Obstetrical staff nurses experiences of clinical learning

Nurse Education in Practice 15 (2015) 44e51

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Obstetrical staff nurses experiences of clinical learning Linda M. Veltri* University of Wisconsin, Milwaukee, PO Box 413, 220 E. Kenwood Blvd, Milwaukee, WI 53201, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Accepted 8 October 2014

The clinical learning experience is used in nursing programs of study worldwide to prepare nurses for professional practice. This study's purpose was to use Naturalistic Inquiry to understand the experiences of staff nurses in an obstetrical unit with undergraduate nursing students present for clinical learning. A convenience sample of 12 staff nurses, employed on a Family Birth Center, participated in semistructured interviews. The constant comparative method as modified by Lincoln and Guba was used to analyze data. Five themes related to staff nurses experiences of clinical learning were identified: Giving and Receiving; Advancing Professionally and Personally; Balancing Act; Getting to Know and Working with You; and Past and Present. This research highlights staff nurses' experiences of clinical learning in undergraduate nursing education. Staff nurses exert a powerful, long lasting influence on students. A need exists to prepare and judiciously select nurses to work with students. Clinical agencies and universities can take joint responsibility providing tangible incentives, financial compensation, and recognition to all nurses working with nursing students. © 2014 Elsevier Ltd. All rights reserved.

Keywords: Undergraduate nursing Clinical learning Staff nurses

Nursing programs around the world devote much time and many resources to clinical learning. The clinical learning experience (CLE) is a widely used, critical component of undergraduate nursing education, essential to preparing nurses for professional practice (Aghamohammadi-Kalkhoran et al., 2010; Dunn and Hansford, 1997; Koontz et al., 2010). In the clinical workplace what nursing students' learn and how learning takes place depends on the theoretical lens used to view teaching and learning. Many theoretical perspectives, including behavioral, cognitive, constructionist, social-cognitive, and situated cognition influence students' learning (Emerson, 2007; Wilkinson, 2004). Situated and social-cognitive theories are relevant to discussion of clinical learning because both believe learning is influenced by the situation where it occurs. As such, the learning process is inseparable from the context or real-world experience (Merriam and Caffarella, 1999; Paige and Daley, 2009). They are inseparable because interactions between “people, the tools, and the context of the situation” are recognized as relevant (Paige and Daley, 2009, p. 98). When situated or social-cognitive theory is used to structure clinical learning, the nurse-teacher facilitates learning, models effective strategies in real-world learning environments, and

* Present address: Oregon Health and Science University, 1250 Siskiyou Blvd, Ashland, OR 97520, USA. Tel.: þ1 503 753 7171; fax: þ1 541 552 6055. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.nepr.2014.10.006 1471-5953/© 2014 Elsevier Ltd. All rights reserved.

provides support, feedback and advice to learners (Woolley and Jarvis, 2007). Viewing learning as a social experience allows creation of communities of practice, which provide students opportunity to learn from each other through the exchange of ideas and provision of feedback (Lave and Wenger, 1991; Wenger, 1998; Woolley and Jarvis, 2007). Involvement in the education of nursing students is an expected part of professional nursing practice (American Nurses Association [ANA], 2004; Nursing and Midwifery Council, 2008a). Staff nurses make important contributions to the CLE in undergraduate nursing education. Working with students can be rewarding for registered nurses (RNs; Aghamohammadi-Kalkhoran et al., 2010; Wilkinson, 2004). The clinical setting is perceived by students as the most influential context in which nursing knowledge and skills are acquired (Chan, 2004). Researchers have shown students' learning, impressions of nursing, and perceptions of clinical learning are influenced by attitudes, actions, and behaviors of nurses encountered in the clinical workplace, with staff nurses exerting the greatest influence on students' learning (Charleston and Happell, 2005; Grealish and Ranse, 2009; Papp et al., 2003; Ranse and Grealish, 2007; Stockhausen, 2005; Vallant and Neville, 2006). A global shortage of nursing faculty and nurses exists (Nardi and Gyurko, 2013). In response, nursing schools have admitted more students, which increase reliance on staff nurses' participation in the CLE (Courtney-Pratt et al., 2011; Henderson and Eaton, 2012;

