Healthcare Students' Perceptions of the Quality of the Clinical Learning Environment in Morocco: A Cross-Sectional Study

Background The clinical learning environment (CLE) is critical for developing the practical skills needed in healthcare professions. This study aimed to evaluate healthcare students' perceptions of the quality of the CLE using the Arabic version of the Clinical Learning Environment, Supervision and Nurse Teacher (ar. CLES + T) scale. The study also aimed to evaluate the tool's measurement invariance and compare perceptions among student groups. Methods This cross-sectional study was carried out at two health education institutes in Morocco throughout the academic year 2018-2019 among 1550 undergraduate students who had just finished a clinical practicum in a hospital or primary healthcare facility. Data were gathered using the ar. CLES + T scale. Confirmatory factor analysis (CFA) and multigroup CFA were performed. The measurement invariance of the ar. CLES + T scale was assessed across gender, study year, and clinical practicum duration, using configural invariance, metric invariance, scalar invariance, and strict invariance. The t-test and analysis of variance were used to compare the mean scores of the student groups. Results Students expressed positive perceptions toward the CLE. The “Pedagogical atmosphere on the ward” dimension scored the highest, while the “Role of the nurse teacher” dimension received the lowest scores. The measurement invariance of the ar. CLES + T scale by gender, study year, and clinical practicum duration was established. First-year students and those with an extended practicum period were the most satisfied. Conclusion To promote effective learning in the clinical environment, nurse teachers might use innovative teaching approaches tailored to their evolving role in these settings. Moreover, extending the duration of clinical practicum can further enhance student learning outcomes.


