Learning challenges of nursing students in clinical environments: A qualitative study in Iran
Shahram Baraz, Robabeh Memarian, Zohreh Vanaki
Department of Nursing, School of Medical Sciences, Tarbiat Modares University, Tehran, Iran
|Date of Web Publication||06-Aug-2015|
Dr. Robabeh Memarian
Department of Nursing, School of Medical Sciences, Tarbiat Modares University, Tehran
Source of Support: The Ethics Committee affiliated to
Tarbiat Modares University supported and approved the study, Conflict of Interest: None
Background: Clinical learning environment is a complex social entity. This environment is effective on the learning process of nursing students in the clinical area. However, learning in clinical environment has several benefits, but it can be challenging, unpredictable, stressful, and constantly changing. In attention to clinical experiences and factors contributing to the learning of these experiences can waste a great deal of time and energy, impose heavy financial burden on educational systems, cause mental, familial and educational problems for students, and compromise the quality of patient care. Therefore, this study was carried out with the goal of determining the learning challenges of nursing students in clinical environments in Iran. Materials and Methods: In this qualitative study carried out in 2012-2013, 18 undergraduate nursing students were selected by using purposive sampling method from the Faculty of Nursing and Midwifery of Tehran and Shahid Beheshti Universities. Semi-structured interviews were used to collect data. The content analysis method was used to determine relevant themes. Results: Two themes were derived from the data analysis, which represented the students' clinical learning challenges. These two themes included insufficient qualification of nursing instructors and unsupportive learning environment. Conclusions: Identification of the students' clinical learning challenges and actions to remove or modify them will create more learning opportunities for the students, improve the achievement of educational goals, provide training to nursing students with the needed competencies to meet the complex demands of caring and for application of theories in practice, and improve the quality of healthcare services.
Keywords: Challenges of clinical learning, clinical learning environment, Iran, nursing students, qualitative study
|How to cite this article:|
Baraz S, Memarian R, Vanaki Z. Learning challenges of nursing students in clinical environments: A qualitative study in Iran. J Edu Health Promot 2015;4:52
|How to cite this URL:|
Baraz S, Memarian R, Vanaki Z. Learning challenges of nursing students in clinical environments: A qualitative study in Iran. J Edu Health Promot [serial online] 2015 [cited 2019 May 21];4:52. Available from: http://www.jehp.net/text.asp?2015/4/1/52/162345
| Introduction|| |
Clinical learning experience is located at the center of nursing education. In various aspects, it is effective on the development of professional nursing. Therefore, it is used widely in teaching and learning of undergraduate nursing students.  The clinical learning objectives are included for empowerment of nursing students to develop clinical competencies and socialization in the nursing profession. These events occur within a complex and dynamic learning environment, called as the clinical environment. ,
Clinical environment is defined as an interactive network of forces within the clinical setting that influences clinical learning by students. Hence, for ensuring the usefulness and effectiveness of clinical environment in learning, these factors must also be specified and reviewed.  However, learning in clinical environments has several benefits, but at the same time, it can be challenging, unpredictable, stressful, and constantly changing. 
It has been shown that compared to positive clinical experiences, negative clinical experiences have additional effects on trust, attitude, and students learning in clinical setting.  In attention to clinical experiences and factors contributing to the learning of these experiences can waste a great deal of time and energy, impose heavy financial burden on educational systems, cause mental, familial and educational problems for students, and compromise the quality of patient care. Thus, most of the students are unable to handle or finish the course in the required and defined time.  It is a contributing factor in the attractiveness, clinical environment beneficiary, increasing the learning opportunities, and identification of influencing factors on learning of nursing clinical caring.  On the other hand, due to the dependence of educational system's credibility on the learning of its students, the directors of educational planning are required to understand all the contributing factors of learning from the learner's perspective. 
The complexity of learning in the clinical environments has led the researchers to investigate about the existing factors in this environment, such as the psychosocial atmosphere in clinical departments, perceived experience from the learning environment (positive or negative), interpersonal relationships, and so on. Studies have shown that most of the learning environments, despite having many benefits for nursing students, do not provide a positive learning situation for nursing students. ,
Chan showed that the students are often faced with challenges during the courses of clinical learning, which make them feel vulnerable.  Rahmani et al., quoting Campbell et al., have stated that the quality of clinical training provided by nursing educators and the support received by the students from clinical nurses are the most important influencing factors on nursing students' learning.  Other studies have stated that the incompetence of instructors, negative attitudes, and the weak support of students can cause detrimental effects on learning. , Students were also concerned about the issue that due to the shortage of positive role model, individual providers are not able to learn and provide the best caring approach. 
