LC 5

S YS T E M AT I C R E V I E W
The influence of workplace culture on nurses’ learning

experiences: a systematic review of qualitative evidence
Kate Davis Sarahlouise White Matthew Stephenson
Joanna Briggs Institute, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
EXECUTIVE SUMMARY
Background
A healthy workplace culture enables nurses to experience valuable learning in the workplace. Learning in the
workplace enables the provision of evidence-based and continuously improving safe patient care, which is central to
achieving good patient outcomes. Therefore, nurses need to learn within a workplace that supports the imple-
mentation of evidence-based, professional practice and enables the best patient outcomes; the influence of
workplace culture may play a role in this.
Objectives
The purpose of this review was to critically appraise and synthesize the best available qualitative evidence to
understand both the nurses’ learning experiences within the workplace and the factors within the workplace culture
that influence those learning experiences.
Inclusion criteria
Types of participants
Registered and enrolled nurses regulated by a nursing and midwifery board and/or recognized health practitioner
regulation agency (or their international equivalent).
Phenomena of interest
This review considered studies that described two phenomena of interest: the nurses’ learning experience, either
within an acute healthcare workplace or a workplace-related learning environment and the influence of workplace
culture on the nurses’ learning experience (within the workplace or workplace-related learning environment).
Context
This review considered studies that included nurses workingin an acutehealthcare organization within a Western culture.
Types of studies
This review considered studies that focused on qualitative evidence and included the following research designs:
phenomenological, grounded theory and critical theory.
Search strategy Published and unpublished studies in English from 1980 to 2013 were identified using a three-step
search strategy, searching various databases, and included hand searching of the reference lists within articles
selected for appraisal.
Methodological quality
For studies meeting the inclusion criteria, methodological quality was assessed using a standardized checklist from
the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI).
Data extraction
Qualitative data were extracted from articles included in the review using the standardized data extraction tool from
the JBI-QARI.
Data synthesis
Qualitative research findings were pooled using the Joanna Briggs Institute Qualitative Appraisal and Review
Instrument (JBI-QARI). This involved the aggregation and synthesis of findings to generate a set of categories, which
were then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that could be
used as a basis for evidence-based practice.
Correspondence: Kate Davis, kdavis@wli.sa.edu.au

There is no conflict of interest in this project.
DOI: 10.11124/JBISRIR-2016-002219
JBI Database of Systematic Reviews and Implementation Reports ß 2016 THE JOANNA BRIGGS INSTITUTE 274
©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

SYSTEMATIC REVIEW K. Davis et al.
Results
Fourteen articles were identified following appraisal and a total of 105 findings (85 unequivocal and 20 credible)
were extracted from included studies and grouped into eight categories based on similarity of meaning.
Subsequently, categories were grouped into two synthesized findings. The two synthesized findings were as follows:
Organizational influences
Enabling nurses to demonstrate accountability for their own learning, along with clear organizational systems that
provide resources, time, adequate staffing and support, demonstrates encouragement for and the value of nurses’
learning and education.
Relational dynamics
Nurses value their peers, expert nurses, preceptors, mentors and educators facilitating and encouraging their
learning and professional development.
Conclusion
An optimal workplace culture is central for nurses to experience valuable and relevant learning in the workplace. To
emphasize the importance of nurses’ learning in the workplace, working and learning is understood as an integrated
experience. Consequently, a dual system that enables nurses to demonstrate accountability for their own learning, along
with clearorganizational and educational systems, is required to demonstrate the value innurses’ learning and education.
Keywords Education; nursing; organization; professional development; workplace culture
Summary of findings1
Systematic review title: The influence of workplace culture on nurses’ learning experiences: a
systematic review of the qualitative evidence
Participants: Registered and enrolled nurses regulated by a nursing and midwifery board and/or
recognized health practitioner regulation agency (or their international equivalent)
Phenomena of interest: The nurses’ learning experience, either within an acute healthcare workplace
or a workplace-related learning environment and the influence of workplace culture on the nurses’
learning experience (within the workplace or workplace-related learning environment)
Context: Nurses working in an acute health care organization within a Western culture
Synthesized finding Type of Dependability Credibility ConQual Comments
research score
Organizational influ- Qualitative High Down- Moderate Downgraded
ences grade one one level due to
level mix of unequi-
Enabling nurses to vocal (U) and
demonstrate account- credible (C)
ability for their own findings
learning, along with
clear organizational sys- 46U þ 12C
tems that provide
resources, time, ade-
quate staffing and sup-
port, demonstrates
encouragement for and
the value of nurses
learning and education.

(Continued)

Relational dynamics Qualitative High Down- Moderate Downgraded
grade one one level due to
Nurses value their peers, level mix of unequi-
expert nurses, precep- vocal (U) and
tors, mentors and educa- credible (C)
tors facilitating and findings
encouraging their learn-
ing and professional 39U þ 8C
development.
Background Observed behavioral irregularities when people

healthy workplace culture enables nurses to interact:
A experience valuable learning in the work-
place.2–7 Learning in the workplace is valuable as
Group norms
Espoused values
it can enable the provision of evidence-based and Formal philosophy
continuously improving safe patient care, which is Rules of the game
central to achieving good patient outcomes.8–14 Climate
Additionally, workplace learning is valuable as it Embedded skills
informs the scope and progression of nursing practice Habits of thinking, mental models and/or
and is also linked with the regulatory requirements linguistic paradigms
related to the nurse as a professional.15–17 Therefore, Shared meanings
nurses need to learn within a workplace that supports ‘‘Root metaphors’’ or integrating sym-
the implementation of evidence-based, professional bols.18(p.14–16)
practice and enables the best patient outcomes; the
influence of workplace culture may play a role in In relation to nurses’ learning experiences, the
this.8,9 aspects listed above are relevant to workplace culture
For the purpose of this review, it is useful to because they reflect issues, values or things that group
provide a clear definition of culture as it relates to members (or nurses) hold in common.18 This is a
an organization, or part of an organization, such significant point within this article because the con-
as a workplace. In the organizational context, cept of culture implies a shared history or evolution
Schein18(p.18) defines culture in the following way: that has contributed to the current structural stability,
The culture of a group can now be defined as a depth and breadth, within an organization and can
pattern of shared basic assumptions learned by have an impact on a nurses’ learning experience.18
a group as it solved its problems of external Notably, the impact can be significant; culture is an
adaptation and internal integration, which has enduring force that continues, even when some mem-
worked well enough to be considered valid and, bers of an organization may leave.18
therefore, to be taught to new members as the correct It is also noted that in organizational research
way to perceive, think and feel in relation to literature, there has been a historical debate on the
these problems. meanings of, and differences and similarities between
Schein also noted that culture is an abstract and organizational culture and organizational climate.19
powerful force, but to be useful it needs to be observ- It is therefore noted that adhering to the strict histori-
able.18 Therefore, for the purpose of this article, cal and theoretical paradigm differences between
although the term culture refers to the definition as organizational culture and climate is beyond the scope
stated above by Schein, it also relates to the following of this systematic review.20 Instead, as Schein noted,
‘‘observable events and underlying forces’’ listed climate is considered a factor within culture; there-
below: fore, organizational climate is recognized as different

from culture. Furthermore, within the context of this organizational culture. Therefore, in understanding
article, climate is one factor within overall organiz- the influence of workplace culture on nurses’ learn-
ational culture and contributes to and is a part of ing experiences, it is important to be mindful of the
culture, but is not culture itself. Building on Schein’s complexities associated with culture and its assess-
definition and in an effort to elucidate how culture is ment.
manifest in the workplace, it is useful to apply Ross- As the relationship between workplace culture
Walker’s observation: and patient outcomes is not definitively established
in the literature,24,26,27 it will be useful to explore the
‘‘Workplace culture (as a learned and shared phenom- literature concerning a different relationship: that of
ena) exists on two levels -the visible artefacts (i.e. the nurses’ learning experiences and the influence on
physical structures and symbols, rituals and ceremo- those experiences of workplace culture. Understand-
nies, language,stories and legends), andthe observable ing what happens at the ward or unit-based and
behaviours, where artefacts dictate the group’s under- individual level, where learning takes place and care
lying behaviour and decision-making.’’21(p.3084) is provided, is the key to understanding workplace
learning and workplace and/or organizational cul-
The above phenomena will be considered in terms ture. Furthermore, this may set the scene for under-
of their influence on nurses’ learning experiences. standing workplace culture and patient outcomes
Also, having already noted that climate is a contrib- into the future.
utor to workplace culture, the significance of Snow’s In conducting a preliminary search for existing
work on workplace climate is relevant to nurses’ systematic reviews on this topic, reviews were ident-
learning experiences within the workplace. Snow ified that addressed the links between leadership,28
notes the following: nursing workloads,21 professional practice,29 cul-
tural diversity,30 team collaboration31 and work-
‘‘Climate is one of the most powerful, yet overlooked, place culture, but were silent on the relationship
factors when determining the performance of a between learning and the influence of workplace
particular work team. In fact, it has been demon- culture.
strated that climate accounts for up to 30% of the This systematic review therefore seeks to under-
variance in performance on a particular unit.’’22(p.393) stand the quality of the nurses’ learning experi-
ences in relation to workplace culture. In essence,
As will later be explored, it is difficult to separate there is a body of evidence and literature address-
working or ‘‘performance’’ from learning.23 There- ing learning and workplace culture17,32 – 36; how-
fore, extrapolating from Snow’s statement above, ever, this has not been systemically considered to
and acknowledging that climate is a contributing enable its application in the clinical context and
force to workplace culture, understanding, defining, provision of recommendations for evidence-based
improving and maintaining a healthy workplace support of nurses’ learning experiences within
culture is relevant to work performance, as well as the workplace.
nurses’ learning, evidence-based practice and safe Within this review, nurses’ learning experiences
patient outcomes.8,9,12,20,22 are explored both in the clinical workplace and more
However, a definitive link between organiz- broadly within the healthcare organization, such as
ational culture and patient outcomes is unclear.24,25 staff development and continuing education depart-
Therefore, nursing and healthcare leaders need to ments, or work-related professional learning experi-
remain cognizant that any link between culture and ences. Therefore, recognizing and understanding the
patient outcomes needs to be based on sound complexity of relationships and factors in the work-
research, both qualitative and quantitative, as place is necessary to promulgate a healthy work
relevant to particular organizational requirements.26 culture within the workplace. Henderson noted
Mannion’s26 significant report entitled ‘‘Measuring the urgency of this by highlighting that ‘‘organiz-
and Assessing Organizational Culture in the NHS’’ ations, by their very nature, do not readily encourage
noted that due to the complexity of culture within new learning. Staff largely rely on established sys-
modern healthcare systems and organizational life, tems to perform their jobs with minimal resistance
there was much to understand in relation to and stress’’.32(p.198)

When considering nurses’ learning experiences Inclusion criteria

and their association with implementing evidence- Types of participants
based practice, Newman et al. noted in their project This review considerd studies that included regis-
on implementing evidence-based practice in the tered and enrolled nurses regulated by a nursing and
healthcare organization that ‘‘the results of the proj- midwifery board and/or recognized health prac-
ect correspond with findings from other studies of titioner regulation agency (or their international
change in the organization of nursing practice, equivalent)39 working in a Western acute hospital
which suggests that structural organizational factors or healthcare facility. Non-Western facilities were
will be key determinants of the successful imple- excluded due to a lack of consistency in health
mentation of changes.’’37(p.105) practitioner regulation, as well as healthcare stand-
Hence, for nurses to provide contemporary, ards, accreditation and other non-organizational
relevant, evidence-based care, it is essential that they cultural factors.
are supported in their learning and particularly All studies focusing on undergraduate nursing
during workplace learning. As new nursing and students were not considered for inclusion; how-
related evidence and skills emerge, nurses need to ever, postgraduate or post-registration nurses were
engage with this knowledge, synthesize and apply it included. The rationale for this is that post-regis-
in practice. Moreover, to retain this new knowledge tration and graduate nurses have a level of com-
and skills and build the capabilities of nursing staff, petence and skill to enable them to learn and
it is desirable to have nursing staff committed to perform to a certain competence level in a range
lifelong learning. To have nurses with an active of environments. Nursing students have not yet
approach to their lifelong learning, it is necessary reached this level of performance or competence
to have a concomitant healthy workplace culture.35 and do not have the experience or understanding of
In relation to the methodology of studies to be the workplace that a registered nurse does; there-
appraised and reviewed, for the purpose of this fore, nursing students’ perceptions and under-
qualitative systematic review, the aim is to facilitate standing in relation to learning and the influence
an increased understanding of nurses’ learning of workplace culture may differ from those of
experiences. Therefore, this systematic review con- registered nurses.
sidered research study designs that were broadly
interpretive such as phenomenology, grounded Phenomena of interest
theory, ethnography, action research and feminist This review considered studies that described two
research. Additionally, although the primary goal of phenomena of interest. The first phenomenon was
this systematic review was not to critique workplace the nurses’ learning experience, either within an
cultures, if a clear understanding of nurses’ learning acute healthcare workplace or a workplace-related
experiences in the workplace is established, a call for learning environment (e.g. a continuing education
change in workplace culture may be a future possi- department within a healthcare organization). The
bility. second phenomenon was the influence of workplace
The objectives, inclusion criteria and methods of culture on the nurses’ learning experience (within
analysis for this review were specified in advance and the workplace or workplace-related learning
documented in a protocol.38 environment).
Types of studies
Objectives This review considered studies that focused on qual-
The purpose of this review was to critically appraise itative evidence and included the following research
and synthesize the best available qualitative evidence designs: phenomenological, grounded theory and
to understand the quality, value and type of learning critical theory.
nurses experience within the workplace. In particu-
lar, the review explored the relationship between Context
workplace culture and the influence this can have on This review considered studies that included nurses
a nurse’s learning experience within a clinical work- working in an acute healthcare facility within a
place or organization. Western culture.

Search strategy OR Continuing and Education OR professional and

The search strategy aimed to find both published and development OR post-graduate and learning
unpublished studies. A three-step search strategy AND
was utilized in this review. First, an initial limited Service culture OR workplace culture OR workplace
search of CINAHL was undertaken followed by OR work culture OR organization culture OR
analysis of the text words contained in the title organization ethos OR corporate culture OR Service
and abstract and of the index terms used to describe environment OR organization environment OR
an article. This formed the basis of a preliminary workplace environment OR Work environment
logic grid as shown in detail for the PubMed search, OR Corporate environment OR organization cli-
in Appendix I. Second, the logic grid was then mate OR corporate climate OR Healthy and work
adapted and a second search applying a customized and environment OR Support
logic grid to each database was undertaken across all AND
included databases (see Appendix I). A research Qualitative OR Qualitative and Experience OR
librarian was consulted in the initial stages of plan- Lived experience OR Perception OR Perceived OR
ning to ensure rigor and appropriateness of search Understanding OR Ethnography OR Phenomenol-
terms applied across databases. Third, hand search- ogy OR Feminist and research OR Critical and
ing the reference lists within articles selected for research OR Action and research OR systematic
appraisal was undertaken at the final searching review
stage.
English language studies published from 1980 to Method of the review
2013 were considered for inclusion in this review. Articles selected for retrieval were assessed by two
Senge’s40 seminal work, ‘‘The Fifth Discipline’’ pub- independent reviewers for methodological validity
lished in 1990, heralded the articulation of the prior to inclusion in the review using standardized
impact culture has within organizations. Further, critical appraisal instruments from the Joanna Briggs
it marked the introduction of the concept of learning Institute Qualitative Assessment and Review Instru-
organizations, that is: ment (JBI-QARI, see Appendix II). Any disagreements
that arose between the reviewers were to be resolved
‘‘. . .organizations where people continually expand through discussion or with a third reviewer; however,
their capacity to create the results they truly desire, this did not eventuate.
where new and expansive patterns of thinking are The reviewers met prior to conducting critical
nurtured, where collective aspiration is set free, and appraisal to clarify precise definitions of critical
where people are continually learning how to learn appraisal criteria. Criterion 1 was clarified because
together.’’40(p.8) at first reading a number of the articles appeared
unclear on the philosophical position – agreement
Thus, the purpose of this time period was to
was required on how to assess this consistently.
include the literature preceding the introduction of
Likewise, the reviewers came to an agreement on
this concept and integrate it with later literature
criterion 6 and what it meant for the researcher to
related to nurses’ experiences of learning in
state a position both culturally and theoretically
the workplace.
The databases searched included: PubMed, within their study. No single criterion was deemed
essential and no minimum number of criteria was
CINAHL, Scopus, ERIC and Embase
deemed essential to form the basis for inclusion.
The search for unpublished studies included Pro-
Each article was assessed on its own merits in
Quest Theses and Dissertations
relation to the criteria, and often it was failure to
Initial keywords used to formulate the logic grid
meet the inclusion criteria rather than the criteria
were:
that formed the basis for exclusion.
Nursing OR specialties OR nursing staff OR nurses
OR nurse or clinician or health
AND Data extraction
Learning OR nurse education OR education OR in- Qualitative data were extracted from articles
service OR in-service training OR staff development included in the review using the standardized data

extraction tool from JBI-QARI computer software nurses. Studies included both male and female
(see Appendix III). The data extracted included nurses, with an age range of 26 to 55 years. Experi-
specific details about the populations, study methods ence levels varied from advanced beginner to
and outcomes of significance to the review question expert.41 Overall, the studies were inclusive of
and specific phenomena of interest. participants with a range of years of experience
and professional representation.
Data synthesis The stated phenomena of interest within the 14
Qualitative research findings were pooled using JBI- articles reviewed have been broadly categorized into
QARI. This involved the aggregation or synthesis of two phenomena. First, those concerning nurses’ learn-
findings to generate a set of statements that ing experiences within the clinical workplace and
represented aggregation, through assembling the second, those related to learning experiences not
findings rated according to their quality, and cate- within the clinical workplace, but still linked to the
gorizing these findings on the basis of similarity in organization. The second category of phenomena
meaning. These categories were then subjected to a related to learning experiences linked to nurses’ pro-
meta-synthesis to produce a single comprehensive set fessional development and nursing roles, but were
of synthesized findings that could be used as a basis within a staff development unit or other workplace,
for evidence-based practice. higher education supported or related venue. The
phenomena of interest were reasonably homogenous
Results and all were concerned with nurses’ perceptions,
Description of studies experiences and factors that impacted on their learn-
As shown in Figure 1 (PRISMA [Preferred Reporting ing, either within the clinical workplace or supported
Items for Systematic Reviews and Meta-Analyses] (or impeded) by the organization (see Appendix IV).
flow diagram), 20,983 articles were identified from a The setting for the studies was acute healthcare
detailed search process across a number of selected organizations:
databases. The large number of articles originally Five studies were in multiple hospitals/
identified may, in part, be attributed to the use of regions.42–46
generic search terms such as ‘nurses’ and ‘learning’. Six studies were in a single hospital or multiple
Additionally, a large number of articles relating to wards within the single hospital.5,47–51
students’ learning and clinical topics were originally Two studies were in a single hospital ward.52,53
retrieved. One study did not report the specific setting.54
Articles were imported from databases into End-

