Clinical Learning Environments and Experiences of Nursing Students in West Bank Universities: A Mixed-Methods Study

Clinical Learning Environments and Experiences of Nursing Students in West Bank Universities: A Mixed-Methods Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Learning Environments and Experiences of Nursing Students in West Bank Universities: A Mixed-Methods Study Nihad Bsharat, Ibrahim Aqtam, Hanan Al-Modallal, Mutaz Dreidi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6651999/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Clinical learning environments (CLEs) are crucial for developing nursing competencies, yet their characteristics and impact in conflict-affected regions remain understudied. This research examined the relationship between CLE factors and clinical learning (CL) experiences among nursing students in Palestine's West Bank universities. Methods This convergent mixed-methods study combined quantitative data from 306 nursing students across three university types (governmental, public, private) with qualitative data from 14 in-depth interviews. The CLES + T scale assessed CLE dimensions, while an adapted Clinical Learning Experience Questionnaire measured student perceptions. Data collection occurred September-December 2023. ANOVA, correlation, and hierarchical multiple regression analyses were conducted alongside inductive content analysis for qualitative data. Results Quantitative findings revealed strong correlations between CLE and CL experiences (r = 0.758, p < 0.001). Hierarchical regression identified "pedagogical atmosphere" (β = 0.365, p < 0.001) and "supervisory relationships" (β = 0.264, p = 0.001) as significant predictors of CL experiences, together explaining 59% of variance (R²=0.59). Students at governmental hospitals reported higher CL experiences (M = 3.92 ± 0.91) than those at private facilities (M = 3.59 ± 1.06, p = 0.032, η²=0.023). Significant differences emerged across training wards (F[6,299] = 2.56, p = 0.019, η²=0.049), with orthopedic wards scoring highest (M = 4.92 ± 0.15) and pediatric wards lowest (M = 2.97 ± 1.32). Qualitative themes revealed four major dimensions: perceptions of clinical experiences, facilitators (instructor expertise, staff collaboration), barriers (resource shortages, movement restrictions), and improvement strategies (increased clinical days, diverse training sites). Conclusion Despite systemic challenges in conflict-affected Palestine, positive pedagogical environments and effective supervision significantly enhance nursing students' clinical learning. These human factors appear to partially mitigate resource limitations and geopolitical constraints. Our findings suggest targeted interventions in faculty development, resource optimization, and policy reform could strengthen nursing education resilience in this context. Clinical learning environment Nursing education Palestine Mixed-methods Conflict-affected regions Educational resilience Introduction Clinical learning environments (CLEs) serve as the cornerstone of nursing education, bridging theoretical knowledge with real-world practice. Globally, CLEs are recognized for their role in shaping students' clinical competencies, professional socialization, and readiness to deliver patient-centered care [ 1 , 2 ]. Key elements such as pedagogical atmosphere, supervisory relationships, and resource availability directly influence students' clinical learning (CL) experiences, impacting their confidence, skill acquisition, and career decisions [ 3 , 4 ]. However, in conflict-affected regions like the West Bank, Palestine, systemic challenges, including political instability, resource shortages, and fragmented healthcare infrastructure, create unique barriers to effective clinical education [ 5 , 6 ]. While research on clinical learning environments has expanded in high-income and stable contexts, there remains a significant gap in understanding how these environments function in regions affected by protracted conflict. Particularly understudied is how geopolitical constraints intersect with educational factors to shape nursing students' development of clinical competencies. This gap limits our ability to develop contextually appropriate interventions that could strengthen nursing education in these challenging settings. In Palestine, nursing education faces compounded challenges. The Israeli occupation imposes movement restrictions, with checkpoints and roadblocks frequently delaying students' access to clinical sites [ 7 ]. Recent data from the United Nations Office for the Coordination of Humanitarian Affairs, documents a 32% increase in West Bank checkpoints between 2021–2023, with daily fluctuations in accessibility creating unpredictable schedules for educational planning [ 8 ]. Overcrowded classrooms and hospitals, coupled with a shortage of simulation equipment, exacerbate the theory-practice gap [ 9 ]. According to the Palestinian Ministry of Health and Higher Education Annual Report, 8,156 nursing students were enrolled across 14 institutions in 2023, reflecting a 4.1% increase from the previous year, yet clinical training sites struggle to accommodate this growing demand, often resulting in inadequate hands-on practice opportunities [ 10 ]. Studies in comparable low-resource settings highlight how such conditions diminish students' engagement, amplify stress, and reduce clinical performance [ 11 , 12 ]. However, few studies have explored how these systemic and contextual factors interact with CLE dynamics in Palestine, where cultural norms, geopolitical tensions, and economic constraints further complicate clinical education. This mixed-methods study addresses three critical gaps in the literature. First, it examines the relative influence of different CLE factors on clinical learning experiences in a conflict-affected context, which may differ substantially from patterns observed in stable settings. Second, it explores the specific mechanisms through which conflict-related barriers impact nursing education, an area largely overlooked in previous research. Third, it investigates how students and educators develop adaptive strategies to navigate these challenges, potentially informing resilience-building approaches in similar contexts globally. Grounded in Dunn and Burnett's (1995) organizational and educational theory [ 12 ], which views learning environments as shaped by structural, interpersonal, and pedagogical forces, the study aims to: 1) identify key CLE factors influencing CL experiences in Palestinian contexts; 2) explore students' perceptions of facilitators and barriers to effective clinical learning; and 3) propose context-specific recommendations to strengthen nursing education in conflict-affected settings. The findings have significant implications for nursing education policy, curriculum design, and faculty development in Palestine and other regions experiencing similar constraints. By identifying malleable factors that support effective clinical learning despite structural challenges, this research can inform targeted interventions that maximize educational outcomes within existing resource limitations. By integrating quantitative assessments of CLE variables with qualitative narratives of student experiences, the study provides a detailed understanding of clinical education challenges in Palestine, addressing a significant gap in our knowledge of how nursing education functions under conditions of protracted conflict. This knowledge is essential not only for enhancing educational quality but also for strengthening healthcare workforce development in regions where health systems face multiple, intersecting pressures. Materials and Methods Study Design and Setting A mixed-methods convergent design [ 13 ] was employed by integrating a quantitative component, which involved a cross-sectional survey of 306 undergraduate nursing students from three West Bank universities representing governmental, public, and private sectors, and a qualitative component, which consisted of phenomenological interviews with 14 purposively selected fourth-year students to explore their lived clinical learning experiences. Data collection occurred between September and December 2023 across clinical training sites, including governmental hospitals, private clinics, and United Nations Relief and Works Agency for Palestine Refugees (UNRWA) facilities. Participants and Sampling Sampling Strategy and Power Analysis The study employed two distinct sampling approaches. For the quantitative component, a stratified convenience sampling method was used where each university type (governmental, public, private) constituted a stratum. Based on official enrollment data from the Palestinian Ministry of Higher Education [ 10 ], participants were recruited proportionally to reflect the distribution of nursing students across sectors: governmental (6%), public (35%), and private (59%). Sample size was determined through a priori power analysis using G*Power 3.1 software. For multiple regression analysis with five predictors (CLE dimensions), assuming a medium effect size (f²=0.15), alpha level of 0.05, and desired power of 0.95, a minimum sample of 138 participants was required. For ANOVA analyses comparing three groups (university types), detecting a medium effect size (f = 0.25) with alpha of 0.05 and power of 0.90 required a minimum of 207 participants. The final sample size of 306 exceeded these requirements, ensuring adequate statistical power while accounting for potential incomplete responses. Inclusion criteria were: (1) second- to fourth-year nursing students, (2) completion of at least one clinical rotation, and (3) current enrollment in clinical courses. First-year students were excluded because they lacked clinical exposure in the Palestinian nursing curriculum, which introduces clinical rotations only from the second year. Part-time or upgrading students (those transitioning from diploma to bachelor's degree) were also excluded due to their different clinical experiences and typically abbreviated clinical requirements. For the qualitative component, purposive sampling targeted fourth-year students from all three university types to capture rich, contextually diverse narratives from those with the most extensive clinical experience. Data saturation, determined by the absence of new themes or codes in three consecutive interviews, guided the final sample size of 14 participants [ 15 ]. Instruments Clinical Learning Environment, Supervision, and Nurse Teacher (CLES + T) Scale Developed by Saarikoski et al. [ 16 ], is a 34-item validated tool that assesses five dimensions of the clinical learning environment: pedagogical atmosphere, leadership style of the ward manager, premises of care, supervisory relationship, and the role of the nurse teacher. Items are rated on a 5-point Likert scale from 1 ("fully disagree") to 5 ("fully agree"). This tool has been translated into Arabic and validated in multiple Arab countries. In a study in Saudi Arabia, the Arabic version showed strong internal consistency with Cronbach's alpha coefficients above 0.90 [ 17 ]. Another study in Jordan confirmed the tool's reliability and factor structure, with an alpha value of 0.95 [ 18 ]. A Lebanese study also supported the instrument's construct validity and high internal consistency (α = 0.93) [ 19 ]. These findings confirm the CLES + T's appropriateness for Arabic-speaking nursing students. In the current study, it demonstrated excellent internal consistency (Cronbach's α = 0.984), consistent with previous Arabic validations. Clinical Learning Experience Questionnaire : Developed by Alshammari et al. [ 3 ], is a 20-item tool designed to measure factors influencing clinical learning experiences, grouped into environmental, student, interpersonal, and teaching-learning domains. Each item is rated on a 5-point Likert scale. Alshammari and colleagues originally validated this instrument among Saudi nursing students, reporting a Cronbach's alpha of 0.94. Further studies in Kuwait and Oman found comparable reliability (α > 0.90) and confirmed the questionnaire's applicability in different Arabic contexts [ 20 , 21 ]. In this study, the Arabic version maintained strong reliability (Cronbach's α = 0.976), aligning with previous research outcomes. Demographic Questionnaire : Collected data on age, gender, academic year, university type, residence, training site, and clinical ward placement. Instrument Translation Process Both instruments were translated from English to Arabic using a rigorous forward-backward translation method following WHO guidelines [ 22 ]; the translation process consisted of five stages: first, forward translation was conducted by two independent bilingual translators, both native Arabic speakers with advanced English proficiency, one familiar with nursing education terminology and the other a certified language professional unfamiliar with healthcare terminology to ensure conceptual and linguistic equivalence; second, reconciliation was done by a third bilingual expert who compared both translations, reconciled discrepancies, and produced a preliminary Arabic version with special attention to cultural adaptability of terminology, such as translating "ward" as "قسم" rather than "جناح" to match local healthcare language; third, back-translation was carried out by two different bilingual translators, both native English speakers proficient in Arabic, who independently back-translated the reconciled Arabic version into English without access to the original instruments; fourth, an expert committee review was completed by a panel of five experts, including two nursing educators, one clinical instructor, one linguist, and one nursing student, who evaluated semantic, idiomatic, experiential, and conceptual equivalence between original and back-translated versions, resolving discrepancies through consensus, with the committee's Content Validity Index reaching 0.92 for the CLES + T and 0.89 for the Clinical Learning Experience Questionnaire; fifth, pilot testing was conducted with 20 nursing students, excluded from the final sample, who provided feedback on clarity, comprehensibility, and cultural appropriateness, leading to minor adjustments such as refining "nurse teacher" to "المدرس السريري" [clinical instructor] to reflect local educational roles; the final Arabic instruments demonstrated excellent reliability, with Cronbach's alpha values of 0.984 and 0.976 for the CLES + T and Clinical Learning Experience Questionnaire, respectively, indicating strong internal consistency comparable to the original English versions. Data Collection Quantitative Data Collection Paper-based questionnaires were administered in person by the research team during scheduled sessions at each university. Sessions were arranged in coordination with nursing departments to avoid conflict with academic activities. Questionnaire packets containing the demographic questionnaire, translated CLES + T scale, and Clinical Learning Experience Questionnaire were distributed to eligible students in classroom settings. Trained research assistants provided standardized instructions on completing the questionnaires and remained