Researches carried out in Iran have indicated the poor efficacy of nurses at the bedside. The results of Dehghan Nayeri et al.'s study have shown that the nurses often do not provide the required care for the patients, which reflects what that they learned in the classrooms. 
The study results of Haj Bagheri et al., Sharif and Masoomi, and Salehi et al. showed that nursing education systems in Iran do not have proper functioning and the students are not satisfied of learning the necessary skills for nursing employment. ,, The findings of Cheraghi et al. in Iran indicated the inefficiency of teaching-learning process regarding the acquisition of knowledge and practical skills among the learners. It was mentioned that there was not much attention to the learners and aspects of their learning.  In recent years, the government and people of Iran have criticized nurses regarding their poor quality of patient care.  This criticism has resulted in increase in the number of studies about the nature and quality of students' clinical learning. Regarding the liability and the role of nurses in maintaining and promotion of health in the community, special attention should be paid to the quality of education and nursing students' learning. Students are invaluable sources of information about the quality and the effectiveness of educational endeavors. Reviewing their experiences can improve the quality of education and learning. Failure to meet these expectations is the inhibiting factor in teaching and learning. 
The researcher's experience as a faculty member with 8 years of clinical and training experience indicated that the students in their learning process in clinical settings are faced with many challenges. Most of these challenges can affect their learning in different aspects. Therefore, this study was conducted with the aim of determining effective factors on clinical learning qualitatively.
| Materials and Methods|| |
A qualitative study was used with content analysis approach. Qualitative research is the best approach in order to explore the ideas and values among different social groups. 
Eighteen undergraduate nursing students were selected purposefully from the Faculty of Nursing and Midwifery of Shahid Beheshti and Tehran Universities in 2012-2013. The inclusion criteria were students with a history of at least one semester of clinical practice and willingness to participate in the study. Primarily, we selected the study participants from forth-year students who had considerable experience of the study subject. Then, the other participants were also selected by using snowball sampling. Sampling with maximum variation was performed to obtain a wide range of experiences and views. The samples were selected from both genders and from the second, third, and fourth academic years.  Out of these 18 students, 12 were female and 6 were male students. The age range of participants was between 18 and 24 years; nine students were in fourth year, six in third year, and three students were from the second year.
This study has been approved by the ethics committee of Tarbiat Modares University. The aim of the study was explained to all of the participants. They were also informed that participation in this study was voluntary and whenever they wanted, they could withdraw from the study. They were also assured that all the interviews would remain anonymous and confidential. Meanwhile, before participating in the study, written informed consents were obtained from all participants to participate in the research and have their interviews recorded. Semi-structured interviews were used to gather information. This approach, in comparison to quantitative methods, can lead to deeper understanding of the phenomenon under study.  Twenty-two interviews were conducted with 18 nursing students. The duration of the interviews varied between 30 and 90 min.
The interviews were conducted individually in the interviewing room of nursing faculty. Some examples of open-ended questions to start interviewing undergraduate nursing students included: What factors are affecting your learning in bedside? Was/were there any time, places, or situations during the clinical course in which you have learned less? Explain the situation or circumstances.
What factors have negatively affected your learning?
There were also follow-up questions for further collection of the desired details and increasing the depth of interviews. At the end of each interview session, the participant was asked to add any supplementary information not addressed by the interviewer. This question included the individual experiences of the students or any other extra things. Collecting data and analyzing them were performed concurrently, and the interviews were stopped after obtaining data saturation. 
Data were analyzed by using qualitative content analysis based on the recommendations of Morse and Field.  Inductive approach was used in this study for data analysis. Depletion process of data began simultaneously with data collection. Immediately after each interview, the interviews were handwritten word by word. Then, for drowning in data and to obtain one general sense about the data, the interview transcripts were reread several times. Each interview was analyzed before the next interview. Meaningful units were extracted from the statements of participants that included their experiences. Line by line, the interviews were read and encoded. Then, the codes with similar meanings were grouped into subsets. The subsets were placed inside narrower sets based on similarity, compliance, proportionality, and relevance. Finally, the analysis process was completed with determination and clarification of themes.
