGAR

Background : Clinical learning environment is considered the foremost place for professional practice for nursing students. Students on clinical settings are exposed to unexpected learn ing experiences. This study was intended to find out the level of satisfaction in nursing stu - dents with their clinical learning environment. Methods: A descriptive cross-sectional research design was carried out among 84 nursing students who were studying in Bachelor in Science of Nursing from Hamro School of Nursing, Biratnagar, Morang. Non-probability enumerative sampling was used to select sample. Standard tool Clini cal Learning Environment, Supervision and Nurse Teacher (CLES+T) evaluation scale was used to assess level of satisfaction on clinical learning environment among nursing students. Data were analyzed by using descriptive and inferential statistics. Results: The findings of the study revealed that most of the students (84.5%) were satisfied with their clinical learning environment. Further, statistical significant association was found between students satisfaction level with frequency of meeting nursing teacher and use of e-communication tools during placement. Conclusions: Majority of the students are satisfied with their clinical learning environment with highest satisfaction with role of nursing teacher in clinical placement and lowest in pedagogical atmosphere. Thus, satisfaction could be utilized as a significant contributing variable towards the improvement of clinical learning situations so as to fulfill the requirements and desires for nursing students.


INTRODUCTION
Clinical education is an important part in the curriculum of nursing programs as it provides nursing students with ample of opportunities for development of competencies in nursing practice. 1 Clinical learning environment (CLE) is vital for facilitating nursing students for achieving their learning outcome. 2 CLE is extremely advantageous in acquainting students with clinical judgment and decision-making, in exhibiting them to various socio-cultural, biological, psychological and mental aspects of patients' care, 3 in bracing their critical thinking 4 and in daring students to recognize the result of their mistakes. 5 CLE according to nursing students point of view is "the most anxiety-provoking component of nursing education" 6 as they have to satisfy a dual role, that of the learner and that of the worker. 7 Satisfaction is major criteria that represent the customer's level of pleasure and in determining quality that is provided through the process of services. 8 There is a relation between the level of satisfaction regarding the field of study and their learning outcomes. 9 Clinical experience and satisfaction are elements that affect nursing student's educational outcome. 10 Clinical learning environment is vital for nursing students so they can be able to achieve desired learning outcomes. 11,12 There exist a huge gap between theory and practice and the students conflicting role to act in clinical settings as a learner or as a student. Nursing educators are still challenged about component of good learning environment for students and new graduates. Thus, this study aimed to assess the level of satisfaction of nursing students with their clinical learning environment.

METHODS
A descriptive cross-sectional research study design was used to assess the level of satisfaction of nursing students with their clinical learning environment. The study was carried out at Hamro School of Nursing, Biratnagar. The populations of this study were all the nursing students who have completed at least one clinical rotation studying at Hamro School of Nursing, Biratnagar. Required sample for this study was calculated by using the formula for finite population. To reduce non-response error additional 10% was taken so sample size was 75, calculated based on prevalence (p) value as 0.73 and total population (n) as 84. 14 Non probablity enumerative sampling technique was used to for the study. All B.Sc. Nursing students from second year to fourth year were enrolled in the study. Total 84 nursing students were used as sample for the study. As the research was focused on assessing the level of satisfaction on clinical learning environment, all nursing students expect the first year are exposed to maximum number of clinical rotation. Thus, all the nursing students from second to fourth year were included in the study.
Self administered questionnaire was developed after reviewing of related literature for collection of data on different independent variables of the participants. And standardized tool, Clinical Learning Environment, Supervision and Nurse teacher (CLES+T) evaluation 15 scalewasused to assess the level of satisfaction of nursing students with their clinical learning environment. Respondents are asked to score their perception of each item on a 5-point Likert-type scale ranging from "fully disagree" to "fully agree". 15 There are three sub dimension which measures the total satisfaction of the students (possible score 3-15 scale, with a higher score indicating greater satisfaction).where score equal to and greater than 10 indicated satisfied and score less than 10 indicated dissatisfied 16 Level of satisfaction was divided into two categories satisfied and dissatisfied.
CLES+T scale is valid and reliable tool. CLES+T scale Reliability, Cronbach's alpha: 0.83. 17 The research instrument content validity was set by research advisor, subject expert and linguistic professionals.
The research instrument was pre-tested among 10 B.Sc. Nursing students studying at second year of Nobel Medical College and Teaching Hospital. The internal consistency of instrument was established by Cronbach' Alpha test where the test result was: 0.79. Data was collected after getting ethical clearance from Nepal Health Research Council (NHRC). Informed and written consent was obtained from respondents before interviewing them. The data was collected from 2019-12-15AD to 2019-12-30 AD. The data was analyzed using the IBM SPSS version 20 for analysis. Chi-square test was applied to measure the associations between dependent and independent variables. Pearson's correlation coefficient test was used to find out the relationship between sub dimensions of CLES+T scale and satisfaction score.

