Clinical instruction is an essential component of nursing education as the key arena in which nursing students transition from theory to practice in order to care for patients. Ideally, students need to demonstrate competency in nursing practice while studying supportive learning environments with shared academic and practice partnerships [1, 2]. However, maintaining effective clinical teaching environments remains a major challenge for academic institutions across the world [3].

Major challenges in clinical teaching, as previously reported in the literature, include the problems encountered by nursing students as they work in the clinical setting [4, 5]. The students report inadequate supervision by clinical staff [2]; unsafe clinical placement [6, 7]; insufficient clinical experiences [7]; competition with other health programs for limited practice settings (Copeland, 2020); scarcities of qualified clinical instructors [2, 8, 9]; and heavy clinical instructor workloads [8-10]. In addition, the changing nature of the clinical learning environment can produce other problems for nursing students. As a result, identifying the problems commonly encountered by students in the hospital can lead to solutions that result in better learning experiences and increased satisfaction with nursing as a profession [5].

There is a relationship between the conditions of the learning environment and the professional development of students. An optimal clinical learning environment positively impacts student learning, while a poor environment can negatively impact professional progress [11, 12]. The unsuitable clinical environment can create some difficulties for nursing students in their professional learning and development [13]. Not recognizing the challenges students encounter in the clinical environment reduces the effectiveness of the educational experience, limits student growth, and negatively impacts the development of professional skills and clinical competencies [14]. Students experiencing an ineffective clinical learning environment are at increased risk of leaving the nursing profession [15]. However, few international studies have focused on identifying the challenges encountered by nursing students in the clinical learning environment. Identifying these challenges is important to improving the quality of a clinical training program.

In Jordan, few studies have explored the general effectiveness of nursing education. In 2012, for example, a qualitative study that explored the experiences of nursing students in their clinical training found a supportive clinical environment, motivation and goal-directed practice, and it further highlighted that the instructor and staff nurse role models were important factors of effective learning. Also, incongruences between the expectations of students, preceptors, instructors, and nursing staff; and the differences between their realities and expectations were identified as central clinical practice challenges [12]. The purpose of this study was to identify the nursing students' perspectives about the challenges they encounter in the clinical learning environment

A total of 250 questionnaires were distributed to participants, while 187 completed questionnaires were returned (a response rate of 74.8%). Most participants were female (67.4%), with an average age of 21.5 years enrolled in their second (34.2%), third (32.1%) or fourth (33.7%) year of the nursing program. Approximately half the participants attended private universities and most participants were traditional students “non-bridging”, without previous clinical experience outside the university. The demographic data are presented in Table 2.

From the item response analysis, about half the students noted fear of making mistakes; inadequate facilities for students (i.e., lobby, changing room, break room, and conference room); limited community awareness and patient knowledge about the nursing profession; fear of infection; and lack of equipment in the clinical setting as the most common challenges students encountered. The least commonly cited challenges included clinical instructors not being prepared for clinical teaching; not involving students in their evaluation; and lack of student support from teachers. The data are presented in Table 3.

Consistent with our findings, the most important challenges against clinical education as reported in previous studies included inadequate facilities and poor working conditions, lack of access to conference rooms, non-academic hospitals, limited cases for learning experiences on the nursing units, and poor educational planning [17-19]. Similar to this study, nursing students in Botswana reported inadequate organizational support, limited resources, and limited equipment (e.g. trolleys) as negative factors in the clinical learning environment [20-23]. Also, these challenges resulted in delays experienced in clinical procedures, and other missed learning opportunities. The limited personal protective equipment results in a heightened risk for students’ exposure to infectious materials, which produces fear and anxiety (Moyimane et al., 2017).

A challenging atmosphere in the clinical environment for nursing students has negative effects on learning opportunities, reduces learning enthusiasm, and diminishes motivation [24]. Planning to change the bad atmosphere of the clinical environment to provide more comprehensive and germane facilities for nursing students during clinical practice can thus be

effective in creating learning opportunities, providing the safe and desired quality of care, and improving multi-disciplines collaboration [24].

Another challenge reported by students in the current study was the lack of community and patients’ knowledge about the nursing profession and role. This result is consistent with previous studies which reported the challenge of a lack of recognition and awareness of the role of nurses among patients and society, in addition to the lack of cooperation from patients and neglecting education and nursing interventions [22, 23]. The following challenges were addressed by students as the most important issues they faced in clinical education: fear of committing mistakes, fear of infection, and lack of availability of equipment in the clinical setting.

Students’ fear of committing mistakes and fear of infection might be explained by different reasons, such as inadequate preparation for entering the clinical environment [24], and insufficient practice and lack of skills before entering the clinical environment. Nursing students learn the fundamentals of nursing in classrooms and school laboratories, and dealing with human beings in the inherently stressful context of health provision increases the emotional stress and fear experienced by students, including fear of acquiring infections and committing mistakes [25]. Related to such feelings, a lack of self-confidence has also been reported as a major cause of fear and anxiety in nursing students [26]. A recent study revealed that nursing students’ fear may be related to educators’ destructive criticism during clinical procedures or observation by service users (patients and their relatives) [27]. Nursing students’ stress and fear for meeting the clinical environment objectives affect their health and interrupt their learning processes [28]. Therefore, to improve clinical education, educators should facilitate simulation and provide constructive feedback to the students, after the procedure and in private. Furthermore, it is highly recommended to avoid the presence of patients’ relatives while performing clinical procedures, to help students reduce their fear.

Previous studies showed that inappropriate behavior and lack of collaboration from clinical staff cause a negative attitude and discomfort among students [29], including a lack of appropriate communication between students and clinical staff [30]. Clinical staff can help create a supportive learning environment through a proper relationship with nursing students [21].

The least commonly cited challenges were clinical instructors not being prepared for clinical teaching; not involving students in their evaluation; and lack of student support from teachers. This means that the students were satisfied with their clinical instructors’ performance, competencies, and support. In addition, the students verified that the instructors participated in their evaluation process and gave them feedback. These results contradict the previous findings [17], which reported minimum concern from instructors to their students’ educational needs and evaluation. The findings of the current study related to this area can be justified by many explanations, such as involving students in their evaluation and having competent and well-prepared clinical instructors. These are considered basic requirements in the education process, and core elements of all national and international accreditation standards followed by most nursing faculties in Jordan.

Nursing students should be prepared for clinical practice in positive learning environments with sufficient resources to support active learning. Despite the increased focus on creating positive learning environments, nursing students in Jordan continue to report many challenges that negatively impact their clinical practice experiences. The study provides the baseline information necessary to begin developing improvement strategies. In this regard, qualitative research to further understand the lived experience of the students might be useful to develop targeted interventions to enhance the clinical learning environment.

This study was conducted at three universities located in Amman, the capital city of Jordan, so, assessing students’ perspectives about challenges of clinical education in a baccalaureate nursing program from other universities outside Amman will support the generalizability of the findings. Also, there were no validated instruments available, which is considered a major limitation of this study.