Trustworthiness is an important component in the process of a qualitative research. For this purpose, credibility, dependability, confirming the ability, and transferability were evaluated. Control procedures were used by qualified personnel (peer checking) for validation of the data. For this purpose, the interviews were coded and classified independently by the authors. Then, the themes were compared with each other. In the absence of agreement in connection with the themes, the authors held discussions to reach a principal agreement. Besides peer-checking, we also used the member-checking method for establishing credibility. For this purpose, after analyzing each interview, a summary of the codes and obtained themes was given to the individual participant. The participants were asked to confirm the extracted codes with the expressed experiences and ambiguous cases were resolved. The method of comparative analysis of continuous data was used to check the validity of data.
Also, the researcher tried to have theoretical sensitivity and a high critical thinking during the period of data collection and analysis to obtain valid and reliable data. For this purpose, the researcher tried not to remove the relevant data intentionally or inadvertently and not to put irrelevant data in the analysis process. Continuous involvement with the subject and the obtained data, in addition to performing sampling with maximum variation among the students selected from different academic semesters increased the credibility of data.  We employed the external member-checking technique for ensuring the transferability of the study findings. Accordingly, we asked two outsiders who had similar experiences of the study subject to determine the congruence between the study findings and their own experiences. In order to verify ability, the researcher recorded and reported the research process and the route of decisions accurately to provide the opportunity for others to investigate. In order to check the consistency, external observers' method was used to evaluate the similarity of their understanding with that of the researcher and search for inconsistent cases. 
| Results|| |
The students expressed the incompetency of the nursing instructors and non-supportive learning environment as the most important challenges of clinical learning. The first theme included four categories: Inadequate preparation, inadequate clinical supervision, inappropriate approach in using instructional strategies, and distorted evaluation process. The second theme also consisted of four categories: Non-supportive interpersonal communication, lack of access to direct experience, traditionalism in clinical behavior, and stressful psychosocial environment. The following sections show the meaning of each theme and sub-theme with relevant quotations.
Insufficient competence of nursing instructors
Based on students' experiences, they mentioned the most important influencing factors were inadequate academic and practical preparation, inadequate clinical supervision, inappropriate approach in using instructional strategies, and marred evaluation. These factors reduce the ability of the instructors for training and providing an environment for effective learning in students. Students' experiences in this field specified that most of the instructors, especially novice teachers, had no adequate clinical experience, theoretical and practical knowledge, and capabilities. A student said:
"For example, we were at the hospital… Our instructor was a novice graduate student. Our knowledge was more than her regarding reading the ECG and medications. For example, when we would have an explanation of one drug for each other, the instructor opened her notebook and began taking notes to this extent."
Clinical experiences and expertise are among the most important components of intervention, which will facilitate using the knowledge from instructors to teach students. The students were complaining about their instructors' lack of skill and clinical experiences. In this field, a student stated:
"For example, I wanted to take ABG of a woman named B. I wanted the instructor to come with me. But, when I tried for a few times and the blood stopped, I did not continue. It was interesting that she herself did not know and could not do. So, when the instructor did not know, how could she teach me to learn?"
The consequence of the instructor's insufficient scientific capability was losing her credibility in front of the personnel and students. Therefore, the ward personnel did not allow either the instructor or the students to do any work. So, learning opportunities would be lost for the students. A student said:
"We were in the orthopedic ward. The instructor was illiterate and his reputation in the ward was ruined. When we go in that ward, the personnel say, 'Thank you very much. You do not have to do anything.' They agree, not only with the instructor, but also with us. They say, 'When the instructor is illiterate and cannot do anything, her students are the same because the students are so much lower than the instructor.' We did not do anything in the orthopedic ward."
The presence of instructor at the bedside means having a source of reassurance and a sense of confidence for the students. According to our participants, irresponsible or incompetent instructors strive to detach themselves from clinical education. Accordingly, our participants were complaining about the poor attendance of some instructors at clinical education courses, the loss of learning opportunities, and the sense of being abandoned in clinical settings. Most of the students were complaining about the insufficient presence of instructor in clinical wards, being abandoned in the wards, and wasting the opportunities to learn. In this field, a student stated:
"Some instructors only have the name and title of an instructor. They come in the morning. Then they go and come back at noon. Only one time they come and go quickly. They leave the students in the ward. Of course, it is true that we work on our routine procedures, but we are not able to understand things or read the files or understand something out of the file. They do not introduce any new cases. We have been abandoned for long times and they have been following their own work."
