Nurse Education Today 34 (2014) e18–e26

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Nurse Education Today journal homepage: www.elsevier.com/nedt

Review

Role modeling in undergraduate nursing education: An integrative literature review Adele Baldwin a,⁎, Jane Mills b, Melanie Birks a, Lea Budden a a b

School of Nursing, Midwifery and Nutrition, James Cook University, Townsville, Queensland 4810, Australia School of Nursing, Midwifery and Nutrition, James Cook University, Cairns, Queensland 4878, Australia

a r t i c l e

i n f o

Article history: Accepted 19 December 2013 Keywords: Nurse academic Nurse education Preceptor Role modeling Undergraduate nursing studies

s u m m a r y The transition of nursing education from the hospital setting to the university sector over recent decades has opened dialog about who is guiding the development of nursing students' professional identity. In addition, there is ongoing debate over real or perceived gaps between nursing student learning in the university and the clinical area, how this translates into professional behaviors and how well students make the transition between the two settings. This paper presents the findings of an integrative literature review into the topic of role modeling in undergraduate nursing education. This review was conducted to identify and appraise research findings about role modeling of professional behaviors for undergraduate nursing students. Literature reviewed from 2000 onwards assesses what is currently known about role modeling of undergraduate nursing students. A systematic search of the databases of CINAHL, Scopus and PubMed from 2000 onwards resulted in the selection of 33 articles for deeper analysis. Two clear themes emerged from the literature, the first relating to nurse clinicians as role models for students during clinical placements and the second relating to nurse academics as role models in the academic setting. Findings from this integrative literature review show an imbalance in the recognition of the role modeling of professional behaviors in the clinical versus the academic setting. Nurses in academic settings have more contact with the students over their period of study and as such, the significance of nurse academics as student role models requires further investigation. © 2013 Elsevier Ltd. All rights reserved.

Introduction Role modeling has a number of definitions and interpretations in the literature, but it is widely accepted that it refers to the observation of behaviors or attitudes of someone that one admires and the subsequent adopting of those behaviors or attitudes for oneself (Cruess et al., 2008). Role modeling in health is represented in the literature, predominantly in relation to health professionals' role modeling healthy behaviors for the community (Blake et al., 2011; Yancey et al., 2011). However, health professionals' role modeling for students receives sporadic attention. Role modeling by experienced practitioners for students in medical education is the subject of frequent discussion (Alpert, 2011; Byszewski et al., 2012; Cruess et al., 2008; Curry et al., 2011; Kenny et al., 2003); role modeling in other health disciplines, including rehabilitation sciences is not so common (Hobson and Walmsley, 2006). Comparatively, role modeling in nursing education has been the subject of limited previous research. Current trends in nursing education to produce work-ready graduates include adopting a range of innovative teaching and learning ⁎ Corresponding author. E-mail address: [email protected] (A. Baldwin). 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.12.007

strategies to integrate all ways of learning nursing knowledge into curricula design (Baldwin et al., in press; Benner et al., 2009). Developing an understanding of covert teaching practices such as role modeling will allow for their inclusion in formal curricula that incorporates multiple ways of student learning. Background/literature Aim This review was conducted to identify and appraise research findings about role modeling of professional behaviors for undergraduate nursing students. Specifically this paper will identify who the role models are for undergraduate nursing students and in what setting the role modeling occurs for undergraduate nursing students. Method A systematic literature search was conducted using the following key terms: role model*, nurs*, educat*, and student to search the CINAHL, ProQuest and Scopus databases. The search was date limited

A. Baldwin et al. / Nurse Education Today 34 (2014) e18–e26

from 1999 to 8th December 2012 and included peer-reviewed journal articles, IN PRESS articles, and those published in English. The following table lists the results from each of these searches (see Table 1). The initial literature search strategy was re-run in July 2013 to ensure that there were no recent additions to the literature that had been missed. This resulted in the inclusion of a new paper presenting the results of research into role modeling published in July 2013.

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Results The literature was read and reread several times in the process of analysis. Of the 33 papers included the large majority (n = 26) discuss research findings related to role modeling during clinical placement. Comparatively, only seven articles report findings related to role modeling in the academic setting. The two themes identified in this integrative literature review therefore are:

