Role Modelling in Undergraduate Nursing Education: An Integrative Literature Review

Abstract

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

Full text

Review
Role modeling in undergraduate nursing education: An integrative
literature review
Adele Baldwin
a,
⁎,JaneMills
b
, Melanie Birks
a
,LeaBudden
a
a
School of Nursing, Midwifery and Nutrition, James Cook University, Townsville, Queensland 4810, Australia
b
School of Nursing, Midwifery and Nutrition, James Cook University, Cairns, Queensland 4878, Australia
summaryarticle info
Article history:
Accepted 19 December 2013
Available online xxxx
Keywords:
Nurse academic
Nurse education
Preceptor
Role modeling
Undergraduate nursing studies
The transition of nursing education from the hospital setting to the university sector over recent decades has
opened dialog about who is guiding the development of nursing students' professional identity. In addition,
there is ongoing debate over real or perceived gaps between nursing student learning in the university and
the clinical area, how this translates into professional behaviors and how well students make the transition
between the two settings. This paper presents the findings of an integrative literature review into the topic of
role modeling in undergraduate nursing education.
This review was conducted to identify and appraise research findings about role modeling of professional behaviors
for undergraduate nursing students. Literature reviewed from 2000 onwards assesses what is currently known
about role modeling of undergraduate nursing students. A systematic search of the databases of CINAHL, Scopus
and PubMed from 2000 onwards resulted in the selection of 33 articles for deeper analysis.
Two clear themes emerged from the literature, the first relating to nurse clinicians as role models for students
during clinical placements and the second relating to nurse academics as role models in the academic setting.
Findings from this integrative literature review show an imbalance in the recognition of the role modeling of
professional behaviors in the clinical versus the academicsetting. Nurses in academic settings have more contact
with the students over their period of study and as such, the significance of nurse academics as student role
models requires further investigation.
© 2013 Elsevier Ltd. All rights reserved.
Introduction
Role modeling has a number of definitions and interpretations in the
literature, but it is widely accepted that it refers to the observation of be-
haviors or attitudes of someone that one admires and the subsequent
adopting of those behaviors or attitudes for oneself (Cruess et al.,
2008). Role modelingin health isrepresented in the literature,predom-
inantly in relation to health professionals' role modeling healthy behav-
iors for the community (Blake et al., 2011; Yancey et al., 2011).
However, health professionals' role modeling for students receives spo-
radic attention. Role modeling by experienced practitioners for students
in medical education is the subjectof frequentdiscussion (Alpert, 2011;
Byszewski et al., 2012; Cruess etal., 2008; Curry et al., 2011; Kenny et al.,
2003); role modeling in other health disciplines, including rehabilita-
tion sciences is not so common (Hobson and Walmsley, 2006). Com-
paratively, role modeling in nursing education has been the subject of
limited previous research.
Current trends in nursing education to produce work-ready gradu-
ates include adopting a range of innovative teaching and learning
strategies to integrate all ways of learning nursing knowledge into
curricula design (Baldwin et al., in press; Benner et al., 2009). Develop-
ing an understanding of covert teaching practices such as role modeling
will allow for their inclusion in formal curricula that incorporates
multiple ways of student learning.
Background/literature
Aim
This review was conducted to identify and appraise research
findings about role modeling of professional behaviors for under-
graduate nursing students. Specifically this paper will identify who the
role models are for undergraduate nursing students and in what setting
the role modeling occurs for undergraduate nursing students.
Method
A systematic literature search was conducted using the following
key terms: role model*, nurs*, educat*, and student to search the
CINAHL, ProQuest and Scopus databases. The search was date limited
Nurse Education Today xxx (2013) xxx–xxx
⁎Corresponding author.
E-mail address: adele.baldwin@jcu.edu. au (A. Baldwin).
YNEDT-02655; No of Pages 9
0260-6917/$ –see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2013.12.007
Contents lists available at ScienceDirect
Nurse Education Today
journal homepage: www.elsevier.com/nedt
Please cite this article as: Baldwin,A., et al., Role modeling in undergraduate nursingeducation:An integrative literature review, Nurse Educ. To-
day (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.007

from 1999 to 8th December 2012 and included peer-reviewed journal
articles, IN PRESS articles, and those published in English. The following
table lists the results from each of these searches (see Table 1). The
initial literature search strategy was re-run in July 2013 to ensure that
there were no recent additions to the literature that had been missed.
This resulted in the inclusion of a new paper presenting the results of
research into role modeling published in July 2013.
Results
Search results were combined and duplicates removed. Abstracts of
the 714 articles identified in the searches were downloaded and read to
assess their relevance to the aim of this integrative literature review. Of
these 714 abstracts, 116 articles were retained and the full text of each
was downloaded for further reading. Of these 116 papers, 84 were
discarded as not relevant to the question posed, leaving a final thirty-
two articles for review. The inclusion of the 2013 published paper by
Nouri et al. (2013) results in a total of thirty-three articles for review.
