“Correction does much, but encouragement does more. Encouragement after censure is as the sun after a shower.” —Johann Wolfgang von Goethe

Today’s clinical learning environments can seem overwhelming. Learners, instructors and staff members all face extraordinary challenges in health care workplaces. Students can be recent high school graduates, adult learners supporting families, or newcomers to the country who are continuing to work on their language and literacy skills. Common concerns are high costs of tuition that result in unmanageable debt, and competition to achieve top marks. Many students travel significant distances to the clinical site and balance heavy study commitments.

Similarly, instructors are often employed only on a sessional or contract basis. They are also balancing work and family obligations that are separate from the clinical learning environment. As well, professional staff members at a clinical site, who are ultimately responsible for client safety and care, are frequently employed on a contract basis and may work at several different facilities. At times, professional staff members may view learners as an additional burden rather than an opportunity for professional development. Non-professional staff may find themselves assisting learners.

Creating a learning community among learners, teachers and staff cannot be left to chance. The complex social context of the current clinical learning environment makes intentional teaching approaches essential, approaches grounded in an understanding of how learning occurs for students. In this chapter we discuss the clinical learning environment, who the teachers are, and who the students are. We provide creative and easy-to-implement strategies that offer practical guidance to instructors for managing the everyday occurrences faced by clinical teachers in this unique ‘classroom.’

Students in health care education programs at universities complete practicums in a clinical learning environment in addition to attending academic classes. Clinical practicums are considered essential to professional competence in most health-based professions. For example, clinical practicums are viewed as essential to the curriculum by programs in medicine (Ruesseler & Obertacke, 2011), nursing (Courtney-Pratt, FitzGerald, Ford, Marsden & Marlow, 2011), pharmacy (Krueger, 2013), physical therapy (Buccieri, Pivko & Olzenak, 2013; McCallum, Mosher, Jacobson, Gallivan & Giuffre, 2013), occupational therapy (Rodger, Fitzgerald, Davila, Millar & Allison, 2011), dietetics (Dietitians of Canada, n.d.), radiation therapy (Leaver, 2012), paramedic training (McCall, Wray & Lord, 2009) and dental hygiene (Paulis, 2011). Internationally, clinical practicum placements for students in these and other health care disciplines are in markedly short supply. Available placements may be in programs offering care only to seriously ill clients, may be inundated with learners from the health disciplines, and may be experiencing budget cuts and staff shortages (Brown et al, 2011; Roger, Webb, Devitt, Gilbert & Wrightson, 2008).

The real world learning environment where students in the health professions complete their clinical practicums is an “interactive network of forces” (Dunn & Burnett, 1995) rich in opportunities for learners to transfer theory to practice. Setting out sequences of learning activities in unpredictable clinical environments can be more difficult to plan and structure than in traditional classroom environments. Both planned and unplanned experiences must be taken into account.

Planned Experiences

Curriculum. Following direction from a curriculum is a widely used planned learning experience in the clinical learning environment of any professional health care program. At the curricular level, clinical practicums are usually arranged before students are granted admission to their program of study. A curriculum is the range of courses and experiences a learner must successfully complete in order to graduate. Curricula are expected to include a philosophical approach, outcomes, design, courses and evaluation strategies. Clinical practicums can be structured as courses in the curriculum, either as part of a theoretical course or as a standalone course. Clinical practicums must be considered in relation to available health care facilities that are able to accommodate students.

Curricula in programs educating future practitioners in health fields are strongly affected by requirements of professional associations, regulatory agencies and approval boards. Curricula must address discipline-specific competencies. Throughout the curricular planning process, program planners from educational institutions must negotiate with administrators of service agencies to find suitable clinical practicum sites.

Since the education of health care professionals now occurs in universities rather than in the agencies providing service, negotiating, designing and evaluating clinical practicums in relation to the overarching curriculum is seldom a linear process. One consideration is program structure, or the duration and division of learning to be undertaken by students. Here, modes of delivery matter: program structure could be framed around face to face settings in traditional classrooms, distance delivery or a blending of both. Partnerships between institutions and consortiums or collaborations among institutions also matter. When programs are structured to be delivered at a distance, learners may have to travel and find accommodation in a different geographical area in order to attend their practicums. In both face to face and distance programs, international practicum experiences may be available and even required.

Another consideration is the program model or organization of required courses, elective courses, laboratory experiences and clinical practicums within the curriculum. In clinical practicums, the program model guides the method of instruction that will be used. For example, the program model may require that students are taught in small groups by a clinical instructor, in one-to-one interaction with a preceptor, or a combination of these and other instructional methods.

In the health disciplines, coordinating instruction extends well beyond the actual institutions of learning and into clinical agencies. Scheduling, faculty and budgets must all be addressed. The instructors and preceptors who teach students during their clinical practicums may have no other association with the university. Similarly, university faculty assigned to teach in a particular clinical area may have no current association with a particular agency.

Program Design. Program design configures the program of studies, including the courses selected, practicum experiences, relationships among courses, and the policies that communicate this information. Designs may include building with blocks of required study, building by spiralling back and adding to previous content at different points, and establishing opportunities for specific tasks such as an essential psychomotor skill. Clinical teachers seldom have input into how programs are structured, the type of model used to organize content, or the design influencing how and when information is presented. However, all those involved in educating students must seek a basic understanding of the ‘big picture’ curriculum that students follow.

Traditionally, curricular organizing strategies often revolved around the medical model. The hospital areas of medicine, surgery, pediatrics, maternity and psychiatry framed the focus of learning for health practitioners. This model is strongly aligned with hospital-based apprenticeship orientations to learning and is now considered somewhat outdated in today’s complex and ever-changing health care system (Benner, Sutphen, Leonard & Day, 2010; Diekelmann, 2003; Tanner, 2006).

Today, programs are more often organized around a conceptual framework generated within the discipline or around the outcomes expected of graduates. For example, with outcomes such as promoting health, thinking critically and making decisions, curriculum planners would organize content related to each of these outcomes in different courses throughout the program. Evaluation methods would be determined in relation to these outcomes and would include a wide range of educational measurements. Examples might be multiple choice exams and scholarly papers in academic classes, and skill mastery or client communication in clinical practicums.

Levelling is the process of linking program content, introduced at different times and in different courses, to the evaluated outcomes expected of graduates. Levelling requires planned opportunities for students to build on their previous knowledge and work incrementally towards achieving more complex outcomes. However, if a limited number of clinical placements are available, scheduling appropriate clinical opportunities for students at all levels is particularly challenging. Introductory level students may find themselves in practicums where they must care for acutely ill individuals. In many instances, practicum placements are more suited to advanced learners than to students in basic health care programs.

Further, instructors, staff and students can find it difficult to link the learning outcomes and evaluation methods that flow from a program’s unique conceptual framework with the day-to-day work of a clinical agency. This may be another consequence of the limited associations between universities and clinical agencies. Although links between learning outcomes and day-to-day practice are made during planning by representatives of the universities and the agencies, the links may not always be clearly communicated to the staff actually working with learners.

Admission criteria are another important curricular element in appreciating the complexities of planned aspects of clinical learning environments. Some learners come to a health-related program of study with less than a high school education. Others come to post-secondary education with high school completion and are being introduced to a college, technical institute or university for the first time. Still other learners have at least one level of certification or an undergraduate or graduate degree. At any level, qualifications for admission may have been completed in another country and in another language. Learners may also have been awarded credit for prior learning or transfer programs.

Clinical agencies often host learners from a variety of different programs and admission requirements will be different for each program even within the same discipline. For example, while one registered nurse program may require high school completion, another may accept adult learners who have completed bridging programs. Inconsistent admission criteria among programs can leave agency staff members unsure of what learners are expected to know when they arrive, particularly when coupled with learning outcomes and evaluation methods that may not seem straightforward. In turn, staff can feel confused about how learners should be progressing and the specific task-based competencies they should be achieving.

