Social Learning Dynamics in the Clinical Learning Environment(CLE) Experienced by Nursing Students in Two Kenyan Newborn Units (NBUs)

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Professional socialisation which facilitates the journey to becoming a nursing professional, happens in the classroom and during clinical practicum, with substantial learning attributed to the training received at the clinical practicum. Various teaching and learning models are used in nursing education, most of them being formal and structured in nature. However, social learning which is informal and unstructured has been credited with having a greater impact on clinical learning for nurses. However, there is a gap in understanding how social theories of learning could help to enhance clinical teaching, especially in low-resource settings. This study explored the social learning dynamics of nursing students in two Newborn Units in Kenya. Methods This was an exploratory study where qualitative data were collected in two public hospitals. A total of 81 hours of non-participant observations were undertaken and 62 in-depth interviews were conducted. Staff and student interactions were observed as they delivered care to newborns. Staff, across cadres, and nursing students attending clinical practicum were interviewed thereafter using a semi-structured approach. Data were analysed thematically using Nvivo software. Two social learning frameworks informed data analysis: Communities of Practice and the Socio-cognitive Theory of Learning. Results Two main themes emerged: 1) opportunities for social learning and 2) influences on social learning. Opportunities for social learning in the clinical learning environment encompassed the sub-themes: conversational (ward teachers, meetings, group collaborations) and observational (role modelling). Influences on social learning were grouped into the following sub-themes: personality factors, environmental factors and structure of clinical placement. Discussion and Conclusions Social learning was a central learning avenue for nursing students in the clinical learning environment. Specific influences on social learning were identified, as well as measures to make social learning more successful for optimum learning outcomes. Recommendations from this study include the incorporation of social learning frameworks into nurse training, capacity building of ward staff as role models, and structuring the clinical placement and clinical learning environment for social learning to thrive. Clinical trial number: not applicable Professional socialisation nursing education clinical practicum clinical learning environment Social Theories of Learning (SToLs) Community of Practice (CoP) Socio-Cognitive Theory of Learning (SCToL) Role Modelling Figures Figure 1 Background The journey to becoming a nurse is consolidated through professional socialisation, meaning the acquisition of knowledge, skills, attitudes, roles, values, and culture associated with a certain profession, through interaction with qualified members of that profession [1-3] leading to professional identity development (PID)[3]. For nurses, professional socialisation takes place both in the classroom during formal training, and in the clinical learning environment (CLE) during their clinical practicum [3-5], with students commonly spending more total time in the clinical environment than the classroom during their training [6].These clinical learning environments provide real-life exposure to patient care and clinical decision-making. As such, learning experienced in the clinical learning environment is responsible for developing essential clinical and non-clinical nursing competencies[7, 8] and bridging the theory-practice gap, under the mentorship and supervision of qualified nursing colleagues [9]. Fundamental to professional socialisation is the phenomenon of social learning characterised by its unintentional, unstructured, tacit and dynamic nature [10, 11]. Social learning occurs through participation in a sociocultural context[12] and is consequently a prominent teaching and learning paradigm within the clinical learning environment[12]. Despite often being unintentional and unstructured, social learning is an important avenue through which the hidden curriculum[13] consisting of values, behaviours, norms and culture of a Community of Practice(CoP) is conveyed [14, 15]. Literature on applying Social Theories of Learning (SToLs) in health education and research on the same is scarce[12], especially in low-resource settings. Mukhalalati et al reported the implementation of SToL interventions in the Health Profession Education Program (HPEP) led to collaboration, improved learning outcomes and Professional Identity Development (PID)[12]. Despite this evidence of the value of SToLs in the clinical environment, the focus often remains on the more structured processes of clinical teaching and education [9]. This is demonstrated in numerous studies on students' and nurses’ experiences within the Clinical Learning Environment (CLE), and supervision and assessment[16, 17]. However, social learning techniques such as role modelling, feedback, discussions, reflection and group collaborations to implement clinical education are also described [9, 18-20]. An example is the preceptorship model; a clinical teaching model, which leverages role modelling and feedback from the preceptor in the transformation of the student into a graduate nurse [9, 