Each of the final 33 papers was analyzed for content, rigor, reliability
and relevance to the research. As a recognized framework for evaluation
of published research, the Critical Appraisal Skills Programme (CASP)
tools were used as criteria for this purpose. CASP questions were utilized
to promote an objective, consistent analysis of the research findings
reported in the included articles (CASP, 2010). The choice of the specific
CASP instrument used was based on the research methods in the paper
under review. That is, the qualitative tool was used for qualitative
research and the cohort tool was used for quantitative research. Papers
reporting mixed methods research were all presented in two parts; the
qualitative component in one paper and the quantitative component in
another, thus, the relevant tool was used to review each paper as an
independent publication. The standard template from CASP (CASP,
2010) using 10 questions to assess qualitative articles and 12 questions
to assess quantitative articles was employed. Using the CASP instru-
ments facilitated a systematic appraisal of the trustworthiness of the
current research as it pertains to the research question. Table 2 contains
the final set of papers analyzed in this literature review according to
theme. Key issues from the CASP analysis are also identified in the
Summary of findings column.
Literature Review
The articles in this review relate the findings of research studies that
utilized a range of research methods, of which 27 were qualitative
studies and four were quantitative. Three of the articles were reporting
the qualitative findings of a mixed method research design. These sam-
ple sizes varied in number from as few as four participants to a
maximum number of 320 in the qualitative studies and from 10 to
1903 for the quantitative studies. Further, the specificity of the research
question being asked will also impact on the sample size from which to
gather the data, although this may impact on the transferability of
findings in some cases.
Results
The literature was read and reread several times in the process of
analysis. Of the 33 papers included the large majority (n = 26) discuss
research findings related to role modeling during clinical placement.
Comparatively, only seven articles report findings related to role
modeling in the academic setting. The two themes identified in this
integrative literature review therefore are:
1. Nurse clinicians as role models in the professional development of
nursing students during clinical placement
2. Nurse academics as role models in the professional development of
nursing students.
Theme 1: Nurse Clinicians as Role Models in the Professional Development
of Nursing Students
Twenty-six out of 33 publications relate to nursing students'
experiences in a clinical setting, in particular relating to compulsory
clinical placement experience undertaken during their course of study.
Of these papers, two manuscripts report findings from research with
nurses working in the clinical setting, including facilitators, mentors
and preceptors; twenty report the experiences of nursing students;
and four report findings from research with both clinicians and
students. Overall each of the articles analyzed reflects students having
positive experiences in clinical areas. However within this, students re-
port that feelings of inclusion and valuing of their knowledge and skills
impact on how they responded to their clinical placements and in turn
how well they achieved the associated learning outcomes. Both stu-
dents and nurses in clinical areas report the important role that experi-
enced clinicians play in the professional development of students.
Two of the papers included were literature reviews (Allan et al., 2008;
Dorsey and Baker, 2004) and one paper presents the findings of a meta-
synthesis of the current literature about the development of nursing
students' perceptions of patients as human beings (Rudolfsson and
Berggren, 2012).
A strong element of this theme is how students adopt the behaviors
of clinician role models they work with to varying degrees. However,
some of the articles pay particular attention to the student experience
of being exposed to both good and bad role models (Perry, 2009)and
students' intuitive choice to emulate those they perceive to be “good
nurses”(Donaldson and Carter, 2005; Ferguson, 2011; Grealish and
Ranse, 2009). Other authors also discuss how students “pick and
choose”which professional traits they adopt (Gray and Smith, 2000;
Hanson, 2013; Levett-Jones et al., 2007). Students report adopting traits
that they perceive value good clinical practice, are centered around the
patient or recipient of care, show respect for, and receiverespect from
colleagues, and those professional behaviors that demonstrate that a
nurse wants to be a part of providing care to a patient. Even a bad role
model can have a positive impact on the student in that they recognize
the type of nurse they do not want to be (Grealish and Ranse, 2009). The
characteristics of good and bad role models include reference to how
experienced clinicians include and respect the student, how they
Table 1
Search terms.
Database Search terms Limitations Results
Scopus Role model* AND nurs* AND educat* AND student Publication years 1999–2012
Limit to English;
Journal articles including IN PRESS
555
CINAHL Role model* AND nurs* AND educat* AND student Publication years 1999–2012
Limit to English;
Journal articles including IN PRESS
8
PubMed Role model* AND nurs* AND educat* AND student Publication years 1999–2012
Limit to English;
Journal articles including IN PRESS
151
2A. Baldwin et al. / Nurse Education Today xxx (2013) xxx–xxx
Please cite this article as: Baldwin,A., et al., Role modeling in undergraduate nursingeducation:An integrative literature review, Nurse Educ. To-
day (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.007

provide care to the patient, and if they follow best practice and evi-
denced based guidelines (Perry, 2009; Rudolfsson and Berggren, 2012).
Identifying the characteristics of good and bad role models weaves
through the literature with several articles (Gray and Smith, 2000;
Grealish and Ranse, 2009; Hayajneh, 2011; Lee et al., 2002) clearly
defining each of these behavior types. Researchers describe characteris-
tics including mentor approachability, ability to instill confidence,
create a relaxing atmosphere, be available when needed, act as a
student advocate, support learning, tolerate students' mistakes, show
confidence in student abilities and respect student opinions, demon-
strate skills, show genuine interest in patients, and provide students
with timely feedback (Hayajneh, 2011). Another study identifies
students' highest rated characteristic of an effective clinical educator
as being “a good role model”, while the highest rated characteristic of
an effective clinical educator by clinical educators was “enjoys nursing”.
