Student nurses experience of learning in the clinical environment.
ABSTRACT The clinical learning environment is a complex social entity that influences student learning outcomes in the clinical setting. Exploration of this environment gives insight into the educational functioning of the clinical areas and allows nurse teachers to enhance students' opportunities for learning. Since Cyprus is undergoing major reforms in nursing education, building on the experience and knowledge gained, this study aims to explore the present clinical situation and how this would impact on nursing education moves to the university. As nursing education would take on a different approach, it is assumed the learning approach would also be different, and so utilization of the clinical environment would also be improved. Six hundred and forty five students participated in the study. Data were collected by means of the clinical learning environment and supervision instrument. A statistically significant correlation was found between the sub-dimensions "premises of nursing care" and "premises of learning" indicating that students are relating learning environment with the quality of nursing care and patient relationships. The ward atmosphere and the leadership style of the manager were rated as less important factors for learning. The majority of students experienced a group supervision model, but the more satisfied students were those with a "personal mentor" that was considered as the most successful mentor relationship. The findings suggest more thorough examination and understanding of the characteristics of the clinical environment that are conductive to learning.
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ABSTRACT: This paper is a report of an international study of patients' and nurses' perceptions of nurse caring behaviours. Current economic constraints on healthcare systems, demand to increase the quality of care and the incorporation of the consumers' perspective into care, have created a need to develop a clear understanding of nursing behaviours which convey caring. Patients in different areas of the world report different expectations of nurses' caring actions when compared to nurses' views. A descriptive comparative survey design was used to analyse a sample of surgical patients (n = 1659) and their nurses (n = 1195) in 88 wards of 34 hospitals in Cyprus, the Czech Republic, Finland, Greece, Hungary and Italy. Data were collected in autumn 2009 using the Caring Behaviours Inventory-24. Nurses' and patients' responses were compared using both inferential and descriptive statistics. Independent samples t-tests showed important differences between nurses' and patients' views. Although both groups perceived knowledge and skill as being the most important sub-scale, the nurses' responses were higher compared to patients (P < 0·05) with important differences in the 'assurance of human presence' (P < 0·001) and the 'respectful deference to others' (P < 0·001) sub-scales. Cross-country comparisons showed important differences between the nurses' (F = 24·199, P < 0·001) and patients' views on caring (F = 26·945, P < 0·001). Important differences were observed between patient-nurse perceptions in the participating countries. The results form a foundation for future research into the development of a common international perspective about caring behaviours between patients and their nurses.Journal of Advanced Nursing 08/2011; 68(5):1026-37. · 1.53 Impact Factor
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ABSTRACT: Research evidence supports that the role of the professional practice environment is crucial for the delivery of quality care as it is significantly correlated with patient and nurse outcomes. However, in countries sharing similar cultural and ethnic backgrounds, like Cyprus and Greece, as well as the increased mobility of patients and healthcare workers, there is a lack of information regarding this issue. The aim of this study is to explore and compare Cypriot and Greek nurses' perceptions of their professional practice environment. A descriptive comparative survey was employed using a sample of nurses in Cyprus (N = 150) and Greece (N = 147). Information was collected with the Revised Professional Practice Environment Scale (RPPE). The results revealed significant differences between the two countries in three out of eight factors of the RPPE, with Greece's mean value being higher than Cyprus's: Handling Disagreements and Conflicts, Leadership and Autonomy in Clinical Practice, and Teamwork. The findings generate additional knowledge about the organizational context of care delivery that might help nursing leaders to understand how nurses perceive their work environment and how this influences their work, and consequently the care provided. The results can be utilized by nurse ward managers to improve the quality of nursing care provided. Further research is needed using different approaches to explore nurses' experience in more depth. Measuring nurses' perceptions of their professional practice environment may assist managers and policymakers in introducing interventions that contribute to a better practice environment and consequently to improved nursing, as well as patient, outcomes.International Nursing Review 01/2014; · 0.94 Impact Factor
- Nursing times 09/2013; 109(37):18-20.