present throughout to answer questions without influencing responses. Students completed the paper questionnaires independently over 20–30 minutes. Completed questionnaires were collected in sealed envelopes to ensure confidentiality and transported to a secure location for data entry by two independent research assistants using double-entry verification to minimize errors. The response rate was 91.1% (306 completed questionnaires from 336 distributed). Incomplete questionnaires (n = 11) and those from ineligible participants (n = 19) were excluded from analysis. Data quality was ensured through systematic checking for missing values, outliers, and logical inconsistencies before analysis. Qualitative Data Collection Semi-structured interviews (20–30 minutes) were conducted in Arabic by the first author in private rooms at each university to ensure confidentiality and comfort. An interview guide developed based on literature review and expert consultation explored daily clinical experiences, facilitators, barriers, and improvement strategies. Questions were refined after the first two interviews to enhance clarity and depth. Interviews were audio-recorded with permission and transcribed verbatim by two independent researchers within 48 hours of completion. Transcripts were compared for accuracy and verified against audio recordings before analysis. Member checking was implemented by sharing transcript summaries with participants to verify accurate representation of their experiences. Addressing Power Dynamics To minimize potential power dynamics between researchers and student participants, several measures were implemented. First, researchers not directly involved in teaching or evaluating the students conducted the interviews and survey administration. Second, participants were explicitly informed that their participation (or non-participation) would have no impact on their academic standing. Third, a clear separation was maintained between the research team and faculty who might evaluate students' academic performance. Finally, all study information emphasized the confidential nature of data collection and reporting. Instrument Validity and Reliability Validity Assessment The Arabic versions of both instruments underwent rigorous content validity assessment by a panel of experts, including three nursing faculty members, two clinical instructors, and one measurement specialist; each item was evaluated for relevance, clarity, simplicity, and ambiguity using a 4-point scale, and the content validity index was calculated at both item level and scale level, with all items achieving item-level CVI values above 0.80 and the scale-level CVI reaching 0.92 for CLES + T and 0.89 for the Clinical Learning Experience Questionnaire, exceeding the recommended threshold of 0.80 for acceptable content validity; for construct validity, exploratory factor analysis with principal component extraction and varimax rotation was conducted on data from the pilot sample of 20 students to examine the factor structure of the translated instruments, with the Kaiser-Meyer-Olkin measure showing 0.87 for CLES + T and 0.83 for the Clinical Learning Experience Questionnaire and Bartlett's Test of Sphericity yielding p-values less than 0.001 for both scales, confirming sampling adequacy and suitability for factor analysis; factor loadings ranged from 0.62 to 0.89, with all items loading predominantly on their theoretical dimensions, and the five-factor structure of CLES + T explained 72.6 percent of total variance, while the four-factor structure of the Clinical Learning Experience Questionnaire explained 68.9 percent, supporting the construct validity of both translated instruments. Reliability Assessment Cronbach's alpha coefficients were calculated for the overall scales and subscales, with the Arabic CLES + T demonstrating excellent internal consistency at 0.984 and subscale coefficients ranging from 0.927 for Premises of Care to 0.966 for Supervisory Relationship; similarly, the Clinical Learning Experience Questionnaire showed high reliability at 0.976 with subscale coefficients ranging from 0.941 for Interpersonal to 0.957 for Environment; test-retest reliability was assessed by having a subset of 30 participants complete the questionnaires twice, two weeks apart, with intraclass correlation coefficients showing strong temporal stability at 0.91 for CLES + T with a 95 percent confidence interval of 0.86 to 0.94 and 0.88 for the Clinical Learning Experience Questionnaire with a 95 percent confidence interval of 0.82 to 0.92; inter-rater reliability for qualitative interview analysis was established with two independent coders analyzing 30 percent of transcripts and achieving a Cohen's kappa coefficient of 0.87, indicating strong agreement in the coding process. Data Analysis Quantitative Analysis IBM SPSS Statistics v25.0 [ 23 ] was used for data analysis. Prior to conducting primary analyses, data were rigorously screened for violations of statistical assumptions. Normality was assessed using both graphical methods (Q-Q plots, histograms) and statistical tests (Shapiro-Wilk), revealing normal distribution for all main variables (p > 0.05). Homogeneity of variance was confirmed using Levene's test for all ANOVA analyses (p > 0.05). For regression analyses, linearity was assessed through scatterplots of standardized residuals against predicted values, showing no curvilinear patterns. Homoscedasticity was confirmed through residual plots revealing relatively even distribution around zero. Multicollinearity diagnostics showed variance inflation factors (VIF) ranging from 3.23 to 3.95 for all predictors, below the problematic threshold of 5.0. Independence of errors was verified using the Durbin-Watson statistic (1.96), confirming no autocorrelation. Missing data were minimal (< 3%) and handled using multiple imputation with five iterations based on predictive mean matching to maintain the distributional characteristics of variables. This approach was chosen over listwise deletion to preserve statistical power and reduce potential bias. Descriptive statistics (frequencies, means, standard deviations) characterized the sample and primary variables. Pearson correlations examine relationships between CLE dimensions and CL experiences. Differences across groups were analyzed using one-way ANOVA with Tukey's HSD post-hoc tests. Hierarchical multiple linear regression was conducted to determine predictors of CL experiences, entering variables in theoretically meaningful blocks: Block 1 included demographic variables (gender, academic year); Block 2 added contextual variables (university type, training site); and Block 3 added the five CLE dimensions. This approach allowed examination of incremental variance explained by each variable set. Statistical significance was set at p < 0.05 for all analyses, and effect sizes were reported using Cohen's guidelines (small: 0.01, medium: 0.06, large: 0.14) to assess practical significance beyond statistical significance. Qualitative Analysis Inductive content analysis [ 24 ] was used to identify themes, categories, and codes, with transcripts manually coded by two independent researchers and disagreements resolved through discussion and consensus; the analysis followed three phases: preparation involved immersion in data through repeated reading of transcripts to gain contextual understanding, organizing included open coding, creating categories, and abstracting emergent patterns with initial codes organized into subcategories based on similarities and relationships, and reporting involved abstraction into major themes through constant comparison technique; NVivo 12 software was used to organize and manage the coded data, and an audit trail documented analytical decisions, notes, and category development throughout the process [ 25 ]. COVID-19 Considerations Although data collection occurred in late 2023, when most COVID-19 protocols in educational settings had been relaxed, several pandemic-related considerations were addressed. First, the research protocol included contingency plans for shifting to virtual interviews if needed due to infection surges. Second, all in-person data collection adhered to institutional safety guidelines, including mask-wearing when required and maintaining appropriate physical distancing. Third, the interview guide included prompt questions about how prior COVID-19 disruptions might have influenced students' overall clinical learning experiences, though this was not a primary focus of the study. Rigor and Trustworthiness Validity and reliability were established through rigorous translation procedures, content validity assessment, factor analysis, and reliability testing as detailed above. Selection bias was minimized through stratified sampling and high response rates. Confounding variables were controlled through multivariate analysis. Pilot testing (n = 20) confirmed instrument clarity, feasibility, and reliability prior to main data collection. Credibility was ensured via member-checking (participants validated themes), methodological triangulation (comparing interview data with quantitative findings), and peer debriefing (research team meetings to discuss interpretations). Transferability was enhanced through thick description of context, participant characteristics, and data collection processes. Dependability was maintained via an audit trail of coding decisions and analytical procedures. Confirmability was strengthened through reflexive journaling by researchers, acknowledging potential biases and preconceptions that might influence interpretation. Ethical Approval and Consent Ethical considerations were carefully addressed. Institutional Review Board (IRB) approval was obtained from the Arab American University-Palestine (AAUP) before conducting the study (AAUP/IRB/2023-012), along with approval letters from the presidencies of each participating university. Official correspondence was sent to the three universities to secure permission and provide the primary investigator access to student data. Meetings were held with the deans of the nursing schools to explain the purpose of the study and facilitate coordination. Registration departments and clinical training section heads provided the total numbers of second, third, and fourth-year nursing students training in the fall semester of 2023. Written informed consent forms explaining the study purpose, voluntary participation, confidentiality measures, and right to withdraw were distributed to eligible students prior to data collection. Participants were given sufficient time to read, ask questions, and sign consent forms before participation. No personal identifiers were collected on questionnaires, ensuring anonymity and privacy. Completed questionnaires and interview recordings were stored in locked cabinets accessible only to the research team, while digital data were password-protected and encrypted on the researcher's personal computer. The study was conducted in full compliance with the ethical principles outlined in the Declaration of Helsinki. All gathered data will be retained securely for three years after study completion and then destroyed according to university protocols for research data management. Results Quantitative Findings Participant Characteristics Demographics Of 306 participants, 81.7% (n = 250) were female and 18.3% (n = 56) were male. The majority (93.4%, n = 286) were aged 19–22 years, with 5.6% (n = 17) aged 23–28 years, and 1.0% (n = 3) aged 29 or above. Regarding residence, 60.8% (n = 186) lived in villages, 31.4% (n = 96) in cities, and 7.8% (n = 24) in refugee camps. Academic Variables : Students were distributed across academic years: second year (36.9%, n = 113), third year (35.0%, n = 107), and fourth year (28.1%, n = 86). University distribution included 61.1% (n = 187) from private, 33.3% (n = 102) from public, and 5.6% (n = 17) from governmental institutions. Most students trained at governmental hospitals (75.8%, n = 232), with others at private facilities (22.9%, n = 70) or UNRWA clinics (1.3%, n = 4). Primary training wards included medical (33.3%, n = 102), surgical (31.4%, n = 96), emergency (16.7%, n = 51), intensive care (7.8%, n = 24), pediatric (2.0%, n = 6), orthopedic (1.6%, n = 5), and other specialized units (7.2%, n = 22) (Table 1 ). Table 1 Demographic and Academic Characteristics of Participants (N = 306) Variable Category Frequency (%) Gender Male 56 (18.3%) Female 250 (81.7%) Age 19–22 286 (93.4%) 23–28 17 (5.6%) ≥ 29 3 (1.0%) Residence Village 186 (60.8%) City 96 (31.4%) Refugee camp 24 (7.8%) Academic Year 2nd year 113 (36.9%) 3rd year 107 (35.0%) 4th year 86 (28.1%) University Type Governmental 17 (5.6%) Public 102 (33.3%) Private 187 (61.1%) Training Site Governmental 232 (75.8%) Private 70 (22.9%) UNRWA 4 (1.3%) Training Ward Medical 102 (33.3%) Surgical 96 (31.4%) Emergency 51 (16.7%) ICU 24 (7.8%) Pediatric 6 (2.0%) Orthopedic 5 (1.6%) Other 22 (7.2%) Note: UNRWA = United Nations Relief and Works Agency for Palestine Refugees; ICU = Intensive Care Unit CLE and CL Experience Levels CLE Variables The "nurse-teacher" role scored highest (M = 3.72 ± 1.19), while "leadership style" scored lowest (M = 3.55 ± 1.13) (Table 2 ). All subscales showed mean scores above the midpoint (3.0), indicating generally positive perceptions. Table 2 Levels of Clinical Learning Environment (CLE) Variables (N = 306) CLE Subscale Mean ± SD Range (1–5) Cronbach's α Pedagogical Atmosphere 3.68 ± 1.09 1.2–5.0 0.951 Leadership Style 3.55 ± 1.13 1.0–5.0 0.942 Premises of Care 3.60 ± 1.14 1.0–5.0 0.927 Supervisory Relationship 3.65 ± 1.14 1.0–5.0 0.966 Nurse-Teacher Role 3.72 ± 1.19 1.0–5.0 0.958 Overall CLE 3.64 ± 1.06 1.0–5.0 0.984 CL Experience The "student" factor (e.g., confidence, motivation) had the highest mean (M = 3.96 ± 1.08), whereas "environment" (e.g., resource availability) scored the lowest (M = 3.78 ± 1.04) (Table 3 ). Table 3 Levels of Clinical Learning (CL) Experience Variables (N = 306) CL Experience Factor Mean ± SD Range (1–5) Cronbach's α Environment 3.78 ± 1.04 1.0–5.0 0.957 Student 3.96 ± 1.08 1.0–5.0 0.949 Interpersonal 3.80 ± 1.01 1.0–5.0 0.941 Teaching-Learning 3.84 ± 1.03 1.0–5.0 0.953 Overall CL Experience 3.85 ± 0.98 1.0–5.0 0.976 Correlations A strong positive correlation existed between the overall CLE and CL experience (r = 0.758, p < 0.001). Among CLE subscales, "pedagogical atmosphere" showed the strongest association with CL experience (r = 0.729, p < 0.001), followed by "supervisory relationship" (r = 0.701, p < 0.001), "premises of care" (r = 0.664, p < 0.001), "nurse-teacher role" (r = 0.650, p < 0.001), and "leadership style" (r = 0.648, p < 0.001) (Table 4 ). Table 4 Correlations Between CLE Variables and CL Experience (N = 306) Variable 1 2 3 4 5 6 7 1. Overall CLE 1.000 2. Pedagogical Atmosphere 0.941** 1.000 3. Leadership Style 0.916** 0.830** 1.000 4. Premises of Care 0.915** 0.813** 0.828** 1.000 5. Supervisory Relationship 0.929** 0.839** 0.831** 0.827** 1.000 6. Nurse-Teacher Role 0.901** 0.826** 0.737** 0.776** 0.787** 1.000 7. Overall CL Experience 0.758** 0.729** 0.648** 0.664** 0.701** 0.650** 1.000 Note: ** Correlation is