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1Stoffels M, et al. BMJ Open 2019;9:e029397. doi:10.1136/bmjopen-2019-029397
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How do undergraduate nursing students learn in the hospital setting? A scoping review of conceptualisations, operationalisations and learning activities
Malou Stoffels ,1,2 Saskia M Peerdeman,1,3 Hester E M Daelmans,1,4 Johannes C F Ket,5 Rashmi A Kusurkar1,6
To cite: Stoffels M, Peerdeman SM, Daelmans HEM, et al. How do undergraduate nursing students learn in the hospital setting? A scoping review of conceptualisations, operationalisations and learning activities. BMJ Open 2019;9:e029397. doi:10.1136/bmjopen-2019-029397
► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2019- 029397).
Received 24 January 2019Revised 02 October 2019Accepted 21 October 2019
For numbered affiliations see end of article.
Correspondence toMalou Stoffels; m. stoffels@ amsterdamumc. nl
Original research
© Author(s) (or their employer(s)) 2019. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.
ABSTRACTObjectives Although clinical learning is pivotal for nursing education, the learning process itself and the terminology to address this topic remain underexposed in the literature. This study aimed to examine how concepts equivalent to ‘learning in practice’ are used and operationalised and which learning activities are reported in the nursing education literature. The final aim was to propose terminology for future studies.Design The scoping framework proposed by Arksey and O’Malley was used to answer the research questions and address gaps in the literature. Two systematic searches were conducted in PubMed, EBSCO/ERIC and EBSCO/CINAHL between May and September 2018: first, to identify concepts equivalent to ‘learning in practice’ and, second, to find studies operationalising these concepts. Eligible articles were studies that examined the regular learning of undergraduate nursing students in the hospital setting. Conceptualisations, theoretical frameworks and operationalisations were mapped descriptively. Results relating to how students learn were synthesised using thematic analysis. Quality assessment was performed using the Critical Appraisal Skills Programme checklist.Results From 9360 abstracts, 17 articles were included. Five studies adopted a general, yet not explained, synonym for learning in practice, and the other approaches focused on the social, unplanned or active nature of learning. All studies used a qualitative approach. The small number of studies and medium study quality hampered a thorough comparison of concepts. The synthesis of results revealed five types of learning activities, acknowledged by an expert panel, in which autonomy, interactions and cognitive processing were central themes.Conclusions Both theoretical approaches and learning activities of the current body of research fit into experiential learning theories, which can be used to guide and improve future studies. Gaps in the literature include formal and informal components of learning, the relation between learning and learning outcomes and the interplay between behaviour and cognitive processing.
InTRODuCTIOnLearning in the clinical setting is crucial for becoming a competent nurse.1 However, although a vast body of knowledge exists on factors that influence learning, the process itself remains underexposed in the literature.2 Understanding learning in the clinical setting can help design, supervise and evaluate indi-vidual learning trajectories. In the nursing education literature, just as in other health professions education literature, different terms are used to describe and study learning in clinical practice, with different underlying theoretical or conceptual frameworks.
This study aimed to examine how different concepts equivalent to ‘learning in prac-tice’ are used and operationalised and which learning activities are reported in the nursing education literature. The final aim was to propose a terminology to guide future studies. To our knowledge, the only study that included distinct concepts of clinical learning in the health setting in a review before was a concept analysis of work- based learning in healthcare education from 2009.3 The
Strengths and limitations of this study
► This study followed a rigorous design, using an established research framework, a comprehensive two- step search strategy and a well- documented selection process.
► The analysis of both conceptualisations, study qual-ity and study results allowed for the identification of quantitative and qualitative gaps in the literature.
► A limitation is that the literature search only covered undergraduate nursing education in the hospital set-ting, while a comparison with literature on learning in practice in other health professions would enrichen our understanding of potential conceptualisations.
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authors identified common attributes, enabling factors and consequences of workplace learning and proposed a definition. The current review built on this work by critically examining the use of these concepts within the context of undergraduate nursing education and by analysing their outcomes.
To enable comparison of the literature, this study focused on undergraduate students in the general hospital setting. This context is the traditional setting for nursing training and offers a wide array of multidimen-sional learning opportunities4 through the presence of different healthcare professionals and students, as well as complex and acute patients. Moreover, this study is limited to undergraduate (also called bachelor, diploma or asso-ciate degree) education, which is the initial training that prepares for registration as a nurse, in which students learn the profession and shape their identity. As a final demarcation allowing for the contrasting of concepts, we focused on studies about how students learn during their regular day to day work at the ward, instead of evaluations of specific interventions or models.
MeThODS AnD AnAlySISThe scoping review approach was chosen, as it can help understand complex concepts through clarifying defini-tions and conceptual boundaries5 and enables to identify key concepts and gaps in the literature.6 The approach developed by Arksey and O'Malley7 and refined by Levac et al8 and the Joanna Briggs Institute9 was used, consisting of the six stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; (5) collating, summarising and reporting the results and (6) expert consultation. Reporting on this scoping review followed the PRISMA Extension for Scoping Review checklist,10 as outlined in online supplementary file 1. The review followed an a priori developed research protocol11 (see online supple-mentary file 2) with a little deviation by choosing the Crit-ical Appraisal Skills Programme (CASP) checklist12 over the quality indicators of Buckley et al,13 as this allowed for more specific and systematic quality assessment. As antici-pated, study questions and refined inclusion criteria were added during the search process.
Stage 1. Identifying the research questionThe original research question was:
‘How are different concepts that are used as an equiva-lent to learning in the hospital setting operationalised in the undergraduate nursing education literature?’
As scoping is an iterative process,7 the following research question was added based on the findings along the search process:
‘Which activities do undergraduate nursing students learn from in the clinical setting?’
Stage 2. Identifying relevant studiesAs suggested by the Joanna Briggs Institute,9 a compre-hensive search strategy was iteratively developed (by
MS and JCFK) following the Peer Review of Electronic Search Strategies 2015 guideline statement,14 starting with a broad search (search step 1) to inform the subse-quent search strategy (search step 2). The different search queries were first developed for PubMed and later extended to EBSCO/ERIC and EBSCO/CINAHL. See our search strategy for both steps in online supplemen-tary file 3.
In search step 1, from inception to May 2018, the terms ‘learning in clinical practice’ and ‘undergraduate nursing students’ were combined to identify concepts that are used as an equivalent to ‘learning in clinical practice’ and that could be included in the second search step. Eligible concepts were those relating to the process of clinical learning rather than specific aspects of it or associated factors. The first 200 abstracts were screened by the two reviewers (MS and RAK) independently to extract poten-tially eligible concepts. As the two reviewers reached full agreement on potentially eligible concepts within these first 200 abstracts, the first reviewer screened the rest of the abstracts. After all abstracts had been screened, all concepts were discussed between the two reviewers and a final selection of concepts to be included in the second search step was made. Disagreements were resolved through comparison of the concepts with the inclusion criteria, based on their use within the abstract. Potentially eligible concepts of which the meaning remained unclear after discussion were also added to the list of concepts to be used in search step 2. Other concepts coming up during the search and selection process that appeared eligible were added to the selection of concepts after discussion between the reviewers. See online supplemen-tary file 4 for concepts and reason for inclusion/exclu-sion in the second search step.
In search step 2, between May and September 2018, each of the identified concepts was combined with ‘undergraduate nursing students’ to find studies opera-tionalising these concepts in the literature about nursing students’ learning in practice. After these two searches, reference lists of included studies were checked for addi-tional publications meeting inclusion criteria.
Stage 3. Study selectionTwo researchers (MS and RAK) independently screened abstracts from search step two and assessed the eligi-bility for full text retrieval. Selected full- text studies were compared between the reviewers with disagreements being resolved through discussion and consensus and with input from the full research team.
The inclusion criteria were developed iteratively. The initial inclusion criteria were:
► Original research or reviews in peer reviewed journals that have learning in undergraduate clinical nursing practice in the hospital setting as one of their main topics, regardless of publication date and type of article.
► Studies that examine how students learn in the clin-ical hospital setting.
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In line with the aim of the study, the inclusion criteria were refined to:
► Original research or reviews in peer reviewed jour-nals, regardless of publication date, type of article and study quality, that examine the learning of undergrad-uate nursing students in the clinical hospital setting as it regularly occurs.