Student nurses experience of learning in the clinical environment
Evridiki Papastavroua,*, Ekaterini Lambrinoua, Haritini Tsangarib, Mikko Saarikoskic,
aSchool of Health Sciences, Department of Nursing, Cyprus University of Technology, 215, Dromos Lemesou 2252 Latsia, P.O. Box 12715 Nicosia, Cyprus
bUniversity of Nicosia, 46 Makedonitissas Ave., 1700, Cyprus
cUniversity of Applied Sciences, Health Care Education, PL 20, 20 701 Turku, Finland
dUniversity of Turku, Turku Hämeenkatu 10, Turku, Finland
a r t i c l e i n f o
Accepted 26 July 2009
s u m m a r y
The clinical learning environment is a complex social entity that influences student learning outcomes in
the clinical setting. Exploration of this environment gives insight into the educational functioning of the
clinical areas and allows nurse teachers to enhance students’ opportunities for learning. Since Cyprus is
undergoing major reforms in nursing education, building on the experience and knowledge gained, this
study aims to explore the present clinical situation and how this would impact on nursing education
moves to the university. As nursing education would take on a different approach, it is assumed the learn-
ing approach would also be different, and so utilization of the clinical environment would also be
improved. Six hundred and forty five students participated in the study. Data were collected by means
of the clinical learning environment and supervision instrument. A statistically significant correlation
was found between the sub-dimensions ‘‘premises of nursing care” and ‘‘premises of learning” indicating
that students are relating learning environment with the quality of nursing care and patient relation-
ships. The ward atmosphere and the leadership style of the manager were rated as less important factors
for learning. The majority of students experienced a group supervision model, but the more satisfied stu-
dents were those with a ‘‘personal mentor” that was considered as the most successful mentor relation-
ship. The findings suggest more thorough examination and understanding of the characteristics of the
clinical environment that are conductive to learning.
? 2009 Elsevier Ltd. All rights reserved.
Nursing education in Cyprus has been developing for almost
over a century. The first nursing training programme started in
1946 (Antoniou, 1990) but officially, planned courses for general
nurses were organized and commenced in 1960 when Cyprus
was declared as an independent state. Nursing education became
responsibility of the Ministry of Health and with the assistance
of the World Health Organization, aimed to establish nursing edu-
cation in Cyprus ‘‘on a high international level” (WHO, 1960). Dur-
ing mid 1990s nursing in Cyprus experienced a first educational
transformation with the upgrading of courses to a diploma level,
although it remained under the umbrella of the Ministry of Health.
A major evaluation report from experts from the World Health
Organization (WHO, 1987) identified problems similar to those re-
ported in other countries, like linking theory to practice, poor
acquisition of skills and problems in the supervision of clinical
practice. Two studies regarding nursing education in Cyprus also
confirmed weaknesses in the level of support both nurse teachers
and clinical teachers are able to provide to nursing students in Cy-
prus (Antoniou, 1990; Papastavrou, 1997). In 2002, a team of ex-
perts from the EU member states performed an evaluation
mission (peer review) with the support of TAIEX (Technical Assis-
tance and Information Exchange) in Cyprus (EU, 2002) which re-
sulted in improving the continuous education programs for nurses.
Nursing in Cyprus has followed the apprenticeship model for
many years, which enabled nurses to learn their trade ‘on the
job’ as the school of nursing was attached to the hospital and pro-
vided the professional education necessary to support healthcare
needs. This model provided a practice-based workforce, however
it was criticized as it was questioned whether the preparation
met the needs of a changing health service (Longley et al., 2007).
Consequently, a number of significant changes occurred, the most
radical being the shift to the tertiary section (The Republic of Cy-
prus, 2003) and the development of privatization in education that
has given an end to the state monopoly of nurse training which has
now became a marketable commodity.
The reformation of the traditional nursing education system
and the integration with higher education is suggested to have
many advantages (Owen, 1988) as well as complexities like the
1471-5953/$ - see front matter ? 2009 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +357 25 583842 (H), +357 22 001605 (O), mobile:
+357 99 545021.
E-mail address: firstname.lastname@example.org (E. Papastavrou).
Nurse Education in Practice 10 (2010) 176–182
Contents lists available at ScienceDirect
Nurse Education in Practice
journal homepage: www.elsevier.com/nepr
skepticism whether theory would diminish clinical skills and prac-
tice (Barton, 1998). As in many countries the reason for this move
was to improve the educational experience of students and thus
the competence of graduates. In many areas of Europe, this transi-
tion took place more than one or two decades ago and the impor-
tance of clinical education for quality nursing care has gained
increasing attention over the last years. The integration of nursing
into higher education in the early 90s and the move to higher edu-
cation in the UK, resulted in the introduction of several innovations
like the supernumerary student status and the adoption of various
roles including; the lecturer employed by the University; joint
appointments; mentors; specialist and advanced practitioners
including the nurse consultant; and more recently the clinical
nurse educator (Pollard et al., 2007). An increase in theoretical
components of nurse education was generally well received; how-
ever the increasing theory–practice divide is often attributed to the
move of nurse education into Higher Education. There were con-
cerns that focusing on theoretical aspects of nursing impacted on
clinical skills, consequently, it was questioned whether nurses
gained adequate preparation to carry out the required skills in
practice (Longley et al., 2007).