Background
Health education is crucial for developing skilled individuals who can work as competent professionals.Clinical practicum is an essential component of health education programs, representing 40%-50% of European programs [1].Clinical learning environment (CLE) has been widely recognized as a crucial learning area in health education because student learning occurs with patient contacts in a real clinical setting that no other solution, such as simulation, can fully replicate [2].Te factors of CLE have been identifed to include the physical layout, psychosocial and interactional elements, organizational culture, and elements related to teaching and learning, such as efective teaching and student involvement [3].
Positive CLE can contribute to student professional development [1,3], achievement of learning outcomes, increased self-confdence, and satisfaction with the healthcare profession [3].However, negative CLE can lead to dissatisfaction with the feld, increasing the risk of students' failure or even complete abandonment of the healthcare pursuit [1,3] ultimately contributing to the global shortage of healthcare professionals [3].Terefore, evaluating the CLE is an important step to identify areas for improvement and enhance student clinical learning experiences.
Te quality of the supervisor-student relationship is the most important factor in shaping a student's professional development during clinical practicums [1].Tere are various models of student supervision in the clinical context.Traditional methods of supervising students often relied on group-based approaches, whereas modern approaches prioritize personalized, one-on-one supervision [4].A systematic review discovered that students were more satisfed with their supervisory relationships, which was linked to the students' experience with an individualized supervision model [5].Students value confdential supervision meetings because it allows them to freely discuss the emotional challenges and reactions they encounter while caring for patients [6].
Moreover, students from six European countries valued the individualized supervision provided by their nurse teacher from the educational institute, as well as their support in enhancing learning and decreasing stress associated with clinical practicum [7].Nevertheless, various studies have noted a general decline in the involvement of nurse teachers in clinical practice [6,8,9].With the nurse education transition to higher education in many European countries, the clinical role of the nurse teacher has evolved from a competent practitioner to an intermediary between clinical settings and educational institutions [6,9].Furthermore, there is often confusion about what nurse teacher is supposed to do in clinical settings.Teir role lacks a clear defnition [1].Previous research revealed negative perceptions among students regarding the clinical role of the nurse teacher [4,5,[10][11][12][13][14][15][16][17] probably due to these changes.To address this issue and improve nurse teacher's cooperation with students, studies highlight the need to develop novel alternative approaches, such as digital educational technologies [7,9,18], to complement rather than substitute the physical presence of nurse teachers during placements [18].Furthermore, the nurse teacher's clinical role should be revised to include clear responsibilities for student supervision during clinical practicum [7], distinct from the responsibilities of clinical supervisors [9].
In Morocco, research in nursing education is still in its earlier stages.So far, there have been few research types on the actual CLE.Te primary focus has been on validating tools to assess the efectiveness of the CLE [19,20].Tus, we have not got a clear picture of Morocco's CLE until now.With the aim of providing an initial understanding of student-perceived CLE and suggesting improvements in clinical education, this study embarks on this exploration.
In 2013, the nursing education system in Morocco underwent substantial structural adjustments to align with the Bologna process, similar to other European Union countries [21].Tis transition marked a shift from the traditional model, where state diplomas were awarded upon completion of vocational studies, to a university-based system emphasizing the attainment of Bachelor's, Master's, and Doctoral degrees [22].Education occurs at the level of public institutions known as Higher Institutes of Nursing Professions and Health Techniques (ISPITS).Tese institutes, overseen by the Ministry of Health, provide higher education programs.Te ISPITS includes 10 core institutes and afliated units, strategically situated around the country.
Te undergraduate degree program is available to students in fve specifc areas: nursing, midwifery, health techniques, rehabilitation, and medical-social assistance.Each pathway may comprise one or more options.Troughout this article, "healthcare students" refers to those pursuing any of these specialized felds.Te license cycle lasts three years and consists of 2310 hours of theoretical and practical courses.Each academic year is divided into two semesters, each lasting 16 weeks.Te license cycle in six semesters includes 38 training modules classifed into main and complementary modules.Due to its importance, the clinical practicum is considered a main module.
Clinical practicums may begin as early as the frst year for specifc programs.In the second and third years, they become a substantial part of the curriculum, occupying over half (more than 51%) of the educational programs.At present, the duration of each practicum module is 120 hours.Previously, it spanned 160 hours longer but was adjusted to conform with the new educational standards implemented in higher education institutions.Clinical practicums can be full-time or part-time, and take place in public health facilities or other approved structures that provide students with learning opportunities.
To improve nursing education and ensure the transition to higher education, ISPITS has increased its recruitment of teachers with a doctorate in health sciences.Training for the PhD cycle focusing on nursing sciences is currently being prepared and will launch soon at the ISPITS.Te recent creation of research structures would enable nursing research to take its rightful place within ISPITS though there are still challenges to be addressed [23].Following a similar approach, the master's level training in nursing education has been extended to encompass all ISPITS, leading to a rise in the number of teachers qualifed to serve as full-time faculty members at the education institutes.Tey deliver both theoretical and practical instructions in academic settings and supervise students in clinical placements relevant to their area of expertise.
In addition to their patient care responsibilities, the head nurses of the unit and the nursing staf also provide clinical supervision to students.Most European countries also use a similar supervision approach called the preceptor model [24].Group supervision remains the traditional approach widely used in Moroccan settings.Nonetheless, there has been a signifcant shift toward personalized supervision in many European countries [4].Tis individualized approach is recognized as the most impactful and critical model of supervision for students' professional development [1], as well as contributing to their satisfaction throughout clinical training [5,13,[25][26][27].
Tis study aimed to evaluate Moroccan healthcare students' perceptions of the quality of the CLE using the validated ar.CLES + T scale.Te study also aimed to assess 2 Nursing Research and Practice the tool's measurement invariance and compare perceptions among student groups.Terefore, the study aimed to test the following hypothesis: (1) Healthcare students had positive perceptions of the CLE (2) Te measurement invariance was established to compare students' perceptions by gender, student year, and clinical practicum duration (3) Tere were diferences among students' perceptions based on gender, student year, and duration of clinical practicum Te fndings from this study can inform strategies for enhancing clinical education and preparing competent professionals who can deliver high-quality patient care.

