Nursing students’ satisfaction with the academic program: A cross sectional study

In higher education, students’ satisfaction is viewed as an indicator of program success, and higher satisfaction levels among students are correlated with better intellectual and social achievements. This study aimed to assess nursing students’ satisfaction with the academic program at one academic institution. A cross-sectional descriptive study was conducted. A convenience sampling method was used to include 328 students using the Undergraduates Nursing Students Academic Satisfaction Scale (UNSASS) to assess the level of nursing students’ satisfaction with the academic program. The overall mean score of satisfaction was 51.72 out of 100 (SD=14.63). The highest score was observed regarding the program design and delivery dimension (mean±SD score=53.91±18.51), while the lowest satisfaction score was attributed to the support and resources dimension (49.62±18.13). The study recommends conducting a comprehensive and consistent evaluation to measure student satisfaction and expectations in resources and facilities in order to guide decision-making and improve the effectiveness of students’ educational programs. It is suggested that the UNSASS may expand its applicability to master students and evaluate programs that are not accredited by international accreditation in future studies.


Introduction
*Students' satisfaction has been assessed in different academic and non-academic settings (Eyck et al., 2009). In the 1960s, the first study conducted on academic satisfaction was originated from occupational satisfaction. Academic satisfaction is regarded as the subjective evaluation of the whole educational experience and is defined as a psychological state that results from the confirmation or not of the students' expectations regarding their academic reality. Academic satisfaction is considered a dynamic process that can be affected by different factors such as the institution's characteristics, educational context, students' perception, and learning environment (Ali, 2012;Tsurkan, 2020).
It is the role of the educational and training institutions to assess nursing students' satisfaction regarding the undergraduate program to enhance effective learning among candidates and improve the overall success of the institution. Satisfied students show generally more willingness and effort in attending the classes and being involved within the coursework and the institution commitments and diverse activities (Al-Kuwaiti et al., 2014). Such evaluation provides valuable indications for strategic planning and is part of the pedagogic actions aiming to ensure the best learning experience for students to enable them to acquire beneficial knowledge and achieve professional fulfillment (Delaram and Hosseini, 2014;Dovhopola, 2019). Thus, students' satisfaction surveys and their outcomes are good indicators of the quality and competitiveness among colleges and universities and their level of fulfillment of their respective missions. Further, published results of such surveys are useful for recruiters and employers to target the best-qualified graduates, with the most adequate curricula (Al-Kuwaiti et al., 2014). Furthermore, academic satisfaction constitutes an effective method to promote interaction between students and professors, and scholars, thus offering the opportunity to share ideas and experiences and enriching the intellectual debate at the theoretical and practical levels (Abouelfettoh and Mumtin, 2015;Tovkanets, 2019).
A review of the literature shows a lack of research studies that investigated satisfaction among nursing students (Papastavrou et al., 2016). In Saudi Arabia, a study investigated factors affecting nursing student's satisfaction with e-learning experience in King Khalid University, Saudi Arabia; it revealed that learners 'attitude toward electronic resources, anxiety, flexibility, technology quality, and learner perceived interaction with others are the critical factors affecting learners' perceived satisfaction (Ali, 2012). The lack of such studies could be a major impediment to the planning and improvement of institutional services and educational programs and teaching methods, which altogether qualify the educational process. Hence, we conducted this study to assess the levels of satisfaction among undergraduate nursing students toward their academic programs at King Abdul-Aziz University. We also investigated the sociodemographic factors associated with academic satisfaction.
This study aimed to assess nursing students' satisfaction with the academic program at one academic institution.

Materials and methods
A cross-sectional study was conducted at the Faculty of Nursing at one academic institution in Jeddah, Saudi Arabia. The sample of this study incorporates 2 nd , 3 rd , and 4 th year undergraduate nursing students. The inclusion criteria involved all nursing students who were registered at the faculty and pursuing any of the nursing specialties provided by the faculty including medical and surgical, critical care, pediatrics, obstetrics and gynecology, community health, geriatrics, psychiatry and mental health, and administration.
The study used the Undergraduates Nursing Students Academic Satisfaction Scale (UNSASS), adapted from Dennison and El-Masri (2012) to assess participants' satisfaction with the faculty's academic program. The scale consists of 48 items grouped into the following four dimensions: in-class learning experience (16 items); clinical teaching (15 items); program design and delivery (12 items); and support and resources (five items). For each item, responses were assessed using a Likert scale ranging from strongly disagree (1) to strongly agree (5). A score was calculated for each dimension by adding up the corresponding item scores, and an overall satisfaction score was calculated with a higher score indicating greater satisfaction with the academic program. The UNSASS was validated by five specialized faculty staff including assistant and associate professors. The survey was completed by collecting nursing students' socio-demographic characteristics, such as age, marital status, number of children, permanent residence, and academic year.