Curricular structure, model, design, outcomes, evaluation methods and admission requirements of a program are planned with great care. They offer ‘big picture’ direction and open doors for learning in the clinical environment. Even so, unpredictable events are sure to emerge once clinical practicums are underway. In the following section, we discuss the heart of any clinical learning environment for many students, instructors and staff, the unplanned aspects of clinical learning.

Unplanned Experiences

The clinical learning environment is equivalent to a classroom for students during their practicums (Chan, 2004), yet few clinical agencies resemble traditional classrooms. In their clinical classrooms, learners hope to integrate into agency routines and feel a sense of belongingness (Levett-Jones, Lathlean, Higgins & McMillan, 2008). Learners want to feel welcome and accepted by staff and they want staff to help teach them how to practice confidently and competently (Courtney-Pratt, FitzGerald, Ford, Marsden & Marlow, 2011; Henderson, Cooke, Creedy & Walker, 2012). Students expect and require feedback on their performance and they must have opportunities for non-evaluated student–teacher discussion time (Melrose & Shapiro, 1999) and critical reflection (Duffy, 2009; Forneris & Peden-McAlpine, 2009; Mohide & Matthew-Maich, 2007). Learners need time to progress from one level of proficiency to another (Benner, 2001). Just as learners in classroom environments need support to develop competence in their chosen professions, learners in clinical practicums need a supportive clinical learning environment.

While supportive clinical classrooms are hoped for, clinical teachers must also be well prepared for unplanned experiences that raise barriers to learning. Research suggests that clinical learning environments may not be as supportive as learners would like. For example, Brown et al.’s (2011) work with undergraduate students from ten different health disciplines reveals significant differences between learners’ descriptions of their ideal learning environment and what they experience during their actual clinical practicums. Although participants in Brown et al.’s study express satisfaction with their learning experiences, they describe a mismatch between what they hoped for and what actually occurred. Similarly, recently graduated nurses indicate significant differences between the kinds of practicums they deem good preparation for practice and those they actually attended (Hickey, 2010).

Investigations into experiences of physical therapy students were unable to conclusively define a quality learning environment, in part because of the diverse instructional practices by different community agencies overseeing students’ practicums (McCallum et al., 2013). Over the last decade and in several different countries, student nurses rated their clinical experiences highly for their sense of achieving tasks but much lower for accommodating individual needs and views (Henderson, Cooke, Creedy & Walker, 2012). Although university students are encouraged to question existing practice and the status quo, students find that staff in their clinical placements are seldom open to innovation or challenges to routine practices (Henderson, Cooke, Creedy & Walker, 2012).

Staff shortages, and other issues with which clinical agencies struggle, can leave students feeling that they are not receiving the direction they need and that they are a burden to staff (Robinson, Andrews-Hall & Fassett, 2007). Students may feel alienation rather than the sense of belongingness they hope for (Levett-Jones, Higgins & McMillan, 2009). Students may express fear and discomfort in their relationships with staff (Cederbaum & Klusaritz, 2009, p. 423). Clinical learners have felt rejected, ignored, devalued and invisible (Curtis, Bowen & Reid, 2007). These findings suggest that in some instances health care students are not receiving the support they need.

By acknowledging that both unplanned and planned aspects of learning will occur in all clinical learning environments, educators can plan fitting responses. Clinical agencies will always have a professional duty to prioritize safe patient care over providing learners with clinical classrooms that align with their curriculum and individual needs. As a consequence, and in spite of careful planning by university and agency program representatives, students may perceive their learning environment as unsupportive.

However, international leaders in the health disciplines are calling on clinical agency staff to view clinical teaching as part of their own professional development. They ask clinical agency staff to aid the next generation of professionals by striving to provide quality clinical learning environments where students do feel supported (Courtney-Pratt, FitzGerald, Ford, Marsden & Marlow, 2011; Koontz, Mallory, Burns & Chapman, 2010). Programs are testing new models of instruction (Franklin, 2010). Individual clinical teachers are striving to implement innovative teaching approaches that can create mutually beneficial connections between learners and staff during clinical practicums. Recognizing when unplanned aspects of clinical learning environments distract from student learning is an important first step in triggering change. Evaluation surveys are one way to cast a spotlight on troublesome areas.

Clinical Learning Environment Inventory. Surveys to measure the quality of clinical learning environments are available. For example, the Clinical Learning Environment Inventory (CLEI) was developed in Australia by Chan (2001, 2002, 2003) to measure student nurses’ perceptions of psychosocial elements in clinical practicums. The CLEI consists of an Actual form that assesses the actual learning environment and a Preferred form that assesses what the student would ideally like in a learning environment. The CLEI is a self-report instrument with 42 items classified into six scales: personalization, student involvement, task orientation, innovation, satisfaction and individualization. Students respond using a four-point Likert scale with the response options Strongly Agree, Agree, Disagree and Strongly Disagree. Inventory factors of the instrument have been modified to include student centredness (Newton, Jolly, Ockerby & Cross, 2010).

The CLEI has also been abbreviated to a 19-item scale measuring students’ satisfaction with their actual learning environment in two aspects of their clinical experience—clinical facilitator support of learning and the clinical learning environment. The Clinical Learning Environment Inventory-19 (CLEI-19; Salamonson, Bourgeois, Everett, Weaver, Peters & Jackson, 2011) is shown in Table 1. The CLEI-19 can be used in formal evaluation processes implemented by university program evaluators. It can also be used more informally by agency staff and clinical teachers interested in strengthening their own clinical classroom environments.

Table 1. Abbreviated Clinical Learning Environment Inventory (CLEI-19)

Reproduced with permission (Salamonson, Bourgeois, Everett, Weaver, Peters & Jackson, 2011)
Clinical facilitator support of learning component: Items 1, 2R, 4, 6, 8R, 9, 10, 12R, 14R, 16, 17R, 18R.
Satisfaction with clinical placement: Items 3,5R, 7, 11R, 13R, 15, 19.
Items are scored 5, 4, 2 or 1 respectively for responses SA, A, D, and SD. Items marked with R are scored in the reverse manner. Omitted or invalidly answered items are scored 3.

Instructions: We would like to know what your last clinical placement was ACTUALLY like.
Indicate your opinion about each statement by selecting your response

Incidental Learning. Adult educators Marsick & Watkins (1990, 2001) name learning that can occur as an accidental by-product of doing something else as incidental learning. Incidental or unintentional learning differs from formal learning, where learners register with educational institutions to complete a program of study. Incidental learning also differs from informal learning where learners intentionally seek out further information by, for example, joining a study group.

Although incidental learning is unplanned, learners are aware after the experience that learning has occurred. Incidental learning occurs frequently while a person is completing a seemingly unrelated task, particularly in the workplace. It is situated, contextual and social. It can happen when watching or interacting with others, from making mistakes, or from being forced to accept or adapt to situations (Kerka, 2000). Clinical practicums, both those that students find supportive and those they do not find supportive, offer unprecedented opportunities for incidental learning. Tapping into these opportunities can turn potentially negative experiences into positive ones.

In sum, the clinical learning environment is one of the most important classrooms for pre-service students. This environment offers a range of planned and unplanned opportunities for learners to practice and achieve the competencies they need. Clinical placements are in short supply for most disciplines and may not always be as supportive as learners hope for. Clinical teachers can find foundational guidance for their own courses in curricular structure, model, design, outcomes, evaluation methods, admission requirements and tactics for levelling student learning.

Both unplanned and planned aspects of learning must be expected. University training programs for health professionals are separate from most clinical agencies, so clinical staff responsible for guiding learners may not be fully aware of students’ programs. Instruments such as the Abbreviated Clinical Learning Environment Inventory (CLEI -19) can serve as a measure of how students perceive their clinical practicums. Ensuring that incidental or accidental learning is acknowledged and celebrated can begin to turn potentially negative clinical experiences into times of valuable learning.

Teaching in the health care professions is a dynamic process. Practitioners can share their clinical expertise with novices beginning their career or with more expert colleagues advancing their knowledge. One of the strongest motivators for becoming a clinical instructor is a desire to influence student success and shape the next generation of health professionals in your discipline, ultimately influencing the quality of care provided by future practitioners (Penn, Wilson & Rosseter, 2008). Clinical teachers are influential role models who continuously demonstrate professional skills, knowledge and attitudes (Davies, 1993; Hayajneh, 2011; Janssen, Macleod & Walker, 2008; Okoronkwo, Onyia-Pat, Agbo, Okpala & Ndu, 2013; Perry, 2009).

