As noted in the findings section, the mean score of the participants in the SCCQ was higher than the achievable average. It is possible that the proper use of coping styles, the adaptation of clinical environment characteristics with personality traits, and the spiritual view of serving patients have increased the readiness of students to enter the clinical clerkship. Although it is impossible to draw causal conclusions from a correlational study, the evidence suggests having the characteristics that prepare a student to deal with the problems of the clinical clerkship can reduce the "reality shock" and increase the clinical clerkship satisfaction [38].
All the variables presented in the study were positively correlated with the students' clinical clerkship satisfaction; while, neurosis (of personality dimensions) was negatively correlated. Findings are in concert with previous studies [8, 11, 39].
According to previous studies and the logical exception, all the correlations with students' clinical clerkship satisfaction were sensibly assumed, except positive correlation of emotion-focus coping considering the previous literature, it was presumed to be negative [40, 41]. However, the use of emotion-focused coping strategies does not always have a negative consequence such as increasing stress; for example, in uncontrollable situations, this coping style can be helpful [24]. Due to the low experience of nursing students in the first entering the clinical clerkship, they are likely to face many uncontrollable situations that require the use of emotion-focused coping strategy [8, 25]. Temporary use of emotion-focused coping, in situations which are not controllable, like experiencing a heart attack or waiting to undergo a surgery, can be beneficial but the case is different with long-run use of it as a special coping style [24]. As a result, a negative correlation between using emotion-focused coping style in students and satisfaction with their clinical clerkship cannot be took granted and the obtained results might be due to the situations in which the participants in the present study faced them.
The results of hierarchical regression analysis showed personality dimensions which were entered in firs step for predicting of clinical clerkship satisfaction in nursing students had a significant role; among five factors of personality, only extraversion predicted satisfaction with clinical clerkship of intern nursing students. Considering the definition of extraversion [13], students who were sociable, others lover and enjoyed talking to patients and also, those who had a tendency to acquire various experiences from their clinical practice, were more satisfied with their clinical clerkship [42, 43]. Nurses who are more extroverted are more likely to participate in teamwork and solve problems with the help of their colleagues which leads to increased clinical performance [44] and then satisfaction with the clinical course. However, as the length of the clinical clerkship increases, students become more skilled at communicating with patients, other nurses and their supervisors, and as a result become more extroverted which giving them better performance [8].
The results of regression analysis showed spirituality predicts satisfaction with clinical clerkship among intern nursing students. In the other words, considering the definition of spirituality, the students who found nursing as a meaningful and sacred career were more satisfied with their clinical clerkship. These findings are consistent with previous studies [22, 45, 46]. One study found Iranian nurses consider helping patients as an act of worshiping and believe that this contribution brings them spiritual rewards [21]. Evaluation of job values and job satisfaction among neophyte nurses [7], revealed "philanthropic" values play an important role in nurses' job satisfaction and nurses who look at their job as an opportunity to help other people have more satisfaction with their job. It seems among Iranian students of nursing, some spiritual values are assimilated into job values and cause an increase in their satisfaction with clinical practice [46]. Although this finding was expected, it cannot be declared spirituality is always associated with positive outcomes in caregivers [47, 48] and cannot necessarily predict their satisfaction [48].
Finally, the results showed problem-focused coping can predict satisfaction with clinical clerkship and emotion-focused coping had no role to play here, which is consistent with available evidence [40, 49]. According the definition of problem-focused coping, the students who try to encounter reality shock and the factors producing stress in clinical settings and find a way around are more satisfied with their clinical clerkship comparing with those are motivated by excitation of stressful events. Students who are able to deal with the problems of the clinical clerkship and use planful problem-solving strategies outperform than those who engage in dependent behaviors such as indisputable agreement with the decision made by others. They use knowledge and experience to identify or manage patient care problems, do not expect the supervisor to solve their clinical problems, and therefore they have better evaluation about their clinical performance [50]. However, it seems as the length of the clinical clerkship increases, students gain more professional competencies and use more problem-oriented coping [8, 28].
