Challenges faced by student nurses and midwives in clinical learning environment – A systematic review and meta-synthesis

Objectives: This systematic review aimed to offer insight and understanding, through synthesis of findings from studies that report on perspectives of student nurses/midwives, clinical instructors, clinical nurses/midwives on the challenges faced by student nurses/midwives in the clinical learning environment (CLE). Design: All primary qualitative research studies published in the English language that reported on the views of student nurses/midwives, clinical instructors and clinical nurses/midwives on the challenges faced by student nurses/midwives in the CLE were included. Data sources: The electronic databases of Medline EBSCO (1946-), CINAHL (1970), Embase Ovid (1974-), ScielO, WHOLIS (2002-), ASSIA (1985-), Web of Science (1956-), PsycINFO (1800s-) and Maternal and Infant Care (1970-) were searched in November 2019. Review methods: Retrieved papers were reviewed independently by two authors for selection by title, abstract and full text, and two authors agreed for inclusion of the papers. The COREQ criteria checklist was used for assessment of methodological quality of the included studies. Results: The review included 32 studies published over 22 years between 1997 and 2019 involving 853 nursing/ midwifery students, clinical instructors, and clinical nurses/midwives from 14 countries. Three key themes emerged: ‘The support structure ’ , ‘Personal factors ’ , and ‘Planning and organisation – influence of extrinsic factors ’ . Conclusion: Attitude of clinical staff, instructors, and significant others had a major influence on students ’ clinical learning. Lack of a sense of belongingness and self-motivation to learn, and perceived fear of doing errors were some of the demotivating factors. Lack of resources to facilitate need-based training, staff shortages, workload and inconsistencies between theory and practice were other key challenges in the CLE. Understanding the challenges faced by students in clinical practice can help overcome the barriers leading to development of competent and confident nurses and midwives.


Background
Clinical learning is an indispensable part of nursing and midwifery education programme and an integration of theoretical and practical learning experiences which plays an important role in the acquisition of professional abilities (Ironside et al., 2014;Jonsén et al., 2013;Aghamohammadi-Kalkhoran et al., 2011). An optimal clinical learning environment (CLE) brings a positive impact on students' professional development (Phillips et al., 2017;Chesser-Smyth, 2005); however, there are many challenging factors which influence students' learning in the CLE (Hartigan-Rogers et al., 2007). Inappropriate clinical evaluation, unsuitable programming of clinical education, and organisational shortcomings (Rafiee et al., 2014), unsupportive learning environment (Baraz et al., 2015), inadequate clinical supervision (Rajeswaran, 2017), and difficulties in transferring theoretical knowledge into clinical practice (Mabuda et al., 2008;Sharif and Masoumi, 2008) are viewed as hindrance in clinical learning.
Communication being a key factor in CLE training students on effective communication before exposing them to the CLE is vital (Chamberlain, 1997). Regular observation and supervision of students' practice (Jamshidi et al., 2016), use of trained mentors, sufficient support staff and longer allocations to the clinical areas (Begley, 1999), counselling students to overcome their anxiety, and ongoing training of the mentors and preceptors (Rajeswaran, 2017) are some of the recommended strategies to overcome the possible challenges in CLE. Understanding the factors that influence clinical learning and their complex dynamics allows holistic consideration of students' needs (Leea et al., 2018). Therefore, this systematic review was conducted to identify the challenges faced by students in the CLE to improve effectiveness of clinical learning and help stakeholders to solve these challenges through developing practical and need-based strategies.
'Student nurses/midwives', in this systematic review, present the trainee students undergoing their nursing/midwifery training. 'Clinical staff' present the qualified and registered clinical nurses/midwives who are employed in the clinical settings where the studies have been conducted. Clinical staffs also include the mentors or preceptors who are clinical staffs and play a role in supporting and guiding students in clinical practice. 'Clinical instructors' present the tutors and lecturers from the academic institutions or universities. 'Significant others' refer to patients, patients' family and peers who have been described in the studies to have influence on student nurses'/midwives' clinical experience in the CLE. CLE refers to the clinical settings where student nurses/ midwives are posted as part of their training programme to gain clinical experience.

Aim
To synthesise best available evidence on the challenges faced by student nurses/midwives in the CLE.

Objectives
To determine the perspectives of student nurses/midwives, clinical instructors, clinical staffs (clinical nurses/midwives) on the challenges faced by student nurses/midwives in the CLE.