Study Design, Sample, and Settings
. Tis cross-sectional study was conducted at two government health education institutes in Morocco during the academic year 2018-2019.Participants were included based on the following criteria: (1) undergraduate students in their frst, second, or third year of a nursing or other health professions; (2) those who have recently completed a clinical practice course in a hospital ward or primary healthcare setting; and (3) those who provided informed consent.Exclusion criteria included students with no prior clinical experience and those who declined to participate.Using Cochran's formula [28,29], this study requires at least 349 participants to achieve results with a 95% confdence level, a 5% margin of error, and an expected mean score and standard deviation of 3.26 (0.84), based on previous research [11] conducted in an Arab country similar to Morocco.However, to raise the power and precision of the study, all eligible students from the two institutions were included.

2.2.
Instrument.Tis study used the CLES + T scale [1] to evaluate healthcare students' perceptions of the CLE.Te CLES + T scale has been evaluated and validated in various studies.Te scale demonstrated good reliability and validity in diverse contexts, including an Arabic version used in this study.Te present study's Arabic CLES + T scale had good internal consistency, with a Cronbach's alpha coefcient of 0.93 for all subscales.A previous study has demonstrated the ar.CLES + T scale's validity for Moroccan healthcare students [19].Te ar.CLES + T scale comprises 34 items across fve dimensions: pedagogical atmosphere on the ward, leadership style of the ward manager, premises of care on the ward, supervisory relationship, and role of the nurse teacher.Following their last clinical practicum, students completed a paper questionnaire at their institute, rating each item on a 5-point Likert scale.Tey also answered demographic and learning data questions (age, gender, degree program, student year, clinical placement, and duration of clinical practice).

Statistical Analysis.
Descriptive statistics including frequencies and percentages were used to summarize demographic and learning data.Te total mean score of the questionnaire was calculated as the mean of all item scores.Similarly, mean scores were calculated for each of the fve dimensions by averaging the ratings of the corresponding items.Higher scores indicate more positive perceptions of the clinical learning environment, supervision, and the role of the nurse teacher.
To assess the measurement invariance of the Arabic CLES + T scale, confrmatory factor analysis was frst performed to evaluate the model ft.If the factorial structure of a construct remains consistent across diferent subgroups, then measurement invariance can be assumed, indicating that the factor structure remains unchanged across these subgroups.
Gender, student year, and duration of clinical placement were the factors used to evaluate measurement invariance.Te lavaan package was utilized to conduct a measurement invariance test through multiple-group factor analysis [30] for R statistics and weighted least squares mean and variance adjusted (WLSMV) estimation.Te models proposed by Millsap and Yun-Tein [31] for ordered categorical variables were tested using the following procedure: confgural invariance, which had no restrictions other than those needed for model identifcation, was tested frst, followed by metric invariance where all factor loadings had to be similar.Scalar invariance was also tested, which required the threshold restriction already needed for model identifcation and was similar to weak invariance.Finally, strict invariance was tested, which involved restricting the unique variance to 1.
When conducting a measurement invariance test, the diference in the χ 2 statistic is frequently employed, but due to its susceptibility to sample size, the primary indicator is the diference value of the comparative ft index (ΔCFI), which is a criterion of model ft [32].To address the risk of overrejection with a small sample size, the diference values of the root mean square error of approximation (ΔRMSEA) and the standardized root mean square residual (ΔSRMR) are used as subcriteria.Chen [32] recommended the following cutof criteria for noninvariance: ΔCFI ≤ −0.01, ΔRMSEA ≥ 0.01, and ΔSRMR ≥ 0.015.Te authors noted that among the various indices used, CFI was the most highly consistent, whereas RMSEA tended to be more affected by factors, such as study population and model intricacy.
Students' perceptions were compared by gender, year of study, and duration of clinical practicum using either the ttest or analysis of variance (ANOVA), depending on the data distribution.Statistical analyses were conducted with IBM SPSS Statistics 23.0 and Amos 23.0 software.

