This study was conducted using a mixed-methods explanatory sequential design in August 2024. The quantitative phase preceded the qualitative phase, allowing the initial quantitative findings to inform the qualitative exploration [16] . This approach facilitated a comprehensive understanding of the research problem by combining numerical data with rich, descriptive insights [16] .

The research was conducted at MTRH in Eldoret, Kenya. This national referral hospital serves as a primary clinical training site for diploma nursing students from MTRH-CHS and the KMTC Eldoret Campus (KMTC-EC). The target population included a total of 676 students. Of these, the accessible population meeting the eligibility criteria for the study was 304 students, second- and third-year students (102 from MTRH-CHS, and 202 from KMTC-EC) who were placed at MTRH for clinical attachments.

Given the relatively small and well-defined accessible population of 304 eligible diploma nursing students, a census sampling method was deemed most appropriate. This approach was chosen as it maximizes on the representativeness of the sample and eliminates selection bias [17] [18] . All eligible students—those in their second or third year and undergoing clinical placements at MTRH—were included. Students unwilling to provide informed consent were excluded. This approach maximized data reliability and eliminated selection bias.

Data collection employed two primary tools: a structured questionnaire and a semi-structured focus group discussion (FGD) guide. The questionnaire consisted of demographic items and 5-point Likert-scale questions addressing the study’s variables of interest. For qualitative data, focus group discussions (FGDs) were conducted with four groups of 6 - 8 students each, two for each institution. The FGDs explored experiences and perceptions of the preceptorship model in clinical learning.

Prior to official data coaction, a pilot test of the data collection tools was done using a sample population of 33 students in a neighboring hospital of similar level. Reliability was assessed using Cronbach’s Alpha to measure internal consistency, for which the questionnaire demonstrated high reliability with a Cronbach’s Alpha value of 0.850. The standardized item analysis yielded a slightly lower but still strong value of 0.840 across all the items in the questionnaire. These results indicate that the instrument was reliable and consistent for collecting data on factors affecting clinical learning among diploma nursing students.

Quantitative data were coded and entered into Excel for cleaning and then analyzed using SPSS version 27. Descriptive statistics summarized demographic data and response patterns while inferential statistics including chi-square tests, correlation, and multiple linear regression were used to model relationships between variables and clinical learning performance. For the inferential statistics, composite scores for “student performance”, SRF (student-related factors), TIR (training institution-related factors), and CSR (clinical setting-related factors) were calculated by averaging the individual Likert-scale item responses. Thus, for the composite scores, higher values indicate more positive perceptions of the respective factors, and lower values denote more negative perceptions. Qualitative data were transcribed to text from the audio recordings and analyzed thematically.

Ethical approval was secured from Kenya Methodist University followed by a research license from the National Commission for Science, Technology, and Innovation (NACOSTI). Participants were first informed about the study’s objectives, procedures, and voluntary nature before being asked to voluntarily consent in writing. Confidentiality was ensured through unique alphanumeric identifiers and secure storage of data.

The study sample consisted of a total of 304 respondents, which was 100% response rate. In terms of age distribution, the majority of participants were between 20 - 24 years, accounting for 229 (76.8%) of the total sample, followed by 52 (17.4%) who were in the 25 - 29 age bracket, and 17 (5.7%) who were aged 15 - 19 years. Regarding gender, female participants made up 184 (60.5%) of the respondents, while 120 (39.5%) were male. As for the institutions of study, students from the KMTC-EC formed the larger group, with 202 (66.4%) participants, while 102 (33.6%) were from MTRH-CHS. This demographic distribution reflects a youthful cohort predominantly in the early stages of their professional training, with a higher representation of females, and a significant portion attending KMTC ( Table 1 ).

Self-perceived performance in clinical placements revealed several notable trends. A significant portion of respondents, 146 (48.03%), strongly agreed that they effectively applied nursing knowledge during clinical placements, with a mean score of 4.27 (SD = 0.95). Similarly, 148 (48.68%) strongly agreed that their clinical reasoning abilities enabled effective patient assessment and care planning, reflecting a high mean of 4.26 (SD = 0.90). However, in managing complex patient cases, a smaller percentage, 99 (32.57%), strongly agreed, indicating slightly lower confidence in this area, with a mean of 3.99 (SD = 0.93). Notably, the ability to integrate evidence-based knowledge showed more neutral responses, with 54 (17.76%) neither agreeing nor disagreeing and a mean of 3.97 (SD = 0.99). Overall, the students reported high confidence in their clinical skills, but areas such as managing complex cases and integrating evidence-based care showed room for improvement ( Table 2 ).

