Nursing students’ perceptions on clinical learning environment and mental health: a multicenter study

Abstract Objective: this study aimed at evaluating the perceptions of Nursing students from public universities in three European Union countries on mental health and clinical learning environments, a topic that has been rarely investigated in the literature. Method: data collection took place using a demographic data form, the Clinical Learning Environment, Supervision and Nurse Teacher Scale, and the Mental Health Continuum Short Form. A total of 571 participants from Turkey, Lithuania and Portugal were included in the study. Results: there was a significant difference among the three groups regarding clinical learning environment and mental health status (p<.001). Supervision was the most valued element. The Portuguese students presented the highest mean in the Mental Health Continuum Short Form and Clinical Learning Environment, Supervision and Nurse Teacher Scale scores (p<.001). Age, gender and mental health were effective in the Clinical Learning Environment, Supervision and Nurse Teacher Scale scores. Conclusion: the results indicated that the Mental Health Continuum Short Form and Clinical Learning Environment, Supervision and Nurse Teacher Scale scores obtained by the Portuguese Nursing students were higher. It was also revealed that the students’ perceptions on the clinical learning environment were affected by age and gender, and that their perceptions on mental health were influenced by the Clinical Learning Environment, Supervision and Nurse Teacher scale scores.

improvements in the recognition of degrees and academic qualifications, and the creation of a European Credit Transfer and Accumulation System (ECTS) (12) . Nursing education has been transformed over the last decades and this transformation is continuing. The European Union and the Bologna Process have influenced changes in Nursing education (13) .
In addition to the Bologna process, Nursing schools acknowledge the importance of exposing students to diverse cultures through international exchanges and study-abroad experiences that enrich knowledge, understanding and the healthcare practice (13) . Exchange programs such as Erasmus Exchange provide students with the opportunity to recognize professional selfconfidence development, different Nursing education systems, healthcare services and different cultures.
Nursing educators need to socialize their students into the cultural context of the Nursing practice system. Addressing the advantages, disadvantages and benefits of dealing with a diverse group of students leads to a profound effect on the prospects of the Nursing practice healthcare environment (14) .
Each country has its own legislation, culture, health The nurses' per capita income level presents its highest value in Lithuania and the lowest in Turkey. This leads to job migration of nurses to other European countries due to better remuneration, easy access to recruitment networks and, sometimes, previous experience in the Erasmus Exchange program (15)(16)(17) .
Various studies have been conducted to evaluate clinical learning environment and mental health separately (5)(6)(7)(9)(10) . However, an extensive literature review indicated no multicultural studies comparing clinical environment and mental health in Nursing students.
International collaborative research between countries in the field of Nursing education raises the profile of Nursing as a postgraduate profession. Given the cultural

Sample definition
All the participants were undergraduate Nursing students from provinces of Turkey, Portugal and Lithuania, accounting for a total of 500, 360 and 340 students, respectively. Sample size for each school was calculated using an online software calculator (19) . At a 95% confidence level of and a 0.5 confidence interval, optimal sample size was calculated at 217, 186, and 181 for the Turkish, Portuguese and Lithuanian students, respectively. However, 10 students from Turkey and 3 from Lithuania were excluded from the study as they provided incomplete or incorrectly completed questionnaire forms. As a result, a total of 207 students from Turkey, 186 from Portugal and 178 from Lithuania were included in the study.

Participants
The Nursing students eligible to participate in the study included those who had completed at least one internship program, were national or native speakers of the study country and were aged at least 18 years old.
Nursing students from a different country, such as from the Erasmus exchange program, did not participate in the study. All the students who volunteered to participate in the study filled in the data collection form between May 2019 and February 2020. In the Lithuanian school, the data were collected from second-, third-and fourth-year students, as there was no internship program for first-year students. Similarly, in the Turkish school, the data were The data analyst was not aware of the participants' demographic characteristics.

Ethical aspects
The study was conducted in accordance with the principles expressed in the Declaration of Helsinki.

Instruments used to collect the information
The data collection forms included a demographic data form, the Clinical Learning Environment, Supervision and Nurse Teacher Scale (CLES+T) (20) and the Mental Health Continuum Short Form (MHC-SF) (21) .

Demographic data form
The form consisted of six questions probing the students' demographic characteristics and daily habits Rev. Latino-Am. Enfermagem 2022;30:e3528.