Becoming a Clinical Teacher

The Influence of Employment Category. Employment categories exert an important influence on the clinical teaching role. Some clinical teachers are full- or part-time employees of universities or agencies hosting clinical practicums. Workload for these teachers is negotiated with their employers and they are given release time for preparation and attendance in their assigned clinical areas. Other clinical teachers may be employed only on a contract basis.

Over the past decade, contract faculty have become the new majority at universities (Charfauros & Tierney, 1999; Gappa, 2008; Meixner, Kruck & Madden, 2010). Contracts can offer positions such as limited-term full-time faculty (Rajagopal, 2004), part-time faculty, sessional instructors, term instructors (Puplampu, 2004), and adjunct faculty (Meixner, Kruck & Madden, 2010). These faculty “are paid per course taught and are seldom offered benefits such as health insurance or access to retirement plans” (Meixner, Kruck & Madden, 2010, p. 141). Clinical teachers may be employed in different ways and at several different institutions.

Although contract employment offers employees flexibility and independence, workers who are employed on a contract basis may feel less secure in their jobs, and their sense of well-being may be negatively affected (Bernhard-Oettel, Isaksson & Bellaagh, 2008). Contract employees can feel marginalized and disadvantaged (Guest, 2004).

In university health care programs, PhD qualifications are usually required for permanent academic positions, leaving many highly skilled practitioners under-qualified (Jackson, Peters, Andrew, Salamonson & Halcomb, 2011). Often, clinical teachers are continuing their own education through graduate studies at the masters or doctoral level at the same time that they are instructing in clinical practicums. However, contract work may not accommodate the time that clinical teachers need to complete assignments for their own studies or to attend to family matters. Given the high demand for placements at clinical agencies, the times that students are scheduled to attend practicums cannot be altered and substitute instruction is seldom available.

Uncertainty about whether their employment contract will be continued can leave clinical teachers who are employed only on time-limited contracts hesitant to risk implementing new ideas. Student evaluations of teachers can reflect issues that are beyond teacher control, and yet these evaluations influence contract renewals. Student feedback is the main form of assessment for effectiveness of clinical teachers (Center for Research on Teaching and Learning, 2014; Fong & McCauley, 1993; Kelly, 2007). For some practitioners, contract employment with a university may seem less predictable than a clinical agency position.

Transitioning from Practitioner to Educator. As with any career change, the role transition from practitioner to educator can cause feelings of anxiety, isolation and uncertainty (Anderson, 2008; Dempsey, 2007; Little & Milliken, 2007; McDermid, Peters, Daly & Jackson, 2013; Penn, Wilson & Rosseter, 2008). Although specific tasks required of clinical teachers can be learned, the language, culture and practices of a university can be unfamiliar and difficult to grasp (Penn, Wilson & Rosseter, 2008). For many practitioners, discussing specific expectations for the faculty role both formally with program leaders and informally with other teachers can help.

Competencies expected of clinical teachers (Robinson, 2009) include

• being both a skilled practitioner and a skilled educator
• excellent interpersonal and professional communication skills
• implementing a range of assessment and evaluation methods
• leadership and administrative skills
• maintaining professional development and scholarship activities

Juggling the roles of practitioner and educator, and feeling as though they must be near perfect in both, can leave clinical teachers feeling threatened (Griscti, Jacono & Jacono, 2005). The professional development activities required to gain and retain competence in each role are different. Practitioners must continue to provide client care in new and different ways, and attend in-service workshops on new skills, products and equipment being used in their clinical agencies. Educators must integrate knowledge from the discipline of education, understand student-centred approaches to learning, and initiate a scholarly program of research and publication. Common to both roles are keeping up to date with research findings, attending conferences or other educational events, and undertaking self-directed study projects.

Moving beyond simply maintaining competence and towards excellence in the two roles takes time. At different points in their careers, clinical teachers may commit more time and effort to one role than the other. New clinical teachers who are experienced practitioners may initially focus on understanding the educator competency of assessing and evaluating learners.

Once novice clinical teachers gain expertise and confidence as university faculty members, they may collaborate with experienced researchers and authors to complete scholarly activities. At other times, clinical teachers may find it helpful to return to practice and strengthen their clinical expertise. Mentorship from more experienced faculty can help clinical teachers establish and work towards achieving realistic career goals (Billings & Kowalski, 2008).

Effective Clinical Teachers

The identity of clinical teachers as individuals, and as practitioners and educators, has a significant impact on their effectiveness in the clinical learning environment. The ways in which an instructor understands the process of learning will ultimately guide how they go about teaching (Hand, 2006). Rather than simply teaching as they were taught, clinical teachers are now actively seeking ways to strengthen the scholarship of educating learners in clinical learning environments (Buccieri, Pivko & Olzenak, 2013; Schmutz, Gardner-Lubbe & Archer, 2013; Sabog, Caranto & David, 2015).

If we view the clinical environment through the eyes of students, it is not unexpected that learners perceive effective teachers as individuals who demonstrate caring behaviours (Jahangiri, McAndrew, Muzaffar & Mucciolo, 2013), who are calm during stressful experiences (Smith, Swain & Penprase, 2011), who exercise patience (Cook, 2005; Parsh, 2010), and who demonstrate enthusiasm for their profession and for teaching (Gaberson & Oermann, 2010). Teachers who are approachable can help students feel less anxious and more confident (Chitsabesan, Corbett, Walker, Spencer & Barton, 2006; Sieh & Bell, 1994). Students appreciate teachers who make themselves available outside of clinical time, who take the time to answer questions without seeming annoyed, and who provide students with time to debrief and discuss issues (Berg & Lindseth, 2004). Students find it helpful when teachers are not controlling or overly cautious and allow students to learn the practice skills they need through actually doing them (Masunaga & Hitchcock, 2011). In short, students value respectful collegial relationships with their teachers (Kelly, 2007).

Effective and student-centred clinical teachers empower their students. Empowering teaching behaviours include enhancing students’ confidence, involving them in making decisions and setting goals, making learning meaningful, and helping them to become more autonomous professionals in their discipline (Babenko-Mould, Iwasiw, Andrusyszyn, Spence Laschinger & Weston, 2012). Empowering teachers care about, commit to and create with their students towards a shared vision that anything is possible (Chally, 1992).

Empowering strategies that foster a shared vision between clinical teachers and students include inviting students to identify the kinds of approaches that best support their learning style (Melrose, 2004). Effective teachers support students in identifying their personal strengths and working with teachers to build on these strengths (Cederbaum & Klusaritz, 2009). Empowering educators affirm student efforts, share positive messages and create supportive dynamics within the learning group (Chally, 1992). Note that empowering strategies also re-direct students when their work is unsatisfactory or off track.

In higher education settings, educators must assess and evaluate students’ work, thus affording educators power over whether students can continue in a course or program. The inherent tension in holding power over students while seeking to empower or share power is not easily resolved. Ultimately, clinical teachers must determine students’ grades, whether students are capable of practicing safely in their discipline, and whether students can progress in their chosen field.

In sum, clinical teachers are role models who serve their profession by nurturing and supporting the next generation of practitioners. Clinical teachers affiliated with university programs can be employed in different ways. They may be part-time or full-time continuing faculty or they may be employed on time-limited contracts for each course taught. Clinical teachers may work for several different learning institutions and clinical agencies.

Given that finding substitutes to cover clinical teaching commitments is difficult, instructors should establish contingency plans such as student phone fan-out lists for when they are ill.

In most instances, full-time faculty are qualified at the PhD level. Often clinical teachers are undertaking graduate study at the same time as they instruct in clinical practicums. Planning time to complete your own study assignments while teaching is essential.