The ethical approval was obtained from the University's institutional review board. At the end of the activity time all 2 nd , 3 rd , and 4 th year nursing students were informed about the study. All participants were informed that their participation was fully voluntary, that they have the right to freely withdraw at any time of the interview, and that their privacy and confidentiality will be fully respected. Prior to administering the questionnaire, implied consent for participation in this study was obtained by filling the questionnaires. Each participant was allowed 20 minutes to complete it. Data collection was conducted between 01 March and 31 May 2018.
The questionnaire was piloted among a sample of 30 eligible students. The clarity of the items was assessed, and the overall reliability of the UNSASS tool was tested and showed Cronbach's alpha=0.967, indicating high internal consistency of the tool in the study population. Data were analyzed using IBM SPSS software package version 20.0. Categorical variables were presented using number and percent, while numerical ones were presented using range, mean, and standard deviation (SD). The significance of the obtained results was judged at the 5% level. The used tests were Student t-test for normally distributed quantitative variables, to compare between two studied groups and F-test (ANOVA) for normally distributed quantitative variables, to compare between more than two groups. A p-value<0.05 was considered for statistical significance. Table 1 demonstrates the characteristics of the study sample. A total of 328 undergraduate nursing students successfully completed the questionnaire, with a response rate=96.5%. Of the total participants, 145 (44.2%) were in the second year, 120 (36.6) in the third year, and 63 (19.2%) in the fourth year. All undergraduate nursing students were below 30 years old. Moreover, 98.8% were single, and 68.9% were living with their families, while 22.6% lived on the campus. Table 2 shows mean satisfaction scores regarding the different questionnaire subscales as well as the overall scores. The mean±SD overall satisfaction score was 51.72±14.63 out of 100. Regarding subscales, participants were most satisfied with program design and delivery (mean±SD score=53.91±18.51), while they were least satisfied with support and resources (49.62±18.13). Bivariate correlations between the subscale scores showed moderate to high correlations with Pearson's correlation coefficients ranging from 0.581 (p<0.001), between In-class Teaching and Support and Resources scores, to 0.756 (p<0.001) between Clinical Teaching and Program Design and Delivery subscale score. The second highest correlation was between In-class Teaching and Clinical Teaching with Pearson's correlation coefficient=0.737 (p<0.001). Reliability testing showed very high internal consistency for all subscales (Cronbach's alpha 0.811-0.945) and overall scale (Cronbach's alpha=0.967) construct.   Table 3 presents the percentage of the mean±SD score of the underlying items of in-class teaching dimension, which ranged from 2.89±1.01 regarding detailed feedback received on student's work and written assignments to 3.34±0.81 regarding Faculty members' efforts to assist students when asked. The next two highest satisfaction scores were observed regarding the ability to express academic and other concerns to faculty members (3.32±0.78) and easiness to approach faculty members (3.31±0.81).  Table 4 shows mean satisfaction scores regarding clinical teaching among nursing students. For this dimension, mean±SD satisfaction scores ranged from 2.84±0.98 regarding clinical instructors giving verbal and written feedback concerning students' clinical experience to 3.17±0.94 regarding clinical instructors' openness to discussions and differences in opinions. The next two highest satisfaction scores were observed regarding clinical instructors' level of knowledge and clinical expertise (3.14±0.95) and consistency of instructions among different clinical and lab instructors (3.14±0.95). Clinical instructors provide enough opportunities for independent practice in the lab and clinical sites 3.10 0.95 5 Q29

Results and discussion
Clinical instructors encourage me to link theory to practice 3.08 0.93 6 Q30 Instructions are consistent among different clinical and lab instructors 3.14 0.90 2 Q31 Faculty members behave professionally 3.12 0.93 4 Table 5 presents mean satisfaction scores among nursing students' regarding program design and delivery. The mean±SD satisfaction scores in this dimension ranged from 3.08±0.96 satisfaction score regarding overall reasonability and achievability of the program to 3.26±0.91 regarding the contribution of the program courses in overall student's personal development. The program is designed to facilitate teamwork among students 3.20 0.96 4 Q38 The program enhances my problem solving or critical thinking skills 3.16 0.97 5 Q39 There is a commitment to academic excellence in this program 3.12 0.89 8 Q40 As a result of my courses, I feel confident about dealing with clinical nursing problems 3.09 0.95 11 Q41 Going to class helps me better understand the material 3.16 1.02 5 Q42 I am able to experience intellectual growth in the program 3.16 0.95 5 Q43 Overall, the program requirements are reasonable and achievable 3.08 0.96 12 Table 6 shows the mean scores of nursing students' satisfaction regarding academic support and resources. Scores ranged from 2.86±1.00 regarding facilities' appropriateness to facilitate students' learning to 3.11±0.96 regarding secretaries' professionalism.  Table 7 compares overall academic satisfaction across the different sociodemographic factors of the participating nursing students. Students living with their family had greater academic satisfaction (mean ± SD overall satisfaction score=54.16±14.82) compared with those living alone (49.46±11.71) and those living on campus (45.12±12.89), and the difference was statistically significant (p<0.001). Additionally, overall satisfaction scores were highest among 2 nd year students (56.38±15.31) and lowest among 3 rd year ones (44.41±10.70), p<0.001. No statistically significant difference in mean overall satisfaction scores was observed across students' marital status or the number of children. The associations of the different subscales' scores with the demographic factors are also depicted in Table 7, showing significant differences in all subscale scores by residency and academic year.