Study protocol
A study protocol was developed and registered in PROSPERO in 2019.

Criteria of studies
This systematic review includes all primary qualitative research studies published in the English language that reported on the views of student nurses/midwives, clinical instructors and clinical staffs on the challenges faced by student nurses/midwives in the CLE. Quantitative studies or studies that were published in other languages were excluded.
The PICo (P-Population, I-Interest, Co-Context) approach was used to break down the specific objectives and underpin the search strategy.
Population (P): This included the population of interest. The terms to identify Population (P) included student nurses/midwives, clinical instructors (tutors/lecturers) and clinical staffs (clinical nurses/ midwives/preceptors/mentors) (e.g. 'nurse' OR 'nurses' AND/OR 'midwife' OR 'midwives'). Interest (I): This included the views or experiences. Terms to identify the Interest (I) were related to identifying views and perspectives (e. g. 'view or views' OR 'Perspective or perspectives') of the participants. Context (Co): This included the context around the CLE. Terms to identify the Context (Co) included challenges in CLE (e.g. 'challenge' OR 'challenges' OR 'barrier' OR 'barriers').

Search and selection
The electronic databases of Medline EBSCO (1946-), CINAHL (1970), Embase Ovid (1974, ScielO, WHOLIS (2002-), ASSIA (1985-), Web of Science (1956-), PsycINFO (1800s-) and Maternal and Infant Care (1970-) were searched for primary and qualitative research studies that reported on views of student nurses/midwives, clinical instructors and nurses/midwives on the challenges in CLE. A sample of the search result from three of the databases are provided in Appendix 1.
Each retrieved paper was reviewed independently by two reviewers ((MD, JJ), (KR, AD), and (DS, KM)) using Covidence by title, abstract and full text. Disagreements were discussed with the third author (SP) for a decision on inclusion or exclusion.

Assessment of methodological quality
A modified version of the COREQ quality criteria checklist developed by Tong et al. (2007) incorporating four additional items related to aim (no.9), design (no.11 and 12) and analysis (no.32) was used for assessment of methodological quality of the included studies (Appendix 2). Each study was independently reviewed by two authors for assessment of methodological quality, and disagreements were resolved by the third author for a decision on inclusion or exclusion.

Data extraction
A data extraction tool (Table 1) was developed to extract data from included studies by two independent reviewers.

Data analysis
NVivo software package was used to manage data. Thematic analysis was conducted using Braun and Clarke's (2006) framework following the steps of familiarising with data, generating codes, grouping the codes to derive sub-themes, and grouping the sub-themes meaningfully to derive the themes, and finally producing the findings. Participants' verbatim were used as quotations to illustrate the findings.

Results
The search resulted in a total of 32 studies following selection by title, abstract, full text, and assessment of methodological quality (Fig. 1).
A total of 11,759 studies (after removing duplicates (n = 11)) were retrieved from database searching, of which 118 studies were included from selection by title and abstract for full text review. A total of 84 studies were excluded from selection by full text (not related to the inclusion criteria (n = 30 studies) and wrong study design (n = 54 studies)) leaving 34 studies for assessment and reporting of methodological quality. The 34 studies were reviewed for methodological quality using the modified version of the COREQ criteria checklist, and of these, two studies, through independent review by two authors, were concluded to have low scores in methodological quality related to study design     (Appendix 3) and hence, were excluded leaving 32 studies for data extraction and thematic analysis.

Summary characteristics of included studies
The results showed that the 32 studies (Table 1) were published over 22 years between 1997 and 2019 in 14 countries (eight high income (12 studies) and six middle and low income (20 studies) countries) involving over 853 participants including nursing students (n = 717 (male students (n = 36)), student midwives (n = 53), clinical staff (nurse and midwives) (n = 6) and clinical instructors (n = 41). Data were collected using individual interviews (13 studies), focus groups (7 studies), both (five studies) and other methods such as observation, reflection, field notes, response to open ended question, and photographs (seven studies).

Thematic analysis
Findings from all studies were compared, contrasted, aggregated, integrated, and synthesised to derive the themes. Three key themes emerged: 'The support structure', 'Personal factors', and 'Planning and organisationinfluence of extrinsic factors'. Each theme had several sub-themes (Fig. 2). Table 2 presents the themes and subthemes reported in the studies.