L.M. Veltri / Nurse Education in Practice 15 (2015) 44e51

National League for Nursing, 2013). Various models used to frame clinical learning rely on staff nurse participation in the CLE. For example, the traditional faculty supervised model, common in the United States (US), involves a group of nursing students assigned to academic clinical faculty (AFC) for a period of time and placed in acute-care settings where they are paired with a staff nurse to provide care for one or two patients (Barnett et al., 2010; Tanner, 2006). Staff nurses paired with students in this manner are not routinely compensated for their work beyond their regular rate of pay. In contrast, the clinical studentepreceptor or mentor model, typical in the United Kingdom (UK) and Australia, is used to frame clinical learning (Barnett et al., 2010; Nursing and Midwifery Council, 2008b). Under this model a nurse from the clinical agency works one to one with a student assigned to the clinical setting for several weeks (Barnett et al., 2010). Prior to working as a studentepreceptor, US nurses may be required to complete a special course and may receive additional pay when precepting students. Nurses in the UK working in a similar role must meet specific, pre-determined criteria (Nursing and Midwifery Council, 2008b). Nurses' precepting students Australia and other nations do not receive additional financial compensation (Rains, 2012). Academia's reliance on nurses in the clinical workplace to assist with the education of students makes it necessary to understand how staff nurses experience their unstructured work with students. Unstructured work is defined as a temporary studentestaff nurse relationship occurring when RNs have an assignment involving work during one shift with a student present on the nursing unit for CLE with ACF present on the unit. The unstructured studentestaff nurse relationship stands in contrast to the studentepreceptor or mentor relationship. Much has been published about the studentepreceptor model of clinical learning. Limited knowledge exists about how staff nurses, in situations other than the studentenurse preceptor relationship experience their role in helping students learn. Therefore, this study's purpose was to understand staff nurses experiences of conducting their unstructured work on an obstetrical unit with undergraduate nursing students present on the unit for clinical learning. Literature Review A computer-assisted search of published literature in the English language within the past 23 years was retrieved from nine data bases in the domains of nursing, psychology, education, medicine, allied health, and business. Three qualitative studies, focusing on the traditional faculty supervised model of clinical learning and exploring different aspects of nurses' work with undergraduate nursing students, were identified. Hathorn et al. (2009) purposed to discover American nurses' attitudes toward nursing students and how nurses' negative attitudes developed. Brammer (2006) investigated ways Australian nurses understand and approach their informal role with students while O'Callaghan and Slevin (2003) studied Irish nurses' perceptions of their student supervisory role. This study expands current knowledge by exploring American staff nurses' unstructured experiences with undergraduate nursing students. In professional-educational programs like nursing, the learning environment is separated into two venues: academia and the field. Students enrolled in these types of programs acquire different forms of knowledge: knowing that and knowing how (Table 1). In nursing, know how is primarily developed in the clinical workplace (Chan, 2004; Gaberson and Oermann, 2007). Experience in the clinical environment allows students to enter the real world of nursing; learn from knowledgeable nurses; construct a personal and professional identity as a nurse; confirm their practice of what

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Table 1 Forms of knowledge and definitions. Term

Definition

Knowing that

Formal, generalized theoretical knowledge generated through theory-based scientific investigation such as that typically learned in the classroom or laboratory environment. Craft knowledge developed through experience in the workplace

Knowing how

Adapted from Benner (2002), Dunn et al. (2000) and Spouse (2001).