Note bibliographic software and 24 duplicate titles One of the studies was set both in acute care
were removed. A total of 20,959 titles were then hospitals within the National Health Service (NHS)
reviewed and 19,522 articles not relevant to the and private aged care or residential units. Data
topic were removed, remaining n ¼ 1437. Abstracts relating to the acute care facility only were extracted
were then reviewed and 1290 records excluded that or if comparative data were extracted this is reported
did not meet the inclusion criteria. The remaining within the review.
147 full-text articles were reviewed and 135 Six different countries were represented in the
excluded that did not meet inclusion criteria; 12 review:
articles were then identified for appraisal – these Australia48,52
articles were hand searched and a further two articles, Canada43,45,47
totaling 14 articles, were critically appraised. All 14 United States42,49,50
articles taken to appraisal were included in the sys- Sweden5
tematic review (see Appendices IV and V). United Kingdom44,46,51,54
The studies included in the review were published Norway.53
during the period 1994–2013. The participants
included within the studies ranged in experience A range of qualitative methodologies were
from new or graduate nurses with eight months represented in the studies as listed below, the pre-
working experience, through to advanced practice dominant being phenomenology.
nurses, nurse managers, enrolled and registered 11 phenomenological studies:

Identification
Records idenﬁed through

Duplicates removed
database searching
(n =24)
(n = 20,983)
Titles screened for eligibility Records excluded

(n =20,959) (n =19,522)
Screening
Abstracts excluded, did

Abstracts screened
not meet protocol criteria
(n =1,437)
(n = 1290)
Full-text arcles assessed Full-text arcles excluded,

for eligibility did not meet protocol
(n =147) criteria
(n = 135)
Eligibility
Studies included in
qualitave appraisal
(Hand searching)
(n = 12 +2 = 14)
Studies included in
Included
qualitative synthesis
(meta-aggregation)
(n = 14)
From: Moher D, Libera A, TetzlaﬀJ, Altman DG, The PRISMA Group (2009). Preferred Reporng Items for Systemac Reviews and Meta-
Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097
Figure 1: PRISMA flow diagram for retrieved studies, excluded and included studies
Phenomenological44 Realistic evaluation51

Longitudinal descriptive study48 Qualitative report.5
Exploratory study54 Two grounded theory studies:
Field study53 One grounded theory43
Descriptive qualitative design42 One grounded theory principles.46
A case study approach49,50,52 One critical theory study:
Narrative inquiry45 Action research.47

Methodological quality Table 1: Number of studies included and excluded

Overall, the methodology of articles included was Number of studies Number of studies
sound (see Table 1). In particular, criteria 2, 3, 4 and included excluded
5, all relating to congruity of research methodology
and study question, data collection and analysis 14 0
techniques, were strong (see Table 2). Additionally,
criterion 8 that addresses participants’ voices, as
research findings, also has its genesis in praxis.
would be expected in a strong qualitative study,
Munn et al.1(p.2) note the following:
was addressed well in all studies. Criteria 1,6, 7
The meta-aggregative method has been explicitly
and 9, perhaps some of the more peripheral criteria
of study quality, were not consistently addressed aligned with the philosophy of pragmatism in order
to deliver readily usable synthesized findings to
across the included studies. In several studies, these
inform decision making at the clinical or policy level.
criteria were not fulfilled or it was not possible to
As a result, the meta-aggregative approach to qual-
make this judgment due to unclear reporting.
itative synthesis is particularly suited for reviewers
attempting to answer a specific question about
Findings of the review healthcare practice or summarizing a range of views
Results of meta-synthesis of qualitative research regarding interventions or health issues.
findings
A total of 105 findings (85 unequivocal and 20 Synthesized finding 1: Organizational factors
credible) were extracted from included studies and Enabling nurses to demonstrate accountability for
grouped into eight categories based on similarity of their own learning, along with clear organizational
meaning (see Table 3). Subsequently, categories were systems that provide resources, time, adequate staff-
grouped into two synthesized findings. Table 4 illus- ing and support, demonstrates encouragement for
trates the relationship between the underpinning find- and the value of nurses’ learning and education.
ings, contributing categories and final synthesized The first synthesized finding relates to the organ-
findings. izational factors that contribute to a workplace
culture, and thus influence nurses’ learning experi-
Meta-aggregation ences. Four categories generated by 58 findings
The process of meta-aggregation was used to contributed to this synthesized finding. Categories
explore and group findings embedded with nurses’ will be presented with a few key findings and their
experiences of learning in the workplace or related supporting illustrations below. All extracted findings
environment (see Figure 2). Real experiences and can be found in Appendix VI.
voices were essential to provide the necessary
evidence required to ‘‘inform decision-making’’ Category 1: Accountability/critical and reflective
and guide practice.1 Embedded in the findings thinking
was the notion that the nurses’ learning experience Nurses’ accountability is a journey; nurses are
was essential to professional and practice develop- accountable for their own learning and need to be
ment and that the workplace was important willing to take on learning opportunities. However,
to facilitate (or hinder) this.42,43,45,47,49,50,53 they also need to work in systems that support and
Chase47 succinctly expressed support for this when encourage their learning and education, as this in
she noted that professionalism and learning were turn develops critical and reflective thinking.
integrated in such a way that one could not be a It was apparent in this category that nurses
professional without making learning part of the accepted responsibility not only for their clinical
work role. practice but also for their learning and the import-
Through the process of meta-aggregation, it was ance and relevance of this to their patients and their
also noted that nurses learn through ‘‘doing’’43,45 practice development. Nurses valued and clearly
and their learning experience is often one of praxis.50 identified the importance of both mandatory
It is not surprising then that meta-aggregation, and non-mandatory learning but required the
a valuable process for synthesizing qualitative ‘‘streamlined’’ support of the organization to enable

Table 2: Final assessment table
Citation Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10
46
Swallow VM, Chalmers H, Miller J, Piercy C, Sen B 2001 N Y Y U Y N N Y U Y
51
McCormack B and Slater P 2006 U Y Y Y Y Y N Y Y Y
49
Leonard DJ 1994 Y Y Y Y Y Y Y Y N Y
50
Rossi LR 1995 Y Y Y Y Y Y Y Y Y Y
45
Jantzen D 2004 Y Y Y Y Y Y Y Y Y Y
52
Govranos M and Newton JM 2014 U Y Y Y Y Y N Y Y Y
5
Hallin K and Danielson E 2008 U Y Y Y Y N Y Y Y Y
44
Hughes E 2005 U Y Y Y Y N Y Y Y Y
43
Aleco VN 2009 Y Y Y U Y Y U Y Y U
54
Bahn D 2007 Y Y Y Y Y U Y Y Y Y
42
Beal JA, Riley JM, Lancaster DR 2008 U Y Y Y Y N Y Y Y Y
53
Bjørk IT, Tøien M, Sørensen AL 2013 U Y Y Y Y N N Y Y Y
47
Chase LG 1999 Y Y Y Y Y Y Y Y Y Y
48
Fox R, Henderson A, Malko-Nyhan K 2005 Y Y Y Y Y N Y Y Y Y
Table 3: Included articles and findings
Citation Unequivocal Credible (equivocal)

43
Aleco VN 2009 27 1
54
Bahn D 2007 3 0
42
Beal JA, Riley JM, Lancaster DR 2008 16 1
53
Bjørk IT, Tøien M, Sørensen AL 2013 3 2
48
Fox R, Henderson A, Malko-Nyhan K 2005 8 0
52
Govranos M and Newton JM 2014 5 3
5
Hallin K and Danielson E 2008 2 1
44
Hughes E 2005 6 3
49
Leonard DJ 1994 3 3
47
Chase LG 1999 0 2
45
Jantzen D 2004 3 1
50
Rossi LR 1995 4 2
51
McCormack B and Slater P 2006 3 0
46
Swallow VM, Chalmers H, Miller J, Piercy C, Sen B 2001 2 1
Findings 85U 20C
Total findings 105
C, credible; U, unequivocal.

Table 4: Relationship between underpinning findings, categories and synthesized statements

(individual study findings and supporting illustrations are listed in Appendix VI)
Synthesis name and

Total findings Title and category sentence
Findings – mixed U and C Accountability/critical and reflective thinking Organizational influences
Nurses’ accountability is a journey; nurses are Enabling nurses to
46U þ 12C accountable for their own learning and need to demonstrate accountabil-
be willing to take on learning opportunities; ity for their own learning,
58 mixed findings however, they also need to work in systems along with clear organiz-
that support and encourage their learning and ational systems that pro-
education, as this in turn develops reflective vide resources, time,
and critical thinking adequate staffing and
support, demonstrate
Managers/leadership/administration encouragement and value
A close link between education and manage- of nurses learning and
ment to enable the provision of resources, education
education, support and professional develop-
ment activities can result in a better working
environment and empower nurses
Resources: staffing/budget/work schedule/time

Material resources, time and/or financial sup-
port for learning in and out of the workplace
need to be provided to support nurses’ learning
Workplace environment/culture
The physical environment, work organization
and staff interactions support diverse opportu-
nities for nurses to learn in the workplace.
However, it is equally important to have
support and respect from the organization,
demonstrated through time in and out of the
workplace for thinking, growing, learning and
raising the level of professionalism

Table 4 (Continued)
Synthesis name and

Total findings Title and category sentence
Findings – mixed U and C Learning and education Relational dynamics
Integrating working with formal and informal Nurses value their peers,
39U þ 8C learning strategies, along with access to experts, expert nurses, preceptors,
educators and education support, facilitates mentors and educators
47 mixed findings learning and professional development to facilitate and encou-
rage their learning and
Mentors and preceptors professional development
Preceptors and mentors can recognize nurses’
capabilities and support learning in the work-
place
Patients’ stories
Retelling what has happened, conveying the
centrality of practice is valuable to nurses’
learning
Peers/colleagues/seniors/expert nurses
Nurses value and learn from colleagues’ clinical
experience, knowledge, support, role modeling
and enthusiasm
C, credible; U, unequivocal.
this learning and deliver best practice to from computers, policy manual, from textbooks;’’
their patients. Bob said: ‘‘we were flipping through the man-
Learning needs to be personally useful and ual. . .okay the manual is right here we can just read
applicable: from it when we need to. . .’’43(p.128)
‘‘One nurse stated that she personally ‘reflects’ on Learning from the experience of mistakes:45(p.96)
action however several of the nurses pointed out that ‘‘I probably did make mistakes. I get it, you know
learning and retention were aided by partnering I get that I didn’t do it right. As long as they aren’t
with others, by being mentored, and by ‘doing’ harmful, making mistakes.’’ . . .‘‘You don’t learn
either by themselves or with others in a group from the times when things go normally, but I
setting’’.47(p.25) learned from the times when things go bad.’’45(p.101)
It is a two-way street. Even when the environment Showing that she could handle things and do them
is supportive of nurses, they need to be willing to be by herself. The following narrative expresses her
supported: perspective:
‘‘The issue is not support. . . Support is here. It is a ‘‘. . .usually those were like bad experiences of
willingness to use the support to do something that feeling overwhelmed of having too much going on
you think will be useful.’’42(p.491) with my patients. Trying to manage all by myself
In this study, the participants often referred to because you want (sigh), you know, it’s this thing
using these guidelines as ‘‘looking up,’’ ‘‘sticking,’’ in nursing where you want to show that you can
or ‘‘abiding by’’ the policies and procedure manual handle a lot of things as a new grad and you know
in their practice. Diana said: sometimes (sigh) you wouldn’t want to ask for
‘‘I stick to the policies and procedures . . . I look up help, and you want to be able to do it yourself
procedures and policies and diagnosis on line;’’ so that you knew you could do it so that, that’s
Lillian said: ‘‘we know where to find the answers frustrating.’’ 43(p.120)

Practice issue: The influence of workplace Eight categories

culture on nurses’ learning experiences
Identification
1. Accountability/critical and reflective thinking

Nurses’ accountability is a journey; nurses are
accountable for their own learning and need to be
Search for appropriate research reports willing to take on learning opportunities, however, they
(refer to PRISMA flow diagram) also need to work in systems that support and
encourage their learning and education, as this in turn
develops reflective and critical thinking.
2. Managers/leadership/administration
Critical appraisal and selection of appropriate
A close link between education and management to
studies to include
enable the provision of resources, education, support
and professional development activities, can result in a
better working environment and empower nurses.
Finding
Study methodologies:
3. Resources: staffing/budget/work schedule/time
Phenomenological, grounded theory and Material resources, time and/or financial support for
critical Inquiry learning in and out of the workplace need to be
provided to support nurses’ learning.
4. Workplace environment/culture
Aggregate 105 unequivocal and credible The physical environment, work organization and staff
findings from 14 studies into 8 categories interactions support diverse opportunities for nurses to
learn in the workplace. However, it is equally important
to have support and respect from the organization,
Categorization
demonstrated through time in and out of the workplace

for thinking, growing, learning and raising the level of
Synthesize 8 categories into 2 synthesized professionalism.
findings
5. Learning and education
Integrating working with formal and informal learning
strategies, along with access to experts, educators and
Two synthesized findings education support, facilitates learning and professional
development.
Organizational influences
6. Mentors and preceptors
Enabling nurses to demonstrate accountability Preceptors and mentors can recognize nurses,
for their own learning, along with clear capabilities and support learning in the workplace.
organizational systems that provide
resources, time, adequate staffing and 7. Patients’ stories
support, demonstrates encouragement for
Synthesis
Retelling what has happened, conveying the centrality

the value of nurses’ learning and education. of practice is valuable to nurses’ learning.
Relational dynamics 8. Peers/colleagues/seniors/expert nurses
Nurses value and learn from colleagues’ clinical
Nurses value their peers, expert nurses, experience, knowledge, support, role modelling and
preceptors, mentors and educators facilitating enthusiasm.
and encouraging their learning and professional
development.
Recommendations for practice
1. Health care organizations, when allocating and managing budgets, resources, time and staffing, should
provide clear links between management and education practice that actively support and value nurses’
learning and enable nurses to demonstrate accountability for their learning. (Grade A)
2. Workplaces should implement policies, procedures and systems that value and support nurses in
accessing their peers, expert nurses,
Created by preceptors,
XMLmind mentors
XSL-FO and
. educators. (Grade A)
Converter
Figure 2: The process of meta-aggregation

Category 2: Managers/leadership/administration the ones down below aren’t going to get that sense of
A close link between education and management accomplishment.’’42(p.491)
to enable the provision of resources, education, Inhibiting factors around continuing nursing edu-
support and professional development activities cation (CNE) in the workplace:
can result in a better working environment and ‘‘Needs to be a closer link between management
empower nurses. and education. . .as change will not be possible if they
The findings underpinning this category were at are not linked. . ..education fails to capture the work-
times emotive and expressed the strength of feeling place context. . .I think that education works on the
participants had regarding the impact on their learn- premise that it can stop and educate but the work-
ing by managers, administrators and leaders as place, particularly a busy acute setting, doesn’t
‘‘resource controllers’’. This category was consistent stop. . .a lot of education could happen in the work-
with the aforementioned accountability category, as place as its happening’’.52(p.5)
it did not disregard the nurses’ role in pursuing their A lack of support in implementing change as well
own learning experiences, as evident in the as how managers’ leadership styles played a part in
first example. the ‘no-change’ culture of nursing:
The learning experience. Taking part on formal ‘‘If I had my manager’s support I’d feel much
study activities appeared to be problematic and it empowered, I’d feel a lot more positive and enthu-
seemed to stem from a lack of regular educational siastic. I’d feel a lot happier in general. . .the manage-
appraisals. ment on the unit where I work are very negative
‘‘We are supposed to have one (regular appraisal) towards nursing staff so I’ve had years of lack of
annually. . . I have been here for five years. . . We support, lack of progression’’.44(p.47)
should have them (regular appraisals) but it is vir- First-line managers:
tually impossible at the moment. . .’’ 54(p.728) ‘‘. . .the head nurses could be the greatest facili-
For others, the experience was different: tators of education because they need to support it
‘‘We usually see the manager yearly. . . if you have and allow them time. . . the greatest hindrance is the
an interest in certain courses you are encouraged to same thing, the lack of it’’.49(p.85)
do them. Study time is decided between you and your They spoke of the tangible value of an environ-
manager during your personal appraisal. . .but it ment that supports learning from mistakes, that is,
would have to come from me wanting to do the opportunity to change patterns of practice that
it.’’54(p.728) improve patient care and provide greater satisfaction
Frustration with their belief that they were not to the nurse in the delivery of care:
adequately supported for their level of practice ‘‘I had this plan. Okay this didn’t work out so
expertise: well, but maybe it didn’t work out well at [this]
‘‘I don’t think nurses get that kind of adminis- particular time I [know] I’m responsible for how it
trative support when they are at an advanced prac- turns out. But this great plan doesn’t work out the
tice level.’’42(p. 490) right way.’’ She continued her dialogue, describing a
Seamless support at every level. . .they over- process of reaching out to her nurse manager to
whelmingly felt that a nurse manager who ‘‘makes address the problem. ‘‘You knock on her door,
things happen’’ and supports nurses at all levels of [she says] oh come on in, have a seat and I say look
professional growth is critical: this didn’t quite work out. What did I do
‘‘I have had good nurse managers, but M brings wrong?’’.42(p.491)
out the best in people. She enables me to think
beyond what I think of myself.’’42(p.490) Category 3: Resources: staffing/budget/work
Support for the development of scholars and schedule/time
scholarly nursing practice is also needed from the Material resources, time and/or financial support for
nurse executive team: learning in and out of the workplace need to be
‘‘When you have the top ones focusing on better provided to support nurses’ learning.
development in nursing practice, that’s the trickle- This category was closely related to the above;
down effect. If you don’t have it from the top, then however, it clearly focused more on the resource