Theme 1 -The support structure
Lack of a support structure in the CLE was a key challenge and was  (54) Studies included after assessment for methodological quality (n = 32) Studies excluded after assessment of methodological quality (n=2) Studies included after data extraction and data analysis (n = 32)

Studies included from selection by title and abstract (n = 118)
Studies excluded by title and abstract (n =11,641) reported in 31 of the 32 studies. Four interlinked sub-themes were identified and presented with participants' verbatim as illustrations.

1.i. Attitude of clinical staff and significant others -a key factor
Students' adjustment to the CLE and their learning was strongly determined by and dependent on the clinical staffs' attitude. Positive attitude of clinical staffs, primarily the nurses and midwives, had a positive impact on the overall learning process.
However, in contrast, negative attitude of staffs was described as having a negative impact on students' learning in the CLE.
"Their (midwives') attitude often is…because you're a student you don't need to do that right now. …you need to get to basics." (Midwifery student) (Chamberlain, 1997, p. 89, South of England).
Behaviour of clinical staffs was dependent on attitude of the personin-charge of the clinical area.
"Nurses treat us differently when the supervisor is around…If a more senior nurse is cooperative and likes to help students then the rest of the nurses tend to be helpful too" (Nursing student) (Bawadi et al., 2019, p. 5, Jordan).
Attitude and behaviours of mentors or preceptors also had a significant influence on students' learning in the CLE. Being accepted and valued by a preceptor had a positive impact on students' learning.
"Some preceptors take on more of an authority figure, the students become afraid to ask questions." (Nursing student) (Killam and Heerschap, 2013, p. 686, Canada).
"Some preceptors are overloaded with responsibilities and working night shifts or long shifts makes them tired and not capable of following on students' learning needs".
Attitude of patients, sometimes, was described as being influential in the learning process in the CLE.
"Patient relatives' attitude towards me changes sometimes when they realise I am a student."  Peers' attitude was reported to have, both, positive and negative impact in the learning process.
"We always work together with my friends and help each other to make up for each other. Sometimes we visit patient together and support each other during practices" (Nursing student) (Arkan et al., 2018, p. 130, Turkey).

1.ii. Clinical instructorsattitudes and attributes
A total of 20 studies reported on clinical instructors' attitudes and characteristics, and their influence in learning process in the CLE. Presence and regular supervision provided by a clinical instructor were highly valued as key factors in facilitating a positive learning experience.
"Some instructors put a lot of stress on us and hurry us…some of them don't let us do the tasks at all." (Midwifery student) (Ahmadi et al., 2018b, p. 67, Iran).
While some reported this as being a motivating factor, others described how it had a negative impact on students' learning process. This was mostly related to the clinical instructors' lack of confidence or lack of interest to engage in teaching or enhancing students' learning.
"There was no instructor who could practically and professionally execute ideal care in the clinical environment. Mostly they had low skills and capabilities, their practical skill was low." (Nursing student) (Jasemi et al., 2018, p. 24, Iran).
The communication and collaboration among clinical staff and clinical instructors were acknowledged as a crucial factor in CLE.
"The communication skills of the instructors are very important. When the instructor cannot communicate with nurses, how do nurses collaborate with students?" (Nursing student) (Aliafsari et al., 2018, p. 220, Iran).  valued, a few students reported this as being the most stressful factor.

While presence and regular supervision by clinical instructors were
"I can say the most stressful things are the supervisors because whenever they come … they don't look at positives, they only look at the bad things... So when you realise that the lecturer has come, you became tensed up and stressed." (Nursing student) (Msiska et al., 2014, p. 39, Africa).
"Tutors can make or break the clinical experience to the point that some students don't want to continue" (Nursing student) (O'Mara et al., 2014;Rabori et al., 2019, p. 211, Canada).
However, in general, support from a clinical instructor was viewed as an important factor in the CLE.
"My instructor doesn't support me…When I am supported, I can provide better care for my patients. My instructor does not respect me in front of the patients or the nurses. I feel like an orphan in the hospital." (Nursing student) (Rabori et al., 2019, p. 1986.

