Angela M. Koontz
Judy L. Mallory
Jane A. Burns
Shelia Chapman
Staff Nurses and Students:
The Good, The Bad, and The Ugly
Elements identified by student nurses as impacting
learning in the clinical learning environment were explored. A significant element
identified by participants was
the staff nurse. Strategies for
improvement and increasing
learning opportunities are
included in the discussion.
Angela M. Koontz, MS(N), RN, is a
Nursing Instructor, Caldwell Community
College and Technical Institute, Hudson,
NC.
Judy L. Mallory, EdD, RN, CNE, is
Associate Director, School of Nursing,
Western Carolina University, Candler,
NC.
Jane A. Burns, PhD, RN, is Assistant
Professor, Western Carolina University,
Black Mountain, NC.
Shelia Chapman, MSN, RN, is Assistant
Professor of Nursing, Western Carolina
University, Candler, NC.
240
O
ne of the most valuable components of a nursing program is the clinical learning environment (CLE). This setting provides students with
unique learning opportunities in which classroom theory and skills are
put to the test with real life situations. Clinical learning environments
include hospitals, doctors’ offices, health departments, hospice units, and
other health care settings utilized for student learning. The CLE differs
from the classroom or lab setting in many ways. Typically, the classroom
and labs are controlled by instructors. This includes lectures, labs, tests,
dress codes, student conduct, break times, attitudes, and the learning
environment atmosphere. The CLE is a different story.
Massarweh (1999) described the clinical setting as a clinical classroom. However, the CLE is unpredictable and relatively out of the nursing
instructor’s control. Attitudes, work ethics, staff members, unit environment, equipment and supplies, census, and patients and family members
are elements of the CLE that cannot be controlled by instructors. This
unpredictable environment is very different from the classroom and can
be a major shock for students.
Also, the transition from student-learner to student learner-worker
can be difficult and confusing for students and even the CLE staff. Staff
members may view students as workers only, especially when patient care
demands are high. Pearcey (2007) indicated nursing students are taught to
provide holistic care but at times may be faced with more technical tasks
than holistic patient care.
In this research study, the various elements of the CLE’s role in the
development of student nurses’ perceptions of nursing were explored.
The above-mentioned factors are but a few of the elements that influence
learning within the CLE. The aim of this study was to explore student nurses’ perceptions of their CLE experiences with the hopes of discovering
positive and negative factors influencing learning.
Conceptual Framework
Among student nurses, the CLE is perceived as the most influential
context for gaining nursing skills and knowledge (Chan, 2001). Benner’s
(1982) theory outlined the process of a nurses’ development from a new
graduate or novice to an expert nurse. Benner described the sequence in
which nurses attain their skills and knowledge in the clinical environment.
The different stages of Benner’s (1982) theory are novice, advanced
beginner, competent, proficient, or expert nurse. Three common themes
further define nurses’ development. First, clinical knowledge does not rely
on the principles of theory alone but is intertwined with patient interaction and responses to care. The student nurse may experience anxiety
MEDSURG Nursing—July/August 2010—Vol. 19/No. 4
regarding the clinical rotation
because of his or her novice level
of skill and knowledge. The second
theme describes the development
of perceptual awareness, the ability to separate relevant information
from the irrelevant within a clinical
problem (O’Connor, 2001). Perceptual awareness stems from the
nurse’s intuition about the clinical
problem. Individual nursing intuition develops with knowledge and
experiences gained from previous
clinical problems. O’Connor (2001)
stated, “...intuition is not guessing
or feeling; it is a deep knowing, and
a necessary element of expert
practice” (p. 48). The third theme
represents a quality of the expert
nurse that cannot be taught in a
classroom, but through the interaction of nurse-patient practice.
An expert nurse not only knows
what is important within a clinical
problem, but also what needs to be
done. This conveys confidence
and assurance to patients and
their families.
Benner’s (1982) novice-to-expert theory explained how nurses’
intuition develops with knowledge
and experiences from clinical practice. Nursing students begin their
education as novices. O’Connor
(2001) indicated the novice stage
describes the initial stage of development for nursing students. “The
novice’s focus is on rule-based
activities and the application of theoretical knowledge” (p. 49). Upon
graduation, nursing students are
advanced beginners. “Task completion rather than patient management is the goal of the advanced
beginner” (O’Connor, 2001, p. 50).
