Review Article

Key elements of a healthy clinical learning environment for undergraduate nursing students

Adél Geldenhuys, Andile M. Mafilika, Naomi Hattingh, Natasjha Engelbrecht, Petronella M. Schroeder, Memme G. Makua, Gisela H. van Rensburg

Received: 24 June 2026; Accepted: 26 June 2026; Published: 16 Sept. 2026

Copyright: © 2026. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Nurse educators and clinical facilitators must understand how the clinical learning environment influences undergraduate nursing student’s development into competent, well rounded nursing practitioners. The purpose of this structured literature review was to identify elements of a healthy clinical learning environment. The guided research question was: ‘What is meant by a healthy clinical learning environment for undergraduate nursing students?’. The Population–Concept–Context framework was used to assist in a focused inquiry into the relevant population, concepts and context. To capture relevant literature, the search strategy included CINAHL, Medline, EBSCOhost, Academic Search Ultimate and LitMaps databases, using specific key terms aligned with the framework. Thematic coding was conducted inductively, followed by conceptualising and interpreting the themes. Proper orientation, clear expectations, structured clinical placements, active mentorship, emotional support well-being, effective communication, consistent feedback and a sense of belonging promote a healthy clinical learning environment. Stressors of clinical placement include inadequate support, ineffective feedback and a lack of psychological safety. These stressors influence the student’s ability to achieve learning outcomes.

Contribution: This review synthesises the key elements of a healthy clinical learning environment, highlighting the relational, organisational and educational factors that support undergraduate nursing students’ learning and well-being. It provides evidence-informed recommendations to strengthen collaboration between NEIs and clinical placement sites, thereby enhancing student support, clinical learning experiences and successful achievement of learning outcomes.

Keywords: healthy clinical learning environment; nursing education institution; nurse educator; professional growth; teaching and clinical learning environment; undergraduate nursing student.

Introduction

Background

Nursing education and training aim to respond to the ever-changing healthcare needs of society, thus requiring nurses who are knowledgeable and skilled. Skilled nurses work mainly as autonomous nurse practitioners in a range of healthcare settings, providing essential care of a high standard and providing complex care using the best available evidence and technologies where appropriate (South African Nursing Council [SANC], 2023). In the undergraduate nursing programme, education and training consist of both a theory component and a practical component. Clinical learning is an integral part in developing clinical competencies of undergraduate nursing students (Eyikara & Baykara, 2017; Panda et al., 2021; Visiers-Jiménez et al., 2021).

Undergraduate nursing students acquire clinical learning outcomes through structured clinical facilitation and clinical assessments (formative and summative). Clinical facilitators and nurse educators monitor the process of effective participation in the provision of patient care and work within a healthcare team (Mbakaya et al., 2020). The healthcare work environment, and more specifically the nursing work environment is defined as an environment that is safe, empowering, contributing to work engagement and job satisfaction (Hegazy et al., 2021). A healthy nursing work environment guarantees a physical and mental safe workplace for nurses, resulting in quality patient care. The concept of a healthy nursing work environment is critical to ensure quality patient care. (Wei et al., 2018).

A healthy clinical learning environment is an interactive network of forces in a clinical setting that influences the undergraduate nursing students’ clinical outcomes and impacts positively on their professional development and confidence (Panda et al., 2021; Zhang, 2022). The clinical learning environment also have an influence on the undergraduate nursing student’s satisfaction with the nursing profession. The clinical learning environment can significantly influence the experiences of nursing students. If the environment is negative, it may hinder learning outcomes and in turn, compromise their preparation for clinical practice (Flott & Linden, 2016). It is therefore critical to ensure a healthy clinical learning environment where undergraduate nursing students are prepared for professional development and growth into practice. Nursing education institutions (NEIs) and clinical placement hospitals should collaborate in creating a healthy clinical learning environment, in order for the nursing student to benefit from an engaged and committed healthy nursing workforce (Ying et al., 2023).

The clinical learning environment plays a significant role in influencing the nursing students’ professional behaviours and in the acquisition of clinical competencies for real-world practice (Cant et al., 2021; Mbakaya et al., 2020). According to Gruppen et al. (2018), there is a need to theoretically define the dynamics of the clinical learning environment and its impact on various educational outcomes. The undergraduate nursing student spends a significant amount of time in the clinical environment, and therefore, it is important to create a healthy clinical learning environment to enable the nursing student to meet the learning outcomes. Thus, understanding what a healthy clinical learning environment entails is imperative.

The purpose of this literature review was to identify elements of a healthy clinical learning environment. Understanding what a healthy clinical learning environment entails, nurse educators are guided in their quest to create a healthy clinical learning environment to ensure effective, well-developed and well-rounded nursing practitioners.