Among the implications of the absence of an instructor in the ward is that the student loses her confidence for nursing care and there will be less control on the situation that occurs. This also makes the student to experience the feeling of being not useful and not having any worth. In this regard, a student stated:
"I have chosen this profession recently. Already I was not interested. When I see that there is no instructor in the ward, I do not know what to do. I have just got a blood sample and the vessel was torn, all these cases are undermining my morale. I think the instructor must accompany the students in the ward."
Students also complained about the instructors' use of improper maintenance strategies to teach, including the focus for the implementation of routine operating procedures, and integration of theory and clinical education. Students expressed that too much focus of the instructor on the implementation of strategic operational procedures reduces the necessary time for scholarly discussion with the instructor about the patient and the related nursing care. Regarding this, a student stated:
"At 8 a.m., anyone who took more blood is pretty good. Students and laboratory personnel have no right to take blood. You should only get the samples. So, we spend most of our time in the ward just to do this. Not even once, they let us to go at bedside and observe the symptoms or discuss about the patient with the instructor."
The data obtained from the interviews revealed that most of the instructors, especially the novice instructors without having adequate clinical experiences, prefer to teach and train the students by using the theoretical approach. A part of their clinical education is performed as speech and theoretical discussions, which are presented in the conference room or outside the ward without having direct attention to patient care, expectations, and learning activities asked by the students. These conditions take them away from the bedside and they are engaged in theoretical materials. Situation of convergence theory will lead to the formation of feeling of being not useful in the students. In these circumstances, the students do not even have interpersonal and appropriate professional communication with the clinical staff. These conditions put them and their nursing instructor in isolation and make them separated from the clinical environment. One consequence of this situation is the reduction in their clinical learning. Regarding this, one of the students said:
"In clinical practice, there was a bad method, and it was about the subject of the conference. Conference in my opinion is a complete theory. When we are at bedside, it is not necessary to learn theory. In clinical courses, there should be practical educations; however, we, unfortunately, didn't receive such educations. We always have the same repeated conference. This case causes us to feel that we do not have the required performance and we are not useful, and cannot be a successful nurse."
Process of distorted evaluation
Clinical evaluation process as a mental process was perceived by the students as complex and difficult. The usage of non-standard forms of evaluation and evaluation without creating learning situations for students were the important aspects which the students mentioned as barriers to learning. About the usage of non-standard forms, a student stated:
"I do not know how these forms are provided. For example, it has 20 items. Within our ward, we will not even face with 10 items. Then, the instructor himself writes the scores. Then, it is possible that some students really do not deserve it. The students are discouraged. So, for me, it doesn't matter how I try. I see that eventually, the instructor's evaluation is not true."
Some students had claimed that they saw the evaluation forms at the start of training course, but these forms do not play any roles in this evaluation by the instructor and the instructors evaluated the students according to their own tastes. A student said:
"Evaluations of the instructors are all according to their own tastes. Believe it. For example, we went to dialysis ward last semester. I was always present at quarter past seven in the morning. I connected the patient to the related device, and I would teach him. I worked too much for that ward, but at the end of the semester, my score was lower than that of others, while my friend, who was weaker in all the trainings, received a higher score. I really don't know by using which standard, the score was given."
Interview data showed that some of the instructors, especially the novice instructors, evaluated the student without providing the necessary opportunity for a student to learn. This has triggered disenchantment and frustration among the students and also reduced their clinical learning. In this regard, a student said:
"Master's students who assume the responsibility of our clinical education, and when we go to bedside, suddenly they come and ask: What is the nursing care for this patient? Or ask other questions. I had not checked the patient's condition. I had not read the related file. Last semesters, I only lost my energy during clinical practices. I came to this conclusion that it was useless. No matter how to read. Because during the time spent at bedside, I cannot in a few minutes do my best for nursing diagnosis. The instructor did not give a chance to read. However, the time passed and my score was very low. So, I do not go looking for another case."
Unsupportive learning environment
Among the important effective factors on students learning is supportive learning environment. This theme included four sets which are non-supportive interpersonal communication, lack of access to direct experience, traditionalism in clinical behavior, and stressful psychosocial environment. The importance of communication in promoting students' clinical learning is undeniable.