The hierarchical regression analysis showed personality dimensions and spirituality can significantly predict problem-focused coping of intern nursing students. Among personality dimensions, extraversion and openness could predict problem-focused coping. The findings are consistent with previous studies [51, 52]. Extraversion, as a general tendency to be assertive, is defined as being active and doing gregarious practice. These individuals tend to be cheerful and therefore, it is logical to have good relation with others [13] and seeking social support as a subpart of problem-focused coping style [24]. Openness (to clerkship experiences), also, is defined as the tendency to ponder novel ideas, unconventional values, and divergent thinking [13]. Therefore, it can be assumed individuals with high score in openness are flexible, creative, and capable of exploiting a number of more efficient coping strategies to deal with distressing situations [24]. In general, extraversion increase the openness to new experiences in clinical settings by improving the students’ communications with patients, other students and supervisors and so allows students to cope with clinical problems by considering new experiences and in a problem-focused manner [51].
It was also found that spirituality predicted problem-focused coping. In other words, students who were able to find meaning and sanctity in their clinical clerkship were more likely to use problem-oriented coping. A few studies have been carried out on the relationship between spirituality and general coping strategies, most of these studies refer to the role of spirituality as a way to cope with stress as "spiritual coping" [53, 54]. Spirituality can help gather or focus resources on problem solving and so it is expected spiritual coping have more closely relationship with problem- focused coping [55].
In coping with stress, three roles are considered for spirituality: 1) providing a meaning for life, 2) helping people to have a sense of control in various situations, and 3) improving self-esteem in coping with stressful situations [56]. The role of spirituality in predicting problem-focused coping style in nursing students can be justified by the fact that spirituality gives students a sense of control and confidence in working with real patients so that they seek to find solutions to problems. In other words, spirituality includes wide range of personal, spiritual and existential beliefs that may be utilized in dealing with stress lead a person to use problem-oriented coping; therefore, spirituality can improve life satisfaction by increasing the use of problem-focused coping styles or problem-focused coping strategies can play a mediating role in the relationship between spirituality and life satisfaction [57].
Finally, the results of regression analyses showed personality dimensions and spirituality were not able to significantly predict emotion-focused coping in nursing students. The findings are inconsistent with previous studies [36, 51]. This finding can be attributed to students' low use of emotion-oriented coping strategies. Evidence suggests nursing students tend to use more problem-oriented coping strategies in clinical situations than emotion-focused [28, 49]. Consequently, regardless of personality traits or spirituality, students may not have been tendency to use emotion-oriented coping strategies. On the other way, duration of the clinical clerkship in this study was not controlled; while, students with more clinical experience than those with low experience may be more likely to use problem-oriented coping situations than emotion-focused [8].
Conclusion and Recommendation
Based on the findings, it can be concluded spirituality is an important factor in predicting clinical clerkships satisfaction and problem-focused coping in nursing students. Therefore, paying attention to spiritual needs in nursing students can be effective both in better coping with the stressful situations of clinical setting and in enhancing their satisfaction with clinical clerkships. Also, considering the role of problem-focused coping in predicting satisfaction with clinical clerkship, helping students to resolve their clinical problems rationally and enhancing their problem solving skills in dealing with clinical stresses can be associated with their clinical clerkship satisfaction. Considering the role of extraversion in predicting the satisfaction with clinical clerkship and problem-focused coping in nursing students, it can be concluded, probably, the training of social behaviors, communication skills and proper interaction with patients and hospital staffs (extraversion characteristics) can also help nursing students in effective coping with stressful work situations and also increase their clinical clerkship satisfaction.
Limitations
Considering the correlational design of the study, it is not possible to draw any causal conclusions from the findings. In order to be more confident in the findings of this study, especially regarding limited studies on the role of spirituality in clinical setting and the spiritual needs of nursing students, more similar studies should be conducted. Given spirituality [58] and coping strategies [59] are to some extent dependent on ethnicity, the generalizations of the research findings to other ethnic groups should be carried out with caution and it is suggested that similar studies are conducted in other ethnic groups. This cross-sectional study was conducted to assess the factors predicting clinical clerkship satisfaction, it is suggested further studies utilized longitudinal method to assess these factors.