Results

1. Nurse clinicians as role models in the professional development of nursing students during clinical placement

Search results were combined and duplicates removed. Abstracts of the 714 articles identified in the searches were downloaded and read to assess their relevance to the aim of this integrative literature review. Of these 714 abstracts, 116 articles were retained and the full text of each was downloaded for further reading. Of these 116 papers, 84 were discarded as not relevant to the question posed, leaving a final thirtytwo articles for review. The inclusion of the 2013 published paper by Nouri et al. (2013) results in a total of thirty-three articles for review. Each of the final 33 papers was analyzed for content, rigor, reliability and relevance to the research. As a recognized framework for evaluation of published research, the Critical Appraisal Skills Programme (CASP) tools were used as criteria for this purpose. CASP questions were utilized to promote an objective, consistent analysis of the research findings reported in the included articles (CASP, 2010). The choice of the specific CASP instrument used was based on the research methods in the paper under review. That is, the qualitative tool was used for qualitative research and the cohort tool was used for quantitative research. Papers reporting mixed methods research were all presented in two parts; the qualitative component in one paper and the quantitative component in another, thus, the relevant tool was used to review each paper as an independent publication. The standard template from CASP (CASP, 2010) using 10 questions to assess qualitative articles and 12 questions to assess quantitative articles was employed. Using the CASP instruments facilitated a systematic appraisal of the trustworthiness of the current research as it pertains to the research question. Table 2 contains the final set of papers analyzed in this literature review according to theme. Key issues from the CASP analysis are also identified in the Summary of findings column.

2. Nurse academics as role models in the professional development of nursing students.

Literature Review The articles in this review relate the findings of research studies that utilized a range of research methods, of which 27 were qualitative studies and four were quantitative. Three of the articles were reporting the qualitative findings of a mixed method research design. These sample sizes varied in number from as few as four participants to a maximum number of 320 in the qualitative studies and from 10 to 1903 for the quantitative studies. Further, the specificity of the research question being asked will also impact on the sample size from which to gather the data, although this may impact on the transferability of findings in some cases.

Theme 1: Nurse Clinicians as Role Models in the Professional Development of Nursing Students Twenty-six out of 33 publications relate to nursing students' experiences in a clinical setting, in particular relating to compulsory clinical placement experience undertaken during their course of study. Of these papers, two manuscripts report findings from research with nurses working in the clinical setting, including facilitators, mentors and preceptors; twenty report the experiences of nursing students; and four report findings from research with both clinicians and students. Overall each of the articles analyzed reflects students having positive experiences in clinical areas. However within this, students report that feelings of inclusion and valuing of their knowledge and skills impact on how they responded to their clinical placements and in turn how well they achieved the associated learning outcomes. Both students and nurses in clinical areas report the important role that experienced clinicians play in the professional development of students. Two of the papers included were literature reviews (Allan et al., 2008; Dorsey and Baker, 2004) and one paper presents the findings of a metasynthesis of the current literature about the development of nursing students' perceptions of patients as human beings (Rudolfsson and Berggren, 2012). A strong element of this theme is how students adopt the behaviors of clinician role models they work with to varying degrees. However, some of the articles pay particular attention to the student experience of being exposed to both good and bad role models (Perry, 2009) and students' intuitive choice to emulate those they perceive to be “good nurses” (Donaldson and Carter, 2005; Ferguson, 2011; Grealish and Ranse, 2009). Other authors also discuss how students “pick and choose” which professional traits they adopt (Gray and Smith, 2000; Hanson, 2013; Levett-Jones et al., 2007). Students report adopting traits that they perceive value good clinical practice, are centered around the patient or recipient of care, show respect for, and receiverespect from colleagues, and those professional behaviors that demonstrate that a nurse wants to be a part of providing care to a patient. Even a bad role model can have a positive impact on the student in that they recognize the type of nurse they do not want to be (Grealish and Ranse, 2009). The characteristics of good and bad role models include reference to how experienced clinicians include and respect the student, how they

Table 1 Search terms. Database

Search terms

Limitations

Results

Scopus

Role model* AND nurs* AND educat* AND student

555

CINAHL

Role model* AND nurs* AND educat* AND student

PubMed

Role model* AND nurs* AND educat* AND student

Publication years 1999–2012 Limit to English; Journal articles including IN PRESS Publication years 1999–2012 Limit to English; Journal articles including IN PRESS Publication years 1999–2012 Limit to English; Journal articles including IN PRESS

8

151

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Table 2 The literature review summary. Participants

Summary of findings

Qualitative Phenomenology Focus groups

Clinical nurses and students n = 40

2. The qualities of an effective mentor from 2000 the student nurse's perspective: findings from a longitudinal study

Staff perception of student learning refers to ‘those willing to be role models and those who were not’. Recommendations to make staff aware of the impact they have as role models. Quality of the role model is linked to the level of respect from peers. The relationship between the researcher and the participants and the ethics approval were not discussed. Being knowledgeable linked (by students) to how they perceived the mentor practiced as a nurse. A good mentor is a good role model, professional, organized, caring and self-confident. The discussion about methodological justification was not specific. The students rated the characteristic of ‘Is a good role model’ as number 1 ranking of characteristics of effective clinical educators. The educators rated the characteristic of ‘Is a good role model’ as number 4. The relationship between the researcher and participants was discussed only from a coercion perspective.