Students were complaining about non-supportive relationship of the instructors and clinical nurses with them. In the interviews, the students indicated about behavioral and verbal violence of the instructors, lack of criticism acceptance by the instructors, and not caring about the students learning repeatedly. Harsh morality of the instructor with the students resulted in fear in the students due to which they did not dare to ask their questions. It even formed the sense of isolation in the students and withdrew them from the treatment team. The following statement reflected this issue:
"We were afraid of bad morality of the instructor and his uproar in the wards. He would shortchange us in front of other students. So, we do not go towards him. Even one day, he didn't let one of the students to come into the classroom. It was a mess. Due to fear, we prefer not to ask any questions."
One of the qualities of ineffective instructors in dealing with scientific questions of the students was lack of criticism acceptance by the instructor. Regarding this, a student said:
"For example, I'd read that in acidosis and alkalosis phases, the primary factor which should be referred to be interpreted is pH. But the instructor did not accept and she said 'No,' and 'the right answer is oxygen.' There is a series of ambiguous questions. When we discuss and we show the books and resources, the instructors do not accept."
The consequence of lack of criticism acceptance by the instructor will discourage the students toward the course and the instructor. Therefore, the students put lesser efforts fewer in learning. A student said:
"I believe that firmly insisting on our own mistakes is not a sound practice. It disgusts students with the instructor and the course. One may have not more interest in relating with such an instructor. Obviously, learning will also be ineffective. We won't be eager to communicate with the instructor. Therefore, our learning would be lower."
Students were also complaining about unprofessional behaviors of the nurses at the bedside, such as disrespect, lack of cooperation, and unprofessional expectations from them.
"In general, the nurses insulted the character of students and this caused that I, myself and other students became bored of it. Therefore, I do not scout them anymore and didn't do the ward's works."
"From the second semester when we entered the ward, I remember that the head nurse ordered not to allocate any jobs to the newcomers or those in the second or the third semesters. It was the same for 2-3 semesters. We didn't do any procedures in the wards. We did not know many things regarding clinical practices up to the end of our sixth or seventh semester."
One of the unprofessional behaviors of the personnel with the students was to ask them things, which are not defined as their tasks. They were asking a lot of personal things. Therefore, they reduced their cooperation with nurses. The consequence of this behavior was isolation and withdrawal of the student from the treatment team. A student said:
"When the personnel face the students, a feeling of being exploited occurs in the students. They wanted us to go and collect stereotypes radiology or remove the bandage flattened over the patient's head by the doctor. When I saw that they want to exploit us, we went to the treatment room and sat down."
Stressful psychosocial environment
Students expressed that clinical environments with poor psychosocial conditions can have a negative impact on their learning. For fear of encountering threatening health situations, the students were less involved in clinical activities. In this regard, a student stated:
"Earlier, I became needle stick for 3-4 times consecutively. Later, due to the fear of getting sick, for three semesters, I didn't involve in doing things like angiocut tagging or blood sampling because I feared again to become a needle stick."
Students also expressed about creating fear and anxiety by the instructors while performing the procedure and being with one companion in the ward, which has its own negative impact on their learning. Therefore, in most situations, the students were not ready to perform clinical practices and they were losing motivation.
"But, there is also an instructor, who always says, 'Do not go, because you'll ruin it. Do not go. You'll spoil the patient vessel. I am stressed.' And the instructor doesn't say how to do it. So, I did not go to see the vessel again. I just touched the patient's skin and said to the instructor that I am not able to do it. The teacher quickly took it from me."
Inappropriate atmosphere was among the other expressed aspects. Lack of coordination among the group members (apprenticeship and internships) and the members of the group ridiculing were indicated by the nursing students which affected them in better learning.
"I've been in some groups that really I was being ridiculous. When I had a question, the students said, 'Ah, go away and do your job.' So, I did not dare to ask my questions."
Traditionalism in clinical practice
Interview data showed that the attitude of nurses and even nursing students about healthcare services is not systematic and scientific. Technical and mechanical skills without compliance to the standards of caring principles had replaced patient-centered principles. Therefore, because the dominant behavior in this ward was not appropriate to the structure of nursing knowledge, which they learned in theory classes, it will not form an appropriate learning environment for the students. One of the students said:
"Our work is always a routine job in the ward. Last semester, we were in the heart ward, where we had given the related heart medication. Already, we give gastrointestinal drugs now in this ward. What a pretty job! We are always doing repetitive and routine works and there is no news about the knowledge and science of nursing."