Ethical Approval.
Te research protocol received ethical approval from the Mohammed V University of Rabat Ethics Committee (IRB: 69-2019).All participants received written information about the study's goals, confdentiality, anonymity, and voluntary contribution.Participants who signed the consent form, completed the questionnaire, and returned it were considered to have provided informed consent.
Nursing Research and Practice

Student Characteristics.
Te questionnaire was completed by 1550 students, achieving a 95% response rate.Te majority of students (81%) were females, with a mean age ranging from 17 to 20 years (71% of respondents).Nursing students constituted a signifcant proportion of the participants (61%).Te majority of respondents (82%) completed their clinical practicum at hospitals.Second-year students represented 45% of the respondents, followed by frst-year students (32%) and third-year students (23%).Te clinical practicum period lasted four weeks for almost half (46%) of the participants and the ward manager was most often (38%) responsible for student supervision, followed by the nurse and the specialized nurse.Group supervision was the most common type of supervision adopted (62%).More than half of the participants said they had never had an unscheduled meeting with their supervisor.Student characteristics are shown in Table 1.

Students' Perceptions of the Quality of the CLE.
Students expressed overall positive perceptions toward their CLE, with an average score of 3.17 ± 0.76 on the total ar.CLES + T scale.Among the dimensions, "Pedagogical atmosphere on the ward" received the highest score (3.31 ± 0.82), indicating the most favorable perception.Conversely, the "Role of the nurse teacher" dimension received the lowest score (3.08 ± 1.03).Within this dimension, "Teory and practice integration of nurse teacher" was the most appreciated subdimension (3.31 ± 1.14), whereas "Relationship with mentor student and nurse teacher" was rated the least favorably (2.88 ± 1.19) (details are shown in Table 2).

Students' Perceptions of Quality of the CLE by Gender.
A gender diference was found in the "Pedagogical atmosphere on the ward" dimension.Male students perceived this dimension more favorably than female students (3.46 ± 0.79 vs 3.27 ± 0.83, P < 0.001).No signifcant gender diferences were observed in other dimensions (see Table 4 for details).

Students' Perceptions of the Quality of the CLE by Student
Year.First-year students reported the highest satisfaction with the total ar.CLES + T scale and its dimensions    Nursing Research and Practice (3.33 ± 0.71), while third-year students reported the lowest (2.98 ± 0.75, P < 0.001).Tis indicates a signifcant diference in student satisfaction across year groups (details in Table 4).

Students' Perceptions of the Quality of the CLE by Clinical
Practicum Duration.Students who completed a longer clinical practicum period reported signifcantly high mean scores compared to those who completed a shorter period regarding the "Pedagogical atmosphere on the ward" dimension (3.46 ± 0.83 vs 3.17 ± 0.74, P < 0.001), the "Leadership style of the ward manager" dimension (3.40 ± 0.98 vs 3.26 ± 0.92, P < 0.001), and the "Premises of care on the ward" dimension (3.35 ± 0.95 vs 3.09 ± 0.81, P < 0.001) (details in Table 4).