21]. Role modelling, a social learning technique, described in the Socio-Cognitive Theory of Learning(SCToL) as the acquisition of behaviours through observation and imitation, has also been credited for the acquisition of clinical competencies [22]. The clinical learning environment is rich in social learning opportunities for nursing students on clinical placement to develop their professionalism, however, the potential of social learning as a formal strategy for clinical teaching has not been fully explored in nurse education [9, 19, 23-25]. Study Objective Broad Objective This study, whose relevant findings are drawn from the Pathways Study [26], explored the social learning dynamics impacting the professional socialisation of nursing students in the Newborn Units (NBUs) of two public hospitals in the LMIC setting of Kenya. Specific 1. To identify opportunities for social learning that foster clinical learning and professional development of nursing students 2. To identify social learning drivers and barriers to effective clinical learning and professional development among nursing students METHODS Design Relevant qualitative data from the Pathways Study,[26] were extracted and analysed in this current study. (JJ, CW) 1 Study sites The study sites were 2 high volume newborn units in two public teaching and referral hospitals in Kenya (table 1 below), purposively selected to represent NBUs from two different levels of teaching and referral hospitals in Kenya. Both sites admit nursing students for clinical practicum rotations. Table 1: Comparison table providing a summary of contextual information relevant to the results and findings of the study, specific to the data collection period and nursing fraternity. Key: H1-Hospital 1 (1st data collection site) H2-Hospital 2 (2nd data collection site) Aspect H1 H2 Level Tertiary-level Teaching and referral hospital Secondary-level Teaching and Referral Hospital NBU Layout Sub-divided into sub-wards catering to various categories of patients. Open layout Context A specialist hospital NBU that received pre-registration nursing officer interns, post-graduate paediatrics medical trainees, sub-speciality neonatal fellow trainees, and basic nursing and post-basic specialist nursing trainees. general hospital NBU that receives pre-registration (intern) nursing. nutrition, medical and clinical officers in addition to basic and post-basic nursing trainee Data Collection Non-participant observations (NPOs) were first undertaken in the units followed by in-depth interviews (IDIs) in the two wards by two qualified researchers (JJ, CW). A semi-structured interview guide was used to collect data. The interview guide was developed as part of the larger study, The Pathways Study, and is available in the published protocol for that study[26]. The interview guide explored the formation of social ties and communication between staff as they delivered care in two neonatal units in Kenya. Non-participant observation focused on nursing students' socialization with staff and peers, participation in care provision, and learning situations and affordances within the ward. In-depth interviews were undertaken to gain an understanding of the dynamics around communication, social ties and advice-seeking behaviours amongst students and Health Care Workers (HCWs) providing care to newborns. IDIs were conducted mainly in English with some participants occasionally switching to Swahili in some sections. IDIs were recorded, transcribed, translated and transcripts de-identified. NPOs were recorded in the form of observation notes while IDIs were recorded, transcribed and transcripts deidentified. Data Analysis The core study team (JJ, CW, CB 2 ) engaged in weekly reflexivity sessions where they discussed emerging patterns in the data. NPO and IDI data relevant to social learning dynamics within the NBU clinical learning environments were exported to NVivo 12 Plus and thematic analysis conducted by JJ. Inductive codes were grouped into two broad themes with sub-themes under each providing more detailed findings within each theme (JJ). The coding framework used for this analysis is available as supplementary data file (Appendix 1). Theoretical Underpinnings We drew on two theoretical frameworks to explore the social learning dynamics in two case study newborn units in Kenya: 1) Albert Bandura’s socio-cognitive theory of learning - first developed in 1977 and subsequently refined, explains how observation and interaction with others are principal facilitators of learning and reproduction of behaviour[27]. Bandura’s model proposes role modelling, where the teachers within a social context model behaviours which are reproduced by learners, as they engage in the cognitive processes [28]. Vicarious reinforcement (where wanted behaviour is rewarded)and vicarious punishment (where unwanted behaviour is discouraged through punishment)are determinants of imitation and reproduction of observed behaviour[12]. 