Students' satisfaction is a complex and multifactorial concept that provides valuable data for colleges and universities to make their curriculum more responsive to the needs of a changing marketplace (Witowski, 2008;Eyck et al., 2009;Papathanasiou et al., 2014;Liba et al., 2019). The assessment of nursing students' satisfaction in the current study showed moderate overall satisfaction with higher levels regarding the program design and delivery, where student were relatively more students perceived courses to be beneficial in enhancing their overall professional development and analytical skills and were satisfied with the variety and relevance offered by the faculty's program. On the other hand, relatively lower levels of satisfaction were observed regarding academic support and resources by the faculty to the student, highlighting concerns about the suitability of the facilities to learning as well as about accessibility and equipment of computer and clinical labs. The overall level of academic satisfaction was significantly associated with students' residency mode, as those living with their families displayed the highest levels of satisfaction versus those living on campus. Furthermore, a significant drop in satisfaction level was observed in the 3 rd academic year, followed by a re-increase in the 4 th year.
Satisfaction about the dimension relating to the program design and delivery encompasses students' critical appraisal of the quality of the scientific and technical content of the program proposed by the faculty and the efficiency of the overall learning methodology. This dimension entailed the highest satisfaction scores in the present study with minor variance across its 12 items, as the mean item scores ranged between 3.08 and 3.26. Students' ratings reflected the perceived benefit and appropriateness of the curriculum with respect to the goals and capacities. Several authors highlighted the relationship between the student's overall academic satisfaction and academic development, which is perceived by the student as the acquirement of new intellectual and practical skills. It was further demonstrated that higher satisfaction levels were closely associated with students' confidence in faculty members' knowledge of the subject matter, along with setting clear goals to students and offering quality teaching with an appropriate workload (Wiers-Jenssen et al., 2002;Hessler and Humphreys, 2008;Salamonson et al., 2010). These observations stress the importance of balancing intellectually stimulating teaching, including subject variety and analytical skills, with reasonably achievable goals that consider students' aptitude and baseline skills. Such balance is vital to maintain students' motivation to learn while reinforcing their self-confidence. Of note, although not significant, the relatively lower satisfaction score regarding reasonability and achievability of overall program requirements that were observed in the present study is probably the content volume and workload during the academic year, which is directly correlated to the item. A conducted study reported higher satisfaction among nursing students in relation to clearly described syllabus and content relevance to current nursing practice. In addition, this may also be explained by the English syllabus while the majority of students have an exclusively Arabic instruction background (i.e. primary and secondary) (Chen and Lo, 2015;Chajka, 2018).
The present study also showed the lowest satisfaction regarding the support and resources dimension, specifically concerning the suitability of the facilities, including classrooms, clinical and computer labs, to students' learning. By looking at the issue, a probable explanation might be inadequate lab supplies and equipment, lack of maintenance of simulated manikins and audiovisual materials, and inadequate number and size of classrooms and clinical labs with regards to the growing number of students. Comparable observations of such dissatisfaction were reported that students were less satisfied with equipment in the nursing lab, noting that equipment was not always up-to-date, sufficient for their use, and in good repair. By contrast, a study conducted for nine years in a mid-sized Midwestern U.S. university, reported the highest satisfaction levels among 5.223 students regarding the class size of major courses, which was positively correlated with satisfaction with the major curriculum as well as with ten other factors of satisfaction such as course availability, quality of instruction, program variety, and overall college experience (Tessema et al., 2012). In these terms, a study demonstrated that simple measures to enhance the convenience of computing facilities such as availability of computers with a high-speed internet connection, behavior of lab attendants, labs timings, and availability of e-journals may be important determinants of student's satisfaction Abbasi et al. (2011). Further, regular evaluation and maintenance of the resources, facilities, and services of the nursing laboratory and library have an impact on sustaining overall student satisfaction (Ansari, 2002).