Competent nurses show greater
awareness in distinguishing what is
important from what is not important. Clinical experiences have contributed to the development of this
awareness. Also, patient focus
increases as organization and management of multiple patients
becomes easier. Proficient nurses
demonstrate expanded personal
awareness and intuition above that
of competent nurses. O’Connor
noted expert nurses are able to
respond intuitively to a patient situation because they understand
what is needed and why. O’Connor
suggested expert nurses have
developed from a state of critical
MEDSURG Nursing—July/August 2010—Vol. 19/No. 4
thinking to thinking like a nurse.
Benner’s theory differentiated the
levels of nursing expertise and
supported the clinical setting as an
essential aspect of nursing education.
Literature Review
Databases utilized for this literature review included EBSCOhost,
MEDLINE, and CINAHL. CLEs, student nurses, student nurses’ perceptions of CLEs, and student nurses’ perception of learning in the CLE
were the main topics searched,
with initial searches limited to the
past 5 years. The results for more
specific articles related to student
nurses’ perceptions of learning in
the CLE were limited. The timeframe was revised to include the
past 15 years. Research topics of
student nurses, CLEs, perceptions,
and learning provided a broad
range of articles related to nursing,
nurse educators, and pharmacology and medical students. However,
results for student nurses’ perceptions of the CLE and learning were
small.
Previous studies described
other influences on student nurse
perceptions of CLE experiences. A
study completed by Dunn and
Hansford (1997) explored the perceptions of the CLE held by 229
second- and third-year student
nurses. Qualitative data obtained
from student interviews revealed
five major themes: staff-student
relationships, nurse manager commitment, patient relationships, student satisfaction, and hierarchy
and ritual. Researchers found
interpersonal relationships between the participants in the CLE
were significant in the development of a positive learning environment. Also, within the CLE, a
positive learning environment was
the result of student satisfaction as
well as an influential factor for creating a positive learning environment. Dunn and Hansford (1997)
suggested good collaboration
among nurse educators, clinical
sites, and other participants providing clinical education of student
nurses promotes the creation of a
positive CLE and the development
of well-educated, competent nurses. A more recent study conducted
by Ranse and Grealish (2007)
explored nursing students’ experience of learning in the clinical setting of a dedicated education unit
using a communities of practice
framework. “Open forums should
be held for clinicians to discuss
their concerns regarding facilitating student learning and to collaboratively develop strategies to
support student learning in practice” (Ranse & Grealish, 2007, p.
176).
Papp, Markkanen, and von
Bonsdorff (2003) conducted a
study related to student nurses’
perceptions regarding their clinical
learning experiences. Data were
collected through unstructured
interviews with 16 student nurses.
Participants were asked to
describe the importance of the
CLE along with good and bad
learning experiences. Three major
factors were revealed: the appreciation and support received by students, the quality of mentoring and
patient care, and students’ selfdirectedness. Students felt clinical
practice and available opportunities provided a reflection of the
process of becoming a professional nurse. This study also supports
the previous suggestion by Dunn
and Hansford (1997) regarding the
establishment of good collaboration between nurse educators and
clinical learning environment staff
to create a positive learning environment.
Purpose
This study was conducted to
explore student nurses’ perceptions of their CLE experiences.
Prior research related specifically
to student nurses’ perceptions of
learning in the CLE was limited.
The aim of this project was to raise
awareness of the significance of
the CLE and identify positive
and/or negative factors within a
CLE which affect learning from the
student nurse perspective.
Methodology
The design of this study was
descriptive and exploratory with a
qualitative approach. It used elements of grounded theory or the
general inductive method which
allows researchers to collect and
categorize data, describe emerging
central phenomenon, and then
241
recycle earlier steps (Polit & Beck,
2008).
Institutional review board
approval for this study was provided by the participants’ university
and the graduate school of
Western Carolina University. Confidentiality statements were signed
by the researcher and the transcriptionist regarding all data collection. Participants were made
aware of the confidentiality statements and security measures,
which included shredding of all
notes, transcripts, and any copies
pertaining to the study by the
researcher 6 months after the
study was completed.
A formal presentation was
made regarding the project to the
potential target group participants, senior baccalaureate nursing students in their last semester
of education at a single North
Carolina university. A written information sheet detailing the purpose, implications, and potential
harm or benefits of the project was
given to prospective participants.