This results in the following exclusion criteria:Studies: ► evaluating organisational models or interventions, ► about factors influencing learning in clinical practice,
including supervision styles, teaching methods and clinical learning environment,
► outside the general hospital setting, ► about very specific student populations, patient popu-
lations or settings (eg, palliative care) generating results that might be limited to that setting,
► about interprofessional learning, ► about the acquisition of specific skills, ► about student’s ‘experience’ of clinical learning
without explicit reference to the learning process.As the study aimed to examine how learning in practice
is operationalised in peer- reviewed research, books, book reviews, commentaries, letters to the editor, PhD theses and reports were excluded.
Stage 4. Charting the dataSelected studies were documented including study char-acteristics (year, country, methodology, study question, study design, participants, outcomes), conceptualisation of learning in practice (definitions, theoretical underpin-nings/rationale, operationalisations), results, learning activities and study quality. Two researchers piloted and refined the data extraction form on the first five studies. The completed form was discussed in the research team for accuracy and validity. Learning activities were extracted by two reviewers independently (MS and RAK), and the other variables were initially charted by the first reviewer and checked by the second reviewer. Learning activities were separated from other study results by going through the result sections of the studies and underlining findings (themes, observations, quotes) that referred to how nursing students learn in the hospital setting. When possible, the original wordings were used in the data chart. Colloquial expressions that lost meaning outside the context of the article were slightly rephrased. Although formal assessment of study quality in scoping reviews is debated,6 9 quality assessment of included studies by the CASP checklist12 was decided on to address qualitative gaps in the literature.8
Stage 5. Collating, summarising and reporting resultsData were analysed in two ways. First, descriptive accounts of concepts, theories, subsequent operationalisations and study quality were given and compared. Second, a data- driven thematic analysis of learning activities was conducted.15 These findings were categorised using open
coding. All the results were compared and consolidated through consensus between MS and RAK.
Stage 6. expert consultationIn order to confirm our findings, we presented our anal-ysis of the learning activities to four experts of different institutions in the Netherlands (a senior clinical educator, a coordinator of clinical education, a head of nursing education department and a coordinator of nursing education). Short semistructured (telephone) inter-views were conducted, in which a written summary of the findings was presented and respondents were asked (1) whether they recognised the findings, (2) whether they missed anything and (3) whether they had any other comments on the findings.
Patient and public involvementAs education is essential for improving patient care, patients will eventually benefit from the body of knowl-edge this study contributes to. However, specific interests of patients have not been investigated. Patients have not been involved in the design or the conduct of the study. The consulted experts can be considered participants of this study and will be informed about the results as soon as it has been published.
ReSulTSSearch resultsThis initial search to identify concepts yielded 7211 abstracts, of which 5658 remained after removing dupli-cates. As the two reviewers (MS and RAK) reached full agreement on potentially eligible concepts after screening the first 200 abstracts, the remaining abstracts were screened by MS only. Seventy potentially eligible concepts were extracted. After discussion between the reviewers, 22 concepts were selected, to which 3 concepts were added later in the process, so the second search was run with 25 different concepts. See online supplementary file 4 for concepts and reason for inclusion/exclusion in search step 2. The second search, using the 25 concepts selected in the initial search, generated 9360 results of which 5880 remained after duplicates were removed. A total of 83 abstracts were selected for full text reading and 17 studies were included (see online supplementary file 5 for excluded full texts and reason for exclusion). Three pairs of studies were based on (partly) overlapping data,16–21 but were all included as the results only partly overlapped. Reference list screening of the full text arti-cles did not generate any extra results. See figure 1 for a flow diagram of search step 2.
General study characteristicsAll included studies examined the process of undergrad-uate nursing students’ learning in the clinical setting, as a result of their primary aim or as a significant secondary finding of a broader research question. Six of the studies18–23 investigated undergraduate nursing students’
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Figure 1 Flow diagram article screening and selection search step 2.
learning in both the classroom setting and the clinical setting. One of the studies included nursing students and midwifery and social work students.24 However, data presentation in the current study is restricted to findings concerning nursing students in the clinical setting. All were primary studies, of which 16 were qualitative studies and 1 mixed methods.21 Publication year ranged from 1987 to 2018. Studies were conducted in different coun-tries in Europe, Middle East, North America and Oceania.
Study qualityTable 1 shows the quality of the included studies as assessed with the CASP tool.12 In the only mixed method study included,21 the quantitative data were analysed only descriptively and were used to inform the qualitative data. Therefore, this study was also appraised with the CASP. To summarise, in the majority of studies, it was unclear how the results answered the research question, because of a lack of clear aims, lack of clear operationalisation or both, in spite of clear descriptions of the process of data analysis and its outcomes.
Concepts, operationalisations and learning activitiesTable 2 summarises the main concepts, operationali-sations, frameworks, findings and learning activities of the 17 selected studies. Findings concerning concep-tualisation and operationalisation as well as the results concerning learning activities will be discussed in the following paragraphs.
ConceptualisationsMain conceptsTo analyse how learning in practice was approached, we compared the main concepts of study, usually reflected in the aims of the paper. Five of the papers studied a concept that was a synonym for learning in clinical practice such as
clinical learning experience or workplace learning.17 25–28 However, in none of these studies the concept was defined or justified. The remaining 11 studies examined a specific concept related to learning in general, which was studied within the context of clinical practice. In four of the studies, this concept concerned social learning, either in general or from specific groups that are naturally present in the nursing ward.16 24 29 30 In five of the studies, the non- conscious, unplanned nature of learning was explic-itly targeted by the concepts of experiential, informal and hidden curriculum learning.20–23 31 The remaining studies focused on the active role of the student in learning by investigating learning styles,32 or a specific combination of both the process and effects of learning as reflected in the concept of transformative learning.18 19
Theoretical frameworksThe five studies that used a theoretical or conceptual framework to structure the study, used Wenger’s commu-nity of practice26 or Mezirow’s transformative learning theory.16–19 Three of the studies tried to extend on existing theories using a grounded theory approach.20 21 25 The remaining nine studies discussed their research questions and findings in the light of previous literature relevant for their specific study,22 23 27 28 some of them referring to theories about learning such as Eraut’s theory of informal learning, Melia’s theory of professional socializsation,30 or Kolb’s learning cycle.20–22 27 32
OperationalisationsNine studies used interviews, narratives or both to address students’ experiences of learning in general18 19 25 26 31 32 or specifically learning from interactions.16 17 24 The different approaches shared a semistructured nature, in which a few main topics were introduced by the researcher, to which students could bring up their ideas and experi-ences. Some authors20–22 combined an exploration of what students understood by experiential learning, with an examination of their actual experiences in experi-ential learning. Finally, in three of the studies, learning was operationalised by the observation of interactions between nursing students and peers or colleagues that play a role in learning.16 29 30
Comparison of conceptualisations and operationalisationsMost of the studies, apart from the ones that focus on social interactions, adopted a very open approach to examine learning in practice, irrespective of the concepts and theoretical frameworks used. This resulted in a variety of overlapping outcomes. Together with the small number of studies, a thorough comparison of the suit-ability of different concepts was difficult. However, the overarching focus on students’ personal, unplanned learning experience as a result of social interactions, suggests that the use of concepts derived from construc-tivist and social- cultural theories are most appropriate for studying clinical learning in nursing education.33
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Tab
le 1
Q
ualit
y of
the
incl
uded
stu
die
s as
ass
esse
d w
ith t
he C
AS
P12
too
l
Bar
az
et a
l32B
urna
rd20
Bur
nard
21C
arey
et
al29
Dad
gar
an
et a
l25G
idm
an24
Gre
alis
h an
d
Ran
se26
Gre
en a
nd
Ho
llow
ay22
Kea
r18K
ear19
Man
nine
n16M
anni
nen
et a
l17M
ayso
n an
d
Hay
war
d31
Ro
ber
ts30
Sey
lani
et
al23
Sto
ckha
usen
27W
ind
sor28
Was
the
re a
cle
ar
stat
emen
t of
th
e ai
ms
of t
he
rese
arch
?
Yes
No
Yes
Yes
No
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
Is a
qua
litat
ive
met
hod
olog
y ap
pro
pria
te?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Was
the
res
earc
h d
esig
n ap
pro
pria
te
to a
dd
ress
the
aim
s of
the
res
earc
h?
