4

Chapter 1

Introduction

Student nurses have different clinical experience, most especially when they are placed

in the private and public hospital setting. Moreover, it has been a fact that there is indeed a

huge difference in the learnings provided in terms of environmental factors. Clinical

exposure in the nursing field during the undergraduate years is an integral part of the

education. Student nurses are taught to prepare themselves to be able to do and know certain

aspects in providing and giving care to the patients. Additionally, the clinical scope will help

stimulate the students to think critically to be able to solve problems in regards with the

needs of their patients.

As discussed in a concept analysis type of literature, there are four attributes that affect

the learning experience of the students. These in the form of physical space, psychosocial and

interaction factors, organizational structure and teaching and learning components (Flott &

Linden, 2015). With these characteristics provided and determined, an environment that has

all the positive attributes of the four given characteristics will likely lead to determining the

positive learning outcome of the students, as well as their self-confidence in their chosen

field of expertise.

For higher education institutions that offer health-related courses, it is a relevant and

significant concern that they choose and support partnerships in clinical learning

environments that will provide quality clinical experience, to aid in the also providing the

society with future competent health care providers (Papastavrou, Dimitriadou, Tsangari &

Andreou, 2016). In context to the importance of clinical exposure to the nursing education,

the study by Jamshidi, Molazem, Sharif, Torabizadeh and Najafi Kalyani (2016) discusses
 5

that “The clinical area of nursing education is of great important for nursing students in the

selection or rejection of nursing as a profession (p. 1).” With this, an integration of both

theory and practice with good clinical supervision could enable student nurses expand their

knowledge, increasing their confidence with their own abilities and competence.

The purpose for this is to reduce future errors and provide health consumers with

caregivers who are competent at their own craft, in this case, student nurses are molded to

become one of the first-line responders to emergencies and bedside care. Their impact on the

lives of their patient will show a nurtured community. Therefore, the goal of this study is to

examine the difference of clinical exposure of student nurses when they are placed in the

public and private hospital setting, providing insight to develop an effective strategy and

policy in nursing education.

Research Questions

This study will be conducted to determine and compare the experiences of student

nurses in the public and private hospital setting. More so, the objective of the study aims to

answer the following questions:

1. What is the extent of clinical exposure of the respondents of private hospitals in terms

of:

a. Skills;

b. Environment and

c. Patient?

2. What is the extent of clinical exposure of the respondents of public hospital in terms

of:

a. Skills;
 6

b. Environment and

c. Patient?

3. Is there a significant difference on the clinical exposure of the respondents between

private and public hospitals?

4. Is there a significant difference on the clinical exposure of the respondents when

grouped according to:

a. Age;

b. Gender and

c. Year Level?

Hypotheses

The following hypotheses were formulated based on the research questions listed

above:

1. There is no significant difference on the clinical exposure of the respondents between

public and private hospitals.

2. There is no significant difference on the clinical exposure of the respondents when

grouped according to age, gender, and year level.

Significance of the Study

The findings of this study will benefit students not only in nursing but other health-

related profession. The greater demand of knowledge about this matter will reveal whether a

need for more effective, teaching approaches and exposures is needed to ensure competent

health professionals in the future. Moreover, specific groups will see this study and its results

as beneficial to:
 7

School Administrators. The study will be a start for the initiating of innovation within

the academe, uncovering new methods in the development of the quality nursing education

under their nursing and health-related programs.

Colleges of Nursing. This will help administrators in the nursing programs understand

the everyday experiences of their students and will uncover new measures to implement

policies that will cater to the needs of the students as they achieve for greater heights in their

endeavors as giver of care.

Clinical Instructors. The study will help clinical instructors understand the perception

of their students towards their clinical exposure, which in turn, will serve as basis for

evaluation on the current teaching approaches and eventually address the needs of their

students.

Student Nurses. The study will promote confidence that could aid to control their fear

and anxiety, and choose to maximize learning and quality of service they will render to their

patients during their clinical duty.

Future Researchers. The pages of this study will provide additional information

leading them to contribute new knowledge for the current available data regarding this topic

and to conduct further studies.

Scope and Delimitation

The study will center on the clinical exposure of student nurses within public and

private hospital settings. Samples will comprise of 91 respondents under the BS Nursing

program who will be enrolled for Academic Year 2019-2020, in a private higher education

institution situated in Metro Manila, who will answer a self-constructed survey-

 8

questionnaire. However, the Level 1 nursing students will be eliminated to participate due to

not having been exposed to clinical duties.

