Nurse Education in Practice 63 (2022) 103391

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Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953

Review

Factors in the clinical learning environment that influence caring behaviors

of undergraduate nursing students: An integrative review
Ergie P. Inocian a, *, Meredith B. Hill a, Rhea Faye D. Felicilda-Reynaldo b, Susan H. Kelly a,
Emmanuel D. Paragas c, Melanie T. Turk a
a
School of Nursing, Duquesne University, Pittsburgh, PA, USA
b
School of Nursing, Missouri State University, Springfield, MO, USA
c
Department of Nursing, West Liberty University, WV, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: The aim is to explore literature on the influence of the clinical learning environment on caring behaviors of
Caring behaviors undergraduate nursing students.
Clinical learning environment Background: Caring is a fundamental aspect of nursing practice. However, factors of and in clinical learning
Clinical placement
environment that help shape the caring behaviors of nursing students as part of their education journey remain
Communication
Nursing students
understudied.
Role modeling Design: A modified version of Cooper’s five-stage integrative review method was used.
Simulation Methods: Four databases (Cumulative Index of Nursing and Allied Health, PubMed, Scopus and Embase) were
searched for research studies published from 2011 to 2021 in peer reviewed journals, written in English and
addressing caring behaviors among nursing students in the clinical learning environment. A combination of
keywords with Boolean operators was used including: “nursing students OR nursing undergraduates OR student
nurses” and “clinical learning environment” AND “caring behaviors”. Reporting followed the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses statement guidelines.
Results: Empirical evidence was drawn from 11 studies including seven qualitative designs, three quantitative
designs and one mixed method design. The results of this review suggest that factors in the clinical learning
environment influence nursing students’ ability to develop caring behaviors. Specifically, the five themes of: [1]
role modeling of clinical faculty and professional nurses, [2] creating a conducive clinical learning environment,
[3] effective communication skills, [4] positive effect of simulation and [5] alternative clinical placements may
facilitate the development of caring behaviors among nursing students.
Conclusion: The findings highlight the factors in the clinical learning environment that influence nursing stu­
dents’ caring behaviors. Improving students’ clinical learning experiences and implementing more effective role
modeling and teaching strategies may advance their caring abilities. The information generated from this review
provides evidence on how to enhance the clinical learning environment to develop students’ caring behaviors,
subsequently leading to more optimal patient outcomes.

1. Introduction to achieving student learning outcomes resulting in the development of

The Bachelor of Science in Nursing (BSN) program has clinical
components providing nursing students rich and varied opportunities
for practice experience to care for patients across the continuum of care
(American Association of Colleges of Nursing [AACN], 2008). An
effective and supportive clinical learning environment (CLE) is essential
necessary skills, knowledge and behavior required to provide safe and
quality patient care (Chan et al., 2019; Flott and Linden, 2016; Nord­
quist et al., 2019). The CLE refers to the “social interaction, organiza­
tional cultures and structures and physical and virtual spaces that
surround and shape participants experiences, perceptions and learning”
(Josiah Macy Jr. Foundation, 2018, p.17). In nursing education, CLE

* Correspondence to: School of Nursing, Duquesne University, Fisher Hall 550 K, 600 Forbes Ave., Pittsburgh, PA 15282, USA.
E-mail addresses: inociane@duq.edu (E.P. Inocian), Hillm3@duq.edu (M.B. Hill), fayefelicilda@missouristate.edu (R.F.D. Felicilda-Reynaldo), kellys8@duq.edu
(S.H. Kelly), emmanuel.paragas@westliberty.edu (E.D. Paragas), turkm@duq.edu (M.T. Turk).

https://doi.org/10.1016/j.nepr.2022.103391
Received 15 February 2022; Received in revised form 21 June 2022; Accepted 22 June 2022
Available online 24 June 2022
1471-5953/© 2022 Elsevier Ltd. All rights reserved.
E.P. Inocian et al.
refers to any setting where nursing students apply theory to practice
through actual or simulated patient care (Flott and Linden, 2016).
Several researchers have developed valid and reliable instruments
for assessing students’ perception of their CLE (Chan, 2002; Newton
et al., 2010; Salamonson et al., 2011). Empirically-based factors of the
CLE salient to students include student-centeredness, affordances and
engagement, individualization, fostering workplace learning, valuing
nurses’ work and innovative and adaptive workplace culture (Newton
et al., 2010). Significant differences exist between students’ perceptions
of the actual and ideal CLE. Students prefer an environment with a
higher level of personalization, student involvement, satisfaction, task
orientation, teaching innovation and individualization (Yazdankhahfard
et al., 2020). However, factors of and in the CLE that help shape the
caring behaviors of nursing students as part of their education journey
remain understudied.