management role of the manager rather than the ‘‘We need more time off-line as there is simply not
‘‘resource control’’ and relational or broadly inter- enough time on a shift to do anything like look up
personal dynamics of the role. Resource manage- and learn about your patients. You have to do it
ment not only clearly influenced nurses’ learning when you go home.’’. . .However, a positive response
experiences but also permeated their entire work- towards attempting to address poor staffing levels
ing experience, the lack of time, resources and included: ‘‘Even though I have heard of staffing
‘‘busyness’’ could lead to a sense of disillusionment problems elsewhere, my ward bent over backwards
and powerlessness and this was consistently to make my transition easy. They made sure that I
reflected in the tone of the participants’ voices. always had less patients at the beginning and, if they
The opposite is also true, incidence of effective were of a higher dependency, I had a smaller
resource allocation facilitated nurses’ learning load.’’48(p.196)
experiences. In congruence with the previous Learning new ideas can ultimately lead to apathy
theme, these experiences were consistent from and disillusionment because of the climate of the
new graduates through to experienced and expert working environment. Reasons why nurses cannot
nurses. effect change were illustrated:
Even scholars need support. Resources such as ‘‘I think they’re [nurses] too busy. There’s no
time, flexibility, administrative support and encour- time. . .too many demands. . .they haven’t got the
agement to continue to grow as an experienced time to go and start a new idea with all the paper-
clinical scholar were consistently mentioned as lack- work. . .There’s not enough staff [or] time to do the
ing yet critical to scholarly nursing practice: basics, let alone try out new ideas. . .sometimes
‘‘I need help from the institution. . . time and there’s resistance from other members of the multi-
expertise. I want to publish but I don’t know disciplinary team. . .it fosters apathy and negativity
how.’’42(p.490) and that’s perpetuating.’’44(p.47)
Participants expressed feelings of dissatisfaction Increased workload and low staffing ratios:
with their employing organization’s lack of support ‘‘I just find the severity of the patients’ sickness is
to continue their post-registration education: getting worse so much and that makes the job
‘‘I found it quite hard because the trust did not heavier like people are not healthy, obesity is on
help in any way, either financially or by allowing the rise which puts more physical work on us. . . I
time for study days. I had to do it all in my own time find frustrating too is people’s expectations when
and so did others.’’54(p.728) they come to the hospital. . .some families or patients
Attitudes to learning. Staff shortages and time who expect to get one-on-one every minute of care
constraint factors were reported as affecting inter- . . . I am sorry I don’t have time to even do basic
viewees’ ability to attend study sessions, both man- ADLs. . . you didn’t get a four year degree to run for
datory and non-mandatory: the rest of your life, you leave work exhausted
‘‘It is all down to being able to spare the staff. . .if physically and mentally exhausted who would want
you need to do a day’s work. . .the work comes to do that for twenty years.’’43(p.132–133)
first.’’54(p.728)
An inherent gap between the expectation and the Category 4: Workplace environment/culture
reality of how a workplace values scholarly nursing The physical environment, work organization and
practice surfaced: staff interactions support a positive work environ-
‘‘On paper, [the administration] says, yes, we ment and enable diverse opportunities for nurses to
value you. But will that garner me any more resour- learn in the workplace. Equally, it is important to
ces? Probably no.’’42(p.490) have support and respect from the organization,
Of all the resources cited as essential, time was the demonstrated through time in and out of the work-
predominant theme: place for thinking, growing, learning and raising the
‘‘I am free to do it [solving a challenging clinical level of professionalism.
problem] on my own time. I’m just not suppor- Participants addressed the importance of working
ted.’’42(p.490) in a milieu that sets dual expectations for high stand-
The need for adequate staffing levels of appro- ards of patient care along with high expectations for
priate skill mix in the wards: professional development. One nurse noted that the

milieu of the workplace needs to shift to become a management were thought as important for their
place where: growth:
‘‘There’s room for thinking about problems in a ‘‘The unit is fairly supportive . . . I learnt to
different way, coming to different solutions that may prioritize (organize her work) from other senior
have better outcomes.’’42(p.489–490) nurses, from colleagues;’’ ‘‘I have support around
The duality of expectations for high patient care me, full support.’’ This person described full support
standards and professional development results in an as ‘‘be able to be working independently but still
environment that fosters enthusiasm and optimism have someone to bounce your ideas off and kind of
and has the important outcome of: be watching.’’43(p.117)
‘‘Raising the level of professionalism and refresh- On the other hand, lack of support in the work-
ing [nurses’] pride’’ . . . ‘‘It is a good place to work place had a negative impact on their learning:
because they [the hospital] foster independent think- As Janet said: ‘‘I found myself on a unit that was
ing and collaborative practice.’’42(p.490) full of turnover. . .and support wasn’t there and
An inherent problem in nursing is how you can everybody hated their job.’’43(p.118)
foster professional growth and take care of patients
at the same time: Synthesized finding 2: Relational dynamics
‘‘You have to have an environment that allows Nurses value their peers, expert nurses, preceptors,
nurses not to be at the bedside all the time, but mentors and educators facilitating and encouraging
[provides time] to be growing and learning. . .There their learning and professional development.
There are ways for the structure and management to The second synthesized finding relates to the
allow that [to happen].’’42(p.490) relationships and relational dynamics that contrib-
Openly valuing scholarly nursing practice: ute to a workplace culture, and thus influence nurses’
‘‘The culture of the hospital respects nursing. So learning experiences; there were a total of four
therefore, when you feel that [respect], you give your categories generated from 47 findings. Categories
best and the patient gets the best.’’42(p.490) will be presented with a few key findings and their
Handover in the morning and afternoon. The supporting illustrations below. All extracted findings
handover was a setting for multiple learning possi- can be found in Appendix IV.
bilities as well as an occasion for dispute:
‘‘It’s the important things we air and discuss, but I Category 5: Learning/education
know some think that this should be discussed some Integrating working with formal and informal learn-
other time. I think I can see a pattern – the nurses ing strategies, along with access to experts, educators
who work quickly themselves want the report to be and education support, facilitates learning and
short and to the point, and most of the students and professional development.
inexperienced nurses want to discuss just like I and Within an acute care organization, nurses learnt
many of the other seasoned nurses.’’53(p.432) equally in and out of the workplace, and both
Distribution of work around the whiteboard. experiences were valuable and supported by access
After handover, two or three of the nurses would to experts, educators and formal and informal learn-
start to match the nurses on duty to the different ing strategies. Interestingly, it would seem that novi-
patients. Inherent in such discussions was the judg- ces or less experienced nurses placed greater value on
ment of patient complexity versus nurse competence learning in the clinical workplace; their classroom
(or incompetence), who needed to learn what and experience had positioned them with an immediate
from whom, and how much was a reasonable need to apply their knowledge to practice and to
amount of work for each nurse: continue their learning through practice develop-
‘‘I have never thought about those situations as a ment. More experienced nurses, although they did
setting for learning, just as a way of organizing our not underestimate the value of clinical workplace
work.’’53(p.433) learning, were more able to independently contextu-
Learning in clinical settings was positively influ- alize their learning. Experienced nurses valued the
enced by a supportive learning environment. Sup- expert nurses and educators outside the workplace
port and respect from peers, senior nursing staff, (i.e. in the classroom setting) but still valued the
members of the multidisciplinary team and nursing patients’ place in their learning and the ability of the

educator or expert to present their learning through patients to expect, I am focusing more on my inter-
patient scenarios or case studies.49 actions with patients and how to interact with them
Education availability. In conjunction with sup- and I am learning also about what’s in the com-
port for nursing education by administration is edu- munity for long term care or assisted living I am
cation availability. Education availability was noted learning all those other things . . . I am relating more
in the number and variety of programs offered to to theory like I have more time for communication
staff on all three shifts. The hospital has a career with my patients now, and I try to remember all
progression program: those you know therapeutic communication listen-
‘‘To recognize excellence in all areas of nursing ing skills.’’43(p.131)
practice and to promote the advancement of pro-
fessional nursing.’’49(p.83) Category 6: Mentors/preceptors
The impact on professional development was Mentors and preceptors can recognize nurses’ capa-
important. Indeed, the practice-focused nature of bilities and support learning in the workplace.
the facilitated learning enabled nurses to recognize Mentors and preceptors were a valuable facilita-
and value their own ability to lead change: tor of nurses’ learning experiences, particularly
‘‘Something I wouldn’t have done without within the workplace. Nurses never seemed to ‘‘out-
Accredited work-based learning (AWBL) I wouldn’t grow’’ the need for this expert guidance or peer
have had the confidence to do it.’’46(p.821) coaching, and they expressed their experiences as
Learning under supervision. Learning during this positive throughout their career.42
period is described as inadequate and unsatisfactory. The participants strongly believed that mentors
This is expressed in the following narratives: continue to be essential at all levels of career develop-
‘‘The clinical educators are very important it’s ment, even for those at the pinnacle of their careers:
good to know that there is someone there that if you ‘‘You need mentors who can see what you bring
have a question and nobody else can help you or to the table that you may not necessarily see in
everybody is busy that you know you can go to. . . yourself. I know what is required to be a scholar
since I’ve been here it’s hard I haven’t really seen the and I love it. I am thankful to those around here who
clinical educator a whole lot so it’s hard to get expect the best from all of us.’’42(p.490)
certified at things if you have to seek them Allocation of a preceptor on a one-to-one basis:
first.’’43(p.113) ‘‘It is great when you are able to work with your
They learn better through doing, performing and preceptor because you have always got someone to
hands-on activities rather than watching someone bounce queries against. It also means that you can
else demonstrating the-how-to. Comments from discuss conflicting information. I had too many
participants were: experiences where I stuck to the procedure manual
‘‘I learn by doing so I think it’s important for me as we were told, but some staff do exactly the
to be doing things . . . rather than watching people do opposite and tell you to ignore the manual. My
them.’’43(p.118) preceptor was able to explain the differences and
Learning in clinical settings was appreciated. . . appropriate ways of modifying the manual.’’48(p.197)
because they found out that there are learning oppor- Buddy shifts and supervised learning in clinical
tunities, practically, everyday: settings are very essential during the initial period of
‘‘I learn by actually doing it, someone showed me their work, especially if the new graduates have not
how to do it the first time I’ll remember it but I had previous work experience in clinical settings:
actually have to be able to do it continuously I need ‘‘. . .because I haven’t had experience in health-
to be shown how to do it then I am okay.’’43(p.122) care before so I was completely green behind the ears
Commitment to the profession. . . becoming when it comes to just being in hospital . . . it’s been a
informed practitioners, and recognizing the need year and not just myself but there are other girls . . . I
for life-long learning: haven’t touched heparin and had no idea I didn’t
‘‘. . . I am still learning everyday but I am not prime a line you know what I mean like I just didn’t
learning tasks any more . . . so what I am learning know. I didn’t know it’s very stressful and I think
now is um all those other things outside of the task that it’s very important that a buddy system or
like discharge planning, you know, what to tell having a good clinical educator on the floor.’’43(p.128)

Category 7: Patients/stories Frustration with the lack of motivation in some of

Retelling what has happened, conveying the central- their colleagues, which some nurses viewed as gen-
ity of practice is valuable to nurses’ learning. erational differences:
Nurses were clear that patients and their stories ‘‘Some are not interested in advancing. Some not
had a central role in both their teaching and learning interested in learning new things.’’42(p.491)
experiences. Moreover, these stories were used to The importance of a positive attitude of clinical
exemplify nurses’ clinical decision-making and staff and nursing management:
reflection in action. That is, the patient stories were ‘‘Our area has a good social network [among the
integrated into the teaching/learning experience and staff] and this has made it a good environment to
were used as tools to facilitate learning ‘‘reflection’’ work in—better than where some others are work-
and ‘‘decision-making.’’ ing. I have been fortunate.’’48(p.195)
Working together with the patients: Participants saw senior staff as a valuable and
‘‘I think they need me. I have expertise and one of accessible resource:
my important contributions is to take the young ones ‘‘In a good way everybody has a role in educa-
with me and teach them. I like the difficult cases tion.’’52(p.4)
where there is a lot to do. I use them explicitly to Many nurses were being drawn into a cycle of
show how I reflect and decide on actions.’’53(p. 434) frustration when learning new things:
Learning from stories. Jill and Ann both describe ‘‘I feel quite excited about bringing it [new ideas]
how they have used stories to learn from and to teach to the workplace. . . that can quickly turn to frus-
others. When giving an orientation, rather than tration when it is not met with the same enthusiasm
listing complications, Jill said: by your work colleagues.’’44(p.46)
‘‘You give concrete examples. . .those case Learning from the experience of others. Nurses
scenarios always seem to hit home for nurses. . .even learn from working alongside more experienced or
even if it is just in a conversation. ‘This is what ‘‘differently experienced’’ colleagues:
happened here.’ I think there are a lot of valuable (Jill’s workplace)
things that we learn from what’s happened.’’45(p.104) ‘‘Well, it has a lot of people that work there who
have many years of experience to be learning from.
Category 8: Peers/colleagues/seniors/expert The nurses have been in [that specialty area] for a
nurses long time. . ..that makes it a learning environ-
Nurses value and learn from colleagues’ clinical ment.’’45(p.102)
experience, knowledge, support, role modeling Learning the job through role modeling from
and enthusiasm. peers:
The value and power of words cannot be under- ‘‘I looked up to her because she was so knowledge-
estimated and contributed to a positive workplace able and I respected and admired the way she took
environment. Experts, peers and others’ experience care of people. . .she was a great role model.’’50(p.150)
were all valuable and relevant to nurses’ learning
experiences; conversely, if these were absent, they
were also seen as inhibitors to learning. If a resource- Discussion
ful person could not be contacted when needed – this The objective of this review was to synthesize the
was considered not only a barrier to learning but also best available evidence on the influence of workplace
to safe patient care, and left the nurse disempowered culture on nurses’ learning experiences. The quality,
and anxious. value and type of learning the nurse experienced
Support from peers was also considered essential. within the workplace environment was not explicit,
Enthusiasm and encouragement were noted to be rather it was embedded in the facilitators and bar-
important: riers of learning that relate to the workplace culture.
‘‘Working with positive people who are upbeat Factors within the workplace or organizational
and not with somebody who is going to be negative culture that influenced nurses’ learning included
or lazy. If they are not enthusiastic then you feel that leadership, managers and management systems
you can’t get enthused around them because they and practices, access to accountability and support
will think that you are crazy.’’42(p.491) for education and professional development and

access to and support from mentors, preceptors, nurses, Fox48 noted that learning in the workplace
peers, colleagues and expert nurses. Importantly, was also crucial for the new nurse or nurse ‘‘in
these factors were consistently presented as either transition" to a workplace. Fox48 initially defined
facilitators or barriers to nurses’ learning experi- ‘‘in transition" as a ‘‘period of time when a new staff
ences. Therefore, factors occurring within the work- member undergoes a process of learning and adjust-
place or organizational culture were static and ment in order to acquire the skills, knowledge and
consistent, but their power to influence nurses’ learn- values required to become an effective member of the
ing was either a facilitator or a barrier. This was health care team’’.p.193 Fox then built a picture of the
applicable both within the clinical workplace, and nurse in transition as a learner and therefore schol-
more broadly throughout the organization. arly, and requiring a practice environment that bal-
For the purpose of this review, workplace culture anced caregiving with professional development.
referred to the collective structures, systems and Further, Fox48 also noted that culture can influence
resultant behaviors evident in a work environ- the transition and therefore learning experience of
ment.21 The influence of workplace culture extended the new nurse.
beyond the ‘‘clinical environment’’, recognizing that Workplace culture can influence learning – both
the complexities within an organization and the informal (in the workplace) and formal (outside the
resultant climate also impact on nurses’ learning workplace). Bjørk53 identified that the leader is
experiences. crucial in determining a culture that will support
Consequently, nurses’ learning experiences were nurses’ learning. Bjørk53 also noted that the physical
explored that related not only to the local workplace layout of the ward, how nurses navigate and use this
environment but were also inclusive of learning and how the leader role models within it can all
experiences more generally within the organization, support or hinder nurses’ learning. Therefore, it can
such as staff development and continuing education be seen that the physical structure also contributes to
departments, or work-related professional learning workplace culture. Bjørk53 reinforced the notion
experiences. The defining factor was that the learn- that the leader’s role is to develop a culture of mutual
ing experience was related to professional and work- support and learning as well as to provide the struc-
place development, in or out of the clinical tural support for knowledge sharing.
environment.
A healthy workplace culture was one that Organizational influences
embraced scholarly nursing practice and balanced Enabling nurses to demonstrate accountability for
caregiving with professional development.42 Schol- their own learning, along with clear organizational
arly nursing practice refers to nursing practice in systems that provide resources, time, adequate staff-
which the nurse is learning as part of the practice ing and support, demonstrates encouragement for
process. In reference to this, Beal calls for ‘‘new and the value of nurse’ learning and education (syn-
clinical practice models that incorporate key thesized finding 1).
environmental factors and address inherent tensions The categories that were synthesized to develop
between time devoted to patient care delivery and the first synthesized statement point to the organiz-
advancing professional development’’.42(p.492) ational influences within a workplace that facilitate
Building on this, it seems evident that patient care or inhibit nurses’ learning experiences, either directly
delivery and professional development are both val- within the clinical environment or tangentially
uable parts of nursing practice and both are influ- through their access to work or professionally
enced by the context of workplace culture. However, related learning experiences. These categories –
this raises the question of the role of professional now referred to as factors – included nurses’
development and clinical learning and whether these accountability and capability to think and act crit-
are separate processes from nursing practice. Indeed, ically and reflectively, the leadership administration
it is proposed that they are not separate, but differ- and management who control distribution of the
ent, complex, yet all necessary and integrated com- organizational resources, the allocation of and
ponents of professional nursing practice. actual organizational resources, that is, budget,
Although Beal’s42 findings are difficult to gener- work schedule and time available, and lastly, the
alize as they refer to a highly educated group of workplace culture or environment itself – both