Theoretical Framework

The “Experiential Learning Theory” will be used to anchor the primary objective of

this research study. The theoretical framework is authored by David Kolb in 1984.

Concrete
Experience (CE)

Accommodating Diverging

Active Reflective
Experimentation Observation
(AE) (RO)
Converging Assimilating

Abstract
Conceptualization
(AC)

Figure 1. Kolb’s experiential learning theory (ELT). Adapted from Experiential Learning

Theory: A Dynamic, Holistic Approach to management Learning, Education and

Development, by A. Y. Kolb & D. A. Kolb, 2009.

According to Kolb, Boyatzis, and Mainemelis (1999), the theory suggests that a certain

experience is transformed into knowledge, creating a process which is called “learning.”

Additionally, this theory includes two modes of obtaining or grasping experience which

includes Concrete Experience (CE) and Abstract Conceptualization (AC), and two modes

that transforms experience which are Reflective Observation (RO) and Active

Experimentation (AE). In this four-stage cycle, concrete experiences will lead to

 9

observations and reflections. As they watch, abstract will be conceptualized, which will lead

to thinking and idealization. Once abstract is conceptualized, actual experimentation will

then occur.

Kolb, Boyatzis and Mainemelis (1999) further clarifies that the “watchers” tend to

favor reflective observation, while the “doers” favor active experimentation.

Research Paradigm

Dependent Variable Independent Variable Dependent Variable

Public Hospital Clinical Exposure Private Hospital

Moderating Variables

A. Age
B. Gender
C. Year level

Figure 2. Research Paradigm on clinical exposure of student nurses in public and

private hospitals.
 10

Definition of Terms

For better understanding, the terms integrated within this research study were defined

operationally:

Student nurse – person who is studying or training to become a nurse.

Clinical practice – field of experience and activities for student nurses which includes being

exposed in the actual healthcare setting.

Private hospital – a hospital owned by a company or organization and privately funded

through payment for medical services by patient consumers.

Public hospital – a hospital owned by the government, which provides medical care free of

charge.

Skills – interventions performed by student nurses in the hospital duty.

Environment – the setting of which the student nurses is exposed.

Patient – person who utilizes healthcare services which are handled by student nurses during

their clinical exposure.

 11

Chapter 2

Review of Related Literature

This chapter will provide local and international related literatures and studies on the

clinical exposure of student nurses in public and private hospitals.

Nursing Education in the Philippines

A study by Masselink and Lee (2010) suggested through their results that nursing

schools in the Philippines have provided migration opportunities for undergraduate student

nurses for expanding student diversity within the nursing education. In context to the result

provided by Masselink and Lee, despite the increasing need for nurses in the local setting,

many are not swayed by this problem and are blindsided by the opportunities that other

countries can offer plus the negativity that may have been contributed by early clinical

exposure among student nurses, affecting their judgement and insights on the health care

delivery system in the country.

However, student nurses are taught and trained thoroughly, learning to respond first

hand on emergencies, provide care at the bedside, and most especially, the art and science of

caring is embedded within them in the course of four years (Usher, et al., 2015). After years

of education, as discussed by the Bureau of Local Employment – Department of Labor and

Employment in an online article, (n. d.), the BSN degree qualifies them to practice the

nursing profession, however, another factor to become a full-fledged registered nurse is one

must be able to pass the board examination to obtain official license issued by the

Professional Regulation Commission (PRC). In the Philippines, approximately about more

than 100,000 student nurses graduate each year (Labrague, McEnroe-Petite, Gloe, Tsaras,

Arteche, & Maldia, 2016).

 12

In terms of clinical exposure, the BS Nursing curriculum in the Philippines includes

Related Learning Experience (RLE) as part of the requirements to be completed to be able to

be conferred with such degree. This is a teaching approach for the student nurses to develop

the competencies required in the field of nursing. In view of this, the RLE approach is

applicable in two areas, the guided practice in the skills laboratory and in the actual clinical

exposure. The clinical exposure should at least have 33.5 RLE units, or 1,708.5 hours for the

13 major subjects with RLE (Commission on Higher Education [CHED] Memorandum

Order No. 14, series of 2009).

Clinical Exposure

“Nurses’ competence is based on the knowledge and skill taught to them (p. 1),” as

discussed by Jamshidi, Molazem, Sharif, Torabizadeh, and Najafi Kalyani (2016). Learning

skills on hand, and on a real patient will increase both confidence of the student nurse to

execute such intervention. Though classroom education has been a conventional intervention

for students to obtain knowledge, clinical training will provide opportunity for students to

convert classroom-obtain knowledge into practice.