Caring is the essence of nursing practice and a core value of the
profession (Fenizia et al., 2019; Labrague et al., 2017). Students often
enter nursing school because they want to help and care for people.
Provision of compassionate care is characterized by the union of
empathy related to nurses’ desire to alleviate patients’ suffering and
address individualized care needs and the use of therapeutic commu­
nication (Su et al., 2020; Watson, 2018). Nurses should build authentic
caring relationships through mutual respect, active listening and holistic
approach with their patients (Watson, 2018). Humanistic caring is
conceptualized as the ability of nurses to communicate and establish
therapeutic relationships with patients (Wang et al., 2022; Watson,
2018). Caring can be described as “instrumental caring”, which refers to
the act of doing the care to achieve positive patient outcomes through
implementation of evidence-based practices and as an “expressive car­
ing” that involves patient-centered attitudes during interactions to meet
the psychosocial needs of patients (Fenizia et al., 2019; Loke et al.,
2015). However, there is a growing perception that nurses appear to be
lacking in the expressive aspect of caring and sometimes fail to provide
compassionate and competent care (Inocian et al., 2021; Su et al., 2021;
Wiechula et al., 2016; Yau et al., 2019). A variety of factors such as life
experiences, understanding of attitudes or perceived notions of nursing
may attribute to a deficit in the expressive aspect of caring (Karlsson and
Pennbrant, 2020; Loke et al., 2015).
The Caring Behavior Inventory (CBI) has been commonly used to
measure caring behaviors of nurses and nursing students in terms of: 1)
assurance of human presence; 2) professional knowledge and skill; 3)
respectful deference to others; and 4) positive connectedness (Fenizia
et al., 2019; Wolf et al., 1994; Wu et al., 2006). A substantial body of
evidence demonstrates a discrepancy between the expectations of the
nurse and patient about the nature of caring relationship, shaped by the
environmental context of clinical practice (Romero-Martín et al., 2019;
Wiechula et al., 2016). Student experiences in the clinical settings may
affect the development of their caring competencies, as all CLE are
unique.
Thus, this integrative review aimed to explore current literature on
the influence of the CLE on the caring behaviors of undergraduate
nursing students. The findings generated from this review will assist
faculty to create meaningful clinical learning experiences among
nursing students. Since caring behaviors can be learned, faculty may
implement or enhance current teaching strategies to be used in the
clinical environment, thus facilitating the preparation of students for
their role as a professional nurse.
2. Research question
What is the influence of CLE on caring behaviors of undergraduate
nursing students?
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Nurse Education in Practice 63 (2022) 103391
3. Methods
3.1. Design
A modified version of Cooper’s (1982, 1984) five-stage integrative
review method was followed, as described by Whittemore and Knafl
(2005): problem identification, data collection through literature search
including identification of search terms and appropriate online data­
bases, data evaluation, data analysis and presentation of results. This
broad approach of review allows inclusion of key primary evidence and
synthesis of nursing research with diverse methodologies (Whittemore
and Knafl, 2005; Labrague et al., 2020) to gain understanding of the
influence of the CLE on caring behaviors among nursing students and
identify gaps in the literature. Reporting followed the PRISMA
(Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
statement guidelines (Moher et al., 2009). Ethics approval and consent
to participate were not applicable given that the data for this integrative
review was from the literature.
3.2. Search strategy
To address the research question: “What is the influence of CLE on
caring behaviors of undergraduate nursing students?”, a comprehensive
literature search with assistance from a health sciences librarian was
undertaken. Four databases (Cumulative Index to Nursing and Allied
Health Literature (CINAHL), PubMed, Scopus and Embase) were
accessed to identify relevant articles as they contain vast numbers of
nursing journals. The following search terms were used with the Boolean
operators: (nursing students OR nursing undergraduates OR student
nurses) AND (clinical learning environment) AND (caring behaviors).
Manual handsearching of relevant articles was conducted through
ancestry approach by reviewing the references of previously retrieved
literature for additional articles not identified in the original search.
Subsequently, descendancy approach was employed using Google
Scholar to find citation indexes of references that are more recent to key
articles. Endnote reference manager and Covidence review management
software were used to store search results, screen abstracts and full-
length articles of the retrieved papers and make decisions to include
or exclude articles in this review.
3.3. Inclusion/exclusion criteria
This review of the literature included research studies based on the
following criteria: (1) published from 2011 to 2021 to evaluate the latest
evidence in nursing education; (2) included BSN students; (3) published
in the English language; (4) in peer-reviewed journals with full text
available and; (5) explored the influence of the CLE on caring behaviors.