2) Communities of Practice (CoP) – With a related theory of Legitimate Peripheral Participation (LPP), the Communities of Practice theory stems from the work of Lave and Wenger in 1991 on apprenticeship. A CoP is a group of people with a common interest engaged in innovating and sharing knowledge through social participation[11, 12]. The CoP is charged with propagating competencies, including the non-clinical ones, to newcomers. LPP theory emphasises learning within a sociocultural context, the CoP, where newcomers' participation results in their identity development and contribution to the practice development[10-12, 29]. Social learning processes are postulated to, therefore, occur within the CoP. Ethics Research ethics approval for the Pathways Study was obtained from the Kenya Medical Research Institute (KEMRI)(KEMRI/SERU/CGMR-C/241/4374) and the Oxford Tropical Research Ethics Committee (OxTREC)(OxTREC 519-22) [26]. Informed consent was collected from all participants [26]. RESULTS Table 2: Data Collection Summary Table Tool Hospital 1 -H1 Hospital 2 -H2 Total Non-participant observations (NPOs) shifts 16 9 25 Shifts Total Hours 40 Hours 41 Hours 81 Hours In-depth Interviews (IDI) Cadre No. Cadre No. 62 Participants Medical doctors 5 Medical Doctors 3 Nursing Officers 19 Nursing Officers 14 Nursing Students 9 Nursing Students 3 Nutritionist 2 Nutritionist 1 Medical Officer Intern 1 Clinical Officer Intern 3 Nutrition Interns 2 Total 35 Total 27 Two organising themes emerged, with five sub-themes: Opportunities for social learning Conversational interactions Observational interactions Influences on Social Learning: Personality factors, Environmental factors Structure of clinical placements Table 3: Summary of main themes and sub-themes Theme 1: Social Learning Opportunities Conversational Observational (Role Modelling) Ward Teacher Ward nurse Ward Doctor Meetings Ward rounds Handover Continuous Medical Education (CMEs) Group Collaborations Peer-to-peer Intra-professional Inter-professional Modelled practices Punctuality & Time management Documentation & Records Management Infection Prevention & Control (IP&C) practices Respect, empathy & compassion towards mothers. Teamwork Leadership Work ethic Theme 2: Influences on Social Learning Personality factors Structure of clinical placements Environmental factors Students Initiative & pro-activeness Attitude Interest Teachers Approachability/Friendliness Communication style Willingness to teach/help Respect towards mothers Knowledge & Competence Work ethic Experiential learning Feedback mechanism Student intake Placement duration Organisational culture Physical space/layout of the unit Attitude towards students Theme 1: Opportunities for Social Learning in the clinical learning environment Learning opportunities which facilitated social learning processes in the clinical learning environment included participation, communication, engagement, collaboration, modelling, reinforcement and feedback. The students engaged with members of the community as they participated in care delivery, and this aligned with the CoP’s framework of apprenticeship. The engagement could either be conversational, involving verbal exchanges, or purely observational where the student immersed in the CoP would observe and imitate both clinical and non-clinical competencies of staff who were the role models in the environment, as described in the SCToL. Conversational: Ward Teacher Ward teachers comprised of clinical staff including nurses, medical doctors and nutritionists. They had achieved a high level of competence and status and were viewed as experts within the community of practice. The ward nurse was the nursing students’ gatekeeper to professionalisation, enabling entry into the community of practice and access to learning opportunities. Students were taught and instructed by the qualified nurses on shift. Whilst in the units, students observed and actively participated in care provision under the instruction and supervision of the ward nurses. Students would perform tasks such as changing linen, cleaning, nasogastric tube insertion and drug administration. In H1, one nurse would administer drugs from 9 am always accompanied by a student. She would teach the students how to measure and administer the drugs. Ward nurses were available to answer questions and to offer help and advice concerning nursing care. They encouraged students to be proactive, ask questions and seek assistance. The doctors working in the NBU also engaged with nursing students while administering care and conducting ward rounds. Often, the doctors worked with nurses, in the presence of nursing students. Doctors taught during ward rounds and engaged those present, including nursing students. Doctor- “Students, yeah, the students that I’m allocated with.. because.. you see the students are usually very many and our unit is very busy. So, the students that you are allocated with obviously will guide them, you will be in constant communication with them.” Conversational: Meetings Three forms of meetings were observed: Ward rounds, handovers & CMEs. Meetings were an opportunity for nursing students to observe, engage and collaborate with experts of the profession as they demonstrated and shared knowledge. They would later reproduce what they observed as they delivered care. Meetings were an important interprofessional learning opportunity for student nurses where interprofessional teamwork was modelled. Nursing students' attendance of ward rounds, whilst good in H1, was comparatively poor in H2. This could be attributed to two factors: the high number of babies that made their workload high, and the high number of trainees and students within the unit, making the ward round crowded. Nursing students would attempt to join in but would eventually drop out. During one medical round in H1, a consultant was observed directing a question to a nursing student while in H2 one neonatal fellow engaged small groups