Qualitative Research Article r w7

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Nurse Education Today

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The transfer of theoretical knowledge to clinical practice by nursing students and the difficulties they experience: A qualitative study

Ulviye Günaya,⁎, Gülsen Kılınçb a Department of Pediatric Nursing, The Faculty of Health Sciences, Inonu University, Malatya 44280, Turkey b Department of Psychiatric Nursing, Faculty of Health Sciences, Inonu University, Malatya 44280, Turkey

A R T I C L E I N F O

Keywords: Nursing students Theoretical knowledge Clinical practice Difficulties Experience Transfer Qualitative study

A B S T R A C T

Background: Nursing education contains both theoretical and practical training processes. Clinical training is the basis of nursing education. The quality of clinical training is closely related to the quality of the clinical learning environment. Objectives: This study aimed to determine the transfer of theoretical knowledge into clinical practice by nursing students and the difficulties they experience during this process. Methods: A qualitative research design was used in the study. The study was conducted in 2015 with 30 nursing students in a university located in the east of Turkey, constituting three focus groups. The questions directed to the students during the focus group interviews were as follows: What do you think about your clinical training? How do you evaluate yourself in the process of putting your theoretical knowledge into clinical practice? What kind of difficulties are you experiencing in clinical practices? Results: The data were interpreted using the method of content analysis. Most of the students reported that theoretical information they received was excessive, their ability to put most of this information into practice was weak, and they lacked courage to touch patients for fear of implementing procedures incorrectly. As a result of the analysis of the data, five main themes were determined: clinical training, guidance and communication, hospital environment and expectations. Conclusions: The results of this study showed that nursing students found their clinical knowledge and skills insufficient and usually failed to transfer their theoretical knowledge into clinical practices. The study observed that nursing students experienced various issues in clinical practices. In order to fix these issues and achieve an effective clinical training environment, collaboration should be achieved among nursing instructors, nurses, nursing school and hospital managements.

Additionally, the number of nursing educators should be increased and training programs should be provided regarding effective clinical training methods.

1. Introduction

Nursing education involves theoretical and practical educational processes. Students are taught how to provide care for people in dif- ferent healthcare settings (Dinmohammadi et al., 2016), with education occurring in classrooms, laboratories and clinics. While the classroom environment provides students with largely theoretical information, the clinical environment provides opportunities to put theoretical in- formation into practice (Kelly, 2007).

Practical experience in health care settings is the foundation of nursing education. The primary purpose of practical experience is to improve the students' professional knowledge and skills, but it also involves improvement of skills of research, critical thinking, self-

esteem, independent decision-making, and effective interpersonal communication (Dinmohammadi et al., 2016; Elcigil and Sarı, 2007; Papp et al., 2003). The quality of practical learning is closely related to the quality of the clinical learning environment (Dinmohammadi et al., 2016; Elcigil and Sarı, 2007). In the literature, it was found that nursing students' academic motivation increased as the quality of their clinical learning environment improved (Aktaş and Karabulut, 2016). The success of education in the clinical environment is influenced by var- ious factors. These are the instructors, students, healthcare profes- sionals employed at the clinic, and the physical environment (Pollard et al., 2007). When one or more of these factors are inadequate, clinical education may not be achieved at a desired level (Aktaş and Karabulut, 2016). This situation may lead prospective nursing students to

https://doi.org/10.1016/j.nedt.2018.02.031 Received 18 May 2016; Received in revised form 6 February 2018; Accepted 26 February 2018

⁎ Corresponding author at: Inönü University, Faculty of Health Sciences, Malatya 44280, Turkey. E-mail addresses: ulviye.gunay@inonu.edu.tr (U. Günay), gulsen.bektas@inonu.edu.tr (G. Kılınç).

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experience inability and anxiety (Elliott, 2002; Hoel et al., 2007). Nurse training in Turkey started in 1921 with the establishment of

six month “voluntary caregiver courses”. Literate daughters of wealthy families were accepted for these courses. Later, nursing schools that provided training on a high school level were opened (Ergöl, 2011). Undergraduate level nurse education in Turkey began in 1955. How- ever, nurses were taught at the undergraduate level only in five uni- versities until 1994. Because of the scarcity of nurses in Turkey during this period, training was provided via 18-month courses (Korkmaz, 2011). Despite these differences in nurse education in Turkey, all nurses who graduated from these schools or courses were given the same title of nurse. These nurses were granted the same authority and responsi- bilities. This situation negatively affected the process of professionali- zation of nurses (Ulusoy, 1998).