Methods

A structured review of the literature was conducted to address the following primary research question: ‘What is meant by a healthy clinical learning environment for undergraduate nursing students?’ Although elements of scoping review methodology were drawn upon to enhance transparency and methodological rigour, the review did not adhere to all prescribed stages of a formal scoping review. Consequently, the study is presented as a literature review rather than a scoping review. The Population–Concept–Context (PCC) framework was used to guide the formulation of the research question and to delimit the scope of the review. This framework supported a focused examination of literature related to undergraduate nursing students (population), characteristics of a healthy clinical learning environment (concept) and clinical education settings (context). The inclusion criteria for the review were developed, encompassing studies related to a clinical learning environment for nursing students. The review considered various research designs from studies published between 2013 and 2023, provided they were peer-reviewed and in English.

As part of a broader research project on student support strategies, this literature review aimed to establish a foundational understanding of student support in the clinical environment within the nursing education and training space. Understanding what constitutes a healthy clinical learning environment is essential, as the clinical setting represents undergraduate nursing students’ primary site of professional socialisation and skills development. The quality of this environment directly influences students’ learning experiences, emotional well-being, sense of belonging and ability to achieve clinical learning outcomes. By identifying and synthesising key elements that characterise a healthy clinical learning environment, the review provides an evidence-informed foundation to guide NEIs and clinical placement sites in creating supportive, psychologically safe and educationally effective clinical settings for undergraduate nursing students.

The evidence search was exhaustive and methodical, incorporating databases such as CINAHL, Medline, EBSCOhost, Academic Search Ultimate and LitMaps. The search strategy was tailored using specific key terms and aligned with the PCC framework to capture relevant literature comprehensively. The following key terms were used to search for the literature: health AND teaching and clinical learning environment; optimal learning environment; conducive clinical environment; health and wellness AND nursing student OR healthcare student.

The search results initially yielded 2918 records. The selection of evidence involved careful screening to eliminate duplicates, followed by assessing titles and abstracts for their initial relevance. This process was conducted in two stages: initially, eight independent researchers reviewed the literature individually to identify potentially relevant studies based on the predefined inclusion criteria. This was followed by a collaborative consensus process, during which the researchers met to compare selections, discuss discrepancies and agree on the final set of studies to be included in the review. One researcher subsequently withdrew from the group; however, the agreed-upon procedures and outcomes of the selection process remained unchanged.

Data extraction, shared between the remaining seven researchers, was conducted manually, adhering to a standardised framework. This approach ensured consistency and comprehensiveness in charting the data, facilitating a practical synthesis of the findings. Discrepancies were addressed and resolved through collaborative discussions, aiming to achieve unanimous agreement on the inclusion of specific data.

Data were extracted from the included sources and analysed using inductive thematic analysis. This involved iterative reading of the literature, open coding of relevant findings and the grouping of codes into higher-order themes. The themes were subsequently conceptualised and interpreted to synthesise key elements associated with a healthy clinical learning environment. The collaborative consensus approach enriched the analysis, aligning the emergent themes with the focus of the review. The study was guided by the framework for ethical research as outlined by Tricco et al. (2016), which emphasises transparency, methodological rigour and responsible reporting in evidence syntheses. In applying this framework, the review was conducted using a clearly defined research question, a transparent search strategy and explicit inclusion criteria, ensuring accountability and ethical integrity throughout the review process. The foundational principles embraced in this context pertain to academic integrity, the educational merit of the study, its scientific robustness, and ethical oversight. Independent screening of sources followed by collaborative consensus discussions further contributed to reducing selection bias and enhancing the trustworthiness of the review findings.

Ethical considerations

An application for full ethical approval was made to the University of South Africa, College of Human Sciences Research Ethics Review Committee and ethics consent was received on 22 February 2023. The ethics approval number is HSHDC/635/2017.

Review findings

Three themes and associated categories were conceptualised and interpreted to synthesise key elements associated with a healthy clinical learning environment as depicted in Table 1.

Theme 1: Clinical learning experience

Clinical learning is a fundamental component of nursing education, bridging theoretical knowledge with hands-on practice (Daneshfar & Moonaghi, 2025). It provides students with opportunities to apply their classroom learning in real-world healthcare settings, enhancing their clinical competencies, critical thinking and professional identity (Ratish, 2025). The clinical learning experience is shaped by multiple factors, including the quality of supervision, the availability of learning resources, interactions with healthcare teams and the overall supportiveness of the clinical environment (Lyman & Mendon, 2021). A well-structured clinical learning experience not only prepares nursing students for their future roles but also fosters resilience and confidence in their professional practice (Singer et al., 2022). Understanding the dynamics of clinical learning is essential to ensuring that nursing students receive the guidance, exposure and practical skills needed to deliver safe and effective patient care.