Title

Year

Author(s)

Journal/source

Gray, M. & Smith, L.

Journal of Advanced Nursing

Qualitative Grounded theory Longitudinal approach

n = 10 students interviews and diary n = 7 diary only

Quantitative using NCTEI instrument Nursing Clinical Teacher Effectiveness Inventory Integrative literature review of studies between 1992 and 2002

n = 104 second year nursing students n = 17 clinical educators (30 third year student responses excluded)

3. Nursing students' and clinical educators' perceptions of characteristics of effective clinical educators in an Australian university school of nursing

2002

Lee, W., Cholowski, K. & Williams, A.

Issues and Innovations in Nursing Education

4. Mentoring undergraduate nursing students: assessing the state of the science

2004

Dorsey, L. & Baker, C.

Nurse Educator

5. The value of role modeling: Perceptions of undergraduate and diploma nursing (adult) students

2005

Donaldson, J. & Carter, D.

Nurse Education in Practice

Qualitative Grounded theory

6. Belongingness: a montage of nursing students' stories of their clinical placement experiences 7. Said Another Way: The Impact of Mentorship on Clinical Learning

2007

Levett-Jones, T., Lathlean, J. McMillan, M. & Higgins, I.

Contemporary Nurse

Qualitative phase of mixed methods study

2007

Kilcullen, N.

Nursing Forum

Qualitative, descriptive Focus group interviews

8. Leadership for learning: a literature study 2008 of leadership for learning in clinical practice

Allan, H., Smith, P. & Lorentzon, M. Journal of Nursing Management

Literature review about how national changes affected clinical experiences for students

9. RN as gatekeeper: gatekeeping as monitoring and supervision

2008

Brammer, J.

Journal of Clinical Nursing

Qualitative Phenomenography interviews

10. Belongingness: A prerequisite for nursing students' clinical learning

2008

Levett-Jones, T. & Lathlean, J.

Nurse Education in Practice Journal of Nursing Education

Qualitative arm of mixed methods Interviews Qualitative Longitudinal microethnographic

2009 11. Cultivating Authentic concern: Exploring how Norwegian students learn this key nursing skill

Christiansen, B.

Recommendations for further research to clarify the most effective mentoring systems; communication strategies; follow up; and how this translates to student and graduate retention. Search strategies and data analysis tool discussed, although the exclusion criteria were not identified. Students benefit from supervised practice with constructive feedback. Undergraduate Student confidence and competence appears to improve if the student n = 20 Diploma is exposed to ‘good’ role models. n = 22 Small sample size is a limitation as identified by the authors. The aim of the study and ethics were not clearly stated and the findings not generalizable. Belongingness it an important factor in a positive learning Third year nursing environment. students The sampling strategies were not clearly stated. n = 18 3rd year diploma students Role modeling a ‘most important’ aspect of learning. n = 29 The relationship between researcher and participants and the limitations of the study were clearly stated. Role modeling = less experienced nurses learning from more experienced ones, allows linking between art and science of nursing Four themes specific to belongingness and learning were identified. The RNs the students worked with were perceived to be the most influential on student learning in clinical practice Students Adequate preparation of RNs for the supervision of students on n = 24 placement impacts on the outcomes for students. The relationship between researcher and participants was not clearly identified. Nursing students Belonging is fundamental to being a nurse. n = 18 The relationship between researchers and participants, sampling and limitations were not clearly identified. n=4 Conclusion encourages incorporating relation skills in curricula as well as subject content. Fellow students and teachers are ‘valuable resources’. The relationship between the researcher and the participants was not clearly stated.

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Research methods

Theme 1: Nurse clinicians as role models in the professional development of nursing students Journal of 2000 Atack, L., Comacu, M., Kenny, R., 1. Student and staff relationships in a LaBelle, N. & Miller, D. Nursing clinical practice model: impact on Education learning

Title Year

Journal/source

Research methods

Participants

2009

Grealish, L. & Ranse, K.

Contemporary Nurse

Qualitative Narrative inquiry

n = 49

13. Role modeling excellence in clinical nursing practice

2009

Perry, B.

Nurse Education in Practice

Qualitative Interpretive with phenomenological underpinning

14. An exploration of the clinical learning experience of nursing students in nine European countries

2010

Warne, T., Johansson, U., Papastavrou, E., Tichelaar, E., Tomietto, M., Vanden Bossche, K., Moreno, M. & Saarikoski, M.

Nurse Education Today

Quantitative Questionnaire purposive sample Descriptive statistical analysis

15. Nursing students' experiences with incivility in clinical education

2011

Anthony, M. & Yastik, J.