physical, organizational and as a series of personal vulnerable to follow a destructive path of disillusion-
relationships or interactions. ment, if their learning was not supported.
Nurses, as registered practitioners, are account- The findings underpinning the two categories
able both morally and legally to their patients and Management, leadership and administration and
the community; they have a ‘‘duty of care’’ Resources: staffing/budget/work schedule/time were
embedded and accepted in their very practice.15 at times emotive and expressed the strength of feel-
However, nurses practice within a workplace, and ing participants had regarding the impact on their
in relation to learning, the workplace culture needs learning by managers, administrators and leaders as
to support their accountability; nurses neither by ‘‘resource allocators’’. It was at this organizational
their very nature practice in isolation nor can they level that nurses felt they were particularly facilitated
isolate practice from learning. Through this review, or inhibited with their learning experiences. Signifi-
it is asserted that the notion of ‘‘accountability’’ is cantly, it was not only learning in the clinical
recognized internationally16,17 in the literature as a environment that was impacted but also perform-
concept embedded in nursing practice, but more- ance appraisal and professional development oppor-
over, as relevant to learning. Furthermore, the Aus- tunities away from the clinical environment. It is also
tralian national competency standards for the of note that these experiences were consistent from
registered nurse15 include the notion of accountabil- new graduates through to experienced and expert
ity in all domains of nursing practice, although most nurses.42,43,47,53
explicitly in the ‘‘professional practice’’ and ‘‘critical Overall, the literature was imbibed with an
thinking and analysis’’ domains of practice. experience at all levels of nurses experiencing a lack
Therefore, a dual system is called for that enables of support from management and leadership. How-
nurses to demonstrate accountability for their own ever, the converse cannot be underestimated as Beal
learning through workplace and organizational ena- reports in relation to learning and practice that ‘‘a
blers. Burke notes, ‘‘one understudied work environ- nurse manager who respects, values and supports the
ment variable is accountability, defined as the degree work of clinical nurses decreases stress and positively
to which the organization, culture, and/or manage- affects satisfaction and retention.’’42(p.488)
ment expects learners to use trained knowledge and The Registered Nurses’ Association of Ontario,
skills on the job and holds them responsible for doing Healthy work environments Best Practice Guide-
so’’.55(p.282) Clearly, Burke frames accountability lines16 note that ‘‘healthy work environments for
within the work culture context and identifies the nurses are defined as practice settings that maximize
necessity for this in enabling ‘‘worker’’ accountabil- the health and well-being of the nurse, quality
ity; however, ‘‘worker accountability’’ is contingent patient/client outcomes, organizational performance
upon organization culture, management and train- and societal outcomes’’.16(p.14) The workplace is
ing.55 further noted to be an important learning environ-
A key facilitator or barrier to nurses’ learning was ment. Billet notes:
the support provided by way of resource control and ‘‘The way workplaces afford opportunities for
administration; this related to the links between key learning and how individuals elect to engage in
leadership, management and education roles. If a activities and with the support and guidance pro-
lack of support was experienced, this became tan- vided by the workplace, is central to understanding
gible within the organization, it permeated through workplaces as learning environments.’’56(p.209)
to create a ‘‘no-change’’ culture.44 This was a Billet notes Lave’s assertion that ‘‘there is no
dangerous culture, as even if nurses did learn, learn- separation between participation in work and lear-
ing could not be transferred to or embedded within ning’’.56(p.210) If there can be no separation in learn-
the organization; nurses could not apply their learning, this presents the notion that learning can be
ing in the form of practice change or development. either facilitated or hindered by work, but cannot be
This is supported by Burke55 who noted in consider- separated from it, and the suggestion of a workplace
able detail the work environment influences that environment that supports learning is critical.
were required to enable the support and transfer Beal42 presented the idea that professional growth
of learning into the workplace. Hughes44 further at work is ‘‘an inherent problem’’ and questioned
supports this by noting that nurses would be how you can consciously construct a healthy culture

with the right leadership, skill mix and professional to frustration if staff could not ‘‘access’’ educators
development support, while maintaining the level of and have their skills certified.43
work performance required in acute environments.42 The impact of significant staff on nurses’ learning
Aleco43 noted that learning in the clinical setting was was such that it enabled them to recognize and value
positively influenced by a supportive learning their own ability to lead change.43 This was quite a
environment, and Bjørk53 went on to enumerate different outcome from Hughes’44 narration of dis-
the physical opportunities for learning in the ward illusionment when learning was unable to be trans-
environment, whereas Leonard49 identified the value ferred to practice.
of workplace-related learning such as that which Acquiring professional nursing competence is a
takes place in a staff development or continuing lifelong experience and continuing education oppor-
education department. tunities are important components in the nurses’
It cannot be overstated that the value of nurses ability to perform a satisfactory job. Hence, a great
learning is not only in the individual experience but deal depends on demands and opportunities avail-
also in the application of that learning to the practice able in the workplace.5 Additionally, the ability to
situation. Those situations and consequences in think critically and reflectively are skills that are
organizations that either inhibit or facilitate the acquired through a learning process and once again
application of what has been learned in training are embedded in the Australian national competency
back on the job – referred to in the literature as standards for the registered nurse15 and therefore
‘‘transfer climate’’57 – have been shown to influence required in nurses’ ‘‘everyday’’ practice. Govranos
transfer outcomes directly. In the context of acute notes that ‘‘nurses are required to be flexible, critical
healthcare organizations, transfer outcomes can be thinkers, striving to deliver safe and effective patient
considered to influence nursing practice outcomes.55 care’’.52(p.1) Therefore, fostering lifelong learning
and educational opportunities within practice is
Relational dynamics important. Facilitating this learning requires gaining
Nurses value their peers, expert nurses, preceptors, nurses’ acceptance and integration of education into
mentors and educators facilitating and encouraging their everyday practice and the ward team.52
their learning and professional development (syn- To contextualize the importance of workplace
thesized finding 2). learning, its relationship to practice development
The categories that were integrated to develop the and its relevance to the increasing complexity of
second synthesized statement related to the inter- care required, Bahn asserts that ‘‘in practical terms,
personal relationships and factors that facilitate or if practicing nurses stopped learning they would not
inhibit nurses’ learning experiences, either directly be able to keep up with changes: they would not be
within the clinical workplace or tangentially able to adapt to new demands from the public they
through their access to work or professionally serve and the world in which to live and work would
related learning experiences. These factors included become an alien, disturbing environment’’.54(p.724)
access to and interaction with educators, peers, Enthusiasm and encouragement from peers was
colleagues, expert nurses, preceptors, mentors and noted to be important. The value and power of
patients as a series of personal relationships words cannot be overemphasized in contributing
or interactions. to nurses’ learning experiences and a positive work-
When provided with learning experiences and place culture.42,48 Nurses’ learning experiences were
supported by staff within the workplace, learning enabled by supportive relationships both within the
was a positive experience of growth and change.43 workplace and the organization. Through interact-
Learning in the clinical setting was valued and ing with and observing peers and more experienced
appreciated; nurses stated that they could find and nurses, the significance of both the value of the
value learning opportunities practically every day.43 learning and its application to practice were highly
However, if leadership, management or peer support regarded. Burke supports this by noting that ‘‘per-
were not provided, these opportunities risked being haps the most consistent factor explaining the
overlooked. Similarly, clinical educators were valued relationship between the work environment and
for the support they provided to nurses’ learning transfer is the support trainees receive to use their
experiences. However, this could rapidly deteriorate new skills and knowledge’’.55(p.281) Burke goes on to

state that research on the role of supervisors and patient outcomes.8–14 Furthermore, the linking of
peers was separate from ‘‘transfer climate’’ because nurses’ learning experiences to culture and patient
each ‘‘variable was found to contribute a unique outcomes could be a hallmark for future education,
influence on training transfer across several stud- management and practice strategy.
ies’’.55(p.281) It can now be stated with assurance that a healthy
Nursing peers and experts alike were valuable in workplace culture is a prerequisite for nurses to
supporting nurses’ learning and the converse experience valuable and relevant learning in the
was also true. If a resourceful person was not avail- workplace.2–7,42,47,49,59 To emphasize the import-
able when required, it was a barrier to learning ance of nurses’ learning in the workplace, it has been
and left the nurse feeling disempowered and asserted that working and learning cannot be sep-
anxious.43,45,50,52 The value of peer support within arated – that one is contingent upon the other.56 If
the workplace becomes critical when Billett’s23(p.462) working and learning are contingent, then the nurs-
assertion is noted: ing profession must take special heed of Billett’s
‘‘Individuals who are only able to access routine declaration regarding the workplace environment:
work activities and/or are denied support when faced ‘‘The invitational qualities of the workplace will
with unfamiliar tasks will likely have more limited shape the potential of both the learning through
learning outcomes than those able to participate in everyday activities and those intended to be provided
new activities supported closely by experienced co- through intentional guided practices such as guided
workers.’’23(p.462) learning strategies. These reciprocal qualities
The patients were a central part in nurses’ learn- emphasize the need to see learning perhaps more
ing.45,50,53 The experienced nurses would con- broadly as an ongoing process of engagement in
sciously organize the less experienced nurses, take conscious thought.’’23(p.478)
them to the bedside, review a patient’s story and
support the nurses in learning from this.53 They Implications for practice
listened to their stories, made their assessment and This review proposes that a healthy workplace
provided care. In fact, one nurse stated that it was culture is a prerequisite for nurses to experience
difficult to progress unless you had provided the valuable and relevant learning in the workplace.
patient with the opportunity to tell their story.50 It To emphasize the importance of nurses’ learning
seemed that there was a therapeutic aspect to the in the workplace, it has been asserted that work-
patient telling their story. It is suggested that the ing and learning is an integrated experience for
telling of the story was no ordinary process of recall; nurses, and that a dual system that enables nurses
perhaps the healing was partly contingent on the to demonstrate accountability for their own learn-
telling? As Hawkins and Lindsay observe regarding ing, along with clear organizational systems that
patients’ stories: ‘‘They provide us with new and provide resources, time, adequate staffing, peer and
important information, and encourage holism education support, is required to facilitate the
and a move to a more therapeutic approach to encouragement and value of nurses’ learning and
care.’’58(p.S14) education.
Conclusion Recommendations for practice

The 14 articles included in this review have eluci- The following recommendations are made for the
dated our understanding of nurses’ learning experi- clinical practice workplace:
ences and how forces within the workplace culture (1) Healthcare organizations, when allocating and
influence these. The 105 illustrated findings have managing budgets, resources, time and staffing,
provided a rich source of evidence for understanding should provide clear links between manage-
both facilitators and barriers to nurses’ workplace ment and education practice that actively sup-
learning. port and value nurses’ learning and enable
Importantly, the learning that takes place within nurses to demonstrate accountability for their
the workplace and is influenced by the workplace learning (grade A).
culture, is also relevant to the implementation of (2) Workplaces should implement policies, pro-
evidence-based practice and the achievement of safe cedures and systems that value and support

nurses in accessing their peers, expert nurses, 8. Jeffs L, Beswick S, Lo J, Campbell H, Ferris E, Sidani S.
preceptors, mentors and educators (grade A). Defining what evidence is, linking it to patient outcomes,
and making it relevant to practice: insight from clinical
Implications for research nurses. Appl Nurs Res 2013;26(3):105–9.
9. Fitzsimons E, Cooper J. Embedding a culture of evidence-
It has been noted that workplaces that actively
based practice. Nurs Manag 2012;19(7):14–9.
facilitate the application of nurses’ learning back
10. Ulrich B, Kear T. Patient safety and patient safety culture:
into the workplace provide an effective ‘‘transfer foundations of excellent health care delivery. Nephrol Nurs
climate’’ and can contribute to practice develop- J 2014;41(5):447–57.
ment. Therefore, further qualitative and comprehen- 11. Shekelle PG, Wachter RM, Pronovost PJ, Schoelles K, McDo-
sive research is required to elucidate extrinsic factors nald KM, Dy SM, et al. Making health care safer II: an
impacting on learning transfer within the workplace, updated critical analysis of the evidence for patient safety
as well as intrinsic factors related to learning within practices. Evid Rep Technol Assess (Full Rep) (211):2013:1–
the nurse. Regarding the latter point, research needs 945.
to focus on the detail of the nurse’s personality and 12. Page AE. Keeping patients safe: transforming the work
inner experience. environment of nurses Washington DC, USA: The National
Press Acadamies; 2004.
Organizations that enable nurses to work and
13. Dückers M, Faber M, Cruijsberg J, Grol R, Schoonhoven L,
learn as an integrated experience and hold nurses
Wensing M. Safety and risk management interventions in
accountable for learning can assist the application of hospitals: a systematic review of the literature. Med Care Res
nurses’ learning into clinical practice. Future Rev 2009;66(6 Suppl):90S–119S.
research then should focus on the concepts related 14. Al-Ateeq EA. The relationship between registered nurses’
to the learning transfer climate such as strategic perceptions of their work environment and their percep-
links, supervisory support and nurses’ accountability tions of patient safety culture. Fairfax, VA: George Mason
and learning. University; 2008.
15. Nursing and Midwifery Board of Australia. National com-
petency standards for the registered nurse. Melbourne,
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Appendix I: Detailed search strategy

PubMed logic grid
PubMed: 1þ2 þ3 þ 4 advanced search ¼ 2265 results
Workplace Qualitative
Nursing Learning culture research
nursing[mh:noexp] learning[mh:noexp] Service culture[tw] OR Qualitative research[mh] OR
OR nursing[mh] OR OR learning[tw] workplace culture[tw] qualitative research[tw] OR
nursing[tw] OR nur- OR nurse educa- OR work place[tw] OR experience[tw] OR lived
ses[mh] OR nur- tion[tiab] OR edu- culture[tw] OR work cul- experience[tw] OR
ses[tw] OR cation[mh] inservice ture[tw] OR organiz- perception[tw] OR
nurse[tw] OR clini- training[mh] OR ational culture[mh] OR perceived[tw] OR understan-
cian[mh] OR clini- inservice trai- organizational culture[tw] ding[tw] OR ethnography[tw]
cian [tw] OR health ning[tw] OR staff OR organizational cul- OR phenomenology[tw] OR
[mh] OR health development[tw] ture[tw] OR corporate feminist research[tw] OR
[tw] OR special- OR continuing edu- culture[tw] OR ethos [tw] critical research[tw] OR action
ties[tw] OR special- cation [tw] OR pro- OR service environ- research[tw] OR systematic
ties[tw] OR nursing fessional development[tw] OR service review[tw] OR
staff[mh] ment[tw] OR post- environment[tw] OR phenomenolog[tw]
graduate lear- organization environ-
ning[tw] ment[tw] OR organiz-
ation environment[mh]
OR work environ-
ment[tw] OR corporate
environment[tw] OR
organization climate[tw]
OR organization clima-
te[tw] OR corporate cli-
mate OR support[tw]

CINAHL final search terms, 2 October 2013: 11,535 results
nursing OR nurses AND; learning OR AND;‘‘Service culture’’ AND; ‘‘Qualitative stu-

OR nurse OR clini- education OR ‘‘staff OR ‘‘workplace culture’’ dies’’ OR ‘‘qualitative
cian OR health development’’ OR OR ‘‘work place’’ OR research’’ OR experi-
‘‘continuing edu- culture OR ‘‘work cul- ence OR ‘‘lived experi-
cation’’ OR ‘‘pro- ture’’ OR ‘‘corporate ence’’ OR perception
fessional develop- culture’’ OR ethos OR OR perceived OR
ment’’ OR ‘‘post- ‘‘service environment’’ understanding OR eth-
graduate learning’’ OR ‘‘organization nography OR phenom-
environment’’ OR enology OR ‘‘feminist
‘‘organization environ- research’’ OR ‘‘critical
ment’’ OR ‘‘work research’’ OR ‘‘action
environment’’ OR ‘‘cor- research’’ OR ‘‘systema-
porate environment’’ tic review’’ OR
OR ‘‘organization cli- ‘‘grounded theory’’
mate’’ OR
‘‘organization climate’’
OR ‘‘corporate climate’’
OR support OR ‘‘organ-
izational culture’’ OR
‘‘organizational culture’’
OR ‘‘organization cul-
ture’’ OR
‘‘organization culture’’
OR ‘‘corporate culture’’
SCOPUS final search terms, 13 October: 1990 results
(nurs) AND; learn OR AND; workplace cul- AND; (qualitative OR

educat OR train ture‘‘ OR research OR study)
OR ‘‘staff develop- ’’organization environ-
ment’’ OR ‘‘pro- ment‘‘ OR ’’work
fessional develop- environment‘‘ OR
ment’’) ’’organizational culture"
OR ethos)

Embase final search terms, 13 October 2013: 1566 results
(nursing/exp OR nur- AND; (learning/exp AND; (culture/exp OR AND; (’qualitative

sing OR nurses/exp OR learning OR culture OR ’organiz- research’/exp OR ’quali-
OR nurses OR nurse/ ’nurse education’/exp ational culture’/exp OR tative research’ OR
exp OR nurse OR OR ’nurse education’ ’organizational culture’ experience/exp OR
health/exp OR health OR education OR OR ’work environment’/ experience OR ’lived
OR ’nursing staff’/ ’inservice training’/ exp OR ’work environ- experience’/exp OR
exp OR ’nursing exp OR ’inservice ment’ OR ’organization ’lived experience’ OR
staff’) training’ OR ’in-ser- climate’/exp OR ’organ- perception/exp OR per-
vice training’/exp OR ization climate’ OR ception OR understand-
’in-service training’ ’organization climate’/ ing/exp OR
OR ’staff develop- exp OR ’organization understanding OR eth-
ment’/exp OR ’staff climate’) nography/exp OR eth-
development’ OR nography OR
’continuing edu- phenomenology/exp OR
cation’/exp OR ’con- phenomenology OR
tinuing education’ ‘action research’/exp OR
OR ’professional ’action research’ OR
development’/exp OR ’systematic review’/exp
’professional develop- OR ’systematic review’)
ment’)

ERIC final search terms, 11 November 2013: 289 results
nursing[mh:noexp] AND; learning[mh:- AND; Service cul- AND; Qualitative