Category 1: Clinical placement planning

Students learn how to apply practical skills in the clinical learning environment and apply what was taught in theory in the clinical environment. A supportive clinical environment can allow the nursing student to meet the expected learning outcomes. Bodys-Cupak et al. (2019) stated that the first encounter the nursing student has with the clinical environment is very important, as this exposes them to the natural environment of the profession. A study by Hobenu et al. (2025) indicated the discrepancies between educators’ and nursing students’ understanding of clinical facilitators’ role. Hobenu et al. (2025) further indicated that facilitators may lack the training or organisational support to meet expectations. Often, this encounter determines whether the nursing student further their studies or not. According to Lawal et al. (2015), nurse educators should determine strategies to improve the learning and socialisation of nursing students in the clinical environment. The need for proper orientation in the clinical learning environment is stated by Lyman and Mendon (2021). Nursing students expect clear guidance from clinical facilitators or nurse educators regarding what to anticipate during clinical placement day (Delany et al., 2015).

A study conducted by Singer et al. (2022) emphasised the necessity of well-planned clinical placements for nursing students to achieve their expected learning outcomes. One of the hurdles encountered by these students in clinical settings is feeling disconnected from the team. To foster a sense of belonging, it is crucial to optimise the duration of their placement in the clinical learning environment. This optimisation not only helps the student integrate into the team but also enables them to meet the required clinical learning outcomes. Thoughtful planning of clinical placements within a learning environment prior to transitioning to the next clinical setting is imperative for students to acclimate and successfully achieve their clinical outcomes.

Lawal et al. (2015) stated in their study that the nursing student expects to have the necessary resources and learning opportunities to care for real patients and apply what was taught in theory to the clinical environment. Lawal et al. (2015) further stated that there is a need to improve the learning opportunities as well as increase the time spent in the clinical environment to complete outcomes without time constraints. Not providing adequate learning opportunities or sufficient time to allow the nursing student to complete the expected learning outcomes will result in not achieving the required standard and clinical competencies. In contrast, a study by Birks et al. (2017), indicated that longer placement is effective in meeting the learning outcomes, shorter placement periods can be effective when it is well-planned and supported by consistent and clear expectations.

The expectations of the nursing students are that clinical facilitators and nurse educators should be skilled and have the necessary competencies to facilitate them in the clinical learning environment. In the study of Ten Hoeve et al. (2017), nursing students felt dissatisfied with the quality of teaching and facilitation that was not up to the expected standard, and this impacted the nursing students’ ability to meet the required learning outcomes and facilitation of theory-practice integration. Ten Hoeve et al. (2017) further stated that nursing students experience the contact with the patient as positive but experienced a lack of support from the NEI and limited collaboration between the nurse educator and the clinical facilitator.

Category 2: Enhancing clinical learning

A study conducted in the United States by Singer et al. (2022) mentioned that nursing students need to feel a sense of belonging and be a contributing member of the nursing team. The same authors stated that it is crucial that the clinical facilitator is skilled in order to adequately guide the students for them to be able to find their feet or settle in the clinical environment. In a study conducted in Oman, D’Souza et al. (2013) also identified the time to settle in as an important aspect of a conducive clinical experience for nursing students. To ensure clinical placement in a specific discipline is sufficient for the undergraduate nursing students, nurse educators and clinical facilitators should plan carefully (Singer et al., 2022).

A supportive clinical learning environment has an influence on the undergraduate nursing student’s ability to be successful in their learning because the clinical learning environment experience can be stressful (D’Souza et al., 2013; Lawal et al., 2015). Nurse educators and undergraduate nursing students should be equally involved in the clinical learning environment and should be learning from each other. Shared experiential learning or transformative learning emphasises mutual engagement where the knowledge construction is co-created in a collaborative and reciprocal approach to clinical learning (Cheng, 2025; Van Rensburg & Matahela, 2025). Collaboration between clinical staff and the NEI is vital. Effective communication and teamwork are key to ensuring student success. D’Souza et al. (2013) found that incorporating different learning styles in the clinical learning environment creates a higher level of thinking in nursing students. Furthermore, students find it easier to learn from patients than from textbooks.

Nursing student-educator interaction is a major influence on success in the clinical learning environment. Contact and interaction between the nursing student and the educator in the clinical environment should be encouraged (D’Souza et al., 2013). Yu et al. (2021) also highlighted that professional development for nurses does need support from clinical staff and NEI staff. The same authors found that students need active participation during nursing rounds to improve their confidence and competence.