Journal of Nursing Education

Qualitative phenomenology with purposive sampling

16. Empowerment and being valued: A phenomenological study of nursing students' experiences of clinical practice

2011

Bradbury-Jones, C., Sambrook, S. & Nurse Irvine, F. Education Today

Qualitative Hermeneutic phenomenology

17. From the perspective of new nurses: What do effective mentors look like in practice?

2011

Ferguson, L.

Nurse Education in Practice

Qualitative Grounded theory

18. Role model clinical instructor as perceived by Jordanian nursing students

2011

Hayajneh, F.

Journal of Research in Nursing

Qualitative Critical Incident Technique

19. Supporting student nurse professionalization: the role of the clinical teacher

2012

Brown, J., Stevens, J. & Kermode, S. Nurse Education Today

Qualitative component of a mixed methods study investigating the role model attributes of clinical teachers

20. Nursing students' perspectives on the patient and the impact of the nursing culture: a meta-synthesis

2012

Rudolfsson, G. & Berggren, I.

Meta-synthesis “to create one single study from the findings of several qualitative studies” 15 research articles and 2 dissertations were reviewed

Journal of Nursing Management

Summary of findings

Students identified what they did/didn't want to be which influenced their learning behaviors. The relationship between researcher and participants clearly stated but the authors identified limited generalizability of the findings due to the small sample size. n=8 Role modeling is more than teaching tasks. Identifies characteristics that participants (regarded as exemplary nurses) have. The sampling strategy was based on assumptions, and no limitations were identified. n = 1903 Discussed mentorship across curricula across 17 European SONs. The supervisory relationship is one of the most important influences on students' clinical experiences and on students' professional development. Differences between countries and the large sample size were identified as limitations of this research. n = 21 The outcomes of this study include the recommendation that the expectation of being a role model is clarified with all staff by nurse managers; and the proposal to support the use of dedicated education units to promote positive role modeling. The relationship between researchers and participants and the limitations of the research was not clearly discussed. First year nursing students Explored the concept of empowerment of nursing students in clinical n = 13 areas. Discussed what supportive behaviors of the clinicians promoted empowerment of students that could be linked to role modeling. The relationship between researchers and participants was clearly identified and discussed as a limitation of the research. n = 25 Research relates to mentors, and the connection they have with the new nurse. Crossover with mentoring and role modeling. There was limited discussion about methodology, relationship between researcher and participants, and the limitations of the research. Participants identified motivating behaviors of role model clinical Nursing students instructors, related to availability, advocacy and support for students. n = 156 The relationship between researcher and participants was not clearly Critical incidents stated. The sample limits generalizability of findings. n = 210 Role modeling is one of seven domains of professional socialization of Teachers nursing students and the clinician is an important role model. n=7 The power relationship between researchers and participants was Graduates addressed by modifying the initial study design to meet institutional n=7 Convenience sample, with ethics approval. an apparent coincidence of 7 participants in each sub set Total of 601 nursing Open and Closed Door described by the authors as the central students metaphors. Student nurses learn about compassion and virtue in practice by observing and working with clinicians, and identified with the nurses they worked with in clinical settings. Students could acquire ethical professional behaviors or not which is dependent upon the clinicians and the settings they are exposed to during their clinical practicums. No mention is made of the role that the academic staff plays. The study findings, limitations and study design were clearly presented.

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Author(s)

12. An exploratory study of first year nursing students' learning in the clinical workplace

(continued on next page)

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Table 2 (continued) Title

Year

Author(s)

Journal/source

Theme 1: Nurse clinicians as role models in the professional development of nursing students 2012 Hellstrom, E., Martensson, G. & Nurse 21. To take responsibility or to be an Kristofferzon, M. Education onlooker. Nursing students' experiences Today of two models of supervision

2012 Keeling, J. & Templeman, J. (In press)

23. Nursing students' perceptions of clinical 2012 Kristofferzon, M., Martensson, G., Mamhidir, A. & Lofmark, A. (In supervision: The contributions of preceptors, head preceptors and clinical press) lecturers

Participants

Summary of findings

Qualitative “Descriptive design with a qualitative approach”