In comparison to the students in this study, clinical educators' rank “is a
good role model”as the fourth highest characteristic (Lee et al., 2002).
These student perceptions of thecharacteristics of aneffective educator
are reinforced by Perry (2009) who describes good role models as
exemplary nurses who possess extensive clinical knowledge and skill
as well as high level interpersonal skills.
Six of the 26 articles (n = 386) reviewed in this theme pay particu-
lar attention to the professional training and support required by
preceptors and facilitators in order to enhance students' learning expe-
riences in the clinical setting, including the need for clear links between
the education provider and clinical area (Brammer, 2008; Brown et al.,
2012; Ferguson, 2011; Hayajneh, 2011; Sanderson and Lea, 2012;
Walker et al., 2013). The context in which these links are discussed is
predominantly about required preceptor/facilitator support to provide
a consistent high quality clinical learning experience for the student.
These requirements include the education provider clearly articulating
learning objectives and outcomes to the student and the clinical area
with the aim of minimizing the so-called theory–practice gap.
Theme 2: Nurse Academics as Role Models in the ProfessionalDevelopment
of Nursing Students
Seven of the articles included in this integrative literature review
(n = 798) relate in some way to nurse academics' role modeling
professional behaviors for undergraduate nursing students (Del Prato,
2012; Haigh and Johnson, 2007; Johnson-Farmer and Frenn, 2009;
Klunklin et al., 2011; Nouri et al., 2013; Ramage, 2004; Robinson-Wolf
et al., 2004). Similar to studies of clinical role modeling, each of the
papers addressing role modeling by nurseacademics identifies the traits
of an effective role model. These traits include demonstrating enthusi-
asm for nursing practice and demonstrating positive attitudes towards
nursing through teaching and learning (Del Prato, 2012; Haigh and
Johnson, 2007; Johnson-Farmer and Frenn, 2009; Klunklin et al., 2011;
Nouri et al., 2013; Ramage, 2004; Robinson-Wolf et al., 2004).
Nurse academic teaching of professional nursing behaviors is
specifically referred to as the ‘hidden’or ‘informal’curricula by Del
Prato (2012), an idea also discussed in broader terms by other authors
(Haigh and Johnson, 2007; Klunklin et al., 2011; Robinson-Wolf et al.,
2004). Haigh and Johnson (2007) call for informal course content such
as role modeling professional behaviorsto be more formally recognized
and to be firmly embedded in futurenursing curricula.Characteristicsof
professional behaviors include demonstrating desired attitudes and
values (Haigh and Johnson, 2007), showing respect and value for
patients, colleagues and students (Klunklin et al., 2011), displaying
scholarly traits (Robinson-Wolf et al., 2004) and conveying belief in
the nursing students' ability to learn (Del Prato, 2012). Nouri et al.
(2013) expand on the role modeling expected of nurse academics
(instructors) in Iran to include serving “as students' parents”(p. 141)
as part of a role that assumes responsibility for “developing students
emotionally, spiritually, and intellectually”(p.141). Klunklin et al.
(2011) concur with Nouri et al. in that in Thai culture, the nurse
academics act as “the students' parents”(p. 86). Health care is a
community service that is defined by the community it serves and the
expectations of that service will undoubtedly be influenced by cultural,
spiritual and religious beliefs. For example, Nouri et al. (2013) describe
desirable characteristics of Iranian nurse teachers to include “maintain-
ing friendships and complimentary rituals such as apologizing”(p.141).
The importance of these characteristics in the Iranian communities is
high, while in other cultures it may not be afforded such a high priority.
The findings of the research of Klunklin et al. (2011) and Nouri et al.
(2013) open the discussion about role modeling in relation to the
cultural influences potentially making role modeling a subjective
topic. Thus, the characteristics of a good role model will vary depending
upon the context in which it is being discussed. However,the findings of
Nouri et al. (2013) and Klunklin et al. (2011) areconsistentwithother
researchers in this theme in that they found that a good role model
contributed to self-discovery, self-motivation and self-confidence in
nursing students, valued high quality nursing care and was enthusiastic
about developing the nursing profession.
Teaching practices and strategies that include role modeling with
the aim of promoting or facilitating learning were also identified
in this group of publications. Using a range of teaching strategies
(Johnson-Farmer and Frenn, 2009) and providing timely and positive
feedback (Del Prato, 2012; Robinson-Wolf et al., 2004) are identified
as professional traits of good nurse academics' role modeling behaviors
that facilitate the growth of the students' professional identity.
Several of the articles reviewed in this theme acknowledge that
nursing students quickly gain the ability to recognize nurse academics
as good and bad role models and appear to understand the influence
these people have on their novice practice (Donaldson and Carter,
2005; Gray and Smith, 2000; Grealish and Ranse, 2009). Gray and
Smith (2000),Donaldson and Carter (2005),andGrealish and Ranse
(2009) expand on this point and report the observation that nursing
students gradually move away from their mentors as their skills and
confidence in practice develop. Thus, the value of role modeling at an
early stage in their academic career is recognized by students
themselves.