1.iii. Sense of belongingness -identity confusion
A sense of being accepted and recognised as part of the team in the clinical environment, reported in 17 studies, was described as an important factor in the learning process.
"A sense of belonging means to me being accepted by the nursing staff and when nursing staff provide help and support and…give me more than they take from me. When they make me feel like … a team, when we have a positive communication, and when they teach me something that I didn't know before." (Nursing Student) (Albloushi et al., 2019, p.71, Saudi Arabia).
Being actively involved in the clinical work gave the students a feeling of being part of the team and accepted, and motivated them to learn.
"...when my tutor gave me that chance to just work on my own and consult her once in a while when I needed something, it just made me feel comfortable and accepted..." (Nursing student) (Mattila et al., 2010, p.155, Finland).
A lack of sense of belongingness was a major demotivating factor in the CLE. Being 'singled out' or lack of positive communication and being treated as an outsider with lack of support structure in the CLE gave the students a feeling of isolation. Most students, especially the new first year students, found this experience challenging and scary. Students expressed the feelings of being discouraged and demotivated in the CLE with loss of self-identity.
"I…have identified the problem … I needed expert knowledge to be able to do something about the situation … I didn't get any help … I think they might have neglected my analysis…" (Nursing Student) (Manninen et al., 2013. p. 138, Sweden).
3.3.4. 1.iv. Disrespect and discrimination. Feelings of being disrespected or discriminated, reported in 17 studies, were other key challenging factors in the CLE.
"The way of treating practicing students was different among clinical nurses. One preceptor let me do a task, viewing it as appropriate, but another preceptor did not allow me to do the same." (Nursing Students) (Ahn and Choi, 2019, p.51, South Korea).

Theme 2 -personal factors
Feeling motivated to learn in the CLE was a facilitator in the learning process. Lack of confidence, preparedness, and motivation to learn were reported in 28 studies as challenges in the CLE. A number of personal factors were reported as being challenging in the learning process. Three subthemes were derived in this context.

2.i. Lack of motivation to learna key factor
Students described a number of reasons for their lack of motivation or interest to learn in the CLE, and this was reported in 23 studies. Lack of support from clinical instructor and clinical staffs and preceptors and peers, lack of respect from patients, and significant others were all contributing to the lack of enthusiasm to learn in the CLE.
"The behasvior of the staff with the students is so unfair that they've lost their motive and don't like to work and learn anymore" (Nursing student) (Dadgaran et al., 2013, p. 6, Iran).
Students' lack of confidence was described as a challenging factor in the learning process.
"Students often do not have enough confidence early in their internship…they gradually become more confident as they get used to the hospital and its environment…" (Clinical Instructor) (Jamshidi et al., 2016, p. 4, Iran).
Clinical instructors, on the other hand, described students' selfmotivation as the key to a positive learning experience.
"Some students are not interested or motivated to learn and expect to be spoon fed. However, they do need to study and if they do not do so then how is this fault of the instructor?" (Clinical instructor) (Bawadi et al., 2019, p. 6, Jordan).

2.ii. Perceived fear
Students, in 20 studies, described their perceived fears around doing mistakes, or harming the patient, or failing in their evaluation, etc. as challenging factors in the CLE.
"I am concerned that I don't know enough and that I might make a mistake that could affect my nursing career or that I could harm a patient." (Nursing students) (Levett-Jones et al., 2015, p.306, Australia).
"I feel that I don't know what to do all the time … He (the patient) gets anxious and so do I!… His life is in the hands of this machine and me!" (Nursing student) (Cooper et al., 2005, p.297, WI).
"If I raise the concern during this placement, can I get my Practice Assessment Document signed? The students prefer to do this statement about poor practice after they finish [their placement]" (Focus group with Link Lecturers) (Harrison-White and Owens, 2018, p.81, United Kingdom).
In one study students expressed their concerns over fear of litigation as a result of errors.
"In the classroom … students are reminded of their responsibilities … They [instructors] say that midwives often are not supported in healthcare settings by healthcare authorities. It is said that when the medical commission for forensic medicine wants to find the person who is guilty for negligence, obstetricians are always more supported than midwives … This makes me worried. This is one of my concerns …" (Midwifery student) (Ahmadi et al., 2018a, p. 112, Iran).
The fear of receiving negative feedback was another demotivating factor.
"…It has happened to me a lot…They shiver…I asked some and they replied 'we're afraid of being told that we are making mistakes…'" (Clinical Nurse) (Najafi et al., 2019, p. 5, Iran).
Being a student was described as feeling 'powerless' with fears around being victim of criticism due to lack of knowledge and required skills.
"if you're a student…you're really quite scared to deny anyone anything… I think it's the pressure of …not wanting to look dumb when you already feel so powerless." (Nursing student) (Killam and Heerschap, 2013, p. 686, Canada).