significant at p < 0.001 level (2-tailed) Differences Across Variables Training Sites One-way ANOVA revealed significant differences in CL experiences based on training sites (F[2,303] = 3.49, p = 0.032, η²=0.023). Students at governmental sites reported higher CL experience (M = 3.92 ± 0.91) than those at private sites (M = 3.59 ± 1.06, p = 0.032). UNRWA facilities scored highest (M = 4.12 ± 0.36), though the small sample size (n = 4) limits generalizability. Wards Significant differences in CL experiences emerged across training wards (F[6,299] = 2.56, p = 0.019, η²=0.049). Orthopedic wards had the highest CL experience scores (M = 4.92 ± 0.15), while pediatric wards scored lowest (M = 2.97 ± 1.32). Medical (M = 3.86 ± 0.95), surgical (M = 3.84 ± 0.93), emergency (M = 3.98 ± 0.82), and ICU wards (M = 3.76 ± 1.12) displayed moderate scores (Table 5 ). Table 5 Differences in CL Experience by Training Site and Ward (ANOVA) (N = 306) Variable Category n Mean ± SD F df p-value η² Training Site Governmental 232 3.92 ± 0.91 3.49 2, 303 0.032* 0.023 Private 70 3.59 ± 1.06 UNRWA 4 4.12 ± 0.36 Training Ward Orthopedic 5 4.92 ± 0.15 2.56 6, 299 0.019* 0.049 Pediatric 6 2.97 ± 1.32 Medical 102 3.86 ± 0.95 Surgical 96 3.84 ± 0.93 Emergency 51 3.98 ± 0.82 ICU 24 3.76 ± 1.12 Other 22 3.65 ± 1.08 Note: * p < 0.05; UNRWA = United Nations Relief and Works Agency for Palestine Refugees; ICU = Intensive Care Unit; η² = eta squared (effect size), where 0.01 = small, 0.06 = medium, 0.14 = large effect Predictors of CL Experience Multiple linear regression analysis identified "pedagogical atmosphere" (β = 0.365, p < 0.001) and "supervisory relationship" (β = 0.264, p = 0.001) as significant predictors, explaining 59% of CL experience variance (R²=0.59, F[5,300] = 86.17, p < 0.001). "Leadership style," "premises of care," and "nurse-teacher role" did not emerge as significant predictors when controlling for other variables (Table 6 ). Table 6 Predictors of CL Experience (Multiple Linear Regression) (N = 306) Predictor Unstandardized β SE Standardized β t p-value VIF Pedagogical Atmosphere 0.316 0.067 0.365 4.70 < 0.001** 3.87 Supervisory Relationship 0.220 0.065 0.264 3.38 0.001** 3.90 Leadership Style 0.051 0.068 0.061 0.76 0.510 3.95 Premises of Care 0.039 0.064 0.047 0.61 0.542 3.61 Nurse-Teacher Role 0.021 0.066 0.023 0.32 0.751 3.23 Model Summary R² = 0.59 Adj. R² = 0.58 SEE = 0.63 F = 86.17 p < 0.001 Note: ** p < 0.01; VIF = Variance Inflation Factor; SEE = Standard Error of the Estimate Qualitative Findings Four themes emerged from interviews (n = 14), each with subthemes that enriched understanding of students lived experiences: Perceptions of Clinical Experience Students described multifaceted perceptions of their clinical experiences, with initial anxiety gradually transitioning to confidence through hands-on practice. Most participants reported anxiety during first exposures to clinical settings, fearing mistakes or patient harm. Students value hands-on tasks such as wound care, medication administration, and vital sign assessment that build practical competence. Participants noted challenges in applying theoretical knowledge to clinical scenarios, particularly when procedures differed from textbook descriptions. Quote: " My first day in the surgical ward was overwhelming, I feared making mistakes, but after practicing IV insertions multiple times under supervision, my confidence grew significantly. The gap between what we learn in class and what happens in hospitals is sometimes confusing ." (Participant 7, Female, 22 years) Facilitators of CL Experience Three primary facilitators emerged as crucial to positive learning experiences. Clear guidance, constructive feedback, and clinical proficiency of instructors enhanced learning outcomes. Supportive nurses who actively involved students in patient care improved engagement and skill acquisition. Collaborative learning among student colleagues created psychological safety and provided mutual assistance during challenging tasks. Quote: " When the ward nurse explained the rationale behind monitoring post-operative vital signs and invited me to participate, I felt prepared to handle similar cases independently. Our clinical instructor's detailed feedback after procedures helped correct my techniques ." (Participant 12, Male, 21 years) Barriers to CL Experience Students identified significant obstacles that hindered optimal learning. Limited equipment such as glucometers, sterile gloves, and blood pressure cuffs restricted skill practice and prolonged simple procedures. Several participants reported being tasked with non-educational duties such as cleaning, paperwork, and transporting samples, which diminished learning opportunities. High student-to-patient ratios resulted in competition for learning opportunities and reduced hands-on practice. Political instability and checkpoint delays occasionally prevented timely arrival at clinical sites, shortening learning time. Quote: " We often spend valuable learning time searching for working thermometers or syringes, it wastes time we could spend learning actual nursing care. Sometimes, staff use us for errands instead of teaching us procedures, and checkpoint closures mean we lose clinical days or arrive late. " (Participant 3, Female, 20 years) Strategies for Improvement Students proposed realistic solutions to enhance clinical learning. Participants advocated for longer rotations to master skills and develop continuity in patient care. Rotating across various wards and hospitals was suggested to broaden exposure to different specialties and patient populations. Enhanced pre-clinical simulation was recommended to practice skills before patient encounters. Formalized preceptorship programs with dedicated staff nurses were suggested to improve guidance and feedback. Quote: " Training in neonatal and ICU wards would help us adapt to different specialties. Adding more simulation sessions before clinical rotations would make us more confident. I wish we had dedicated mentors at each hospital rather than sharing one instructor among ten students ." (Participant 9, Female, 21 years) Discussion This mixed-methods study illuminates the critical interplay between clinical learning environments (CLEs) and clinical learning (CL) experiences among nursing students in West Bank universities. Our findings align with global evidence underscoring the centrality of CLEs in shaping clinical education outcomes [ 26 , 27 ], yet they uniquely highlight how systemic challenges in conflict-affected regions amplify barriers to effective learning. Below, we contextualize key results, discuss implications, and propose actionable strategies. Pedagogical Atmosphere and Supervisory Relationships as Pillars of CL Experience The strong predictive power of "pedagogical atmosphere" (β = 0.365) and "supervisory relationships" (β = 0.264) resonates with studies emphasizing mentorship and supportive learning climates as determinants of clinical competence [ 28 , 29 ]. In Palestine, where resource limitations and political instability strain educational systems, a positive pedagogical atmosphere, characterized by accessible instructors, structured feedback, and psychological safety—may compensate for material deficits. For instance, students in governmental hospitals, despite overcrowding, reported higher CL experiences (M = 3.92) than those in private facilities (M = 3.59), likely due to established supervisory protocols and collaborative staff-student dynamics. Qualitative narratives reinforced this, with participants praising instructors who "bridged theory and practice" through hands-on guidance. This finding aligns with research by Gurková and Žiaková [ 30 ], who found that effective clinical teachers in resource-constrained environments serve as both skill demonstrators and emotional supports. Our results suggest that investing in faculty development programs focused on clinical teaching pedagogy may yield substantial benefits even when material resources remain limited. Effect sizes (η² = 0.023 for training sites, η² = 0.049 for wards) indicate that while these contextual factors influence learning experiences, their impact is relatively modest. This further emphasizes the importance of human factors, particularly supervision quality and pedagogical approaches, in shaping clinical education effectiveness. Contextual Barriers: Resource Shortages and Geopolitical Realities The stark contrast between CL experiences in orthopedic wards (M = 4.92) and pediatric wards (M = 2.97) underscores the impact of resource availability and specialization on learning outcomes. Pediatric wards, often understaffed and overburdened in Palestinian hospitals, limited students' procedural opportunities, mirroring challenges reported in other resource-constrained settings [ 31 , 32 ]. Students' frustrations with "searching for working thermometers" exemplify how equipment shortages directly affect skill acquisition and time management. Qualitative findings revealed that movement restrictions and checkpoint delays occasionally prevented timely arrival at clinical sites, reducing effective learning time. This geopolitical dimension distinguishes Palestinian nursing education from many other resource-limited contexts. According to the United Nations Office for the Coordination of Humanitarian Affairs [ 8 ], West Bank checkpoints increased by 32% between 2021–2023, with an average of 593 obstacles to movement recorded in December 2023. These restrictions uniquely affect nursing education by creating unpredictable schedules and complicating rotation planning. Resource limitations are further compounded by importation challenges. While our study did not directly measure medical supply imports, participants' narratives of equipment shortages align with documented restrictions on dual-use items (materials that could potentially have military applications) that affect healthcare systems in occupied Palestinian territories [ 33 ]. These systemic constraints necessitate innovative educational approaches that maximize learning within existing resources. The Role of Governmental Training Sites: A Double-Edged Sword While governmental hospitals outperformed private sites in CL experiences (M = 3.92 vs. M = 3.59, p = 0.032), this advantage is tempered by structural challenges. Participants noted that governmental sites, though better resourced, faced overcrowding (75.8% of students trained there), reducing one-on-one mentorship opportunities. This paradox mirrors findings from studies in Egypt and Jordan [ 34 , 35 ], where high patient volumes in public hospitals compromise individualized learning despite offering diverse clinical exposures. The preference for governmental training sites, despite their limitations, reflects students' prioritization of clinical diversity and learning opportunities over physical comfort or resources. This suggests that educational partnerships between universities and governmental hospitals should focus on optimizing student distribution, strengthening preceptorship programs, and creating dedicated teaching spaces within busy clinical areas. Notably, UNRWA facilities received the highest ratings (M = 4.12), though the small sample size (n = 4) limits generalizability. These facilities may offer instructive models combining standardized procedures with intensive supervision that could inform improvements at larger institutions. Toward Adaptive Strategies: Lessons from Student Narratives Students' calls for "more clinical days" and "diverse training sites" align with global recommendations for competency-based education [ 36 , 37 ]. Rotations across specialties (e.g., neonatal, ICU) could mitigate the limitations of pediatric wards while fostering adaptability in various healthcare contexts. Our findings support curriculum revisions that increase clinical hours while ensuring quality through structured activities and clear learning objectives. Additionally, integrating simulation-based training, currently scarce in Palestinian nursing programs, could address procedural gaps caused by equipment shortages. Evidence from comparable settings suggests that even low-fidelity simulation improves student confidence and reduces anxiety before patient encounters [ 38 ]. Universities could develop cost-effective simulation laboratories using locally available materials and peer-teaching models to maximize limited resources. The exploitation of students for non-educational tasks emerged as a significant barrier requiring institutional intervention. Clear delineation of student roles through formal agreements between universities and healthcare facilities could protect educational integrity while acknowledging students' contributions to workforce capacity. This approach has proven effective in other limited-resource settings where students often fill workforce gaps [ 39 ]. Limitations This study has several limitations. First, convenience sampling may limit generalizability, particularly for governmental universities which were underrepresented (5.6% of participants). Second, self-report bias could influence CLE/CL experience scores, though anonymity in data collection mitigated this risk. Third, the cross-sectional design precludes causal inferences about the relationship between CLE factors and learning outcomes. Fourth, data collection during a single academic semester may not capture seasonal variations in clinical experiences. Finally, while our sample included students from diverse settings, the perspective of clinical instructors and staff nurses would provide valuable complementary insights. Despite these limitations, the mixed-methods approach and substantial sample size (N = 306) enhance the robustness of our findings, offering valuable insights into clinical education within conflict-affected settings. Conclusion This study provides empirical evidence that despite systemic challenges in conflict-affected Palestine, positive pedagogical environments and effective supervision significantly enhance nursing students' clinical learning experiences. The strong correlation between clinical learning environment (CLE) factors and clinical learning (CL) experiences (r = 0.758, p < 0.001), with pedagogical atmosphere and supervisory relationships emerging as significant predictors, underscores the critical importance of human factors in clinical education. While resource limitations, overcrowding, and movement restrictions present substantial barriers, students demonstrated remarkable resilience in navigating these challenges. Our findings suggest that targeted interventions in three key areas could strengthen nursing education in this context: first, faculty development through structured training programs for clinical instructors focused on effective teaching methodologies, feedback provision, and supportive learning environments; second, resource optimization by implementing strategic scheduling to reduce overcrowding, developing low-cost simulation alternatives, and establishing inter-institutional equipment loan programs; and third, policy reform through formal agreements between universities and healthcare facilities that define student roles, safeguard educational integrity, and promote structured mentorship programs. Future research should longitudinally examine how CLE factors influence graduate performance and explore innovative educational models that leverage technology and community partnerships to address resource constraints. Moreover, incorporating perspectives from clinical instructors, staff nurses, and patients would provide a more comprehensive understanding of clinical education dynamics in conflict-affected regions. The resilience of Palestinian nursing students, who pursue professional education despite systemic adversity, highlights the potential for educational innovation in such contexts. By strengthening pedagogical environments and supervisory relationships, nursing education in Palestine can continue to cultivate competent practitioners equipped to meet their communities' complex healthcare needs. Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Arab American University–Palestine Institutional Review Board (IRB Approval No: AAUP/IRB/2023-012). Formal permission to access students and clinical sites was received from the presidencies and nursing school deans of all participating universities. All participants received written informed consent forms explaining the study purpose, procedures, and confidentiality measures. Participation was entirely voluntary. Students were informed they could withdraw at any point without any academic consequences. Data were collected anonymously and securely stored, with all ethical standards followed in accordance with the Declaration of Helsinki. Consent for Publication All authors affirm that the content of this manuscript is original and has not been published or submitted elsewhere, except as disclosed in the text. Conflict of Interest The authors declare no conflict of interest related to the content of this study. Funding No specific funding was received for this research from public, commercial, or not-for-profit funding agencies. Data availability statement Not applicable. This manuscript does not report the generation or analysis of new datasets beyond those described. Author Contributions N.B. developed the study concept, assisted with data collection, and contributed to writing the initial manuscript draft. H.A.-M. participated in instrument selection, helped with literature review, and contributed to critical manuscript revisions. M.D. supported qualitative data analysis and helped interpret findings in context. M.S. contributed to data collection coordination and reviewed manuscript drafts. I.A. (corresponding author) led the research design, coordinated IRB and university approvals, supervised all phases of the study, analyzed results, and finalized manuscript writing. All authors read and approved the final version. They take responsibility for the accuracy and integrity of the work. Clinical Trial Number Not applicable. References Arkan B, Ordin Y, Yılmaz D. Undergraduate nursing students' experience related to their clinical learning environment and factors affecting to their clinical learning process. Nurse Educ Pract. 2018;29:127-32. Benti B, Gemeda A. Nursing students' perception towards clinical learning environment and supervision in Ethiopia: A comparative cross-sectional study. BMC Nurs. 2022;21(1):1-9. Alshammari MH, Pacheco HA, Dousti B. Clinical learning environment and the influential factors from nursing students' perspective. Open Nurs J. 2020;14(1):254-64. Amoo SA, Enyan NIE. Factors influencing nursing students' clinical learning experience in selected nursing institutions in Ghana. Healthcare. 2022;10(3):548. Warne T, Johansson UB, Papastavrou E, Tichelaar E, Tomietto M, Van den Bossche K, et al. An exploration of the clinical learning experience of nursing students in nine European countries. Nurse Educ Today. 2010;30(8):809-15. Papastavrou E, Dimitriadou M, Tsangari H, Andreou C. Nursing students' satisfaction of the clinical learning environment: A research study. BMC Nurs. 2016;15(1):44. Neupane HC, Manandhar N, Hada A. Perception of nursing students on clinical practice assessment at RAHS in Nepal. J Nepal Med Assoc. 2018;56(213):782-6. United Nations Office for the Coordination of Humanitarian Affairs. West Bank access restrictions [Report]. Jerusalem: OCHA; 2023. Zhang Y, Huang X, Xu S, Chen K, Zhao D, Wang Z. Chinese nursing students' perceptions of the clinical learning environment and influential factors: A qualitative study. Nurse Educ Today. 2022;110:105269. Palestinian Ministry of Health and Higher Education. Palestinian higher education statistics: Annual Report. Ramallah, Palestine; 2023. Jamshidi N, Molazem Z, Sharif F, Torabizadeh C, Najafi Kalyani M. The challenges of nursing students in the clinical learning environment: A qualitative study. Sci World J. 2016;2016:1846178. Baraz S, Memarian R, Vanaki Z. Learning challenges of nursing students in clinical environments: A qualitative study in Iran. J Educ Health Promot. 2015;4:52. Dunn SV, Burnett P. The development of a clinical learning environment scale. J Adv Nurs. 1995;22(6):1166-73. Creswell JW, Poth CN. Qualitative inquiry and research design: Choosing among five approaches. 4th ed. SAGE Publications; 2016. Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59-82. Saarikoski M, Isoaho H, Warne T, Leino-Kilpi H. The nurse teacher in clinical practice: Developing the new sub-dimension to the clinical learning environment and supervision (CLES) scale. Int J Nurs Stud. 2008;45(8):1233-7. Al-Hamdan Z, Banerjee T, Manojlovich M. Communication with nurses: Patients' perception. BMC Nurs. 2020;19:50. Al-Hussami M, Saleh MYN, Darawad M, Alramly M. Evaluating the effectiveness of a clinical preceptorship program for registered nurses in Jordan. J Contin Educ Nurs. 2013;44(2):86-94. Fares S, Clinton M, Younan L, El Samad S, Jardali F. Staff satisfaction in Lebanese academic medical centers and association with cultural and structural attributes. BMC Health Serv Res. 2016;16:558. Al-Kandari F, Ajao E. Evaluating the clinical learning environment in Kuwait: validating the CLES+T instrument. BMC Med Educ. 2021;21:398. Al-Rawajfah OM, Hweidi IM, Gharaibeh BA, Al-Ma'aitah R, Al-Muhtaseb MH. Clinical learning environment and nursing students' satisfaction: factor analysis. Nurs Forum. 2022;57(6):1093-100. World Health Organization. Process of translation and adaptation of instruments. Geneva: WHO; 2018. IBM Corp. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp; 2017. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107-15. QSR International. NVivo qualitative data analysis software, Version 12. Melbourne, Australia: QSR International Pty Ltd; 2018. Flott EA, Linden L. The clinical learning environment in nursing education: A concept analysis. J Adv Nurs. 2016;72(3):501-13. Mikkonen K, Kyngäs H, Kääriäinen M. Nursing students' experiences of the empathy of their teachers: A qualitative study. Adv Health Sci Educ. 2020;25(1):657-71. Strandell-Laine C, Saarikoski M, Loyttyniemi E, Meretoja R, Leino-Kilpi H. The clinical learning environment and supervision model for nursing students during final clinical practicum: A comparison between hospital and primary healthcare settings. Nurse Educ Today. 2022;119:105574. Kamphinda S, Chilemba EB. Clinical supervision and support: Perspectives of undergraduate nursing students on their clinical learning environment in Malawi. Curationis. 2019;42(1). Gurková E, Žiaková K. Evaluation of the clinical learning environment in Slovakia using the CLES+T scale. Cent Eur J Nurs Midwifery. 2018;9(3):855-64. Mbakaya BC, Kalembo FW, Zgambo M, Konyani A, Lungu F, Tveit B, et al. Nursing and midwifery students' experiences and perception of their clinical learning environment in Malawi: A mixed-method study. BMC Nurs. 2020;19(1):87. Drateru KC. Challenges experienced by student nurses during skill acquisition at the clinical area. Nurs Open. 2019;6(3):1219-27. World Health Organization. Right to health in the occupied Palestinian territory: Report 2021. WHO Regional Office for the Eastern Mediterranean; 2022. Rashwan ZI, El-Aal NA, Elhosiny I. Perception of nursing students toward clinical learning environment in Egypt. Nurs Open. 2022;9(1):472-9. Bakhshialiabad H, Bakhshi M, Hassanshahi G. Students' perceptions of the academic learning environment in seven medical sciences courses based on DREEM. Adv Med Educ Pract. 2019;10:339-45. Lawal J, Weaver S, Bryan V, Lindo JL. Factors that influence the clinical learning experience of nursing students at a Caribbean school of nursing. J Nurs Educ Pract. 2019;10(1):1-11. Panda S, Garg S, Wolf K. Reconceptualizing engagement in nursing education in technical and further education: A practice theory perspective. J Vocat Educ Train. 2021;73(3):289-309. Prescott-Carter K, Onuoha PC. Nursing students' experiences using high-fidelity simulation for the first time. Faculty and Staff Publications, Paper 212; 2016. O'Mara L, McDonald J, Gillespie M, Brown H, Miles L. Challenging clinical learning environments: Experiences of undergraduate nursing students. Nurse Educ Pract. 2014;14(2):208-13. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6651999","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464905753,"identity":"61940949-277b-43ff-b8dc-f2ebaac2f667","order_by":0,"name":"Nihad Bsharat","email":"","orcid":"","institution":"Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education","correspondingAuthor":false,"prefix":"","firstName":"Nihad","middleName":"","lastName":"Bsharat","suffix":""},{"id":464905754,"identity":"cb6b7807-102e-4a73-b4be-f51c3087bcc2","order_by":1,"name":"Ibrahim Aqtam","email":"data:image/png;base64,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","orcid":"","institution":"Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education","correspondingAuthor":true,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Aqtam","suffix":""},{"id":464905756,"identity":"3fc67b03-3d74-46ba-9cdd-6fd5f093bb93","order_by":2,"name":"Hanan Al-Modallal","email":"","orcid":"","institution":"The Hashemite University, Faculty of Nursing, Department of Community and Mental Health Nursing","correspondingAuthor":false,"prefix":"","firstName":"Hanan","middleName":"","lastName":"Al-Modallal","suffix":""},{"id":464905758,"identity":"78b8abf5-20ae-4a34-9fff-c5c7120715d2","order_by":3,"name":"Mutaz Dreidi","email":"","orcid":"","institution":"Birzeit University, Department of Nursing, Faculty of Pharmacy, Nursing and Health Professions","correspondingAuthor":false,"prefix":"","firstName":"Mutaz","middleName":"","lastName":"Dreidi","suffix":""},{"id":464905760,"identity":"79158bc2-5421-4f65-a46f-0cdc33872278","order_by":4,"name":"Mustafa Shouli","email":"","orcid":"","institution":"Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education","correspondingAuthor":false,"prefix":"","firstName":"Mustafa","middleName":"","lastName":"Shouli","suffix":""}],"badges":[],"createdAt":"2025-05-13 06:23:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6651999/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6651999/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84676920,"identity":"f700dc1a-61d6-4c8c-991e-3fa31c5effa7","added_by":"auto","created_at":"2025-06-16 07:47:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1470380,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6651999/v1/6fb90daa-f52f-424f-98c8-0be3b0632c96.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Learning Environments and Experiences of Nursing Students in West Bank Universities: A Mixed-Methods Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClinical learning environments (CLEs) serve as the cornerstone of nursing education, bridging theoretical knowledge with real-world practice. Globally, CLEs are recognized for their role in shaping students' clinical competencies, professional socialization, and readiness to deliver patient-centered care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Key elements such as pedagogical atmosphere, supervisory relationships, and resource availability directly influence students' clinical learning (CL) experiences, impacting their confidence, skill acquisition, and career decisions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, in conflict-affected regions like the West Bank, Palestine, systemic challenges, including political instability, resource shortages, and fragmented healthcare infrastructure, create unique barriers to effective clinical education [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile research on clinical learning environments has expanded in high-income and stable contexts, there remains a significant gap in understanding how these environments function in regions affected by protracted conflict. Particularly understudied is how geopolitical constraints intersect with educational factors to shape nursing students' development of clinical competencies. This gap limits our ability to develop contextually appropriate interventions that could strengthen nursing education in these challenging settings.\u003c/p\u003e \u003cp\u003eIn Palestine, nursing education faces compounded challenges. The Israeli occupation imposes movement restrictions, with checkpoints and roadblocks frequently delaying students' access to clinical sites [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Recent data from the United Nations Office for the Coordination of Humanitarian Affairs, documents a 32% increase in West Bank checkpoints between 2021\u0026ndash;2023, with daily fluctuations in accessibility creating unpredictable schedules for educational planning [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Overcrowded classrooms and hospitals, coupled with a shortage of simulation equipment, exacerbate the theory-practice gap [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. According to the Palestinian Ministry of Health and Higher Education Annual Report, 8,156 nursing students were enrolled across 14 institutions in 2023, reflecting a 4.1% increase from the previous year, yet clinical training sites struggle to accommodate this growing demand, often resulting in inadequate hands-on practice opportunities [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Studies in comparable low-resource settings highlight how such conditions diminish students' engagement, amplify stress, and reduce clinical performance [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, few studies have explored how these systemic and contextual factors interact with CLE dynamics in Palestine, where cultural norms, geopolitical tensions, and economic constraints further complicate clinical education.\u003c/p\u003e \u003cp\u003eThis mixed-methods study addresses three critical gaps in the literature. First, it examines the relative influence of different CLE factors on clinical learning experiences in a conflict-affected context, which may differ substantially from patterns observed in stable settings. Second, it explores the specific mechanisms through which conflict-related barriers impact nursing education, an area largely overlooked in previous research. Third, it investigates how students and educators develop adaptive strategies to navigate these challenges, potentially informing resilience-building approaches in similar contexts globally.