Allan et al. (2008) found in their literature review, that despite some
perceptions about the questionable clinical credibility of academics,
there is a lack of supporting evidence for such assumptions.
All of the papers in this review discussed role modeling in nursing
education in relation to registered nurses role modeling for nurses.
Nursing students are exposed to a number of influences during their
course of study in all settings. There is very little reference to the
influence of other health professionals, consumers or organizations
that may influence the clinical learning experiences for nursing students.
It is interesting to note, however, that Saarikoski et al's. (2013)
reports of the 1903 nursing students surveyed in their study, 59% iden-
tify their most important role model as mentors (nurses in clinical
practice); 27% as mentors/nurse teachers; and 14% as nurse teachers.
Internationally there are numerous models for the delivery of nursing
educational programs and the associated clinical experiences and the
vast range of titles for the teachers' roles that challenge the transferabil-
ity of these findings. As an example, the findings of the research
conducted by Etheridge (2007) investigating the experiences of new
graduates show that new RNs believe that their faculty members were
role models. However, even in the broadest sense, there is sufficient
evidence that nursing students perceive clinical nurses to be the most
important role models for their practice.
Discussion
As nursing education becomes increasingly student-centered
(Horsfall et al., 2012; Stanley and Dougherty, 2010), students' experi-
ences and perceptions are becoming a primary focus of inquiry. Hence
the need to identify, from a student's perspective, the level of role
modeling by academics, and the degree to which this influences their
3A. Baldwin et al. / Nurse Education Today xxx (2013) xxx–xxx
Please cite this article as: Baldwin,A., et al., Role modeling in undergraduate nursingeducation:An integrative literature review, Nurse Educ. To-
day (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.007

Table 2
The literature review summary.
Title Year Author(s) Journal/source Research methods Participants Summary of findings
Theme 1: Nurse clinicians as role models in the professional development of nursing students
1. Student and staff relationships in a
clinical practice model: impact on
learning
2000 Atack, L., Comacu, M., Kenny, R.,
LaBelle, N. & Miller, D.
Journal of
Nursing
Education
Qualitative
Phenomenology
Focus groups
Clinical nurses and
students
n=40
Staff perception of student learning refers to ‘those willing to be role
models and those who were not’.
Recommendations to make staff aware of the impact they have as role
models. Quality of the role model is linked to the level of respect from
peers.
The relationship between the researcher and the participants and the
ethics approval were not discussed.
2. The qualities of an effective mentor from
the student nurse's perspective: findings
from a longitudinal study
2000 Gray, M. & Smith, L. Journal of
Advanced
Nursing
Qualitative
Grounded theory
Longitudinal approach
n = 10 students
interviews and diary
n = 7 diary only
Being knowledgeable linked (by students) to how they perceived the
mentor practiced as a nurse.
A good mentor is a good role model, professional, organized, caring and
self-confident.
The discussion about methodological justification was not specific.
3. Nursing students' and clinical educators'
perceptions of characteristics of effective
clinical educators in an Australian uni-
versity school of nursing
2002 Lee, W., Cholowski, K. & Williams,
A.
Issues and
Innovations in
Nursing
Education
Quantitative using NCTEI in-
strument
Nursing
Clinical
Teacher
Effectiveness
Inventory
n = 104 second year
nursing students
n = 17 clinical educators
(30 third year student
responses excluded)
The students rated the characteristic of ‘Is a good role model’as number
1 ranking of characteristics of effective clinical educators.
The educators rated the characteristic of ‘Is a good role model’as
number 4.
The relationship between the researcher and participants was
discussed only from a coercion perspective.
4. Mentoring undergraduate nursing
students: assessing the state of the
science
2004 Dorsey, L. & Baker, C. Nurse Educator Integrative literature review of
studies between 1992 and
2002
Recommendations for further research to clarify the most effective
mentoring systems; communication strategies; follow up; and how
this translates to student and graduate retention.
Search strategies and data analysis tool discussed, although the
exclusion criteria were not identified.
5. The value of role modeling: Perceptions
of undergraduate and diploma nursing
(adult) students
2005 Donaldson, J. & Carter, D. Nurse
Education in
Practice
Qualitative
Grounded theory
Undergraduate
n=20
Diploma
n=22
Students benefit from supervised practice with constructive feedback.
Student confidence and competence appears to improve if the student
is exposed to ‘good’role models.
Small sample size is a limitation as identified by the authors.
The aim of the study and ethics were not clearly stated and the findings
not generalizable.
6. Belongingness: a montage of nursing
students' stories of their clinical
placement experiences
2007 Levett-Jones, T., Lathlean, J.
McMillan, M. & Higgins, I.
Contemporary
Nurse
Qualitative phase of mixed
methods study
Third year nursing
students
n=18
Belongingness it an important factor in a positive learning
environment.
The sampling strategies were not clearly stated.
7. Said Another Way: The Impact of
Mentorship on Clinical Learning
2007 Kilcullen, N. Nursing Forum Qualitative, descriptive
Focus group interviews
3rd year diploma students
n=29
Role modeling a ‘most important’aspect of learning.
The relationship between researcher and participants and the
limitations of the study were clearly stated.