nurses do; validate nursing as a career choice; engage in decision making; develop confidence, problem-solving, time management, organizational, and psychomotor skills; and begin to understand about human caring in a way that cannot be explicated in the classroom or learned from a book or simulation experience (Ard et al., 2008; Baxter and Boblin 2008; Chan, 2004; Ip and Chan, 2005; Koontz et al., 2010; Lofmark and Wikblad, 2001; Nolan and Chung, 1999; Sand-Jecklin and Schaffer, 2006; Stockhausen, 2005). Increased enrollment in nursing programs creates need for more nurses to supervise students in the clinical workplace. Nurses, pressured by the nursing shortage, heavy workloads, and high acuity of patients may feel stressed by added responsibility for student supervision Therefore, nurses may be reluctant to work with students and perceive students as a burden (Andrews et al., 2005; Hathorn et al., 2009; Hautala et al., 2007; Matsumura et al., 2004). Undergraduate nursing student satisfaction increases when the clinical environment is positive, accepting, welcoming, appreciative, cooperative, and collaborative (Henderson et al., 2006a; Koontz et al., 2010; Lofmark and Wikblad, 2001; Ranse and Grealish, 2007). Students perceive human relationships, such as those with staff nurses, as a high priority; students also desire greater personalization and willingness of staff nurses to engage in a teaching relationship (Ip and Chan, 2005; Lofmark and Wikblad, 2001; Papp et al., 2003). Students were more committed and encouraged to stay in nursing following a positive CLE and when the CLE was perceived to be personalized (Andrews et al., 2005; Henderson et al., 2006b; Pearcey and Elliott, 2004). Students are disappointed when the workplace is unwelcoming and their work is not acknowledged by nurses. Learning barriers are created when nurses do not take students seriously, make condescending comments, and demonstrate lack of acceptance, support, supervision, feedback, or interest in supervising students (Levett-Jones et al., 2007; Ranse and Grealish, 2007). Lack of nursing support contributes to students' negative perceptions of the CLE, the nursing unit, and the workplace institution. As a result, students' may not seek employment within the institution and consider leaving nursing, further exacerbating the nursing shortage (Andrews et al., 2005; Henderson et al., 2006b; Pearcey and Elliott, 2004). Methods Naturalistic Inquiry (NI) allows holistic exploration of the human experience (Lincoln and Guba, 1985). NI permitted accumulation of sufficient information to describe nurses' experience in the natural context of a Family Birth Center (FBC) with undergraduate nursing students assigned for clinical learning. Following Institutional Review Board approval this study was carried out in an urban, not-for-profit, in Magnet® hospital the Pacific Northwest. Study participants were recruited as a convenience sample from staff RNs. Inclusion criteria were: Englishspeaking, baccalaureate-prepared RN currently employed in the facility's FBC who had worked in an unstructured manner with

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L.M. Veltri / Nurse Education in Practice 15 (2015) 44e51

undergraduate nursing students assigned to the labor and delivery or postpartum units. RNs were excluded if they worked more than half their regular scheduled shifts as a nurse/unit manager or charge nurse (CN) or if they had only worked with undergraduate nursing students as a preceptor. One participant, working primarily as a CN was included in the final study sample because of her valuable insights about the FBC. A sample of 12 RNs was sufficient to generate an in-depth, thick description of the shared perceptions, beliefs, and experiences of RNs employed on the FBC. The researcher and individual participants met on a mutually agreed date and place; participant questions were addressed, and signed informed consent obtained. An audio-recorded, semistructured interview lasting 20e60 minutes followed. The interview began with the researcher asking rapport-building and demographic questions (Table 2). Questions became more specific and focused on the research topic as the researcher gained a sense of the salient information participants could provide. Other data sources included the researcher's field notes taken during the interview(s) and demographic information collected. At the conclusion of the interview, participants received a $10 gift card. Data confidentiality was maintained by creating a roster listing names of nurses participating in this study along with a unique identifying code number. This number was noted on their taperecorded interview, transcribed interview, and field notes. The master roster and other data collected were kept in a locked filing cabinet accessible only to the researcher. An interpretive continuous approach to data analysis was used in accordance with Lincoln and Guba's (1985) elucidation of the Glaser and Strauss (1967) constant-comparative method to process, reduce, and analyze data into categories. Audio recordings were transcribed by a professional transcriptionist. A manual system and software program NVivo 8® were used to store, organize, and code data. Accuracy of data collection and analysis procedures was assured by an experienced qualitative researcher. Trustworthiness was ensured using criteria for establishing credibility, transferability, dependability, and confirmability described by Lincoln and Guba (1985). Demographic data were analyzed using descriptive statistics. Eleven participants were White; one's race/ethnicity was unknown. All participants held a baccalaureate degree in nursing. Table 3 summarizes sample demographics and characteristics. The following five themes emerged which captured staff nurses unstructured experiences with undergraduate nursing students assigned to the nursing unit during students CLE. Giving and receiving Working with students provided nurses an opportunity to give back to the profession and receive personal satisfaction. Giving back was accomplished by fulfilling a personal and professional responsibility, obligation, or nursing duty; fostering students' Table 2 Semi-structured interview guide. 1. Tell me about your background as a Registered Nurse. 2. Tell me about your experiences working with students. 3. What is it like for you to work with a student during his or her clinical learning experience? 4. What effect does working with a student have on your work? 5. What makes working with a student easier for you? 6. What makes it more difficult? 7. What do you think other nurses should know about working with students in the clinical setting? 8. What do you think educators should know about your work with students? 9. Is there anything else you would like to say about your experiences working with students in the clinical setting?

