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Nursing students’ experiences with clinical placement in residential aged care facilities: a systematic review protocol of qualitative evidence

Keeping-Burke, Lisa1,5; McCloskey, Rose1,5; Donovan, Cindy2; Yetman, Linda3; Hansen, Linda4,5

Author Information
JBI Database of Systematic Reviews and Implementation Reports: May 2018 - Volume 16 - Issue 5 - p 1109-1116
doi: 10.11124/JBISRIR-2017-003495
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The World Health Organization (WHO) predicts that the proportion of the world's population who are 60 years of age and over will grow from 12% to 22% between 2015 and 2050.1 Specifically, the population of those who are 85 years and over is expected to increase by 351% between 2010 and 2051.1 With advances in care, along with population longevity, many older adults are expected to accumulate multiple chronic conditions during their lifetime2-6 and place unprecedented demands on health care systems across the globe.7-12 Accordingly, health care workers will be called upon to meet the care needs of this growing and aging population.13 As the largest group of health professionals, comprising more than 50% of the health care workforce in most countries,13 nurses in particular will play a critical role in helping to meet the needs of older adults.14,15 It is therefore necessary for nurses to be interested and have competency in gerontological nursing, and for nursing programs to prepare students to care for this population.

Nursing education programs play a key role in preparing future nurses to be responsive to changing health care environments. Throughout their education, students have opportunities to work in a range of community and institutional health care settings and to develop competency in preventative, supportive, restorative and curative aspects of nursing care. Although nursing educational programs direct considerable efforts to ensure that graduates have the skills and knowledge necessary to practice in a variety of settings,15-17 questions around graduate nurses being prepared for the realities of the practice environment have been raised.17,18 For instance, despite the recognition that much of nurses’ time will be spent caring for older adults, gerontology is not always a required component of many students’ educational preparation.19-21 According to the Institute of Medicine,22,23 nursing programs often focus on acute care rather than other aspects of health care, such as primary care, community, and/or long-term care. Nursing programs tend to organize curricula around traditional medical specialties, such as acute care, medicine, surgery and maternal-child health.24 These specialized areas typically emphasize diseases and medical conditions and not the unique needs of the older adult.25 During clinical placements in acute care settings, students may also witness situations in which nurses and other health care professionals do not enjoy working with older adults and ultimately provide suboptimal care.19 Designing curricula to ensure meaningful theoretical and clinical experiences in community and long-term care settings can provide opportunities for students to master a wide range of competencies and help to foster interest in gerontological nursing practice.26-28 Although many students may choose to work in acute care settings after graduation, gaining knowledge and experience in care of older adults is crucial, as the majority of nurses will, in all likelihood, provide care for older adults in some capacity throughout their careers.

In 2016, the WHO released a document titled Health Workforce for Ageing Populations which called for a transformation in how nurses and other health care professionals are educated.13 This call reflects an acknowledgment that health care professionals are educated to respond to acute illness and that insufficient numbers of educational programs provide students with clinical experiences in environments that focus exclusively on older adults.13 Current recommendations state that nursing curricula should contain both theoretical and clinical practice gerontological components.19-21 Despite a review of the literature that indicates an increase of gerontological content in nursing programs throughout North America over the past two decades, one Canada-wide study by Baumbusch and Andrusyszyn29 found only 54% of undergraduate nursing programs had a required gerontological course, and only 8% had clinical experiences specifically in gerontology. More recently, it has been reported that 79% of nursing and social work programs in Canada integrate gerontological content into their programs and that 21% have stand-alone gerontological courses.30 Similar results have been reported globally31-35 with calls from the WHO for more practice experiences in environments that focus on caring for older adults.13

Many factors have been identified as contributors to the lack of attention given to gerontology in undergraduate nursing curricula, including: (i) an absence of mandated competencies pertaining to older adults in accreditation standards, (ii) curriculum overload, (iii) a lack of interest or enthusiasm among faculty and students, (iv) a lack of consensus as to what knowledge relates specifically to older adults, (v) an absence of faculty members who are specialized in gerontological nursing, and (vi) limited clinical opportunities in gerontology.26,36,37 According to Boswell,38 there are associations between low levels of knowledge of aging, poor attitudes, and a lack of interest in working with older adults. Many researchers report that student attitudes and interest in working with older adults can improve following gerontological clinical experiences.38-43