8. Leadership for learning: a literature study
of leadership for learning in clinical
practice
2008 Allan, H., Smith, P. & Lorentzon, M. Journal of
Nursing
Management
Literature review about how
national changes affected
clinical experiences for
students
Role modeling = less experienced nurses learning from more
experienced ones, allows linking between art and science of nursing
Four themes specific to belongingness and learning were identified.
The RNs the students worked with were perceived to be the most
influential on student learning in clinical practice
9. RN as gatekeeper: gatekeeping as moni-
toring and supervision
2008 Brammer, J. Journal of
Clinical Nursing
Qualitative
Phenomenography interviews
Students
n=24
Adequate preparation of RNs for the supervision of students on
placement impacts on the outcomes for students.
The relationship between researcher and participants was not clearly
identified.
10. Belongingness: A prerequisite for nurs-
ing students' clinical learning
2008 Levett-Jones, T. & Lathlean, J. Nurse
Education in
Practice
Qualitative arm of mixed
methods
Interviews
Nursing students
n=18
Belonging is fundamental to being a nurse.
The relationship between researchers and participants, sampling and
limitations were not clearly identified.
11. Cultivating Authentic concern:
Exploring how Norwegian students learn
this key nursing skill
2009 Christiansen, B. Journal of
Nursing
Education
Qualitative
Longitudinal
microethnographic
n = 4 Conclusion encourages incorporating relation skills in curricula as well
as subject content.
Fellow students and teachers are ‘valuable resources’.
The relationship between the researcher and the participants was not
clearly stated.
4A. Baldwin et al. / Nurse Education Today xxx (2013) xxx–xxx
Please cite this article as: Baldwin,A., et al., Role modeling in undergraduate nursingeducation:An integrative literature review, Nurse Educ. To-
day (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.007

Title
Year Author(s) Journal/source Research methods Participants Summary of findings
12. An exploratory study of first year
nursing students' learning in the clinical
workplace
2009 Grealish, L. & Ranse, K. Contemporary
Nurse
Qualitative
Narrative inquiry
n = 49 Students identified what they did/didn't want to be which influenced
their learning behaviors.
The relationship between researcher and participants clearly stated but
the authors identified limited generalizability of the findings due to the
small sample size.
13. Role modeling excellence in clinical
nursing practice
2009 Perry, B. Nurse
Education in
Practice
Qualitative
Interpretive with
phenomenological
underpinning
n = 8 Role modeling is more than teaching tasks.
Identifies characteristics that participants (regarded as exemplary
nurses) have.
The sampling strategy was based on assumptions, and no limitations
were identified.
14. An exploration of the clinical learning
experience of nursing students in nine
European countries
2010 Warne, T., Johansson, U.,
Papastavrou, E., Tichelaar, E.,
Tomietto, M., Vanden Bossche, K.,
Moreno,M.&Saarikoski,M.
Nurse
Education
Today
Quantitative
Questionnaire purposive
sample
Descriptive statistical analysis
n = 1903 Discussed mentorship across curricula across 17 European SONs.
The supervisory relationship is one of the most important influences on
students' clinical experiences and on students' professional develop-
ment.
Differences between countries and the large sample size were identi-
fied as limitations of this research.
15. Nursing students' experiences with
incivility in clinical education
2011 Anthony, M. & Yastik, J. Journal of
Nursing
Education
Qualitative phenomenology
with purposive sampling
n = 21 The outcomes of this study include the recommendation that the
expectation of being a role model is clarified with all staff by nurse
managers; and the proposal to support the use of dedicated education
units to promote positive role modeling.
The relationship between researchers and participants and the
limitations of the research was not clearly discussed.
16. Empowerment and being valued: A
phenomenological study of nursing stu-
dents' experiences of clinical practice
2011 Bradbury-Jones, C., Sambrook, S. &
Irvine, F.
Nurse
Education
Today
Qualitative
Hermeneutic phenomenology
First year nursing students
n=13
Explored the concept of empowerment of nursing students in clinical
areas. Discussed what supportive behaviors of the clinicians promoted
empowerment of students that could be linked to role modeling.
The relationship between researchers and participants was clearly
identified and discussed as a limitation of the research.
17. From the perspective of new nurses:
What do effective mentors look like in
practice?
2011 Ferguson, L. Nurse
Education in
Practice
Qualitative
Grounded theory
n = 25 Research relates to mentors, and the connection they have with th e
new nurse.
Crossover with mentoring and role modeling.
There was limited discussion about methodology, relationship between
researcher and participants, and the limitations of the research.
18. Role model clinical instructor as
perceived by Jordanian nursing students
2011 Hayajneh, F. Journal of
Research in
Nursing
Qualitative
Critical Incident Technique
Nursing students
n = 156
Critical incidents
n = 210
Participants identified motivating behaviors of role model clinical
instructors, related to availability, advocacy and support for students.
The relationship between researcher and participants was not clearly
stated. The sample limits generalizability of findings.
19. Supporting student nurse
professionalization: the role of the
clinical teacher
2012 Brown, J., Stevens, J. & Kermode, S. Nurse
Education
Today
Qualitative component of a
mixed methods study
investigating the role model
attributes of clinical teachers
Teachers
n=7
Graduates
n=7
Convenience sample, with
an apparentcoincidenceof
7participantsineachsub
set
Role modeling is one of seven domains of professional socialization of
nursing students and the clinician is an important role model.