Yu et al. (2021) highlighted that nurse educators are responsible for displaying a positive attitude and presenting as a successful role model to be able to promote the interest of nursing students in the nursing profession. The study by Ekstedt et al. (2019) found two supervisory model types, with a specific focus on peer support. Students were grouped in pairs and worked under the supervision of a ‘preceptor’ for the day. With this model, students gave higher marks and indicated they felt they received individual supervision on the day as opposed to a model where a traditional supervision model was used. Students in this study also indicated that having more than one facilitator was beneficial. Lawal et al. (2015) concurred that students benefit from a good quality relationship between education staff and clinical staff in the clinical learning environment.

Inocian et al. (2022) found several studies where the role modelling of clinical facilitators and professional staff enhanced students’ caring behaviour. In these instances, clinical facilitators influenced student nurses by displaying caring behaviour. The same authors also highlighted the effective communication by education staff in advocating for a patient as a beneficiary in their development of a caring attitude.

Delany et al. (2015) identified several aspects where the nursing student’s stress can be minimised, such as pre-clinical placement preparation of the student by the education staff. Certain teaching methods, for instance bed side teaching, help alleviate the stress levels of the nursing students as well as a programme to enhance the nursing students’ ‘resilience’ to clinical learning environment-related stress.

Lawal et al., 2015 found that supportive teamwork among clinical staff and nursing students can enhance learning and decrease stress experiences, therefore aiding in contributing to the nursing student’s socialisation into the nursing profession. Lawal et al. (2015) identified the necessity of clinical staff being prepared for their role in supporting nursing students through clinical placement and socialising nursing students into the nursing profession and developing a caring attitude.

Theme 2: Student-related stressors

A healthy clinical learning environment is essential for fostering the professional development and well-being of nursing students. However, navigating this environment presents unique challenges, with student-related stressors emerging as a significant theme. These stressors stem from various sources within the clinical setting, such as high expectations, unfamiliar practices and interactions with patients and staff. The ability to manage this stress effectively is equally crucial, as it impacts not only the students’ learning outcomes but also their emotional resilience and confidence. Stress management strategies, tailored to the clinical teaching and learning environment, serve as vital tools in promoting a supportive and empowering space for students to thrive. This theme highlights the dual aspects of understanding stressors and developing coping mechanisms within the clinical learning context.

Category 1: Sources of stress in the clinical environment

Various authors (Alanazi et al., 2023; Bodys-Cupak et al., 2019; Delany et al., 2015; Lawal et al., 2015; Lyman & Mendon, 2021) agree that undergraduate nursing students experience stress when they are placed in the clinical learning environment. Bodys-Cupak et al. (2019) point out that although managed stress may contribute to growth and development, uncontrolled or severe stress is detrimental, affecting nursing students’ mood to the point that they do not take action to resolve the stressor. Skills development is then reduced, or students abandon their training.

Nursing student-related stressors: Nursing student-related stressors draw attention to student emotions associated with their perceptions of their abilities. Lawal et al. (2015) as well as Lyman and Mendon (2021) note that these stressors decrease as nursing students’ abilities develop from first year to third and fourth year. Initial exposure to the clinical learning environment results in anxiety and self-consciousness because of feelings of incompetence. Ewertsson et al. (2017) further explain that the awareness of how crucial clinical skills are can heighten anxiety among nursing students. Furthermore, nursing students are unsure of what to expect as well as what the expectations from the clinical team might be (Lyman & Mendon, 2021). The uncertainty and related anxiety, along with fear of appearing incompetent, limit the students’ engagement with the clinical role. (Delany et al., 2015; Ewertsson et al., 2017).

Management-related stressors: Compounding the nursing student-related stressors is the response from supervisors. Self-consciousness increases with feeling constantly under a magnifying glass. The supervisors conduct may also create stress. Supervisors’ taking over or interfering while the nursing students are in the process of caring for patients not only limits the opportunity to develop skills, but nursing students feel intimidated and more unsure about themselves (Delany et al., 2015). In addition, supervisors and other clinical staff who emphasise the pecking order between themselves and students, refuse to assist, disrespect and bully students, contribute to an unsupportive clinical work environment (Berhe & Gebretensaye, 2021; Delany et al., 2015).

Environment-related stressors: Inocian et al. (2022) refer to the clinical environment as an obstructive factor, in that the students experience the clinical environment to differ from the information that the teaching staff impart. Participants in the studies by Ten Hoeve et al. (2017) and Alanazi et al. (2023) highlight that theory-practice inconsistency led to stress because it left nursing students ill-prepared for clinical demands, inhibiting the propensity to develop caring skills. Delany et al. (2015) call attention to the stress caused by the change in environments. Nursing students move from the more controlled Faculty surroundings to the dynamic, at times unpredictable, clinical environment where learning opportunities may present impromptu, as alluded to by D’Souza et al. (2013). More to the specific skills, Bodys-Cupak et al. (2019) found that contact with distressed patients, dying patients and interacting with relatives were sources of anxiety to nursing students.