Studies were excluded if full text was not available, they were unpub­
lished manuscripts and if articles did not address the potential impact of
the CLE on caring behaviors among nursing students. The systematic
search of four databases yielded 257 articles and eight articles were
identified through handsearching as displayed in Fig. 1, that is in total
265 articles. Eighty-five were assessed at full text. Finally, 11 studies
were identified that met the set criteria.
3.4. Methodological quality appraisal
The Mixed Methods Appraisal Tool (MMAT) checklist was used to
assess the methodological quality of the included articles in this review,
as it allows the reviewers to concomitantly appraise or describe studies
with diverse designs including quantitative, qualitative and mixed
methods studies (Hong et al., 2019; Pluye et al., 2009). For each quality
criterion, the presence/absence may be scored 1 and 0, respectively. A
summary quality score was calculated for each paper by summing the
total score obtained across relevant items and dividing by the total
possible score, with a greater score indicating higher quality (Pluye
E.P. Inocian et al.
Fig. 1. Modified PRISMA flow diagram utilized in identifying included articles.
et al., 2009). MMAT has two general screening questions for all study
designs including: (1) clear research question; and (2) data collection
allows one to address the research question. Qualitative studies were
appraised according to: (1) appropriate approach to answer the research
question; (2) adequate data collection methods to answer the research
question; (3) findings adequately derived from the data; (4) results
substantiated by the data; and (5) coherence between data sources,
collection, analysis and interpretation. Quantitative descriptive studies
were screened according to: (1) sampling strategy to address research
question; (2) sample represents targeted population; (3) appropriate
measurements; (4) low responsive bias; and (5) appropriate use of sta­
tistical analysis to answer the research question. Finally, the mixed
method design appraised the following: (1) rationale provided for using
mixed methodology; (2) effective integration of various components of
the study; (3) integration of qualitative and quantitative components
interpreted; (4) divergences and inconsistencies addressed; and (5)
adherence to quality criteria of methods involved, in addition to the
above criteria for quantitative and qualitative designs (Hong et al.,
2019). Mixed method study appraisal is based on all the 17 criteria (two
general questions + five criteria specific for quantitative + five criteria
specific for qualitative and additional five criteria specific for the mixed
method design) while quantitative and qualitative studies are scored
only based on the seven criteria (two general questions + five criteria
specific for quantitative or qualitative study).
The level of evidence of each included study was categorized as Level
I: evidence from systematic reviews or meta-analysis of relevant clinical
trials; Level II: evidence derived from at least one well-delineated ran­
domized controlled trial; Level III: well-delineated clinical trials without
randomization; Level IV: well-delineated cohort and case–control
studies; Level V: systematic reviews of descriptive and qualitative
studies; Level VI: evidence derived from a single descriptive or
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Nurse Education in Practice 63 (2022) 103391
qualitative study; and Level VII: the opinions of authorities or report of
expert committees (Melnyk and Fineout-Overholt, 2015). MMAT quality
scores and level of evidence for all sample studies are shown in Table 1.
3.5. Data extraction and synthesis
Data extraction was performed by two authors. The information
extracted from each article included authors/year, country, research
purpose/aim, design and sample, data collection method and key find­
ings. Content analysis was employed as a technique to synthesize find­
ings as it can be applied in both quantitative and qualitative nursing
studies (Elo and Kyngäs, 2008). This method proceeds in three phases of
theme development: preparation, organizing and reporting. The authors
discussed and reviewed the overarching code categories to generate
applicable themes. Content validation was sought from two other clin­
ical faculty with administrative background and clinical experience.
4. Results
4.1. Characteristics of included studies
This review included studies published from 2011 to 2021. However,
there were no studies published in 2011 and 2012 that met the inclusion
criteria. Eleven studies that met the criteria were published from 2013 to
2021 and were included in the final review. More than half of the studies
used qualitative approach (n = 7), three were quantitative and one used
a mixed method design. Studies were conducted in Canada (n = 2),
South Africa (n = 2) and the remaining studies were completed in each
of the following countries: USA, Indonesia, China, Sweden, Australia
and Italy. One study was performed in multiple countries: Greece, India,
Philippines and Nigeria (Labrague et al., 2015). Sample sizes ranged
E.P. Inocian et al.
Table 1
Characteristics of 11 included studies.
Authors & Year Country Research aim/purpose
Abdurrahman Indonesia To analyze the effects of
et al. (2020) interpersonal communication,
emotional intelligence,
supervision and achievement
motivation on caring behaviors
of student nurses in applying
nursing care.
Ferri et al. Italy To explore the perceptions of
(2020) caring behaviors by nursing
students during their clinical
practice training.
Labrague et al. Four countries To explore the impact of
(2015) (Greece, Indian, instructors’ caring on students’
Philippines, perceptions of their own caring
Nigeria) behaviors.