Yes
Can
’t te
llYe
sYe
sN
oYe
sC
an’t
tell
Can
’t te
llYe
sC
an’t
tell
Yes
Yes
Yes
Yes
No
Yes
Yes
Was
the
rec
ruitm
ent
stra
tegy
ap
pro
pria
te
to t
he a
ims
of t
he
rese
arch
?
Yes
Can
’t te
llYe
sYe
sC
an’t
tell
Yes
Can
’t te
llC
an’t
tell
Yes
Can
’t te
llC
an’t
tell
Can
’t te
llC
an’t
tell
Can
’t te
llYe
sN
oN
o
Was
the
dat
a co
llect
ed in
a w
ay
that
ad
dre
ssed
the
re
sear
ch is
sue?
Yes
Can
’t te
llC
an’t
tell
Yes
Yes
Can
’t te
llYe
sC
an’t
tell
Can
’t te
llYe
sC
an’t
tell
Yes
Yes
Yes
Can
’t te
llYe
sYe
s
Has
the
rel
atio
nshi
p
bet
wee
n re
sear
cher
an
d p
artic
ipan
ts
bee
n ad
equa
tely
co
nsid
ered
?
No
Can
’t te
llC
an’t
tell
Yes
No
Yes
Yes
No
No
No
No
Can
’t te
llYe
sC
an’t
tell
No
No
No
Hav
e et
hica
l iss
ues
bee
n ta
ken
into
co
nsid
erat
ion?
Yes
can’
t te
llC
an’t
tell
Yes
Yes
Yes
Can
’t te
llN
oYe
sC
an’t
tell
Can
’t te
llYe
sYe
sYe
sYe
sYe
sN
o
Was
the
dat
a an
alys
is s
uffic
ient
ly
rigor
ous?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Can
’t te
llYe
sYe
sC
an’t
tell
Yes
Yes
Yes
Is t
here
a c
lear
st
atem
ent
of
find
ings
?
Yes
Yes
No
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
CA
SP,
Crit
ical
Ap
pra
isal
Ski
lls P
rogr
amm
e.
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Tab
le 2
M
ain
conc
epts
, op
erat
iona
lisat
ions
, fra
mew
orks
, find
ings
, lea
rnin
g ac
tiviti
es o
f the
incl
uded
stu
die
s
Co
ncep
tual
isat
ion
Op
erat
iona
lisat
ion
Lear
ning
act
ivit
ies
Mai
n te
rm(s
) use
d t
o
des
crib
e le
arni
ng in
p
ract
ice
Defi
nitio
n, if
p
rovi
ded
, in
italic
s
Mai
n co
ncep
t st
udie
dD
efini
tion,
if p
rovi
ded
, in
ital
ics
The
ore
tica
l o
r co
ncep
tual
fr
amew
ork
fo
r in
terp
reti
ng r
esul
ts/
exp
licit
ref
eren
ce t
o
lear
ning
the
ori
es
Sum
mar
y o
f o
per
atio
nalis
atio
nM
ain
stud
y re
sult
s, a
rran
ged
ac
cord
ing
to
the
stu
die
s’
ob
ject
ives
Lear
ning
act
ivit
ies
for
nurs
ing
stu
den
ts in
the
ho
spit
al
sett
ing
, id
enti
fied
by
the
revi
ewer
s in
the
stu
die
s’
resu
lt s
ecti
ons
Bar
az e
t al
32
(201
4)Le
arni
ng p
roce
ss in
cl
inic
al s
ettin
gLe
arni
ng s
tyle
s in
clin
ical
se
ttin
gIn
div
idua
l’s p
refe
rred
m
etho
ds
of k
now
led
ge
and
ski
ll ac
qui
sitio
n an
d
info
rmat
ion
orga
nisa
tion
No
theo
retic
al
fram
ewor
k, u
sed
, re
fere
nce
to K
olb
’s
stag
es o
f exp
erie
ntia
l le
arni
ng
Sem
istr
uctu
red
inte
rvie
ws
abou
t w
hat
and
how
st
uden
ts le
arn
in t
he
clin
ical
set
ting
Thre
e cl
inic
al le
arni
ng s
tyle
s1.
Th
ough
tful
ob
serv
atio
n2.
Le
arni
ng b
y d
oing
3.
Lear
ning
by
thin
king
►
Car
eful
ob
serv
atio
n of
rol
e m
odel
s p
erfo
rman
ce
►R
eflec
tive
obse
rvat
ion
dur
ing
clin
ical
rou
nds
►
Par
ticip
atin
g in
med
ical
rou
nds
►
Clin
ical
rou
nds
►
Nur
sing
rou
nds
by
inst
ruct
ors
and
cla
ssm
ates
►
Act
ive
invo
lvem
ent
in p
roce
dur
es
►C
arin
g fo
r se
nsiti
ve p
atie
nts
►
Act
ive
colla
bor
atio
n w
ith p
eers
►
Mai
ntai
ning
con
tinui
ty b
y m
akin
g ac
tive
pat
ient
co
ntac
t an
d r
epea
ting
nurs
ing
pro
ced
ures
►
Ass
umin
g re
spon
sib
ility
for
pat
ient
car
e
►M
emor
isin
g in
fo b
y hi
stor
y ta
king
►
Acc
ount
abili
ty fo
r cl
inic
al h
omew
ork
►
Inq
uirin
g st
aff a
nd p
eers
►
Crit
ical
thi
nkin
g
►M
onito
ring,
crit
iqui
ng, a
void
ing
unsa
fe p
ract
ice
Bur
nard
21C
linic
al e
xper
ienc
esE
xper
ient
ial l
earn
ing
‘Exp
erie
ntia
l lea
rnin
g’
has
bee
n us
ed t
o d
escr
ibe
man
y d
iffer
ent
sort
s of
ed
ucat
iona
l ap
pro
ache
s ra
ngin
g fr
om
the
use
of in
tera
ctiv
e gr
oup
str
ateg
ies)
to
accr
editi
ng p
eop
le fo
r th
eir
life
exp
erie
nce
whe
n co
nsid
erin
g th
ose
peo
ple
fo
r en
tran
ce t
o co
urse
s
No
theo
retic
al
fram
ewor
k, u
sed
, re
fere
nce
to K
olb
’s
stag
es o
f exp
erie
ntia
l le
arni
ng
In- d
epth
inte
rvie
ws
abou
t ho
w s
tud
ents
per
ceiv
e ex
per
ient
ial l
earn
ing
Defi
nitio
ns o
f exp
erie
ntia
l le
arni
ng:
1.
Som
ethi
ng m
ore
than
just
b
eing
tau
ght
2.
Som
ethi
ng t
hat
you
use
whe
n yo
u us
e yo
ur o
wn
exp
erie
nce
3.
Lear
ning
in t
he c
linic
al s
ettin
g
►
Just
doi
ng
►Ju
st b
eing
the
re
►Le
arni
ng b
y se
eing
►
Sel
ectin
g on
e of
the
nur
ses
as a
rol
e m
odel
►
Bei
ng p
erso
nally
invo
lved
and
imm
erse
d in
the
le
arni
ng s
ituat
ion
Bur
nard
20C
linic
al e
xper
ienc
esE
xper
ient
ial l
earn
ing
No
defi
nitio
n p
rovi
ded
w
ith ju
stifi
catio
n: ‘i
t ap
pea
rs t
hat
the
term
ca
n b
e us
ed b
y d
iffer
ent
peo
ple
in d
iffer
ent
way
s’
No
theo
retic
al
fram
ewor
k, u
sed
, re
fere
nce
to K
olb
’s
stag
es o
f exp
erie
ntia
l le
arni
ng
Inte
rvie
ws
abou
t ho
w
stud
ents
and
tut
ors
exp
erie
nce
exp
erie
ntia
l le
arni
ng a
nd q
uest
ionn
aire
ab
out
per
cep
tions
of
exp
erie
ntia
l lea
rnin
g
Exp
erie
ntia
l lea
rnin
g1.
is
lear
ning
by
doi
ng2.
is
per
sona
l lea
rnin
g3.
in
volv
es r
eflec
tion
Stu
den
ts m
ostly
rel
ate
exp
erie
ntia
l lea
rnin
g to
lear
ning
in
the
clin
ical
set
ting.
►
Lear
ning
by
taki
ng p
art
►
Doi
ng a
nd r
eflec
ting.