Facilitation-related stressors: The way clinical facilitation takes place may be a source of stress to nursing students. Ten Hoeve et al. (2017) and Berhe and Gebretensaye (2021) emphasise that insufficient support from both teaching staff and the clinical team during clinical placement contributes to demoralisation and attrition. Students are sensitive to any feedback, whether intentional or unintentional. Lyman and Mendon (2021) point out that students take note of verbal and non-verbal cues. Due to students’ emotions of uncertainty, they might read more into actions than was intended, as the study by Lyman and Mendon (2021) showed. Planned evaluation, being a source of intentional feedback, might provide valuable information for further development, but from the study by Alanazi et al. (2023), students also found it a source of stress because of the comparative nature thereof. Ten Hoeve et al. (2017) and Lawal et al. (2015) emphasised in their studies that clinical staff should be adequately prepared to receive students in their units and possess the necessary knowledge and skills to support their development within the clinical setting.

Lawal et al. (2015) suggest that if both faculty and clinical preceptors lack insight into the clinical experiences of nursing students, it may contribute to negative consequences. Therefore, an awareness of the mentioned stressors is important, and strategies to manage and cope with them should be developed and employed throughout theory and clinical teaching.

Category 2: Stress management strategies employed in the clinical teaching and learning environment

Stress has also been reported to have an impact on the clinical teaching-learning environment attributed to instructors, faculty, supervisors, academic workload, evaluation processes, clinical practice, challenging patients and families, leading to high levels of stress and anxiety among nursing students (Brehmer et al., 2022; Eyikara & Baykara, 2017; Gruppen et al., 2018; Panda et al., 2021; Zhang et al., 2022).

In response to these high levels of stress and anxiety of nursing students, studies show that nursing students employ various stress management strategies in the clinical and teaching-learning environment. These strategies are outlined as follows:

Reflective practices: Nursing students’ satisfaction was described to have risen through reflective journaling and had significantly changed the clinical teaching and learning environment positively (Brehmer et al., 2022; Gruppen et al., 2018). This approach helps nursing students to continuously find answers to problems related to patient care and supports students’ competence development (Visiers-Jiménez et al., 2021).

Taking control of own learning: In a study conducted by Lekalakala-Mokgele and Caka (2015), learning in the clinical learning environment was facilitated when nursing students took responsibility and control of their learning, contributing to increased self-confidence.

Positive coping strategies: A positive clinical learning environment can enhance students’ motivation to continue in the nursing profession. A conducive learning environment is created through positive interpersonal relationships with other team members (Mbaya et al., 2020; Zhang et al., 2022).

Debriefing practices: Debriefing and group discussion post clinical experiences were reported to be more desirable by the nursing students as this exercise provided an opportunity to identify areas of strengths and weaknesses, which provided guidance for future clinical learning Lawal et al., 2015).

Bodys-Cupak et al. (2019) found student coping strategies as either active or passive and added that nursing students employ different combinations of strategies depending on the level of stress, the age, gender and educational progress of the student. The strategies are either productive, unproductive or counterproductive according to Lyman and Mendon (2021).

Theme 3: Student support in the clinical learning environment

Student support in the clinical learning environment is essential for fostering confidence, competence and overall well-being among nursing students. The transition from classroom-based learning to clinical practice can be challenging, as students are required to apply theoretical knowledge in real-world healthcare settings while adapting to the demands of patient care. A well-structured support system, including mentorship, constructive feedback and emotional support from clinical educators, preceptors and peers, enhances students’ learning experiences and professional development. Effective student support not only reduces stress and anxiety but also promotes resilience, motivation and a sense of belonging within the healthcare team. By ensuring that students feel guided, valued and equipped to navigate clinical challenges, institutions can cultivate a positive learning environment that prepares nursing students for successful integration into professional practice.

Category 1: Student feedback in the clinical teaching and learning environment

The quality of interaction among nursing students, clinical training specialists and nurse educators holds paramount importance, forming the bedrock of engagement and feedback. This interaction can be either positive, supportive and motivating or, conversely, negative, which breeds unfavourable attitudes and behaviours (Ekstedt et al., 2019). Research conducted by Delany et al. (2015), emphasised the significance of positive and dynamic student-supervisor relationships during clinical placements. Feedback in the clinical learning environment stands as a fundamental element within the dynamic interaction between educators and nursing students. Furthermore, feedback encompasses the critical evaluation of a student’s actions against established expectations, with the overarching objective of elevating the nursing student’s performance to a proficient level. This continuous process plays a pivotal role in monitoring and fostering the progress of the nursing student. Nursing students value feedback and enjoy contact with the expert and opportunities created to ask questions and clarify concepts, particularly if the clinical field is challenging. When executed in a constructive and supportive manner, feedback morphs into a potent motivational catalyst (Burgess et al., 2020; Mowchun & Davila, 2022). However, the involvement of the nursing student in the process of learning and preparation for sessions is as important and may influence the feedback-seeking responses from nursing students (Mowchun & Davila, 2022). It is of utmost importance that both nursing students and clinical facilitators and/or educators do their part to ensure effective feedback. According to the literature, the following categories of feedback were identified:

Lack of feedback: Feedback is a compass for nursing students’ direction. Deprivation of feedback can erode confidence and heighten anxiety. Nursing students may resort to self-assessment, often underestimating their abilities if they are high performers or overestimating their capabilities if they struggle (Burgess, 2020). In a study done in China, nursing students reported the clinical supervisors not even knowing their names, robbing them of the confidence to participate in discussions (Zhang et al., 2022).

Unclear feedback: In discussions surrounding the psychological safety of nursing students, feedback encompasses both verbal and non-verbal communication cues, irrespective of the nursing educator’s intent. External feedback is crucial to prevent nursing students from drawing their own conclusions about their progress (Burgess et al., 2020). Ambiguous feedback significantly undermines nursing students’ progress and psychological safety (Lyman & Mendon, 2021).

Judgemental feedback: In a non-supportive environment where feedback is laden with criticism and condescension, nursing students find it challenging to gain insight and enhance their clinical skills (Lekalakala-Mokgele & Caka, 2015). Feedback should be non-judgmental and descriptive in nature (Burgess et al., 2020). In a study done by Ewertsson et al. (2017), it was found that clinical facilitators would rebuke nursing students for mistakes instead of following a reflective theoretical explanation. The relationship between the student nurse and clinical facilitator is key in teaching daily routine and practical skills and needs to remain positive.

Discrepancies in feedback: Delany et al. (2015) noted nursing students’ reports of disparities in feedback. Supervisors often provided positive feedback but then assigned poor grades, causing confusion and denting nursing students’ confidence. Some supervisors tended to micromanage tasks, stifling students’ independence. Nursing students also expressed frustration with supervisors who demanded very specific responses, overlooking alternative approaches. Nursing students felt that ‘being closely watched’ led to anxiety, impeding their ability to think and plan effectively (Delany et al., 2015). Some preceptors will correct nursing students even though they did not make a mistake, suggesting a ‘better’ way of doing a procedure. It was also reported that preceptors would demonstrate a procedure without allowing the nursing students to demonstrate back and ensure that they do it correctly (Ewertsson et al., 2017).

Category 2: Nursing student support in the clinical environment

Good quality relationships in the clinical environment relate to a supportive environment. One of the elements of a supportive environment is peer relationships. Positive peer relationships could provide optimism and motivation (Alanazi et al., 2023). Furthermore, in a supportive environment, motivation soars, leading to enhanced clinical competence, establishing a foundation for interpersonal relationships and fostering a positive atmosphere conducive to increased learning and teamwork among nursing students and hospital staff (Yu et al., 2021). In a study done on the clinical learning environment, supervision and future intention to work as a nurse, the basic components of such a supportive clinical learning environment are supervision, pedagogical atmosphere in the ward, the role of the nurse educator, leadership style of the ward manager and premises of nursing in the ward. These components are based on the Clinical Learning Environment Supervision and Teacher Scale (CLES+T) instrument developed in 2008 (Zhang et al., 2022).

According to Zhang et al. (2022), the pedagogical atmosphere for student nurses within the clinical learning environment includes support, respect and encouragement from the nursing staff. If nursing students are accepted as part of the team, it fosters a sense of belonging and creates a psychologically safe space to learn and practice new skills. Psychological safety may include different elements for different individuals. However, it complements other elements within the clinical learning environment. The psychological environment is not only structural but also speaks to the human element in the people involved in the clinical learning. The manner in which the nursing staff accept, support and involve the nursing students can portray a sense that they are welcome and do not bring a burden on the unit. This influences the help-seeking behaviour from nursing students. The CLES+T instrument also mentions the role of educators or clinical facilitators (Zhang et al., 2022). In King et al. (2020), the educator’s role is emphasised. When clinical facilitators create opportunities for student involvement, it increases levels of enthusiasm and motivation among the student nurses.

Another important element during the placement of nursing students in the clinical environment is the preparedness of both the nursing student and the clinical facilitator to reduce unwanted surprises. Clear documentation explaining the learning activities and placement gives the nursing student the opportunity to prepare mentally and academically. Time to prepare gives a sense of emotional safety for the nursing student (King et al., 2020).