Written consent for participation
and permission to audiotape the
meetings for transcription were
obtained after participants had the
opportunity to read the information sheet and have any questions
answered. Participants were informed fully regarding the proposed research and its voluntary
participation. During this presentation, the setting, dates, and times
for meetings were discussed. In
accordance with expressed desires of the majority of participants, focus group meetings were
arranged in on-campus rooms before and after participants’ scheduled classes.
A total of 10 participants volunteered for the study, three males
and seven females ages 21-52. The
researcher led three semi-structured focus group meetings with a
set of trigger questions aimed at
addressing the research questions.
Group 1 consisted of two participants, Group 2 consisted of five
participants, and Group 3 consisted of three participants. In an
effort to provide anonymity, numbers were used in place of participants’ names. The meetings were
audiotaped for greater accuracy of
data collection. Verbal permission
242
for recording was obtained at the
beginning of each meeting. A digital recorder with memory card was
used for recording. The memory
card was given to a transcriptionist for written transcription of each
meeting. An electronic file for each
meeting was created along with
three paper copies of each meeting
transcript.
Analysis of the Data
Methods of qualitative analysis
to determine the most effective
approach were reviewed. Thomas’s
(2006) general inductive approach
was utilized to sort and organize
the collected data. The assumption
of this approach “...is to allow
research findings to emerge from
the frequent, dominant, or significant themes inherent in raw data,
without the constraints imposed by
structured methodologies” (p. 238).
Credibility
Credibility is more consistent
with qualitative research and
refers to “confidence in the truth of
the data and interpretations of
them” (Polit & Beck, 2008, p. 539).
Strategies used to enhance the
quality of this research study
included audiotaping of all interviews to capture rich details, peer
examination of the data by a nurse
educator with qualitative research
experience, and data triangulation.
According to Darlington and Scott
(2002), the process of analysis
identifies patterns emerging from
the data and the relationship
among those patterns. Investigator
triangulation was utilized to
“reduce the possibility of biased
decisions and idiosyncratic interpretations of the data” (Polit &
Beck, 2008, p. 547). A researcher
and an assistant independently
read the transcripts and began
compiling a list of codes. The
researchers compared their list of
codes to create a master list in
which the data were coded into
categories and common themes.
Findings
The use of open-ended questions provided the opportunity for
participants to respond in their
own words (Polit & Beck, 2008).
The questions gave structure to
the discussions without hamper-
ing expression of beliefs or feelings. The responses provided rich,
detailed descriptions, and examples of student nurses’ perceptions of learning in the CLE.
Question 1: To what degree do
clinical learning experiences
impact student nurses’ perceptions of nursing?
Common participant responses
included holistic, caring, empowering health, and presence. As the
interviews progressed, participants
were asked to discuss what they
knew about what nurses do.
Participant 2’s response was typical
of other participants: “They’re a
direct care giver. They’re an advocate, educator, case manager.”
Question 2: What elements of
the CLE do student nurses identify
as having a positive impact on
learning?
Preceptorship. The most common theme identified by participants as having a positive impact
on learning in the CLE was the preceptorship. According to Participant 1, “Being with a preceptor
and feeling a part of the team, it
was my best clinical experience. I
got to do so many different things,
getting familiar with the equipment, IVs and trach training, and
just that kind of stuff that normally
you don’t get a lot of hands on.
And also, in my preceptorship, I
got a lot of experience. The most
intimidating factor of nursing to
me was calling doctors and giving
reports. They helped encourage
me to do that or just broke it in
slowly. I thought that was good
because we never get any of that in
a traditional clinical.”
As the interview progressed,
participants were asked what
made the preceptorship so important. As Participant 1 noted, “And
when you have somebody who is
really open, really glad to have a
student, glad more people are
going into nursing because they
care about nursing and they want
more people to do it, they’re more
open to questions.”
Ironically, Participant 4 identified non-receptive preceptor nurses as having a positive impact on
learning. “But I think certainly
that’s not ideal and working with
nurses that aren’t receptive to the
student experience sucks, but it’s
MEDSURG Nursing—July/August 2010—Vol. 19/No. 4
also a preparation for real life.
We’re going to have administrators
that we don’t like; we’re going to
have colleagues that we don’t like.”
Responsibility and trust. Responsibility and trust were also commonly reported themes. Responsibility was perceived as instrumental in increasing confidence.
Establishing trust with instructors,
nurses, and patients in the student
role was viewed as positive.