Table 3 Sample demographics and characteristics. Demographics

Total number (percentage) (n ¼ 12)

Range

Mean

Age RN experience Years worked as RN Years worked in OB Years worked this hospital Years worked in unstructured manner with nursing students Unit worked Postpartum Labor and delivery Both postpartum and labor and delivery Other nursing roles Relief charge University clinical instructor Hours worked/week Full time equivalent ¼ 36 h Part time ¼ 24 h Resource ¼ variable hrs Shift worked Nights ¼ 7pme7am Days ¼ 7ame7pm Evenings ¼ 3pme11pm Variable Number of hours worked/shift 12 h 8h Variable hours RN certification Yes No In progress Works as a formal preceptor Yes No Participates in clinical laddera Yes No Clinical ladder rank Level 4 Level 3 Level 2 Level 1

12 (100%) 12 (100%)

27e48

38.3

3e25 yrs 3e25 yrs 3.5e25 yrs 1.5e25 yrs

12.3 9.2 11.4 10.7

7 (58%) 3 (25%) 2 (17%)

6 (50%) 3 (25%) 7 (58%) 3 (25%) 2 (17%) 2 8 1 1

(17%) (67%) (8.0%) (8.0%)

10 (83%) 1 (8.0%) 1 (8.0%) 6 (50%) 4 (33%) 1 (8.0%) 9 (75%) 1 (8.0%) 8 (67%) 4 (33%) 5 3 0 0

(42%) (25%) (0.0%) (0.0%)

a Two participants (17%) were currently not eligible for the clinical-ladder program because of their employment status as a resource nurse and two (17%) were not participating in this program.

interest in an area of nursing that is their 'love'; assisting with students' preparation for nursing practice; and retention in the nursing workforce. Many nurses enjoyed working with students, especially when students were prepared for, interested, and engaged in their own learning. One nurse relayed it was beneficial to work with students because they could teach new things to nurses. At times, nurses found working with students to be challenging and stressful, especially if nurses were new to nursing and the unit or inexperienced in their role; or if the nurse was assigned students for several shifts in a row; feeling tired, sick, dealing with personal issues, sleep deprived, having a bad day; or when it was a ‘crazy day’ on the unit. Under these conditions nurses preferred not to work with a student because they felt it would be difficult to provide the student with an optimal learning experience. A recent nurse graduate and a veteran nurse explain situations where they would decline to work with students: Being a new grad … I don't like being responsible for a student at the same time … because I can't focus on the student. If I had

L.M. Veltri / Nurse Education in Practice 15 (2015) 44e51

any assignment … where I was nervous or not feeling like on top of my game I would not take a student … that would be for both the patient's sake and the student's sake. Ninety-five percent of the time I feel very excited to be able to hang out with the students, … if it's my fourth 12 [hour shift] in a row and I'm tired and my knees are aching and my back is aching and I've got lots of stuff going on its hard to give up energy to be with the students just for the day … I feel like I wouldn't have enough energy to do a good job.

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quality nursing care. The presence of students reminded nurses to slow down, provide more thorough nursing care and patient teaching, review policies, procedures, and healthcare providers' orders, and be more attentive to patients. After a very long pause, a veteran nurse admitted: [When I have a student] I might be more attentive to the patients than maybe I would otherwise be. … I might actually go into [the patient's] room even though I'm watching the monitor strip. … I interact with the patient more when I have a student. … I am maybe more proactive in getting the patient delivered in hopes that the student can have that experience.