OR nursing[mh] OR noexp] OR lear- ture[tw] OR workplace research[mh] OR quali-
nursing[tw] OR nur- ning[tw] OR nurse culture[tw] OR work tative research[tw] OR
ses[mh] OR nur- education[tiab] OR place[tw] OR cul- experience[tw] OR lived
ses[tw] OR nurse[tw] education[mh] inser- ture[tw] OR work cul- experience[tw] OR per-
OR clinician[mh] OR vice training[mh] OR ture[tw] OR ception[tw] OR percei-
clinician [tw] OR inservice training[tw] organizational cul- ved[tw] OR
health [mh] OR OR staff develop- ture[mh] OR organiz- understanding[tw] OR
health [tw] OR spe- ment[tw] OR conti- ational culture[tw] OR ethnography[tw] OR
cialties[tw] OR spe- nuing education [tw] organizational cul- phenomenology[tw] OR
cialties[tw] OR OR professional ture[tw] OR corporate feminist research[tw]
nursing staff[mh] development[tw] OR culture[tw] OR ethos OR critical research[tw]
post-graduate lear- [tw] OR service environ- OR action research[tw]
ning[tw] ment[tw] OR service OR systematic
environment[tw] OR review[tw] OR phenom-
organization environ- enolog[tw]
ment[tw] OR organiz-
ation environment[mh]
OR work environ-
ment[tw] OR corporate
environment[tw] OR
organization climate[tw]
OR organization clima-
te[tw] OR corporate cli-
mate OR support[tw]
ProQuest final search terms, 30 November 2013: 3338 results
AB,TI(nursing or AND; AB,TI(learning AND; AB,TI (service or AND; AB,TI (qualitative

nurses or nurse) or ‘‘nurse edu- workplace or work or or research or experi-
cation’’ or education organization or ence or ‘‘lived experi-
or ‘‘inservice train- organization or corpor- ence’’ or perception or
ing’’ or ‘‘staff devel- ate or service and perceived or understand-
opment’’ or environment or climate ing or ethnography or
‘‘continuing edu- or culture) phenomenology or fem-
cation’’ or ‘‘pro- inist research or critical
fessional develop- research or action
ment’’ or ‘‘post- research or ‘‘systematic
graduate learning’’) review’’)

Appendix II: QARI appraisal instrument

Appendix III: QARI data extraction instrument


Appendix IV: Included studies and extraction data

Phenomena of
Methods (qualitative interest (P1–3, as Authors (Article): Con-
data collections tech- described in find- clusions (C) Recommen- Reviewer’s notes and
Study Methodology niques) Participants ings) dations (R) Result (RS) conclusions
Aleco VN. Theory Classical grounded Data were collected 14 RNs Nurses’ learning Aleco made numerous Nurses learning in the
becoming alive: the theory method: this using informal inter- experiences in recommendations, below clinical environment –
learning experiences proposed study used views, observations and clinical settings are selected significant workplace – focus on
of newly graduated grounded theory field notes. recommendations: neophyte nurse in their
nurses. Dissertation: method to study Theoretical sampling Recommendations for first 3 years of practice.
[University of Cal- nurses’ learning was used to achieve Nursing Services .that This article explored the
gary (Canada)]; experiences during maximum representation nursing administrators in influence of factors
2009 the first 3 years within the sample. the healthcare services (including workplace
after graduation. Data were analyzed address the salient issues culture) affecting nurses’
The time frame of 3 using constant compara- related to the orientation learning experiences –
years after gradu- tive analysis, which and socialization of predominantly as they
ation is appropriate resulted in the gener- newly graduated nurses relate to their first 3
as it will allow the ation of a core variable in clinical settings.(p.199) years in the clinical prac-
new graduates to ‘‘theory becoming alive’’ tice environment – (i.e.
have had a sus- and four supporting Supportive Clinical how the culture supports
tained period of categories and their cor- Environment It is there- learning)
clinical experiences, responding sub- fore very essential that
allowing sufficient categories managers in clinical set-
time for reflection tings create an environ-
and contemplations ment that is conducive
of their experiences to teaching and learning
and to encourage new
Aim: The purpose nurses to feel safe in
of this research was asking questions. A cli-
to explicate nurses’ mate of openness,
learning experiences respect, acceptance, and
in clinical settings. . . support is essential for
and articulate how learning in clinical set-
learning from tings (Merchant,
experiences contrib- 1989).(p.201)
uted to the develop-
ment of the nurses’ Professional development
professional experti- Structuring and conduct-
se(p.6) ing professional develop-
ment programs are
essential for the progress
of healthcare organiz-
ations and the pro-
motion of quality patient
care.(p.201)
Preparation of First-Line
ManagersA written pro-
tocol of how nurses
become eligible to pro-
gress into their develop-
mental levels, regardless
of time, might be valued
as good practice.(p.203)

(Continued)
Phenomena of
Bahn D. Orientation Phenomenological: Semi-structured and one- Enrolled (division 2) P1 Reasons and C1 ‘‘Management has a Nurses’ learning 1. In
of nurses towards exploratory study to-one personal inter- and RNs who have motives for nurses responsibility to encou- the workplace 2.
formal and informal views or are currently tak- taking part in var- rage staff participation Released for professional
learning: motives Aim: to gain infor- ing part in CE, n ¼ ious categories of but equally, it is the development (PD) or
and perceptions. mation on the cur- Tape recording and tran- 162 learning nurses’ responsibility to higher education (HE).
Nurse Education rent orientation of scribing with coding and Total participant take a proactive role in This article explored the
Today. 2007 Oct; enrolled (division1) participant permission EN and RN num- P2 Factors that the formulation of the influence of factors
27 (7):723-30 and registered bers n ¼162: influence nurses’ organization’s training/ (including workplace
nurses towards con- EN (division 2) n learning activities learning program.’’(p.729) culture) affecting nurses’
tinuing education & ¼42 and the views and learning experiences –
lifelong lear- RN n ¼ 58 þ 15 þ perceptions of their C2 ‘‘Effective resource predominantly as they
ning(p.723) 28 ¼ 101 learning experiences management is needed relate to HE and conti-
Withdrawals n ¼ to encourage and nuing education (CE) –
19(p.726) promote all levels of (i.e. how the culture sup-
professional develop- ports learning, but not in
ment, which can only be the workplace
achieved if managers are
aware of what resources Some of the conclusions
are available for edu- were critical of lower
cational purposes and level nurses and their
how to access accessing formal learning
them.’’(p.729) experiences, that is, their
lack of proactively seek-
C3 ‘‘Nurses need to ing appropriate PD. It
reflect critically on the would have been useful
reasons why they some- to compare the numbers
times have no say in of nurses who experi-
what professional devel- enced this with those
opment is available to who did not
them.’’(p. 729)
Certainly, the data
C4 ‘‘Outlining selection regarding organizational
procedures and a clear culture, policies, pro-
rational for the allo- cedures and individual
cation of contestable manager roles and beha-
funding must be in place viors influenced nurses’
to ensure fairness and learning experiences
equity.’’(p.729)
C5 ‘‘. . .regular pro-

fessional development
appraisals’’(p.729)
R1 ‘‘Further research on
the possible attendance
or non-attendance by
staff to health and safety
training and specialist
mandatory input and its
effect on client care
could help enhance the
nurses’ sense of responsi-
bility and accountability
for keeping up to date
with developments in
that area.’’(p.729)

(Continued)
Phenomena of
Beal JA, Riley JM, Phenomenological: Semi-structured inter- Participants: 36 P3 Work environ- Rs1 The major study This article focused on
Lancaster DR. descriptive qualita- views were conducted at female RNs with a ment elements that finding is that the highly educated nurses.
Essential elements of tive design the workplaces of 36 mean age of 47 develop and sustain optimal practice environ- The ‘‘scholar’’ in nursing
an optimal clinical experienced clinical years and with a scholarly nursing ment embraces scholarly practice includes the
practice environ- Aim: to describe nurses mean of 24 years of practice nursing practice and bal- belief that the nurse is
ment. J Nurs Adm. essential elements experience ances care giving with an ‘‘active learner.’’
2008 Nov; 38 for an optimal Data were collected professional develop- Therefore, learning
(11):488 93 clinical practice using an open-ended ment.(p.488) experience is essential
environment interview guide that had and the workplace is
wherein scholarly been validated C1 ‘‘. . .the findings pro- important to facilitate
nursing practice vide new insights into (or hinder) this
flourishes(p.488) A subset of data from a unique key elements
larger qualitative study essential for the develop- An optimal practice
was analyzed using con- ment of scholarly environment (i.e. work-
tent analysis nursing practice in place) is one that
hospital environ- embraces (promotes and
Content analysis was ments.’’(p.488 and 492) supports) scholarly nur-
conducted using the sing practice and a place
NVivo (QSR Inter- R1 Future research that balances caregiving
national Pty Ltd., Cam- focusing on different with professional devel-
bridge, MA, USA) professional practice opment(p. 489)
software program models that support
scholarly nursing prac-
tice is warranted.(p.492)
Bjørk IT, Tøien M, Phenomenological: The study triangulated 17 full-time pos- P1 Opportunities C1 ‘‘This study again The workplace culture
Sørensen AL. Field study: A field three methods of data itions for nurses. Of for informal learn- underscores the import- can influence learning –
Exploring informal study was con- collection: participant the nurses, eight ing ance of the leader’s role both informal (in the
learning among hos- ducted in Norway observation, ad hoc con- had worked in the in promoting informal workplace) and formal
pital nurses. Journal with data from a versations and formal ward for less than 2 P2 Nurses in a hos- learning through build- (outside the workplace).
of Workplace Learn- clinical setting col- interviews years and four pital ward ing a culture that facili- The leader is crucial in
ing. 2013; 25 lected in 2007– nurses had between tates and supports determining a culture
(7):426-440 2008.(p.428) Analysis was an iterative 15 and 20 years of learning for all nurses on that will support nurses’
process (Srivastava and experience. Two of the ward.’’(p.437) learning. The physical
Aim: to explore the Hopwood, 2009), start- the nurses were layout of the ward, how
opportunities for ing during the first males R1 ‘‘. . .the important nurses navigate and use
informal learning observational session, effect of physical struc- this and how the leader
among nurses work- continuing during writ- tures on learning oppor- role models within it can
ing on a hospital ing up of the field notes tunities have not all support or hinder
ward.(p.426) and also when reading attracted much attention nurses’ learning. The
detailed notes before the in nursing, and this physical structure is also
next observational ses- should now be an arena part of a workplace cul-
sion.(p.430) for further ture. This article
research.’’(p.437) reinforced the notion
that the leader’s role is
R2 There is a need for to develop a culture of
intervention studies that mutual support and
support nursing leaders learning as well as to
in facilitating informal provide the structural
learning among support for knowledge
staff.(p.437) sharing (from Bjørk)

(Continued)
Phenomena of
Chase LG. What Critical inquiry: Questionnaire Focus 279 surveys distrib- P1 The meaning of The author identified Chases’ thesis focused on
makes learning action research groups Individual inter- uted, 51 returned learning multiple recommen- mid-career nurses, so
meaningful for mid- views, taped & tran- dations from her thesis, this data set was compli-
career nurses? Mas- scribed Data Focus group – four P2 For mid-career including the following mentary to other articles
ter’s Thesis: [Royal triangulation(p.429–430) or eight partici- nurses two key recommen- focusing on new nurses
Roads University pants; report dations: or advanced practice or
(Canada)]; 1999 The overall analysis of unclear expert nurses; it contrib-
the data and the specific 1. Provide a venue where uted to a rounded pic-
data analysis of the data Three individuals’ nurses who have partici- ture of nurses’
collect and sorted within interviews pated in ongoing learn- experiences of learning
each data-gathering ing or education in their and in particular what
methods allowed for tri- area do expertise can they require to enhance
angulation that is, identi- share their knowledge. this. Chase found that
fying and corroborating The emphasis would be nurses need to be
similar patterns across to make time to prepare respected and acknowl-
the three data sour- an education session and edged for their learning,
ces.(p.22) to reward them for their and importantly, sup-
expertise and time. Sup- ported and facilitated in
port from the nurse this by managers and
manager and director of leaders. Once again,
acute services is critical these nurses describe
themselves as ongoing
2. Broadcast and learners and provide
acknowledge those support for the notion
nurses who have com- that nurses are accounta-
pleted or are in the pro- ble and reflective, but
cess of completing any require organizational
and all education support to achieve this
courses. This emphasizes
that nurses’ ongoing
learning is important
and honored. Mid-career
nurses describe them-
selves as ongoing lear-
ners with personal and
career needs that are
both work related and
life related
3. Other general con-

clusions from the thesis
included the following:
The organizations’ lea-

ders both managers and
directors need to encou-
rage and support the
development of relation-
ships within nursing
The organizations’ lea-

ders need to reward
learning about practice
When nurses examine

and reflect on personal
practice and collaborate
with others, they are
able to identify existing
theory and personal
theory from current
practice
Providing a supportive
peer environment to
encourage discussion and
dialogue is

(Continued)
Phenomena of
Fox R, Henderson Phenomenological: Focus groups 16 RNs in phase I P1 Nurses new to R1 ‘‘Rather than promis- This article focused on
A, Malko-Nyhan K. longitudinal descrip- and 12 RNs in the organization ing the offer of assist- newer nurses. This
‘They survive tive study Data collection was car- phase II perceptions ance, which is not article initially defines
despite the organiz- ried out over two separ- always forthcoming, dis- ‘‘transition’’ as a term
ational culture, not ate, but related, phases: Total n ¼ 28 P2 Elements imple- cussion is probably bet- generally used to define
because of it’: a Phase I (2–3 months mented by the ter focused around a ‘‘period of time when
longitudinal study of after the commencement organization to ‘difficult’ situations that a new staff member
new staff percep- date of employment) and assist new nurses’ new staff might encoun- undergoes a process of
tions of what consti- Phase II (6–9 months integration ter and strategies to deal learning and adjustment
tutes support during after the commencement with them when in order to acquire the
the transition to an date of employ- resources are often lack- skills, knowledge and
acute tertiary facil- ment).(p.194) ing.’’(p.198) values required to
ity. International become and effective
Journal of Nursing RNs employed Decem- C1‘‘. . . the provision of member of the health –
Practice.2005; 11 ber 2001 to April 2002 adequate guidance and care team.’’
(5):193-199 recruited during Nursing assistance through bud-
Orientation dying with a preceptor Therefore, this and other
and allocating time with articles build the picture
Data were analyzed the- the preceptor.’’(p.198) of the nurses as learner
matically by listening to and linked to being
tapes and reading tran- C2 ‘‘Provision of edu- scholarly as well as one
scripts to identify the- cation assistance and in transition and needing
mes(p.195) being ‘welcomed’ to learn. Culture can
through support and influence a transition
friendly interac- and the role of the scho-
tions.’’(p.198) larly nurse
C3 ‘‘. . . over time, new

staff had a capacity to
shift their focus from the
organization providing
these needs to a more
self-reliant mode. In the
self-reliant mode, new
staff members learnt
about the organization
and fulfilled their needs
through ‘getting to know
the system’ and aligning
themselves with the
‘good’ people.’’(p.198)
C4 ‘‘In light of these

findings, it might be
more astute for the
organization during the
orientation phase to give
a more realistic appraisal
of the situations that
new staff might encoun-
ter.’’(p.198–199)

(Continued)
Phenomena of
Govranos M, New- Phenomenological: a Four focus groups (total Permanent nursing P1 Clinical ward- R1 ‘‘Further work is This article explored the
ton JM. Exploring case study approach n ¼ 23). Groups created staff (n ¼ 50) based nurses’ values required to explore role of the CNE in facil-
ward nurses’ percep- using convenience employed on a and perceptions nurses’ perceptions of itating nurses’ pro-
tions of continuing Aim: To explore sampling. Followed by medical–surgical continuing education fessional development.
education in clinical clinical ward-based six individual interviews ward; division 1 P2 Factors that across a range of clinical CE was seen by the
settings. Nurse Edu- nurses values and (Staff were selected for RNs and division 2 impact on continu- areas; or whether man- majority of participants
cation Today. 2014; perceptions towards interview according to ENs ing education in the datory CPD has an influ- as a necessary element of
http://dx.doi.org/ continuing edu- their grade or level of ward encing effect on their nursing practice, yet
10.1016/ cation and what fac- experience – 1 each values.’’(p.5) some nurses appeared
j.nedt.2013.07.003 tors impact on from the six levels in the ‘‘apathetic’’ to it and a
continuing edu- table on p 3). Iterative R2 ‘‘Reducing the com- values clarification exer-
cation in the data analysis throughout partmentalisation of edu- cise supported this,
ward(p.25) data collection(p.2) cation and work by exposing nurses’ values
nurses requires atten- to learning. Time con-
(p.5)
tion.’’ straints and the everyday
occurrences on a shift
R3 ‘‘Exploration of were significant impacts
values and perceptions on nurses’ learning.
of the CNE and CE and However, learning
organizational strategic opportunities could still
goals may assist in find- be created within that
ing a common everyday environment by
vision.’’(p.5) correct skill mix and
allocation of seniors to
R4 ‘‘CNE’s need to support, work with and
explore with ward teach less experienced
nurses their values and staff. The role of the
beliefs so that barriers to CNE was meaningful
CE can be addressed, to and requires further clar-
promote collaboration in ification and study. For
creating a learning cul- nurses to maintain pro-
ture.’’(p.5) fessional development,
they need CE to be inte-
C1 ‘‘The values clarifica- grated into the work-
tion exercise challenged place
many nurses to uncover
their beliefs within their
practice setting, and how
CE is integrated into
their workplace cul-
ture.’’(p.5)
Hallin K, Danielson Phenomenological: Semi-structured inter- Fifteen RNs: 13 P1 RNs’ perceptions C1 ‘‘The increasing com- The phenomenon of
E. Registered qualitative report view women and two of their work and plexity of health care interest in this article
Nurses’ perceptions men(p.63) professional devel- requires extremely was RNs’ perceptions of
of their work and Aim: The aim of the Interpretive content opment skilled RNs and co-oper- their work and pro-
professional devel- study was to eluci- analysis ation between employers fessional development.
opment. Journal of date RNs’ percep- and educators.’’(p.69) The article focused on
Advanced Nur- tions of their work RNs’ 6 years postgra-
sing.2008; 61 and professional C2 ‘‘New nursing pro- duation and again con-
(1):62-70 development 6 years grams need to match the tributed to a rounded
after gradua- growing demands and data set. This article
tion.(p.62) work environments, and further complimented
workplaces need to offer Govranos, but noted
professional development that workplace edu-
and create Magnet-type cation needs to match
working environ- the growing demands of
(p.69)
ments.’’ work environments and
workplaces need to offer
C3 ‘‘The unique contri- professional development
bution of nurses to and create magnet-type
patient care needs to be working environments.
recognized if nurses are Hallin also called for
to be encouraged to nurses’ achievements to
‘grow old’ in the profes- be recognized
(p.69)
sion.’’
R1 ‘‘More research is
also needed into how to
provide opportunities for
RNs to continue to
develop professionally
whilst fulfilling their
usual work
demands.’’(p.69)