The process of transitioning from practitioner to educator can seem overwhelming. Expectations for university faculty members may not always be clear. Seeking out mentors and collaborating with experienced faculty involved in research and publication activities can help new clinical teachers develop their own program of scholarship. As both educators and practitioners, clinical teachers must gain and maintain competence in both areas. At different times in their career, clinical teachers may focus more on one set of these competencies.

In addition to demonstrating competence and expertise in their discipline, effective clinical teachers project a calm, patient, approachable and enthusiastic attitude during their interactions with students. Effective clinical teachers go beyond what is required of them and find ways to empower and inspire students with the idea that anything is possible. Whether students are progressing well, need re-directing or are failing, effective clinical teachers work from a student-centred approach based on student strengths to affirm and support students to success.

Like snowflakes, no two students are alike. Learners coming to clinical areas of health care may be young adults beginning their higher education at a local college or university, adult learners just launching their university learning, or may have already completed undergraduate or graduate degrees. Students may be living at home with family or far away in a new location. Some may have been awarded advanced credit. Other students may have been educated in different countries and may have cultural orientations that are unfamiliar to teachers, peers or agency staff. In addition to their studies, many university students are employed either part-time or full-time. Many students have extensive family responsibilities.

Despite this range of individual student diversity, teachers can expect that students in the health care professions will find the clinical learning environment stressful, at least initially. While all learners will experience and project the emotions they are feeling in unique ways, research suggests that commonalities exist. Students are likely to fear that they will harm clients, they desire to help people, they need to integrate theory and clinical practice, and they desire to master psychomotor skills (O’Connor, 2006). Mastering psychomotor skills can seem to dominate students’ views of what they feel is most important during clinical practicums. After graduating, however, learners report that having time and opportunities to practice their communication, time management and organizational skills is actually more important (Hartigan-Rogers, Cobbett, Amirault & Muise-Davis, 2007).

The high cost of tuition is a concern for most university students. Coupled with living costs that can include travel and additional accommodation at out-of-town clinical practicum sites, students face significant debt. Given the sacrifices that students in health care fields make to earn credentials in their chosen profession, understandably they usually expect to be awarded top marks and feel devastated when their efforts are graded as poor or failing.

Intergenerational Diversity

Students, teachers, clinical agency staff and clients come from different backgrounds and have different perspectives and ways of interacting. These diverse perspectives become apparent in clinical practicums as students are required to communicate with individuals with whom they have little in common. One way of understanding these diverse perspectives is to consider learners and the health care team members they must interact with in relation to the generational groups they were born into.

Although the term diversity is often used in relation to race or ethnicity, diversification can occur when multiple generations work or study together (Fry, 2011; Johnson & Romanello, 2005; Weston, 2006). Each generation grows up with different life experiences and these experiences influence how members of a generational cohort view the world, how they communicate, and how they approach teaching and learning (Billings, 2004; Notarianni, Curry-Lourenco, Barham & Palmer, 2009).

A generation is a group of people or cohort who progress through time together, holding or sharing a common place in history. Each group shares social and political events that usually span 15 to 20 years. As a result, they view the world differently than generations born before and after. However, we must not make assumptions that all individuals of a particular age will demonstrate characteristics associated with their cohort. In some instances, though, linking an individual’s way of being in the world with characteristics expected from their generational group can be useful. Viewing learners and those they interact with through a generational lens can promote awareness of today’s students, their expectations, and how teachers can respond to their needs (Earle & Myrick, 2009).

Currently, four active generations are interacting in schools, workplaces, homes, families and communities (Gibson, 2009; Weston, 2006). These four generations are known as the Traditionalists or Veterans or Silent Generation, born between 1900 and 1945; Baby Boomers or Sandwich Generation, born between 1946 and 1964; Generation X or Nexers, born between 1965 and 1980; and Millennials or Generation Y or Net Generation, born between 1981 and 2002. A fifth generation, Generation Z, learners born after 1995, is now entering universities.

Traditionalists. Students are most likely to meet Traditionalists as clients during clinical practicums. Having lived through World Wars and the Great Depression, those born during this period commonly experienced hardship. As a result they worked hard, were loyal and believed the sacrifices they made would be rewarded (Tilka Miller, 2007). The world of this generation was very different than today. News came from newspapers and radios; shopping was done locally. Members of this generation were willing to conform to their parents’ beliefs, rather than rebel, and they have been able to adapt to changes in the world (Johnson & Romanello, 2005). Their early work environments had clearly defined hierarchies, with plainly outlined rules, roles, policies and procedures that employees were required to implement (Weston, 2006).

In health care environments, uniforms offered immediate explanations to this generation of who the health care providers were and what could be expected from them. In today’s fast-paced and technology-rich health care environments, Traditionalists may be unsure of students’ roles and may find their explanations difficult to understand.

Baby Boomers, now in their 50s, 60s and 70s, are presently the largest cohort working in health care (Fry, 2011). Students will meet members of this generational group primarily as the clinical leaders and practitioners in their practicums. Many Boomers grew up in a healthy, flourishing economy where hospitals and schools thrived. Positive social influences on this generation encouraged baby boomers to think as individuals from a young age, to express themselves creatively, and to speak out when not in agreement with others.

Many women in this generation were socialized into the primarily female professions of nursing or teaching, as these educational opportunities were widely available (Hill, 2004). Women of the Boomer generation were the first to work outside the home. This resulted in appreciably different home lives for the next generations.

In response to growing up in an era of prosperity, Boomers were willing to work long hours to pursue their goals, often in a relentless manner that may have negatively affected their personal lives (Stewart & Torges, 2006). Boomers are now often sandwiched between caring for their aging parents and their adult children. They are also investing considerable time, effort and money into health maintenance and retirement (Johnson & Romanello, 2005). Given their leadership roles and experience in health care, Baby Boomers may be seen as intimidating by students.

Generation Xers, now in their 30s and 40s, are a much smaller group and have been referred to as a bridge between the generations born before and after the introduction of the Internet (Wortsman & Crupi, 2009). They grew up with computers, video games and microwaves, and are comfortable and skilled using new technologies. They expect instant access to information.

Members of this cohort were raised by two working parents or by single mothers and thus became known as the ‘latch key’ generation. They learned to manage on their own, became resourceful, and increasingly relied on friends (Walker, Martin, White & Elliot, 2006; Weston, 2006). Generation Xers have been described as having little regard for corporate life, challenging authority and expecting to have their opinions considered (Earle & Myrick, 2009; Walker, Martin, White & Elliot, 2006; Weston, 2006).

In health care environments, Generation Xers entered the workforce during the turbulent 1990s period of downsizing and restructuring. Many were unable to find full-time or continuing employment (Fry, 2011). As a result, they do not view employment as security (Hill, 2004). Opportunities for promotion may seem eclipsed by the Baby Boomers who remain in the workforce. Students will encounter Generation Xers among their peers, teachers and clinical agency staff. Until relationships are forged, students may find that Generation Xers seem impatient and somewhat unwilling to offer in-depth explanations.

Millennials, who are in their teens through to early 30s, were raised by Boomers who were actively involved in their learning. They have high levels of self-confidence and share a close relationship with their parents and members of their parents’ generation (Hill, 2004). Millennials are the second largest generational cohort in the general population (Buruss & Popkess, 2012; Wortsman & Crupi, 2009). They are fully comfortable with technology and with living in a diverse world. Millennials are considered the most culturally diverse generation of all time (Earle & Myrick, 2009; Walker, Martin, White & Elliot, 2006).

This group of learners has a strong capacity to multitask, but their multitasking has the potential to erode their capacity to sustain focus and attention (Sherman, 2009). Their education has equipped Millennials with abilities to work well collaboratively and on teams, extending respect to each member of a group (Wortsman & Crupi, 2009). This cohort is accustomed to and requires immediate feedback (Bednarz, Schim & Doorenbos, 2010) and positive reinforcement (McCurry & Martins, 2010).

Millennials will be present in student, teaching and staff groups. Students may find that individuals from this group are fun-loving, friendly and approachable, particularly if students are Millennials themselves. Some members of this generational cohort may have had limited exposure to failure or even to negative feedback.