According to the research authored by d’Souza, Karkada, Parahoo, and

Venkatesaperumal (2015) which focused on the clinical learning environment of nursing

students in Oman, through this exposure, students are able to develop “independence, critical

thinking, and clinical judgement, problem solving skills, ethics, safety practices, and sense of

responsibility (p. 833).”

Clinical experiences and the factors that come along will contribute to the learning of

student nurses. Every exposure can waste a great deal of time and energy, and over and

above that, nursing education and the clinical exposure impose burden financially for both
 13

student and parents. Poor clinical exposure and supervision can cause and compromise

patient care. Furthermore, the same qualitative literature provides result with two themes

from the analysis of their data, and one of the two themes were unsupportive learning

environment as a students’ clinical learning challenges (Baraz, Memarian, & Vanaki, 2015).

Further, a literature emphasizes that four aspects affect a student’s exposure in the clinical

area, and in the physical aspect, facilities, material equipment, and learning tools were

presented to have great contribution in one’s learning (Haraldseid, Friberg, & Aase, 2015).

In terms of environment and supervision during clinical exposure, different medical

institutions have their own way of handling student nurses in their workplaces, creating

policies, objectives and guidelines to assist student nurses. A study by Moyimane, Matlala,

and Kekana (2017) discusses the objective of clinical practice for student nurses mandated by

the South African Nursing Council which provides the up and coming registered nurses of

meaningful learning opportunities in all ears of clinical placement to ensure that, when the

time of completion comes, these student nurses will be able to provide quality nursing care to

their patients on their own judgement.

Public and Private Hospitals

Healthcare institutions are learning environments for nursing students. Hospital

leadership styles, mentorship, supervision, communication, acquitting with the registered and

experienced nurses are factors that affect nursing students in one way or another. Over and

above that, it is a place where nursing students potentially develop their skills. Thus, theories

should be translated in to practice so that students can experience working in the real-life

situation.
 14

The Philippine health care system consists of hospitals that are either publicly owned

by the government or privately own by non-government organizations (Picazo, 2015). And

with this, this becomes a criteria for health consumers, for it has been embedded among

individuals that the public and private sectors provide services that are not of the same level

when it comes to promoting health services of quality (Alijanzadeh et al, 2016). Moreover,

among the perspective of the respondents, proper medical equipment and appropriate

facilities for patents were two of the qualities that showed significant difference between the

public and private sectors (p < 0.05). And in contrast to a study by Haraldseid, Friberg, and

Aase (2015) revealed in the study they have conducted that four aspects affect a student’s

exposure in the clinical area, and in the physical aspect, facilities, material equipment, and

learning tools were presented to have great contribution in one’s learning. With this qualities

lacking, clinical exposure among this sectors can severely affect and impact the students’

confidence and professional growth and development when they are not able to put their

theoretical knowledge into practice.

Additionally, a study by Ward et al (2015) presented through their results that the

quality and trust provided by the private hospital are better than of public hospitals. With this

information at hand, this is also a possibility that a better learning outcome can come from

private sectors for they provide quality care, which is ideally taught in the nursing education

as well.

In contrast, another study have found that the public and private hospital setting

presents no significant differences. In terms of patients treated, the public sector tends to

cater slightly older individuals who may also have a lower socio-economic status, riskier

lifestyle and higher morbidity rate than of the private hospital setting. More so, the study
 15

emphasizes that the quality provided by both sectors are the same, however, in similar views

with other literatures, the private sector tend to have the latest and a more higher number of

equipment compared to the public sector, which usually obtains their funding from the

government (Tynkkynen & Vrangbæk, 2018).

Clinical Exposure and Skills

Clinical duties are the riskiest professional jobs ever, and a simple mistake can cause

one’s life unexpectedly. In order to execute certain skills and interventions appropriate to

their patients, clinical exposure is a very important factor to obtain enough knowledge to

save one’s life (Noviyanti, Handiyani, & Gayatri, 2018).

Research showed that nursing students still lack the appropriate skills toward patient

safety. The study by Solvik and Struksnes (2018) revealed several findings in regards to skill

development. Majority of nursing students reported that although exercise in the clinical lab

is one of many ways to prepare a student for practice, they were not able to perceive the

difference in resemblance of occurrences of exercises in the actual hospital setting. Lastly,

students with previous experience were less confident to master a certain procedure in the

clinical practice.