Today, nursing degrees are more widely available throughout Turkey and the number of registered nurses has reached the desired level for the population. Presently, the number of schools providing education at the undergraduate level in Turkey is 96. The education process is designed to be at least four years with students completing 4600 h of theoretical and practical experience (Ergöl, 2011; Ulusoy, 1998). While nursing schools in Turkey are sufficient in terms of quantity, the quality of education is not at the desired level.

In Turkey, various problems are experienced in nurse education both the school and the clinical environments. These may include: lack of sufficient number of highly qualified nursing instructors, students' inability to receive adequate guidance from educators, lack of sufficient support for students by clinical nurses, lack of suitable role models, negative approaches of healthcare personnel, communication problems, high numbers of nursing students, insufficient laboratory and classroom environments, and problems regarding clinical practices (Celik and Bayraktar, 2004; Elcigil and Sarı, 2007; Aydın and Argun, 2010; Kostak et al., 2012; Karadağ et al., 2013).

It is unknown how nursing students can transfer theoretical knowledge to practice in the clinical setting where they experience various problems. This issue needs to be examined in depth, as well. The results obtained from this study can contribute to increasing the quality of nursing education both in Turkey and in the world.

For this reason, this study was carried out with the aim of de- termining the situations in which nursing students the transferred of theoretical knowledge to clinical practice and the difficulties they ex- perience.

2. Method

2.1. Study Design and Participants

The study was conducted with nursing students in a university lo- cated in the east of Turkey between May and June 2015. This study was conducted using a phenomenological method, using a qualitative re- search design. The purpose of phenomological interviews is to obtain detailed and multidimensional qualitative information regarding par- ticipant perspectives, knowledge, experiences, opinions, feelings, atti- tudes and habits about a specified topic (Corbin and Strauss, 1990; Lawrence and Tar, 2013). This method was deemed appropriate to receive detailed information from nursing students about the focus of the study. Data were collected using the method of focus group inter- views. The study was conducted with 2nd (focus group 1), 3rd (focus group 2) and 4th (focus group 3) year nursing students. An an- nouncement was made to all students about the study. A focus group was formed with 10 volunteering students from each year. A total of three focus group interviews were conducted with a total of 30 stu- dents. Pre-interviews were conducted with 10 students one month be- fore the focus group interviews. The aim was to understand if semi- structured questions were sufficient to examine the subject. At the end of this process, incomprehensible phrases were revised in the interview form, and opinions and ideas related to the form were acquired from

three experts in the field of nursing. The data from the preliminary interviews were not used because the corrections were made to the questions after the preliminary negotiations. In the subsequent stage, focus group interviews with the participants were carried out.

2.2. Ethical Considerations

The ethical approval was granted by the Scientific Research and Publications Ethics Board of İnönü University, and the institutional permission was granted by the Faculty of Medical Sciences. The struc- ture, aim and procedures of the study were explained to the students. Additionally, participants were also informed that their participation in the study was in a voluntary basis, and the information gathered from the interviews would be written down and used only for scientific purposes. Written consents were received from the students who wanted to participate in the study.

2.3. Data Collection

In-depth and semi-structured interviews were used for data collec- tion. Participants were asked open-ended questions in the interviews (Corbin and Strauss, 1990). These were based on an interview guide, which was formulated based on a critical review of the literature (Table 1). Each focus group interview was recorded and transcribed verbatim. Each lasted an hour. The principal researcher performed all focus group interviews. The researcher refrained from using judg- mental, condoning and negatory statements and attitudes during the interviews. All of these interviews were carried out in a meeting room at the hospital.

2.4. Data Analysis

Data were analyzed using qualitative content analysis. Content analysis is a research technique used to derive reproduceable and valid results regarding the content of data (Graneheim and Lundman, 2004). Both researchers independently transcribed the audio recordings gath- ered as a result of the focus group interviews. They read and reread transcripts and coded the same, similar and different statements. The researchers gathered and compared their coding work. As a result of this comparison, it was seen that the coding work of both researchers was the same. In the next stage, the coded data were organized, and the main themes and sub-themes (Corbin and Strauss, 1990; Graneheim and Lundman, 2004) of the study were determined (Table 2).

3. Results

The mean age of 30 participants including sophomore, junior, and senior year nursing students was found to be 20.8 years. 55% of parti- cipants were female.