Generation Zers are people born after 1995, who comprise one-quarter of the North American population (Kingston, 2014). They lived through the terrorist bombings of 9/11 and the 2008 recession. Known as screenagers or digital natives, members of this cohort have grown up with the internet, social media and smartphones, and are considered the most connected generation in history (McCrindle & Wolfinger, 2014; Sparks & Honey, n.d.). Raised in inclusive classrooms, Generation Zers are collaborative and over half will be university educated (Sparks & Honey, n.d.). They work quickly, can have short attention spans, communicate with symbols, and may not be precise or put effort into their writing (Sparks & Honey, n.d.).

Clinical teachers can use information about generational diversity as an introduction to who their students are and to create individualized instruction that will help them succeed. The wisdom gleaned from Traditionalists; the drive modeled by Baby Boomers; the resourcefulness demonstrated by Generation Xers; the team spirit so ready to be tapped in the Millennials; and the connectivity of Generation Zers can all be integrated into innovative teaching strategies.

Emotional Diversity

Another way to understand the diverse perspectives students bring to their clinical learning environment is to examine the diverse range of emotional issues many face. Just as members of the general population deal with learning disabilities, substance abuse, poor mental health or many other emotionally taxing problems, so do students enrolled in health care programs. Increased numbers of students with learning disabilities (Child & Langford, 2011; McPheat, 2014: Meloy & Gambescia, 2014; Ridley, 2011; Sanderson-Mann, Wharrad & McCandless, 2012), substance abuse problems (Monroe & Kenaga, 2010; Murphy-Parker, 2013), and poor mental health (Arieli, 2013; Megivern, Pellerito & Mowbray, 2003; Storrie, Ahern & Tuckett, 2012) are successfully completing their programs. Although help and accommodation for these students is more readily available, the stigma associated with their issues makes students reluctant to share the challenges they are working through.

Clinical teachers are not, and should not be, learning disability specialists or addiction and mental health counsellors. They must, however, know what program resources are available to students. All clinical teachers, whether they are full-time continuing faculty or teaching only one clinical course, should visit their university counselling centre and become fully informed about services offered.

Learning disabilities. Most accommodations for learning disabilities are geared to academic class activities. For example, students with dyslexia benefit from supplemental study skills modules (Wray, Aspland, Taghzouit & Pace, 2013). If these kinds of modules are available, clinical teachers should familiarize themselves with the content and highlight clinical applicability during clinical conference discussions. This would normalize the use of such resources. Non-dyslexic students might also find the supplemental activities a useful way to transfer theory to practice.

Research is beginning to reveal more about the nature of the difficulties experienced by learning disabled students in clinical placements. For example, dyslexic nursing students have more trouble writing patient notes and using care plans than non-dyslexic students (Morris & Turnbull, 2006). Dyslexic students struggle with clinical documentation, drug calculations and patient handovers (Sanderson-Mann, Wharrad & McCandless, 2012). Supports established in the academic setting may not be communicated to people instructing and precepting students in the clinical setting (Howlin, Halligan & O’Toole, 2014.) Learning disabled students state that they would benefit from time spent with a clinical placement mentor who understands their specific learning issues (Child & Langford, 2011). Early referral and testing for students experiencing difficulties associated with dyslexia should be encouraged so that students can receive the support they need as soon as possible (Ridley, 2011).

Focusing on abilities offers important balance in any discussion of disabilities. Individuals with learning disabilities have been characterized as focused, resilient, empathetic, compassionate and intuitive, and they are known to have excellent interpersonal and problem-solving skills (Wray, Aspland, Taghzouit & Pace, 2013). These attributes are highly valued in health care practitioners. Many clinicians with learning disabilities have found suitable strategies to overcome their learning difficulties and are thriving in their field.

Substance abuse. The incidence of substance abuse among health care professionals and students is both under-researched and under-reported, but 10% to 15% of health care professionals are estimated to be afflicted with alcohol or drug addiction (Monroe & Kenaga, 2010). In most jurisdictions, reporting is mandatory when any professional or student is impaired. When clinical teachers encounter an impaired student, the student must be sent off the clinical area immediately and the incident reported to the teacher’s supervisor. With this action, safety must be considered in areas such finding alternative transportation if the student drove to the clinical site. Instructor and student should contract to discuss the incident when the student is no longer impaired.

Neither students nor practitioners should ever practice when impaired. Unfortunately, individuals with substance abuse issues may not believe they have a problem and may be reluctant to seek help. When clinical teachers identify substance abuse or the potential for substance abuse in their students and initiate referrals to university counselling services, they provide a critical lifeline. Throughout the world, programs are becoming available that offer confidential, non-punitive assistance for health care professionals and students suffering from addictions (Monroe & Kenaga, 2010). Ignoring issues related to substance abuse is not an option.

Poor mental health. Students with emotional problems are present across health care disciplines and in clinical placements. Learners with mental health issues can demonstrate inappropriate behaviours including anger, neediness and inability to complete tasks (Storrie, Ahern & Tuckett, 2012). They may display poor motivation, negativity, overconfidence or an inability to work as a member of the health care team. They may not accept responsibility for their actions and may not change their behaviour in response to feedback.

In response, clinical teachers can feel anxious, distressed, intimidated or unsure about what to do (Storrie, Ahern & Tuckett, 2012). When students present with a psychiatric or mental health crisis, they must be accompanied to an emergency treatment facility. In non-emergency situations, the best course of action is less clear. University counselling services are not immediately available to students when they are in practice areas. Other members of the student group, as well as agency clients and staff, will be affected by any inappropriate student behaviour.

Storrie, Ahern & Tuckett (2012, p. 101) suggest the following four strategies that clinical teachers can consider when responding to students with poor mental health.

1. Communicate with colleagues in advance about high risk students who might have special needs in a clinical placement.
2. Maintain a consistent approach by following university procedures. If a student has a complaint, they are to first address it at a local level with clinical teachers. If the complaint is not resolved, students must formalise the complaint via a letter to a university supervisor.
3. Keep a clear audit trail by documenting any encounter with the student and regularly briefing your immediate supervisor.
4. Determine if the problem can be managed by rearranging the design of the student’s study plan. A revised plan will consider the student’s needs and strengths, but still maintain academic expectations.

Developing Independence

Health care students may be generationally or emotionally diverse, but they share the common goal of needing to develop professional independence during their clinical practicums. Through a stepwise process of gradually decreasing direction and guidance from teachers and agency staff, learners must work towards practicing independently. University-educated professionals in health care fields are required to think and act on their own, with limited or no direction from professional colleagues. Crisis is an everyday occurrence. Once learners graduate, they will be expected to implement client care independently.

The processes and strategies that learners use to develop independence as practitioners are inherently difficult to understand. Seminal literature from the field of adult education indicates that a key element in developing independence in any educational activity is for students to take responsibility for their learning above and beyond responding to instructions (Boud, 1988; Knowles, 1975). Becoming independent requires students to choose suitable learning activities, reflect on their effectiveness, and initiate any needed changes (Holec, 1981; Little, 1991).

In chaotic clinical learning environments, where maintaining client safety is critically important, students can feel unsure about how they could or should go beyond what they have been instructed to do. An inherent tension lies between providing safe client care and initiating new or perhaps unfamiliar activities in clinical practicums. Ameliorating that tension is different from trying out new ideas in academic classroom settings. Students may not feel that they have developed the independence they need to function in a complex professional role until nearly a year after they graduate (Melrose & Wishart, 2013).

In sum, students in the health care professions are a diverse group. Some will be new to university and others will be experienced adult learners. Despite differences in their backgrounds, they can all be expected to be highly invested in their education and will have made sacrifices to complete clinical practicums. Most will feel anxious initially, particularly in their desire to provide safe care and to pass course requirements.

Student groups will include learners from different generations. Clinical teachers may find it helpful to come to know their students as members of a generational cohort. Students will meet Traditionalists or older adults as clients and Baby Boomers or middle-aged adults as clinical leaders and practitioners. They will meet Generation Xers in their 30s and 40s and Millenials in their 20s in peer, instructor and agency staff groups. They will meet Generation Zers in their late teens and early 20s in peer groups. Traditionalists are known for their wisdom and experience; Baby Boomers for their leadership and drive; Gneeration Xers for their resourcefulness and willingness to challenge; Millenials for their confidence and team spirit; and Generation Zers for their ability to work collaboratively.