►
Ob
serv
ing
role
mod
els
Car
ey e
t al
29Le
arni
ng in
clin
ical
se
ttin
gs/
lear
ning
w
ithin
the
clin
ical
p
ract
ice
envi
ronm
ent;
C
linic
al le
arni
ng
Pee
r- as
sist
ed le
arni
ng in
w
hich
stu
den
ts a
cqui
re
skill
s an
d k
now
led
ge
thro
ugh
the
activ
e he
lp
pro
vid
ed b
y st
atus
eq
uals
or
mat
ched
com
pan
ions
(T
opp
ing,
200
5).
–O
bse
rvat
ion
of in
tera
ctio
n p
atte
rns
bet
wee
n st
uden
tsTh
ree
them
es c
ontr
ibut
ing
to
imp
act
of p
eer-
assi
sted
lear
ning
:
►P
eers
as
faci
litat
ors
to
dev
elop
lear
ning
►
Wor
king
tog
ethe
r as
pee
rs t
o d
evel
op c
linic
al p
ract
ice
and
d
eliv
er c
are
►
Pos
itive
sup
por
t an
d
inte
ract
ion
from
pee
rs t
o en
hanc
e ne
twor
king
and
d
evel
op w
orki
ng s
truc
ture
►
Wat
chin
g d
emon
stra
tions
by
othe
r st
uden
ts
►A
skin
g q
uest
ions
►
See
king
ad
vice
and
gui
dan
ce
►D
iscu
ssin
g d
evel
opm
ent
pla
ns
►D
iscu
ssin
g p
ract
ice
stan
dar
ds
►
Cha
lleng
ing
each
oth
er’s
kno
wle
dge
►
Sha
ring
role
s
►S
harin
g ex
per
ienc
es o
f clin
ical
pra
ctic
e
►D
iscu
ssin
g ch
alle
nges
of fi
ndin
g on
e's
way
in t
he
clin
ical
env
ironm
ent
Con
tinue
d
on October 5, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2019-029397 on 8 D
ecember 2019. D
ownloaded from
7Stoffels M, et al. BMJ Open 2019;9:e029397. doi:10.1136/bmjopen-2019-029397
Open access
Co
ncep
tual
isat
ion
Op
erat
iona
lisat
ion
Lear
ning
act
ivit
ies
Dad
gara
n et
al5
Clin
ical
lear
ning
Clin
ical
lear
ning
–S
emis
truc
ture
d in
terv
iew
s ab
out
how
stu
den
ts
exp
erie
nce
thei
r cl
inic
al
lear
ning
; sub
seq
uent
ob
serv
atio
ns o
f stu
den
ts
in t
he c
linic
al s
ettin
g w
ith a
fo
cus
on in
tera
ctio
ns
Five
cat
egor
ies
and
one
‘cor
e va
riab
le’:
1. F
acin
g un
favo
urab
le c
linic
al
fact
s2.
Ana
lysi
s of
a c
linic
al s
ituat
ion
and
ap
pro
pria
te d
ecis
ion
mak
ing
i. B
ridgi
ng t
he g
ap b
etw
een
pra
ctic
e an
d t
heor
yii.
S
trug
gle
for
clin
ical
in
dep
end
ence
iii.
Dyn
amis
miv
. S
trug
gle
to a
cqui
r e c
linic
al
com
pet
ence
Two
app
roac
hes
to le
arni
ng:
1.
Mic
role
arni
ng2.
M
acro
lear
ning
►
Tryi
ng t
o fig
ure
out
wha
t re
gula
tions
are
and
wha
t th
ey
shou
ld b
e th
roug
h d
etec
tion
of t
he e
nviro
nmen
t
►M
odify
lear
ning
defi
cits
to
fight
the
feel
ing
of b
eing
un
able
to
answ
er q
uest
ions
►
Try
to a
naly
se t
he s
ituat
ion
and
mak
e an
ap
pro
pria
te
dec
isio
n
►In
crea
se t
heor
etic
al k
now
led
ge t
hrou
gh r
ead
ing
boo
ks
and
ask
ing
que
stio
ns
►In
the
war
d, r
evie
w a
lread
y le
arnt
mat
eria
ls
(reco
nstr
uctiv
e th
inki
ng)
►
Ana
lysi
s of
clin
ical
issu
es (c
linic
al r
easo
ning
)
►M
akin
g lin
ks b
etw
een
theo
ry a
nd p
ract
ice
►
Des
ign
care
pla
ns
►O
rgan
isin
g ca
re o
n th
e b
asis
of s
elf-
mad
e ca
re p
lans
►
Doi
ng t
asks
ind
epen
den
tly
Gid
man
24Le
arni
ng in
pra
ctic
eLe
arni
ng fr
om p
atie
nt
stor
ies
No
theo
retic
al
fram
ewor
k, u
sed
, re
fere
nce
to E
raut
’s
theo
ry o
n in
form
al
lear
ning
Con
vers
atio
nal i
nter
view
s ab
out
stud
ents
’ p
erce
ptio
ns o
f the
ir le
arni
ng e
xper
ienc
es o
f lis
teni
ng t
o p
atie
nt s
torie
s
1.
Stu
den
ts v
alue
list
enin
g to
st
orie
s fo
r le
arni
ng2.
S
tud
ents
dev
elop
re
latio
nshi
ps
with
pat
ient
s3.
S
tud
ents
lear
n fr
om t
he
sub
ject
ive
and
em
otio
nal
per
spec
tive
of p
atie
nts
4.
Stu
den
ts t
hink
bac
k to
the
ir ow
n p
erso
nal s
torie
s w
hen
carin
g fo
r p
atie
nts
5.
List
enin
g to
sto
ries
has
a p
ositi
ve im
pac
t on
un
der
stan
din
g p
atie
nts
and
a
com
mitm
ent
to p
atie
nt c
are
►
List
enin
g to
pat
ient
s' p
erso
nal s
torie
s
►B
uild
ing
rela
tions
hip
s w
ith p
atie
nt
►Li
sten
ing
to r
elat
ives
of a
pat
ient
►
Refl
ectin
g on
per
sona
l exp
erie
nces
Gre
alis
h an
d
Ran
se26
Lear
ning
in t
he
wor
kpla
ce, c
linic
al
lear
ning
Lear
ning
in t
he c
linic
al
wor
kpla
ceC
omm
unity
of p
ract
ice
Stu
den
ts’ w
ritte
n na
rrat
ives
ab
out
whe
re t
hey
lear
nt
whi
le o
n cl
inic
al p
lace
men
t
Thre
e th
emat
ic c
onst
ruct
s, c
alle
d
‘lear
ning
trig
gers
’:1.
P
artic
ipat
ion
(or
obse
rvat
ion)
of
a t
ask
or p
roce
dur
e th
at
lead
s to
(tak
es t
hem
into
) a
com
ple
x, d
ram
atic
rea
din
g of
nu
rsin
g w
ork
2.
Bei
ng p
erso
nally
(em
otio
nally
) co
nfro
nted
by
the
wor
k (h
igh
chal
leng
e)3.
M
eetin
g nu
rses
who
co
ntrib
ute
to t
he d
evel
opm
ent
of a
n im
age
of w
hat
the
stud
ents
wan
ts t
o b
e as
a
nurs
e
►
Bei
ng in
volv
ed in
the
pra
ctic
al a
spec
ts o
f car
ing
for
a p
atie
nt
►S
hift
ing
focu
s fr
om t
he t
ask
to t
he p
erso
n
►Ta
lkin
g to
pat
ient
s’ r
elat
ives
►
Look
ing
at t
he p
atie
nt a
s a
per
son,
tak
ing
an in
tere
st
in t
heir
need
s
►E
ngag
ing
in p
osto
per
ativ
e ob
serv
atio
ns
►A
ssis
ting
pat
ient
s in
litt
le t
hing
s
►G
ivin
g m
edic
atio
ns
►B
eing
per
sona
lly (e
mot
iona
lly) c
onfr
onte
d b
y th
e w
ork
►
Exp
erie
ncin
g p
ositi
ve a
nd n
egat
ive
emot
ions
►
Taki
ng r
esp
onsi
bili
ty
►Ta
lkin
g to
pat
ient
s
►M
eetin
g nu
rses
who
con
trib
ute
to t
he d
evel
opm
ent
as
an im
age
►
Iden
tifyi
ng a
res
iden
t nu
rse
as a
rol
e m
odel
►
Rec
eivi
ng fe
edb
ack
from
res
iden
t nu
rses
►
Alig
ning
per
sona
l pra
ctic
e w
ith w
hat
is o
bse
rved
►
Wor
king
ind
epen
den
tly in
a s
upp
ortiv
e su
rrou
ndin
g
►W
itnes
sing
poo
r p
ract
ice
Tab
le 2
C
ontin
ued
Con
tinue
d
on October 5, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2019-029397 on 8 D
ecember 2019. D
ownloaded from
8 Stoffels M, et al. BMJ Open 2019;9:e029397. doi:10.1136/bmjopen-2019-029397
Open access
Co
ncep
tual
isat
ion
Op
erat
iona
lisat
ion
Lear
ning
act
ivit
ies
Gre
en a
nd
Hol
low
ay22
Lear
ning
in t
he
clin
ical
set
ting
Exp
erie
ntia
l lea
rnin
gN
o th
eore
tical
fr
amew
ork,
use
d,
refe
renc
e to
Kol
b’s
st
ages
of e
xper
ient
ial
lear
ning
Non
- dire
ctiv
e in
terv
iew
s ab
out
stud
ents
' un
der
stan
din
g, e
xper
ienc
e an
d in
terp
reta
tion
of
exp
erie
ntia
l lea
rnin
g
Six
the
mes
:1.