Létourneau et al. Canada To develop a cognitive learning
(2021) model of the ‘humanistic caring’
competency from the lived
experiences of nursing students
and graduates of a competency-
based programme.
Létourneau et al. Canada To report on nursing students’
(2020). and nurses’ lived experiences
that facilitate and hinder the
development of humanistic
caring
Ma et al. (2013) China To investigate baccalaureate
nursing students’ caring ability
in the context of China and to
explore the role of clinical
practice learning in the
development of students’ caring
skills
Mathe et al. South Africa This study was performed to
(2021) gain an understanding of South
African student nurses’
experiences of professional
nurses’ role-modelling of caring.
Nyqvist et al. Sweden To identify the factors that
(2020) support nursing students
learning in the ambulance
service from both the students’
and supervisors’ perspectives
Peddle et al. Australia To explore the development of
(2019) non-technical skills through
virtual patients for
undergraduate nursing students.
Nurse Education in Practice 63 (2022) 103391
Research design and Data Collection Key Findings MMAT
sample Method Quality
score &
Level of
evidence
Quantitative research Researcher-made Clinical supervision and 6/7,
with path analysis Likert-scale interpersonal communication Level II
Simple random sampling questionnaire had a positive impact on caring
technique: 271 behavior.
respondents from 871
populations
Three-cohort Caring Behaviors The two CBI-24 dimensions of 7/7,
observational study Inventory-24 (CBI- instrumental caring, “Doing Level IV
415 first, second and 24) with competence” and
third-year nursing “Providing effective care”,
students presented the greatest increase
during nursing training because
students attended simulations in
nursing skill labs and are more
trained in the use of technical
instruments.
Descriptive, Nursing Students’ The teacher–student 7/7,
nonexperimental design Perception of relationship and interaction Level VI
Convenience samples of Instructor Caring impacts the development of
586 student nurses (NSPIC) and the caring competencies of nursing
Caring Behavior students through positive
Inventory (CBI) faculty role modeling.
Interpretive Interview Guide Humanistic caring is developed 7/7,
phenomenology in stages through nursing Level VI
Convenience and education and clinical practice
snowball sampling through communication skills as
methods: 26 participants it relates to students’ conception
(18 students and 8 nurses) of humanistic caring.
Interpretive Semi-structured Research participants expressed 7/7,
phenomenology individual interview that the nurse educators’ Level VI
A convenience sample of approach could promote, or
nursing students (n = 18) limit, their development
and nurses (n = 8) Nurse educators as role models
was emphasized longitudinally
in each group of participants.
Mixed-methods Caring Ability Facilitators of caring ability 16/17,
598 students participated Inventory (CAI) and were: (i) promoting a sense of Level VI
in survey and16 students focus group professional responsibility and
from there were interviews ethics; (ii) providing an arena in
interviewed. which to practice caring, and
(iii) learning from positive role
models.
Barriers were: (i) a critical
practice learning environment;
(ii) encountering inappropriate
clinical teachers, and (iii)
experiencing shock at the
contrast between an idealized
and the real environment.
Phenomenological, Focus groups, Three themes were identified. 7/7,
qualitative research observations and 1: inconsistency in the clinical Level VI
Purposive sample 23 field notes environment; 2: effective and
fourth-year student nurses ineffective role-modelling of
(6 males and 17 females) caring; and 3: carelessness
cascading.
Descriptive design with a Four group The findings of this study show 7/7,
qualitative approach interviews that reflection, preparations, Level VI
A convenience sample of motivation, trust and the
16 nursing students and context are essential factors
15 clinical supervisors supporting undergraduate
nursing students’ learning
caring skills during their clinical
education in the ambulance
service.
Case study Focus groups and Interaction with virtual patients 7/7,
71 nursing students interviews aid in developing knowledge, Level VI
skills and non-technical skills
including communication,
situation awareness, teamwork,
(continued on next page)
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E.P. Inocian et al. Nurse Education in Practice 63 (2022) 103391

Table 1 (continued )
Authors & Year Country Research aim/purpose Research design and Data Collection Key Findings MMAT
sample Method Quality
score &
Level of
evidence

decision making skills and

humanistic attributes of duty,
advocacy and empathy.
Subke et al. South Africa To explore, describe and Qualitative Semi-structured Creation of conducive clinical 7/7,
(2020). illuminate nursing students’ Appreciative Inquiry (AI) interviews learning environment to Level VI
best 10 s-year nursing students optimize caring.
encounters of caring in the
clinical learning environment.
Wi Mahmoud USA To describe the caring and Descriptive exploratory Journal summaries Two themes emerged in the 7/7,
and cultural diversity behaviors of cross-sectional design and clinical caring behaviors: self-caring and Level VI
Schuessler US nursing students studying with secondary analysis of evaluations caring presence.
