93J Gandhara Med Dent Sci
October - December 2025
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ORIGINAL ARTICLE
FROM CONTEXT TO VALIDATION: PSYCHOMETRIC EVALUATION OF THE CLINICAL
LEARNING ENVIRONMENT TOOL IN PAKISTAN
Ayaz Ul Haq 1, Brekhna Jamil2, Nowshad Asim3, Muhammad Ijaz4, Samreen Riaz5
ABSTRACT
OBJECTIVES
The purpose of this study was to establish the validity and reliability of the
Clinical Learning Environment Tool (CLE -T) within the Pakistani culture
and context.
METHODOLOGY
A quantitative descriptive study was conducted from June to November 2023.
This study was conducted in two phases. Phase one focused on content
validation using an online form, while phase two involved field testing and
psychometric evaluation. The adapted 34-item tool was then administered to
392 nursing students from government colleges in Khyber Pakhtunkhwa,
Pakistan, selected via probability random sampling. Reliability was assessed
using Cronbach's alpha and item-total correlations, while construct validity
was examined through exploratory factor analysis. Ethical approval and
informed consent were obtained prior to the commencement of data
collection.
RESULTS
The study prioritizes cultural alignment, content and construct validity,
internal consistency, and test-retest reliability. Results demonstrate strong
content validity with high Content Validity Index (CVI) and Content Validity
Ratio (CVR) scores, supported by a Cronbach's Alpha coefficient of 0.980,
indicating reliability. Factor analysis identifies three dimensions: supportive
learning, communication, and learning scenario efficacy. The validated CLE-
T emerges as a reliable resource for educators and policymakers, fostering
effective clinical learning environments and skilled healthcare professionals.
CONCLUSION
The paper suggests broader validation across contexts and longitudinal
exploration, affirming the CLE-T as a valuable tool for educators and
policymakers.
KEYWORDS: Clinical Learning Environment, Student Satisfaction, Nursing
Care Quality, Mentor/Preceptor, Nursing Teacher
How to cite this article
Haq AU, Jamil B, Asim N, Ijaz M,
Riaz S. From Context to Validation:
Psychometric Evaluation of the
Clinical Learning Environment Tool in
Pakistan. J Gandhara Med Dent Sci.
2025;12(4):93-96. https://doi.org/10.3776
0/jgmds.12-4.774
Date of Submission: 12-08-2025
Date Revised: 03-09-2025
Date Acceptance: 04-09-2025
1MHPE Scholar, Institute of Health
Professions Education & Research,
Khyber Medical University, Peshawar
2Professor of Medical Education, Institute
of Health Professions Education &
Research, Khyber Medical University,
Peshawar
4MHPE Scholar, Institute of Health
Professions Education & Research,
Khyber Medical University, Peshawar
5MHPE Scholar, Institute of Health
Professions Education & Research,
Khyber Medical University, Peshawar
Correspondence
3Nowshad Asim, Assistant Professor
of Medical Education, Institute of
Health Professions Education &
Research, Khyber Medical University,
Peshawar
+92-300-5898407
drnowshadasim@kmu.edu.pk
INTRODUCTION
The CLE is a complex system that covers the basics,
influencing the professional growth of nursing students
by fostering clinical judgment and critical thinking
through their exposure to various aspects of patient
care.1 Despite its importance, nursing students often
perceive the CLE as anxiety-inducing due to balancing
their roles and tasks of learner and worker. The level of
student satisfaction within the CLE is closely linked to
several factors, including the quality of nursing care,
supervision, mentorship, and interactions with their
nursing instructors.2 Recognizing the influence of the
CLE, this research examines the factors that impact
student satisfaction and the overall effectiveness of the
clinical learning experience. Factors such as mentor
expertise, ongoing feedback, clinical conferences, and
the alignment of theory and practice emerge as critical
determinants of student satisfaction. Additionally, the
study acknowledges the significance of appreciation
and support in shaping positive clinical experiences,
which surpasses the influence of the physical
environment.3,4 Against this background, the recent
emphasis on enhancing the quality of CLE underscores
the need for an educational shift and a stronger
integration between academic coursework and on-the-
job training, as reflected in the adoption of various
supervision models. To address the gaps in
understanding the CLE’s impact in the Pakistani
context, this research focuses on adapting and
validating the Clinical Learning Environment Tool
(CLE-T).7,8 The unique cultural and contextual factors
in Pakistan, including cultural beliefs, socio-economic
status, language barriers, and resource limitations,
94 J Gandhara Med Dent Sci
October - December 2025
necessitate an examination of the validity and reliability
of assessment tools.9,10 This study aims to fill the gap
by validating and adapting the Clinical Learning
Environment Tool (CLE-T) for use in Pakistan.