Nursing students n=8

Student confidence in clinical practice relates to feeling secure and supported by the supervising nurse. Role modeling not discussed per se, but implied throughout the study findings. The relationship between researchers and participants was acknowledged as a methodological consideration. Role modeling can be positive or negative but in some cases, nursing students use both positive and negative role modeling to guide their own practice in a positive way. The professional behavior role modeled by the clinicians has an effect on students. Research limitations identified by the authors include the relatively small number of participants which could limit generalizability and the inclusion of female students only which could result in a gender bias. Study does not relate specifically to role modeling. It does, however, discuss the students' perceptions of the value of their learning in relation to clinical preceptors and clinical lecturers. In this way the findings allude to a difference in perception of who students use as role models and for what reasons. E.g. The students identify that the clinical lecturers are of greater value for academic guidance. Do nursing students see the clinical lecturers as academics or nurses? There was limited acknowledgement of the relationship between researchers and participants. The authors identify the relatively small sample from one setting to potentially limit generalizability. Students perceived mentors to be their most important role model. Role modeling is a core element to building professional identity and becoming a nurse. The relationship between the researchers and the participants was not clearly identified. Explored the experiences of clinical facilitators in rural settings. Does not refer to role modeling as such, but does discuss helping students to develop a professional identity. The very specific sample in the study may limit the generalizability of findings. This study compared facilitation vs preceptorship for clinical placement. No direct mention of role modeling however the comments about the type of support students received from the RNs they worked alongside imply role modeling behaviors. E.g. ‘assists me in developing a better understanding of the role of the nurse’; has a good relationship with the ward/unit staff'. Students preferred group facilitation and the quality of the supervision was most highly regarded. The limitations include a small response rate which may limit transferability of findings.

Nurse Education in Practice

Final year nursing Qualitative students Phenomenological approach Individual interviews and focus n = 10 groups

Nurse Education Today

Qualitative Cross-sectional survey

Quantitative Purposive sample of Descriptive quantitative survey undergraduate nursing students in 9 European countries in 2007–2008 n = 1903 n=8 Qualitative Phenomenological approach Individual in depth interviews

24. Students' experiences of cooperation with nurse teacher during their clinical placements: An empirical study in a Western European context

2012 Saarikoski, M., Kaila, P., Lambrinou, E., Canaveras, R., (In Press) Tichelaar, E., Tomietto, M. & Warne, T.

Nurse Education in Practice

25. Implementation of the Clinical Facilitation model within an Australian rural setting: The role of the Clinical Facilitator

2012 Sanderson, H. & Lea, J. (In Press)

Nurse Education in Practice

26. Facilitator versus preceptor: Which offers the best support to undergraduate nursing students?

2012 Walker, S., Dwyer, T., Moxham, L., Broadbent, M. & Sander, T. (In press)

Nurse Education Today

Quantitative Cross-sectional online survey of undergraduate nursing students at a Queensland university

Nursing students n = 107

n = 159

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22. An exploratory study: student nurses' perceptions of professionalism

Research methods

Title Year

Author(s)

Journal/source

Theme 2: Nurse academics as role models in the professional development of nursing students 1. Negotiating multiple roles: link teachers 2004 Ramage, C. Issues and in clinical nursing practice Innovation in Nursing Education

Participants

Summary of findings

Qualitative Grounded theory

n = 28

Study was undertaken to explore the role of the nurse teacher in clinical practice. Findings include the statement that senior nursing students tend to seek information and guidance from nurses rather than teachers, although in the earlier years of study, they tend to use the teacher as the expert. Limitation: this study concentrates on the role of the teacher in a clinical setting. The aim of the research was not clearly stated. There was limited discussion about methodological justification. Nurse teachers are required to be role models and show respect, empathy and support for the students. The nurse teachers' perceptions of their own role modeling behaviors was consistently of a high standard. Is self reporting good enough to reliably reflect the situation? The findings of this study may have limited generalizability. The emphasis placed by nurse educators on altruism, honesty and academic achievement as important to ‘pass on’ to the undergraduate nursing students No students were surveyed The findings may have limited generalizability in an international context. Found that engagement and the ability to relate it to practice had positive influences. Teaching excellence includes the use of role modeling by faculty as part of a dynamic process. There was limited discussion about sampling, ethics, the relationship between researcher and participants, and the methodology. The pattern of ‘demonstrating professionalism’ in the faculty strengths — good role model was the second highest indicator. The limitations of the generalizability of the findings clearly described by the authors. Author refers to the formal and hidden curriculum in nurse education. Students perceive that the behaviors of Academic staff should be practicing what you preach. Role modeling the caring behaviors in their interactions with students. The aim of the research was not clearly stated. Findings include that role models in Iran were responsible for the emotional, spiritual and intellectual development of students. This includes role models serving as “students' parents (p. 141)” among other characteristics that may make broader application in an international context difficult. Generalizability of findings may be limited.

2. Role model behaviors of nursing faculty members in Thailand

2011

Klunklin A., Sawasdingha, P., Visekul, N., Funashima, N., Kameoka, T., Nomoto, Y. & Nakayama, T.

Nursing and Health Sciences

Qualitative Descriptive study using questionnaire

Nursing faculty members n = 320

3. Attitudes and Values of Nurse Educators: An International Survey

2007

Haigh, C. & Johnson, M.

International Journal of Nursing Education Scholarship

Quantitative Questionnaires distributed in conference packs at a nurse educator conference.

n = 74

4. Teaching Excellence: what great teachers teach us

2009

Johnson-Farmer, B. & Frenn, M.

