Angela M.
Koontz
Staff Nurses and Students:
The Good, The Bad, and The Ugly
Elements identified by stu-
dent nurses as impacting
learning in the clinical learn-
ing environment were ex-
plored. 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
Judy L. Mallory
Jane A. Burns
Shelia Chapman
O ne of the most valuable components of a nursing program is the clin-
ical 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 class-
room. However, the CLE is unpredictable and relatively out of the nursing
instructor’s control. Attitudes, work ethics, staff members, unit environ-
ment, 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 nurs-
es’ 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 interac-
tion 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 abili-
ty to separate relevant information
from the irrelevant within a clinical
problem (O’Connor, 2001). Percep-
tual awareness stems from the
nurse’s intuition about the clinical
problem. Individual nursing intu-
ition 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 inter-
action 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-ex-
pert theory explained how nurses’
intuition develops with knowledge
and experiences from clinical prac-
tice. Nursing students begin their
education as novices. O’Connor
(2001) indicated the novice stage
describes the initial stage of devel-
opment for nursing students. “The
novice’s focus is on rule-based
activities and the application of the-
oretical knowledge” (p. 49). Upon
graduation, nursing students are
advanced beginners. “Task comple-
tion rather than patient manage-
ment 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 impor-
tant. Clinical experiences have con-
tributed to the development of this
awareness. Also, patient focus
increases as organization and man-
agement 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 situ-
ation 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 educa-
tion.
Literature Review
Databases utilized for this liter-
ature review included EBSCOhost,
MEDLINE, and CINAHL. CLEs, stu-
dent nurses, student nurses’ per-
ceptions of CLEs, and student nurs-
es’ 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 time-
frame 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 pharmacolo-
gy and medical students. However,
results for student nurses’ percep-
tions 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 per-
ceptions 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 com-
mitment, patient relationships, stu-
dent satisfaction, and hierarchy
and ritual. Researchers found
interpersonal relationships be-
tween the participants in the CLE
were significant in the develop-
ment of a positive learning envi-
ronment. Also, within the CLE, a
positive learning environment was
the result of student satisfaction as
well as an influential factor for cre-
ating a positive learning environ-
ment. Dunn and Hansford (1997)
suggested good collaboration
among nurse educators, clinical
sites, and other participants pro-
viding clinical education of student
nurses promotes the creation of a
positive CLE and the development
of well-educated, competent nurs-
es. A more recent study conducted
by Ranse and Grealish (2007)
explored nursing students’ experi-
ence of learning in the clinical set-
ting of a dedicated education unit
using a communities of practice
framework. “Open forums should
be held for clinicians to discuss
their concerns regarding facilitat-
ing student learning and to collab-
oratively develop strategies to
support student learning in prac-
tice” (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 appreci-
ation and support received by stu-
dents, the quality of mentoring and
patient care, and students’ self-
directedness. Students felt clinical
practice and available opportuni-
ties provided a reflection of the
process of becoming a profession-
al nurse. This study also supports
the previous suggestion by Dunn
and Hansford (1997) regarding the
establishment of good collabora-
tion between nurse educators and
clinical learning environment staff
to create a positive learning envi-
ronment.
Purpose
This study was conducted to
explore student nurses’ percep-
tions 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 ele-
ments 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 provid-
ed by the participants’ university
and the graduate school of
Western Carolina University. Con-
fidentiality statements were signed
by the researcher and the tran-
scriptionist regarding all data col-
lection. Participants were made
aware of the confidentiality state-
ments 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 partici-
pants, senior baccalaureate nurs-
ing students in their last semester
of education at a single North
Carolina university. A written infor-
mation sheet detailing the pur-
pose, 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 informa-
tion sheet and have any questions
answered. Participants were in-
formed fully regarding the pro-
posed research and its voluntary
participation. During this presenta-
tion, the setting, dates, and times
for meetings were discussed. In
accordance with expressed de-
sires of the majority of partici-
pants, focus group meetings were
arranged in on-campus rooms be-
fore and after participants’ sched-
uled classes.
A total of 10 participants vol-
unteered for the study, three males
and seven females ages 21-52. The
researcher led three semi-struc-
tured focus group meetings with a
set of trigger questions aimed at
addressing the research questions.
Group 1 consisted of two partici-
pants, Group 2 consisted of five
participants, and Group 3 consist-
ed of three participants. In an
effort to provide anonymity, num-
bers were used in place of partici-
pants’ 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 digi-
tal recorder with memory card was
used for recording. The memory
card was given to a transcription-
ist 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 signifi-
cant 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 inter-
views 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 inter-
pretations 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 ques-
tions provided the opportunity for
participants to respond in their
own words (Polit & Beck, 2008).
The questions gave structure to
the discussions without hamper-
MEDSURG Nursing—July/August 2010—Vol. 19/No. 4
ing expression of beliefs or feel-
ings. The responses provided rich,
detailed descriptions, and exam-
ples of student nurses’ percep-
tions of learning in the CLE.
Question 1: To what degree do
clinical learning experiences
impact student nurses’ percep-
tions of nursing?
Common participant responses
included holistic, caring, empower-
ing 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 advo-
cate, educator, case manager.”
Question 2: What elements of
the CLE do student nurses identify
as having a positive impact on
learning?
Preceptorship. The most com-
mon theme identified by partici-
pants as having a positive impact
on learning in the CLE was the pre-
ceptorship. According to Parti-
cipant 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 equip-
ment, 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 impor-
tant. 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 identi-
fied non-receptive preceptor nurs-
es 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
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. Respon-
sibility and trust were also com-
monly reported themes. Respon-
sibility was perceived as instrumen-
tal 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 responsibil-
ity you have and I guess not free-
dom, but more trust you have from
your instructors and the nurses.”