(2017) abroad data Three themes emerged in the
12 female students in the cultural diversity behaviors:
junior year enhancing interactions, learning
something new, and
appreciating another culture.

from 10 to 598 student nurses in different year levels of the BSN pro­
gram. Two qualitative studies included eight nurses (Létourneau et al.,
2020, 2021) and another qualitative study included 15 clinical super­
visors (Nyqvist et al., 2020), in addition to the student nurses as research
participants. Quantitative data were measured using the Caring
Behavior Inventory (CBI), Caring Ability Inventory (CAI) and a validated
researcher-made questionnaire. Meanwhile, focus-groups, individual
interviews, observations, field notes, journal summaries and clinical
evaluations were employed in qualitative inquiries to collect data (see
Table 1).
4.2. Methodological quality score and level of evidence
There was a total of nine studies that were at the level VI evidence
including seven qualitative studies (Létourneau et al., 2020, 2021;
Mathe et al., 2021; Nyqvist et al., 2020; Peddle et al., 2019; Subke et al.,
2020; Wi Mahmoud and Schuessler, 2017), one descriptive study (Lab­
rague et al., 2015) and one mixed method design (Ma et al., 2013). One
cohort study (Ferri et al., 2020) was at the level IV evidence and one
quantitative study using simple random technique (Abdurrahman et al.,
2020) was at the level II evidence.
Nine studies (Ferri et al., 2020; Labrague et al., 2015; Létourneau
et al., 2020, 2021; Mathe et al., 2021; Nyqvist et al., 2020; Peddle et al.,
2019; Subke et al., 2020; Wi Mahmoud and Schuessler, 2017) addressed
the appraisal questions based on MMAT criteria (score: 7/7). One mixed
method design included in the review (Ma et al., 2013) did not
adequately explain the divergence and inconsistencies between quan­
titative and qualitative results (score: 16/17). Different strategies to
address the divergences have been suggested such as reconciliation,
initiation, bracketing and exclusion (Pluye et al., 2009). One quantita­
tive study using simple random technique (Abdurrahman et al., 2020)
did not clearly justify the sampling strategy used with its inclusion and
exclusion criteria (score: 6/7). All studies were included in the review
regardless of quality score (see Table 1).
4.3. Synthesis of findings
Content analysis of the included articles in this review generated five
themes in the CLE that influenced caring behaviors among nursing
students, namely: 1) role modeling of clinical faculty and professional
nurses (Labrague et al., 2015; Létourneau et al., 2020; Ma et al., 2013;
Mathe et al., 2021); 2) creating a conducive clinical learning environ­
ment (Abdurrahman et al., 2020; Ma et al., 2013; Mathe et al., 2021;
Subke et al., 2020); 3) effective communication skills (Abdurrahman
et al., 2020; Létourneau et al., 2021); 4) positive effect of simulation
(Ferri et al., 2020; Peddle et al., 2019); and 5) alternative clinical
placements (Nyqvist et al., 2020; Wi Mahmoud and Schuessler, 2017)
(Fig. 2).
4.3.1. Theme 1: role modeling of clinical faculty and professional nurses
Several studies found that the role modeling of the clinical faculty
and professional nurses had an impact on the caring behaviors of nursing
students. A descriptive study with a convenience sample of 586 student
nurses across four different countries explored the impact of instructors’
display of caring behaviors on students’ perceptions of their own caring
behaviors through positive faculty role modeling (Labrague et al.,
2015). Moreover, an interpretive phenomenological study in Canada
found the nurse educator’s approach either promoted or limited the
development of nursing students’ humanistic caring, with nurse edu­
cators as role models (Létourneau et al., 2020). In the CLE, nurse edu­
cators have ample opportunities to guide nursing students toward
enhancing caring behaviors as they care for vulnerable patients.
In addition, a mixed-methods study examined the role of clinical
practice learning in the development of caring skills among 598 nursing
students in China (Ma et al., 2013). A significant facilitator of caring
ability for the nursing students who were surveyed was learning from
positive role models. For example, professional nurses who focused on
individualizing each patient’s care rather than focusing on completing
necessary tasks enhanced students’ caring development (Ma et al.,
2013). The ability to provide individualized and holistic patient care can
be overlooked as nurses become task-oriented (Ma et al., 2013). Simi­
larly, a phenomenological, qualitative research study in South Africa
explored the exposure of 23 nursing students to professional nurses’ role
modeling in the clinical setting found that professional nurses being
approachable and available led to effective role modeling for students
(Mathe et al., 2021). Not surprising, professional nurses who were
hostile and bitter towards students were ineffective role models (Mathe
et al., 2021). This behavior may also lead to students becoming appre­
hensive to approach the nurses or ask questions regarding their care of
patients. Therefore, positive role modeling from nurses can prove as an
important factor in nursing students’ development of caring behavior.