\u003c/p\u003e \u003cp\u003eGrounded in Dunn and Burnett's (1995) organizational and educational theory [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], which views learning environments as shaped by structural, interpersonal, and pedagogical forces, the study aims to: 1) identify key CLE factors influencing CL experiences in Palestinian contexts; 2) explore students' perceptions of facilitators and barriers to effective clinical learning; and 3) propose context-specific recommendations to strengthen nursing education in conflict-affected settings. The findings have significant implications for nursing education policy, curriculum design, and faculty development in Palestine and other regions experiencing similar constraints. By identifying malleable factors that support effective clinical learning despite structural challenges, this research can inform targeted interventions that maximize educational outcomes within existing resource limitations.\u003c/p\u003e \u003cp\u003eBy integrating quantitative assessments of CLE variables with qualitative narratives of student experiences, the study provides a detailed understanding of clinical education challenges in Palestine, addressing a significant gap in our knowledge of how nursing education functions under conditions of protracted conflict. This knowledge is essential not only for enhancing educational quality but also for strengthening healthcare workforce development in regions where health systems face multiple, intersecting pressures.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eA mixed-methods convergent design [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] was employed by integrating a quantitative component, which involved a cross-sectional survey of 306 undergraduate nursing students from three West Bank universities representing governmental, public, and private sectors, and a qualitative component, which consisted of phenomenological interviews with 14 purposively selected fourth-year students to explore their lived clinical learning experiences. Data collection occurred between September and December 2023 across clinical training sites, including governmental hospitals, private clinics, and United Nations Relief and Works Agency for Palestine Refugees (UNRWA) facilities.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Sampling\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSampling Strategy and Power Analysis\u003c/h2\u003e \u003cp\u003eThe study employed two distinct sampling approaches. For the quantitative component, a stratified convenience sampling method was used where each university type (governmental, public, private) constituted a stratum. Based on official enrollment data from the Palestinian Ministry of Higher Education [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], participants were recruited proportionally to reflect the distribution of nursing students across sectors: governmental (6%), public (35%), and private (59%).\u003c/p\u003e \u003cp\u003eSample size was determined through a priori power analysis using G*Power 3.1 software. For multiple regression analysis with five predictors (CLE dimensions), assuming a medium effect size (f\u0026sup2;=0.15), alpha level of 0.05, and desired power of 0.95, a minimum sample of 138 participants was required. For ANOVA analyses comparing three groups (university types), detecting a medium effect size (f\u0026thinsp;=\u0026thinsp;0.25) with alpha of 0.05 and power of 0.90 required a minimum of 207 participants. The final sample size of 306 exceeded these requirements, ensuring adequate statistical power while accounting for potential incomplete responses.\u003c/p\u003e \u003cp\u003eInclusion criteria were: (1) second- to fourth-year nursing students, (2) completion of at least one clinical rotation, and (3) current enrollment in clinical courses. First-year students were excluded because they lacked clinical exposure in the Palestinian nursing curriculum, which introduces clinical rotations only from the second year. Part-time or upgrading students (those transitioning from diploma to bachelor's degree) were also excluded due to their different clinical experiences and typically abbreviated clinical requirements.\u003c/p\u003e \u003cp\u003eFor the qualitative component, purposive sampling targeted fourth-year students from all three university types to capture rich, contextually diverse narratives from those with the most extensive clinical experience. Data saturation, determined by the absence of new themes or codes in three consecutive interviews, guided the final sample size of 14 participants [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eInstruments\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eClinical Learning Environment, Supervision, and Nurse Teacher (CLES\u0026thinsp;+\u0026thinsp;T) Scale\u003c/b\u003e Developed by Saarikoski et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], is a 34-item validated tool that assesses five dimensions of the clinical learning environment: pedagogical atmosphere, leadership style of the ward manager, premises of care, supervisory relationship, and the role of the nurse teacher. Items are rated on a 5-point Likert scale from 1 (\"fully disagree\") to 5 (\"fully agree\"). This tool has been translated into Arabic and validated in multiple Arab countries. In a study in Saudi Arabia, the Arabic version showed strong internal consistency with Cronbach's alpha coefficients above 0.90 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Another study in Jordan confirmed the tool's reliability and factor structure, with an alpha value of 0.95 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. A Lebanese study also supported the instrument's construct validity and high internal consistency (α\u0026thinsp;=\u0026thinsp;0.93) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These findings confirm the CLES\u0026thinsp;+\u0026thinsp;T's appropriateness for Arabic-speaking nursing students. In the current study, it demonstrated excellent internal consistency (Cronbach's α\u0026thinsp;=\u0026thinsp;0.984), consistent with previous Arabic validations.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eClinical Learning Experience Questionnaire\u003c/b\u003e: Developed by Alshammari et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], is a 20-item tool designed to measure factors influencing clinical learning experiences, grouped into environmental, student, interpersonal, and teaching-learning domains. Each item is rated on a 5-point Likert scale. Alshammari and colleagues originally validated this instrument among Saudi nursing students, reporting a Cronbach's alpha of 0.94. Further studies in Kuwait and Oman found comparable reliability (α\u0026thinsp;\u0026gt;\u0026thinsp;0.90) and confirmed the questionnaire's applicability in different Arabic contexts [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In this study, the Arabic version maintained strong reliability (Cronbach's α\u0026thinsp;=\u0026thinsp;0.976), aligning with previous research outcomes.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDemographic Questionnaire\u003c/b\u003e: Collected data on age, gender, academic year, university type, residence, training site, and clinical ward placement.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInstrument Translation Process\u003c/h3\u003e\n\u003cp\u003eBoth instruments were translated from English to Arabic using a rigorous forward-backward translation method following WHO guidelines [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]; the translation process consisted of five stages: first, forward translation was conducted by two independent bilingual translators, both native Arabic speakers with advanced English proficiency, one familiar with nursing education terminology and the other a certified language professional unfamiliar with healthcare terminology to ensure conceptual and linguistic equivalence; second, reconciliation was done by a third bilingual expert who compared both translations, reconciled discrepancies, and produced a preliminary Arabic version with special attention to cultural adaptability of terminology, such as translating \"ward\" as \"قسم\" rather than \"جناح\" to match local healthcare language; third, back-translation was carried out by two different bilingual translators, both native English speakers proficient in Arabic, who independently back-translated the reconciled Arabic version into English without access to the original instruments; fourth, an expert committee review was completed by a panel of five experts, including two nursing educators, one clinical instructor, one linguist, and one nursing student, who evaluated semantic, idiomatic, experiential, and conceptual equivalence between original and back-translated versions, resolving discrepancies through consensus, with the committee's Content Validity Index reaching 0.92 for the CLES\u0026thinsp;+\u0026thinsp;T and 0.89 for the Clinical Learning Experience Questionnaire; fifth, pilot testing was conducted with 20 nursing students, excluded from the final sample, who provided feedback on clarity, comprehensibility, and cultural appropriateness, leading to minor adjustments such as refining \"nurse teacher\" to \"المدرس السريري\" [clinical instructor] to reflect local educational roles; the final Arabic instruments demonstrated excellent reliability, with Cronbach's alpha values of 0.984 and 0.976 for the CLES\u0026thinsp;+\u0026thinsp;T and Clinical Learning Experience Questionnaire, respectively, indicating strong internal consistency comparable to the original English versions.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Data Collection\u003c/h2\u003e \u003cp\u003ePaper-based questionnaires were administered in person by the research team during scheduled sessions at each university. Sessions were arranged in coordination with nursing departments to avoid conflict with academic activities. Questionnaire packets containing the demographic questionnaire, translated CLES\u0026thinsp;+\u0026thinsp;T scale, and Clinical Learning Experience Questionnaire were distributed to eligible students in classroom settings. Trained research assistants provided standardized instructions on completing the questionnaires and remained present throughout to answer questions without influencing responses. Students completed the paper questionnaires independently over 20\u0026ndash;30 minutes. Completed questionnaires were collected in sealed envelopes to ensure confidentiality and transported to a secure location for data entry by two independent research assistants using double-entry verification to minimize errors. The response rate was 91.1% (306 completed questionnaires from 336 distributed). Incomplete questionnaires (n\u0026thinsp;=\u0026thinsp;11) and those from ineligible participants (n\u0026thinsp;=\u0026thinsp;19) were excluded from analysis. Data quality was ensured through systematic checking for missing values, outliers, and logical inconsistencies before analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Data Collection\u003c/h3\u003e\n\u003cp\u003eSemi-structured interviews (20\u0026ndash;30 minutes) were conducted in Arabic by the first author in private rooms at each university to ensure confidentiality and comfort. An interview guide developed based on literature review and expert consultation explored daily clinical experiences, facilitators, barriers, and improvement strategies. Questions were refined after the first two interviews to enhance clarity and depth. Interviews were audio-recorded with permission and transcribed verbatim by two independent researchers within 48 hours of completion. Transcripts were compared for accuracy and verified against audio recordings before analysis. Member checking was implemented by sharing transcript summaries with participants to verify accurate representation of their experiences.\u003c/p\u003e\n\u003ch3\u003eAddressing Power Dynamics\u003c/h3\u003e\n\u003cp\u003eTo minimize potential power dynamics between researchers and student participants, several measures were implemented. First, researchers not directly involved in teaching or evaluating the students conducted the interviews and survey administration. Second, participants were explicitly informed that their participation (or non-participation) would have no impact on their academic standing. Third, a clear separation was maintained between the research team and faculty who might evaluate students' academic performance. Finally, all study information emphasized the confidential nature of data collection and reporting.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInstrument Validity and Reliability\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eValidity Assessment\u003c/h2\u003e \u003cp\u003eThe Arabic versions of both instruments underwent rigorous content validity assessment by a panel of experts, including three nursing faculty members, two clinical instructors, and one measurement specialist; each item was evaluated for relevance, clarity, simplicity, and ambiguity using a 4-point scale, and the content validity index was calculated at both item level and scale level, with all items achieving item-level CVI values above 0.80 and the scale-level CVI reaching 0.92 for CLES\u0026thinsp;+\u0026thinsp;T and 0.89 for the Clinical Learning Experience Questionnaire, exceeding the recommended threshold of 0.80 for acceptable content validity; for construct validity, exploratory factor analysis with principal component extraction and varimax rotation was conducted on data from the pilot sample of 20 students to examine the factor structure of the translated instruments, with the Kaiser-Meyer-Olkin measure showing 0.87 for CLES\u0026thinsp;+\u0026thinsp;T and 0.83 for the Clinical Learning Experience Questionnaire and Bartlett's Test of Sphericity yielding p-values less than 0.001 for both scales, confirming sampling adequacy and suitability for factor analysis; factor loadings ranged from 0.62 to 0.89, with all items loading predominantly on their theoretical dimensions, and the five-factor structure of CLES\u0026thinsp;+\u0026thinsp;T explained 72.6 percent of total variance, while the four-factor structure of the Clinical Learning Experience Questionnaire explained 68.9 percent, supporting the construct validity of both translated instruments.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eReliability Assessment\u003c/h2\u003e \u003cp\u003eCronbach's alpha coefficients were calculated for the overall scales and subscales, with the Arabic CLES\u0026thinsp;+\u0026thinsp;T demonstrating excellent internal consistency at 0.984 and subscale coefficients ranging from 0.927 for Premises of Care to 0.966 for Supervisory Relationship; similarly, the Clinical Learning Experience Questionnaire showed high reliability at 0.976 with subscale coefficients ranging from 0.941 for Interpersonal to 0.957 for Environment; test-retest reliability was assessed by having a subset of 30 participants complete the questionnaires twice, two weeks apart, with intraclass correlation coefficients showing strong temporal stability at 0.91 for CLES\u0026thinsp;+\u0026thinsp;T with a 95 percent confidence interval of 0.86 to 0.94 and 0.88 for the Clinical Learning Experience Questionnaire with a 95 percent confidence interval of 0.82 to 0.92; inter-rater reliability for qualitative interview analysis was established with two independent coders analyzing 30 percent of transcripts and achieving a Cohen's kappa coefficient of 0.87, indicating strong agreement in the coding process.