This study has been informed by previous work in other coun-
tries, in regards to the transition into tertiary sector for nursing
education. Building on the experience and knowledge gained in
these countries, this study aims to explore the present clinical sit-
uation and how this would impact on nursing education moves to
the university. As nursing education would take on a different ap-
proach, it is assumed the learning approach would also be differ-
ent, and so utilization of the clinical environment would also be
improved. The results of the study will be used to reorganize nurs-
ing practice as a part of the design of the new curriculum aiming to
equip students of nursing with the competencies required to meet
the complex demands of care and to apply theory in practice.
Student supervision and clinical practice
Historically, the clinical support roles in Cyprus followed the
British model of nursing education, with the ‘‘one teacher” (nurse
teacher had dual responsibility for classroom and clinical teach-
ing), a role that was suggested as a method of resolving the the-
ory–practice segregation (Lambert and Glacken, 2004). In an
attempt to alleviate nurse teacher workload and address the long
debated theory–practice divide clinical teachers were employed
in the 1980s and these posts lived for over 20 years. More recently,
the role of mentors was introduced because it was considered that
collective teaching would be more beneficial in supporting stu-
dents in the clinical area and reducing the theory–practice gap.
Mentors were experienced staff nurses who attended 1 day semi-
nar preparation that was provided by the teachers of the School,
but unfortunately the ambiguous nature of their role and the expe-
rience of challenges in fulfilling their roles effectively as a conse-
quence of workloads, insufficient time, inadequate staff levels,
primary patient care responsibility and lack of coherent training
and support, made mentorship inadequate.
The clinical learning environment as explored in this study con-
sists of the ward atmosphere that incorporates items like how easy
the staff members are to approach, the spirit of solidarity among
nursing staff and encouragement of students to participate in the
discussions. The leadership style refers to the attitude of the ward
manager towards the staff members, his or her appreciation of the
efforts of individual employees and the leader’s behavior as a team
member (Saarikoski and Leino-Kilpi, 2002). The ‘‘ward premises”
includes the nature of care delivery, the wards nursing philosophy,
the delivery of care, e.g. individualized, the flow of information re-
lated to patient care and the documentation of nursing, like for
example the nursing care plans and the daily recording of nursing
procedures (Saarikoski et al., 2002). The supervisory relationship
was explored by examining concepts that measured the pedagog-
ical and psychological content of the relationship, including the
mentor’s attitude towards supervision, individualized approach
and feedback to the student.
One of the main features of nursing as a science and a profes-
sion is that nursing education is characterized by a close relation-
ship between theory and practice, meaning that nursing cannot be
learned through either theory or practice only. However clinical
learning takes place in the complex social context of the clinical
environment that is defined in several ways (Dunn and Hansford,
1997; Saarikoski and Leino-Kilpi, 2002; Papp et al., 2003) and con-
sists of different important elements.
The theoretical framework of this study is based on the dyadic
nature of the clinical environment: One is the learning environ-
ment including the ward atmosphere, the culture and the com-
plexities of care, and the other is the supervisory relationships
between students, clinical and school staff (Saarikoski and Leino-
Kilpi, 2002). The clinical learning environment is also seen as a
concept that can be measured although numerous research pro-
jects insisted on the qualitative approach of exploring the students’
experiences (Chun-Heung and French, 1997; Papp et al., 2003; Pey-
rovi et al., 2005; Chesser-Smyth, 2005). Some measurement instru-
ments for assessing aspects of the clinical learning environment
have been developed (Dunn and Hansford, 1997; Callaghan and
McLafferty, 1997; Chan, 2001; Saarikoski and Leino-Kilpi, 2002;
Hosoda, 2006) including most of the components synthesizing a
clinical environment as an area of learning.