Student groups will also include learners with emotionally diverse needs related to learning disabilities, substance abuse or poor mental health. To accommodate these learners and ensure public safety, clinical teachers must have a clear understanding of any program resources and policies relevant to special needs students. Key strategies for supporting troubled students include 1) documenting both student behaviours and teacher responses implemented to help, and 2) consistently keeping supervisors informed.

Students and teachers in clinical learning environments share the common goal of developing independent practitioners. Becoming independent is work in progress for students, teachers and clinicians alike. By grounding instruction in the premise that students will soon be on their own and responsible for their practice, the importance of supporting students towards initiating and managing their own learning becomes clear.

Clinical environments are ‘classrooms’ rich with planned, unplanned and incidental opportunities for creative teaching and meaningful learning. Some clinical placements may not be as supportive as learners would like and clinical agency staff may not be fully aware of students’ programs. Still, more practitioners are embracing the view that supporting students is a valuable part of their own professional development.

Clinical teachers, whether they are continuing faculty members or employed only on a course-by-course basis, are impactful role models who can make a critical difference in their students’ lives. Students view effective clinical teachers as individuals who are calm, patient, enthusiastic and approachable. Excellent teachers seek to empower and inspire their students. Clinical teachers are often continuing their own graduate studies and juggling career plans that require expertise in both their practice discipline and in the field of education.

The students that clinical teachers meet in clinical practicums come from diverse generational backgrounds. Some will need unique instructional and institutional support as they deal with issues such as learning disabilities, substance abuse or poor mental health. Clinical teachers must familiarize themselves with polices related to special needs students and with any counselling resources that are available to students. The stakes are high in university health care programs and students have all made sacrifices. They want to succeed, to earn top marks and to practice independently once they graduate.

In this chapter we examined the clinical learning environment and asked who the teachers and students are in this environment. We hope the creative strategies mentioned will provide practical ideas to help clinical teachers with the complex problems they face daily. Perhaps the process of questioning and seeking to understand how our learners see the clinical environment is as important as the answers themselves.

Anderson, J. (2008). An academic fairy tale: A metaphor of the work-role transition from clinician to academician. Nurse Educator, 33(2), 79–82.

Arieli, D. (2013). Emotional work and diversity in clinical placements of nursing students. Journal of Nursing Scholarship, 45(2), 192–201. doi: 10.1111/jnu.12020

Babenko-Mould, Y., Iwasiw, C., Andrusyszyn, M., Spence Laschinger, H. & Weston, W. (2012). Nursing students’ perceptions of clinical teachers’ use of empowering teaching behaviours: Instrument psychometrics and application. International Journal of Nursing Education Scholarship, 9(1), Art. 5. doi: 10.1515/1548-923X.2245

Bednarz, H., Schim, S. & Doorenbos, A. (2010). Cultural diversity in nursing education: Perils, pitfalls, and pearls. Journal of Nursing Education, 49(5), 253–260.

Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice. (Commemorative ed.). Boston: Pearson Education.

Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses. A call for transformation. San Francisco: Jossey-Bass.

Berg, C. & Lindseth, G. (2004). Student’s perspectives of effective and ineffective nursing instructors. Journal of Nursing Education, 43(12), 565–568.

Bernhard-Oettel, C., Isaksson, K. & Bellaagh, K. (2008). Patterns of contract motives and work involvement in temporary work: Relationships to work-related and general well-being. Economic and Industrial Democracy, 29(4), 565–591. doi:10.1177/0143831X08096231

Billings, D. (2004). Teaching learners from varied generations. The Journal of Continuing Education in Nursing, 35(3), 104–105.

Billings, D. & Kowalski, K. (2008). Developing your career as a nurse educator: The importance of having (or being) a mentor. Journal of Continuing Education in Nursing, 39(11), 490–491.

Bond, M. (2009) Exposing shame and its effect on clinical nursing education. Journal of Nursing Education, 48(3), 132–140.

Boud, D. (1988; Ed.). Developing student autonomy in learning. London: Kogan Page.

Brown, T., Williams, B., McKenna, L., Palermo, C., McCall, L., Roller, L., Hewitt, L., Molloy, L., Baird, M. & Aldabah, L. (2011). Practice education learning environments: The mismatch between perceived and preferred expectations of undergraduate health science students. Nurse Education Today, 31, e22-e28. doi:10.1016/j.nedt.2010.11.013

Buccieri, K., Pivko, S. & Olzenak, D. (2013). Development of an expert clinical instructor: A theoretical model for clinical teaching in physical therapy. Journal of Physical Therapy Education, 27(1), 48–57.

Buruss, N. & Popkess, A. (2012). The diverse learning needs of students. In D. M. Billings & J. A. Halstead (Eds.), Teaching in nursing: A guide for faculty, (4th ed., pp. 15–33). St. Louis, MO: Elsevier Saunders.

Cederbaum, J. & Klusaritz, H. (2009). Clinical instruction: Using the strengths-based approach with nursing students. Journal of Nursing Education, 48(8), 422–428.

Center for Research on Teaching and Learning (2014). Guidelines for evaluating teaching. Ann Arbour MI: University of Michigan. Available at http://www.crlt.umich.edu/tstrategies/guidelines

Chally, P. (1992). Empowerment through teaching. Journal of Nursing Education, 31(3), 117–120.

Chan, D. (2001). Combining qualitative and quantitative methods in assessing hospital learning environments. International Journal of Nursing Studies, 38(4), 447–459.

Chan, D. (2002). Development of the Clinical Learning Environment Inventory: Using the theoretical framework of learning environment studies to assess nursing students’ perceptions of the hospital as a learning environment. Journal of Nursing Education, 41(2), 69–75.

Chan, D. (2003). Validation of the Clinical Learning Environment Inventory. Western Journal of Nursing Research, 25(5), 519–532.

Chan, D.S. (2004). Nursing students’ perception of hospital learning environments—an Australian perspective. International Journal of Nursing Education Scholarship, 1(1), 1–13.

Charfauros, K. H. & Tierney, W. G. (1999). Part-time faculty in colleges and universities: Trends and challenges in a turbulent environment. Journal of Personnel Evaluation in Education, 13(2), 141–151.

Child, J. & Langford, E. (2011). Exploring the learning experiences of nursing students with dyslexia. Nursing Standard, 25(40), 39–46.

Chitsabesan, P., Corbett, S., Walker, L., Spencer, J. & Barton, J. (2006). Describing clinical teachers’ characteristics and behaviours using critical incidents and repertory grids. Medical Education, 40, 645–653.

Cook, L. (2005). Inviting teaching behaviours of clinical faculty and nursing students’ anxiety. Journal of Nursing Education, 44(4), 156–161.

Courtney-Pratt, H., FitzGerald, M., Ford, K., Marsden, K. & Marlow, A. (2011). Quality clinical placements for undergraduate nursing students: A cross-sectional survey of undergraduates and supervising nurses. Journal of Advanced Nursing, 68(6), 1380–1390. doi: 10.1111/j.1365-2648.2011.05851.x

Curtis, J., Bowen, I. & Reid, A. (2007). You have no credibility: Nursing students’ experiences of horizontal violence. Nurse Education in Practice, 7(3), 156–163.

Davies, E. (1993). Clinical role modelling: Uncovering hidden knowledge. Journal of Advanced Nursing, 18, 627–636.

Dempsey, L. M. (2007). The experiences of Irish nurse lecturers’ role transition from clinician to educator. International Journal of Nursing Education Scholarship, 4(1), 1–12.

Diekelmann, N. (2003). Teaching the practitioners of care: New pedagogies for the health professions. Madison, WI: University of Wisconsin Press.