Discussion
Moroccan healthcare students generally held positive perceptions of their CLE, as evidenced by this study.However, their average ratings on the CLES + T scale fell below 4 out of 5, suggesting room for improvement in student satisfaction.Tis observation aligns with fndings from other Arab countries like Saudi Arabia and Oman [10][11][12].Notably, studies from European countries reported strong satisfaction (above 4) across all CLES + T components [5].Tese comparisons highlight the need for enhancements to the Moroccan CLE to bridge the gap with other regions.
Te study identifed the "pedagogical atmosphere on the ward" as the most valued aspect of the CLE.Tis fnding aligns with a wider review using the CLES + T scale, where all studies reported positive scores above 3 for this element [5].Tis emphasizes the importance of fostering a supportive learning environment.Students thrive when surrounded by motivated and committed staf who actively engage and inspire them, allowing them to focus on their educational growth.Conversely, a negative environment can force students to prioritize their well-being, hindering their learning potential [1].
Te study identifed the "Role of the nurse teacher" as the least valued aspect of the CLE, consistent with fndings from 16 other countries, although with inconsistencies [5].Tis result might be related to the subdimension "relationship among student, mentor, and nurse teacher," which received the lowest score among Moroccan students.Interestingly, a Slovakian study reported similar results [13], while Finnish students scored this subdimension the highest [6,16].Studies indicated that students' satisfaction increases with more frequent meetings with their supervisors and teachers [6,10,16,26].However, more than half of the participants in this study reported never having an unexpected meeting with their supervisors.
Te nurse teacher's infrequent or missing interactions with the students could be related to the nurse teacher's reduced direct involvement in clinical areas, a trend seen in European countries following the transition to higher education [8].Tis shift has moved the clinical role of the nurse teacher from a primarily hands-on practitioner to a mediator between educational institutions and healthcare providers [9].Consequently, clinical teaching has diminished as teachers prioritize research and publication for career advancement within academic settings [1,9].Despite this, a well-structured CLE, combined with regular guidance from the clinical teacher, promoted active learning in students [12].Obviously, physical presence in clinical settings may not always be necessary for a nurse teacher, but fnding innovative ways to foster cooperation remains crucial [1].A study conducted in nine European countries suggests that using e-communication strategies can signifcantly strengthen communication between clinical teachers and their students [9].
Another factor potentially contributing to the low score for the student-mentor-nurse teacher relationship is the inherent stress particularly when students are under observation or evaluation [13].Tis could explain why Moroccan students gave the lowest score to the statement "In our common meeting, I felt that we are colleagues." Students perceived the "cooperation with ward staf" aspect of the nurse teacher role negatively.Tey were least likely to believe that the nurse teacher worked as a team member, aligning with fndings from Sweden [33][34][35] and Finland [6,16].However, in Norway, a "dual preceptor team" model, where teachers and clinical staf collaborate, shows a positive impact on student learning [36].Tese fndings demonstrated that operating as a member of a nursing team does not efectively refect the role of the nurse teachers in modern academic contexts of nursing education, especially given their limited participation in clinical practice [6,33,35].Although Moroccan nurse teachers may have less direct clinical involvement, this does not diminish their clinical credibility, as students afrmed their ability to bridge the gap between theory and practice.Tis emphasizes that clinical credibility does not necessarily require constant clinical activity [34].
Similar to a previous Korean study [37], this study demonstrated the measurement invariance of the ar.CLES + Tscale, ensuring it measures the same concepts across diferent student groups.Te fndings confrmed the tool's reliability for evaluating the quality of the CLE regardless of gender, student year, and clinical practicum duration.Measurement invariance across these groups was validated at the confgural, metric, scalar, and strict invariance levels.Consequently, scores generated from this tool can be meaningfully compared across these three variables.
Te present study found no signifcant correlation between gender and the overall mean score in line with previous European studies [4,25,33,36].However, a clear diference emerged in the way male and female students perceived the pedagogical atmosphere on the ward.Male students rated this dimension higher than female students in agreement with prior studies that identifed notable diferences between genders in the evaluation of certain CLES + T dimensions [11,[38][39][40].Tese fndings suggest the need for further investigation to understand the underlying reasons for this disparity and to develop strategies to improve the clinical experiences of female students.
Tis study showed a decline in student perceptions of the CLE as they progressed through their academic year.Conversely, an Ethiopian study revealed increased 6 Nursing Research and Practice satisfaction with each year [40].Other studies using the CLES + T tool found no signifcant diferences in student experiences based on their year of study [4,25].Similar fndings to the present study were reported in Cyprus and Koréa [26,37].Students' perspectives on the CLE might shift as they gain clinical experience.While initially drawn to the environment due to the novelty of learning new skills [41], their assessments might become more critical as they develop deeper understanding of fundamental concepts and their capacity for refection improves [16].Additionally, clinical supervisors and teachers might provide difering levels of supervision based on student experience, with a greater focus on frst-year students who are novel to the environment [37].Tis scenario could also apply in Morocco, where third-year students indicated dissatisfaction with the supervisory relationship and the role of the nurse teacher rather than the learning environment itself.Terefore, it is critical to inform supervisors and teachers about this phenomenon and encourage them to maintain strong supervision for students in their last year of training.
In the present study, satisfaction levels correlated with clinical practicum duration.Longer placements resulted in the most satisfed students.Tis outcome aligns with an earlier study across nine European countries [4].Other studies reported the opposite, attributing this diference to the lower percentage of students who had completed extensive clinical training [10,13,42].However, training to be a nurse requires sufcient time spent with patients [4].Research suggests an ideal clinical placement period of approximately 7 weeks [43].Terefore, the current length of clinical practicum for Moroccan students appears insufcient and should be extended to 7 weeks or more.Tis extended period would allow students to fully capitalize on the learning situations they fnd meaningful, sufcient, and diverse in the Moroccan healthcare settings.