Participant 1 noted, “I think
that the most positive experiences
I’ve had, have been when I was on
my own and I felt like I had the
responsibility of doing something
and I did it. I do things better if I
know it’s my responsibility to get it
done and to do it right and I don’t
have somebody breathing down
my neck – even if it’s taking staples
out or something little. If you can
do it and then later someone says,
‘You did a good job on that,’ but it
wasn’t because they were right
there telling you what to do, it’s
because you did it and you
thought your way through it. That
seems to be the most positive
experience – the more responsibility you have and I guess not freedom, but more trust you have from
your instructors and the nurses.”
Reflection. Participants indicated nurses within the CLE who
reflected on their own student
experiences and tried to make the
CLE experience meaningful for students were perceived as a positive
element. According to Participant 4,
it was nicer to be with nurses who
remembered what it was like to be a
student, versus the ones who said,
“I’m so burnt out on students.”
Different perspectives. Participants also perceived the opportunity to perform or observe skills
with a nurse as a positive experience. This perception included the
opportunity to gain a different perspective on the performance of a
skill as compared to the way they
may had learned it from their
instructor. Nurses also were
viewed as less threatening during
skills performance because they
were not as familiar with the student as the instructor was.
Question 3: What elements of
the CLE do student nurses identify
as having a negative impact on
learning?
MEDSURG Nursing—July/August 2010—Vol. 19/No. 4
Participants had many comments about negative elements
within the CLE that impacted their
learning. Responses ranged from
feeling like an annoyance to the
staff nurses; lack of skills performance opportunities, such as starting IVs; the vast differences in skill
performances among nurses; the
lack of assessing student knowledge and experience before delegating a task to them; and nurses’
confidence level with student
nurses.
The following perception of a
negative element impacting learning in the CLE was identified.
Nurses’ confidence level. Participant 4: “On my last experience,
there was a nurse that was charting, and I was looking over her
shoulder to see how she was charting and everything and she eventually stopped and she was like,
‘Um…I can’t do this.’ And at first it
made me uncomfortable, but later
when she talked to me it was her
insecurity about the new charting
system. I think as a student I
should be watching her chart and
that should be part of my experience.”
Question 4: To what degree do
student nurses perceive that clinical experiences impact their plans
for future nursing practice?
Participants were asked to discuss what impact, if any, their CLE
experiences had on their future
nursing practice. A re-occurring
theme within the responses centered on technology and nursing
documentation. Participants perceived themselves as champions
of technology and role models for
implementing computer documentation. Their rationalization for
this perception stems from the
introduction and utilization of
computers throughout primary
and secondary education levels
which increased confidence and
comfort levels with technology.
Additionally, participants described their ability to take negative experiences and turn them
into positive learning experiences.
When asked to think about their
future as nurses, participants
voiced agreement with the following statement.
Participant 1: “I think the bad
nurses that we’ve had – the ones
that just didn’t give a flip about
anything – have made us better, or
want to be better, because you see
them and you say, ‘I would never
treat my patient like that or roll my
eyes because they can’t feed themselves.’ You see the way that they
treat people or the way they act or
the way they feel and you just
think – ‘I’m sorry for them but I
don’t want to be like that,’ and so
you want to be better.”
Question 5: What additional
factors do student nurses identify
as impacting clinical learning?
Skill acquisition. The majority of
the participants reported a lack of
skill acquisition. At least half of the
participants within this study did
not have a clinical experience
which involved starting an IV or
inserting a urinary catheter in a
patient. Lab time provided opportunities to practice IV and catheter
insertion, and various other invasive procedures. However, participants voiced the desire for more
opportunities to perform skills
prior to graduation from their nursing program.
Participant 1: “And I think IV
time – I would like to have a whole
week where all we did was start IVs
at a clinic or something.”
Nursing Implications
Participant responses described nursing as caring, holistic,
and empowering. The same was
said of what nurses do. Nursing is
perceived as a caring profession
with nurses acting as advocates
and direct care givers.
Discussion
The results of the student nurses’ perceptions toward learning in
the CLE demonstrates the significance of positive and negative elements within a CLE. The four main
positive themes were preceptorship, responsibility/trust, reflection, and different perspectives.
The perception of decreased confidence levels of nurses around students was the main negative
theme.