S
tud
ents
wer
e ab
le t
o d
efine
ex
per
ient
ial l
earn
ing,
usu
ally
en
cap
sula
ting
bot
h cl
assr
oom
an
d c
linic
al e
xper
ienc
e. T
he
imp
orta
nce
of t
he e
xper
ienc
e its
elf a
pp
eare
d fu
ndam
enta
l2.
R
ole
pla
y is
iden
tified
as
the
mai
n ex
amp
le o
f exp
erie
ntia
l te
achi
ng a
nd le
arni
ng3.
S
tud
ents
wer
e aw
are
of
the
issu
es a
risin
g fr
om t
he
pro
ble
mat
ic r
elat
ions
hip
b
etw
een
theo
ry a
nd p
ract
ice
4.
The
imp
orta
nce
of r
eflec
tion
as a
sta
ge in
exp
erie
ntia
l le
arni
ng a
nd o
f refl
ectiv
e p
ract
ice
was
hig
hlig
hted
in
dic
atin
g d
iver
sity
in
app
licat
ion
5.
Con
cern
s re
gard
ing
clin
ical
p
ract
ice
6.
The
imp
orta
nce
of c
linic
al
sup
ervi
sion
vie
win
g it
as
exp
erie
ntia
l lea
rnin
g
►
Wor
king
with
the
clie
nt (i
nclu
din
g th
e in
tuiti
ve e
lem
ent)
►
Par
ticip
atin
g in
tera
ctin
g, s
hare
d le
arni
ng w
ith p
eers
►
Eva
luat
ing
nurs
ing
mod
els
►
Refl
ectin
g
►S
harin
g ex
per
ienc
es
►S
elec
ting
from
pre
viou
s ex
per
ienc
e to
con
trib
ute
to
new
one
s
►P
ract
icin
g of
ski
lls
►P
ract
icin
g w
ith p
eop
le
►P
atie
nt c
are
►
Non
- thr
eate
ning
sup
por
tive
colla
bor
atio
n w
ith a
co
lleag
ue
►Le
arni
ng fo
rm p
ract
ice
and
refl
ectio
n
►In
volv
ing
clie
nts
►
Refl
ectin
g in
the
form
of a
por
tfol
io
►M
aint
aini
ng p
erso
nal j
ourn
als
Kea
r18C
linic
al e
xper
ienc
eTr
ansf
orm
ativ
e le
arni
ngTh
e p
roce
ss o
f crit
ical
ly
refle
ctin
g on
pre
viou
s as
sum
ptio
ns o
r un
der
stan
din
gs in
ord
er
to d
eter
min
e w
heth
er
one
still
hol
ds
them
to
be
true
or
chal
leng
es t
heir
clai
ms
(Mez
irow
)
Tran
sfor
mat
ive
lear
ning
Stu
den
ts’ s
torie
s ab
out
how
the
y ex
per
ienc
ed t
heir
lear
ning
On
anal
ysis
of t
he n
arra
tive
dat
a,
five
thre
ads
emer
ged
from
the
in
terv
iew
s w
ith t
he p
artic
ipan
ts:
1.
Sto
ries
of t
he m
ulti-
face
ted
p
roce
ss o
f lea
rnin
g2.
S
torie
s of
exp
erie
ntia
l lea
rnin
g3.
S
torie
s of
hum
an in
tera
ctio
ns
as c
entr
al t
o d
efini
ng n
ursi
ng
and
car
ing
4.
Sto
ries
that
inte
rtw
ine
per
sona
l life
exp
erie
nces
and
nu
rsin
g5.
S
torie
s of
tra
nsfo
rmat
ive
lear
ning
►
Cre
atin
g a
conn
ectio
n b
etw
een
clin
ical
exp
erie
nce
and
cl
assr
oom
mat
eria
l
►U
sing
pee
rs
►Le
arni
ng h
ow t
o d
o th
ings
►
Mee
ting
pat
ient
s w
ith t
heir
own
stor
ies
►
Look
ing
thin
gs u
p in
one
's b
ooks
►
Pro
vid
ing
end
- of-
life
care
►
Car
ing
for
a p
aed
iatr
ic c
ance
r p
atie
nt a
nd s
eein
g gr
adua
te n
urse
s le
t he
r d
o it
in h
er o
wn
way
►
Lear
ning
to
und
erst
and
the
nee
ds
of p
atie
nts
that
are
un
able
to
com
mun
icat
e
►O
bse
rvin
g ot
her
nurs
es t
o d
eter
min
e w
hat
kind
of
nurs
e th
ey w
ant
to b
e (b
oth
nega
tivel
y an
d p
ositi
vely
)
►Ju
st s
pen
din
g tim
e w
ith p
atie
nts
►
Ob
serv
ing
pat
ient
situ
atio
ns t
hat
wer
e un
just
or
nurs
ing
care
tha
t w
as v
iew
ed a
s su
bop
timal
Tab
le 2
C
ontin
ued
Con
tinue
d
on October 5, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2019-029397 on 8 D
ecember 2019. D
ownloaded from
9Stoffels M, et al. BMJ Open 2019;9:e029397. doi:10.1136/bmjopen-2019-029397
Open access
Co
ncep
tual
isat
ion
Op
erat
iona
lisat
ion
Lear
ning
act
ivit
ies
Kea
r19C
linic
al e
xper
ienc
esTr
ansf
orm
ativ
e le
arni
ngC
hang
es in
mea
ning
p
ersp
ectiv
es t
hat
have
d
evel
oped
ove
r an
in
div
idua
l's li
fetim
e b
ased
on
the
ir lif
e ex
per
ienc
es
(Mez
irow
, 200
0)
Tran
sfor
mat
ive
lear
ning
Stu
den
ts’ s
torie
s ab
out
how
the
y ex
per
ienc
ed t
heir
lear
ning
On
anal
ysis
of t
he n
arra
tive
dat
a,
five
thre
ads
emer
ged
from
the
in
terv
iew
s w
ith t
he p
artic
ipan
ts:
1.
Sto
ries
of t
he m
ultif
acet
ed
pr o
cess
of l
earn
ing
2.
Sto
ries
of e
xper
ient
ial l
earn
ing
3.
Sto
ries
of h
uman
inte
ract
ions
as
cen
tral
to
defi
ning
nur
sing
an
d c
arin
g4.
S
torie
s th
at in
tert
win
e p
erso
nal l
ife e
xper
ienc
es a
nd
nurs
ing
5.
Sto
ries
of t
rans
form
ativ
e le
arni
ng
►
Cre
atin
g a
conn
ectio
n b
etw
een
clin
ical
exp
erie
nces
an
d c
lass
room
mat
eria
l
►In
tera
ctin
g w
ith o
ther
s in
the
clin
ical
env
ironm
ent
►
Und
erst
and
ing
pat
ient
s’ n
eed
s b
y in
tera
ctin
g w
ith
them
►
Ob
serv
ing
nurs
es t
o d
eter
min
e w
hat
kind
of n
urse
th
ey w
ant
to b
e
►P
rovi
din
g en
d- o
f- lif
e ca
re
Man
nine
n et
al17
Lear
ning
pro
cess
in
clin
ical
pra
ctic
e;
lear
ning
thr
ough
p
artic
ipat
ion
and
d
ialo
gue;
lear
ning
in
clin
ical
pra
ctic
e;
lear
ning
at
a cl
inic
al
educ
atio
n w
ard
Exp
erie
nces
of l
earn
ing
at a
clin
ical
war
dA
uthe
ntic
ity a
nd
tran
sfor
mat
ive
lear
ning
Sem
istr
uctu
red
inte
rvie
ws
of h
ow s
tud
ents
ex
per
ienc
ed t
heir
enco
unte
rs w
ith o
ther
s
Two
mai
n th
emes
:1.