Advancing professionally and personally Working with students provided staff nurses opportunities for professional and personal advancement. Nurses who voluntarily participated in the agency's clinical-ladder program received extra financial compensation and paid educational days for each step up the ladder achieved. Teaching was an activity nurses used to quickly climb the clinical-ladder. A nurse, not participating in the clinicalladder program, thought working with students could be a lot of work and suggested this as a reason nurses think they should be compensated for such work. She suggested the lack of incentives affected her attitude about working with students.

Patient and personal safety was a concern for staff nurses as they balanced students' desire to hone their nursing practice with maintaining safety in the workplace. Many nurses did not find the presence of students on the unit compromised patient safety or care because of the measures they took to ensure safety. Other nurses believed the presence of students could potentially be detrimental especially when students did things they were not supposed to or took on more than they were capable of. New and veteran nurses expressed concern their nursing license might be on the line while working with students who acted in an unsafe manner.

Balancing act

Past and present

Participation in the CLE required nurses to balance multiple demands of the clinical workplace and academia. Balancing began when CNs making shift assignments worked to balance student needs with the skill mix and personality of the staff and patient present on the unit. In this study some CNs rarely considered or were unaware of academic and student learning goals. Other CNs made student assignments as an afterthought or based on the kinds of patients or experiences they believed students would learn or benefit from. When making shift assignments a relief CN relayed it was helpful when ACF communicated students' learning needs and experiences. In this study, staff nurses' experiences with students occurred within the context of what nurses described as a busy, chaotic, and changing workplace with more work for nurses. Within this milieu nurses' balanced demands and expectations of the workplace, academia, and students. This job was easier when students were ‘strong’ and could work as the team member. Students with prior clinical rotations were perceived as helpful because they could think critically and function more independently, which freed up time for nurses to attend to other things. One less experienced nurse found working with some students' helped get the work done faster; while other nurses believed students disrupted their work routine or slowed them down. Veteran nurses described how working with students negatively impacts their work:

Staff nurses had a powerful, long lasting influence on what students learned as well as how students felt about their CLE and future nursing practice. Nurses vividly recalled how actions and behaviors of RNs they encountered during their own CLEs affected them personally and professionally as well as what they learned. Two RNs poignantly describe positive and negative ways staff nurses affected them:

It's harder to have a student, because you have this routine down as how to do things and the student kind of messes up the routine. I have to go in and explain what I'm doing and how I'm doing it, which is really fun, but it makes it a harder experience … it's a little bit more challenging day. When they don't listen or they don't seem to have a skill set, if they don't pick up quickly, it makes it more difficult because it slows you down, and I get frustrated … when I get slowed down, and I get behind the eight ball and then I start feeling resentful that I have the student. Many nurses said working with students reminded them to balance the need to accomplish their work with the provision of

I do have some really good experiences of working with a couple different nurses … that let me take a mother/baby couplet and do their assessments and talk with them and take care of them and I was kind of the primary person … I learned a lot and I felt like wasn't just tagging along, that I was somehow important to the process. … because I wanted some assistance with moving a big old man that had had a stroke on and off of a commode, I recall him [the male nurse] saying to me … you need to be able to do that by yourself. … He said to me if you can't hack this maybe you shouldn't be in nursing. As a result of their own CLE some staff nurses vowed they would not treat students the way they had been treated, but would instead be helpful. Two nurses said how they were treated as undergraduate nursing students during their CLE influenced their decision to seek employment at a particular hospital. Table 4 details actions and behaviors staff nurses encountered during their own CLE that facilitated or hindered CLE. Getting to know and working with you Connections among staff nurses, students, and ACF were integral to the CLE. Almost every nurse relayed the importance of getting to know students personally. Nurses worked to integrate students into the workplace, establish working relationships, guide the CLE to meet academic learning goals, and get to know students by inquiring what year of school the student was in, prior clinical experiences, learning goals, and the skills or assessments they could perform. Getting to know students helped the nurse/student

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Table 4 Influential actions and behaviors staff nurses encountered during their own CLE. Positive RN actions and behaviors

Negative RN actions and behaviors

Doing Putting your hands on Doing assessments Being busy Learned from the repetition of it all