The power relationship between researchers and participants was
addressed by modifying the initial study design to meet institutional
ethics approval.
20. Nursing students' perspectives on the
patient and the impact of the nursing
culture: a meta-synthesis
2012 Rudolfsson, G. & Berggren, I. Journal of
Nursing
Management
Meta-synthesis
“to create one single study
from the findings of several
qualitative studies”
15 research articles and 2
dissertations were reviewed
Total of 601 nursing
students
Open and Closed Door described by the authors as the central
metaphors.
Student nurses learn about compassion and virtue in practice by
observing and working with clinicians, and identified with the nurses
they worked with in clinical settings.
Students could acquire ethical professional behaviors or not which is
dependent upon the clinicians and the settings they are exposed to
during their clinical practicums. No mention is made of the role that the
academic staff plays.
The study findings, limitations and study design were clearly
presented.
(continued on next page)
5A. Baldwin et al. / Nurse Education Today xxx (2013) xxx–xxx
Please cite this article as: Baldwin,A., et al., Role modeling in undergraduate nursingeducation:An integrative literature review, Nurse Educ. To-
day (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.007

Table 2 (continued)
Title Year Author(s) Journal/source Research methods Participants Summary of findings
Theme 1: Nurse clinicians as role models in the professional development of nursing students
21. To take responsibility or to be an
onlooker. Nursing students' experiences
oftwomodelsofsupervision
2012 Hellstrom, E., Martensson, G. &
Kristofferzon, M.
Nurse
Education
Today
Qualitative
“Descriptive design with a
qualitative approach”
Nursing students
n=8
Student confidence in clinical practice relates to feeling secure and
supported by the supervising nurse.
Role modeling not discussed per se, but implied throughout the study
findings.
The relationship between researchers and participants was
acknowledged as a methodological consideration.
22. An exploratory study: student nurses'
perceptions of professionalism
2012
(In
press)
Keeling, J. & Templeman, J. Nurse
Education in
Practice
Qualitative
Phenomenological approach
Individual interviews and focus
groups
Final year nursing
students
n=10
Role modeling can be positive or negative but in some cases, nursing
students use both positive and negative role modeling to guide their
own practice in a positive way. The profe ssional behavior role modeled
by the clinicians has an effect on students. Research limitations
identified by the authors include the relatively small number of
participants which could limit generalizability and the inclusion of
female students only which could result in a gender bias.
23. Nursing students' perceptions of clinical
supervision: The contributions of
preceptors, head preceptors and clinical
lecturers
2012
(In
press)
Kristofferzon, M., Martensson, G.,
Mamhidir, A. & Lofmark, A.
Nurse
Education
Today
Qualitative
Cross-sectional survey
Nursing students
n=107
Study does not relate specifically to role modeling. It does, however,
discuss the students' perceptions of the value of their learning in
relation to clinical preceptors and clinical lecturers. In this way the
findings allude to a difference in perception of who students use as role
models and for what reasons. E.g. The students identify that the clinical
lecturers are of greater value for academic guidance.
Do nursing students see the clinical lecturers as academics or nurses?
There was limited acknowledgement of the relationship between
researchers and participants. The authors identify the relatively small
sample from one setting to potentially limit generalizability.
24. Students' experiences of cooperation
with nurse teacher during their clinical
placements: An empirical study in a
Western European context
2012
(In
Press)
Saarikoski, M., Kaila, P.,
Lambrinou, E., Canaveras, R.,
Tichelaar, E., Tomietto, M. &
Warne, T.
Nurse
Education in
Practice
Quantitative
Descriptive quantitative survey
Purposivesampleof
undergraduate nursing
students in 9 European
countries in 2007–2008
n = 1903
Students perceived mentors to be their most important role model.
Role modeling is a core element to building professional identity and
becoming a nurse.
The relationship between the researchers and the participants was not
clearly identified.
25. Implementation of the Clinical
Facilitation model within an Australian
rural setting: The role of the Clinical Fa-
cilitator
2012
(In
Press)
Sanderson, H. & Lea, J. Nurse
Education in
Practice
Qualitative
Phenomenological approach
Individual in depth interviews
n = 8 Explored the experiences of clinical facilitators in rural settings. Does
not refer to role modeling as such, but does discuss helping students to
develop a professional identity.
The very specific sample in the study may limit the generalizability of
findings.
26. Facilitator versus preceptor: Which
offers the best support to undergraduate
nursing students?
2012
(In
press)
Walker, S., Dwyer, T., Moxham, L.,
Broadbent, M. & Sander, T.
Nurse
Education
Today
Quantitative
Cross-sectional online survey
of undergraduate nursing stu-
dents at a Queensland univer-
sity
n = 159 This study compared facilitation vs preceptorship for clinical
placement. No direct mention of role modeling however the comments
about the type of support students received from the RNs they worked
alongside imply role modeling behaviors. E.g. ‘assists me in developing
a better understanding of the role of the nurse’; has a good relationship
with the ward/unit staff'.
Students preferred group facilitation and the quality of the supervision
was most highly regarded.