3.1. Clinical Training

Most of the participants reported that the theoretical information that they received in school was intensive; however, they could not put most of this information into practice, and their clinical practice was

Table 1 The primary questions of the interviews were:

What do you think about your clinical training? Can you explain? How do you evaluate yourself in putting your theoretical knowledge into clinical

practice? How do you evaluate yourself in clinical practice? Can you explain? What kind of difficulties are you experiencing in clinical practice? What is your opinion on how to overcome these problems? What do you think is the appropriate clinical setting? Can you explain?

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not effective. As the students found their clinical knowledge and skills inadequate, they were afraid of providing care for and touching pa- tients. This section is discussed in two sub-themes as “clinical knowl- edge” and “clinical skills”.

3.1.1. Clinical Knowledge The students found their clinical knowledge inadequate. They re-

ceived extensive theoretical information at school. On the other hand, they were not able to put this information into practice:

We are inactive in the practice. We receive intensive theoretical in- formation but we cannot put it into practice.

(Focus group 1, Student 1)

Theoretical education and clinical practice are not taking place in par- allel; what is given in the lecture and what I observe in the clinic are always different from each other; therefore, I cannot maintain control of my patient completely.

(Focus group 2, Student 4)

One student gave a different answer to this question: Our clinical practice training varies from course to course. For example, the instructor of a course taught us what we should absolutely know without overloading too much information. We put what we learned into our practices in clinic. I felt competent in that practice.

(Focus group 2, Student 3)

3.1.2. Clinical Skills The students did not find their clinical skills sufficient. Thus, they

did not trust themselves as they were afraid of incorrect care of people, they did not want to interact with them:

I am afraid of performing patient procedures incorrectly; therefore, I cannot touch patients too much.

(Focus group 1, Student 5)

Whatever the procedure may be, we are hesitant at first. We do not want to harm the patient. On the other hand, if we learned a practice with the instructor, we could do something when we visited the patient later.

(Focus group 2, Student 7)

They tell us at school that “nursing is not only establishing vascular access or measuring vital signs.” We are receiving a comprehensive care training, but we never saw any practice other than vascular access or measuring vitals when we visited the clinic. I do not think I am competent in anything else as I have not carried out any practice other than mea- suring vitals.

(Focus group 2, Student 4)

3.2. Guidance

Students were not able to receive adequate guidance from

instructors in clinical applications. They wanted clinical instructors to be present during procedures and carry out the procedures together. Some clinical instructors were found to be strict and distant to students. So, the students were hesitant to ask questions:

Our instructors are knowledgeable, but they usually do not spare time for us. For example, doctors gather their students at the clinic and provide training. Our professors could also do the same thing. However, they constantly ask questions instead of teaching anything. We are hesitant to ask questions of some of our professors about things we do not know, because they might get angry with us.

(Focus group 2, student 10)

I think you cannot expect something back without giving something back beforehand. It is meaningless to ask in the first week of visiting a totally unfamiliar clinic whether I debriefed the patient or performed a proce- dure. They should first show the debriefing process, so the student is able to inform the patient. We cannot perform procedures without seeing anything.

(Focus group1, student 6)

A student in the 3rd year stated that they were able to receive guidance from their instructors this term (year):

In previous applications, we used to see the actual instructor of the course only once, but since the beginning of this year, the main instructor spends time with us. They teach us and answer our questions. So, they went down to the level of the public. We like it when our instructor spends time with us, recognizes us and is interested in us. However, some instructors are usually too distant and indifferent.

(Focus group 2, student 6)

3.3. Communication

Students experienced problems with some nurses and clinical in- structors. Nurses saw the students as insignificant and they did not cooperate. Similarly, so did some clinical instructors. The students' motivation was diminishing. Their courage to practice was harmed and they started to question their interest in the nursing profession.

This section consists of two sub-themes as “lack of appreciation” and “cooperation”.

3.3.1. Lack of Appreciation Most nurses belittled the students, saw them as unnecessary addi-

tions, ostracized them and ignored them:

Nurses do not consider us as their colleagues. They treat us as if we overcrowd their workplaces. If they appreciated us and cooperated with us, we would also love our profession. On the contrary, they are keeping us away from our profession.

(Focus group 1, Student 3)

We actually expect respect, because we show them respect. Nurses see us as a useless, ignorant and unnecessary bunch. If they appreciated us, we would like our profession and have high motivation.