High motivation was reported by 99 (32.57%, mean = 3.65, SD = 1.27, χ² = 45.502, p = 0.000). Confidence in abilities was high among 132 (43.42%) agreeing and 74 (24.34%) strongly agreeing (mean = 3.75, SD = 1.05, χ² = 78.739, p = 0.000). Anxiety negatively impacted 67 (22.04%) respondents (mean = 2.90, SD = 1.37). Financial constraints presented mixed responses, with 59 (19.41%) strongly agreeing and 58 (19.08%) strongly disagreeing (mean = 3.06, SD = 1.41, χ² = 41.379, p = 0.000). Integration of theory into practice was notable, with 135 (44.41%) strongly agreeing (mean = 4.03, SD = 1.16, χ² = 105.968, p = 0.000). Communication difficulties and lack of self-directedness affected 41 (13.49%) and 31 (10.20%) respondents respectively ( Table 3 ).

The analysis of training institution-related factors highlighted critical gaps, including improper supervision (mean = 2.37, SD = 1.37, χ² = 70.332, p = 0.000), insufficient learning resources (mean = 2.43, SD = 1.32, χ² = 66.000, p = 0.000), and inadequate curriculum coverage of clinical skills (mean = 2.41, SD = 1.29, χ² = 77.212, p = 0.000). Limited opportunities for feedback (mean = 2.48, SD = 1.35, χ² = 66.957, p = 0.000) and ineffective communication between training institutions and clinical sites (mean = 2.32, SD = 1.29, χ² = 47.252, p = 0.000) were also significant ( Table 4 ).

The analysis of clinical setting-related factors revealed key challenges. Lack of cooperation between clinical staff and students was noted, with 47 (15.46%) agreeing and 27 (8.88%) strongly agreeing (mean = 2.61, SD = 1.37, χ² = 64.820, p = 0.000). Inadequate personal protective equipment was reported, with 68 (22.37%) agreeing and 33 (10.86%) strongly agreeing (mean = 3.02, SD = 1.45, χ² = 53.259, p = 0.000). Traumatic experiences were experienced or witnessed by 72 (23.68%) agreeing and 61 (20.07%) strongly agreeing (mean = 2.34, SD = 1.16, χ² = 24.396, p = 0.018). Lack of structured orientation programs was highlighted by 38 (12.50%) agreeing and 16 (5.26%) strongly agreeing (mean = 2.31, SD = 1.20, χ² = 43.860, p = 0.000). Limited opportunities to apply knowledge and develop skills were identified, with 49 (16.12%) agreeing and 14 (4.61%) strongly agreeing (mean = 2.84, SD = 1.38, χ² = 103.513, p = 0.000) ( Table 5 ).

Composite scores were created for each of the major variables by averaging responses within each category to simplify analysis. These scores were used as predictors in correlation and regression analysis to assess their relationship with student performance. Correlation analysis showed that TIR had a low but significant negative correlation with performance (r = −0.31, p < 0.0001), suggesting that factors such as poor supervision and inadequate feedback are linked to lower outcomes. Similarly, CSR exhibited a negative correlation with performance (r = −0.29, p < 0.0001), highlighting the impact of inadequate resources and lack of cooperation in clinical settings. Student-related factors showed no significant correlation with performance (r = −0.004, p = 0.937), indicating minimal influence on outcomes ( Table 6 ).

^aPredictors: (Constant), Clinical setting-related factors, Student-related factors, Training institution-related factors.

^aDependent Variable: Student Performance; ^bPredictors: (Constant), Student-related factors (SRF), Training institution-related factors (TIR), Clinical setting-related factors (CSR).

The multiple linear regression analysis revealed that student factors, clinical setting-related factors, and training institution-related factors (TIR) collectively explained 12.5% of the variance in student performance (R² = 0.125, adjusted R² = 0.116) ( Table 7 ). The model was statistically significant (F = 13.424, p < 0.001). All factors were shown to be statistically significant: SRF positively influenced performance (B = 0.124, t = 2.285, p = 0.023), while TIR (B = −0.148, t = −3.018, p = 0.003) and CSR (B = −0.112, t = −2.133, p = 0.034) had significant negative effects ( Table 8 ).