of students across the disciplines in Q&A sessions during the rounds. There was little participation of staff nurses in ward rounds. When asked about this in the interviews, they blamed the high workload for the lack of time to attend the ward rounds. They would present themselves upon request of the consultant. Nursing students however, felt the ward rounds were effective in the acquisition of clinical knowledge. Nurse Student: “The experience with the ward round was kind of, well, because they could discuss the diseases at a much, at a much, broader view, on how the condition is being managed. And they could give an history on how the previous management have been and the impacts of the management to the newborn……Yeah. You were free to ask a question… And they [doctors and nurses] would answer you…” Students attended and observed the use of reports, patient files and treatment sheets during nurse handover. In H2, students were allocated patients and conducted handovers to their fellow students at the end of shifts. In H1, CMEs were organized and presented by nurses. The attendance comprised nurses and nursing students. In H2, doctors presented CMEs, with the nursing students left behind to manage the ward, depriving them of this learning opportunity. Nurse Student: okay, there are normally CMEs but I don’t know why, I’ve never seen students going.[for CMEs]..I don’t know [why]. Maybe they [hospital staff] think we’re not here to learn, or they think these people [lecturers] will come down [to the wards] and pass the information [to us]...I’d want to attend those CMEs myself…’ Conversational: Group Collaborations Students demonstrated peer-to-peer collaborations while working in groups, discussing and collaborating on nursing tasks such as drug reconstitution, administration, and intubation, and during student-specific handover in H2. Students who were perceived by their peers to be more skilled or experienced, oriented and instructed new students into the unit. Nursing Student: You know, there is a lot of calculations and in class, we're not like being taught [In class] how to calculate. [Instead] You get, you're being taught like these are antibiotics,,…Like at a specific dosage, you know? But here [ward], like, you know, it is, it's the actual thing… you work according to the baby's kgs, that way. So, we were doing a lot of interaction within ourselves, mostly on the drug part Nursing students also gained learning from working in collaboration with non-nursing colleagues, such as clinical officer interns, nutrition officers and interns, doctors and consultants. During an observation session, a nursing student working with a doctor took one baby’s aspirations readings and connected another to an oximeter. Observational; Role Modelling Nursing students, on gaining entry to this professional community, observed and reproduced the clinical skills, behaviours, and norms that they observed, as illustrated below. Modelled practices Punctuality and Time Management Punctuality was observed to be an established norm in one of the study hospitals. Nurses clocked in on time, handovers were done promptly, and medication was administered at the same time daily, which was enforced by leadership. The ward manager reminded her team that once it was past the reporting time, she would draw a line in the attendance page under the last person to arrive on time and the others would then write their names below the line which would indicate the latecomers. Likewise, the student’s coordinator was also observed reprimanding the students on timekeeping and absenteeism. The students in this study hospital were punctual when reporting for shifts and absenteeism was not common. A nurse in H1 told a colleague that sitting is done after teatime, implying that staff should take breaks only after the bulk of the work is done. The case was observed to be different in H2 where time management among nurses was not strict. Some nurses reported for a shift as late as two hours past the shift start time. The afternoon handover in the same unit, would start at 1 pm and drag to 4pm. Within the same unit, the nursing students appeared to emulate this modelled behaviour with some arriving past the reporting time and others failing to show up for shifts. Amongst the staff nurses, no action to discourage the culture was observed. On the other hand, the nurses complained about the students’ lack of discipline in timekeeping and were observed to address the students directly on the matter. However, there was no rectification during the subsequent shifts, and consequently, students missed the early morning medical ward rounds, and some babies were not adequately attended to because the students assigned to them were absent. Documentation and Records management Poor documentation practice was modelled in one study hospital. Staff were constantly looking for missing records and recording was not consistently done. Files did not have a central location, some were by the bedside, and others were either at the nursing station or medical table. Students followed suit and engaged in poor documentation practices which they found within the unit. The consultants complained of poorly documented treatment sheets, with some missing the unique patient numbers which the records officer complained that it resulted in a lack of traceability of patients. In addition, sections of some monitoring charts and kardexes were left blank. Nurses directed the blame for