Early studies in the 1980s examined multiple facets of student
learning on clinical placement and demonstrated the complexity
and demanding nature of the clinical environment, indicating that
this area of learning is unpredictable and far beyond the control of
faculty members (Fretwell, 1980; Ogier, 1981; Orton, 1981; Smith,
1988; Robinson, 1991; Elkan and Robinson, 1993; Twinn and Da-
vies, 1996; Chun-Heung and French, 1997; Jarratt, 1983). Other
studies questioned the effectiveness of clinical settings, claiming
that they fail to provide students with positive examples of behav-
ior (Greenwood, 1993; Lindeman, 1989) and even recognized it as
a source of stress, creating feelings of fear and anxiety which in
turn affect the students’ responses to learning (Kleehammer
et al., 1990; Nolan, 1998; Chesser-Smyth, 2005).
At the same time studies focused on the leadership style of the
ward manager (Fretwell, 1983; Orton, 1981) although the litera-
ture reveals a considerable overlap between the different roles of
ward managers, suggesting that the educational role is neglected
(Gerrish, 1990; Bezuidenhout et al., 1999; Twinn and Davies,
1996). More recent international studies found that the leadership
style of the ward manager remains an important element of learn-
ing (Saarikoski and Leino-Kilpi, 2002) and others support that cul-
tural and organizational factors in the ward often influence
students’ learning experience (Saarikoski et al., 2002; Mantzoukas
and Jasper, 2004; Pearcey and Elliott, 2004).
Later empirical studies concentrated on the supervisory rela-
tionships and supervision that takes place with an individual
supervisor or in a group (Saarikoski, 2003). Terms like ‘‘mentor”,
‘‘preceptor” and ‘‘link teacher” are extensively explored to describe
a supervisory role and the one-to-one relationship between stu-
dent and mentor, or individualized supervision was found crucial
to the process of professional development (Marrow, 1994; An-
drews and Chilton, 2000; Myrick and Yonge, 2001; Earnshaw,
1995; Myrick, 1988).
Other studies focused on staff–student relationships and the
impact this relationship has on students’ learning (Nolan, 1998;
E. Papastavrou et al./Nurse Education in Practice 10 (2010) 176–182
Dunn and Hansford, 1997; Chun-Heung and French, 1997; Atack
et al., 2000; Andrews and Roberts, 2003; Nolan, 1998). Poor staff
relationships, lack of staff commitment to teaching, autocratic
and hierarchical relationships, lack in the student-supervisor rela-
tionship were found as obstructive factors for learning, whereas
feeling part of the team is closely linked to the opportunity to learn
(Lofmark and Wikblad, 2001; Nolan, 1998; Dunn and Hansford,
1997; Myrick and Yonge, 2001). It is also argued that the practice
experience may not be an educational experience because learning
methods like reflection that advance student nurses’ intellectual
development are not actually implemented (Chun-Heung and
French, 1997; Lofmark and Wikblad, 2001; Mantzoukas and Jasper,
Aims of the study
The aim of this study was to explore the students’ experiences
of the clinical environment and supervision of the hospital-based
system of education in Cyprus, and forms the basis for future rep-
lication when nursing has totally moved to the ‘‘university
The specific objectives were:
1. To explore how student nurses find their experience of the
learning environment and supervision in clinical placements.
2. To identify which factors of the clinical environment and super-
vision contribute to learning.
3. To create a data base on clinical learning and supervision that
will form a starting point for future studies in Cyprus.
The research instrument used was the English version of the
Finnish clinical learning environment and supervision (CLES) scale
tested in earlier studies (Saarikoski and Leino-Kilpi, 2002), which
consists of background variables and statements that evaluate
the learning environment and the supervisory relationship. More
specifically, the questionnaire (CLES) consists of 27 statements
and it is sub-divided into five sub-dimensions with the following
number of items: ward atmosphere (five items); leadership style
of the ward manager (four items); premises of nursing care on
the ward (four items); premises of learning on the ward (six items)
and supervisory relationship (eight items). The respondent an-
swers to the statements are on a five-step Likert-type scale.
The only committee that exists in this country is the National
Bioethics Committee and according to the committee’s mission
(http://www.bioethics.gov.cy) this study was not under its juris-
diction. Therefore permission for access to the field of research
was obtained from the director of the school and from each of
the group leader–teachers. The aims of the study were explained
to the students and they were guaranteed anonymity and
For the statistical analysis the software package SPSS was used.