(Focus group 3, Student 1)

Students experienced problems with some clinical instructors. In this case, their motivation decreased, and they felt insignificant:

At school, our instructors tell us “primum non nocere” (first, do no harm). We are saying to them, “first, do not belittle us”. They should appreciate us, not lower our motivation. They should not interrogate us like ‘how can you not know this?’ Instead, they should say “let us do it together”. This is our difference from students of medicine, we are not appreciated or encouraged.

(Focus group 2 student 5)

As some of our instructors have a very stern attitude, we cannot ask questions. When an instructor coming to the clinic is strict, it gives an

Table 2 The results of the study were defined on the basis of these five principal themes:

Main themes Sub-themes

Clinical training Clinical knowledge Clinical skills

Guidance and communication Inadequacy in receiving clinical guidance Lack of appreciation Cooperation

Clinical evaluation Expectations changing based on the instructor Injustice in clinical grading

Hospital environment Lack of resting environments Hygiene problems

Expectations Instructors Nurses School and hospital management

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image of “I am closed to communication”. I want my instructors to be both authoritative and gentle. Even if something is running through my mind a lot, I cannot ask a question to a professor who has a stern atti- tude. Instructors should be approachable. They should work as nurses before becoming academics.

(Focus group 3, student 3)

3.3.2. Cooperation While students complained about nurses not cooperating with them,

nurses in intensive care units did give them the desired attention. This was because they were lacking in number in the intensive care en- vironment.

Some nurses cooperate with us. Some others treat us like as if we are only there to measure blood pressure and draw blood. They make us do their job to alleviate their work load. They use us. Nurses do not embrace us and they do not treat us sincerely. The do not see us as colleagues, they do not cooperate.

(Focus group 1, student 7)

A fourth-year student had a different opinion:

This attitude of nurses is caused by the high number of students. For example, when I went to the intensive care unit, there was a nurse named S. She taught us everything because we were just a few people. She taught us all procedures and said let us do it together. She encouraged us. We were also 4 people in the practice at the Newborn Intensive Care Unit. The nurses there also attended to us in person (one by one).

3.4. Clinical Evaluation

Some students complained about not being fairly evaluated by some clinical instructors. They did not want to fear attending visits in clinical practice or receiving bad grades:

Additionally, some assistants try to look for our mistakes instead of helping us close our gaps in knowledge. They ask questions until we get a negative score. They are satisfied when they give a negative score. Or, in another practice, they ask why we did something in that way, and when we say the main instructor wanted so, they say alright, if they said so it is correct. Despite the fact that they said the opposite 10 min ago… They behave inconsistently.

(Focus 1, student 10)

I do not believe our instructors know us. For example, ask them who this student is, what he is successful in, what she is interested in. I do not think you can get a response in any way. We are not seen as individuals, but considered as a group.

3.5. Environment

The clinic did not have a decent physical environment or a resting area. They were not given cards to open the doors for the clinic, so they had to wait outside for long times. They had no place to store their personal belongings. The sub-themes of this section are discussed as “resting environments” and “hygiene”.

3.5.1. Resting Environments Students reported that they were physically and emotionally ex-

hausted because they had to work/stand for several hours during the clinical rotation and that they did not have an appropriate place to take a break:

We need a room to come in and sit down, have a rest after our job is done. As there is no such room, we wait either in the corridors or next to windows. Even if we are taking a break, we get tired and exhausted because we have to wait standing up.

(Focus group 1, student 3)

When we are exhausted, we occasionally go to the room where the nurses take a break. However, no seats are left for them when we sit down there. They kick us out of the room.

(Focus group3, student 5)

A student had to wait outside the door of the clinic for a long time:

Although we practice in this hospital, we are not able to enter the hospital because we do not have a card to open the door. This is a problematic issue. Even patient relatives are surprised about this. I think relatives of patients should be thinking like ‘even the hospital does not embrace you, does not see you as one of them, how can I trust you’.

(Focus group 1, student 6)

3.5.2. Hygiene Students left their personal belongings at insanitary areas. They also

met their personal needs (toilet usage, etc.) in areas open to everyone:

We should not be putting our belongings into a storage area or a dirty materials room, are our belongings not valuable? We have to have our coats in winter. We are forced to leave them in storage areas and dirty rooms…

(Focus group 3, student 1)

We are not allowed to use the restrooms designated for employees. We use the restrooms downstairs used by the patients. Nurses got angry with students because some materials were spent quickly in the clinic. Last term, a head nurse get angry at us by saying the usage rates of some materials increased since the internships started. She said to us: ‘you will not use the materials of the clinic from now on, you buy them yourself and bring them if you need’.