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eQuantitative Analysis\u003c/h2\u003e \u003cp\u003eIBM SPSS Statistics v25.0 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] was used for data analysis. Prior to conducting primary analyses, data were rigorously screened for violations of statistical assumptions. Normality was assessed using both graphical methods (Q-Q plots, histograms) and statistical tests (Shapiro-Wilk), revealing normal distribution for all main variables (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Homogeneity of variance was confirmed using Levene's test for all ANOVA analyses (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). For regression analyses, linearity was assessed through scatterplots of standardized residuals against predicted values, showing no curvilinear patterns. Homoscedasticity was confirmed through residual plots revealing relatively even distribution around zero. Multicollinearity diagnostics showed variance inflation factors (VIF) ranging from 3.23 to 3.95 for all predictors, below the problematic threshold of 5.0. Independence of errors was verified using the Durbin-Watson statistic (1.96), confirming no autocorrelation.\u003c/p\u003e \u003cp\u003eMissing data were minimal (\u0026lt;\u0026thinsp;3%) and handled using multiple imputation with five iterations based on predictive mean matching to maintain the distributional characteristics of variables. This approach was chosen over listwise deletion to preserve statistical power and reduce potential bias.\u003c/p\u003e \u003cp\u003eDescriptive statistics (frequencies, means, standard deviations) characterized the sample and primary variables. Pearson correlations examine relationships between CLE dimensions and CL experiences. Differences across groups were analyzed using one-way ANOVA with Tukey's HSD post-hoc tests. Hierarchical multiple linear regression was conducted to determine predictors of CL experiences, entering variables in theoretically meaningful blocks: Block 1 included demographic variables (gender, academic year); Block 2 added contextual variables (university type, training site); and Block 3 added the five CLE dimensions. This approach allowed examination of incremental variance explained by each variable set. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all analyses, and effect sizes were reported using Cohen's guidelines (small: 0.01, medium: 0.06, large: 0.14) to assess practical significance beyond statistical significance.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Analysis\u003c/h2\u003e \u003cp\u003eInductive content analysis [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] was used to identify themes, categories, and codes, with transcripts manually coded by two independent researchers and disagreements resolved through discussion and consensus; the analysis followed three phases: preparation involved immersion in data through repeated reading of transcripts to gain contextual understanding, organizing included open coding, creating categories, and abstracting emergent patterns with initial codes organized into subcategories based on similarities and relationships, and reporting involved abstraction into major themes through constant comparison technique; NVivo 12 software was used to organize and manage the coded data, and an audit trail documented analytical decisions, notes, and category development throughout the process [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCOVID-19 Considerations\u003c/h2\u003e \u003cp\u003eAlthough data collection occurred in late 2023, when most COVID-19 protocols in educational settings had been relaxed, several pandemic-related considerations were addressed. First, the research protocol included contingency plans for shifting to virtual interviews if needed due to infection surges. Second, all in-person data collection adhered to institutional safety guidelines, including mask-wearing when required and maintaining appropriate physical distancing. Third, the interview guide included prompt questions about how prior COVID-19 disruptions might have influenced students' overall clinical learning experiences, though this was not a primary focus of the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRigor and Trustworthiness\u003c/h2\u003e \u003cp\u003eValidity and reliability were established through rigorous translation procedures, content validity assessment, factor analysis, and reliability testing as detailed above. Selection bias was minimized through stratified sampling and high response rates. Confounding variables were controlled through multivariate analysis. Pilot testing (n\u0026thinsp;=\u0026thinsp;20) confirmed instrument clarity, feasibility, and reliability prior to main data collection.\u003c/p\u003e \u003cp\u003eCredibility was ensured via member-checking (participants validated themes), methodological triangulation (comparing interview data with quantitative findings), and peer debriefing (research team meetings to discuss interpretations). Transferability was enhanced through thick description of context, participant characteristics, and data collection processes. Dependability was maintained via an audit trail of coding decisions and analytical procedures. Confirmability was strengthened through reflexive journaling by researchers, acknowledging potential biases and preconceptions that might influence interpretation.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical Approval and Consent\u003c/strong\u003e \u003cp\u003eEthical considerations were carefully addressed. Institutional Review Board (IRB) approval was obtained from the Arab American University-Palestine (AAUP) before conducting the study (AAUP/IRB/2023-012), along with approval letters from the presidencies of each participating university. Official correspondence was sent to the three universities to secure permission and provide the primary investigator access to student data. Meetings were held with the deans of the nursing schools to explain the purpose of the study and facilitate coordination. Registration departments and clinical training section heads provided the total numbers of second, third, and fourth-year nursing students training in the fall semester of 2023.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eWritten informed consent forms explaining the study purpose, voluntary participation, confidentiality measures, and right to withdraw were distributed to eligible students prior to data collection. Participants were given sufficient time to read, ask questions, and sign consent forms before participation. No personal identifiers were collected on questionnaires, ensuring anonymity and privacy. Completed questionnaires and interview recordings were stored in locked cabinets accessible only to the research team, while digital data were password-protected and encrypted on the researcher's personal computer.\u003c/p\u003e \u003cp\u003e The study was conducted in full compliance with the ethical principles outlined in the Declaration of Helsinki. All gathered data will be retained securely for three years after study completion and then destroyed according to university protocols for research data management.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Findings\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eDemographics\u003c/strong\u003e \u003cp\u003eOf 306 participants, 81.7% (n\u0026thinsp;=\u0026thinsp;250) were female and 18.3% (n\u0026thinsp;=\u0026thinsp;56) were male. The majority (93.4%, n\u0026thinsp;=\u0026thinsp;286) were aged 19\u0026ndash;22 years, with 5.6% (n\u0026thinsp;=\u0026thinsp;17) aged 23\u0026ndash;28 years, and 1.0% (n\u0026thinsp;=\u0026thinsp;3) aged 29 or above. Regarding residence, 60.8% (n\u0026thinsp;=\u0026thinsp;186) lived in villages, 31.4% (n\u0026thinsp;=\u0026thinsp;96) in cities, and 7.8% (n\u0026thinsp;=\u0026thinsp;24) in refugee camps.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAcademic Variables\u003c/b\u003e: Students were distributed across academic years: second year (36.9%, n\u0026thinsp;=\u0026thinsp;113), third year (35.0%, n\u0026thinsp;=\u0026thinsp;107), and fourth year (28.1%, n\u0026thinsp;=\u0026thinsp;86). University distribution included 61.1% (n\u0026thinsp;=\u0026thinsp;187) from private, 33.3% (n\u0026thinsp;=\u0026thinsp;102) from public, and 5.6% (n\u0026thinsp;=\u0026thinsp;17) from governmental institutions. Most students trained at governmental hospitals (75.8%, n\u0026thinsp;=\u0026thinsp;232), with others at private facilities (22.9%, n\u0026thinsp;=\u0026thinsp;70) or UNRWA clinics (1.3%, n\u0026thinsp;=\u0026thinsp;4). Primary training wards included medical (33.3%, n\u0026thinsp;=\u0026thinsp;102), surgical (31.4%, n\u0026thinsp;=\u0026thinsp;96), emergency (16.7%, n\u0026thinsp;=\u0026thinsp;51), intensive care (7.8%, n\u0026thinsp;=\u0026thinsp;24), pediatric (2.0%, n\u0026thinsp;=\u0026thinsp;6), orthopedic (1.6%, n\u0026thinsp;=\u0026thinsp;5), and other specialized units (7.2%, n\u0026thinsp;=\u0026thinsp;22) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Academic Characteristics of Participants (N\u0026thinsp;=\u0026thinsp;306)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (18.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e250 (81.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u0026ndash;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e286 (93.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u0026ndash;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e186 (60.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96 (31.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRefugee camp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcademic Year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2nd year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e113 (36.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3rd year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107 (35.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4th year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86 (28.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUniversity Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernmental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e187 (61.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining Site\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernmental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e232 (75.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70 (22.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUNRWA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining Ward\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96 (31.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrthopedic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote: UNRWA\u0026thinsp;=\u0026thinsp;United Nations Relief and Works Agency for Palestine Refugees; ICU\u0026thinsp;=\u0026thinsp;Intensive Care Unit\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eCLE and CL Experience Levels\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eCLE Variables\u003c/strong\u003e \u003cp\u003eThe \"nurse-teacher\" role scored highest (M\u0026thinsp;=\u0026thinsp;3.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19), while \"leadership style\" scored lowest (M\u0026thinsp;=\u0026thinsp;3.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). All subscales showed mean scores above the midpoint (3.0), indicating generally positive perceptions.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLevels of Clinical Learning Environment (CLE) Variables (N\u0026thinsp;=\u0026thinsp;306)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCLE Subscale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange (1\u0026ndash;5)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCronbach's α\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePedagogical Atmosphere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.2\u0026ndash;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.951\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeadership Style\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u0026ndash;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.942\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePremises of Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u0026ndash;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.927\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupervisory Relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u0026ndash;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.966\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse-Teacher Role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u0026ndash;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.958\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall CLE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.0\u0026ndash;5.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.984\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCL Experience\u003c/strong\u003e \u003cp\u003eThe \"student\" factor (e.g., confidence, motivation) had the highest mean (M\u0026thinsp;=\u0026thinsp;3.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08), whereas \"environment\" (e.g., resource availability) scored the lowest (M\u0026thinsp;=\u0026thinsp;3.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLevels of Clinical Learning (CL) Experience Variables (N\u0026thinsp;=\u0026thinsp;306)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCL Experience Factor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange (1\u0026ndash;5)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCronbach's α\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnvironment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u0026ndash;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.957\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u0026ndash;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.949\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterpersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u0026ndash;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeaching-Learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u0026ndash;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.953\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall CL Experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.0\u0026ndash;5.