Dietitians of Canada (n.d.). Internships and Practicum Programs [Fact sheet]. Available at http://www.dietitians.ca/Career/Internships-Practicum-Programs/Overview.aspx

Duffy, A. (2009). Guiding students through reflective practice – the preceptors’ experiences. A qualitative descriptive study. Nurse Education in Practice, 9(3), 166–175.

Dunn, S.V. & Burnett, P. (1995). The development of a clinical learning environment scale. Journal of Advanced Nursing, 22, 1166–1173.

Earle, V. & Myrick, F. (2009). Nursing pedagogy and the intergenerational discourse. Journal of Nursing Education, 48(11), 624–630. doi:10.3928/01484834-20090716-08

Fong, C. & McCauley, G. (1993). Measuring the nursing, teaching and interpersonal effectiveness of clinical instructors. Journal of Nursing Education, 37(7), 325–328.

Forneris S.G. & Peden-McAlpine C. (2009). Creating context for critical thinking in practice: the role of the preceptor. Journal of Advanced Nursing, 65(8), 1715–1724.

Franklin, N. (2010). Clinical supervision in undergraduate nursing students: A review of the literature. e-Journal of Business Education & Scholarship of Teaching, 4(1), 34–42.

Fry, B. (2011). A nurse’s guide to intergenerational diversity . Ottawa ON: The Canadian Federation of Nurses Unions.

Gaberson, K. & Oermann, M. (2010). Clinical teaching strategies in nursing (3rd ed.). New York: Springer.

Gappa, J. M. (2008). Today’s majority: Faculty outside the tenure system. Change: The Magazine of Higher Learning, 40(4), 50–54. doi:10.3200/CHNG.40.4.50-54

Gibson, S. (2009). Enhancing intergenerational communication in the classroom: Recommendations for successful teacher-student relationships. Nursing Education Perspectives, 30(1), 37–39.

Griscti, O., Jacono, B. & Jacono, J. (2005). The nurse educator’s clinical role. Journal of Advanced Nursing, 50(1), 84–92.

Guest, D. (2004). Flexible employment contracts, the psychological contract and employee outcomes: An analysis and review of the evidence. International Journal of Management Review, 5-6(1), 1–19.

Hand, H. (2006). Promoting effective teaching and learning in the clinical setting. Nursing Standard, 20(39), 55–63.

Hayajneh, F. (2011). Role model clinical instructor as perceived by Jordanian nursing students. Journal of Research in Nursing, 16(1), 23–32. doi: 10.1177/1744987110364326

Hartigan-Rogers, J., Cobbett, S., Amirault, M. & Muise-Davis, M. (2007). Nursing graduates’ perceptions of their undergraduate clinical placement. International Journal of Nursing Education Scholarship, 4, 1–12.

Henderson, A, Cooke, M., Creedy, D. & Walker, R. (2012). Nursing students’ perceptions of learning in practice environments: A review. Nurse Education Today, 32, 299–302. doi:10.1016/j.nedt.2011.03.010

Hickey, M. (2010). Baccalaureate nursing graduates’ perceptions of their clinical instructional experiences and preparation for practice. Journal of Professional Nursing, 26(1), 35–41. doi:10.1016/j.profnurs.2009.03.001

Hill, K. S. (2004). Defy the decades with multigenerational teams. Nursing Management, 35(1), 32–35.

Holec, H. (1981). Autonomy in foreign language learning. Oxford: Pergamon.

Howlin, F., Halligan, P. & O’Toole, S. (2014). Evaluation of a clinical needs assessment and exploration of the associated supports for students with a disability in clinical practice: Part 2. Nurse Education in Practice, in press.

Jackson, D., Peters, K., Andrew, S., Salamonson, Y. & Halcomb, E. J. (2011). “If you haven’t got a PhD, you’re not going to get a job”: The PhD as a hurdle to continuing academic employment in nursing. Nurse Education Today, 31, 340–344. doi:10.1016/j.nedt.2010.07.002

Jahangiri, L., McAndrew, M., Muzaffar, A. & Mucciolo, T. W. (2013). Characteristics of effective clinical teachers identified by dental students: a qualitative study. European Journal of Dental Education, 17, 10–18. doi: 10.1111/eje.12012

Janssen, A. L., Macleod, R. D. & Walker, S. T. (2008). Recognition, reflection, and role models: Critical elements in education about care in medicine. Palliative and Supportive Care, 6, 389–395. doi: 10.1017/S1478951508000618

Johnson, S. & Romanello, M. (2005). Generational diversity: Teaching and learning approaches. Nurse Educator, 30(5), 212–216.

Kelly, C. (2007). Student’s perceptions of effective clinical teaching revisited. Nurse Education Today, 27(8), 885–892.

Kerka, S. (2000). Incidental learning. Trends and Issues Alert 18. Columbus OH: ERIC Clearinghouse on Adult, Career and Vocational Education. Available at http://www.calpro-online.org/eric/docs/tia00086.pdf

Kingston, A. (2014). Get ready for generation Z. Macleans, 127(28), 42–45.

Knowles, M. S. (1975). Self-directed learning: A guide for learners and teachers. New York: Association Press.

Koontz, A., Mallory, J., Burns, J. & Chapman, S. (2010). Staff nurses and students: The good, the bad, and the ugly. MEDSURG Nursing, 19(4), 240–246.

Krueger, J. (2013). Pharmacy students’ application of knowledge from the classroom to introductory pharmacy practice experiences. American Journal of Pharmaceutical Education , 77 (2), Art 31.

Leaver, D. (2012). Clinical teaching skills for radiation therapy. Radiation Therapist, 21(2), 157–181.

Levett-Jones T., Lathlean J., Higgins I. & McMillan M. (2008). The duration of clinical placements: A key influence on nursing students’ experience of belongingness. Australian Journal of Advanced Nursing, 26(2), 8–16.

Levett-Jones, T., Higgins, I. & McMillan, M. (2009). Staff student relationships and their impact on nursing students’ belongingness and learning. Journal of Advanced Nursing, 65(2), 316–324.

Little, D. (1991). Learner autonomy I: Definitions, issues and problems. Dublin: Authentik.

Little, M. & Milliken, P. J. (2007). Practicing what we preach: Balancing teaching and clinical practice competencies. International Journal of Nursing Education Scholarship, 4 (1), 1–14.

Marsick, V. & Watkins, K. (1990). Informal and incidental learning in the workplace. London & New York: Routledge.

Marsick, V. & Watkins, K. (2001). Informal and incidental learning. New directions for adult and continuing education, 89, 25–34.

Masunaga, H. & Hitchcock, M. (2011). Aligning teaching practices with an understanding of quality teaching: A faculty development agenda. Medical Teacher, 33, 124–130.

McCall, L., Wray, N. & Lord, B. (2009). Factors affecting the education of pre-employment paramedic students during the clinical practicum. Journal of Emergency Primary Health Care 7(4), Article 990334.

McCallum, C., Mosher, P., Jacobson, P., Gallivan, S. & Giuffre, S. (2013). Quality in physical therapist clinical education: A systematic review. Physical Therapy 93(10), 1298–1311.

McCrindle, M. & Wolfinger, E. (2014). The ABC of XYZ: Understanding the global generations. Bella Vista NSW, Australia: McCrindle Research.

McCurry, M. & Martins, D. (2010). Teaching undergraduate nursing research: A comparison of traditional and innovative approaches for success with millennial learners. Journal of Nursing Education, 49(5), 276–279. doi: 10.3928/01484834-20091217-02

McDermid, F., Peters, K., Daly, J. & Jackson, D. (2013). ‘I thought I was just going to teach’: Stories of new nurse academics on transitioning from sessional teaching to continuing academic positions. Contemporary Nurse, 45(1), 46–55.

McPheat, C. (2014). Experience of nursing students with dyslexia on clinical placement. Nursing Standard, 28(41), 44–49.

Megivern, D., Pellerito, C. & Mowbray, C. (2003). Barriers to higher education for individuals with psychiatric disabilities. Psychiatric Rehabilitation Journal, 26(3), 217–232.