Not Doing Just standing there watching No fun if there was nothing to do I was watching the clock Doing everything to keep myself awake Thinking when is this day going to be over I just wanted to leave Observing Tagging along Followed the nurse Never felt like I could get in and get my hands dirty or do something Not being able to experience anything The nurse ignored me did not talk to me for the first 20 minutes Did not want me, which made me want to cry Was not a friend, mentor, somebody you could look or go to Was mean Made me feel bothersome, like a burden Did not really want me there Made it drudgery Did not make it interesting or fun

The nurse welcomed me made me feel comfortable was engaging Gave a little freedom Was not task oriented Did not make me feel dumb Did not make me feel like I did not belong or was a burden Showed how to do things Taught me things I still do Let me do a lot such as assessments, talk with and Care for patients, which make me feel important to the process

dyad plan how to work together and helped nurses' tailor their teaching. Nurses looked out for student learning experiencesda job made easier when students articulated learning goals. A veteran nurse shared how she advocated for change in a student's assignment to provide a good learning experience: [Another nurse] was assigned a student, and her patient was doing absolutely nothing … she was not going to be anything really of value for a labor and delivery experience. … I asked the instructor if she could come with me. … We had monitoring to do … issues to deal with as opposed to [the student] just sitting.

Table 5 Positive and negative undergraduate nursing-student characteristics, Actions and behaviors that influenced staff nurses' unstructured experiences. Positive characteristics, actions and behaviors

Negative characteristics, actions and behaviors

Responsible

Chatted with friends, studied during clinical learning, disappeared Ad-libed, just getting by or putting in time Acted bored or uninterested, shadowed, watched Over confident Did not appear to want to be there Timid, afraid Did not take initiative

Professional Kept an open mind Listened to, stays with nurse Paid attention Interactive, proactive, Actively participated in CLE, takes notes during report Strong Talked with nurse, interacts with patients, steps in to work

Was not assertive Too quiet, soft spoken, stood back, did not interact, needed to be pushed

In this study, connections with ACF emerged as an important element of the CLE. Nurses valued long-term and personal relationships with ACF because it created accountability and made nurses work with students easier and more collaborative. Nurses reported having good relationships with ACF yet desired to work more closely and collaboratively with them if academic requirements did not interfere with nurses' clinical work. Some nurses preferred more ACF involvement in the CLE; collaboration and discussion of academic and student-learning needs; opportunity to debrief; and ability to provide formative feedback about students. One nurse believed it is incumbent on ACF to seek out nurses because nurses are too busy with patient care to track down faculty. A few nurses did not want ACF-student interactions, other academic requirements or paperwork to slow them down, interfere with their work, or cause students to choose between ACF, nurses, or learning opportunities. Other ACF actions helpful to staff nurses' work with students are presented in Table 6. Discussion Five of the themes that emerged from this study are discussed in light of findings from previous studies of undergraduate clinical learning. Giving and receiving

Characteristics, actions, and behaviors students exhibited during their CLE influenced nurses' work with students. Being prepared for clinical learning was the dominant quality nurses desired students to possess. Students who were energetic, prepared, confident, effective communicators, watched for learning opportunities, and actively participated were a joy for nurses to work with. In contrast, students were perceived as a waste of time and drain on nurses' energy when they did not ask questions, exhibit interest in learning, or were not goal directed. One nurse explained how a bad student experience discouraged her from wanting to work with students: You … have to drag them around … to say hey, let's go take out this Foley. Do you want to do it? It seems like you spend a lot of energy … do they even care; are you just wasting your time? … if you have even one of them, those are the students that can really take it down.

The finding that nurses perceived working with students a professional obligation is harmonious with The ANA (2001) Code of Ethics for Nurses, Nursing Scope and Standards of Practice (2004) and other reports that nurses' participation in the education of students is a professional obligation and valued component of professional practice (Brammer, 2006; Hathorn et al., 2009; Nursing and Midwifery Council, 2008a,b; Palmer et al., 2005). The finding that many RNs find their unstructured work with students an enjoyable, personally satisfying, and reciprocal experience is supported by other researchers (Courtney-Pratt et al., 2011; Grealish et al., 2010; Melander and Roberts, 1994). A finding distinct to this study is staff nurse's recognition of personal and workplace factors that hindered their ability to provide optimal student learning experiences and subsequent choice to decline a student assignment. Advancing professionally and personally

Table 5 presents additional characteristics, actions and behaviors students exhibited that influenced nurses' unstructured work with them during their CLE.