Therefore, a supportive environment empowers nursing students to take charge of their own learning, pace their progress, view themselves as proactive learners actively seeking feedback, and reflect on their learning journey (Burgess et al., 2020; Mowchun & Davila, 2022).

Discussion

A healthy clinical learning environment encompasses a multifaceted approach that prioritises active participation by the nursing students, structured learning, supervision, patient-centred care, safety, ethics, reflection, feedback and interprofessional collaboration. In cultivating such an environment, educators and healthcare institutions can empower students to become competent, compassionate and culturally competent healthcare professionals upon completion of their studies.

In clinical learning, the nursing students are encouraged to actively take part in their learning through active engagement with the learning process, participating in clinical activities, asking questions, seeking clarification and actively taking part in patient care under supervision. The active involvement fosters a deeper understanding of the clinical concepts and enhances critical thinking skills, which will assist the nursing students in problem solving during clinical practice (Munangatire et al., 2023).

The curriculum must be well structured to provide effective clinical learning (Ekstedt et al., 2019). A structured curriculum includes planned clinical placements, well-designed clinical rotations that relate to clear learning outcomes and identified clinical learning opportunities. The structured clinical learning will enhance progressive skill development by providing adequate learning opportunities and a variety of clinical scenarios to the nursing student (Ewertsson et al., 2017; Lawal et al., 2015). Adequate supervision and mentorship are crucial components of a healthy clinical learning environment. The nurse educators and clinical staff provide supervision, guidance, support and feedback to the students to overcome clinical challenges. The student feels valued and empowered as they navigate clinical challenges (Alshehri et al., 2023; Ekstedt et al., 2019). Providing effective support in the clinical area is very crucial for the nursing student for optimal development and success in their clinical learning (Stone et al., 2019).

Various authors from various countries concluded that nursing students do experience stress as they enter the clinical learning environment and found different factors contributing to the experiences of stress, including internal and external sources. Singer et al. (2022) agrees and points out that stress affects belongingness, which as Zhang et al. (2022) allude to, has an impact on nursing student’s confidence and impetus for learning. Bodys-Cupak et al. (2020) offer that coping is a principle of stress management, and for students to gain full success from the clinical experience, stress included, optimal coping mechanisms must be implemented. Delany et al. (2015) advocate for coping mechanisms to achieve ‘resilience’, which is not just to manage the stress but to overcome and thrive through it. It is also clear from these authors that individuals have different coping mechanisms, but given time and guidance, effective mechanisms can be developed. In support of this, Lyman and Mendon (2021) report that as students gain confidence and develop their skills in the clinical learning environment, the more effective their coping strategies become.

Stress management strategies include a range of strategies to reduce and manage stress, including yoga, mindfulness, exercise, cognitive behavioural therapy, emotion-focused techniques and problem solving (Amanvermez et al., 2023, p. 12; Lavoie-Tremblay et al., 2022, p. 262; Marcella Henderson et al., 2021, p. 36). Students’ initial coping mechanisms present as passive or counterproductive in that their uncertainty results in avoidance and emotional guarding (Lyman & Mendon, 2021), denial and substance use (Bodys-Cupak et al., 2020), as well as transference (Alanazi et al., 2023). In contrast to this, the more experienced students lean towards active or productive coping mechanisms like problem-solving and staying expectant (Alanazi et al., 2023), maintaining perspective and self-assertion (Lyman & Mendon, 2021) along with planning, acceptance and seeking emotional confirmation (Bodys-Cupak et al., 2020). Throughout the discussions, the authors emphasise the role that the clinical teacher plays not only in the planning and presentation of content but also in building a relationship with the student and acting as a role model (Alanazi et al., 2023; Bodys-Cupak et al., 2020; Lyman & Mendon, 2021).

Professionalism is a cornerstone of nursing education and must not remain confined to theoretical instruction. Instead, it must be exemplified within the clinical setting by role models. Nursing students benefit immensely from observing experienced registered nurses who seamlessly blend clinical skills with professionalism and ethical values through critical thinking. Conversely, when unprofessional preceptors or supervisors guide nursing students, it sows seeds of uncertainty and distrust, rendering feedback ineffective in their growth (Kadhila, 2023). Additionally, nursing students grapple with daily stressful and challenging situations (Bodys-Cupak et al., 2016). Therefore, supervisors should not only assist nursing students in managing these difficulties but also model the coping skills necessary for the development of a positive professional identity (Bodys-Cupak et al., 2016).