Mental Health Continuum Short Form (MHC-SF)
MHC-SF was developed to evaluate mental state from a continuum perspective (27) . It has 14 items, all worded positively, and consists of a 5-point Likert scale (0, never; 1, once or twice a month; 2, about once or twice a week; 3, two or three times a week; 4, almost every day; 5, every day). The total score is calculated based on the sums of all items and higher scores indicate better mental health. The Cronbach's alpha value of the original scale was reported as .89 (21) .
The Portuguese version of MHC-SF was developed (28) .
The Cronbach's alpha value of this version was reported to be .93 (28) . The Turkish version of MHC-SF was developed and its Cronbach's alpha value was reported as .90 (29) .
The Lithuanian version of MHC-SF was developed and its Cronbach's alpha value was reported as .91 (30) . In our study, the Cronbach's alpha value was .846 for the

Data treatment
The study data were collected from volunteer students who were involved in at least one clinical practice between

Data analysis
The data were analyzed using IBM SPSS ® (IBM Corp.,

Characteristics of the sample
The study sample consisted of 571 Nursing students.

Nursing students' perceptions on the elements of Clinical Learning Environments
The results indicated that the Portuguese students had the highest means in all dimensions, while only some of them established a significant difference with those of other groups. In the environment dimension, no significant difference was found between the Portuguese and Lithuanian students (p=.090), whereas a significant difference was identified between the students from those two countries and their peers from Turkey (p<.001). In the supervision than those from the other countries and the Portuguese students were significantly younger than the Lithuanian (p<.005). The sociodemographic and educational characteristics of the students are presented in Table 1.  dimension, a significant difference was found among all three groups (p<.001). As for the teacher dimension, no significant difference was found between the Turkish and Lithuanian students (p=.972), whereas a significant difference was in fact identified between the students from those two countries and their peers from Portugal (p<.001).
The most valued element of the clinical learning environments was supervision for the Portuguese and Turkish students, while it was environment for the Lithuanian students. In contrast, the least valued element was teacher for all three groups. Moreover, a significant difference was found between the Portuguese and Lithuanian students' perceptions on teacher, whereas no significant difference was found with those of the Turkish students (p=.088), according to Table 2.

Discussion
The study provided valuable insight for the Nursing students' perceptions on clinical learning environments and mental health. The results regarding the participants' demographic characteristics, CLES+T scores and MHC-SF scores were discussed in line with the relevant literature.

Characteristics of the sample
The mean age of the participants in this study presented its lowest value in Turkey and the highest in Lithuania. This difference could be due to the absence of first-year Nursing students in the Lithuanian group and of fourth-year Nursing students in the Turkish group.
In terms of gender, the percentage of males was lower among the Lithuanian students than in the other groups. When the studies conducted with Nursing students in Turkey, Portugal and Lithuania were examined, it was verified that the results are similar (31)(32) . Nursing is one of the most female-dominated professions all over the world.
It is thought that a professional group that integrates the characteristics of both genders could contribute positively to the scientific and state-of-the-art development of the profession by diverting attention from gender.

Nursing students' perceptions on Clinical Learning Environments
In our study, the environment, supervision and teacher mean scores of the Portuguese students were found to be higher. Clinical learning requires appropriate and sufficient personnel covered by teachers, supervisors and environment (33) . It is thought that this difference in the study results was due to the inadequacy of the application area, to the excess number of students, and to the lack of supervisors and teachers. The difference in the education system can be shown as another reason for these results.
In line with these results, it is necessary to support Nursing students in the clinical experience. Closing the gap between clinical and theoretical education is one of the main purposes in Nursing education. Clinical education is not only a practice carried out with instructors, but also an educational experience that the student should pursue with experienced clinical nurses (34) .

Nursing students' perceptions on the most valued elements in Clinical Learning Environments
The results indicated that the most valued element was supervision for the Portuguese and Turkish students while it was environment for the Lithuanian students. It is thought that this difference was due to the fact that Nursing students in Portugal and Turkey were unfamiliar with the field of practice and did not have sufficient skills in Nursing interventions; therefore, they expected support from supervisors, especially in applications that require skills.
The clinical environment is the best area in which clinical decision-making can be taught and developed.
Supervisors are key individuals who help students bridge the gap between Nursing theory and practice. A good supervisor facilitates the provision of safe and effective care to the patients. The students' relationship with the supervisor can improve their clinical practice skills (1) .
Local developments regarding the concept of "supervisor" continue in all three countries. perform clinical practices. This shows that these students are exposed to gender bias and labeling (40) . For this reason, supervisors and teachers should be careful about the problems experienced by male students in clinical learning environments due to gender.
Our results indicated that mental health affects all the elements of the clinical learning environment.
The quality of the "learning environment" was a key influence on Nursing students' emotional well-being.
Teacher, supervision and teaching approaches, academic expectations and availability of learning resources are important factors that affected their emotional well-being as well as their academic performance (41) .