In this study, many, but not every nurse was compensated or recognized for working in an unstructured manner with nursing

L.M. Veltri / Nurse Education in Practice 15 (2015) 44e51 Table 6 Academic clinical faculty actions that augment CLE. Prepare students to be on the unit Let students know it is important to ask questions Encourage students to show an interest in learning Have students be proactive in telling nurses what they need/want to learn Provide brief educational seminars to students Make sure students get a lunch break Do not engage in inappropriate chit chat with the nurse Do not pull students away from learning experiences on the unit Be flexible, available and visible Seek out staff nurses working with the students Debrief with the nurse Solicit feedback from nurse about how students are doing Share learning goals with nurse Ensure staff nurse knows how to get a hold of you Be involved in the clinical learning experience Look happy to be there Do not ‘dump’ students and then disappear Connect and communicate with staff nurses

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Hathorn et al. (2009) study expressed liability concerns when working with students, and believed students worked under the auspices of the nurses' license when ACF were not present on the nursing unit. Past and present This study's finding that behaviors by staff nurses toward students exert a powerful influence on what students learned, how they felt about the CLE and the nursing profession, and employment decisions upon licensure are consistent with findings reported over the past 25 years (Andrews et al., 2005, 2006; Grealish and Ranse, 2009; Hart and Rotem, 1994; Papp et al., 2003; Pearcey and Elliott, 2004; Ranse and Grealish, 2007; Windsor, 1987). The finding that staff nurses work with undergraduate nursing students had a long lasting influence on students was exclusive to this study. Getting to know and working with you

students. Lack of incentives was suggested to have bearing on negative attitudes some nurses hold about working with students. Hathorn et al. (2009) similarly reported these factors to negatively impact nurses' attitudes and motivation to work with students. Balancing act In this study CNs rarely considered students learning goals. This practice might be explained by lack of communication and sharing of information between key players in the CLE. Researchers have reported the need for stronger communication between academia, clinical-practice settings, nurses, and ACF to allow for mutual understanding of nursing curriculum, provide and enhance a supportive learning climate, and clarify the roles of students, ACF, and nurses (Chan, 2004; Dunn et al., 2000; Dunn and Hansford, 1997; Ip and Chan, 2005). Absence of information about academic learning goals reported in this study are consistent with those reported by Andrews et al. (2006) and Hathorn et al. (2009). In this study, the CLE occurred within the context of a busy workplace with staff nurses reporting increasing work demands. The finding that the presence of students can be helpful, make nurses' work easier and free up time for nurses is well supported (Hathorn et al., 2009; Matsumura et al., 2004; O'Callaghan and Slevin, 2003; Ranse and Grealish, 2007; Swinny, 2010). Staff nurses also revealed, at times, it was harder to work with students because they disrupted work routines and slowed nurses down. This finding is congruent with other's report that working with nursing students is time-consuming (Grealish et al., 2010; Hathorn et al., 2009; Matsumura et al., 2004; O'Callaghan and Slevin, 2003; Swinny, 2010). In this study, nurses reported improved quality of nursing care as a benefit of being slowed down by students, a finding congruent with Zisberg et al. (2003). This study also found the presence of nursing students on the unit could, at times and under certain circumstances, compromise safety and care. This finding can be explained, in part by the work of Brammer (2008) who reported some nurses lacked awareness about the need to monitor and supervise students they were 'buddied' with for clinical learning. These findings, tempered by Brammer's report that other nurses kept a tight rein on students and Reid-Searl and Happell's (2011) finding that nurses respected the importance of close, direct supervision when students administer medications were consistent with this study's finding that nurses employed measures to maintain patient and students' safety during the CLE. Some nurses were concerned about their own personal liability when working with students. Similarly, nurses participating in