M
utua
l rel
atio
nshi
p2.
B
elon
ging
ness
►
Cre
atin
g a
rela
tions
hip
with
pat
ient
s b
y m
eetin
g th
em
ind
epen
den
tly
►Li
sten
ing
and
com
mun
icat
ing
with
the
pat
ient
/ad
just
co
mm
unic
atio
n to
the
ind
ivid
ual p
atie
nt’s
cap
acity
and
ne
eds
►
Invo
lvin
g th
e p
atie
nt in
the
nur
sing
pro
cess
by
iden
tifyi
ng t
he p
atie
nt's
ow
n re
sour
ces
►
Lear
ning
from
mak
ing
failu
res
►
Han
dlin
g d
ifficu
lt si
tuat
ions
and
feel
ings
►
Col
lab
orat
ing
with
phy
sici
ans,
phy
siot
hera
pis
ts, o
ther
p
rofe
ssio
nals
and
oth
er s
tud
ents
►
Wor
king
tog
ethe
r w
ith o
ther
stu
den
ts, d
iscu
ssin
g p
atie
nt c
are,
sha
ring
exp
erie
nces
giv
ing
sup
por
t,
info
rmin
g an
d s
how
ing
Man
nine
n16Le
arni
ng in
clin
ical
p
ract
ice
Nur
sing
stu
den
ts’
lear
ning
in r
elat
ion
to e
ncou
nter
s w
ith
pat
ient
s, s
uper
viso
rs,
pee
r st
uden
ts a
nd o
ther
he
alth
care
pro
fess
iona
ls
Tran
sfor
mat
ive
lear
ning
and
con
cep
ts
of a
uthe
ntic
ity a
nd
thre
shol
d
Sem
istr
uctu
red
inte
rvie
ws
and
gro
up in
terv
iew
s of
st
uden
ts’ e
xper
ienc
e of
th
eir
lear
ning
with
a fo
cus
on t
heir
enco
unte
rs w
ith
othe
rs. O
bse
rvat
ions
with
fo
llow
- up
inte
rvie
ws
abou
t st
uden
t- p
atie
nt e
ncou
nter
s an
d a
bou
t su
per
visi
on
The
resu
lts s
how
tha
t th
e co
re o
f st
uden
t m
eani
ngfu
l lea
rnin
g is
the
ex
per
ienc
e of
bot
h ex
tern
al a
nd
inte
rnal
aut
hent
icity
.E
xter
nal a
uthe
ntic
ity r
efer
s to
b
eing
in a
rea
l clin
ical
set
ting
mee
ting
real
pat
ient
s. In
tern
al
auth
entic
ity is
ab
out
the
feel
ing
of
bel
ongi
ng a
nd r
eally
con
trib
utin
g to
pat
ient
s’ h
ealth
and
wel
l- b
eing
►
Cre
atin
g m
utua
l rel
atio
nshi
ps
►
Taki
ng c
are
of p
atie
nts
with
ext
ensi
ve n
eed
s fo
r nu
rsin
g in
terv
entio
ns
Tab
le 2
C
ontin
ued
Con
tinue
d
on October 5, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2019-029397 on 8 D
ecember 2019. D
ownloaded from
10 Stoffels M, et al. BMJ Open 2019;9:e029397. doi:10.1136/bmjopen-2019-029397
Open access
Co
ncep
tual
isat
ion
Op
erat
iona
lisat
ion
Lear
ning
act
ivit
ies
May
son
and
H
ayw
ard
31C
linic
al p
ract
ice
exp
erie
nces
Lear
ning
from
hid
den
cu
rric
ulum
Hid
den
cur
ricul
um
invo
lves
the
exp
erie
nce
and
ap
plic
atio
n of
the
ory
and
the
wid
er s
ocia
l co
ntex
t re
late
s to
the
p
ract
ice
dev
elop
men
t
Hid
den
cur
ricul
umS
emis
truc
ture
d in
terv
iew
s ab
out
clin
ical
are
as a
nd
per
sons
tha
t ha
ve b
een
ben
efici
al fo
r st
uden
ts’
lear
ning
as
wel
l as
des
crip
tions
of t
heir
lear
ning
Giv
en a
lack
of a
sum
mar
y of
im
por
tant
the
mes
, I e
xtra
cted
th
ese
find
ings
mys
elf
1.
Car
ing
rela
tions
hip
is c
entr
al
for
nurs
ing;
rel
atio
nshi
ps
with
pat
ient
s ar
e si
gnifi
cant
ex
per
ienc
es2.
R
egis
tere
d n
urse
s an
d t
utor
s ar
e co
ntrib
utor
s to
stu
den
ts’
lear
ning
if t
hey
incl
ude
stud
ents
3.
Stu
den
ts a
ctiv
ely
seek
p
ositi
ve e
xper
ienc
es4.
P
eers
pla
y a
sign
ifica
nt r
ole
in
lear
ning
5.
Imp
orta
nce
of b
eing
par
t of
th
e w
ard
tea
m, f
acili
tate
d b
y th
e w
ard
nur
se6.
Th
eory
- pra
ctic
e ga
p
►
Wor
king
in t
he m
edic
al/s
urgi
cal a
reas
►
Talk
ing
with
/list
enin
g to
clie
nts
►
Hel
pin
g/m
akin
g a
diff
eren
ce fo
r th
e p
atie
nt
►Lo
okin
g at
pos
itive
rol
e m
odel
s
►S
ittin
g to
geth
er w
ith p
eers
/tal
king
to
pee
rs a
bou
t ex
per
ienc
es
►W
atch
ing
sup
ervi
sors
on
nurs
ing
skill
s an
d
com
mun
icat
ion
skill
s
Rob
erts
30C
linic
al le
arni
ng;
info
rmal
on-
the
job
le
arni
ng
Pee
r le
arni
ngP
eer
lear
ning
invo
lves
st
uden
ts le
arni
ng fr
om
each
oth
er
No
theo
retic
al
fram
ewor
k, u
sed
, re
fere
nce
to E
raut
’s
theo
ry o
n in
form
al
lear
ning
and
Mel
ia’s
th
eory
of p
rofe
ssio
nal
soci
alis
atio
n
Ob
serv
atio
n of
stu
den
ts
in c
linic
al p
ract
ice
with
a
focu
s on
pee
r in
tera
ctio
ns
Them
es:
1.
Valu
e p
lace
d o
n fr
iend
ship
s an
d le
arni
ng in
clin
ical
p
ract
ice.
i. S
tud
ents
lear
ning
sur
viva
l sk
ills
(imp
licit
and
exp
licit
rule
s)2.
D
evel
opin
g cl
inic
al s
kills
►
Wor
king
alo
ngsi
de
othe
r st
uden
ts.
►
Pas
sing
alo
ng im
plic
it ru
les
►
Mak
ing
mis
take
s/b
eing
pul
led
up
/cal
led
ab
out
them
►
Sha
ring
clin
ical
ski
lls
►A
skin
g ot
her
stud
ents
for
help
►
Teac
hing
oth
er s
tud
ents
, reg
ard
less
of y
ear
of s
tud
y
Sey
lani
et
al23
(201
2)C
linic
al e
xper
ienc
esIn
form
al le
arni
ngIn
form
al o
r in
dire
ct
lear
ning
can
occ
ur a
s a
func
tion
of o
bse
rvin
g,
reta
inin
g an
d r
eplic
atin
g b
ehav
iour
s d
urin
g ed
ucat
iona
l exp
erie
nces
–S
emis
truc
ture
d in
terv
iew
s ab
out
wha
t ch
ange
s st
uden
ts e
xper
ienc
ed
dur
ing
thei
r st
udy
apar
t fr
om t
heor
etic
al a
nd
pra
ctic
al k
now
led
ge
Five
cat
egor
ies
of s
tud
ents
’ ex
per
ienc
es:
1.