Reliability and validity analyses were applied to confirm the scien-
tific rigor of the translated research instrument. Moreover, descrip-
tives and frequencies on the items of the sub-dimensions of the
scale were found. Statistical tests, such as ANOVA and Bonferroni,
were also performed, in order to examine differences among the
various groups. Analysis of variance (ANOVA) is a statistical proce-
dure that examines if the means of several groups are all equal,
generalizing the t-test to more than two groups, using the F-distri-
bution. Post-hoc tests, such as Bonferroni, are performed when AN-
OVA has shown that there exist differences among the groups, in
order to assess which groups are different, by comparing the
Six hundred and forty five (645) that is 90% of all the undergrad-
uate students of the only Public School of Nursing in Cyprus (Min-
istry of Health) completed the questionnaire. These were the last
students of the hospital-based education system since next semes-
ter students will be admitted to the Department of Nursing at the
Cyprus University of Technology, under different admission
requirements. Some missing data exist randomly in various ques-
tions, and therefore the sample size is not 645 in all variables.
The mean age of the respondents was 20.4 years, with standard
deviation 2.72 years. The clinical placements of respondents were
divided into six different hospitals, covering all regions of Cyprus.
About 226 of the respondents (40%) were first-year students, 195
(40%) were second-year students and 138 (25%) were third-year
students. The clinical placement occurred in several wards, most
common being the medical (24%), the orthopedic (16%) and the
surgical (13.8%) and the remainder 56% were mainly in nephrology,
cardiology, oncology, pediatrics, neurosurgery, gynecology, angio-
thoracics, intensive care or casualty department (Table 1).
Validation of the instrument
For the purpose of this study, the CLES was translated and
blindly back translated from English to Greek (Maneesriwongul
and Dixon, 2004). The validity and reliability of the instrument
was evaluated by considering a random sample of 350 students
out of the total sample of 645 students that participated in the
study. The construct validity of the instrument was analyzed using
exploratory factor analysis (Papastavrou and Lambrinou, 2009).
The total percentage of variance that the factor model explained
was high (67%) and the questions loaded (i.e. were grouped) on
the same factors as the factors in the original questionnaire. The
The hospital departments of student nurses (by clinical specialty).
Intensive care unit
Vasc and thoracic surgery
Out patient department
E. Papastavrou et al./Nurse Education in Practice 10 (2010) 176–182
factors, in order of importance according to the factor analysis re-
sults, are ‘supervisory relationship’, ward atmosphere, premises of
nursing care, premises of learning, and leadership style of the ward
manager. The reliability of CLES was evaluated with the Cronbach’s
alpha reliability coefficients. The alpha value of the total scale was
0.95, which is extremely satisfactory, and the alpha values of the
sub-dimensions ranged from 0.79 to 0.95, which are very satisfac-
tory. More detailed results regarding the construct validity and
reliability of the translated CLES can be found in Papastavrou and
In the total sample of 645 students of the current study, the al-
pha values of the sub-dimensions were again very satisfactory,
ranging from 0.81 to 0.95 (see Table 2). These results are very sim-
ilar to the alpha values (ranging from 0.73 to 0.94) of the Finnish
and English samples when the instrument was validated and
tested in an international comparative study (Saarikoski et al.,
2002). Each sub-dimension was measured as the average of the an-
swers in the corresponding items. The relations between the sub-
dimensions of the instrument were measured with the Pearson
correlation coefficients. The analysis showed that these inter-cor-
relations are highly significant (p < 0.01) for all sub-dimensions
(Table 3), which implies that the properties of a good clinical learn-
ing environment interact together and their theoretical meanings
also interact. Our results, in fact, show stronger relations between
the sub-dimensions compared to the original instrument, where
some of the sub-dimensions (e.g. leadership style of the ward man-
ager) were not significantly related with the other sub-dimensions.
Results on CLES
Students evaluated their clinical learning environment and
supervision by staff nurses as ‘good’. The means of all sub-dimen-
sions varied between 3.27 and 3.61 (on the 1–5 scales) (see Table
2). Moreover, the skewness values of all the sub-dimensions were
negative (?0.51, ?0.38, ?0.59, ?0.39, ?0.47, respectively). The
combination of the results on means and skewness shows that
the assessments of students lean in the direction of positive values
(>3). The highest score was 4.03, equally given to an item measur-
ing the ‘‘ward atmosphere” and an item measuring ‘‘premises of
learning on the ward”. Overall it was the sub-dimension ‘‘premises
of nursing care on the ward” which had the highest mean, since the
scores on the items were consistently high. The lowest overall
evaluation (mean score 3.27) was received by the sub-dimension
‘‘supervisory relationship”. This sub-dimension is, however, the
most consistent since the Cronbach’s alpha for reliability is very
high (0.95). The highest mean in this sub-dimension (3.50) was
achieved for the item ‘‘The mentor showed a positive attitude to-
wards supervision” and the lowest mean (3.12) for the item ‘‘I con-
tinuously received feedback from my mentor”. These two means
are very similar with the corresponding item means found in the
original instrument (3.99 and 2.85, respectively).