Meixner, C., Kruck, S. E. & Madden, L. T. (2010). Inclusion of part-time faculty for the benefit of faculty and students. College Teaching, 58, 141–147. doi:10.1080/87567555.2010.484032

Meloy, F. & Gambescia, S. F. (2014). Guidelines for Response to Student Requests for Academic Considerations: Support Versus Enabling. Nurse Educator, 39(3), 138–142. doi:10.1097/NNE.0000000000000037

Melrose , S. & Shapiro, B. (1999). Students’ perceptions of their psychiatric mental health clinical nursing experience: A personal construct theory exploration. Journal of Advanced Nursing, (30)6, 1451–1458.

Melrose, S. (2004). What works? A personal account of clinical teaching strategies in nursing. Education for Health, 17(2), 236–239.

Melrose, S. & Wishart, P. (2013). Resisting, reaching out and re-imagining to independence: LPNs’ transitioning towards BNs and beyond. International Journal of Nursing Education Scholarship, 10(1), 1–7.

Mohide E. & Matthew-Maich N. (2007). Implementation forum. Engaging nursing preceptor-student dyads in an evidence-based approach to professional practice. Evidence-Based Nursing, 10(2), 36–40.

Monroe, T. & Kenaga, H. (2010). Don’t ask don’t tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing, 20, 504–509. doi: 10.1111/j.1365-2702.2010.03518.x

Morris, D. & Turnbull, P. (2006) Clinical experiences of students with dyslexia. Journal of Advanced Nursing, 54(2), 238–247.

Murphy-Parker, D. (2013). Implementing policy for substance-related disorders in schools of nursing: The right thing to do. Dean’s Notes, 3(4), 1–5.

Newton, M., Jolly, B., Ockerby, C. & Cross, W. (2010). Clinical Learning Environment Inventory: Factor analysis. Journal of Advanced Nursing, 66(6), 1371–1381. doi: 10.1111/j.1365-2648.2010.05303.x

Notarianni, M., Curry-Lourenco, K., Barham, P. & Palmer, K. (2009). Engaging learners across generations: The progressive professional development model. The Journal of Continuing Education in Nursing, 40(6), 261–266. doi:10.9999/00220124-20090522

O’Connor, A. (2006). Clinical instruction and evaluation: A teaching resource. Boston: Jones & Bartlett.

Okoronkwo, I., Onyia-Pat, J., Agbo, M., Okpala, P. & Ndu, A. (2013). Students’ perception of effective clinical teaching and teacher behaviour. Open Journal of Nursing, 3, 63–70. doi.org/10.4236/ojn.2013.31008

Parsh, B. (2010). Characteristics of effective simulated clinical experience instructors: Interviews with undergraduate nursing students. Journal of Nursing Education, 49(10), 569–572.

Paulis, M. (2011). Comparison of dental hygiene clinical instructor and student opinions of professional preparation for clinical instruction. Journal of Dental Hygiene, 85(4), 297–305.

Penn, B., Wilson, L. & Rosseter, R., (2008). Transitioning from nursing practice to a teaching role. The Online Journal of Issues in Nursing, 13(3) Manuscript 3. Retrieved from www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No3Sept08/NursingPracticetoNursingEducation.aspx

Perry, B. (2009). Role modeling excellence in clinical nursing practice. Nurse Education in Practice, 9, 36–44. doi: 10.1016/j.nepr.2008.05.001

Puplampu, K. P. (2004). The restructuring of higher education and part-time instructors: A theoretical and political analysis of undergraduate teaching in Canada. Teaching in Higher Education, 9(2), 171–182. doi:10.1080/1356251042000195376

Rajagopal, I. (2004). Tenuous ties: The limited-term full-time faculty in Canadian universities. Review of Higher Education, 28(1), 49–75.

Ridley, C. (2011). The experiences of nursing students with dyslexia. Nursing Standard, 25, 24, 35–42.

Robinson A.L., Andrews-Hall S. & Fassett M. (2007). Living on the edge: Issues that undermine the capacity of residential aged care providers to support student nurses on clinical placement. Australian Health Review, 31(3), 368–378.

Robinson, C. (2009). Teaching and clinical educator competency: Bringing two worlds together. International Journal of Nursing Education Scholarship, 6(1), Art 20. doi: 10.2202/1548-923X.1793

Roger, S, Webb, G., Devitt, L., Gilbert, J. & Wrightson, P. (2008). Clinical education and practice placements in the allied health professions: An international perspective. Journal of Allied Health, 37(1), 53–62.

Rodger, S., Fitzgerald, C., Davila, W., Millar, F. & Allison, H. (2011). What makes a quality occupational therapy practice placement? Students’ and practice educators’ perspectives. Australian Occupational Health Journal, 58, 195–202.

Ruesseler, M. & Obertacke, U. (2011). Teaching in daily clinical practice: How to teach in a clinical setting. European Journal of Trauma Surgery, 37, 313–316.

Sabog, R., Caranto, L. & David, J. (2015). Effective characteristics of a clinical instructor as perceived by BSU student nurses, International Journal of Nursing Science, 5(1), 5–19. doi: 10.5923/j.nursing.20150501.02

Salamonson, Y., Bourgeois, S., Everett, B, Weaver, R., Peters, K. & Jackson, D. (2011). Psychometric testing of the abbreviated Clinical Learning Environment Inventory (CLEI-19). Journal of Advanced Nursing, 67(12), 2668–2676. doi: 10.1111/j.1365-2648.2011.05704.x

Sanderson-Mann, J., Wharrad, H. & McCandless, F. (2012). An empirical exploration of the impact of dyslexia on placement-based learning, and a comparison with non-dyslexic students. Diversity and Equality in Health and Care, 9, 89–99.

Schmutz, A., Gardner-Lubbe, S. & Archer, E. (2013). Clinical educators’ self-reported personal and professional development after completing a short course in undergraduate clinical supervision at Stellenbosch University. African Journal of Health Professions Education, 5(1), 8–13. doi:10.7196/AJHPE.194

Sherman, R. (2009). Teaching the Net Set. Journal of Nursing Education, 48(7), 359–360. doi:10.3928/01484834-20090615

Sieh, S. & Bell, S. (1994). Perceptions of effective clinical teachers in associate degree programs. Journal of Nursing Education, 33(9), 389–394.

Smith, C., Swain, A. & Penprase, B. (2011). Congruence of perceived effective clinical teaching characteristics between students and preceptors of nurse anesthesia programs. Journal of the American Association of Nurse Anesthetists, 79(4), 62–68.

Sparks & Honey. (n.d.). Meet generation Z: Forget everything you learned about millennials [Power Point]. Available at http://www.slideshare.net/sparksandhoney/generation-z-final-june-17

Stewart, A. & Torges, C. (2006). Social, historical and developmental influences on the psychology of the baby boom at midlife. In S. Whitbourne & S. L. Willis (Eds.) The baby boomers grow up: Contemporary perspectives on midlife (pp. 23–43). Mahwah, HJ: Lawrence Erlbaum Associates.

Storrie, K., Ahern, K. & Tuckett, A. (2012). Crying in the halls: Supervising students with symptoms of emotional problems in the clinical practicum. Teaching in Higher Education, 17(1), 89–103.

Tanner, C. (2006). The next transformation: Clinical education. Journal of Nursing Education. 45, 99–100.

Tilka Miller, E. (2007). Bridging the generation gap. Rehabilitation nursing, 32(1), 2–3, 43.

Walker, J.T., Martin, T., White, J. & Elliot, R. (2006). Generational (Age) differences in nursing students’ preferences for teaching methods. Journal of Nursing Education, 45(9), 371–376.

Weston, M. (2006). Integrating generational perspectives in nursing. Online Journal of Issues in Nursing, 11(2), 2.

Wortsman, A. & Crupi, A (2009). Addressing issues of intergenerational diversity in the nursing workplace. Ottawa ON: Canadian Federation of Nurses Unions.

Wray, J., Aspland, J., Taghzouit, J. & Pace, K. (2013). Making the nursing curriculum more inclusive for students with specific learning difficulties (SpLD): Embedding specialist study skills into a core module. Nurse Education Today, 33, 602–607.