Ensuring its reliability and validity in this context will
help improve healthcare education, allowing for a better
evaluation of clinical environments and ultimately
enhancing student satisfaction and learning outcomes in
Pakistani nursing programs.11,12,13
METHODOLOGY
A quantitative descriptive design was used in two
phases. Phase one focused on content validation using
an online form, while phase two involved field testing
and psychometric evaluation. The study was conducted
at the Government Colleges of Nursing in Khyber
Pakhtunkhwa. This study was conducted from June
2023 to November 2023, following approval from the
Khyber Medical University Advanced Studies and
Research Board (KMU-AS&RB) at its 135th meeting,
vide letter No.DIR/KMU-AS&RB/DE/002043 dated
May 31, 2023. The AS&RB approval certificate was
granted vide No.DIR/KMU-AS&RB/DS/002038 dated
09-10-2023. The study was carried out after approval
from the KMU-IHPER Ethics Board vide Ethical
Clearance Certificate Ref No:1-
11/IHPER/MHPE/KMU/23-22 dated 13-06-2023. A
random sampling method was employed, adhering to
standard practices that suggest a requirement of 10
participants per item. With a total of 34 items included,
this resulted in a target sample size of 340
participants.14 To account for potential missing data, a
total of 392 participants were selected using probability
random sampling. The inclusion criteria consisted of
currently enrolled 5th and 6th-semester nursing students
in Pakistan who had completed at least one clinical
rotation. Exclusion criteria included students not
enrolled in the specified semesters or those unable or
unwilling to provide informed consent. Data collection
was conducted through an online questionnaire
distributed via email and WhatsApp groups. The
questionnaire, adapted for the research context,
collected demographic information and feedback on the
Clinical Learning Environment Tool (CLE-T). The
Content Validity Index (CVI), BSI, and UR were
analyzed using Excel, and the results were presented in
tables.
RESULTS:
All study participants were female, with ages ranging
from 21 to 25 years. All are BS Nursing students of
four different colleges of KP, Pakistan.
Table 1: Content Validity Index (CVI) Content Validity
R a t i o (CVR)
Total Items Content Validity
Index
Content Validity
Ratio
47 1.38 1.76
51 1.5 2.0
54 1.58 2.17
56 1.64 2.29
61 1.79 2.58
63 1.58 2.7
64 1.88 2.76
151 4.44 7.88
Table 1 presents a summary of the Content Validity
Index (CVI) and Content Validity Ratio (CVR) for each
item. Each row corresponds to a specific item, with
columns indicating the total items, CVI, and CVR
values.
Table 2: Case Processing Summary
N %
Cases Valid 392 100.0
Excluded 00 0.0
Total 392 100.0
Table 2 presents the reliability analysis results,
indicating that 392 cases were included in the analysis,
and no cases were excluded. The analysis employed
list-wise deletion across all variables.
Table 3: Reliability Statistics
Reliability Statistics
Cronbach’s Alpha Cronbach’s Alpha
0.98 0.98
The study revealed a high Cronbach’s Alpha of 0.980,
indicating an exceptional level of internal consistency
among the 34 items. This suggests that participants
strongly agreed with each item, reflecting the reliability
of the scale. Item-total correlations further confirmed
the stability of the instrument, as no item deletion
would have improved the alpha value. The data analysis
involved two main components: Content Validity Index
(CVI) and Content Validity Ratio (CVR), which assess
the representation of items in a test or instrument. CVI
measures the proportion of content-valid items, and
CVR assesses expert consensus on the necessity of each
item. In this study, 392 valid cases were analyzed, with
no exclusions, denoting complete data for all variables.
The subsequent reliability analysis, specifically
Cronbach’s Alpha, revealed a remarkably high internal
consistency of 0.980, signifying strong reliability. The
Item-Total Statistics provided insights into the
correlations between individual items and total scores,
revealing the impact of each item on the overall
construct. Further scrutiny involved "Cronbach’s Alpha
if Item Deleted", indicating the impact of removing
specific items on scale reliability. The Kaiser-Meyer-
From Context to Validation: Psychometric Evaluation
95J Gandhara Med Dent Sci
October - December 2025
Olkin (KMO) measure and Bartlett’s test of sphericity
were conducted to validate the dataset’s suitability for
factor analysis, and both tests demonstrated adequacy.
The high KMO value of 0.934, along with significant
relationships among variables (p < 0.001), supported
the application of Principal Component Analysis.
Extraction communalities ranged from 0.493 to 0.797,
indicating substantial variance explanation. Exploratory
Factor Analysis (EFA) using principal component
analysis with varimax rotation revealed a three-factor
structure. The first factor, Supportive Learning,
encompassed reflecting feedback, encouragement, and
guidance provided by clinical supervisors. The second
factor, communication, represented clarity,
accessibility, and interaction between students and
faculty/staff in the clinical environment. The third
factor, learning scenario efficacy, captured the
appropriateness and effectiveness of clinical placements
in facilitating meaningful learning experiences. Overall,
the comprehensive analysis demonstrates robust
validity, reliability, and suitability for factor analysis in
the examined scale or questionnaire.