(Continued)
Phenomena of
Hughes E. Nurses’ Phenomenological Sequential triangulation 200 equally divided P1 NHS and private C1 ‘‘Nurses perceive The aim of Hughes’
perceptions of conti- private nursing sector nurses’ per- professional development article was to ‘‘investi-
nuing professional Aim: To investigate ‘‘Questionnaires (Self- home nurses and ceptions of the value in a positive manner gate NHS and private
development. Nur- NHS & private sec- administered question- public NHS nurses of continuing pro- irrespective of their sector nurses’ percep-
sing Standard. 2005; tor nurses’ percep- naire) and then inter- (i.e. 100 each) fessional develop- clinical environment in tions of the value of con-
19 (43):41-9 tions of the value of views to follow up ment the main.’’(p.49) tinuing professional
continuing pro- interesting lines of Eight nurses for development (CPD), and
fessional develop- inquiry raised in the interview: four from P2 Factors that C2 ‘‘. . .the impact of to analyze the factors
ment (and to response to the ques- private four from influence these per- CPD in the nursing pro- that influence these per-
analyze the factors tions.’’ public ceptions fession is dimin- ceptions and any poten-
that influence these ished. . ..’’(p.49) tial barriers to successful
perceptions and any Eight nurses for follow- P3 Potential barriers CPD.’’ On the whole,
potential barriers to up interviews to successful CPD C3 ‘‘The absence of Hughes found minimal
CPD).(p.41) reflection from the learn- discrepancy in the two
200 questionnaires admi- ing process is evident is groups in terms of both
Purpose of this was nistered (private ¼ pub- some cases and this groups valuing pro-
to sample the differ- lic nurses). Random reduces the impact on fessional development,
ent populations to sampling to 13 nursing practice that educational irrespective of work
determine if the homes and two NHS intervention can environment. However,
challenges in meet- teaching hospitals have.’’(p.49) only data related to
ing the post-regis- acute environments were
tration education C4 ‘‘Reduced inability to extracted – for the pur-
and practice (PREP) alter working practices is pose of this review in
standard (CPD) evident in nursing, not accordance with the
were similar in both only caused by col- inclusion criteria.
settings leagues, but by the lea- Hughes notes the
dership styles of absence of reflection in
managers.’’(p.49) the learning process and
the impact this has on
C5 ‘‘A lack of support practice. A reduced
has culminated in the inability to alter working
frustration and disempo- practices was evident in
werment of nurses who nursing and was related
are unable to improve to peers, managers and
their practices because of leaders
staffing, time and finan-
cial constraints.’’(p.49)
C6 ‘‘It is important that

the nursing profession
adopts a problem solving
approach to the chal-
lenges surrounding pro-
fessional development so
it can offer the modern
service the government
has visualised.’’(p.49)
R1 Leadership courses
should be made available
to all nurses to support
and encourage each ot-
her through the change
process.(p.49)

(Continued)
Phenomena of
Jantzen D. Learning Phenomenological: Eight participants told 8 self-selected first- P1 Positive learning ‘‘Multiple recommen-
stories: A study of Narrative inquiry their story using the fol- line female nur- experiences of first- dations were made by
positive learning (‘‘Learning Stor- lowing methods: ses(p.1) line nurses Jantzen, key of these
experiences to create ies’’)(p.65) (Interpreti- include the following:
positive change. ve)(p.66) Providing detailed notes P2 Inform clinical An examination of the
Master’s Thesis:[- of their story education within characteristics of a learn-
Royal Roads Univer- Aim: to answer the Vancouver Island ing environment, a sup-
sity (Canada)]; 2004 question, ‘‘How can Health Authority portive practice
positive learning environment and the role
experiences of first- of helpers (Daloz, 1986)
line nurses inform could provide important
clinical education insight.’’(p.150–151) ‘‘In
within Vancouver contrast to creating
Island Health simulated scenarios,
Authority?’’(p.1) nurse educators could
facilitate learning out of
the past experiences of
the staff. There are
financial benefits to
using incidental work-
place learning over in-
services and paid edu-
cational days.’’(p.151)
‘‘The findings of this
research project highlight
the influence of organiz-
ational culture on
nurses’ learning. Recom-
mendations related to
the role of leadership,
specifically adminis-
tration, follow: Leader-
ship, such as unit
managers, could create a
workplace culture that
values and practices
shared responsibility for
learning through experi-
ence. A greater appreci-
ation for practical
wisdom in nursing prac-
tice could be nurtured.
VIFIA, and other watch-
ful organizations, should
move to implement
recommendations to
increase support for
first-line nurses, based
on the work of Cooke
(2000, 2001), Ledgister
(2003a; 2003b), Daly
(2001a, 2001b) and
Marsick and Watkins
(2001). A much larger
and more ambitious
level, VIHA and other
healthcare organizations
need to create what I
have identified as
redemptive workplaces.

(Continued)
Phenomena of
The current organiz- The purpose of Jantzen’s

ational culture does not article was to explore
appear to support learn- the positive learning
ing from mistakes, errors experiences of nurses
and misjudgements. and use these to inform
Recent research and the clinical education in a
findings of this project Vancouver Health
suggest that learning Region. Janzen found
from negative experi- through narrative
ences is possible, and inquiry that a supportive
critically important. environment and the role
of helpers were contribu-
‘‘A thorough examin- tors to nurses’ positive
ation of the role of cul- learning experiences.
ture in health care Janzen outlined the
settings on nursing prac- implications of her
tice and professional research for organiz-
development in nursing ations, leaders and
is an area for further clinical educators
study.’’(p.152)
Email recount Nurse leadership and
nurse educators could
gain skill in facilitating
learning through experi-
ence by practice.(p.153)
Reflective journal ‘‘. . .learning from the
expert or experienced in
The written recounts first-line nursing must be
were followed by supported in the next
detailed semi-structured five to ten years. With
interviews two decades of adult
learning theory con-
Method of analysis: firmed in this study of
category analysis first-line nurses, signifi-
cant effort needs to be
made to re-frame organ-
izational and societal
understanding of pro-
fessional development in
nursing.’’(p.154)
Leonard DJ. Factors Phenomenological: a The methods of data col- 14 participants were P1 Nurses’ percep- All below-(p.85) This study focused on
perceived to facili- case study approach lection were interviews, interviewed tions factors that facilitate or
tate and impede critical incidents, obser- impede nurses’ learning
learning in the vations and document experiences more
workplace. J Nurs reviews broadly across an organ-
Staff Dev. March- ization – in particular, a
April 1994; 10 staff development
(2):81-6 department. Leonard
identified specific facili-
tators and barriers to
learning in the work-
place and found it was
important to understand
factors in the workplace
that provide information
on the learning needs of
staff as these can inform
learning program devel-
opment and assist educa-
tors in developing
strategies to overcome
these barriers

(Continued)
Phenomena of
Aim: to determine Data from a total of 14 The vice president P2 Factors that C1, (1–7) ‘‘Factors per-
factors that facilitate interviews were collected for nursing, director facilitate and ceived as facilitating
and impede learning and analyzed. Personal of the staff develop- impede learning learning in the work-
in a hospital nursing data inventories were ment department place setting are (1) sup-
staff development also completed by inter- and four instructors port for education by
department viewees were interviewed. In nursing administration,
addition, two RN (2) availability of edu-
The analytic categories volunteers from four cation, (3) the inviting
for organization and educational pro- atmosphere of the staff
administration and programs were inter- development department,
gram development devel- viewed (4) small size, (5) infor-
oped by Irish (1983) mal learning, (6) the
were used expert instructor, and (7)
support by first line
managers.’’
C2, (1–3) ‘‘Factors per-

ceived to impede learn-
ing are (1) written tests,
(2) the nursing shortage
and (3) the first-line
managers’’
R1 Provide test options

– ‘‘test and exams
tended to create stress
and anxiety in adult
learners in this work-
place setting. . .’’
R2 ‘‘Partnership in
reaching continuing edu-
cation goals.’’ It is
recommended the at the
staff nurse work in part-
nership with the head
nurse to pursue career
objectives while meeting
organizational goals.’’
McCormack B, Sla- Phenomenological: A realistic evaluation Three focus groups, P1 CEFs C1 ‘‘Whilst the roles The aim of McCor-
ter P. An evaluation realistic evaluation methodology was total participants n have had an important mack’s study was to
of the role of the adopted derived from ¼ 24 P2 Impact on function in the active identify whether CEFs
clinical education Aim: to identify the work of Pawson and nurses’ learning coordination of learning made a difference to the
facilitator. Journal whether clinical Tilley (1998).(p.137) senior nurse man- experiences activities in the hospital, learning experiences of
of Clinical Nur- education facilita- agers (equivalent to there is little evidence of nurses in a large teach-
sing.2006; 15:135- tors made a differ- On-the-spot inter- grade I on the UK P3 Large teaching the role directly impacting hospital. McCor-
144 ence to the learning views(p.137) nursing clinical hospital ing on the learning cul- mack concluded that the
experiences of grading structure) ture of clinical CEF role mainly related
nurses in a large One-to-one interviews and consolidation settings.’’(p.143) to education coordina-
teaching hospi- and focus groups(p.138) nurses (new Regis- tion, and although this
tal.’’(p.135) tered Nurses).(p.138) C2 ‘‘The outcomes from was important, it also
Survey(p.138) this evaluation can be limited the impact of the
‘‘On-the-spot inter- subjected to further test- role on nurses’ learning.
views.’’ Up to five ing through ongoing In particular, the role
nurses on each evaluation of the out- had not impacted on the
ward/department comes arising from the ‘‘learning culture’’ of the
were interviewed by learning mechanisms in organization
the researcher (from place.’’(p.143)
50% random
sample of all wards
and departments
with a CEF)
Survey: the total

sample size was 342
nurses

(Continued)
Phenomena of
Data analysis [All RNs between

the grades of ‘‘D’’
Descriptive statistics (junior nurses) and
(mean scores of each ‘‘I’’ (senior nurse
construct) and inferential managers) were
statistics (analysis of var- identified as the tar-
iance and post hoc tests) get population for
across the demographic receipt of the NWI-
data R questionnaire.
From this popu-
Interview data were lation, a stratified
transcribed in full and sample of 20% was
the NUDIST (Non sought]
numerical Unstructured
Data Indexing Searching
and Theorizing) 5.0 soft-
ware package for quali-
tative research (QSR
International Pty Ltd.,
Melbourne, Australia)
was used to manage the
transcribed data and its
analysis
Rossi LR. How Phenomenological: Critical incident ques- 23 advanced prac- P1 Informal learning C1 Informal learning Rossi’s article focused
nurses gain clinical constructivist para- tionnaire, interview and tice nurses strategies was essential to gaining on how nurses gain
expertise through digm and case study organizational documen- clinical expertise clinical expertise through
informal learning in approach tation review P2 How nurses gain informal learning. In
the workplace. Dis- clinical expertise C2A Most informal particular, Rossi focused
sertation [Ann Aim: to examine learning resulting in on the type of informal
Arbor]: Columbia how nurses working P3 Workplace gaining clinical expertise learning nurses experi-
University Teachers in a hospital setting environment focused on the acqui- ence and the processes
College; 1995 gained clinical sition of the job skills or strategies through
expertise through themselves and occurred which they developed
informal learning mainly through the indi- their clinical expertise,
vidual learning mode that is, ‘‘the conditions,
interactions and other
C2B The group and factors which facilitates
institutional learning or impedes such learn-
modes were reported to ing.’’ Rossi’s article elu-
be of far less importance cidated that informal
in acquiring job skills, learning – within the
that is, in acquiring workplace – was critical
increasing levels of to nurses gaining clinical
clinical expertise expertise. Less important
was learning about the
C3 Learning about the organization and self.
organization and learn- Interestingly, the role of
ing about the self-influ- self and peers was
enced clinical learning, important when learning
but were not reported as as a novice, and as
essential to the acqui- expertise was gained,
sition of clinical skills learning through obser-
vation of more expert
C4 The gap between for- nurses. Interestingly,
mal and informal learn- supervisors were more
ing is increasing rarely sources of learn-
exponentially owing to ing
the explosion in medical
technology
C5 Several factors were

found to facilitate infor-
mal learning for nurses,
whereas other factors
acted to impede such
learning
R1 -6(p.257–259)

(Continued)
Phenomena of
Swallow VM, Chal- Grounded theory Focus groups and semi- 21 experienced acci- P1 Nurses’ views C1 ‘‘AWBL was seen as This article focused on
mers H, Miller J, principles: Qualita- structured interviews dent and emergency a facilitated process AWBL – this is a curri-
Piercy C, Sen B. tive design,(p.820) nurses (group 1 P2 Strengths and which recognized inter- culum model that takes
Accredited work- ‘‘Data were gathered AWBL course)(p.820) limitations of professional expertise a flexible approach to
based learning Aim: To determine and analyzed using the AWBL and the knowledge aris- learning and incorpor-
(AWBL) for new practitioners’ views principles of grounded nurses undertaking ing from practice, ates professional devel-
nursing roles: on the strengths and theory.’’(p.820) the BA (Hons) in enabled the development opmental and workplace
nurses’ experiences limitations of Nursing Practice. of individual practice learning into an edu-
of two pilot AWBL. (accredited participant Numbers and influenced service cation program; for the
schemes. Journal of work-based lear- not reported (group delivery through reflec- purpose of this study, it
Clinical Nur- ning).(p.820) 2 AWBL tion and theoretical inte- focused on postgraduate
sing.2001; 10:820- course)(p.820) gration.’’(p.821) workplace learning. This
821 study particularly
16 E-H grade nurses C2 ‘‘The synergy focused on nurses’ views
and five senior nur- between clinical and aca- on the strengths and
sing/medical staff demic development led limitations of AWBL
involved in develop- to rapid learning which and explored their
ing AWBL curricu- was relevant to practice, experiences in relation to
lum(p.820) responsive to service this. Nurses articulated
needs and rigorous the issues that were
enough to meet quality important to them ‘‘in
standards. Initial scepti- relation to practice and
cism about the flexible academic development.’’
nature of AWBL was AWBL was seen as a
overridden by increased facilitated process that
self- confidence arising enabled learning in the
from personal and peer workplace and ulti-
recognition of the mately practice develop-
benefits to patient ser- ment. Further, it
vices which came from influenced the delivery
AWBL. Further AWBL of patient care through
developments, now support of the reflective
underway in nursing as process and ‘‘theoretical
well as other disciplines, integration’’
are being informed by
the findings reported
here.’’(p.821)

18. Davidson JM. The effect of organizational culture on the ego

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Orientation: the partici- ‘‘I really, really enjoyed the (AMNSP). It Unequivocal
pants’ perspectives on the answered questions, that to be honest. . . I think
formal orientation pro- new grad nurses are embarrassed to ask like
gram is described as help- what does a low haemoglobin mean what is a
ful, reinforcing high white cell count. . . we talk about electro-
lytes and things you’re embarrassed as a new
grad to say I don’t know what that means
because you’re afraid it’ll impact how they see
(nurses) practice."(p.110 –111)
The orientation program ‘‘. . .orientation is so much information all at Unequivocal
included too much infor- once I almost think we need to follow up on
mation all at once and orientation like a month later because then it
they suggested a follow- makes more sense when you’ve"(p.111)
up on the orientation
course, Calypso said:
Most of their learning ‘‘. . .the orientation was kind of an overview Unequivocal
happened while working but really looking back I didn’t learn a whole
on the unit lot from that I wish I did, I wish I had the time
to really study that and get to know that, but
the majority of my learning has been like on
the unit working on the unit.’’(p.112)
Learning under supervi- ‘‘the clinical educators are very important it’s Unequivocal
sion: learning during this good to know that there is someone there that
period is described as if you have a question and nobody else can
inadequate and unsatis- help you or everybody is busy that you know
factory. This is expressed you can go to. . . since I’ve been here it’s hard I
in the following narra- haven’t really seen the clinical educator a whole
tives lot so it’s hard to get certified at things if you
have to seek them first."(p.113)
Discovering: clinical prac- ‘‘I didn’t know what to expect. . .in school I Unequivocal
tice fell short of their always had someone follow me and had some-
expectations one to ask;’’ ‘‘not everything that’s in the
textbook is always what’s happening with the
patient’’; ‘‘I read it in textbooks but to see it
happen I need someone to bounce these ideas
off’’; ‘‘I find it easier to learn certain pro-
cedures because it’s easier to relate them to the
patient.’’(p.116)

(Continued)

They need at least 1 year ‘‘Probably close to a year I started to kind of Unequivocal
before they become com- feel comfortable but I still don’t feel totally
fortable working in comfortable like I know I feel comfortable with
clinical settings a lot of skills there’s a few that still I am
not.’’(p.117)
Learning in clinical set- . . .‘‘the unit is fairly supportive . . . I learnt to Unequivocal
tings was positively influ- prioritize (organize her work) from other senior
enced by a supportive nurses, from colleagues." ‘‘I have support
learning environment around me, full support.’’ This person
described full support as ‘‘be able to be work-
ing independently but still have someone to
bounce your ideas off and kind of be watch-
ing.’’(p.117)
On the other hand, lack ‘‘I found myself on a unit that was full of Unequivocal
of support in the work- turnover. . .and support wasn’t there and every-
place had a negative body hated their job.’’(p.118)
impact on their learning
They learn better through ‘‘I learn by doing so I think it’s important for Unequivocal
doing, performing and me to be doing things . . . rather than watching
hands-on activities rather people do them’’;(p.118)
than watching someone
else demonstrating the-
how-to
Immersing: a discrepancy ‘‘My first job was challenging I was the only Credible
between their expec- RN on the unit with LPNs so right away you’re
tations and the expec- the charge nurse from the get go, so I think
tations of the people when you’re a new nurse you don’t really know
[nursing service adminis- what you don’t know . . .when I look at my
trators and mangers (sic)] practice in XXX I think how scary and risky
in the clinical practice that practice really was the biggest thing is that
I didn’t know what I didn’t know.’’(p.159)
Nursing and learning: ‘‘Its kind of scary because it’s much more acute Unequivocal
initial learning experi- from what I have seen before um and I mean
ences as stressful, uncom- too it’s more scary because you don’t have that
fortable, frustrating, not person that you can continuously go to like to
knowing what to expect, draw ideas . . .its more independent thinking . . .
challenging as well as it’s more thinking on your own and think on
experiencing feelings of your feet.’’(p.119)
nervousness