Per
sona
l mat
urity
and
em
otio
nal g
r ow
th2.
S
ocia
l dev
elop
men
t3.
C
lose
ness
to
God
4.
Alte
ratio
ns in
val
ue s
yste
ms
5.
Eth
ical
and
pro
fess
iona
l co
mm
itmen
ts
►
Freq
uent
per
sona
l int
erac
tions
►
Dev
elop
ing
rela
tions
hip
s
►Fr
eque
nt e
xpos
ure
to li
fe a
nd d
eath
situ
atio
ns
►In
tera
ctin
g w
ith o
ther
s
►C
arin
g fo
r p
eop
le w
ith d
iffer
ent
relig
ious
bel
iefs
►
Lear
ning
from
pat
ient
s st
rugg
ling
with
chr
onic
illn
ess
►
Con
tinuo
usly
eng
agin
g w
ith p
eop
le w
ho n
eed
hel
p
►S
eein
g p
atie
nts
suffe
r
►C
omm
unic
atin
g w
ith p
atie
nts
►
Car
ing
for
the
mos
t vu
lner
able
►
Con
fron
ting
the
light
and
dar
k si
des
of l
ife
Tab
le 2
C
ontin
ued
Con
tinue
d
on October 5, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2019-029397 on 8 D
ecember 2019. D
ownloaded from
11Stoffels M, et al. BMJ Open 2019;9:e029397. doi:10.1136/bmjopen-2019-029397
Open access
Co
ncep
tual
isat
ion
Op
erat
iona
lisat
ion
Lear
ning
act
ivit
ies
Sto
ckha
usen
27Le
arni
ng in
the
w
orkp
lace
Lear
ning
in t
he
wor
kpla
ceN
o th
eore
tical
fr
amew
ork,
use
d,
refe
renc
e to
Kol
b’s
st
ages
of e
xper
ient
ial
lear
ning
Stu
den
ts’ j
ourn
als
and
re
flect
ive
grou
p d
ebrie
fings
co
mp
rehe
ndin
g re
flect
ions
on
clin
ical
exp
erie
nces
Them
es1.
E
nter
ing
the
wor
ld o
f the
p
atie
nt2.
C
linic
ians
mak
ing
a d
iffer
ence
3.
Con
stru
ctin
g an
iden
tity
as
a nu
rse
►
Lear
n th
roug
h th
e p
atie
nt’s
exp
erie
nce
►
Rea
ctin
g to
and
dec
iphe
ring
emot
ive
non-
verb
al c
ues
from
the
pat
ient
as
they
car
e fo
r th
em
►In
tera
ctin
g w
ith t
he p
atie
nt
►R
eflec
tivel
y in
terp
retin
g ex
per
ienc
es w
ith t
he p
atie
nt
►S
harin
g an
d d
evel
opin
g ev
eryd
ay n
ursi
ng p
ract
ices
w
ith t
he R
esid
ent
Nur
se (R
N)
►
Con
stru
ctin
g th
eir
own
sche
mat
a of
ad
mira
ble
q
ualit
ies
the
RN
dis
pla
ys
►P
icki
ng u
p li
ttle
tip
s fr
om t
he R
N/li
ttle
thi
ngs
that
she
d
oes
►
List
enin
g to
RN
s
►C
onfir
min
g th
eir
nurs
ing
pra
ctic
es a
nd a
ssim
ilatin
g th
eore
tical
and
clin
ical
kno
wle
dge
►
Pra
ctic
ing
skill
s
►D
oing
wha
t it
is it
tha
t nu
rses
do
►
Act
iviti
es s
uch
as m
akin
g a
bed
or
show
erin
g a
pat
ient
w
hen
cons
ider
ed fr
om a
stu
den
t’s a
chie
vem
ent
per
spec
tive
►
Eng
agin
g w
ith t
he a
ctiv
ities
of n
ursi
ng
►M
akin
g co
mp
aris
ons
and
dis
crim
inat
ions
of p
ract
ices
Win
dso
r28Le
arni
ng in
the
co
ntex
tual
set
ting
of
clin
ical
pra
ctic
e
Clin
ical
lear
ning
ex
per
ienc
eFo
cuse
d in
terv
iew
s ab
out
how
nur
sing
stu
den
ts
per
ceiv
e th
eir
clin
ical
ex
per
ienc
es
Mai
n ca
tego
ries
of le
arni
ng:
nurs
ing
skill
s, t
ime
man
agem
ent,
p
rofe
ssio
nal s
ocia
lisat
ion.
A
pat
tern
of s
tud
ent
dev
elop
men
t th
roug
h th
ree
pha
ses
►
Pra
ctic
ing
nurs
ing
skill
s
►G
oing
bac
k to
boo
ks a
nd jo
urna
ls
►P
orin
g ov
er c
hart
for
hour
s
►C
onsu
lting
oth
er h
ealth
care
pro
vid
ers
►
Writ
ing
pap
ers
►
Ob
serv
ing
nurs
es a
nd p
artic
ipat
ing
in n
ursi
ng
func
tions
►
Pre
par
ing
for
clin
ical
pra
ctic
e in
clud
ing
mee
ting
pat
ient
s, r
ead
ing
char
ts, s
tud
ying
pat
ient
s' h
ealth
ne
eds,
con
sulti
ng s
taff
►
Car
ing
for
lots
of d
iffer
ent
pat
ient
s w
ith d
iffer
ent
dis
ease
s, d
iffer
ent
kind
s of
war
ds,
var
iety
of
inst
ruct
ors,
wor
king
with
diff
eren
t eq
uip
men
t
►W
orki
ng m
ore
sub
seq
uent
shi
fts
with
the
sam
e p
atie
nt
►A
skin
g q
uest
ion
with
out
feel
ing
emb
arra
ssed
►
Ask
ing
que
stio
ns t
o th
eir
pee
rs
Tab
le 2
C
ontin
ued
on October 5, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2019-029397 on 8 D
ecember 2019. D
ownloaded from
12 Stoffels M, et al. BMJ Open 2019;9:e029397. doi:10.1136/bmjopen-2019-029397
Open access
Figure 2 Conceptualisations, operationalisations, learning activities scoping review.
learning activitiesThe thematic analysis allowed us to extract the following classes of activities that are observed or reported to contribute to learning during the daily presence of students in the nursing ward.1. Working as a nurse2. Interacting with ward staff3. Interacting with peers4. Interacting with patients5. Processing information.
1. Working as a nurseStudents learn by actively engaging in nursing practice, including gaining responsibility for designing care plans, organising care, practicing skills and delivering patient care themselves,18 20–22 25–27 32 within a supportive environ-ment.26 Several studies explicitly report how the impor-tance of working independently evolves throughout training.16 17 25 28 It should be noted that this theme may overlap with the other themes and might reflect a more general characteristic of learning in practice.
2. Interacting with ward staffStudents learn by observing both good and poor examples of registered nurses, listening to them and choosing which one could serve as a role model.18–21 23 26–28 31 32 Students learn from other professionals on the ward, for example, by listening to their discussions during rounds17 28 32 or receiving feedback.26 Besides observing nurses, students learn from sharing their work experiences with resident nurses and questioning them.25 27 28 32
3. Interacting with peersStudents learn from peers by working together, ques-tioning each other, sharing experiences, observing each other at work18 22 29 31 32 and teaching each other.30 They pass on implicit rules by asking for advice and guidance. Through discussing standards in practice, development plans and practical issues they challenge each other and expand their knowledge.29 Through dividing the work between them, students optimise their exposure to different learning situations.29
4. Interacting with patientsListening to patients and building relationships is reported as an activity that students learn from.16–18 22 24 26 31 Providing end- of- life care contributes to students’ learning,18 19 23 as well as caring for specific patient groups such as those with different religious beliefs, communication prob-lems, extensive needs, chronic illnesses or who visibly suffer.16–18 23 27 32 Concrete activities that are regarded to be valuable include involving the patient in the nursing process,17 assisting them with little things,26 giving medi-cation, doing postoperative observations and performing simple tasks such as making a bed as long as they can be done independently.26
5. Processing informationA final class of activities refers to how students look up, process and store information related to patient care and their learning process. Reflecting on nursing prac-tice promotes learning,20–22 27 32 sometimes supported by a journal or a portfolio.22 More specifically, students reflect by analysing and comparing nursing practice and thinking how to improve it, making connections with theory and previous experience.18 19 25 27 32 Negative experiences such as not being able to answer questions, witnessing poor practice, making mistakes and emotion evoking encounters, stimulate students to reflect and expand their knowledge and skills.17 18 23 26 30 Students benefit from going through textbooks18 25 28 and patient charts,28 32 as a preparation for the work shift or for specific activities such as patient education.