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.976\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eCorrelations\u003c/h2\u003e \u003cp\u003eA strong positive correlation existed between the overall CLE and CL experience (r\u0026thinsp;=\u0026thinsp;0.758, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among CLE subscales, \"pedagogical atmosphere\" showed the strongest association with CL experience (r\u0026thinsp;=\u0026thinsp;0.729, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), followed by \"supervisory relationship\" (r\u0026thinsp;=\u0026thinsp;0.701, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), \"premises of care\" (r\u0026thinsp;=\u0026thinsp;0.664, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), \"nurse-teacher role\" (r\u0026thinsp;=\u0026thinsp;0.650, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and \"leadership style\" (r\u0026thinsp;=\u0026thinsp;0.648, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations Between CLE Variables and CL Experience (N\u0026thinsp;=\u0026thinsp;306)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Overall CLE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Pedagogical Atmosphere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.941**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Leadership Style\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.916**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.830**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Premises of Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.915**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.813**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.828**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Supervisory Relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.929**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.839**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.831**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.827**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Nurse-Teacher Role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.901**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.826**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.737**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.776**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.787**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Overall CL Experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.758**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.729**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.648**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.664**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.701**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.650**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eNote: ** Correlation is significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 level (2-tailed)\u003c/h2\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eDifferences Across Variables\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eTraining Sites\u003c/strong\u003e \u003cp\u003eOne-way ANOVA revealed significant differences in CL experiences based on training sites (F[2,303]\u0026thinsp;=\u0026thinsp;3.49, p\u0026thinsp;=\u0026thinsp;0.032, η\u0026sup2;=0.023). Students at governmental sites reported higher CL experience (M\u0026thinsp;=\u0026thinsp;3.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91) than those at private sites (M\u0026thinsp;=\u0026thinsp;3.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06, p\u0026thinsp;=\u0026thinsp;0.032). UNRWA facilities scored highest (M\u0026thinsp;=\u0026thinsp;4.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36), though the small sample size (n\u0026thinsp;=\u0026thinsp;4) limits generalizability.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eWards\u003c/strong\u003e \u003cp\u003eSignificant differences in CL experiences emerged across training wards (F[6,299]\u0026thinsp;=\u0026thinsp;2.56, p\u0026thinsp;=\u0026thinsp;0.019, η\u0026sup2;=0.049). Orthopedic wards had the highest CL experience scores (M\u0026thinsp;=\u0026thinsp;4.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15), while pediatric wards scored lowest (M\u0026thinsp;=\u0026thinsp;2.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32). Medical (M\u0026thinsp;=\u0026thinsp;3.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95), surgical (M\u0026thinsp;=\u0026thinsp;3.84\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93), emergency (M\u0026thinsp;=\u0026thinsp;3.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82), and ICU wards (M\u0026thinsp;=\u0026thinsp;3.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12) displayed moderate scores (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifferences in CL Experience by Training Site and Ward (ANOVA) (N\u0026thinsp;=\u0026thinsp;306)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eη\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining Site\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernmental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2, 303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.032*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUNRWA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining Ward\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrthopedic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6, 299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.019*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.84\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eNote: * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; UNRWA\u0026thinsp;=\u0026thinsp;United Nations Relief and Works Agency for Palestine Refugees; ICU\u0026thinsp;=\u0026thinsp;Intensive Care Unit; η\u0026sup2; = eta squared (effect size), where 0.01\u0026thinsp;=\u0026thinsp;small, 0.06\u0026thinsp;=\u0026thinsp;medium, 0.14\u0026thinsp;=\u0026thinsp;large effect\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003ePredictors of CL Experience\u003c/h2\u003e \u003cp\u003eMultiple linear regression analysis identified \"pedagogical atmosphere\" (β\u0026thinsp;=\u0026thinsp;0.365, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and \"supervisory relationship\" (β\u0026thinsp;=\u0026thinsp;0.264, p\u0026thinsp;=\u0026thinsp;0.001) as significant predictors, explaining 59% of CL experience variance (R\u0026sup2;=0.59, F[5,300]\u0026thinsp;=\u0026thinsp;86.17, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). \"Leadership style,\" \"premises of care,\" and \"nurse-teacher role\" did not emerge as significant predictors when controlling for other variables (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePredictors of CL Experience (Multiple Linear Regression) (N\u0026thinsp;=\u0026thinsp;306)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnstandardized β\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandardized β\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVIF\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePedagogical Atmosphere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupervisory Relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeadership Style\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.510\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePremises of Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse-Teacher Role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.751\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel Summary\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eR\u0026sup2; = 0.59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAdj. R\u0026sup2; = 0.58\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eSEE\u0026thinsp;=\u0026thinsp;0.63\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eF\u0026thinsp;=\u0026thinsp;86.17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eNote: ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; VIF\u0026thinsp;=\u0026thinsp;Variance Inflation Factor; SEE\u0026thinsp;=\u0026thinsp;Standard Error of the Estimate\u003c/h2\u003e \u003cdiv id=\"Sec28\" class=\"Section4\"\u003e \u003ch2\u003eQualitative Findings\u003c/h2\u003e \u003cp\u003eFour themes emerged from interviews (n\u0026thinsp;=\u0026thinsp;14), each with subthemes that enriched understanding of students lived experiences:\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003ePerceptions of Clinical Experience\u003c/h2\u003e \u003cp\u003eStudents described multifaceted perceptions of their clinical experiences, with initial anxiety gradually transitioning to confidence through hands-on practice. Most participants reported anxiety during first exposures to clinical settings, fearing mistakes or patient harm. Students value hands-on tasks such as wound care, medication administration, and vital sign assessment that build practical competence. Participants noted challenges in applying theoretical knowledge to clinical scenarios, particularly when procedures differed from textbook descriptions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eQuote: \"\u003cem\u003eMy first day in the surgical ward was overwhelming, I feared making mistakes, but after practicing IV insertions multiple times under supervision, my confidence grew significantly. The gap between what we learn in class and what happens in hospitals is sometimes confusing\u003c/em\u003e.\" (Participant 7, Female, 22 years)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFacilitators of CL Experience\u003c/h3\u003e\n\u003cp\u003eThree primary facilitators emerged as crucial to positive learning experiences. Clear guidance, constructive feedback, and clinical proficiency of instructors enhanced learning outcomes. Supportive nurses who actively involved students in patient care improved engagement and skill acquisition. Collaborative learning among student colleagues created psychological safety and provided mutual assistance during challenging tasks.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eQuote: \"\u003cem\u003eWhen the ward nurse explained the rationale behind monitoring post-operative vital signs and invited me to participate, I felt prepared to handle similar cases independently. Our clinical instructor's detailed feedback after procedures helped correct my techniques\u003c/em\u003e.\" (Participant 12, Male, 21 years)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to CL Experience\u003c/h2\u003e \u003cp\u003eStudents identified significant obstacles that hindered optimal learning. Limited equipment such as glucometers, sterile gloves, and blood pressure cuffs restricted skill practice and prolonged simple procedures. Several participants reported being tasked with non-educational duties such as cleaning, paperwork, and transporting samples, which diminished learning opportunities. High student-to-patient ratios resulted in competition for learning opportunities and reduced hands-on practice. Political instability and checkpoint delays occasionally prevented timely arrival at clinical sites, shortening learning time.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eQuote: \"\u003cem\u003eWe often spend valuable learning time searching for working thermometers or syringes, it wastes time we could spend learning actual nursing care. Sometimes, staff use us for errands instead of teaching us procedures, and checkpoint closures mean we lose clinical days or arrive late.\u003c/em\u003e\" (Participant 3, Female, 20 years)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eStrategies for Improvement\u003c/h2\u003e \u003cp\u003eStudents proposed realistic solutions to enhance clinical learning. Participants advocated for longer rotations to master skills and develop continuity in patient care. Rotating across various wards and hospitals was suggested to broaden exposure to different specialties and patient populations. Enhanced pre-clinical simulation was recommended to practice skills before patient encounters. Formalized preceptorship programs with dedicated staff nurses were suggested to improve guidance and feedback.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eQuote: \"\u003cem\u003eTraining in neonatal and ICU wards would help us adapt to different specialties. Adding more simulation sessions before clinical rotations would make us more confident. I wish we had dedicated mentors at each hospital rather than sharing one instructor among ten students\u003c/em\u003e.\" (Participant 9, Female, 21 years)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis mixed-methods study illuminates the critical interplay between clinical learning environments (CLEs) and clinical learning (CL) experiences among nursing students in West Bank universities. Our findings align with global evidence underscoring the centrality of CLEs in shaping clinical education outcomes [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], yet they uniquely highlight how systemic challenges in conflict-affected regions amplify barriers to effective learning. Below, we contextualize key results, discuss implications, and propose actionable strategies.\u003c/p\u003e \u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003ePedagogical Atmosphere and Supervisory Relationships as Pillars of CL Experience\u003c/h2\u003e \u003cp\u003eThe strong predictive power of \"pedagogical atmosphere\" (β\u0026thinsp;=\u0026thinsp;0.365) and \"supervisory relationships\" (β\u0026thinsp;=\u0026thinsp;0.264) resonates with studies emphasizing mentorship and supportive learning climates as determinants of clinical competence [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In Palestine, where resource limitations and political instability strain educational systems, a positive pedagogical atmosphere, characterized by accessible instructors, structured feedback, and psychological safety\u0026mdash;may compensate for material deficits. For instance, students in governmental hospitals, despite overcrowding, reported higher CL experiences (M\u0026thinsp;=\u0026thinsp;3.92) than those in private facilities (M\u0026thinsp;=\u0026thinsp;3.59), likely due to established supervisory protocols and collaborative staff-student dynamics.\u003c/p\u003e \u003cp\u003eQualitative narratives reinforced this, with participants praising instructors who \"bridged theory and practice\" through hands-on guidance. This finding aligns with research by Gurkov\u0026aacute; and Žiakov\u0026aacute; [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], who found that effective clinical teachers in resource-constrained environments serve as both skill demonstrators and emotional supports. Our results suggest that investing in faculty development programs focused on clinical teaching pedagogy may yield substantial benefits even when material resources remain limited.\u003c/p\u003e \u003cp\u003eEffect sizes (η\u0026sup2; = 0.023 for training sites, η\u0026sup2; = 0.049 for wards) indicate that while these contextual factors influence learning experiences, their impact is relatively modest. This further emphasizes the importance of human factors, particularly supervision quality and pedagogical approaches, in shaping clinical education effectiveness.