A nurse supervised most of the students (247 students or 45%),
a nurse specialist supervised 131 cases (24%), a head-nurse 80
cases or 14.6% and an assistant head-nurse 40 cases (7.3%), another
student supervised 12 students (2.2%), a clinical teacher supervised
2 cases (0.4%), a doctor supervised 1 case (0.2%) and 14 students
(2.6%) were supervised by all of the above. Moreover, 9 students
(1.6%) were supervised by a teacher and 13 students (2.4%) did
not have any supervisor.
In the questionnaire, there were six alternatives regarding
supervisory relationship. Table 4 shows the frequencies for each
alternative. For the analysis, the first three alternatives ((1) the stu-
dent did not have a named supervisor, (2) a personal supervisor/
mentor was named, but the relationship with the mentor did not
work at all, and (3) the named mentor changed during the clinical
placement, even though no change had been planned) were com-
bined into one class and named ‘failed supervisory experiences’.
Results showed that 167% or 30.3% of the respondents had failed
supervisory experiences. Alternatives 4 and 5 ((4) supervision var-
ied according to the shift or place of work and (5) Supervisor had
several students, the so-called team supervision) were combined
and named ‘team supervision’. Results show that of the respon-
dents in this study the majority, 326% or 58%, experienced team
supervision. The remainder of the respondents, 11.4%, had a per-
sonal mentor and the relationship worked in practice. If we con-
sider all alternatives except 4 and 5 (team supervision) as a
‘‘personal mentor relationship”, we can say that only 27.3% of the
respondents who experienced personal mentorship expressed
their satisfaction with that relationship.
We also examined the relation between the continuous variable
reflecting the total satisfaction of students of their supervisory
relationship (measured as the average of the 8 corresponding
items), and the method of supervision. The mean in the group
‘‘failed supervisory experience” was 2.73, in the group ‘‘team
supervision” was 3.37 and in the group with a successful mentor
relationship was 4.18. A statistical difference was examined using
an ANOVA test, which showed that the differences between the
three groups were highly significant (Table 5).
Post-hoc Bonferroni tests, which compared the groups pairwise,
showed that the differences were statistically significant between
The reliability of the Greek version of CLE and descriptives of the five sub-dimensions.
Leadership style of the ward manager
Premises of nursing care on the ward
Premises of learning on the ward
Correlation matrix of the sub-dimensions (CLES).
style of the
Leadership style of the
Premises of nursing
Premises of learning
**Correlation is significant at the 0.01 level.
The alternatives of the supervisory relationship.
The method of supervision
1. The student did not have a named supervisor
2. A personal supervisor (mentor) was named, but the
relationship with the mentor did not work at all
3. The named mentor changed during the clinical placement,
even though no change had been planned
4. Supervision varied according to the shift or place of work
5. Same supervisor had several students, the so-called team
6. Supervisor was a so-called personal mentor and the
relationship worked in practice
E. Papastavrou et al./Nurse Education in Practice 10 (2010) 176–182
all three groups. Therefore, the results say that the most satisfied
students were the students with a successful mentor relationship
and the most unsatisfied students were the ones with a failed
We then examined if the total satisfaction with the supervisory
relationship was different among students with different frequen-
cies in the sessions with the supervisor. The frequency of the pri-
vate sessions varied from none to more than once a week, where
19.3% of the students had no private session, 30.2% had a session
once or twice, 13.6% had a session less than once a week, 15.6%
had a session once a week and 21.3% had a session more than once
a week. An ANOVA test showed that there were significant differ-
ences between the groups (F = 42.25, p-value < 0.001) and Bonfer-
roni tests showed that students who had more frequent sessions
with their supervisor were more satisfied.
There was no statistical difference among students in different
specialty departments (cardiology etc.) (F = 1.37, p-value = 0.150).