Journal of Professional Nursing

Qualitative Grounded theory Interviews

n = 17

5. Strengths and weaknesses of faculty teaching performance reported by undergraduate and graduate nursing students: a descriptive study 6. Students' voices: The lived experience of faculty incivility as a barrier to professional formation in associate degree nursing education

2004

Robinson-Wolf, Z., Beitz, J., Wieland, D. & Vito, K.

Journal of Professional Nursing

Qualitative Descriptive, retrospective design.

n = 317

Nurse Education Today

n = 13 Qualitative Phenomenological, data collected through interviews and symbolic interactionism in data analysis “Qualitative study using a Students content analysis approach” n = 22 Staff n=7

2012 Del Prato, D. (In press)

7. Qualitative study of humanization-based 2013 nursing education focused on role modeling by instructors

Nouri, J., Ebadi, A., Alhani, F., Rejeh, Nursing and N. & Ahmadizadeh Health Sciences

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provide care to the patient, and if they follow best practice and evidenced based guidelines (Perry, 2009; Rudolfsson and Berggren, 2012). Identifying the characteristics of good and bad role models weaves through the literature with several articles (Gray and Smith, 2000; Grealish and Ranse, 2009; Hayajneh, 2011; Lee et al., 2002) clearly defining each of these behavior types. Researchers describe characteristics including mentor approachability, ability to instill confidence, create a relaxing atmosphere, be available when needed, act as a student advocate, support learning, tolerate students' mistakes, show confidence in student abilities and respect student opinions, demonstrate skills, show genuine interest in patients, and provide students with timely feedback (Hayajneh, 2011). Another study identifies students' highest rated characteristic of an effective clinical educator as being “a good role model”, while the highest rated characteristic of an effective clinical educator by clinical educators was “enjoys nursing”. In comparison to the students in this study, clinical educators' rank “is a good role model” as the fourth highest characteristic (Lee et al., 2002). These student perceptions of the characteristics of an effective educator are reinforced by Perry (2009) who describes good role models as exemplary nurses who possess extensive clinical knowledge and skill as well as high level interpersonal skills. Six of the 26 articles (n = 386) reviewed in this theme pay particular attention to the professional training and support required by preceptors and facilitators in order to enhance students' learning experiences in the clinical setting, including the need for clear links between the education provider and clinical area (Brammer, 2008; Brown et al., 2012; Ferguson, 2011; Hayajneh, 2011; Sanderson and Lea, 2012; Walker et al., 2013). The context in which these links are discussed is predominantly about required preceptor/facilitator support to provide a consistent high quality clinical learning experience for the student. These requirements include the education provider clearly articulating learning objectives and outcomes to the student and the clinical area with the aim of minimizing the so-called theory–practice gap. Theme 2: Nurse Academics as Role Models in the Professional Development of Nursing Students Seven of the articles included in this integrative literature review (n = 798) relate in some way to nurse academics' role modeling professional behaviors for undergraduate nursing students (Del Prato, 2012; Haigh and Johnson, 2007; Johnson-Farmer and Frenn, 2009; Klunklin et al., 2011; Nouri et al., 2013; Ramage, 2004; Robinson-Wolf et al., 2004). Similar to studies of clinical role modeling, each of the papers addressing role modeling by nurse academics identifies the traits of an effective role model. These traits include demonstrating enthusiasm for nursing practice and demonstrating positive attitudes towards nursing through teaching and learning (Del Prato, 2012; Haigh and Johnson, 2007; Johnson-Farmer and Frenn, 2009; Klunklin et al., 2011; Nouri et al., 2013; Ramage, 2004; Robinson-Wolf et al., 2004). Nurse academic teaching of professional nursing behaviors is specifically referred to as the ‘hidden’ or ‘informal’ curricula by Del Prato (2012), an idea also discussed in broader terms by other authors (Haigh and Johnson, 2007; Klunklin et al., 2011; Robinson-Wolf et al., 2004). Haigh and Johnson (2007) call for informal course content such as role modeling professional behaviors to be more formally recognized and to be firmly embedded in future nursing curricula. Characteristics of professional behaviors include demonstrating desired attitudes and values (Haigh and Johnson, 2007), showing respect and value for patients, colleagues and students (Klunklin et al., 2011), displaying scholarly traits (Robinson-Wolf et al., 2004) and conveying belief in the nursing students' ability to learn (Del Prato, 2012). Nouri et al. (2013) expand on the role modeling expected of nurse academics (instructors) in Iran to include serving “as students' parents” (p. 141) as part of a role that assumes responsibility for “developing students emotionally, spiritually, and intellectually” (p.141). Klunklin et al. (2011) concur with Nouri et al. in that in Thai culture, the nurse