Similarly, another literature found that clinical practicum aids nursing students to

acquire practical knowledge rather than theoretically, for this allows the students to apply

what they have learned in the classroom setting towards the real-life situation, hence, leading

to the students to improve their skills, providing effective services. This somehow places

stress among students as well, affecting their academics the most, especially when additional

tasks are given to the student nurses. However, in summary, the student nurses who
 16

responded on the study believed that clinical exposure improved their skills in the nursing

practice (Adjei, Sarpong, Attafuah, Amertil, & Akosah, 2018).

Clinical Exposure and Environment

Environment, when it comes to an attribute of the workplace, is one of the inevitable

factors that either brings positive or negative changes. Victor, Ishtiaq, and Iqbal (2016)

conducted a research on the perception of clinical environment among nursing students of a

private college of nursing in Pakistan. Utilizing an analytical cross-sectional survey, this

determined that out of the 195 respondents, 88 (45.13%) showed to some extent agreement

on pedagogical atmosphere, 91 (46.67%) showed to some extent agreement on leadership

style of ward manger, nursing care on the ward and role of nurse teacher 21.54% (42) and

supervisory relationship 20% (39) respectively. Over all, the respondents exhibited high

positive perception, further concluding that “clinical learning is vital in nursing education as it

forms the basis of clinical practice and patient care, therefore, positive perceived environment is

imperative for the nursing students (p. 33).”

Clinical environment can be more appreciated when there are effective leadership,

supervision, and mentorship in the hospital setting. Clinical learning environment is so

important for student nurses because it aids the students to develop self-confidence and

improve their communication skill with the patients that they encounter. Study revealed that

the application of theories in to practice in the learning environment is very minimal with

reports from students that experienced nurses were not willing to show and share their skills

and knowledge with them (Adjei, Sarpong, Attafuah, Amertil, & Akosah, 2018).
 17

Clinical Exposure among Student Nurses in terms of Age

The study authored by Solvik and Struksnes (2018) revealed in their findings that age

did not impact the students’ confidence in mastering certain interventions and exercises in

the clinical practice.

In contrary, a literature has provided evidence that mature aged nursing students

performed a significant higher level of success during their clinical exposure. However,

future researches are recommended to further advance the understanding of the complex

relationship between extrinsic and intrinsic factors of mature age students and their academic

success in higher education (Hayden, Jeong, & Norton, 2016).

Clinical Exposure among Student Nurses in terms of Gender and Year Level

In a descriptive cross-sectional study conducted to determine the nursing students’

perspective on clinical education, 150 nursing students were selected to take part. Results

revealed that the male and female students had different perceptions in several domains of

the clinical education (Heidari & Norouzadeh, 2015).

Given that male nursing students represent a small percentage of the student population

of the nursing program today, a study by Sedgwick and Kellett (2015) revealed that male

students demonstrated significantly lower scores on the efficacy subscale (p = 0.02),

suggesting that males have experienced more feelings of marginalization and discrimination

with the profession, and these can severely affect their performance which creates more bias.

In contrast, another study has included that one of the variables that influence clinical

stress among nursing students is gender, however, in statistics, there is no significant

relationship between clinical practice stress and gender (p = 0.013). Additionally, year level,

conversely did show statistical significance, which is suggestive that senior nursing students,
 18

or those on their fourth and final year has reported that they have been experiencing clinical

practice stress (p < 0.001) (Lee, You, & Park,

Chapter 3

Methodology

This chapter will present the research design utilized, the locale of the study, sampling

technique used, the instrumentation that will be used for data collection, and the statistical

treatment of data.

Research Design

The study will utilize a descriptive-comparative design of quantitative research. This

type of research design is one of the most basic, focusing solely in seeking to describe

phenomenon that occurs, and how they vary (Esser & Vliegenthart, 2017). This study will

aim to examine the experiences of student nurses during their clinical exposure in both the

public and private hospitals when the respondents are grouped according to their

demographics, such as their age, gender, and year level. The study also objectifies the extent

of clinical exposure of the nursing students in terms of the environment, patient and skills.

Population and Sampling

The population of this study will consist of students enrolled under the BS Nursing

program for the first semester of the Academic Year 2019-2020 of a private higher education

institution in Metro Manila. A total of 91 respondents was chosen, using the purposive

convenience sampling technique. However, an inclusion criteria eliminates the level one
 19

nursing students for they are not currently exposed in the clinical areas. Respondents will

come from the sophomores (n = ), juniors (n = ), and senior nursing students (n = ).