For many students, clinical placements are the most important component of their nursing education.44 It is in the clinical setting that students acquire nursing judgment, complex problem-solving ability, socialization into the profession, and mastery of psychomotor skills.45-51 Bisholt et al.52 note that the clinical setting can evoke extreme anxiety and stress for students, which can ultimately impede learning. Ford et al.53 identify the culture of the practice setting as being the most influential factor affecting student learning. In addition to this, placements perceived by students as welcoming and supportive create positive learning experiences,14 whereas practice specialties and patient acuity appear to have considerably less of an effect on perceived learning.54-57 Moreover, the primary focus in most acute care environments is on treatment and cure rather than teaching, learning and professional growth,58 which may not provide ideal conditions for learning.59

Residential aged care facilities are a valuable alternative to hospitals as clinical learning environments.60-62 Residential aged care facilities provide opportunities for students to develop competency and interest in older adults,21 as well as therapeutic relationships with older adults and to practice in settings led predominantly by nurses.39,63 The complexity of residents now entering residential aged care facilities makes learning relevant for students during both the early and later years of their educational program.64,65 The slow paced nature of residential aged care facilities compared to that of hospitals creates conditions that allow students to develop psychomotor skills and practice in a more controlled and supportive environment.66 Unfortunately, many nursing faculty are reluctant to use residential aged care facilities for clinical placements. Faculty concerns regarding the appropriateness of residential aged care facilities for clinical placements include: high numbers of unregulated staff with few nurses available to mentor and support students,61,64,67 high levels of disability and dependence among residents that may contribute to the development of agist attitudes,67-69 and insufficient opportunities to transfer knowledge and skills learned in classroom and laboratory settings.69-70 There is also concern that clinical placements in residential aged care facilities can potentially perpetuate negative attitudes towards the elderly and discourage students from pursuing careers in settings of care for predominantly for older adults.71-72

Student perspectives on residential aged care facilities as clinical leaning environments differ somewhat from those of nursing faculty. Rogan and Wyllie73 report that students develop confidence in their nursing ability, master psychomotor and communication skills, and feel part of a team following a clinical placement in a residential aged care facility. Brynildsen et al.60 describe student learning experiences in residential aged care facilities as “demanding”, “challenging” and “supportive”. While a literature review conducted by Barnett et al.74 identified residential aged care facilities as providing ideal conditions for student learning because residents are generally medically stable with multiple co-morbidities and able to tolerate the extra time students require to complete assessments and perform interventions.

The JBI Database of Systematic Reviews and Implementation Reports, CINAHL, PubMed, The Cochrane Database of Systematic Reviews and PROSPERO were searched and no systematic reviews of nursing students’ experiences with clinical placements in residential aged care facilities were found. Due to this, it was determined that a systematic review of the experiences of nursing students’ with clinical placements in residential aged care facilities is necessary. Conducting such a systematic review will contribute to a greater understanding of how to best prepare nursing students to care for an aging population. The results of this review may further inform nursing curricula and aid faculty with decisions regarding the value of residential aged care facilities as the preferred choice in clinical learning environments.

Inclusion criteria


This systematic review will consider qualitative studies that include undergraduate and diploma nursing students. Participants will include all individuals or groups identified as nursing students independent of the level of learning experience, time spent in the setting, or type of program (such as diploma, enrolled or baccalaureate programs). There will be no limitations regarding age, gender or ethnicity of participants.

Phenomena of Interest

This review will consider studies that investigate nursing students’ experiences and perceptions of residential aged care facilities as a clinical learning environment. Studies that explore students’ understanding of the purpose of the experiences, or views regarding benefits and/or barriers will also be considered.


This review will consider studies on any setting identified as a residential care facility for older adults, including nursing homes, aged care facilities, hostels for the aged, long-term care facilities, and skilled and subacute nursing facilities.