(Continued)

Showing that she could ‘‘. . .usually those were like bad experiences of Unequivocal
handle things and do feeling overwhelmed of having too much going
them by herself on with my patients. Trying to manage all by
myself because you want (sigh), you know, it’s
this thing in nursing where you want to show
that you can handle a lot of things as a new
grad and you know sometimes (sigh) you
wouldn’t want to ask for help, and you want
to be able to do it yourself so that you knew
you could do it so that, that’s frustra-
ting.’’(p.120)
No resourceful person ‘‘I remember I needed to give vitamin K one Unequivocal
that she could contact time and they said through your mouth and we
when she needed help didn’t have (oral) medication. Vials said IM or
with decisions related to IV and nobody else knew what to do and there
clinical situations was no way I could find this information on
the internet . . . the pharmacy was closed and it
was kind of oh! Where am I supposed to get
my information from . . .?’’(p.120)
Nurses want to protect ‘‘what do you mean you don’t know how to do Unequivocal
themselves from being this kind of thing, giving vitamin K, PO . . . I
belittled or humiliated if didn’t feel comfortable using IM or IV vial. . . I
they revealed their lack of just need to protect myself and know that I
knowing was doing right’’(p.121)
Astonishment and frustra- ‘‘it was challenging because I was the one RN Unequivocal
tion when they found out on the unit with LPNs, so right away I was a
that they are assuming a charge nurse from the get go . . . so I think
leadership role from the when you’re a new nurse you don’t really know
very beginning with no what you don’t know . . . so when I went there
preparation for the nur- I was really excited to work and very quickly
sing role learn that a lot of the responsibility was going
to be on me and my decision making so that’s
where I first worked and I call it the school of
hard knocks, because I really didn’t have much
in terms of support. It’s not a big teaching
hospital and not a lot of people to [consult] so
that was my first experience.’’(p.121)

(Continued)

Their learning experiences ‘‘I think we could never have enough I think a Unequivocal
as immersing themselves lot of learning always is going to happen when
and learning on their you finish school even in fourth year when you
own, learning by doing do your practicum. You think you’re practicing
and observing, asking very independently it’s not till you’re actually
questions and doing much working that you realize your mentor or your
by practicing on their RN really does push you and help support you
own and take on a lot of the workload and decision
making . . . so you think you’re doing a lot on
your own but you’re not.’’(p.122)
Learning in clinical set- ‘‘I learn by actually doing it, someone showed Unequivocal
tings was appreciated. . . me how to do it the first time I’ll remember it
because they found out but I actually have to be able to do it
that there are learning continuously I need to be shown how to do it
opportunities, practically, then I am okay.’’(p.122)
every day
Making sense of theoreti- ‘‘I think any experience you have hands on Unequivocal
cal learning: learning with something it becomes more real in your
experiences in real set- mind and you understand it better versus you
tings as different, mean- know having pathophysiology of it explained
ingful, and therefore ‘‘it to you . . . but once you see it and see how the
sticks to the head,’’ disease process kind of affect the other systems
whereas learning in the and how, how it manifests and you know why
classroom and in the nur- you should be ambulating someone with pneu-
sing lab is hard to retain monia . . . it all makes more sense . . . it does
than if it is just kind of this abstract con-
cept. . .for me that’s the way I learn, anyway, is
hands on and seeing it and then I actually will
know it and retain it versus abstract concepts
. . .’’(p.125)
Fitting into the environ- . . . there are so many different areas of people Unequivocal
ment and communicating involved in the care for that one patient so
with the healthcare team when you start on the unit not only you have
members in the real to contend with learning all these skills that
clinical settings is you’re supposed to do you also have to learn
described as demanding you almost have to survive in this environment
you just don’t feel comfortable at first. . . you
have to like fit into this environment and you
have to find your role in it. . .1 think that is
challenging for me it was pretty challenging
. . .(p.126)

(Continued)

The participants often ‘‘I stick to the policies and procedures . . . I Unequivocal
referred to using these look up procedures and policies and diagnosis
guidelines as ‘‘looking on line’’; Lillian said: ‘‘we know where to find
up,’’ ‘‘sticking’’ or ‘‘abid- the answers from computers, policy manual,
ing by’’ the policies and from textbooks’’; Bob said: ‘‘we were flipping
procedure manual in their through the manual. . .okay the manual is right
practice here we can just read from it when we need
to’’(p.128)
Buddy shifts and super- ‘‘. . .because I haven’t had experience in health- Unequivocal
vised learning in clinical care before so I was completely green behind
settings is very essential the ears when it comes to just being in hospital
during the initial period . . .it’s been a year and not just myself but there
of their work. . . are other girls . . . I haven’t touched heparin
and had no idea I didn’t prime a line you know
what I mean like I just didn’t know. I didn’t
know it’s very stressful and I think that it’s
very important that a buddy system or having a
good clinical educator on the floor.’’(p.128)
Committing commitment ‘‘. . . I am still learning everyday but I am not Unequivocal
to the profession. . . learning tasks any more . . . so what I am
becoming informed prac- learning now is um all those other things
titioners and recognizing outside of the task like discharge planning, you
the need for lifelong know, what to tell patients to expect, I am
learning focusing more on my interactions with patients
and how to interact with them and I am
learning also about what’s in the community
for long term care or assisted living I am
learning all those other things . . . I am relating
more to theory like I have more time for
communication with my patients now, and I
try to remember all those you know therapeutic
communication listening skills.’’(p.131)
Dissatisfaction with their ‘‘I found myself on a unit that was full of Unequivocal
job due to lack of recog- nursing turnover they were always having new
nition, appreciation and people and I think the staff was suffering from
lack of learning opportu- constantly meeting new people and support
nities and mentoring wasn’t there. . .I felt constantly on edge. . .I did
not enjoy myself as far as learning goes and so
after few months almost a year I wanted to
move.’’(p.132)

(Continued)

Evolving, becoming ‘‘after two years you have more confidence, Unequivocal
aware: participants experience you build by doing, . . . when things
described their growth as go wrong . . . this is not part of the textbook,
becoming comfortable, they didn’t teach me this at school what do I
knowing, confident, inde- do? Whereas now it’s okay there’s a problem
pendent learners and let’s look at it, let’s take a deep breath what
experienced needs to be done now what can be done later
you prioritize, what the situation is, it is a lot
easier for me now versus being a novice.’’(p.135)
Clinical knowledge is ‘‘If you are a new grad and you’re doing a Unequivocal
acquired from interacting chest dressing and there is a lot of drainage on
with and observing the dressing there is nowhere in the literature
experienced nurses as where it says what action you could take and
well as through personal that’s really when you need to draw on other
experiences in clinical set- peoples experiences. Asking every nurse, letting
tings doctors know about it, is this normal for this
patient or is this normal for any patient.’’(p.136)
Neophyte nurses tend to ‘‘I had a very sick patient on nights, . . . we Unequivocal
build stereotyped impres- were thinking more towards sepsis and it ended
sions about certain up to be the beginning of renal failure because
clinical presentations of he wasn’t zero output, but again with burns its
patients. . .with more different because there are signs and symptoms
exposure to clinical situ- of infection, so it’s a learning experience two
ations; new nurses years after graduating.’’(p.136)
expand their knowledge
and become more critical
thinkers
Comprehending the ‘‘So when I first learnt I was kind of just Unequivocal
whole: at first they were looking on the surgical site and the drains and
relating to the patient’s just looking at what they touched I wasn’t
parts or the pathology, looking at the whole patient, I was so con-
but as they became com- cerned with the flaps, the drains, the Foley
fortable with their know- output. . . now because of the experience, okay
ing and doing, they I can just quickly look at the surgical site and
started to relate to the say that’s what I expect to see like the swelling
health of the whole per- going down or firmness because of the oedema,
son I can briefly look at that and say okay I can
spend more time with the patient and talk to
her how are you feeling?’’(p. 138)

(Continued)

Increased workload and ‘‘I just find the severity of the patients’ sickness Unequivocal
low staffing ratios is getting worse so much and that makes the job
heavier like people are not healthy, obesity is on
the rise which puts more physical work on us. . .
I find frustrating too is people’s expectations
when they come to the hospital. . .some families
or patients who expect to get one-on-one every
minute of care . . . I am sorry I don’t have time
to even do basic ADLs. . . you didn’t get a four
year degree to run for the rest of your life, you
leave work exhausted physically and mentally
exhausted who would want to do that for
twenty years.’’(p.132–133)
AWBL, accredited work-based learning; CE, continuing education; CEF, clinical education facilitator; CNE, continuing nurse educator; CPD, continuing professional
development; EN, enrolled nurse; RN, registered nurse.

Bahn D. Orientation of nurses towards formal and informal learning: motives and perceptions. Nurse
Educ Today 2007 Oct;27(7):723–30

The learning experience: ‘‘We are supposed to have one (regular appraisal) Unequivocal
taking part on formal annually. . . I have been for five years. . . We should
study activities appeared have them (regular appraisals) but it is virtually
to be problematic and it impossible at the moment. . .’’(p.728) For others the
seemed to stem from a experience was different(p.728) U ‘‘We usually see the
lack of regular edu- manager yearly. . . if you have an interest in certain
cational appraisals courses you are encouraged to do them. Study time
is decided between you and your manager during
your personal appraisal. . .but it would have to come
from me wanting to do it."(p.728)
Participants . . .expressed ‘‘I found it quite hard because the trust did not help Unequivocal
feelings of dissatisfaction in any way, either financially or by allowing time for
with their employing study days. I had to do it all in my own time and so
organization’s lack of did others.’’(p.728)
support to continue their
post-registration edu-
cation . . .
Attitudes to learning: ‘‘It is all down to being able to spare the staff. . .if Unequivocal
staff shortages and time you need to do a day’s work. . .the work comes
constraint factors were first’’(p.728)
reported as affecting
interviewees’ ability to
attend study sessions,
both mandatory and non-
mandatory

Beal JA, Riley JM, Lancaster DR. Essential elements of an optimal clinical practice environment. J Nurs
Adm 2008 Nov;38(11):488–93

Working in a milieu that ‘‘there’s room for thinking about problems in a Credible
sets dual expectations for different way, coming to different solutions that may
high standards of patient have better outcomes.’’(p.489–490)
care along with high
expectations for pro-
fessional development. . .
One nurse noted that the
milieu of the workplace
needs to shift to become
a place where. . .
The duality of expec- ‘‘raising the level of professionalism and refreshing Unequivocal
tations for high patient [nurses’] pride" . . . ‘‘It is a good place to work
care standards and pro- because they [the hospital] foster independent think-
fessional development ing and collaborative practice.’’(p.490)
results in an environment
that fosters enthusiasm
and optimism and has the
important outcome of. . .
An inherent problem in ‘‘You have to have an environment that allows Unequivocal
nursing is how you can nurses not to be at the bedside all the time, but
foster professional growth [provides time] to be growing and learning. . .There
and take care of patients are ways for the structure and management to allow
at the same time that [to happen].’’(p.490)
Openly valuing scholarly ‘‘The culture of the hospital respects nursing. So Unequivocal
nursing practice therefore, when you feel that [respect], you give your
best and the patient gets the best.’’(p.490)
An inherent gap between ‘‘On paper, [the administration] says, Yes, we value Unequivocal
the expectation and the you. But will that garner me any more resources?
reality of how a work- Probably not.’’(p.490)
place values scholarly
nursing practice surfaced
Frustration with their ‘‘I don’t think nurses get that kind of administrative Unequivocal
belief that they were not support when they are at an advanced practice
adequately supported for level."(p.490)
their level of practice
expertise
Even scholars need sup- ‘‘I need help from the institution. . . time and Unequivocal
port expertise. I want to publish but I don’t know
how.’’(p.490)
Of all the resources cited "I am free to do it [solving a challenging clinical Unequivocal
as essential, time was the problem] on my own time. I’m just not suppor-
predominant theme ted."(p.490)

(Continued)

The participants strongly ‘‘You need mentors who can see what you bring to Unequivocal
believed that mentors the table that you may not necessarily see in
continue to be essential at yourself. I know what is required to be a scholar and
all levels of career devel- I love it. I am thankful to those around here who
opment, even for those at expect the best from all of us.’’(p.490)
the pinnacle of their
careers
Seamless support at every They overwhelmingly felt that a nurse manager who Unequivocal
level ‘‘makes things happen’’ and supports nurses at all
levels of professional growth is critical. ‘‘I have had
good nurse managers, but M brings out the best in
people. She enables me to think beyond what I think
of myself.’’(p.490)
Support for the develop- ‘‘When you have the top ones focusing on better Unequivocal
ment of scholars and development in nursing practice, that’s the trickle
scholarly nursing practice down effect. If you don’t have it from the top, then
is also needed from the the ones down below aren’t going to get that sense
nurse executive team of accomplishment.’’(p.491)
Support from peers was ‘‘Working with positive people who are upbeat and Unequivocal
also considered essential. not with somebody who is going to be negative or
Enthusiasm and encour- lazy. If they are not enthusiastic then you feel that
agement were noted to be you can’t get enthused around them because they
important. . . will think that you are crazy.’’(p.491)
Participants shared that ‘‘I think that it would be good if the opportunities Unequivocal
there were too many hur- were made easier to achieve. . . It’s not difficult to go
dles and obstacles to to a conference. But if [the logistics] were instead of
developing a scholarly hard, made easy. . . I and on top of that encouraged
nursing practice as opposed to ‘Oh I really need this switch for the
conference day_ and ‘Can you please put the
conference day through?_ and ‘ Well I’ll have to go
on my own time then. . . I think that definitely would
make it easier.’’(p.491)
They spoke of the tangi- ‘‘I had this plan. Okay this didn’t work out so well, Unequivocal
ble value of an environ- but maybe it didn’t work out well at [this] particular
ment that supports time I [know] I’m responsible for how it turns out.
learning from mistakes, But this great plan doesn’t work out the right way."
that is, the opportunity to She continued her dialogue, describing a process of
change patterns of prac- reaching out to her nurse manager to address the
tice that improve patient problem. ‘‘You knock on her door, [she says] oh
care and provide greater come on in, have a seat and I say look this didn’t
satisfaction to the nurse quite work out. What did I do wrong?’’(p.491)
in the delivery of care

(Continued)

It is a two-way street ‘‘The issue is not support. . . Support is here. It is a Unequivocal
even when the environ- willingness to use the support to do something that
ment is supportive of you think will be useful."(p.491)
nurses; they need to be
willing to be supported
Frustration with the lack ‘‘Some are not interested in advancing. Some not Unequivocal
of motivation in some of interested in learning new things.’’(p.491)
their colleagues, which
some nurses viewed as
generational differences
Some participants ‘‘I was only there a couple of days a week. So, as my Unequivocal
expressed concern about hours have increased and my access to the people
the impact of the work who make things happen has increased, I now have
schedule design on scho- the motivation, the time, the support, and the people
larly nursing practice to bounce ideas off of.’’(p.491)

Bjørk IT, Tøien M, Sørensen AL. Exploring informal learning among hospital nurses. J Workplace Learn
2013;25(7):426–40

Pre-rounds with phys- ‘‘interesting because I can listen to the physicians’ Unequivocal
icians in the meeting discussion and experience what issues they think are
room and the staff room important’’ (Rick).(p.431) ‘‘It is your responsibility as
the only nurse there to ensure that communication
with the physicians work and that things are clear to
both them and me."(p.432)
Handover in the morning . . . the handover was a setting for multiple learning Unequivocal
and afternoon possibilities as well as an occasion for dispute. ‘‘It’s
the important things we air and discuss, but I know
some think that this should be discussed some other
time. I think I can see a pattern – the nurses who
work quickly themselves want the report to be short
and to the point, and most of the students and
inexperienced nurses want to discuss just like I and
many of the other seasoned nurses.’’(p.432)
Distribution of work ‘‘I have never thought about those situations as a Credible
around the whiteboard setting for learning, just as a way of organizing our
work.’’(p.433)
‘‘Floating around’’ in the ‘‘They (the physicians) make themselves available to Credible
staff room in dialogue us and some of them really love to teach without
with others. . . even being asked.’’(p.433)
Working together with ‘‘I think they need me. I have expertise and one of Unequivocal
the patients my important contributions is to take the young ones
with me and teach them. I like the difficult cases
where there is a lot to do. I use them explicitly to
show how i reflect on and decide on actions.’’(p.434)

Chase LG. What makes learning meaningful for mid-career nurses? Master’s Thesis: [Royal Roads
University (Canada)]; 1999

Importantly, there was a They described such things as ‘‘safety’’, ‘‘feeling ok Credible
need to make the organiz- to ask stupid questions’’, ‘‘expert support’’, and
ation a ‘‘learning organiz- being valued for experience.’’(p.31)
ation’’
Learning needs to be One nurse stated that she personally ‘reflects’ on Credible
personally useful and action however several of the nurses pointed out that
applicable learning and retention were aided by partnering with
others, by being mentored, and by ‘doing’ either by
themselves or with others in a group setting(p.25)

Fox R, Henderson A, Malko-Nyhan K. ‘They survive despite the organizational culture, not because of
it’: a longitudinal study of new staff perceptions of what constitutes support during the transition to an
acute tertiary facility. Int J Nurs Pract 2005;11(5):193–99