Recommendations

Based on the findings of the review, several key recommendations have been formulated for Nursing Education and Clinical practice to address creating a healthy clinical learning environment for undergraduate nursing students. These recommendations may guide future actions, inform policies and procedures. The recommendations for the study are as follows:

• Structured orientation and placement planning: Programme managers of the NEI to implement and communicate comprehensive orientation programmes to nursing students and clinical facilitators, with clear learning outcomes and role expectations to help students acclimate to the clinical setting.
• Enhanced preparation and role modelling: Nursing education institution management or clinical facility managers to ensure clinical facilitators possess pedagogical skills and clinical competence to guide and model professional behaviour.
• Student-centred support strategies: Nursing education institution and nurse educator to provide support strategies, including access to mentors, peer support groups and reflective practices to manage stress and encourage learning.
• Promotion of positive coping mechanisms: Nursing education institution and programme managers to incorporate training on active stress management strategies, such as mindfulness and reflective journaling, into the nursing curriculum.
• Feedback: Nursing education institution to train nurse educators and clinical facilitators to provide clear, constructive and non-judgmental feedback to foster psychologically safe spaces for student growth.

Collaboration: Nursing education institution faculty members and clinical facility managers to strengthen collaboration between NEIs and clinical placement sites to align educational goals and supervision practices.

Limitations

It is important to acknowledge the limitations of the study for transparency. The limitations of the study are as follows. The review included only peer-reviewed studies published in English between 2013 and 2023, potentially excluding relevant research outside this timeframe or in non-English languages. While studies from multiple countries were included, the findings may not fully reflect the diversity of clinical learning environments globally, especially in underrepresented regions. The findings pertain specifically to undergraduate nursing students and may not be generalisable to other health professions or postgraduate nursing programmes.

Conclusion

This review highlights that a healthy clinical learning environment is essential for developing competent and motivated nursing professionals. The clinical setting bridges theory and practice, where nursing students develop clinical competencies and shape their professional identities. However, the transition can be stressful as a result of inadequate support, misaligned expectations, ineffective feedback and a lack of psychological safety. The review emphasises the need for structured clinical placements, active mentorship, effective communication and stress management strategies. Promoting positive student-staff relationships and offering consistent feedback are crucial for cultivating an environment that supports learning and emotional well-being.

Because stress will be experienced in the clinical learning environment, positive stress coping strategies should be promoted and form part of the clinical learning programme for nursing students.

A healthy clinical learning environment is essential for the development of competent and compassionate nursing professionals. It also ensures quality patient care and is, therefore, essential. However, the students experience many stressors that can negatively influence their experiences and the effectiveness of the learning experience, compromising patient safety and care. Sources of stress identified were nursing-related, management-related, facilitation-related and environmental stressors were identified. By fostering active student participation, structured learning, strong supervision, constructive and supportive feedback, ethical practice, and effective coping strategies, educators and clinical staff can create a supportive setting that encourages growth, critical thinking and professional identity formation. Stress management strategies include reflective and debriefing practices and taking control of one’s learning. Promoting positive coping mechanisms and professionalism within the clinical context further strengthens the learning experience, ensuring nursing students are well-prepared to meet the complex demands of patient care.

Future research may focus on the impact that structure and quality of clinical placement have on the overall learning outcomes across a diverse cultural and institutional context, stress management interventions in promoting emotional resilience for undergraduate nursing students, and how psychological safety, mentorship styles and feedback mechanisms can contribute to clinical competencies.

Acknowledgements

The authors thank Ms Siphiwe Nhiwatiwa who assisted in the initial literature searches.

Competing interests

The author, Gisela H. van Rensburg, serves as an editorial board member of this journal. The authors have no other competing interests to declare. The authors reported that they received funding from UNISA Community Engagement funding, which may be affected by the research reported in the enclosed publication. The authors have disclosed those interests fully and have implemented an approved plan for managing any potential conflicts arising from their involvement. The terms of these funding arrangements have been reviewed and approved by the affiliated University in accordance with its policy on objectivity in research.

CRediT authorship contribution

Adél Geldenhuys: Conceptualisation, Investigation, Methodology, Writing – original draft, Writing – review & editing. Andile M. Mafilika: Conceptualisation, Investigation, Methodology, Writing – original draft, Writing – review & editing. Naomi Hattingh: Conceptualisation, Investigation, Methodology, Writing – original draft, Writing – review & editing. Natasjha Engelbrecht: Conceptualisation, Investigation, Methodology, Writing – original draft, Writing – review & editing. Petronella M. Schroeder: Conceptualisation, Investigation, Methodology, Writing – original draft, Writing – review & editing. Memme G. Makua: Supervision, Writing – review & editing. Gisela H. van Rensburg: Conceptualisation, Methodology, Supervision, Writing – review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.

Funding information

This research received financial support from the UNISA Community Engagement funding for Project CA0056.

Data availability

The data that support the findings of this study are available from the corresponding author, Adél Geldenhuys, upon reasonable request.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

References