The positive role modeling of nurses would show students how to
appropriately handle situations that may arise during patient care,
which ultimately can lead to promoting the delivery of safe and effective
care.
4.3.2. Theme 2: Creating a conducive clinical learning environment
The characteristics of the clinical environment were found to be a
significant component in nursing students’ abilities to develop caring
behavior. A quantitative research study using path analysis and

5
E.P. Inocian et al.
Fig. 2. Five factors (themes) in the clinical learning environment that influence the caring behaviors of undergraduate nursing students.
conducted in Indonesia found increased clinical supervision had a pos­
itive impact on caring behavior among the 271 nursing students sur­
veyed (Abdurrahman et al., 2020). Differences in the expected and
actual CLE can have a profound effect on students caring behavior, as
the information students receive about clinical experiences and what
they are exposed to in the actual setting can vary widely. The in­
consistencies in the clinical environment displayed by the clinical fac­
ulty and professional nurses may limit students’ abilities to develop
caring behavior (Mathe et al., 2021). In fact, students explained they
found clinical experiences helpful in the development of caring behavior
by providing an arena to practice caring and promote a sense of pro­
fessional responsibility and ethics (Ma et al., 2013). Meanwhile, expe­
riencing shock at the contrast between an ideal and realistic
environment was identified as an obstructive factor in the development
of nursing students’ caring abilities (Ma et al., 2013). A qualitative
appreciative inquiry with 10 South African nursing students found their
best encounters of caring led to a conductive clinical learning environ­
ment, which optimized their caring and allowed them to excel in the
clinical setting (Subke et al., 2020). Thus, existing literature suggests
that the creation of a conducive clinical environment is essential for
learning and internalizing caring behavior among nursing students
through close clinical supervision, providing opportunity to practice
caring and demonstrating positive attitudes and practices in the clinical
area.
4.3.3. Theme 3: effective communication skills
An interpretive phenomenology study among 18 nursing students
and eight nurses in Canada revealed that humanistic caring is developed
in stages through nursing education and clinical practice via effective
communication skills (Létourneau et al., 2021). In fact, interpersonal
communication directly and indirectly determined changes in the caring
behavior of nurses by 15.7% (Abdurrahman et al., 2020).
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Nurse Education in Practice 63 (2022) 103391
Communication is an important component for the nurse as they not
only communicate with other healthcare members but as they commu­
nicate to advocate for their patients. Effective communication helps to
establish a relationship of trust with clients, prevent legal problems,
provide professional satisfaction in nursing services and improve the
image of the nursing profession and the image of the hospital (Abdur­
rahman et al., 2020). Therefore, enhancing communication skills may
attribute to improving students’ caring behavior.
4.3.4. Theme 4: positive effect of simulation
A case study methodology which examined the learning of 71 un­
dergraduate nursing students demonstrated that interaction with virtual
patients in simulation labs aided in developing knowledge, skills and
non-technical skills including communication, situation awareness,
teamwork, decision-making and humanistic attributes of duty, advocacy
and empathy (Peddle et al., 2019). Additionally, an observational study
which explored the perceptions of caring behaviors by 415 first, second
and third-year nursing students during their clinical practice training
highlighted an increase in the level of caring behaviors as the nursing
courses progressed. Two of the CBI-24 dimensions of instrumental car­
ing, “Doing with competence” and “Providing effective care,” presented
the greatest increase during nursing training because students attended
simulations in nursing skill labs and were more trained in the use of
technical instruments (Ferri et al., 2020). This finding suggests incor­
porating simulation in preparing nursing students for actual clinical
practice may produce a desirable effect on the caring behavior of
nursing students.
4.3.5. Theme 5: alternative clinical placements
A descriptive study from Sweden focused on the perspectives of both
the 16 nursing students’ and 15 clinical supervisors revealed that
reflection, preparation, motivation and trust were essential factors
E.P. Inocian et al.
supporting undergraduate nursing students’ learning of caring skills
during their clinical time with the emergency medical service and the
ambulance service in the regional county council (Nyqvist et al., 2020).
A descriptive exploratory cross-sectional design with secondary analysis
of journal summaries and clinical evaluations data described the caring
and cultural diversity behaviors of 12 female junior nursing students
from the US studying abroad (Wi Mahmoud and Schuessler, 2017). Two
themes emerged in their caring behaviors such as self-caring and caring
presence and three themes emerged in their cultural diversity behaviors
including enhancing interactions, learning something new and appre­
ciating another culture (Wi Mahmoud and Schuessler, 2017). Thus,
providing students with alternative clinical placements such as experi­
ence in an emergency medical and ambulance service and a study
abroad program may assist undergraduate nursing students to achieve
caring traits and inclusive behavior as they acknowledge differences in
attitudes and beliefs of patient population from various backgrounds.