2.iii. Gendera cultural perspective
Societal expectation of the nursing/midwifery profession and professionals was considered as a challenging factor reported in four studies. Nursing and midwifery were considered as being female dominated professions. This was described, by male students, as being a demotivating factor, which affected their learning in CLE.
"All these problems we face them because now you are going to the female dominated world (female dominated profession) and nobody even told us (male students) that there is challenges in this female dominated world" (Nursing student) (Buthelezi et al., 2015, p. 3, South Africa).
However, some described being a male student was a positive aspect in some ways.
"…the ward staff…are…sometimes rather happy to see male class-mates…Both male and female staffs think that when a male student or male nurse becomes a member of staff in the ward, the atmosphere in the ward will improve…they rather appreciate and rather like to teach our male students." (Nursing student) (Chan et al., 2013, p. 298, HongKong).

Theme 3 -Planning and organisationinfluence of extrinsic factors
Several other factors related to planning and organisation, reported in 20 studies, were described as challenging factors with three interrelated subthemes.

3.i. Lack of resources to facilitate need-based training
Not having the required facilities, and access to physical resources was reported in 17 studies as one of the key factors in the CLE which hindered students' learning.
"Most of the times we are allocated into government hospitals, the materials that are there usually are not enough; they cannot facilitate your learning. Most of the times we are improvising and we don't do the ideal things … So it really affected my learning".
Teaching hospitals were reported as being the ideal environments to facilitate students' learning experience.
"It is very difficult to see some of these cases in the district hospitals because they are usually referred here. So, when we are placed here we get the opportunity to see them live and care for them. I think every student must experience the teaching hospital because of the conditions and machines" (Nursing student) (Atakro et al., 2019, p. 5, West Africa).

3.ii. Inconsistenciesthe theory-practice gap
Fourteen studies reported on students' concerns over the inconsistencies between the knowledge gained in the classroom and the reality in clinical practice. Some of these gaps were related to the differences between rationalising the theory behind the practice. Sometimes clinical staffs taught students the way they practiced, which was not necessarily evidence based or what students were taught in the classroom. These discrepancies led to lack of clarity in practice, and fear in performing a procedure with anxiety around doing errors or harming the patient or being blamed by the instructor or clinical staff or failing in clinical evaluation.
"Theoretical education and clinical practice are not taking place in parallel; what is given in the lecture and what I observe in the clinic are always different from each other…".
"We didn't see many things that we have learnt in theoretical class. It is a difference between real and ideal practice. Many of nurses do not follow established nursing standards. If we follow standards, the nurses may laugh…and I dread this." (Nursing student) (Jahanpour et al., 2016, p. 2, Iran).
"In many cases, we still don't have the necessary theoretical knowledge and due to this, we have not adequate self-confidence to do clinical procedures…" (Nursing student) (Farazi et al., 2018, p. 4, Iran).
Inconsistencies around using a standard and uniform criterion for evaluation was narrated as challenging in CLE.
"Evaluations of the instructors are all according to their own tastes… I really don't know by using which standard, the score was given." (Nursing student) (Baraz et al., 2015, p. 5, Iran).

3.iii. Workload
Seven studies reported the high level of activity in the CLE, and clinical staff being busy and stressed, both, physically and mentally, as demotivating factors in the learning process.
"I am concerned about almost everything to do with clinical placement. The long hours and stress and the full on experience… it all worries me … I don't know how I will cope". (Levett-Jones et al., 2015, p. 306, Australia).
Students described the value of supervision in CLE and how it motivated them to learn new skills with rationale and reduced the gap between their theoretical knowledge and practical experience. However, lack of adequate staffing to facilitate students' supervision in CLE was viewed as a major challenge.
"One nurse has to take care of more than eight patients so that she won't get the time to give equal care or comprehensive care at the same time for all patient … she may fail to meet all the needs of the patient." (Nursing student) (Garner et al., 2014, p. 394, India).