Summary of resultsFigure 2 summarises the findings regarding conceptuali-sations, operationalisations and learning activities.
expert consultationAll four experts acknowledged the synthesised learning activities as the core of clinical training. One of them added a nuance that some activities automatically promote learning (‘learning by doing’), while others require support by staff (eg, ‘peer learning’). Moreover, one of them noted that experiences may only result in learning on O
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after the learning has been made conscious. Compared with their ideal vision of practice learning, another expert missed the active role of the student in creating learning opportunities, as well as formalised elements of learning, such as the formulation of learning goals and the elab-oration of theory learnt in school. However, this was something they missed in their own daily practice as well. Finally, two experts noted that the ‘supervisor’ role of the resident nurse was referred to minimally; it appeared that resident nurses were primarily observed as role models. Two of the experts were surprised by the notion that nega-tive experiences are repeatedly mentioned as learning opportunities.
DiscussionThis study aimed to examine how different concepts equivalent to ‘learning in practice’ are operationalised and which learning activities are reported in the nursing education literature. The final aim was to propose a termi-nology to guide future studies. The scoping approach allowed for identification of gaps in the current litera-ture.7 Five of the 17 reviewed studies adopted a general, yet unexplained, synonym for learning in practice as their object of study, the others approached learning in prac-tice focusing on the social, unplanned and active nature of learning. These foci are in line with the broader liter-ature on practice learning in healthcare education.3 34 Regardless of conceptualisations, all studies adopted a qualitative approach, resulting in various, yet overlap-ping themes. A closer examination of learning activi-ties that were reported throughout the results, revealed five classes of activities that are congruent with separate bodies of literature on the importance of increasing independence,35 interaction with others,36 learning from authentic situations with patients and reflection37 as well as with experiences from our expert panel.
Our eventual aim was to make suggestions about the use of terminology in future research. The use of various terms for the same phenomenon may be inherent to the existence of different learning theories,34 that each lack explanatory power to inform all aspects of clinical educa-tion.38 Unfortunately, as the poor alignment within most studies resulted in similar operationalisations and results irrespective of the concepts used, specific recommenda-tions about how to use these concepts are hard to make on the basis of the current literature. Yet, when considering overarching trends, all concepts and learning activities in the current body of research fit well into a constructivist approach to learning and more specifically experiential learning theories.34 Building on educational theorists like Piaget and Dewey,33 experiential learning theories cover both cognitive and sociocultural approaches to learning,34 sharing the idea that learning evolves from doing, in an individual trajectory that is not predefined, in constant interaction with others, in which reflection and the interaction between theory and practice are central.3 34 Although some of the studies in the current research did use experiential theories or referred to
them,20–22 27 32 a more systematic and justified use of these theories and underlying concepts to frame and interpret research, would benefit future research. For instance, as was commented by one of the experts we consulted, the interactions between behaviour and cognitive processing were underexposed in the current literature. Cognitive approaches of experiential learning building on the work of Kolb39 could offer useful models to study and interpret these interactions. Given the body of work on experiential learning theories including their application in different stages of (medical) education, further elaboration on these theories can add to our understanding of learning and can help design and evaluate learning interventions in and outside the ward.40 41
Although some studies demonstrated how students actively interact with their environment by discussing inconsistencies, asking questions, and reflecting on unde-sirable role models, few of them offered examples of students actively creating learning opportunities or nego-tiating what and how to learn. This is in line with litera-ture showing that students often focus on task completion and fitting into the team at the expense of deepening, broadening and self- regulating their learning.42–44 Future studies should continue to address both individual and environmental factors that affect students’ ability to actively and critically navigate through their clinical placements. In line with our previous recommendations, approaching clinical learning as ‘experiential learning’ may help seeing it as a pathway for personal development rather than getting students adapted to the current work in the ward.45 A next step would be to identify individual preferences and behaviours in appreciating learning opportunities. Caution has to be taken though in labels such as ‘learning styles’ as one of the studies32 did, in the absence of an accurate description of how this has been interpreted.
Not surprisingly, there were frequent references to the informal or hidden nature of clinical learning. As this learning occurs partly unconsciously, it is a challenging subject to define and study.46 In the reviewed studies, informal learning was addressed by what it is not (ie, theo-retical and practical knowledge), and hidden curriculum was described by learning resources that were not reported by participants.31 Formal or formalised activities in the clinical area (such as peer teaching and doing ‘clinical homework’) were not labelled as such. As both formal and informal learning coexist in the practice setting and the dichotomy between the two has been questioned,47 clear definitions of these concepts are required, with which the different activities that student engage in throughout the day can be classified.
In most of the studies, potential or desirable learning outcomes were not articulated and were not separated from outcomes such as professional identity formation or well- being. Studies that did include the intended effect of learning in their definitions, as those of Kear,18 19 did not critically revisit if these outcomes were indeed reported. The lack of predefined outcomes in clinical learning48
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and the scope of this review excluding articles confined to skills performance49 or assessment,50 might explain why learning outcomes received relatively little attention in the reviewed studies. However, critically discussing the learning process in relation to actual and desirable outcomes, with reference to the body of literature on this topic, would improve our understanding of clinical learning.
In this review, clinical learning has been studied from the viewpoint of the student as a learner, as opposed to the perspective of external factors affecting students’ learning. However, as both this review and previous liter-ature have demonstrated,2 learning is a social process that is highly dependent on the environment. If students feel supported by the team they will be more willing to take responsibility and actively create learning opportuni-ties.43 51 The current work adds to our understanding of the student’s role within the complex structure of clinical nursing education and can be a starting point for future research on how individual interactions between students and their environment promote learning.
limitationsThe variety of concepts, processes, definitions and outcomes associated with learning in clinical practice proved challenging in determining the boundaries of our search. The selection was influenced by choice of terminology and framing by the authors of the studies. This review therefore provides insight into the current use of terminology as well as caveats in applying it. Limiting to nursing in the hospital setting excluded us from both theoretical and experimental research on practice learning in other health professions. However, this focus enabled us to synthesise specific findings from the different studies. The approach can be of interest for other health professions and will eventually allow for comparison of the literature. Finally, our synthesis of learning activities is based on studies with heterogeneity in populations, setting and year of publication, in which the same type of activity might have a different meaning. As we reinterpreted some of the data, caution has to be taken in drawing firm conclusions.52 Nevertheless, as the findings were recognised by experts and correspond with existing literature, the categories found are a good starting point for further study.
COnCluSIOnThis review provides an overview of how learning in clinical practice has been addressed in the undergrad-uate nursing education literature and which learning activities are reported. The studies share a constructivist approach to learning, but offer little guidance for the use of specific terminology in future studies due to a lack of alignment within the studies. Studies consistently reveal the importance of working independently, learning from peers, professionals and patients and the cognitive appraisal of learning. Both the approaches and reported
learning activities fit well into experiential learning theo-ries. There is still uncertainty about formal and informal components of learning and how they should be studied, as well as about desirable outcomes of clinical learning and how to incorporate them in research. Given the importance of students’ active engagement in learning as well as their reflection on it, behavioural and cognitive aspects of learning as well as their interactions should be explicitly addressed.
Author affiliations1Medical Faculty, Department of Research in Education, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands2Amstel Academie, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands3Department of Neurosurgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands4Medical Faculty, Department of Skills Training, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands5Medical Library, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands6LEARN! Research Institute for Learning and Education, Vrije Universiteit Amsterdam, Faculty of Psychology and Education, Amsterdam, The Netherlands
Twitter Rashmi A Kusurkar @r_kusurkar
Contributors MS, RAK, HEMD, SMP and JCFHK contributed to the research idea and study design and edited and revised the paper. MS and JCFHK developed the search strategy and executed the search. MS and RAK identified and agreed eligible papers and extracted the data. MS wrote the manuscript. RAK led the supervision of the project.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for- profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
ORCID iDMalou Stoffels http:// orcid. org/ 0000- 0002- 7997- 0864
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