In-class teaching had the second highest satisfaction score in the present study, with faculty members' accessibility, availability, and efforts to assist students and listen to their concerns as being the best-rated items. In the same line, it was stated earlier that the social integration factor could predict the overall nursing student satisfaction level (Freeman-Gibb et al., 2017). The student satisfaction scale used in a study further demonstrated the importance of social interaction between faculty members and students, which is perceived as a mark of respect for the student as an individual Baykal et al. (2005). These conclusions are supported in further studies by Ojeda et al. (2011), Rowbotham (2010, and Zafrir and Nissim (2011), who suggested that social interaction between faculty and students is crucial in developing a positive learning environment, which leads to student satisfaction.
By comparison, the lowest item score in the Inclass teaching dimension was observed regarding feedback on students' work and written assignments. This may be explained in the light of the high students-to-academic staff ratio and excessive assignments required from students, resulting in lack of time and mismanagement of personalized feedbacks. This finding is consistent with another study which reported that less than one-third of students were satisfied with the general feedback they received from teachers, with even fewer students being satisfied with examination feedback Hall et al. (2012).
Another important finding in the clinical teaching dimension is the relatively low score regarding the availability of clinical instructors per student need. This represents an important issue as clinical learning constitutes one of the pillars and specific features of the nursing curriculum. In our institution, such findings may be due to the shortage of staff in relation to increasing students' number, which results in clinical instructors being committed to multiple mentoring responsibilities simultaneously, and in various clinical areas. A comparable point of view showed that the majority of students in clinical training had little satisfaction with mentorship and the methods for clinical education used by trainers Hakim (2013). Another aspect of such dissatisfaction may be related to the severe and scrutinizer attitude of some instructors that may be aversive to students. Students should not feel being constantly scrutinized and subject to criticism opportunity (Abouelfettoh and Mumtin, 2015). This emphasizes the importance of recruiting experienced instructors who have confirmed competency and skills in clinical teaching, as both academic and pedagogic quality of the teacher and mentor are crucial determinants of student satisfaction (Jokelainen et al., 2011;Hendricks et al., 2013;Ramos et al., 2015).
With respect to students' sociodemographic status, the present study has not evidenced a significant association of the levels of academic satisfaction with students' age, gender, or marital status and number of children. This is consistent with a study finding. However, residence mode was a significant factor of satisfaction, and students living on campus had the lowest overall satisfaction scores, by comparison to those living with their families. Students living with their families have the advantage of receiving material and psychological support from their families to cope with the academic requirements and stress, along with being in a suitable environment for learning; whereas students living on campus are disadvantaged. Students at the university experience a high level of stress-related to worry about successes, availability of time, and engagement in patient care (Mohamed and Ahmed, 2012); and residence was demonstrated to be a good predictor for transference as a coping behavior (Shdaifat et al., 2018).
Intriguingly, overall academic satisfaction was significantly decreased among 3 rd year nursing students, while 2 nd year ones had the highest overall academic satisfaction scores. This decline in academic satisfaction was previously reported as students' progress through the program and academic years (Lee et al., 2009;Papastavrou et al., 2016). However, explaining this may warrant further qualitative investigations.

Conclusion
This study provides a detailed evaluation of nursing students' appraisal regarding in-class teaching, clinical teaching, program design and delivery, and facilities and resources provided within the BSN program by the faculty of nursing, and identifies areas of students' satisfaction and dissatisfaction. The study found greater satisfaction about program design and delivery and in-class teaching, which are essential components to enhance student satisfaction with their education and overall curriculum. It is recommended to regularly evaluate and improve nursing programs in order to build a safe, caring, trusting, and respectful learning environment for students using modern and efficient teaching methods and tools, thereby enabling the best learning experience and improving the faculty's reputation. Nursing educators are encouraged to conduct a comprehensive and consistent evaluation to measure students' satisfaction and expectations in resources and facilities in order to guide decisionmaking and improve the effectiveness of their educational programs. It is suggested that the NSSS may expand its applicability to Master students and evaluate programs that are not accredited by the ACEN in future studies.

Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.