The main themes identified in the qualitative data revolved around clinical environment challenges, student confidence and attitudes, and institutional support. Key themes included the alignment of theory and practice, where students reported that theoretical knowledge aligned with clinical experiences, but resources like equipment and staff were often lacking. Nurses’ attitudes significantly impacted learning, with both positive and negative effects on student engagement. Confidence-building through hands-on experience was crucial, though anxiety and self-esteem issues hindered some students. Additionally, the inconsistency in tutor availability and feedback was a major concern, with students feeling unsupported at times. These themes highlight the complex interplay of factors shaping students’ clinical learning experiences. These are summarized in Table 9 .

The findings highlighted the complex role of student-related factors such as motivation, confidence, anxiety, and self-esteem in shaping clinical performance. Motivation emerged as a key determinant of student engagement, consistent with previous research emphasizing its role in fostering clinical competency. Motivated students tend to exhibit proactive learning behaviors, allowing them to integrate theoretical knowledge into practice more effectively [19] [20] . Confidence was also identified as an essential factor, with students reporting that repeated practice and constructive supervision helped them gain self-assurance in clinical skills [21] [22] . This aligns with studies showing that hands-on exposure and preceptorship enhance confidence, enabling students to overcome initial apprehensions and perform tasks independently [23] .

Conversely, anxiety was found to negatively influence student engagement and performance [24] - [26] . Previous research corroborates that anxiety can impair cognitive functioning and hinder decision-making, creating barriers to effective learning in clinical environments [27] . Unfavorable interactions with clinical staff, such as being reprimanded in front of patients, further exacerbated anxiety, making students hesitant to seek help or ask questions [24] [25] . This finding is consistent with studies suggesting that anxiety can lead to avoidance behaviors, which restrict learning opportunities and erode confidence over time [28] . Addressing these challenges requires creating supportive clinical environments that reduce stressors and foster psychological safety [29] .

Self-esteem emerged as another critical factor, with students reporting that their ability to acquire skills was influenced by their confidence in their competencies [29] [30] . The literature emphasizes that high self-esteem is integral to success in clinical settings, as it promotes autonomy and professional development [24] [25] . Students who develop self-efficacy through practice and constructive feedback are better equipped to face the challenges of clinical placements [31] [32] . However, self-esteem can vary based on cultural and individual factors, necessitating tailored interventions to bolster confidence in students who may be struggling [33] [34] .

Resilience, while not explicitly measured, emerged as a sub-theme in the qualitative data. Students who adapted to stressful environments and overcame initial fears demonstrated better performance over time [35] [36] . Resilience has been identified in the literature as a critical trait for nursing students, helping them navigate the demands of clinical practice and develop adaptive coping mechanisms [37] [38] . These findings underscore the importance of fostering resilience through structured support programs and experiential learning opportunities [36] [39] . Interestingly, the absence of a statistically significant relationship between student-related factors and performance suggests that external variables, such as institutional and clinical environment support, may play a more dominant role in determining outcomes. This aligns with studies emphasizing the importance of addressing systemic barriers alongside individual factors to optimize clinical learning [7] [13] .

These findings must also be interpreted within the socio-cultural context of the country wherein the study happened. Literature shows that cultural factors significantly influence nursing students’ clinical learning experiences in Kenya and other African countries and therefore might have influenced these results too [34] [40] . In Kenya, young people are naturally raised to respect authority and honor hierarchical structures, and this can impact students’ ability to speak up about patient safety issues and their learning within the care settings they are exposed to [34] [40] . Also, the collectivist cultures typical of many Kenyan communities may affect professional socialization and adaptation to clinical environments [40] .

Gender dynamics play a key role in how learning happens. Male and female students experience different barriers to effective clinical learning [7] . Kenya’s society has evolved from a past where males received an upper hand in education; thus these may also have a hand in the findings herein. Similarly, social support, including mentoring and supervision, is crucial for culturally diverse nursing students’ success [41] [42] . Gladly, Kenyan nursing systems are increasingly embracing mentorship approaches to ensure learners grasp skills excellently. This is a cultural factor too, because Kenyan communities are primarily closely knot and even skill acquisition happens in community settings. Finally, language barriers and heavy cultural expectations can interfere with professional responsibilities [43] . Improving clinical supervision, orientation, and creating welcoming environments are recommended to address the unique learning needs of culturally diverse nursing students [42] [43] .

Training institution-related factors, such as supervision, feedback, and teaching methods, significantly influenced clinical performance [32] [44] . Inadequate supervision emerged as a critical barrier, consistent with research indicating that effective supervision is essential for bridging the gap between theory and practice [1] [13] . Without proper guidance, students often feel uncertain about applying their theoretical knowledge in real-world settings, limiting their ability to develop essential nursing competencies [45] [46] . Preceptors play a pivotal role in shaping student experiences, but the qualitative data revealed frustrations over inconsistent supervision and a lack of constructive feedback [47] . This finding aligns with studies emphasizing the need for active and supportive mentorship to enhance learning outcomes [32] .