RESULTS
TThe students mean age was 20.63(±1.21) years. Highest percentage (34.5%) of students studied at second year, 96.4% followed Hindu religion. With regards to frequency of meeting the nursing teacher during the last placement, majority of students (86.9%) often met their nursing teacher during placement.      Table 4 shows the level of satisfaction in clinical learning environment among nursing students, where 84.5% of nursing students were satisfied with their clinical learning environment whereas 15.5% of nursing students were dissatisfied with their clinical learning environment.
The Chi-square test showed that the frequency of meeting nursing teacher and using e-communication tools during last significant were statistically associated with the level of satisfaction of the nursing students.  Regarding level of satisfaction of nursing students, 84.5 % of the students were satisfied with their clinical environment which was consistent with the study findings by Papastaurov et.al and Alenazi. 7,9,18 Nursing student's satisfaction with clinical encounters is one significant basis utilized for the assessment of clinical practice in nursing education. Specifically, thought should be given to make clinical settings where students figure out how to incorporate their theoretical knowledge with practice, and nurses are helped to stay up to date with health services information.
Similarly the highest average score was for the role of the nurse teacher (4.02±0.65) sub dimension, followed by a total mean score of the supervisory relationship (4.01±0.78). This is not in accordance with previous research, where highest mean score was for supervisory relationship sub-dimension 14 and pedagogical atmosphere. 19 In the present study, there was a statistically significant relation between nursing students satisfaction level and frequency of meetings with nursing teacher. This finding is consistent with the study conducted by Papastaurov et.al. 7 The nursing teacher is viewed as the individual who is liable for the cautious arranging of the clinical position, and in this manner regular visits upgraded students' clinical experience in light of the fact that those visits guaranteed that students instructive objectives were effectively accomplished in a convenient manner. 20,21 Conversely, nursing students may feel abandoned when they have no or scarcely any visits from nursing teacher, particularly when they are put in new conditions. 21 As far as ofunfamiliar nursing group, authoritative ways of thinking and organizational philosophies, they valued the presence of the nursing teacher so as to give continuous direction to the ward staff with respect to the foreseen performance level at the student's specific phase of learning. 22 Moreover, the nursing teacher role as teacher with a clinical foundation and filling in as a contact between the college and clinical settings has been archived by a few applicable investigations as effective, particularly in distressing circumstances. 23 Similarly there was statistically association between student's level of satisfaction and frequency of using ecommunication tools with nursing teacher. E-commu-nication tool include phone call, mail, messages. This finding is similar with the study result of other study. 7 There is statistically significant positive relationship between overall satisfaction of nursing students and satisfaction on pedagogical atmosphere sub dimension, leadership style of ward manager sub dimension, premises of nursing on the ward sub dimension, supervisory relationship sub dimension and role of nurse teacher sub dimension. When these dimensions are improved, nursing students are likely to be satisfied with their clinical learning environment The limitation of the study might be the heterogeneity of the study sample with regards to their qualification. The second bias is that the study sample was taken from a single setting.

CONCLUSION
The present study concluded that majority of nursing students are satisfied with their clinical learning environment which were statistically significant with the frequency of meeting and using e-communication tools with nursing teacher. It is important to assess nursing student's level of satisfaction as it plays vital role in the education process, thus nursing student's clinical learning environment should be assessed timely so that that their desired outcome can be achieved.Hence, satisfaction could be utilized as a significant contributing variable towards the improvement of clinical learning situations so as to fulfill the requirements and desires for nursing students.