(Focusgroup2, student 7)

3.6. Expectations

In order to have an effective clinical education process, the students had some expectations from nurse educators, clinical nurses and man- agers. These requests could lead them to be active in clinical education, love their profession and feel appreciated.

The students expected nurses in the clinics to appreciate them, to be patient and cooperate with them. Similarly, students expected to be appreciated by their clinical instructors and expected their instructors to accompany them in the clinical area and play an active role in educating them, rather than being a supervisor:

“I want to receive help from them without fear.” (Focus group 3, Student 10)

“I want to be seen as a nurse, not a student.” (Focus group 3, Student 6)

We do not want to live in fear of a visit and be scared all day. (Focus group 2, Student 10)

We want our instructors to understand us and be both tolerant and authoritative. They should help us in the clinic and show us the practice.

(Focus group 2, student 10)

We want a place where we can leave our coats and sit and relax when necessary.

(Focus group 1, Student 7)

4. Discussion

This study showed that prospective nursing students had problems

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in putting their theoretical knowledge into practice, they had deficiency of clinical knowledge and skills, and experienced several problems in the clinic. Most of the students reported that the theoretical information that they received in school was intensive; however, they could not put most of this information into practice and clinical practice was in- adequate. In literature found that nursing students could not adequately put their theoretical knowledge into practice and they faced various difficulties in clinical practices (Aydın and Argun, 2010; Chan et al., 2009; Dinmohammadi et al., 2016; Elcigil and Sarı, 2007). A study conducted to determine the difficulties faced by nursing students in practice found that almost half of the students faced difficulties in clinical practice, the most important of which was failure to put the theoretical information into clinical practice (Karadağ et al., 2013). In a study, students said that the clinical environment is more different than what is described in the classroom. They also indicated that some clinical skills they had learned in the skills laboratory are not practiced quite in the same way in the hospital (Elcigil and Sarı, 2007). In this study, students noted the reasons for this inability as fear of dealing with patients, inability to meet patient needs, fear of making mistakes, and anxiety in interacting with the nurses. They also expressed that they were not able to stay in the clinic environment for long enough. In a study conducted in Iran, prospective nurses reported the clinical knowledge deficit and inadequate preparation for entry into the clinical environment as the main origin of this anxiety (Dinmohammadi et al., 2016). In a similar study carried out in Sweden, it was found that nursing students hesitated to take part in procedures in clinical practice due to fear of making mistakes, uncertainty and dependence (Lofmark and Wikblad, 2001).

According to this study, nursing students noted that they did not receive sufficient support from the clinical instructors. The clinical educators were a few in number and their expertise was different in clinics. The importance of clinical instructors to nursing students in their transfer of theoretical knowledge into practice is without question. Clinical educators could decrease stress and promote effective learning strategies (Killam and Heerschap, 2013). In literature, authors stated that students wanted clinical educators to be knowledge able and competent in their own fields (Kelly, 2007; Tuna, 2015). In an article by Kelly (2007), the most effective educators were described by nursing students as: approachable, supportive, helpful, empathetic and en- couraging. On the other hand, the least effective educators were de- scribed as non-supportive, unapproachable, intimidating and not em- pathetic to students' needs. Various studies in Turkey have shown that nursing students are not supported by clinical educators (Aydın and Argun, 2010; Bayar et al., 2009; Elcigil and Sarı, 2007; Karadağ et al., 2013). Among these, in Bayar et al.'s study (2009), 68.3% of the stu- dents reported that they were not supported by their educator, and as a result, they were afraid. Similarly, Iranian students stated that they are not sufficiently supported and guided by nurse educators and particu- larly staff nurses (Dinmohammadi et al., 2016).

Another element affecting the competency of nursing students in the clinics is the nurses working in the clinic. In this study, students un- derlined the fact that they were perceived as a useless crowd by the nurses and were not supported or encouraged. Students experienced communication problems with the nurses in the clinic. This situation not only lowered their motivation, but also made them feel un- appreciated. Nurses are in the position to be role models for nursing students, behave in an informative manner and assist them to in per- forming procedures. Therefore, it is extremely important for clinical nurses to establish communication and cooperate with students and support them. In investigating the interactions of nurses and students, nurses were found not to play the role of educators and not to provide students with adequate support (Karadağ et al., 2013; Kostak et al., 2012; Serçekuş and Başkale, 2016). On the other hand, in a study conducted with 165 clinic nurses in Turkey, 77.6% of the nurses stated that they saw themselves as good role models for nursing students (Akyüz et al., 2007). Authors of other studies report positive

approaches, cooperation, and proper role modeling of nurses positively affected student clinical practice (Lewin, 2007; Lofmark and Wikblad, 2001; Papp et al., 2003). On the other hand, nurses who acted tough on students and were not sensitive about the learning needs of students affected the learning setting negatively (Chan, 2002; Lofmark and Wikblad, 2001).