The finding that relationships among nurses, students, and ACF are integral to the CLE is supported by other researchers (Atack et al., 2000; Chan, 2004; Courtney-Pratt et al., 2011; Henderson et al., 2006b; Pearcey and Elliott, 2004; Wilkes, 2006). The way nurses in this study worked to know students and integrate them into the workplace is similar to how nurses in Stockhausen's (2005) study approached students, and Courtney-Pratt et al. (2011) reported agreement among students and nurses that students were welcomed and accepted on the nursing unit. The finding that some nurse's desire increased involvement, collaboration, and communication with ACF is supported by others (Andrews et al., 2006; Henderson and Eaton, 2012; Tanda and Denham, 2009), while the finding that few nurses did not want academia or ACF to interfere with their work or students' learning was particular to this study. The finding that staff nurses desired opportunity to provide feedback about student's performance to the students themselves or ACF is contrary to Kilcullen's (2007) report of nurses being fearful about giving students feedback for fear of being criticized. Limitations Study limitations include a small sample size, homogenous sample composition, and single setting. Findings may not generalize to other staff nurses or other healthcare settings. The researcher's experience as an obstetrical nurse and nurse educator is a source of bias. Study Implications Nursing education Nurse educators can use classroom and simulation experiences to prepare undergraduate nursing students with theoretical knowledge, cognitive, psychomotor, affective, safety, and communication skills prior to clinical placement. These experiences can teach students strategies to use when encountering difficult interpersonal situations during their CLE. Employing strategies aimed at helping nurses' cultivate interpersonal skills as well as increasing communication and collaboration between academia, clinical agencies, and nurses working with students could help ensure quality monitoring and supervision occurs during the CLE. Nurse educators can provide nurses with evidence based information about legal liability issues related to their work with students. There is immediate need to correct misconceptions that

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students work on nurses' licenses and inform students about their own professional responsibility and liability. Nursing practice It is vital that staff nurses working in an unstructured manner with students become familiar with academic and clinical-agency guidelines related to students on the unit, engage in appropriate monitoring and supervision of students, and become comfortable providing formative feedback to students and ACF. Clinical agencies taking a ‘no tolerance’ stance toward incivility help create positive learning environments for students as does provision of educational offerings to nurses geared toward effective ways to communicate, evaluate, and support students during their CLE. Clinical agencies and universities can take joint responsibility for providing tangible incentives, financial compensation, and recognition to all nurses for their unstructured work with students. Nursing research A multiple-case study to explore RNs' experiences within the context of different types of nursing units and clinical settings is needed. Future research should be aimed at: corroborating distinctive study findings; discovering what tangible rewards and benefits would encourage, motivate, and keep nurses engaged in unstructured work with students; determine the impact students, when present on the nursing unit for clinical learning, has on patient safety and quality of care; and exploring why some nurses are reluctant to work with students in the clinical workplace. Conclusions Staff nurses' unstructured work with students provides nurses opportunity to fulfill their obligation to the nursing profession and reap other benefits. Nurses' work with students can be constrained by the workplace environment, personal issues, actions, and behaviors exhibited by students and ACF. Study findings support need for clinical agencies and academia to communicate with and prepare nurses for their unstructured work with students. The long lasting impact staff nurses have on student learning should motivate academia, clinical agencies, and nurses to create and provide positive, supportive, and civil learning environments as well as judiciously select staff nurses who work with students in the clinical setting. Acknowledgment Study funded in part by Sigma Theta Tau International, Omicron Upsilon Chapter. References Aghamohammadi-Kalkhoran, M., Karimollahi, M., Abdi, R., 2010. Iranian staff nurses' attitudes toward nursing students. Nurse Educ. Today 31, 477e481. http://dx.doi.org/10.1016/j.nedt.2010.09.003. American Nurses Association, 2001. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, Maryland. American Nurses Association, 2004. Nursing: Scope and Standards of Practice (Washington DC). Andrews, G., Brodie, D., Andrews, J., Hillan, E., Thomas, B., Wong, J., Rixon, L., 2006. Professional roles and communications in clinical placements: a qualitative study of nursing student's perceptions and some models for practice. Int. J. Nurs. Stud. 43, 861e874. Andrews, G., Brodie, D., Andrews, J., Wong, J., Thomas, B., 2005. Place(ment) matters: students' clinical experiences and their preferences for first employers. Int. Nurs. Rev. 52, 142. Ard, N., Rogers, K., Vinten, S., 2008. Headlines from the NLN: summary of the survey on clinical education in nursing. Nurs. Educ. Perspect. 29, 238e245.

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