5. Discussion
This integrative review explored current literature on the factors in
the CLE that influence caring behaviors among undergraduate nursing
students. Current evidence suggests that factors of and in the CLE affect
the nursing students’ ability to develop caring behaviors. Specifically,
role modeling of clinical faculty and professional nurses, creating a
conducive CLE, effective communication skills, positive effect of simu­
lation and alternative clinical placement may help to facilitate the
development of caring behaviors among nursing students.
Findings indicated that through positive role modeling of clinical
faculty and professional nurses in the clinical environment, nursing
students can learn to develop the competence of caring. Perceived caring
increases among undergraduate nursing students as they move to higher
level in the academic program possibly due to their experience with
registered nurses and faculty who model caring behaviors (Wolf et al.,
2018). However, there are barriers that may affect how the caring be­
haviors may be developed in nursing students. For instance, heavy
workloads and professional quality of life among nurses may have an
impact on the practice of compassionate care by nursing personnel
(Chang et al., 2019; Inocian et al., 2021). Students may witness unpro­
fessional behaviors in the CLE, which may deter them from developing
their own caring behaviors (Chang et al., 2019). Therefore, nursing
leaders must create programs that not only help to promote their nurses
to be competent preceptors but decrease their workloads and support
their efforts to achieve this goal. Role modeling is a key component as
nurses begin to develop their caring behaviors. A goal of nursing edu­
cation is to graduate students who have developed caring behaviors,
allowing them to deliver safe and quality patient care. Moreover, clinical
supervision of nursing students through preceptorship program is
required in practice settings to facilitate successful transition to pro­
fessional practice and become compassionate and caring nurses (Powers
et al., 2019). Professional nurses and faculty working with nursing
students in the clinical settings may benefit from continuing professional
development in mentoring and precepting nursing students (Labrague
et al., 2020). Therefore, nurse leaders need to present more opportu­
nities for nurses to grow and evolve in their profession, such as mem­
bership or fellowship in professional organizations.
Providing students with a conductive, welcoming and consistent
clinical learning environment promotes their development of caring
behavior. A caring relationship between the student and the preceptor or
faculty member promotes trust and a sense of warmth, making the
students feel comfortable and invited as part of the team (Hilli and
Sandvik, 2020; Sandvik et al., 2014). In post-graduate education among
physicians, a psychological attribute of safety or an individuals’ per­
ceptions of their ability to speak out in the learning context without risks
or consequences for their professional standing, influenced the learning
process and the outcomes of learning (Caverzagie et al., 2019). This
principle could also be applied in the clinical education of student
7
Nurse Education in Practice 63 (2022) 103391
nurses. Cultivating psychological feeling of safety allows students to
engage in the clinical setting, to learn from experiences and to perform
better (Lyman and Mendon, 2021). It is imperative that the CLE pro­
motes a positive practice environment and a caring atmosphere so that
students can translate their knowledge and skills in clinical practice.
Effective communication is a central element in building a thera­
peutic relationship with patients, which students must demonstrate as a
form of caring expression. Communicating effectively depends on one’s
ability to listen and use both verbal and non-verbal skills to improve
health outcomes and promote patient satisfaction, reflecting their per­
sonal and practical experience as a professional nurse. Nurses may have
difficulty maintaining a dialogue with patients due to lack of time,
organizational and cultural factors and personal fears especially during
complex circumstances (Bullington et al., 2019). Hence, nursing edu­
cation curriculum should integrate communication training as a foun­
dation skill for nursing students to develop authentic nurse-patient
relationship and interact effectively during patient encounters. Tech­
niques should focus on therapeutic strategies and effective communi­
cation tools which help address patients’ healthcare needs. For example,
Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS), an evidence-based approach enhancing communication
skills and teamwork may optimize patient outcomes (Huber and Joseph,
2022).
The findings of this review also support the use of simulation in
further developing caring behaviors among nursing students.
Simulation-based education, using standardized or virtual patients, is a
highly implemented pedagogical approach in nursing schools.
Simulation-based activities allow nursing students to practice clinical
and decision-making skills through different realistic scenarios in a
controlled, non-threatening and safe environment thereby decreasing
anxiety and build confidence and improve the knowledge and skills of
nursing students (Kim et al., 2016; Vural Doğru and Zengin Aydın,
2020). Nurse educators should continue to design, implement and
evaluate simulation-based activities to enhance the development of
caring behaviors.