The limitations include a small response rate which may limit
transferability of findings.
6A. Baldwin et al. / Nurse Education Today xxx (2013) xxx–xxx
Please cite this article as: Baldwin,A., et al., Role modeling in undergraduate nursingeducation:An integrative literature review, Nurse Educ. To-
day (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.007

Title
Year Author(s) Journal/source Research methods Participants Summary of findings
Theme 2: Nurse academics as role models in the professional development of nursing students
1. Negotiating multiple roles: link teachers
in clinical nursing practice
2004 Ramage, C. Issues and
Innovation in
Nursing
Education
Qualitative
Grounded theory
n = 28 Study wasundertaken to explorethe role of the nurseteacher in clinical
practice. Findings include the statement that senior nursing students
tend to seek information and guidance from nurses rather than
teachers, although in the earlier years of study, they tend to use the
teacher as the expert.
Limitation: this study concentrates on the role of the teacher in a
clinical setting.
The aim of the research was not clearly stated. There was limited
discussion about methodological justification.
2. Role model behaviors of
nursing faculty members in Thailand
2011 Klunklin A., Sawasdingha, P.,
Visekul, N., Funashima, N.,
Kameoka, T., Nomoto, Y. &
Nakayama, T.
Nursing and
Health Sciences
Qualitative
Descriptive study using
questionnaire
Nursing faculty members
n = 320
Nurse teachers are required to be role models and show respect,
empathy and support for the students. The nurse teachers' perceptions
of their own role modeling behaviors was consistently of a high
standard.
Is self reporting good enough to reliably reflect the situation?
The findings of this study may have limited generalizability.
3. Attitudes and Values of Nurse
Educators: An International Survey
2007 Haigh, C. & Johnson, M. International
Journal of
Nursing
Education
Scholarship
Quantitative
Questionnaires distributed in
conference packs at a nurse
educator conference.
n = 74 The emphasis placed by nurse educators on altruism, honesty and
academic achievement as important to ‘pass on’to the undergraduate
nursing students
No students were surveyed
The findings may have limited generalizability in an international
context.
4. Teaching Excellence: what
great teachers teach us
2009 Johnson-Farmer, B. & Frenn, M. Journal of
Professional
Nursing
Qualitative
Grounded theory
Interviews
n = 17 Found that engagement and the ability to relate it to practice had
positive influences.
Teaching excellence includes the use of role modeling by faculty as part
of a dynamic process.
There was limited discussion about sampling, ethics, the relationship
between researcher and participants, and the methodology.
5. Strengths and weaknesses of faculty
teaching performance reported by
undergraduate and graduate nursing
students: a descriptive study
2004 Robinson-Wolf, Z., Beitz, J.,
Wieland, D. & Vito, K.
Journal of
Professional
Nursing
Qualitative
Descriptive, retrospective
design.
n = 317 The pattern of ‘demonstrating professionalism’in the faculty stren gths
—good role model was the second highest indicator.
The limitations of the generalizability of the findings clearly described
by the authors.
6. Students' voices: The lived experience of
faculty incivility as a barrier to
professional formation in associate
degree nursing education
2012
(In
press)
Del Prato, D. Nurse
Education
Today
Qualitative
Phenomenological, data
collected through interviews
and symbolic interactionism in
data analysis
n = 13 Author refers to the formal and hidden curriculum in nurse education.
Students perceive that the behaviors of Academic staff should be
practicing what you preach. Role modeling the caring behaviors in their
interactions with students.
The aim of the research was not clearly stated.
7. Qualitative study of humanization-based
nursing education focused on role
modeling by instructors
2013 Nouri, J., Ebadi, A., Alhani, F., Rejeh,
N. & Ahmadizadeh
Nursing and
Health Sciences
“Qualitative study using a
content analysis approach”
Students
n=22
Staff
n=7
Findings include that role models in Iran were responsible for the
emotional, spiritual and intellectual development of students. This in-
cludes role models serving as “students' parents (p. 141)”among other
characteristics that may make broader application in an international
context difficult.
Generalizability of findings may be limited.
7A. Baldwin et al. / Nurse Education Today xxx (2013) xxx–xxx
Please cite this article as: Baldwin,A., et al., Role modeling in undergraduate nursingeducation:An integrative literature review, Nurse Educ. To-
day (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.007

professional development. Nurse academics have the most contact with
students during their course of study, so it is interesting that this topic is
not more widely addressed in the literature.
The literature relating to nurses as role models in the clinical setting
refers to the need for adequate academic preparation, formal support
from education providers, and ongoing professional development for
clinicalfacilitators/educators as essential support strategies for ensuring
nursing students receive appropriate learning experiences in the clinical
area (Burns and Northcutt, 2009). Opportunities for ongoing profes-
sional development to ensure up to date clinical supervision and teach-
ing and assessment practices are essential to ensure that the students
are receiving the best possible clinical experience. This is a frequently
occurring commentary throughout the literature together with recom-
mendations for adequate preparation of clinical facilitators/mentors
for teaching nursing students from research studies that investigate
clinical placement more generally (Cangelosi et al., 2009; Johnston
and Mohide, 2009).