DISCUSSION
The findings from this comprehensive data analysis
provide valuable insights into the validity, reliability,
and suitability of the Clinical Learning Environment
Tool (CLE-T) for factor analysis.15 The use of the
Content Validity Index (CVI) and Content Validity
Ratio (CVR) served as robust measures to assess the
representation and necessity of items in the instrument.
The absence of exclusions in the analysis, with 392
valid cases, underscores the completeness of data for all
variables, enhancing the study’s integrity. Content
validity was initially established through the Content
Validity Index (CVI) and Content Validity Ratio
(CVR), with values ranging from 1.38 to 4.44 for CVI
and 1.76 to 7.88 for CVR across different item pools.
These findings suggest a high degree of expert
consensus on item relevance and necessity. According
to Polit and Beck, CVI values above 0.78 are
considered acceptable for scale development, while
higher CVR values confirm strong agreement on item
inclusion.16 In this study, the elevated CVI and CVR
values indicate that the items comprehensively captured
the intended constructs, ensuring that the tool reflects
the essential components of the clinical learning
environment. Reliability analysis further reinforced the
instrument’s robustness. The Cronbach’s Alpha
coefficient of 0.980 is significantly above the threshold
of 0.70 recommended by Nunnally and Bernstein,
denoting excellent internal consistency.17 This high
reliability coefficient indicates the reliability of the
measurements, affirming the consistency of responses
across the surveyed items. The exploration of Item-
Total Statistics further clarifies the relationships
between individual items and the overall construct,
providing insight into the impact of each item on the
total score. Moreover, the "Cronbach’s Alpha if Item
Deleted" provided valuable perspectives on how
specific items might impact the overall reliability of the
scale. This approach can help identify items that could
be refined or eliminated in future iterations to enhance
the instrument’s effectiveness. The validation of the
dataset’s suitability for factor analysis through KMO
and Bartlett’s Test is crucial. The high KMO value of
0.934 indicates a substantial proportion of shared
variance among variables, reinforcing the dataset’s
appropriateness for factor analysis. Bartlett’s test, with
a low p-value (p < 0.001), confirms the existence of
significant relationships between variables, further
supporting the decision to employ Principal Component
Analysis. The dataset’s suitability for factor analysis
was verified using the Kaiser-Meyer-Olkin (KMO)
measure and Bartlett’s test of sphericity. The KMO
value of 0.934 exceeds the recommended threshold of
0.80, indicating sampling adequacy.18 Moreover, the
significant Bartlett’s test (p < 0.001) confirmed the
presence of sufficient inter -item correlations to justify
exploratory factor analysis (EFA). These findings align
with the psychometric criteria outlined by Tabachnick
and Fidell.19 The communalities between 0.493 and
0.797 indicate the ability of the identified factors to
explain substantial variance in most items, providing
support for the chosen extraction method. This
reinforces the factor structure revealed by Principal
Component Analysis. The analysis establishes the
validity, reliability, and suitability of the evaluated
scale or questionnaire for factor analysis. The high
internal consistency, detailed item-level insights, and
rigorous validation procedures collectively enhance the
methodological rigor, strengthening the credibility of
the findings and supporting informed decisions
regarding the refinement or application of the
instrument in future research.
LIMITATIONS
While Cronbach’s alpha was the primary measure used,
reliance on a single measure may overestimate internal
consistency. Future validation studies of the CLE-T in
Pakistan should incorporate such methods to
substantiate the reliability claims further. Moreover,
longitudinal investigations can be undertaken to
scrutinize the tool's stability and consistency over time.
CONCLUSIONS
Our assessment confirms the Clinical Learning
From Context to Validation: Psychometric Evaluation
96 J Gandhara Med Dent Sci
October - December 2025
Environment Tool’s (CLE-T) strength in measuring the
clinical learning environment. Through comprehensive
content validity evaluation using the Content Validity
Index (CVI) and Content Validity Ratio (CVR), the
CLE-T established sensitive representativeness within
its intended domain. The remarkable Cronbach’s Alpha
coefficient of 0.980 underscores the tool’s exceptional
internal consistency and reliability, reinforcing its
efficacy for assessing the clinical learning environment.
While Item-Total Statistics provided nuanced insights
into item relationships, the observed minimal impact on
reliability upon item exclusion suggests potential item
redundancy. Nonetheless, the CLE-T emerges as a
dependable instrument for evaluating the multifaceted
dimensions of the clinical learning environment.
CONFLICT OF INTEREST: None
FUNDING SOURCES: None
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AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.
Ayaz Ul Haq - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Final Approval
Brekhna Jamil - Concept & Design; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Supervision; Final Approval
Nowshad Asim - Concept & Design; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Supervision; Final Approval
Muhammad Ijaz - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Final Approval
Samreen Riaz - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Final Approval
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From Context to Validation: Psychometric Evaluation