Feedback mechanisms were also found to be critically wanting, with many students reporting that preceptors focused solely on mistakes rather than providing balanced feedback. Effective feedback is essential for fostering reflection and continuous improvement, yet its absence can demoralize students and hinder their progress [48] . Constructive feedback not only helps students identify areas of improvement but also reinforces positive behaviors, fostering motivation and professional growth. Resource shortages further compounded the challenges faced by students, consistent with findings from LMICs, where inadequate infrastructure often limits the quality of clinical education [49] . The lack of simulation labs, sterile equipment, and other essential resources forced students to improvise, compromising both learning quality and safety. Resource constraints not only impede skill development but also expose students to risks, underscoring the need for institutional investments in clinical training infrastructure [50] [51] . The findings highlight the systemic nature of these challenges, suggesting that addressing training institution-related factors requires a multi-faceted approach [52] . Improved supervision, regular feedback, and well-resourced learning environments are critical for ensuring that students receive the support they need to succeed in clinical settings [52] .

The present study’s findings reveal significant deficiencies in clinical setting-related factors that fundamentally compromised nursing students’ clinical performance and learning outcomes [53] [54] . Staff cooperation emerged as a critical determinant, with participants consistently reporting poor collaboration between clinical personnel and students, creating unwelcoming environments that inhibited active learning engagement [13] [55] . This finding corroborates established literature demonstrating that inadequate staff-student relationships create systematic barriers to clinical education effectiveness [7] . The observed disconnect between educational institutions and clinical sites represents a structural failure in clinical education delivery, where students experience reduced opportunities for skill acquisition due to their reluctance to engage with unsupportive clinical staff [56] . This phenomenon reflects broader institutional challenges in maintaining effective partnerships between academic and clinical settings, ultimately undermining the quality of nursing education and necessitating enhanced faculty-practice relationships and comprehensive orientation programs [53] .

Resource inadequacy, particularly the shortage of personal protective equipment (PPE), constituted another significant barrier to optimal clinical performance and contributed to academic distress among nursing students [54] . The data revealed that insufficient PPE not only restricted students’ participation in essential clinical procedures but also generated heightened anxiety levels that further compromised their learning capacity, reflecting the challenging and stressful nature of clinical education [53] . This finding assumes particular significance in light of global health crises, where PPE shortages have been documented to substantially impact healthcare training programs [13] [55] . The relationship between resource availability and student engagement demonstrates a clear correlation between material support and educational outcomes, with resource shortages creating inconsistencies between theoretical knowledge and practical application that adversely affect the clinical learning environment [13] [55] .

The exposure to traumatic experiences without adequate institutional support emerged as a particularly concerning finding, with students reporting significant psychological distress from witnessing challenging clinical events that contributed to anxiety and depression [54] . This finding aligns with literature indicating that unprocessed traumatic exposure in clinical settings can precipitate long-term mental health complications, including anxiety disorders and professional burnout [57] . The absence of structured support mechanisms, including counseling services and systematic debriefing protocols, represents a critical gap in clinical education frameworks that fails to address the need for resilience training and supportive campus climate essential for student well-being [58] . These findings collectively indicate that clinical setting-related factors operate as interconnected systems that either facilitate or impede student learning, emphasizing the necessity for comprehensive institutional reforms incorporating effective communication strategies, coping mechanisms such as debriefing sessions, and family support systems to optimize clinical education outcomes and help students navigate their clinical placements successfully [56] .

This study has several limitations that should be considered when interpreting the findings. First, the reliance on self-reported data introduces the potential for response bias, as participants may have provided socially desirable answers or inaccurately assessed their own clinical learning experiences. Additionally, the study’s single-site design, conducted at Moi Teaching and Referral Hospital, limits the generalizability of the findings to other clinical settings or regions. The cross-sectional nature of the study further restricts the ability to draw conclusions about causality or changes over time. Finally, the modest R² value of 12.5% indicates that while the identified factors explain a portion of the variance in clinical learning outcomes, other unexamined variables likely contribute to the complex nature of the learning process. These limitations suggest that further research with a more diverse sample and longitudinal design is needed to gain a deeper understanding of the factors influencing clinical learning among nursing students.