Other challenging item in students' learning was routine functions and not using the learned theories by the nursing personnel. One student said:
"For example, if we were going to make a dressing in our ward, usually, even when the dressing is open, we see that they are not sterile or something else, for example, using a drug to sterile the wound. Once I felt that those things that I've learned in theory had no use for clinical practices. In theory, they say something, and in practice, they do something else and another event will happen in the ward."
Implementation of such a routine procedure, either by the students or the nurses, will increase the gap between theory and practice. It can create a feeling of depression and worthlessness in the students. This makes the students prefer not to take much effort to learn normative nursing care.
Lack of access to direct experience
Experiences of the participants in the study showed that direct participation in the activities and healthcare techniques have led to a more sustainable learning for them. On the other hand, despite the existence of learning opportunities in the ward, some of the participants complained about the following: Lack of opportunity to experience and perform the technique and operational procedures, failure of cooperation between the patients and students, lack of cooperation and distrust of clinical nurses with students, and diversified training cases in the ward. A student said:
"For example, in a surgical ward, I expected to learn types of dressing up and suture dragging, but the ward routine was such that only the interns can do the dressings and permission was not given to us for dressing."
More cooperation, students' support, and confidence in students to do the job independently can provide conditions for the students to directly experience and learn techniques and care practices.
"But here at the hospital of…, they do not cooperate (clinical nurses). We are not able to practice. They are afraid about the vandalism by us. They don't trust us."
Among the other factors mentioned by the nursing students as a learning challenge was the lack of diversity in clinical cases in the hospital wards:
"But in the routine wards, such as gastroenterology or general surgery ward, there is no specific work or a variety of new cases for learning. We saw only a peptic ulcer case out of gastrointestinal diseases and nothing else."
| Discussion|| |
This study showed that insufficient qualification of nursing instructors and lack of supportive learning environment were among the most important challenges in clinical practice learning of nursing students in Tehran. The students believed that the current educational system in Iran does not perform up to the mark in their learning process. It was mentioned in the studies that the dependent characteristics of clinical instructors  and the quality of the clinical learning environment  are two of the most influential factors on student learning. Cheraghi et al. and Grace et al. referred to the following factors as the aspects of incompetence of a clinical instructor: Lack of clinical experiences, lack of theoretical knowledge, and inadequate monitoring and control on clinical practice. ,
In this study, due to insufficient support of the instructor at the bedside, the students had become vulnerable and there was less confidence in their function and motivation to learn. These results are consistent with the results of Randal  and Edward.  In this study, the students were complaining about being abandoned in clinical wards and inadequate monitoring of instructor in clinical practices. This had caused them to have a sense of powerlessness for the implementation of nursing care. The studies of Andrew et al. and Johnson et al. have shown that clinical supervision has been inadequate. ,
One of the aspects of instructor's incompetence is that while learning nursing care in unfamiliar clinical places, the students have feelings such as being stranded, insecurity, foolishness, and abandonment. In such places, time for teaching/learning decreases dramatically and the students perform clinical practice without the supervision of instructor for a long period of time. In most cases, they just do routine work without receiving the necessary theoretical knowledge. ,
The results of the present study showed that due to the shortage of the full-time faculty members, the nursing faculty was forced to use graduate students and doctoral students with less clinical experiences as an instructor. In 1998, Loffmark (quoted from Beattie) implied that this is an unrealistic expectation that due to their availability and not because of being competent, the selected instructors can be successful in creating and developing a positive learning environment and positive communication between the instructor and the student. However, readiness and capability of the instructor and nursing personnel for training of nursing students has vital importance. 
Nursing instructors and clinical nurses have a key role in developing skilled and accountable nurses. Cheraghi et al. (quoted from Chan Hung and French) indicated that both instructors and clinical nurses should have access to continuing education to maintain their scientific and practical qualifications in order to play an effective role in clinical education.  Therefore, based on the results of this study, it is required to hold continuing education courses to maintain and promote scientific competence of instructors and clinical nurses. Another learning challenge in the point of view of majority of nursing students in the present study was lack of sufficient reliability of clinical evaluation. It was because these evaluations were unable to evaluate correctly scientific knowledge, practical skills, and professional behavior of students. This result is consistent with the study results of Bourbonnais. 