Data Gathering Procedure

In obtaining the complete list of student nurses of the private higher education

institution, the researchers will seek the approval of each appropriate corresponding

departments with a written letter, with full disclosure of the purpose of the study, and an

assurance that data privacy will strictly be implemented.

Statements or items, together with a demographic data checklist will be handed and

distributed among the chosen respondents through a self-constructed survey-questionnaire

which will focus on the clinical exposure of student nurses within public and private

hospitals.

Once the questionnaires are handed over to their respondents, the researchers will

disclose all information regarding the study and will assure that confidentiality of data will

be provided and that no other persons not related or connected within the research study will

take hold of the accomplished questionnaires. Researchers will then allow the respondents to

answer the questionnaires on their own, to promote autonomy and will only provide

explanation if asked to do so. Once all questionnaires are accomplished, they will be placed

in a safe box and will be encoded to begin data analysis.

Instrumentation

The tool that will be utilized to gather the needed data will be through a self-

constructed survey questionnaire which will measure the experiences of student nurses

during their clinical exposure in public and private hospitals. The questionnaire will use a 5-

point Likert scale to indicate and described whether the student nurse ‘never’, ‘seldom’,
 20

‘sometimes’, ‘frequently’, and ‘always’ experience certain intervention during their clinical

exposure.

Statistical Treatment

To be able to answer the objectives of this study, both descriptive and inferential

statistics will be utilized. The extent of clinical exposure to both public and private hospitals

in terms of environment, patient and skill, descriptive statistics such as frequency

distribution, percentage and mean will be used.

Further, inferential statistics such as independent t-test and one-way ANOVA will be

used to determine the difference between clinical exposure to public and private hospital

when the respondents are grouped according to their demographics, such as age, gender and

year level.

Ethical Consideration

This study will consider all participation as voluntary and will allow chosen

respondents to withdraw their chance to accomplish a questionnaire if they wish to do so.

They will also be provided with a letter of invitation to participate and an informed consent

form filled with information regarding the study, adapted through the informed consent

forms template provided by the World Health Organization. This research study has

undergone the ethics review board of Manila Adventist College. To add, respondents will be

given privilege to privacy and confidentiality and rest assured that all the articles

incorporated within the pages of this manuscript will be acknowledged.

 21

References

Adjei, C. A., Sarpong, C., Attafuah, P. A., Amertil, N. P., Akosah, Y. A. (2018). “We’ll

check vital signs only till we finish the school”: experiences of student nurses

regarding intra-semester clinical placement in Ghana. BMC Nursing, 17(1), 23. Doi:

10.1186/s12912-018-0292-0.

Alijanzadeh, M., Zare, S. A. M., Rajaee, R., Fard, S. M. A. M., Asefzadeh, S., Alijanzadeh,

M., & Gholami, S. (2016). Comparison quality of health services between public and

private providers: the Iranian people’s perspective. Electronic physician, 8(9), 2935-

2941. Doi: 10.19082/2935.

Baraz, S., Memarian, R., & Vanaki, Z. (2015). Learning challenges of nursing students in

clinical environments: A qualitative study in Iran. Journal of Education and Health

Promotion, 4. Doi: 10.4103/2277-9531.162345.

d'Souza, M. S., Karkada, S. N., Parahoo, K., & Venkatesaperumal, R. (2015). Perception of

and satisfaction with the clinical learning environment among nursing students. Nurse

Education Today, 35(6), 833-840. Doi: 10.1016/j.nedt.2015.02.005.

Esser, F. & Vliegenthart, R. (2017). Comparative research methods. The International

Encyclopedia of Communication Research Methods, 1-22. Doi:

10.1002/978111890131.iecrm0035.
 22

Flott, E. A. & Linden, L. (2015). The clinical learning environment in nursing education: a

concept analysis. Journal of Advanced Nursing, 72(3), 501-513. Doi:

10.1111/jan.12861.

Haraldseid, C., Friberg, F., & Aase, K. (2015). Nursing students’’ perceptions of factors

influencing their learning environment in a clinical skills laboratory: A qualitative

study. Nurse Education Today, 35(9), e1-e6. Doi: 10.1016/j.nedt.2015.03.015.

Hayden, L. J., Jeong, S. Y., & Norton, C. A. (2016). An Analysis of Factors affecting Mature

Age Students’ Academic Success in Undergraduate Nursing Programs: A Critical

Literature Review. International Journal of Nursing Education Scholarship, 13(1),

127-138. Doi: 10.1515/ijnes-2015-0086.