Strengths and Limitations of the Study.
Te strength of this study is its pioneering evaluation of the Moroccan healthcare CLE from student perspectives, using an internationally validated instrument.However, a limitation is that our fndings may not be generalizable to all of Morocco due to the use of convenience sampling, which does not fully represent the population of Moroccan public institutes.Additionally, the high gender ratio refects the femaledominated nature of the healthcare profession in Morocco.Terefore, it is important to interpret our fndings with caution, as men's and women's perceptions of the CLE may difer.Despite these limitations, our fndings ofer valuable preliminary insights into the CLE, potentially guiding decision-makers in making necessary improvements.

Conclusions and Implications
While Moroccan healthcare students generally held positive views of their CLE, there is room for improvement.Students identifed the pedagogical atmosphere as crucial, yet expressed dissatisfaction with the reduced role of nurse teachers in clinical contexts.Scholarly literature ofers innovative approaches to clinical education that could be implemented in Morocco.Such approaches aim to improve student learning while reducing the need for frequent faceto-face interactions with nurse teachers in clinical settings.Studies suggest the potential of using e-communication tools, such as e-mail, mobile solutions, and virtual learning environments, to strengthen teacher-student relationships during placements [6,9,44].Nonetheless, evidence suggests that e-communication cannot fully replace faceto-face contact [9,44].Another pedagogical alternative is for the nurse teacher to focus on simulated learning in academic environment [6].Tis approach aligns well with Morocco's recent advancements in simulation training, marked by the creation of simulation centers and nurse teacher training initiatives in nursing education institutes.
Te ar.CLES + T scale could be used to evaluate the quality of the CLE among Moroccan healthcare students across variables like gender, study year, and clinical practicum duration.Evaluating the invariance of this tool across diferent variables is crucial to identify factors infuencing clinical learning and guide targeted improvements.
First-year students were the most satisfed with the CLE.Tis suggests that nursing supervisors and teachers may need to adjust their clinical teaching methods to better address the evolving learning needs of students, particularly in their fnal year.Longer practicum periods led to increased student satisfaction.Terefore, extending the practicum duration to at least 7 weeks could be a valuable strategy to enhance student learning outcomes.
Te current study provides an initial exploration of the CLE from the perspective of healthcare students in two Moroccan institutes.For a comprehensive understanding of the CLE across the country, conducting further studies with diverse student populations from diverse clinical settings is recommended.Te ultimate goal is to improve the CLE and prepare competent professionals capable of delivering highquality patient care.

Table 2 :
Mean scores of total ar.CLES + T scale and dimensions (N � 1550).

Table 3 :
Analysis of measurement invariance of the ar.CLES + T scale according to gender, student year, and clinical practicum duration (N � 1550).

Table 4 :
Comparison between mean scores of total ar.CLES + T scale and dimensions among gender, student year, and clinical practicum duration groups of students (N � 1550).
Data are presented as mean (standard deviation).