Discussion
This systematic review offers evidence related to challenges faced by students in the CLE through a synthesis of findings from 32 studies.
Three key themes: 'The support structure',' Personal factors', and 'Planning and organisationinfluence of extrinsic factors' emerged with several subthemes.
Lack of a support structure in the CLE and coping with attitudes of clinical staffs and clinical instructors were described as key challenges. Positive attitude of clinical staffs had a positive impact on students' learning (Arkan et al., 2018;Dadgaran et al., 2013), and students valued this support. While a sense of being part of the team created a positive atmosphere for effective learning, feelings of isolation and lack of sense of belongingness were described as demotivating factors which had a negative impact in the learning process (Albloushi et al., 2019) consistent with findings from previous studies that highlight the role of interpersonal relationship with clinical team members in acquiring selfconfidence and clinical competence (Dunn and Hansford, 1997).
Establishing caring relationships with students is a key to creating a caring learning environment (Asirifi et al., 2013). Poor interpersonal relationships between the students, instructors and clinical staff, with lack of collaboration and/or poor communication were identified as being some key factors that negatively influence students' learning, consistent with findings from other studies (Mabuda et al., 2008;Papp et al., 2003). Clinical staffs' support, and clinical instructors' presence, support, supervision, and guidance were described as essential and motivating factors in the learning process which had a positive reinforcement (Baraz et al., 2015;Jamshidi et al., 2016;Dadgaran et al., 2013). However, a few clinical instructors highlighted the importance of students' self-interest as the key in their learning process (Bawadi et al., 2019).
Perceived fear of harming the patient, being blamed or criticised, failing in the evaluation were major concerns among students (Ahmadi et al., 2018b;Harrison-White and Owens, 2018;Levett-Jones et al., 2015;Cooper et al., 2005). A few students described it as a state of feeling 'powerless' (Killam and Heerschap, 2013). This state of feeling vulnerable and helpless was a key demotivating factor in the learning process. Nursing being viewed as a female dominated profession, male students described themselves as being vulnerable due to the cultural perspectives and societal expectations (Buthelezi et al., 2015).
Availability of the physical resources to facilitate need based learning, access to care of patients, and adequate staffing to support and supervise students were reported as being crucial in the learning process (Atakro et al., 2019;Msiska et al., 2014;Garner et al., 2014). Emphasis on revisiting institutional policies with an effort to develop a stress-free learning environment has been a recommended strategy to facilitate students' learning (Tharania et al., 2017).
One of the major challenges was the existing inconsistencies around the theoretical knowledge and practical experience in the clinical setting. This was a hindrance in the learning process leading to lack of confidence, and fear and anxiousness among students (Günay and Kılınç, 2018;Farazi et al., 2018;Jahanpour et al., 2016). Inconsistencies around students' evaluation criteria in clinical practice was another demotivating factor (Baraz et al., 2015), which has been emphasised in other studies with recommendations to use objective criteria for clinical evaluation (Rafiee et al., 2014;Mamaghani et al., 2018).
Although limited to qualitative studies only, one of the strengths of this review is the unique presentation of views of the key stakeholders, student nurses/midwives, clinical staffs, and instructors, on the challenges faced by students in the CLE. The large number (one-third) of the studies from Iran is one of the possible limitations; however, there were no obvious differences in the findings with regards to the social or cultural context. Non-inclusion of Gray literature is a potential limitation. Although findings of this systematic review are limited to the published studies only, a comprehensive amount of information was obtained from the 32 included studies with implications to improve students' experience in the CLE.

Conclusion
Unsupportive learning environment combined with unwelcoming clinical staff, clinical instructors' lack of expertise, and a lack of sense of belongingness among students are a few key challenging factors with negative impact on students' learning in the CLE. Understanding these factors is essential to take appropriate action to overcome the challenges. Although staffing, workload and access to resources required to meet learning outcomes are some of the issues, there are key challenges associated with reducing the theory-practice gap to maintain clarity and consistency in the learning pathway. Findings of this review has the potential to help the key stakeholders identify the challenges and help establish strategies to overcome the possible barriers in the learning process. This study has implications for academic and clinical institutions by facilitating opportunities to collaborate and develop policies with an emphasis on reducing the possible gaps between theory and clinical practice. This will help improve clarity and consistency in learning and making clinical learning a positive experience for every student in the pathway of developing confident and competent nurses and midwives.

Funding
This systematic review is not funded by any funding organisation.