The education and clinical competency of nurses, who make up the largest health workforce and play a role in complicated decisions and delegation of care, are important factors for improving client outcomes (Coyne et al., 2021). The term “competence” is derived from the Latin word “Competentia” and is interpreted as capability and permission. Later, the term competency and its use were defined in the nursing field by Benner (1984), where nursing competency was recognized as the ability to do a task such that favorable results are achieved (Hailu et al., 2021). Clinical competence (CC) refers to clinical capabilities required by nurses in a clinical environment to successfully carry out tasks based on knowledge, techniques, attitudes, and performance (Kang et al., 2021).
Given that the end goal of nursing education is to train competent nurses and ensure the provision of high levels of patient care, the most important goal of clinical education in nursing is to improve nursing students’ practical skills and clinical qualifications (Rafii et al., 2019). CC development for optimal nursing performance occurs throughout the nursing education process (Alavi et al., 2022). Therefore, clinical education constitutes more than half of formal nursing education courses (Jamshidi et al., 2016).
Internship in clinical education happens in the last year of nursing education as an important approach used to reduce the gap between theoretical and practical knowledge. The program was first used in the late 19th century in the United States to prepare medical students for clinical practice following graduation and to establish maturity in these individuals (Ahmadi et al., 2020). Iran’s undergraduate nursing education program is a four-year course that ends with an internship program. In this program, every year includes two semesters. In the first semester, students learn the theoretical foundations of basic nursing skills in the classroom and practice these skills in the clinical skills center. Along with theory courses, internships in clinical positions start from the second semester and nursing students do their clinical training under the direct supervision of a nursing instructor (from their faculty). The theoretical requirements of nursing education are completed by the end of the third academic year (sixth semester), and in the fourth year (seventh and eighth semesters), students complete the internship course independently and with the direct supervision of supervisors and clinical staff and indirect supervision of supervisors in the form of internships in most clinical departments (Aghaei et al., 2021).
The internship’s goal is to equip students with the necessary professional skills, prepare them for becoming competent nurses and enable them to use theoretical knowledge in practice. In fact, the program helps nursing students work as actual nurses in order to improve their clinical skills and achieve CC (Aghaei et al., 2021). Nonetheless, various factors affect the acquisition of CC, including the educational environment in the ward, the supervisory relationship between students and instructors, and preparation for performance based on nursing education (Getie et al., 2021).
Conceptual framework for hypothesized model
A major goal of all nursing education programs is to provide high-quality learning experiences that result in the growth of CC in nursing students before practice. In general, CC includes comprehension of knowledge, clinical, technical, and communication skills, and the ability to solve problems through the use of clinical judgment (Taylor et al., 2020). In a review study, CC in nursing education was defined in the form of three themes: 1) professional performance with a care perspective, 2) clinical skills and reflective performance, and 3) cognitive, emotional and psychomotor skills combined with a nursing perspective (Lejonqvist et al., 2016).
Based on the literature, the internship program helps nursing interns demonstrate leadership skills in problem-solving, prioritization, decision-making, the delegation of tasks, and accountability by trainers (Aboshaiqah and Qasim, 2018). On the other hand, since there is generally a positive relationship between clinical performance and preparation for self-directed learning (SDL) (Choi and Jeong, 2011), this type of learning is a necessary and effective strategy for the learning of nursing students in the clinical course (Noh and Kim, 2019).
SDL is defined as “A process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes” (van Lankveld et al., 2019). SDL enables individuals to self-assess their learning needs, frame their learning objectives, find resources, implement their learning strategy, and evaluate their learning outcomes (Kang et al., 2021). A self-directed learner takes control over their learning and accepts the autonomy of learning what is important to them. Researchers have found a relationship between higher preparation for SDL and better academic achievement. Therefore, greater preparation for SDL may affect nursing competence (Yang and Jiang, 2014). Many faculty members are drawn to the SDL approach owing to its ability to develop independent learning skills, as well as accountability, responsiveness, and decisiveness, which are important features throughout the profession, in nursing students, and improve their adjustment to the clinical environment. Accordingly, SDL is a necessary and effective approach for nursing students in the clinical period (Noh and Kim, 2019).
Overall, improvement of the learning environment, in which students could have a sense of motivation and participation, can help develop self-learning (Visiers-Jiménez et al., 2021). The clinical workplace is an exciting and dynamic learning environment, and such an environment requires students to develop new competencies, including SDL techniques (Embo et al., 2010). A clinical learning environment (CLE) refers to a clinical workplace in which students of health professions complete their clinical work as part of their education (Sellberg et al., 2021). According to a concept analysis study by Flott and Linden, CLE in nursing education has four components of physical space, psychosocial and interaction factors, organizational culture, and teaching and learning components (Flott and Linden, 2016). The learning environment plays a vital role, especially during the clinical education of nursing students, mainly because of facing their real performance and helping them form their viewpoints about professional jobs and perspectives of the clinical field (Papathanasiou et al., 2014). In other words, clinical learning environments play a basic role in the growth of students’ professional identity and competencies (Immonen et al., 2019).
Literature Review
Many nursing scholars have committed to studying the factors that may affect students’ CC in order to improve this issue in undergraduate nursing students (Yu et al., 2021). For instance, Yang and Jiang (2014) concluded a study to evaluate the relationship between SDL and CC in nursing undergraduates. Similarly, Choi and Jeong (2011) assessed the effect of readiness for self-directed learning on nursing practice competence. Moreover, Alotaibi (2016) attempted to determine the relationship between SDL readiness and the academic performance of students with the mediating role of understanding learning environment needs. In addition, Hwang and Oh (2021) studied the relationship between SDL and problem-solving ability with the mediating role of academic self-efficacy and self-regulated learning among nursing students. Another study was performed to evaluate the relationship between CLE and students’ competence levels (Visiers-Jiménez et al., 2021). Yu et al. (2021) carried out a study to assess the relationship between the CC of graduated nursing students and CLE.
Given the significance of assessing the factors affecting students’ CC and based on the studies mentioned above, the current research aimed to determine the effect of SDL on internship nursing students’ CC with the mediating role of CLE in the form of hypothesis model testing (Fig. 1). Considering the study by Alotaibi (2016), Yu et al. (2021), and Visiers-Jiménez et al. (2021) the following hypotheses were tested in the current research:
H1: SDL directly affects CC.
H2: SDL directly affects CLE.
H3: CLE directly affects CC.
H4: SDL indirectly affects CC.
H5: SDL generally affects CC.