Regarding who the supervisor was (nurse, teacher etc.), in relation
to satisfaction, the results of ANOVA showed that there was a statis-
ticaldifferenceamongstudents(F = 6.39,p-value < 0.0001),butpost-
hoc Bonferroni tests showed that the differences were significant
only between students who did not have a supervisor compared to
students who had a supervisor, in other words students were more
satisfied if they had a supervisor compared to not having one.
Additional results using ANOVA, showed that there was a statis-
tically significant difference between years of study in terms of
their satisfaction (F = 8.89, p-value < 0.001). More specifically, Bon-
ferroni tests showed that the significant difference existed be-
tweenfirst- andthird-year students
second- and third-year students (p-value = 0.037), where first-
and second-year students were more satisfied with their supervi-
sory relationship compared to third-year students.
(p-value < 0.001), and
Nursing students engaged in the traditional training system
perceived their clinical placements and supervision by a qualified
staff as ‘‘good”. These results are similar with studies from other
countries (Saarikoski and Leino-Kilpi, 2002) although the overall
evaluation of the Cypriot students of their clinical placement was
found less positive. The quality of nursing care was identified as
especially important since the respondents rated the ‘‘Premises
of nursing care on the ward” very high. This result is analogous
to the views of the British students in international studies
(Saarikoski et al., 2002) and can be explained in historical terms,
since both the health care system and nursing education in Cyprus
were strongly based on the British tradition. The same observation
was made in the results of studies using different instruments in
Australia (Dunn and Hansford, 1997) and a different methodology
in Iran (Peyrovi et al., 2005). However, this finding is different from
the views of the Finnish students who repeatedly identify the ward
atmosphere as the most important element of the clinical environ-
ment and not the premises of nursing care on the ward (Saarikoski
and Leino-Kilpi, 2002; Saarikoski et al., 2002). A statistically signif-
icant correlation was found between the sub-dimensions ‘‘pre-
mises of nursing care” and ‘‘premises of learning” indicating that
students in Cyprus are relating learning environment with the
quality of nursing care and patient relationships. Although the ap-
proach of this study didn’t allow explanations, the differences of
opinion in the various countries can partly be explained in the con-
text of the meaning of caring that may be of educational or a cul-
tural origin and reflects the plethora of caring definitions presented
in the literature (McCance et al., 1997).
Cypriot students evaluated the ward atmosphere with lower
scores and they also gave the lowest evaluation to the item ‘‘during
staff meetings I felt comfortable taking part in the discussions”.
Two of the elements describing clinical learning experience in sev-
eral studies are: the need of the students to be appreciated (man-
ifested in a learning environment where students are a part of a
nursing care team) and a need to be supported. In qualitative stud-
ies in the UK (Spouse, 2001), Canada (Myrick and Yonge, 2001), Ire-
land, (Chesser-Smyth, 2005) and Sweden (Lofmark and Wikblad,
2001), it was found that mutual respect and positive regard for
others had an impact on the students’ confidence levels. Feeling
a part of a team and treated with respect as an individual is also
identified as a part of the socialization process that reduces anxi-
ety, increases confidence and promotes learning (Lofmark and
Wikblad, 2001; Nolan, 1998).
The leadership style of the ward manager in this study was
identified as less important when compared with earlier studies
in other countries (Fretwell, 1983; Ogier, 1981) and also in later
studies (Wilson-Barnett et al., 1995; Dunn and Hansford, 1997;
Saarikoski et al., 2002) nevertheless Cypriot students gave ward
managers a low evaluation score. However, differences in other
countries (Bezuidenhout et al., 1999; Chesser-Smyth, 2005) can
be explained by different forms of student supervision, different
types of ward organization and the introduction of supernumerary
status and mentorship that has rendered the leadership style less
transparently important to the learning environment in some
areas. It is also possible that the presence of clinical teachers
who are designated to supervise and guide students on the ward
made ward managers abandon their traditional pedagogical role
which they have gradually delegated to the school staff. This find-
ing can also be explained historically in terms beyond nursing edu-
cation and culture. Cyprus was under foreign occupation for
thousands of years and this kind of oppression might have shaped
a climate of suspicion and mistrust about any kind of management.
It is possible therefore that people’s views and consequently stu-
dents’ opinion about leadership and the role of the ward manager
in the promotion of learning was recognized as negative.