Types of studies

This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Qualitative data from qualitative descriptive or mixed methods studies will also be included.


Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of CINAHL, PubMed and ProQuest Nursing and Allied Health Source will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second search using identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies appearing in English will be considered for inclusion in this review. Only studies published within the last 25 years (1992 onward) will be included as this time period is considered most relevant to the realities of gerontological care settings today and the current status of nursing curricula.75-76

Information sources

The databases to be searched for published sources include:

  • Biomed Central
  • ERIC
  • ProQuest Nursing and Allied Health Source
  • PsycINFO
  • PubMed
  • Science Direct
  • Scopus
  • Sociological Abstracts
  • Web of Science.

A sample search strategy for published resources of the PubMed database is included as Appendix I.

The search for unpublished studies will include:

  • American Nurses Association
  • Canadian Nurses Association
  • Conference Proceedings
  • Google/Google Scholar
  • Grey Source: A Selection of Web-based Resources in Grey Literature
  • New Zealand Nursing Research Database
  • OAIster
  • ProQuest Dissertations and Theses
  • Virginia Henderson International Nursing Library.

Initial keywords to be used include: nursing student(s), baccalaureate, diploma, undergraduate, nursing education, clinical education, clinical placement, clinical teaching, nursing home(s), long term care, residential facilities, residential care, assisted living, homes for the aged, nursing home patient(s), student attitude(s), student perspective(s), student perception(s), and student satisfaction.

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological quality prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute.77 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of primary studies will be contacted for questions on missing information or if clarification is needed.

Data extraction

Data from papers included in the review will be extracted by two independent reviewers using the standardized data extraction tool from Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI).77 The data extracted will include specifics details about the phenomena of interest, population, study methods and outcomes of significance to the review question and specific objectives.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI SUMARI.77 This will involve aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. Furthermore, the ConQual approach77 will be used to assess confidence in the findings according to the level of dependability and credibility.

Appendix I: Search strategy for PubMed

Search A PubMed

  • 1. (“Residential Facilities”[Mesh:NoExp] OR “Assisted Living Facilities”[Mesh] OR “Homes for theAged”[Mesh] OR “Nursing Homes”[Mesh] OR “Long-Term Care”[Mesh])
  • 2. AND ((placement AND clinical) OR (education AND clinical))
  • 3. AND (“Students, Nursing”[Mesh] OR “Education, Nursing, Baccalaureate”[Mesh] OR “Education, Nursing”[Mesh:NoExp] OR “Education, Nursing, Diploma Programs”[Mesh])
  • 4. #1 AND #2 AND #3

Search B PubMed

  • 1. (“Students, Nursing”[Mesh] OR “Education, Nursing, Baccalaureate”[Mesh] OR “Education, Nursing”[Mesh:NoExp] OR “Education, Nursing, Diploma Programs”[Mesh])
  • 2. (attitud OR perspectiv OR percept OR experienc OR satisfaction)
  • 3. (“Residential Facilities”[Mesh:NoExp] OR “Assisted Living Facilities”[Mesh] OR “Homes for the Aged”[Mesh] OR “Nursing Homes”[Mesh] OR “Long-Term Care”[Mesh])
  • 4. #1 AND #2 AND #3

NOTing A and B and B and A reveals you need to look at the results from each of those searches

In PubMed and other databases which might contain material not yet assigned controlled vocabulary, text words will be searched in addition to headings. For instance, in PubMed, to account for materials not (yet) assigned MeSH, searches of the following text words will be undertaken. It is anticipated that, in the case of PubMed, such searches might be restricted to the Title/Abstract field.

“residential facility”

“residential facilities”

“assisted living”

“homes AND aged”

“nursing home”

nursing homes

“long-term care”

“long-term care”[Title/Abstract]

nursing homes”[Title/Abstract]

“nursing home”[Title/Abstract]

(homes[Title/Abstract] AND aged[Title/Abstract])

“assisted living”[Title/Abstract]

“residential facility”[Title/Abstract]

“residential facilities”[Title/Abstract]


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clinical placements; experiences; nursing homes; Nursing student; residential aged care facilities