academics act as “the students' parents” (p. 86). Health care is a community service that is defined by the community it serves and the expectations of that service will undoubtedly be influenced by cultural, spiritual and religious beliefs. For example, Nouri et al. (2013) describe desirable characteristics of Iranian nurse teachers to include “maintaining friendships and complimentary rituals such as apologizing” (p.141). The importance of these characteristics in the Iranian communities is high, while in other cultures it may not be afforded such a high priority. The findings of the research of Klunklin et al. (2011) and Nouri et al. (2013) open the discussion about role modeling in relation to the cultural influences potentially making role modeling a subjective topic. Thus, the characteristics of a good role model will vary depending upon the context in which it is being discussed. However, the findings of Nouri et al. (2013) and Klunklin et al. (2011) are consistent with other researchers in this theme in that they found that a good role model contributed to self-discovery, self-motivation and self-confidence in nursing students, valued high quality nursing care and was enthusiastic about developing the nursing profession. Teaching practices and strategies that include role modeling with the aim of promoting or facilitating learning were also identified in this group of publications. Using a range of teaching strategies (Johnson-Farmer and Frenn, 2009) and providing timely and positive feedback (Del Prato, 2012; Robinson-Wolf et al., 2004) are identified as professional traits of good nurse academics' role modeling behaviors that facilitate the growth of the students' professional identity. Several of the articles reviewed in this theme acknowledge that nursing students quickly gain the ability to recognize nurse academics as good and bad role models and appear to understand the influence these people have on their novice practice (Donaldson and Carter, 2005; Gray and Smith, 2000; Grealish and Ranse, 2009). Gray and Smith (2000), Donaldson and Carter (2005), and Grealish and Ranse (2009) expand on this point and report the observation that nursing students gradually move away from their mentors as their skills and confidence in practice develop. Thus, the value of role modeling at an early stage in their academic career is recognized by students themselves. Allan et al. (2008) found in their literature review, that despite some perceptions about the questionable clinical credibility of academics, there is a lack of supporting evidence for such assumptions. All of the papers in this review discussed role modeling in nursing education in relation to registered nurses role modeling for nurses. Nursing students are exposed to a number of influences during their course of study in all settings. There is very little reference to the influence of other health professionals, consumers or organizations that may influence the clinical learning experiences for nursing students. It is interesting to note, however, that Saarikoski et al's. (2013) reports of the 1903 nursing students surveyed in their study, 59% identify their most important role model as mentors (nurses in clinical practice); 27% as mentors/nurse teachers; and 14% as nurse teachers. Internationally there are numerous models for the delivery of nursing educational programs and the associated clinical experiences and the vast range of titles for the teachers' roles that challenge the transferability of these findings. As an example, the findings of the research conducted by Etheridge (2007) investigating the experiences of new graduates show that new RNs believe that their faculty members were role models. However, even in the broadest sense, there is sufficient evidence that nursing students perceive clinical nurses to be the most important role models for their practice. Discussion As nursing education becomes increasingly student-centered (Horsfall et al., 2012; Stanley and Dougherty, 2010), students' experiences and perceptions are becoming a primary focus of inquiry. Hence the need to identify, from a student's perspective, the level of role modeling by academics, and the degree to which this influences their

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professional development. Nurse academics have the most contact with students during their course of study, so it is interesting that this topic is not more widely addressed in the literature. The literature relating to nurses as role models in the clinical setting refers to the need for adequate academic preparation, formal support from education providers, and ongoing professional development for clinical facilitators/educators as essential support strategies for ensuring nursing students receive appropriate learning experiences in the clinical area (Burns and Northcutt, 2009). Opportunities for ongoing professional development to ensure up to date clinical supervision and teaching and assessment practices are essential to ensure that the students are receiving the best possible clinical experience. This is a frequently occurring commentary throughout the literature together with recommendations for adequate preparation of clinical facilitators/mentors for teaching nursing students from research studies that investigate clinical placement more generally (Cangelosi et al., 2009; Johnston and Mohide, 2009). Nursing students are reported to place less value on academic performance than on learning the practical skills and requisite knowledge to form professional identity (Zysberg and Zisberg, 2008). It is also possible that this attitude impacts on who nursing students perceive as their most influential role models whereby the students may not necessarily adopt any behaviors demonstrated by the nurses they are exposed to, they will be selective in what characteristics they seek to emulate. Baxter (2007), author of the CCARE model of clinical supervision, refers to two cultures in nursing education; academic culture and clinical culture. The CCARE model proposed by Baxter (2007) integrates communication, collaboration, application, reflection and evaluation as key aspects of delivering quality patient care based on the blending of both academic and clinical cultures. Baxter outlines foci and goals of each culture with some crossover but notably there are exclusions in each list that highlight perceived differences in who takes responsibility for various aspects of nursing education. For example, according to Baxter the culture of academia includes a focus on learning and focus on theory while the clinical culture includes a focus on quality patient care and focus on practice (2007). In order to facilitate knowledge transfer for the nursing students, the clinical culture should also include a focus on learning and a focus on theory, likewise, the academic culture should include a focus on quality patient care and focus on practice. Taking a whole of profession approach to nursing education aligns with the concept that clinical education can occur in any setting (Ard et al., 2008). Student nurses' learning in the clinical setting is linked to how positive the social ‘feel’ of the clinical area is perceived by them (Levett-Jones and Lathlean, 2008), affirming that learning is a social relationship (Keeling and Templeman, 2013). This type of learning in the academic setting has been largely overlooked in relation to nursing education and further research is required to more fully understand to what degree the professional behaviors of nurses in academic settings influence the professional development of nursing students. In both themes analyzed few of the articles specifically outline the position of the researcher in the study and the relationship of the researcher to the participants. As the majority of the publications report studies undertaken by nurse academics about nursing education and nursing students, clarifying these powerful relationships would seem to be necessary to ensure the credibility and transparency of the research findings reported (Clark and McCann, 2005; Ferguson et al., 2006). Furthermore, the inclusion of nursing students as participants in research projects may in fact contribute to their learning experiences influencing their responses to the research questions (Bradbury-Jones et al., 2011). Building the nursing workforce of the future relies upon leaders providing the necessary learning opportunities to nurture students' professional growth. In order to nurture professional growth it is vital to clearly identify where and from whom students are learning