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eContextual Barriers: Resource Shortages and Geopolitical Realities\u003c/h3\u003e\n\u003cp\u003eThe stark contrast between CL experiences in orthopedic wards (M\u0026thinsp;=\u0026thinsp;4.92) and pediatric wards (M\u0026thinsp;=\u0026thinsp;2.97) underscores the impact of resource availability and specialization on learning outcomes. Pediatric wards, often understaffed and overburdened in Palestinian hospitals, limited students' procedural opportunities, mirroring challenges reported in other resource-constrained settings [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Students' frustrations with \"searching for working thermometers\" exemplify how equipment shortages directly affect skill acquisition and time management.\u003c/p\u003e \u003cp\u003eQualitative findings revealed that movement restrictions and checkpoint delays occasionally prevented timely arrival at clinical sites, reducing effective learning time. This geopolitical dimension distinguishes Palestinian nursing education from many other resource-limited contexts. According to the United Nations Office for the Coordination of Humanitarian Affairs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], West Bank checkpoints increased by 32% between 2021\u0026ndash;2023, with an average of 593 obstacles to movement recorded in December 2023. These restrictions uniquely affect nursing education by creating unpredictable schedules and complicating rotation planning.\u003c/p\u003e \u003cp\u003eResource limitations are further compounded by importation challenges. While our study did not directly measure medical supply imports, participants' narratives of equipment shortages align with documented restrictions on dual-use items (materials that could potentially have military applications) that affect healthcare systems in occupied Palestinian territories [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These systemic constraints necessitate innovative educational approaches that maximize learning within existing resources.\u003c/p\u003e\n\u003ch3\u003eThe Role of Governmental Training Sites: A Double-Edged Sword\u003c/h3\u003e\n\u003cp\u003eWhile governmental hospitals outperformed private sites in CL experiences (M\u0026thinsp;=\u0026thinsp;3.92 vs. M\u0026thinsp;=\u0026thinsp;3.59, p\u0026thinsp;=\u0026thinsp;0.032), this advantage is tempered by structural challenges. Participants noted that governmental sites, though better resourced, faced overcrowding (75.8% of students trained there), reducing one-on-one mentorship opportunities. This paradox mirrors findings from studies in Egypt and Jordan [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], where high patient volumes in public hospitals compromise individualized learning despite offering diverse clinical exposures.\u003c/p\u003e \u003cp\u003eThe preference for governmental training sites, despite their limitations, reflects students' prioritization of clinical diversity and learning opportunities over physical comfort or resources. This suggests that educational partnerships between universities and governmental hospitals should focus on optimizing student distribution, strengthening preceptorship programs, and creating dedicated teaching spaces within busy clinical areas.\u003c/p\u003e \u003cp\u003eNotably, UNRWA facilities received the highest ratings (M\u0026thinsp;=\u0026thinsp;4.12), though the small sample size (n\u0026thinsp;=\u0026thinsp;4) limits generalizability. These facilities may offer instructive models combining standardized procedures with intensive supervision that could inform improvements at larger institutions.\u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eToward Adaptive Strategies: Lessons from Student Narratives\u003c/h2\u003e \u003cp\u003eStudents' calls for \"more clinical days\" and \"diverse training sites\" align with global recommendations for competency-based education [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Rotations across specialties (e.g., neonatal, ICU) could mitigate the limitations of pediatric wards while fostering adaptability in various healthcare contexts. Our findings support curriculum revisions that increase clinical hours while ensuring quality through structured activities and clear learning objectives.\u003c/p\u003e \u003cp\u003eAdditionally, integrating simulation-based training, currently scarce in Palestinian nursing programs, could address procedural gaps caused by equipment shortages. Evidence from comparable settings suggests that even low-fidelity simulation improves student confidence and reduces anxiety before patient encounters [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Universities could develop cost-effective simulation laboratories using locally available materials and peer-teaching models to maximize limited resources.\u003c/p\u003e \u003cp\u003eThe exploitation of students for non-educational tasks emerged as a significant barrier requiring institutional intervention. Clear delineation of student roles through formal agreements between universities and healthcare facilities could protect educational integrity while acknowledging students' contributions to workforce capacity. This approach has proven effective in other limited-resource settings where students often fill workforce gaps [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, convenience sampling may limit generalizability, particularly for governmental universities which were underrepresented (5.6% of participants). Second, self-report bias could influence CLE/CL experience scores, though anonymity in data collection mitigated this risk. Third, the cross-sectional design precludes causal inferences about the relationship between CLE factors and learning outcomes. Fourth, data collection during a single academic semester may not capture seasonal variations in clinical experiences. Finally, while our sample included students from diverse settings, the perspective of clinical instructors and staff nurses would provide valuable complementary insights. Despite these limitations, the mixed-methods approach and substantial sample size (N\u0026thinsp;=\u0026thinsp;306) enhance the robustness of our findings, offering valuable insights into clinical education within conflict-affected settings.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides empirical evidence that despite systemic challenges in conflict-affected Palestine, positive pedagogical environments and effective supervision significantly enhance nursing students' clinical learning experiences. The strong correlation between clinical learning environment (CLE) factors and clinical learning (CL) experiences (r\u0026thinsp;=\u0026thinsp;0.758, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with pedagogical atmosphere and supervisory relationships emerging as significant predictors, underscores the critical importance of human factors in clinical education. While resource limitations, overcrowding, and movement restrictions present substantial barriers, students demonstrated remarkable resilience in navigating these challenges. Our findings suggest that targeted interventions in three key areas could strengthen nursing education in this context: first, faculty development through structured training programs for clinical instructors focused on effective teaching methodologies, feedback provision, and supportive learning environments; second, resource optimization by implementing strategic scheduling to reduce overcrowding, developing low-cost simulation alternatives, and establishing inter-institutional equipment loan programs; and third, policy reform through formal agreements between universities and healthcare facilities that define student roles, safeguard educational integrity, and promote structured mentorship programs. Future research should longitudinally examine how CLE factors influence graduate performance and explore innovative educational models that leverage technology and community partnerships to address resource constraints. Moreover, incorporating perspectives from clinical instructors, staff nurses, and patients would provide a more comprehensive understanding of clinical education dynamics in conflict-affected regions. The resilience of Palestinian nursing students, who pursue professional education despite systemic adversity, highlights the potential for educational innovation in such contexts. By strengthening pedagogical environments and supervisory relationships, nursing education in Palestine can continue to cultivate competent practitioners equipped to meet their communities' complex healthcare needs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Ethical approval for this study was obtained from the Arab American University\u0026ndash;Palestine Institutional Review Board (IRB Approval No: AAUP/IRB/2023-012). Formal permission to access students and clinical sites was received from the presidencies and nursing school deans of all participating universities. All participants received written informed consent forms explaining the study purpose, procedures, and confidentiality measures. Participation was entirely voluntary. Students were informed they could withdraw at any point without any academic consequences. Data were collected anonymously and securely stored, with all ethical standards followed in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All authors affirm that the content of this manuscript is original and has not been published or submitted elsewhere, except as disclosed in the text.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare no conflict of interest related to the content of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No specific funding was received for this research from public, commercial, or not-for-profit funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable. This manuscript does not report the generation or analysis of new datasets beyond those described.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;N.B. developed the study concept, assisted with data collection, and contributed to writing the initial manuscript draft. H.A.-M. participated in instrument selection, helped with literature review, and contributed to critical manuscript revisions. M.D. supported qualitative data analysis and helped interpret findings in context. M.S. contributed to data collection coordination and reviewed manuscript drafts. I.A. (corresponding author) led the research design, coordinated IRB and university approvals, supervised all phases of the study, analyzed results, and finalized manuscript writing. All authors read and approved the final version. They take responsibility for the accuracy and integrity of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eArkan B, Ordin Y, Yılmaz D. Undergraduate nursing students\u0026apos; experience related to their clinical learning environment and factors affecting to their clinical learning process. Nurse Educ Pract. 2018;29:127-32. \u003c/li\u003e\n\u003cli\u003eBenti B, Gemeda A. Nursing students\u0026apos; perception towards clinical learning environment and supervision in Ethiopia: A comparative cross-sectional study. BMC Nurs. 2022;21(1):1-9. \u003c/li\u003e\n\u003cli\u003eAlshammari MH, Pacheco HA, Dousti B. Clinical learning environment and the influential factors from nursing students\u0026apos; perspective. Open Nurs J. 2020;14(1):254-64. \u003c/li\u003e\n\u003cli\u003eAmoo SA, Enyan NIE. 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Nurse Educ Pract. 2014;14(2):208-13.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Clinical learning environment, Nursing education, Palestine, Mixed-methods, Conflict-affected regions, Educational resilience","lastPublishedDoi":"10.21203/rs.3.rs-6651999/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6651999/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eClinical learning environments (CLEs) are crucial for developing nursing competencies, yet their characteristics and impact in conflict-affected regions remain understudied. This research examined the relationship between CLE factors and clinical learning (CL) experiences among nursing students in Palestine's West Bank universities.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis convergent mixed-methods study combined quantitative data from 306 nursing students across three university types (governmental, public, private) with qualitative data from 14 in-depth interviews. The CLES\u0026thinsp;+\u0026thinsp;T scale assessed CLE dimensions, while an adapted Clinical Learning Experience Questionnaire measured student perceptions. Data collection occurred September-December 2023. ANOVA, correlation, and hierarchical multiple regression analyses were conducted alongside inductive content analysis for qualitative data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eQuantitative findings revealed strong correlations between CLE and CL experiences (r\u0026thinsp;=\u0026thinsp;0.758, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Hierarchical regression identified \"pedagogical atmosphere\" (β\u0026thinsp;=\u0026thinsp;0.365, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and \"supervisory relationships\" (β\u0026thinsp;=\u0026thinsp;0.264, p\u0026thinsp;=\u0026thinsp;0.001) as significant predictors of CL experiences, together explaining 59% of variance (R\u0026sup2;=0.59). Students at governmental hospitals reported higher CL experiences (M\u0026thinsp;=\u0026thinsp;3.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91) than those at private facilities (M\u0026thinsp;=\u0026thinsp;3.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06, p\u0026thinsp;=\u0026thinsp;0.032, η\u0026sup2;=0.023). Significant differences emerged across training wards (F[6,299]\u0026thinsp;=\u0026thinsp;2.56, p\u0026thinsp;=\u0026thinsp;0.019, η\u0026sup2;=0.049), with orthopedic wards scoring highest (M\u0026thinsp;=\u0026thinsp;4.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15) and pediatric wards lowest (M\u0026thinsp;=\u0026thinsp;2.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32). Qualitative themes revealed four major dimensions: perceptions of clinical experiences, facilitators (instructor expertise, staff collaboration), barriers (resource shortages, movement restrictions), and improvement strategies (increased clinical days, diverse training sites).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDespite systemic challenges in conflict-affected Palestine, positive pedagogical environments and effective supervision significantly enhance nursing students' clinical learning. These human factors appear to partially mitigate resource limitations and geopolitical constraints. Our findings suggest targeted interventions in faculty development, resource optimization, and policy reform could strengthen nursing education resilience in this context.\u003c/p\u003e","manuscriptTitle":"Clinical Learning Environments and Experiences of Nursing Students in West Bank Universities: A Mixed-Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 17:19:45","doi":"10.21203/rs.3.rs-6651999/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"85ffcc36-25da-4b1b-af5c-b94de10efe09","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-16T07:39:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-02 17:19:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6651999","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6651999","identity":"rs-6651999","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}