Themes identified at 2–3 "Our area has a good social network [among the Unequivocal
months: the importance staff] and this has made it a good environment to
of a positive attitude of work in—better than where some others are work-
clinical staff and nursing ing. I have been fortunate.’’ Alternatively hostility
management (both overt and covert) of colleagues undermined all
of the positive aspects of the transition program.
Behaviors which demonstrated negative attitude
included: ‘‘When you are feeling insecure, it must
show and the senior RNs recognize this and are very
aggressive. It is a real wolf- pack mentality. Instead
of helping, they seem to vent all their frustrations on
you as you are at the bottom of the pile. I really got
no support at all and I have found the whole
experience devastating. The other staff just seem to
be so hostile and everything is blamed on the new
people."(p.193 –194)
The need for adequate ‘‘We need more time off-line as there is simply not Unequivocal
staffing levels of appro- enough time on a shift to do anything like look up
priate skill mix in the and learn about your patients. You have to do it
wards when you go home.’’. . . However, a positive
response towards attempting to address poor staffing
levels included: Even though I have heard of staffing
problems elsewhere, my ward bent over backwards
to make my transition easy. They made sure that I
always had less patients at the beginning and, if they
were of a higher dependency, I had a smaller
load.(p.196)
Accessibility to learning ‘‘We have a good, positive nurse educator in our Unequivocal
opportunities and ward and he makes me feel I can ask for advice
expertise. . . because everyone else is too busy to bother. . .There
was no emphasis or even recognition of any edu-
cational role. . .But there were not enough clinical
staff who could help you and no educator. They
promised us all kinds of support during the induction
but no one was there when it came down to
it.’’(p.196)
Provision of supernumer- ‘‘Nursing is tough and many new nurses do not Unequivocal
ary days realize this. If they have a solid supernumerary
period, it provides a good transfer into the reality of
what life is like as a nurse while they are learning all
about the place and the routine.’’(p.196)

(Continued)

Preceptor and preceptee ‘‘It is good to be on a series of shifts together Unequivocal
being rostered on the because you can get into a routine and can also talk
same shifts through mistakes together afterwards.’’(p.197)
Allocation of a preceptor ‘‘It is great when you are able to work with your Unequivocal
on a one-to-one basis preceptor because you have always got someone to
bounce queries against. It also means that you can
discuss conflicting information. I had too many
experiences where I stuck to the procedure manual
as we were told, but some staff do exactly the
opposite and tell you to ignore the manual. My
preceptor was able to explain the differences and
appropriate ways of modifying the manual.’’(p.197)
Themes identified at 6–9 ‘‘I have found that I am more assertive now and Unequivocal
months: knowing the sys- insist on help, or at least know where to go when I
tem. . .Understanding the need help. I know the system now and it has made
way that the organization the world of difference.’’(p.198)
worked made a positive
difference
Aligning with the good I am really self-reliant now and do not need a Unequivocal
people preceptor. I have some really great mates and we
work as a team."(p.198)

Govranos M, Newton JM. Exploring ward nurses’ perceptions of continuing education in clinical
settings. Nurse Educ Today 2014; http://dx.doi.org/10.1016/j.nedt.2013.07.003

Culture and attitudes: the ‘‘to continue to fulfill our duty of care to patients Unequivocal
nurses’ perception of their and to maintain/reinforce the knowledge previously
role as a nurse and what learnt". . . OR ‘‘the perception is often that education
value CE can add to this is interrupting the work [and] education is compart-
role. . .Underpinning the mentalized to the side. . .Education is one thing and
theme is the importance of this is about work and even though people might say
education and education I need to learn that to do my job, they don’t look at
versus the workplace a lot of education as work related."(p.3)
A culture of busyness, ‘‘Time is our biggest enemy’’ ‘‘You feel as nurses, Unequivocal
where tasks and patient you feel you have to get everything done’’(p.3)
care needs to be done
within a time frame
One-on-one learning was ‘‘invaluable. . .a great way to learn’’(p.4) Credible
also seen as important
Participants saw senior ‘‘in a good way everybody has a role in educa- Credible
staff as a valuable and tion’’(p.4)
accessible resource
The need to be ‘‘up-to- ‘‘CE. . .maintains your skills. . .your professiona- Unequivocal
date" lism. . .your confidences. . .it keeps your registration
as well’’(p.4)
Being ‘‘There"-Being ‘‘They’ve turned into more of a floater rather than Unequivocal
‘‘Seen" [The role of the an educator. . . also the way that our staff have been
CNE and how they inter- treating the educator, a lot of them are confused as
act with the staff in meet- to the role. So I think more of a role definition. . .and
ing their CE the educators really need to set boundaries. . .and
requirements, in particu- support rather than do for’’(p.4)
larly (sic) emerged as an
important influence]
Importantly, CE needs to ‘‘Getting your senior staff away from all those Unequivocal
be available when needed acutely unwell patients and getting the junior staff
and in a timely manner in. . .The younger staff don’t get any exposure to it
and they have to learn just the same. They need to
learn to become those senior nurses.’’(p.5)
Inhibiting factors around ‘‘Needs to be a closer link between management and Credible
CNE in the workplace education. . .as change will not be possible if they are
not linked. . ..education fails to capture the work-
place context. . .I think that education works on the
premise that it can stop and educate but the work-
place, particularly a busy acute setting, doesn’t
stop. . .a lot of education could happen in the work-
place as its happening.’’(p.5)
CE, continuing education; CNE, clinical nurse educator.

Hallin K and Danielson E. Registered nurses’ perceptions of their work and professional development.
J Adv Nurs 2008;61(1):62–70

Shortcomings in the ‘‘You can influence the work if you want to’’ OR. . . Unequivocal
physical work environ- ‘‘It is difficult to influence the work situation other
ment and conflict. . . than to change the workplace or to take further
education’’(p.65)
Having knowledge that is ‘‘I have been ignored and invisible regarding my Unequivocal
seldom made use of interest for research. I have been met with the
attitude that RNs should work and not carry out
research’’(p.66)
Attaining professional ‘‘Being allowed to continue to develop one’s knowl- Credible
growth is no mater of edge and proficiency has been a journey of plea-
course. . . sure’’(p.66)

Hughes E. Nurses’ perceptions of continuing professional development. Nurs Stand 2005;19(43):41–9

Significant barriers to ‘‘You get home, and you’re so tired I’ve got a little Unequivocal
professional development girl and I’d like to spend time with her. The last
were identified. . .days off thing I want to do is read nursing journals when I
and family life are pre- get home.’’(p.45)
cious
Nurses find reflection dif- ‘‘I don’t think they [nurses] use it [PREP] properly Unequivocal
ficult and I think it’s because they really don’t understand
(post-registration education practice) . . .They haven’t
got the guidance they need to get the most out of
it.’’(p.46)
Cycle of frustration when ‘‘I feel quite excited about bringing it [new ideas] to Unequivocal
learning new things the workplace. . . that can quickly turn to frustration
when it is not met with the same enthusiasm by your
work colleagues.’’(p.46)
Apathy and disillusion- ‘‘I think they’re [nurses] too busy. There’s no time- Unequivocal
ment because of the cli- . . .too many demands. . .they haven’t got the time to
mate of the working go and start a new idea with all the paper-
environment. . . work. . .There’s not enough staff [or] time to do the
basics, let alone try out new ideas. . .sometimes
there’s resistance from other members of the multi-
disciplinary team. . .it fosters apathy and negativity
and that’s perpetuating.’’(p.47)
A lack of support in ‘‘Our manager doesn’t listen with her ears open. It’s Unequivocal
implementing change as we’ve always done it this way, I don’t see a need to
well as how managers’ change’. I suppose it’s easy to get stuck in a rut but
leadership styles played a that doesn’t benefit the clients. . .’’ ‘‘If I had my
part in the ‘‘no-change" manager’s support I’d feel much empowered, I’d feel
culture of nursing a lot more positive and enthusiastic. I’d feel a lot
happier in general. . .the management on the unit
where I work are very negative towards nursing staff
so I’ve had years of lack of support, lack of
progression.’’(p.47)
Experience could affect ‘‘It’s all about promoting a better working environ- Unequivocal
the success of the man- ment. . .anybody who wants to bring anything into
ager in fostering an this unit is welcome with open arms because it’s to
environment of discussion the benefit of the clients. . .everyone’s encouraged
and change. . . a more with new ideas. . .it keeps them motivated and inter-
experienced manager ested. . .it’s all about making your working environ-
illustrated her willingness ment interesting to be in.’’(p.48)
to accept change

(Continued)

(p.44)
Here it can be seen that Figure 1 Credible
75 per cent of respon-
dents working in nursing
homes and 77 per cent
working in the NHS had
positive perceptions of
CPD. . .
Nurses indicated that Figure 3(p.45) Credible
they had a positive atti-
tude toward professional
development
Nurses have difficulty in ‘‘not learnt anything new’’ and ‘‘lack of relevance to Credible
reflecting critically on practice.’’(p.44)
their own practice and
applying new learning to
everyday experiences
CPD, continuing professional development.

Jantzen D. Learning stories: A study of positive learning experiences to create positive change. Master’s
Thesis:[Royal Roads University (Canada)]; 2004

Learning from the experi- ‘‘I probably did make mistakes. I get it, you know I Unequivocal
ence of mistakes get that I didn’t do it right. As long as they aren’t
harmful, making mistakes.’’ ‘‘You don’t learn from
the times when things go normally, but I learned
from the times when things go bad.’’(p.101)
Learning from the experi- ‘‘Well, it has a lot of people that work there who Unequivocal
ence of others have many years of experience to be learning
from. . .The nurses have been in [that specialty area]
for a long time. . ..that makes it a learning environ-
ment.’’(p.102)
Learning from stories ‘‘You give concrete examples. . .those case scenarios Unequivocal
always seem to hit home for nurses. . .even if it is just
in a conversation. ‘This is what happened here.’ I
think there are a lot of valuable things that we learn
from what’s happened.’’(p.104)
Learning and life experi- Adult learners bring significant life and work experi- Credible
ence ence to learning or educative experiences. Robin,
Ann and Amelia all stressed the importance of their
own life experience being recognized and acknowl-
edged by educators and nursing leadership. Their
stories were punctuated with an occasional, ‘‘I am
an adult!’’ These participants contrasted this
acknowledgement with experiences in clinical edu-
cation and workplace situations where they have
been made to feel like children.(p.105)

Leonard DJ. Factors perceived to facilitate and impede learning in the workplace. J Nurs Staff Dev Mar-
Apr 1994;10(2):81–6

Support for education ‘‘I think the greatest facilitator is probably our Unequivocal
nursing administration here. . .that supports continu-
ing education so greatly.’’(p.83) ‘‘The Vice-president
believes the 12-member staff development depart-
ment is an ‘investment, a system for accomplishing
the goals of the nursing department.’’ ‘‘He sees
education as ‘career growth and moves staff toward
critical thinking, logic and problem solving activi-
ties.’’
Education availability In conjunction with support for nursing education by Unequivocal
administration is education availability. . .‘‘to recog-
nize excellence in all areas of nursing practice and to
promote the advancement of professional nur-
sing.’’(p.83)
Small groups in class- If I don’t get to hear what other peoples’ thoughts Credible
rooms are. . .then I don’t get a chance to judge myself.(p.83)
Informal learning Instructors she said must possess ‘‘. . .ability to sell, Credible
persuade, negotiate, relate to head nurses; it’s an
important a skill for a staff development person as
being able to stand up and teach in a class-
room.’’(p.84)
Teaching by the expert . . .where the instructor was teaching12-lead electro- Credible
cardiogram interpretation in the assessment of car-
diac emergencies. After the class the learners wrote
that this was their most significant learning experi-
ence in the last 6 months. Another said the instructor
helped me ‘think’(p.84)
First-line manager ‘‘. . .the head nurses could be the greatest facilitators Unequivocal
of education because they need to support it and
allow them time. . . the greatest hindrance is the same
thing, the lack of it.’’(p.85)

McCormack B and Slater P. An evaluation of the role of the clinical education facilitator. J Clin Nurs
2006;15:135–44

142. ‘‘The role of the ‘‘One of the main reasons for establishment (of the Unequivocal
CEF" role) was we wanted a co-ordinated approach as to
how nurse training and development was managed
by the hospital, and there was a need to know who
was trained for such a requirement and also for
statuary regulations. Not only was there the need to
have the records but also provide the trai-
ning. . .’’(Nurse Education Coordinator/1:1 interview/
lines 10–15)(p.141)
Fairly clear understanding ‘‘From the practical side she sorts out the Mandatory Unequivocal
of the CEF role Training, the new starts, the upgrades of people,
she’s involved in the standardization of job descrip-
tions and job roles. Strategically then she looks at
what training the actual staff were looking for and
she’s involved in the (a particular specialist practice
course). . .’’(p.141)
Mentorship systems ‘‘. . .especially for new nurses coming in, we feel we Unequivocal
need someone other than someone on the ward to
speak to if we have a problem. She has helped us as
new nurses to settle in very easily to the ward, she’s
introduced us to the ward and told us of our
expectations and helped with our progression during
our supernumerary period, which is three months’’.
(on-the-spot interview/D grade/lines 19–25)(p.141)
CEF, clinical education facilitator.

Rossi LR. How nurses gain clinical expertise through informal learning in the workplace. Dissertation
[Ann Arbor]: Columbia University Teachers College; 1995

Learning the organization The institution was sometimes seemed as helpful in Credible
through trial and error promoting trial and error learning. Theresa described
alone the need to change units saying, ‘‘I need to grow.’’
She decided to leave her ‘‘home base unit’’ and
attempt a six-month stint in ICU. The organization
supported her experiment’’ prioritizing to hold her
old job in case things did not work out. As Theresa
explained(p.194): ‘‘Six months is not a long time. It
might be hell and it might not. But when you come
back – if that’s the way it works out - you have
more of an appreciation of where you left. Your eyes
are opened rather than working eighteen, twenty
years on the same unit. . .you’ve grown.’’(p.194)
Learning about the Not surprisingly all twenty-three study subjects Credible
Job(p.127) Trial & reported using trial and error – some more than
Error(p.129) others- to improve their on-the-job learning.(p.129)
‘‘[At first] I was so intent on them knowing exactly
what I we doing . . .I wanted to tell them everything
I was going to do. And I really didn’t give them a
chance to ask questions or anything. But now I. . .
You can sort of get a feel for them. . . so I figure I’ll
just tell them the basics, skip over the details. . .and
just listen. I mean you have to listen to them. . .other-
otherwise you just can’t get started. They have to tell
you their story.’’(p.129)
Learning the job through ‘‘Well I think [she] is an exception. Because. . .I mean Unequivocal
role modeling with super- she still works in the clinical area. She’s not afraid to
visors go to 8C and work 2C and work in the ER. And I’m
sure if we needed her on 6B she’d come. . . she’s not
afraid to do that.’’(p.149)
Learning the job through ‘‘I looked up to her because she was so knowledge- Unequivocal
role modeling from peers able and I respected and admired the way she took
care of people. . .she was a great role model.’’(p.150)

(Continued)

Learning the job through ‘‘She sensed my interest and took me under her Unequivocal
mentoring from supervi- wing. . .In fact she gave me responsibility, and gave
sors me some confidence too. I remember very vividly
when she asked me to go along. They were picking
up twins and I was the third set of hands. As we got
there one of the twins was very, very sick and the
other one wasn’t, And she said ‘Ruth, you take care
of this one that is not so ill.’ And I was still in
training. And here she is with the other experienced
nurse caring for the other one. And she just said, ‘If
you have any problems I know you’ll come and get
me’. . .which did wonders for my ego. . .my morale.
And she was right. When I had a question I would
come and say, ‘Karen, this is what’s going on’ She
would share her knowledge. . .so I can really say that,
yes. . .she was my mentor.’’(p.167)
Learning the job through ‘‘We get consults from the experts on skin care. We Unequivocal
committees and task all participate on committees for certain things. . .like
forces we have a skin care committee and we have two
people up there right know who are skin care
committee people. Wed use their input. . .you’ve got
somebody for everything and all [the committees]
are instituted as necessary.’’(p.171)

Swallow VM, Chalmers H, Miller J, Piercy C, Sen BJ. Accredited work-based learning (AWBL) for new
nursing roles: nurses’ experiences of two pilot schemes. J Clin Nurs 2001;10:820–21

Comparison of AWBL It was ‘‘an individual learning pathway not a generic Credible
with prior learning was a way of learning’’ which made the learning outcomes
recurrent theme in both very personal.(p.821) ‘‘but once I went through the
pilots process I thought that was the best way to do it’’
‘‘. . . a learning process. . . we all did it slightly
differently, that is probably what is good about it.’’
Integrated well with prac- ‘‘. . .could do it at work and maybe on days off, so Unequivocal
tice the stresses weren’t built up at work as much as if
you had to take time out [to attend a course].’’(p.821)
‘‘. . . there was work involved in action plans,
objectives and essays but it was easier because it was
in your mind all the time, whereas if you have an
assignment to do about something that you are not
actually doing [at work], it is harder.’’
The impact on pro- ‘‘. . .something I wouldn’t have done without AWBL, Unequivocal
fessional development I wouldn’t have had the confidence to do it.’’(p.821)
was important. Indeed,
the practice-focused
nature of the facilitated
learning enabled nurses to
recognize and value their
own ability to lead
change
AWBL, accredited work-based learning.

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S YS T E M AT I C R E V I E W

The influence of workplace culture on nurses’ learning

Correspondence: Kate Davis, kdavis@wli.sa.edu.au

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Background Observed behavioral irregularities when people

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©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

When considering nurses’ learning experiences Inclusion criteria

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Search strategy OR Continuing and Education OR professional and

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©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Records idenﬁed through

Titles screened for eligibility Records excluded

Abstracts excluded, did

Full-text arcles assessed Full-text arcles excluded,

Phenomenological44 Realistic evaluation51

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Methodological quality Table 1: Number of studies included and excluded

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Table 2: Final assessment table

Table 3: Included articles and findings

Citation Unequivocal Credible (equivocal)

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Table 4: Relationship between underpinning findings, categories and synthesized statements

Synthesis name and

Resources: staffing/budget/work schedule/time

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Synthesis name and

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Practice issue: The influence of workplace Eight categories

1. Accountability/critical and reflective thinking

demonstrated through time in and out of the workplace

Retelling what has happened, conveying the centrality

Recommendations for practice

Figure 2: The process of meta-aggregation

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Category 7: Patients/stories Frustration with the lack of motivation in some of

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©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Conclusion Recommendations for practice

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Appendix I: Detailed search strategy

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CINAHL final search terms, 2 October 2013: 11,535 results

nursing OR nurses AND; learning OR AND;‘‘Service culture’’ AND; ‘‘Qualitative stu-

SCOPUS final search terms, 13 October: 1990 results

(nurs) AND; learn OR AND; workplace cul- AND; (qualitative OR

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Embase final search terms, 13 October 2013: 1566 results

(nursing/exp OR nur- AND; (learning/exp AND; (culture/exp OR AND; (’qualitative

©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

ERIC final search terms, 11 November 2013: 289 results