Heidari, M. R. & Norouzadeh, R. (2015). Nursing students’ perspectives on clinical

education. Journal of Advances in Medical Education and Professionalism, 3(1), 39-

43.

Jamshidi, N., Molazem, Z., Sharif, F., Torabizadeh, C., & Najafi Kalyani, M. (2016). The

challenges of nursing students in the clinical learning environment: A qualitative

study. The Scientific World Journal. 1-7. Doi: 10.1155/2016/1846178.

Kolb, D. A., Boyatzis, R. E., & Mainemelis, C. (2001). Experiential learning theory:

Previous research and new directions. Perspectives on thinking, learning, and

cognitive styles, 1(8), 227-247.

Labrague, L. J., McEnroe-Petitte, D. M., Gloe, D., Tsaras, K., Arteche, D. L., & Maldia, F.

(2016). Organizational politics, nurses’ stress, burnout levels, turnover intention and

job satisfaction. International Nursing Review, 64(1), 109–116. doi:10.1111/inr.12347.

 23

Lee, A. K., You, H. S., & Park, I. H. (2015). Affecting Factors on Stress of Clinical Practice

in Nursing Students. Journal of Korean Academy of Nursing Administration, 21(2),

154-163. Doi: 10.11111/jkana.2015.21.2.154.

Masselink, L. E. & Lee, S. D. (2010). Nurses, Inc.: Expansion and commercialization of

nursing education in the Philippines. Social Science & Medicine, 71(1), 166-172. Doi:

10.1016/j.socsimed.2009.11.043.

Moyimane, M. B., Matlala, S. F., & Kekana, M. P. (2017). Experiences of nurses on the

critical shortage of medical equipment at a rural district hospital in South Africa: a

qualitative study. The Pan African Medical Journal, 28(1), 100. Doi:

10.11604/pamj.2017.28.100.11641.

Noviyanti, L. W., Handiyani, H., & Gayatri, D. (2018). Improving the implementation of

patient safety by nursing students using nursing instructors trained in the use of quality

circles. Proceedings of the 3rd International Conference on Nursing (ICON), 17(2), 53.

Doi: 10.1186/s12912-018-0318-7.

Nurse (n. d.) In Bureau of Local Employment (Department of Labor and Employment).

Retrieved in http://www.ble.dole.gov.ph/index.php/nurse.

Papastavrou, E., Dimitriadou, M., Tsangari, H., & Andreou, C. (2016). Nursing students’

satisfaction of the clinical learning environment: a research study. BMC Nursing,

15(1), 44. Doi: 10.1186/s12912-016-0164-4.

Picazo, O. F. (2015). E. Public hospital governance in the Philippines. Public hospital

governance in Asia and the Pacific, 1(1), 186-188.

 24

Sedgwick, M. G. & Kellett, P. (2015). Nursing Students’ Experience of Belonging during

Clinical Experiences. Journal of Nursing Education, 54(3), 121-129. Doi:

10.3928/01484834-20150218-15.

Solvik, E., & Struksnes, S. (2018). Training Nursing Skills: A Quantitative Study of Nursing

Students’ Experiences before and after Clinical Practice. Nursing research and

practice, 2018. Doi: 10.1155/2018/8984028.

Tynkkynen, L. K. & Vrangbæk, K. (2018). Comparing public and private providers: a

scoping review of hospital services in Europe. BMC Health Services Research, 18(1),

141. Doi: 10.1186/s12913-018-2953-9.

Usher, K., Redman-MacLaren, M. L., Mills, J., West, C., Casella, E., Hapsari, E. D., ... &

Amy, Y. Z. (2015). Strengthening and preparing: enhancing nursing research for

disaster management. Nurse Education in Practice, 15(1), 68-74. Doi:

10.1016/j.nepr.2014.03.006.

Victor, G., Ishtiaq, M., & Iqbal, N. (2016). Perception of Clinical Environment among

Nursing Students of a Private College of Nursing in Pakistan. Medical Channel, 22(2),

33-40.

Ward, P. R., Rokkas, P., Cenko, C., Pulvirenti, M., Dean, N., Carney, S., ... & Meyer, S.

(2015). A qualitative study of patient (dis) trust in public and private hospitals: the

importance of choice and pragmatic acceptance for trust considerations in South

Australia. BMC health services research, 15(1), 297. Doi: 10.1186/s12913-015-0967-0.