Nursing schools may use alternative health care settings for clinical
education including emergency medical and ambulance services and
study abroad programs to enhance caring behaviors among nursing
students in a cross-cultural context. More research maybe needed to
explore learning outcomes of nursing students across clinical placement
arenas other than common acute care settings. For example, CLE in
nursing homes can be optimized with academic-clinical partnerships to
create positive learning experiences among nursing students and pro­
mote basic nursing skills and competencies (Husebø et al., 2018). This
type of CLE may encourage students to choose a career in long-term care
and may facilitate caring behavior development.
5.1. Implications
This review synthesized findings of 11 research articles on the factors
contributing to the development of caring behaviors of undergraduate
nursing students in the clinical learning environment. The knowledge
generated from this review provides guidance in formulating effective
teaching and clinical strategies that can be implemented in nursing
education institutions and healthcare settings. For example,
competency-based education can facilitate the development and
demonstration of holistic and caring competencies among nursing stu­
dents in the CLE (Paragas, 2019). Nurse leaders and educators can
design a structured preceptorship model for nursing students, where
professional nurses receive training in mentoring and precepting
nursing students. University administrators may also consider an
orientation program and continuous professional education programs
for clinical faculty especially those in adjunct positions to incorporate
different teaching approaches and deliver appropriate feedback to
nursing students during clinical placement. The adoption of a mentoring
program for newly hired faculty that pairs them with senior faculty may
E.P. Inocian et al.
also enhance teaching capacities and assure quality of teaching. Pro­
fessional certifications for nurse educators and registered nurses may
further strengthen teaching practices and clinical competences to guide
students. Nurse educators should use available on-campus laboratory
simulation to prepare nursing students for actual clinical exposure.
Nursing schools should consider alternative clinical placement settings
for nursing students to gain practical experience.
5.2. Limitations
There are few limitations in this integrative review. The exclusion of
non-English language papers limits the generalizability of our findings,
yet articles emanated from 12 different countries may support applica­
bility to those locations. Only 11 studies were found to contribute to the
review findings and a larger sample size may be required to generalize
the findings to other settings. The authors acknowledge the absence of
articles from other countries like South America (e.g., Brazil, Argentina,
Bulova, Peru etc.) as a limitation of the current review. The search terms
used may have failed to completely locate all relevant studies that could
have added more insights of the review findings and influenced overall
perspective of the topic. In addition, the authors did not include the
Boolean operators ‘NOT’ and *truncation in the search strategy. The
authors recognized that computer databases may not capture all eligible
studies due to inconsistent terminology and problems with indexing
(Whittemore and Knafl, 2005). Additional research is needed to explore
the factors in the CLE that influence the development of caring behavior
of nursing students internationally, especially in countries where En­
glish is a not the primary language. Cultural education is key in un­
derstanding the clinical experiences of culturally and linguistically
diverse healthcare students (Mikkonen et al., 2016). With the growing
diversity in nursing education, cross-cultural research employing other
research designs such as longitudinal studies may offer additional
perspective on how or if caring behavior changes over time. The
included studies also used various research tools including CBI, CAI,
researcher-made, interview guide, focus groups, journal summaries and
clinical evaluations which posed challenging for the reviewers in
comparing and contrasting the results because of major variability in
scales, structures and content. Researchers should also incorporate
rigorous sampling method such as probability sampling techniques, as
most of the included studies used convenience and purposive sampling.
Lastly, as the current review only included papers published from 2011
to 2021, future integrative reviews may expand search from the date of
inception of each database (e,g., CINAHL from 1981 to 2021; Embase
from 1947 to 2021; Scopus from 2004 to 2021; PubMed from 1996 to
2021).
6. Conclusion
Caring is an essential element of nursing and promotes better patient
outcomes. Caring behaviors among undergraduate nursing students can
be developed through role modeling of clinical and professional nurses,
creation of conducive clinical learning atmosphere, effective commu­
nication, using simulation experiences and placement in alternative
clinical settings. The findings of this integrative review can be used to
improve the clinical environment and develop more meaningful clinical
learning experiences for nursing students. Enhancing nursing students’
clinical experiences and implementing more effective teaching strate­
gies may foster students’ caring abilities. Ultimately, cultivating stu­
dents’ humanistic caring abilities will better prepare them for their roles
as professional nurses. This integrative review provides information to
advance students’ caring behaviors, subsequently leading to more
optimal patient outcomes.
Funding Source
No external funding.
8
Nurse Education in Practice 63 (2022) 103391
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgment
The authors would like to acknowledge Mr. David Nolfi, Head of
Research Engagement, Health Sciences/STEM Initiatives, and Assess­
ment at Gumberg Library, Duquesne University for his valuable assis­
tance in formulating the search strategy and comprehensive search of
literatures in the online databases. The authors also recognize the
involvement of Lena Weinsteiger and Marissa DeRienzio for the assis­
tance in the handsearching of literature.
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