Chan (2002) indicated relationships among students, peers,
instructors, staff nurses, and other
members of the health care team
are vital in providing an environment that is positive, supportive,
243
and conducive to learning. Nurses
in the role of a preceptor or staff
nurse were an influential element
with regard to learning in the CLE
by student nurses. Regardless of
good or bad experiences, participants learned from nurses in the
CLE.
Results showed student nurses
wanted responsibility and trust
from nurses, instructors, and
patients. Students viewed increased responsibility as a confidence builder. Students wanted
preceptors “who understand the
level students are at; and are able,
and willing, to provide regular feedback regarding the student’s performance” (Happell, 2009, p. 375).
Nurses who reflected upon
their own student nurse experiences were perceived by students
as compassionate and supportive
toward students. This was perceived by students as increasing a
sense of acceptance and support:
“...ability (of preceptors) to know
and appreciate the level of knowledge and the limitations of students’ theoretical preparation and
support as a role model in helping
students feel they are safe and valued” (Happell, 2009, p. 375).
Nurses within the CLE offered
different perspectives related to
skills performance. These nurses
demonstrated a skill procedure
that might not follow the exact
steps taught in the classroom setting, but achieved the same end
results without compromising
patient safety or integrity of the
procedure. Students acknowledged
a difference in theory and practice.
Students appreciated the opportunity to participate in nursing activities and learn from observing the
practices of more experienced colleagues (Charleston & Happell,
2005).
The negative theme of
decreased confidence levels of
nurses when working with student
nurses was acknowledged by the
majority of the study participants.
According to Matsumura, Callister,
Palmer, Cox, and Larsen (2004)
nurses may experience professional insecurities if they encounter
challenging situations while educating students. “The clinical
nurse may feel threatened when
working with students, yet, at the
244
same time, realize that one’s ability
to accomplish quality patient care
provides a direct mentoring example to the student” (p. 301).
Assumptions and Limitations
of the Research Project
The qualitative approach utilized by this study supports the
potential transferability of result
findings to similar settings. The
results of this study are general
and transferable to similar undergraduate nursing programs. Drawbacks of this study include participant characteristics (self-selection) and group meetings. Participant characteristics, such as selfselection, limit the specificity of
criteria for participants. It could be
assumed participants wanted to
vent frustrations rather than contribute to the purpose of the study.
The use of group meetings rather
than one-on-one interviews was
utilized for time management and
cost effectiveness.
Nursing Implications
The re-occurring themes identified by participants as having a positive impact on learning in the CLE
were the preceptorship opportunity, acceptance from clinical staff
and the ability of nurses to recall
their own struggles and perceptions of the CLE as nursing students. Participants identified the
desire for compassion, acceptance,
and support from nurses. The need
for nurse preceptors is critical, and
preceptorship or mentoring components should be a part of each
clinical rotation if possible.
“Preceptorship has been consistently acknowledged in the literature as a strategy to maximize the
benefits of clinical nursing education in terms of knowledge and skill
acquisition, confidence, and professional socialization” (Happell, 2009,
p. 372). Student nurses also identified potential strategies for enhancing educational opportunities.
Student nurses’ perceptions
are significant not only for identifying problems or areas of concern,
but also for providing problemsolving strategies. One participant
provided the following recommendation for enhancing student
nurse learning in the CLE: reverse
shadowing.
Participant 1: “I was just thinking, I had a serving job one time,
and I shadowed an employee.
Then they started giving me a
table or two, a slow transition.
Then the last week, they shadowed
me. In the hospital setting, as long
as it wasn’t something life threatening, you could do the same.
After you leave the room, ask (clinical instructor or preceptor), “Ok,
what did you see that I did well,
what could I change, what did I forget to do, what do I need to go
back and do right now?”
The topic of student nurse perceptions provides a wealth of
information regarding learning in
the CLE. As the profession of nursing continues to evolve, the educational experiences and opportunities for learning in CLEs will need
further assessment, research, and
evaluation. Further research of
this topic and other aspects of the
CLE and learning is needed.
Conclusion
This qualitative descriptive
study considered the perceptions
of one group of student nurses
regarding their learning experiences in the CLE. Findings showed
nurses are considered role models
to student nurses, and the utilization of preceptorship in the CLE
enhances student nurse learning.
Lastly, of relevance to learning in
the CLE is the commitment of nurses to reflect upon their past experiences as novice nurses, acknowledge themselves as role models,
and give back to the nursing profession as preceptors.
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