The supervisory relationship was found problematic, since 30%
of the students had ‘‘failed supervisory relationship” and this is
mainly due to reasons of occurrence and organization of supervi-
sion. Students were supervised by a variety of people, ranging from
staff nurses, to managers, doctors, fellow students or they were not
assigned to a supervisor. It is also clear that the mentorship system
did not work as expected and one explanation might be the pres-
ence of clinical teachers that may have prevented the mentors of
undertaking a more active role in student supervision. Although
the organization of clinical practice rested on the school, this find-
ing reflects the apprenticeship system and the dependence of nurs-
ing education from the ministry of health. The majority of students
experienced group or team supervision and these results are very
different from the organization of supervision systems in other
European countries, where the use of mentors and individualized
supervision are very common (Saarikoski et al., 2002, 2007) but
are similar to that in schools where other members of staff acted
as supervisors, the models of team supervision were very common
(Saarikoski et al., 2007).
Differences in satisfaction of supervisory relationship, according to method of
Method of supervisionSatisfaction
1. Failed supervisory
2. Team supervision
3. Successful mentor
*Differences between the three groups are significant at the 0.01 level.
E. Papastavrou et al./Nurse Education in Practice 10 (2010) 176–182
In contrast to other countries, students in Cyprus do not evalu-
ate their supervision experience positively (Saarikoski et al., 2007,
2002) and they are not satisfied from the team supervision model.
Only a small percentage of students (11.4%) find supervisory rela-
tionship successful. Students’ total satisfaction was observed to
have a statistically significant link with the occurrence of supervi-
sion: the more satisfied students were those who had a personal
mentor, where the student-mentor relationship worked in practice
as they had more frequent sessions with their supervisor. There are
also differences in satisfaction between the 1st and 3rd year stu-
dents indicating that either younger students have more frequent
sessions from the supervisor, or that the 3rd year students tend
to be more demanding from the supervisory relationship.
The reliability of the Greek version of the CLES was found to be
very high in this study, indicating that the instrument is an effec-
tive data collection tool for examining the learning environment
in a culture that is very different from the north European coun-
tries. In the factor analysis all items of the instrument fitted into
the expected factors and were grouped on the same factors as
those of the original questionnaire, confirming the construct valid-
ity of the CLES. According to the results of this study, the ‘‘supervi-
sory relationship” is the most important pedagogical activity of the
nursing staff, contributing to the clinical learning environment and
supports the original instrument. However, there are differences in
the second most important factor explaining the variance of vari-
ables, demonstrating that the Cypriot experience regarding impor-
tant variables of the clinical environment is different when
compared to the Finnish and the British ones.
There are limitations in this study. Student data collection was
organized from the only nursing school on Cyprus, so the results
cannot be generalized. The discussion of differences and similari-
ties in the results with other countries mentioned previously must
be considered with caution because of differences in nursing edu-
cation and the organization of clinical practice.
The study offers a valuable insight into student nurses experi-
ence of learning environment and supervision in Cyprus. The num-
ber of participants is quite high when compared to the sample
sizes of other studies despite the limitation that there is only one
school of nursing in Cyprus which is representative of the country.
Conclusions and implications
The results of this study reveal that there are many challenges
for educators and practitioners in coping with changes brought
with the transition of nursing into Higher Education. Integration
will provide academic recognition by higher education, facilitate
sharing of skills and knowledge with other disciplines and give ac-
cess to extensive educational resources (Barton, 1998). However,
since Nursing is predominantly a practice-based profession, it is vi-
tal that nurse education continues to have a strong practical ele-
ment despite its full integration into higher education. It is
worrying that given the importance of learning in the clinical area,
a significant percentage of students experienced failed supervisory
relationships and the majority had team supervision that comes in
contrast with the philosophy and principles of individualization.
The implications of the findings and the challenge for nurse
educators is to find new innovative ways for the re-organization
of nursing curricula and nursing practice so as to match the theo-
retical and academic element with the practical component of
nursing education. There are also opportunities for both educators
and students to work within a more creative environment that will
promote and add to the professional knowledge base (Barton,
The finding that the respondents who experienced personal
mentorship expressed satisfaction with that relationship, is sug-
gesting that the role of the mentor needs to be reformed, strength-
ened and supported. At the same time new roles need to be
explored as well as other pedagogical approaches within the clin-
ical practice in order to decrease the gap that exists between the
academic and the clinical component of nursing education.
This research was supported by a grant from the Cyprus Univer-
sity of Technology. We would also like to thank the students who
participated in the study and Mikko Saarikoski for his permission
to translate and use the data collection instrument.
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