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so that all aspects of knowledge are incorporated into curriculum planning and implementation. Seeking the truth as it stands is an integral first step to developing and implementing strategies aimed at building a resilient, competent and professionally sound nursing workforce. The theory–practice gap identified in the professional literature may be being covertly perpetuated by the inability of all nurses, including students, to identify what students learn, and from whom. As the research shows, nursing students watch and learn from clinical nurse role models during their clinical experiences which may be promoting student nurses' perceptions of learning the ideal in university and the real world in clinical practice (Allan et al., 2008). If nursing students are to view all registered nurses as professional role models without discerning between the clinical and academic settings, then we need to more fully understand how nursing students learn from all nurses they are exposed to in both settings. As outlined by Horsfall et al. (2012), role modeling in the academic setting occurs “whether the teacher is aware of it or not” (p. 932). The professional behavior role modeled in the classroom lays the foundation for attitudes and behaviors that students may adopt in a more acute, stressful clinical setting (Horsfall et al., 2012). Further, it can be argued that nursing education is in itself a specialty area of nursing practice requiring that all academics remain abreast of current best clinical practice to ensure that the content being taught is relevant for current clinical practice. All registered nurses are required to self-assess their competency to practice to be eligible for annual registration in many countries around the world. The continuing competence position statement by the International Council of Nurses (ICN, 2006) refers to lifelong learning and constant updating of nursing knowledge as being fundamental to the provision of safe patient care. As such, it should be reasonable to assume that nurse academics annually review their level of knowledge to determine eligibility for practice, and despite the location of nursing practice remain competent in their area of expertise, including nursing education. Conclusions This review was conducted to identify and appraise research findings about role modeling of professional behaviors for undergraduate nursing students. To date, the extent to which nurses in the clinical setting influence the learning experiences of nursing students appears to have been widely investigated. There is wide agreement that nursing students view clinicians as influential role models for their practice. Research has found however that there is a need for consistent continuing professional development for clinicians who assume this role in order to ensure quality experiences for students. Conversely there is far less in the literature about the impact that nurse educators, or nurses in academic settings have on the professional growth of nursing students. Contemporary teaching practices for nursing include strategies to enhance professional socialization, of which role modeling is an integral component. Nurse academics have a greater role than just conveying theoretical knowledge. Enthusiasm for, and positive attitude towards nursing demonstrated in the classroom have a powerful impact on nursing students' understanding of professional behavior. Current evidence clearly describes how nursing students learn from observing clinicians, however there is a need for further research into the impact and outcomes of nurse academic role modeling for this group to more fully understand how nursing students build professional skills and identity. References Allan, H.T., Smith, P.A., Lorentzon, M., 2008. Leadership for learning: a literature study of leadership for learning in clinical practice. J. Nurs. Manag. 16, 545–555. Alpert, J., 2011. Role modeling: a personal anecdote. Am. J. Med. 124, 281–282. Ard, N., Rogers, K., Vinten, S., 2008. Summary of the survey on clinical education in nursing. Nurs. Educ. Perspect. 29, 238–245.

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Role modeling in undergraduate nursing education: an integrative literature review.

The transition of nursing education from the hospital setting to the university sector over recent decades has opened dialog about who is guiding the ...
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