Nursing students are reported to place less value on academic
performance than on learning the practical skills and requisite knowl-
edge to form professional identity (Zysberg and Zisberg, 2008). It is
also possible that this attitude impacts on who nursing students
perceive as their most influential role models whereby the students
may not necessarily adopt any behaviors demonstrated by the nurses
they are exposed to, they will be selective in what characteristics they
seek to emulate.
Baxter (2007), author of the CCARE model of clinical supervision,
refers to two cultures in nursing education; academic culture and
clinical culture. TheCCARE model proposed by Baxter (2007) integrates
communication, collaboration, application, reflection and evaluation as
key aspects of delivering quality patient care based on the blending of
both academic and clinical cultures. Baxter outlines foci and goals of
each culture with some crossover but notably there are exclusions in
each list that highlight perceived differences in who takes responsibility
for various aspects of nursing education. For example, according to Bax-
ter the culture of academia includes a focus on learning and focus on
theory while the clinical culture includes a focus on quality patient
care and focus on practice (2007). In order to fa cilitate knowledge trans-
fer for the nursing students, the clinical culture should also include a
focus on learning and a focus on theory, likewise, the academic culture
should include a focus on quality patient care and focus on practice.
Taking a whole of profession approach to nursing education aligns
with the concept that clinical education can occur in any setting
(Ard et al., 2008).
Student nurses' learning in the clinical setting is linked to how
positive the social ‘feel’of the clinical area is perceived by them
(Levett-Jones and Lathlean, 2008), affirming that learning is a social
relationship (Keeling and Templeman, 2013). This type of learning in
the academic setting has been largely overlooked in relation to nursing
education and further research is required to more fully understand to
what degree the professional behaviors of nurses in academic settings
influence the professional development of nursing students.
In both themes analyzed few of the articles specifically outline the
position of the researcher in the study and the relationship of the re-
searcher to the participants. As the majority of the publications report
studies undertaken by nurse academics about nursing education and
nursing students, clarifying these powerful relationships would seem
to be necessary to ensure the credibility and transparency of the re-
search findings reported (Clark and McCann, 2005; Ferguson et al.,
2006). Furthermore, the inclusion of nursing students as participants
in research projects may in fact contribute to their learning experiences
influencing their responses to the research questions (Bradbury-Jones
et al., 2011).
Building the nursing workforce of the future relies upon leaders
providing the necessary learning opportunities to nurture students'
professional growth. In order to nurture professional growth it is
vital to clearly identify where and from whom students are learning
so that all aspects of knowledge are incorporated into curriculum
planning and implementation. Seeking the truth as it stands is an
integral first step to developing and implementing strategies aimed
at building a resilient, competent and professionally sound nursing
workforce.
The theory–practice gap identified in the professional literature may
be being covertly perpetuated by the inability of all nurses, including
students, to identify what students learn, and from whom. As the
research shows, nursing students watch and learn from clinical nurse
role models during their clinical experiences which may be promoting
student nurses' perceptions of learning the ideal in university and the
real world in clinical practice (Allan et al., 2008). If nursing students
are to view all registered nurses as professional role models without
discerning between the clinical and academic settings, then we need
to more fully understand how nursing students learn from all nurses
they are exposed to in both settings. As outlined by Horsfall et al.
(2012), role modeling in the academic setting occurs “whether the
teacher is aware of it or not”(p. 932). The professional behavior role
modeled in the classroom lays the foundation for attitudes and behav-
iors that students may adopt in a more acute, stressful clinical setting
(Horsfall et al., 2012).
Further, it can be argued that nursing education is in itself a specialty
area of nursing practice requiring that all academics remain abreast of
current best clinical practice to ensure that the content being taught is
relevant for current clinical practice. All registered nurses are required
to self-assess their competency to practice to be eligible for annual
registration in many countries around the world. The continuing
competence position statement by the International Council of Nurses
(ICN, 2006) refers to lifelong learning and constant updating of nursing
knowledge as being fundamental to the provision of safe patient care. As
such, it should be reasonable to assume that nurse academics annually
review their level of knowledge to determine eligibility for practice,
and despite the location of nursing practice remain competent in their
area of expertise, including nursing education.
Conclusions
This review was conducted to identify and appraise research find-
ings about role modeling of professional behaviors for undergraduate
nursing students. To date, the extent to which nurses in the clinical set-
ting influence the learning experiences of nursing students appears to
have been widely investigated. There is wide agreement that nursing
students view clinicians as influential role models for their practice. Re-
search has found however that there is a need for consistent continuing
professional development for clinicians who assume this role in order to
ensure quality experiences for students. Conversely there is far less in
the literature about the impact that nurse educators, or nurses in aca-
demic settings have on the professional growth of nursing students.
Contemporary teaching practices for nursing include strategies to en-
hance professional socialization, of which role modeling is an integral
component. Nurse academics have a greater role than just conveying
theoretical knowledge. Enthusiasm for, and positive attitude towards
nursing demonstrated in the classroom have a powerful impact on
nursing students' understanding of professional behavior. Current
evidence clearly describes how nursing students learn from observing
clinicians, however there is a need for further research into the impact
and outcomes of nurse academic role modeling for this group to more
fully understand how nursing students build professional skills and
identity.
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