One of the significant problems experienced in Turkey regarding clinical education is the high number of nursing students in clinics. Increases in the number of students in clinics leads to students experi- encing problems with both educators and nurses in the clinic. If the clinical education does not provide the student with the support needed for the planning and fulfillment of the student's tasks, the clinical learning period may be ineffective.

In this study, the students reported that their practical opportunities to perform were reduced, because their numbers in the clinic was high. The number of nursing students has increased in recent years because of the increasing demand for the profession of nursing. This has caused nursing students to spend less time in clinics specific to fields and also a decrease in educator time allocated to students (Papp et al., 2003; Taniyama et al., 2012; Corlett, 2000; Elcigil and Sarı, 2007; Tuna, 2015). The high number of students in clinics may be a factor that hinders communication and cooperation, causing clinical nurses to consider nursing students as crowding them. Additionally, it may cause students and educators to experience physical and mental exhaustion.

Some students reported that no common assessment criteria were identified by educators for the assessment of students in practice, and that expectations varied from educator to educator. While assessing students in terms of their clinical education and theoretical education, clinical educators should be fair, provide clear explanation of what is expected from students, and prepare a guide for these expectations (Bagcivan et al., 2015; Cilingir et al., 2011; Elcigil and Sarı, 2007). Consequently, students may be assessed more fairly, and their moti- vation may improve for practice. In a qualitative study conducted to examine nursing students perceptions of the reliability of their educa- tors, students reported that their educators were using mostly non- verbal communication techniques, were incompetent in relieving stu- dent anxiety or providing an appropriate setting for student achievement, and that the exam questions prepared by their instructors did not accurately reflect the content of what was taught, which de- creased the degree of their perceptions of the reliability of their in- structors (Varagona, 2016).

In this study, one of the problems faced by the students regarding practice was that the physical setting in the clinic was not appropriate. Some of the students reported that there was no place in the practice setting where they can relax and leave their belongings; therefore, they were leaving these belongings in inappropriate areas (storage room, warehouse, etc.) and they were also standing for extended times. In the literature, nursing students reported that they are not able to meet their personal needs in the clinical environment or they meet those in in- appropriate conditions (Aydın and Argun, 2010; Karadağ et al., 2013). In order to love their profession and embrace it, nursing students should firstly be able to meet their physical needs. Clinical settings providing positive physical opportunities will help them feel self-confident and that the profession is worthwhile, and thus improve their motivation.

5. Conclusion and Recommendation

Clinical practice constitutes the main and essential parts of nurse education. Nursing students may achieve effective nursing care to the extent that they are able to sufficiently practice their theoretical knowledge in the clinic environment. The findings of this study showed that nursing students received intensive theoretical information at university; however, they were not able to transfer most of this in- formation into practice. It was found that the nursing students found their clinical skills and knowledge insufficient, and as a result, they were reluctant to touch patients and provide care for them. Providing

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intensive theoretical information to nursing students may make it harder for them to learn the essential issues. Therefore, nursing edu- cators should have nation-wide meetings to review the nursing curri- culum and therefore reduce the load of intensive theoretical informa- tion. Additionally, nurse educators may prepare the students before going into clinical practice by providing them with effective and suf- ficient simulation training.

Educators have a significant role in achieving an effective clinical environment. This study found that the nursing students were not able to receive sufficient guidance from clinical educators, experienced un- equal treatment in clinical evaluation, and had problems in cooperation and communication with nurses and clinical educators. Nursing stu- dents are a part of the nursing team and other members of the team must know that students need not only academic learning but also practical learning. Clinical educators and nurses should practice patient care applications with students, guide them, and encourage them by establishing good communication with them. Clinical educators should determine standards in evaluating the students and inform them about such standards.

It is also important in reaching an effective clinical environment that the physical conditions of the clinic are suitable. The results of this study showed that the physical conditions of the clinic were not suitable and this situation affected the clinical training environment negatively. In order to make the clinical training environment a good learning environment, close cooperation is needed among nursing educators, clinical personnel and administrators. The results of this study will be guiding in the formation of an effective clinical learning environment by nursing educators and administrators.

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