Walsh et al. expressed that in evaluating the clinical performance of nursing students, it is essential to have an effective evaluation tool. That means a clear tool to assess students' performance in clinical settings in a proper manner. The evaluation system is known as the propulsion and motivating factor for the students to learn.  Dissatisfaction with the subjectivity of clinical evaluation and also with the traditional approaches to clinical evaluation alongside with advancements in education have compelled many educational institutions to look for more objective and more reliable methods for evaluation. 
All the factors that the samples in this study emphasized were in line with the recommendations and expressive needs of learners to implement major changes in the current methods of clinical evaluation. For example, according to the majority of the subjects, for bringing about changes, it is necessary to go forward to be specific, objectiveness of evaluation forms and adjusting them with learning goals.
There are considerable evidences about the relationship of one person with one person as the most important factor on learning and the formation of professional competence in the students. 
In this study, it was found that feelings such as harsh confrontation and annoyance of the instructor and lack of criticism acceptance by the instructors at bedside were the barriers to learning, experienced by the students. Loffmark and Wikblad stated that when encountering students with such behaviors, the learning process cannot progress well. Adapting to these circumstances is a waste of lot of time and energy. 
Results of the studies have shown that the students need to have an instructor with high knowledge and assistance. On the other hand, it was expressed that violent behavior of instructors is a stressful source. Violent behavior has had a negative impact on confidence, self-efficacy and self-identity of students, learning and professional growth of students, creation of learning opportunities, and increases the gap between theory and practice. ,
Not only should the faculty members and instructors not stress the students at the bedside, but also they should be aware of stressful sources in the clinical environment to support nursing students. In this context, Melincavage (2011) stated that nursing faculties should ask the faculty members and the nursing personnel to reconsider their behavior and their relationships with students to avoid disrupting the learning process of students. One approach to this is consideration of certain privileges for nursing personnel and instructors for having positive interactions with students. To improve the communication skills, workshops should be held. Behavioral changes of instructors and nursing personnel for better acceptance of the students and supporting them in clinical practice are important for students' learning. 
Clinical nurses play an effective role as the key persons serving as a role model in the learning process of students through communication based on respect, integrity, and mutual interaction with students. They can provide a psychosocial positive atmosphere for students learning in the ward.  It is reported that supportive relationships with students have been used as a key to increase the student security in clinical wards, particularly among the first and second year students. Supportive relationships trigger internalization of the nursing role as a provider of healthcare activities. 
Cheraghi (quoted from Alavi and colleagues) stated that supportive relationship of clinical nurses will cause the acceptance of students as a part of the treatment team and help in proper learning.  On the other hand, improper connection of clinical nurses with students hinders their learning  and threatens the professional growth of the students to remain in the profession. 
In the present study, the students complained about poor psychosocial environment in clinical wards, which caused delay in their learning. Thorkildsen and Råholm stated that having a sense of security at the bedside is a key component in the learning process, which increases the learning opportunities and the formation of professional competences in the students. 
This qualitative study just focused on the learning challenges of a group of nursing students in the culture and context of Tehran. Therefore, the generalization of the findings should be done with caution and it is necessary to conduct further studies on this in different cultures and contexts to find the various factors effective on students' learning, and subsequently have a better understanding of this phenomenon in teaching and learning nursing.
| Conclusions|| |
It is expected that the students play an active role in the learning and training process during the clinical courses. The results of this study clearly indicated that the presence of qualified instructors in all aspects of clinical practice and a supportive clinical environment are significant parameters in the teaching and learning process of students.
The results showed that the current educational system is not functioning properly to transfer knowledge to the students. Therefore, this system would require a series of major changes in the training process of nursing students. Learning activities for students should be performed in an environment where great learning opportunities can be experienced. Useful professional communication of the instructors and nursing personnel with the students is important to facilitate learning and socialization of nursing students. Having a strong vision about the psychosocial specification of a healthy learning environment through identifying the factors that influence clinical learning from the viewpoints of nursing students and trying to resolve these obstacles is necessary for the professional development of nurses.
The findings of this study can be used in bringing about reforms in nursing education. Consequently, it will increase the quality of nursing students in the patient care process. Awareness about these factors is helpful for the students too. Therefore, the transition from student stage to become a nurse can occur very quickly. The results of this research can be applied in future papers about learning and nursing education to increase the students' learning. Further studies should be conducted to resolve the clinical problems of the students as action research.
| Acknowledgments|| |
This study is a part of a PhD thesis, and was carried out with the aim of designing a learning model for nursing students. The authors wish to thank all the students who have helped in the present study.
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