Reflection. Participants indicat-
ed nurses within the CLE who
reflected on their own student
experiences and tried to make the
CLE experience meaningful for stu-
dents 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. Partici-
pants also perceived the opportu-
nity to perform or observe skills
with a nurse as a positive experi-
ence. This perception included the
opportunity to gain a different per-
spective 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 stu-
dent 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 com-
ments about negative elements
within the CLE that impacted their
learning. Responses ranged from
feeling like an annoyance to the
staff nurses; lack of skills perform-
ance opportunities, such as start-
ing IVs; the vast differences in skill
performances among nurses; the
lack of assessing student knowl-
edge and experience before dele-
gating a task to them; and nurses’
confidence level with student
nurses.
The following perception of a
negative element impacting learn-
ing in the CLE was identified.
Nurses’ confidence level. Par-
ticipant 4: “On my last experience,
there was a nurse that was chart-
ing, and I was looking over her
shoulder to see how she was chart-
ing and everything and she eventu-
ally 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 experi-
ence.”
Question 4: To what degree do
student nurses perceive that clini-
cal experiences impact their plans
for future nursing practice?
Participants were asked to dis-
cuss what impact, if any, their CLE
experiences had on their future
nursing practice. A re-occurring
theme within the responses cen-
tered on technology and nursing
documentation. Participants per-
ceived themselves as champions
of technology and role models for
implementing computer documen-
tation. 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 de-
scribed their ability to take nega-
tive experiences and turn them
into positive learning experiences.
When asked to think about their
future as nurses, participants
voiced agreement with the follow-
ing 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 them-
selves.’ 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 opportu-
nities to practice IV and catheter
insertion, and various other inva-
sive procedures. However, partici-
pants voiced the desire for more
opportunities to perform skills
prior to graduation from their nurs-
ing 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 de-
scribed 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 nurs-
es’ perceptions toward learning in
the CLE demonstrates the signifi-
cance of positive and negative ele-
ments within a CLE. The four main
positive themes were preceptor-
ship, responsibility/trust, reflec-
tion, and different perspectives.
The perception of decreased confi-
dence levels of nurses around stu-
dents was the main negative
theme.
Chan (2002) indicated relation-
ships among students, peers,
instructors, staff nurses, and other
members of the health care team
are vital in providing an environ-
ment 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, partici-
pants learned from nurses in the
CLE.
Results showed student nurses
wanted responsibility and trust
from nurses, instructors, and
patients. Students viewed in-
creased responsibility as a confi-
dence builder. Students wanted
preceptors “who understand the
level students are at; and are able,
and willing, to provide regular feed-
back regarding the student’s per-
formance” (Happell, 2009, p. 375).
Nurses who reflected upon
their own student nurse experi-
ences were perceived by students
as compassionate and supportive
toward students. This was per-
ceived by students as increasing a
sense of acceptance and support:
“...ability (of preceptors) to know
and appreciate the level of knowl-
edge and the limitations of stu-
dents’ theoretical preparation and
support as a role model in helping
students feel they are safe and val-
ued” (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 set-
ting, 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 opportu-
nity to participate in nursing activi-
ties and learn from observing the
practices of more experienced col-
leagues (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 profession-
al insecurities if they encounter
challenging situations while edu-
cating 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 exam-
ple to the student” (p. 301).
Assumptions and Limitations
of the Research Project
The qualitative approach uti-
lized by this study supports the
potential transferability of result
findings to similar settings. The
results of this study are general
and transferable to similar under-
graduate nursing programs. Draw-
backs of this study include partici-
pant characteristics (self-selec-
tion) and group meetings. Parti-
cipant characteristics, such as self-
selection, limit the specificity of
criteria for participants. It could be
assumed participants wanted to
vent frustrations rather than con-
tribute 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 identi-
fied by participants as having a pos-
itive impact on learning in the CLE
were the preceptorship opportuni-
ty, acceptance from clinical staff
and the ability of nurses to recall
their own struggles and percep-
tions of the CLE as nursing stu-
dents. Participants identified the
desire for compassion, acceptance,
and support from nurses. The need
for nurse preceptors is critical, and
preceptorship or mentoring com-
ponents should be a part of each
clinical rotation if possible.
“Preceptorship has been consis-
tently acknowledged in the litera-
ture as a strategy to maximize the
benefits of clinical nursing educa-
tion in terms of knowledge and skill
acquisition, confidence, and profes-
sional socialization” (Happell, 2009,
p. 372). Student nurses also identi-
fied potential strategies for enhanc-
ing educational opportunities.
Student nurses’ perceptions
are significant not only for identify-
ing problems or areas of concern,
but also for providing problem-
solving strategies. One participant
provided the following recommen-
dation for enhancing student
nurse learning in the CLE: reverse
shadowing.
MEDSURG Nursing—July/August 2010—Vol. 19/No. 4
Participant 1: “I was just think-
ing, 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 threat-
ening, you could do the same.
After you leave the room, ask (clin-
ical instructor or preceptor), “Ok,
what did you see that I did well,
what could I change, what did I for-
get to do, what do I need to go
back and do right now?”
The topic of student nurse per-
ceptions provides a wealth of
information regarding learning in
the CLE. As the profession of nurs-
ing continues to evolve, the educa-
tional experiences and opportuni-
ties 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 experi-
ences in the CLE. Findings showed
nurses are considered role models
to student nurses, and the utiliza-
tion of preceptorship in the CLE
enhances student nurse learning.
Lastly, of relevance to learning in
the CLE is the commitment of nurs-
es to reflect upon their past experi-
ences as novice nurses, acknowl-
edge themselves as role models,
and give back to the nursing pro-
fession as preceptors.
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continued on page 246
The Good, The Bad, and
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