poor documentation on the students. No appropriate corrective measures were observed to be taken. IP&C Practices Exemplary IP&C practices were consistently observed in one of the study hospitals. Hand sanitisers and face masks were placed strategically on the corridors, entrances and tables. There were posters on the walls on IP&C such as one titled, “Your 5 moments of hand hygiene: Before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, after touching a patient and after touching the patient.” Areas that posed risk of infection were well labelled including incubators. A nurse was observed sending back a mum and a visitor to get and wear face masks before entering the unit. The in-charge told her juniors that sanitisation starts at the entrance. The medication nurse instructed the nursing students working with her to sanitise as they worked. Respect, empathy & compassion towards mothers. In both facilities, nurses modelled respect, compassion and empathy when they engaged and communicated with the mothers. In H2, nurses were observed counselling and consoling mothers who were in tears and anxious about their babies. Nurses took time to offer emotional support to mothers whose babies had died, a practice witnessed by students. When interviewed, students revealed that compassion, empathy and respectful care when nurses communicated with mothers were esteemed and were among the factors considered when deciding which nurse to consult. However, there were a few nurses whom the mothers were hesitant to approach because they were harsh and dismissive. The mothers, who sometimes could not distinguish between the student nurses and the registered nurses, often sought the students' help when they needed assistance such as medication and the insertion of tubes. Students took their time to listen to the mothers. They would try their best to assist, and if they were unable, they would escalate to the nurses. Theme 2: Influences on social learning These were factors prevailing within the clinical environment and community of practice that would promote or hinder social learning processes. They were identified and categorised into 3 groups: Personality factors, environmental factors, and the structure of the clinical placement. The influences provide useful reflection when proposing recommendations for enhanced socialisation within the clinical environment. Personality factors influencing social learning Students-Initiative, pro-activeness, interest, Some students were observed to be always on their feet and were keen to achieve competence in practical skills and fulfil their learning objectives. They engaged more with the nurses on duty and arrived on time. These students were frequently consulted by their peers and volunteered to take up extra duties. Conversely, other students were happy to disappear into the crowd and spend time chatting and browsing their phones. Student “ Yeah. But if you are the kind of person who, you, you know what you came here and you want to gain something from the experience, you'll just go to ward rounds, even if you've not been allocated there, like it was your own initiative, if you don't have that initiative, you'll come take the vitals and leave, the next day vitals, you go.” Nurse “ For the students, the challenge is some don't want to learn, some are willing to learn. Some come, clock, they just loitering in the unit. Others come straight and they want to ask and learn. There are different aspects.” Apart from participating in care, some students took the initiative to learn by asking questions. A nursing student in one unit was observed taking the initiative to ask a nurse if a baby’s line needed to be flushed before she administered medication. Another male student on the night shift within the same unit was observed consulting the night female nurse on how to use the CPAP. Ward Teacher -Interpersonal skills, willingness to teach and help, respect, knowledge, competence, work ethic. Students sought staff who were approachable, willing to teach and competent. Competence of staff was judged by students based on demonstrated skills during the provision of care and how respected and sought after they were by their professional colleagues. Students were able to identify role models with desirable attributes. Nursing Student- ‘When I was working, I believe it’s xxxx because she used to come early and attend to everything, not only in the office. She was still in the office, but you know still, she could come and work in the, with other students, with the babies and with other students and also the co-workers. So, it was much positive.’ Structure of Clinical Placements influencing social learning Experiential learning This was the backbone of the practicum and promoted social learning by giving rise to collaborations with peers, staff across the disciplines. Nursing Student – “It's either learning and through a procedure that the nurse I'm attached to is doing, and I'm present in that procedure or we've finished with the work and everything. When we have finished, during the time for Kardex, because Kardexing you just ask some questions, what you see has an issue, let's say you want to clarify something, I ask the nurse I'm with. You ask her, and she gives you an alternative or gives you another way it should be done.” Feedback No structured feedback system was observed between the nursing officers and the nursing students in both hospitals. What was observed was an ad-hoc form of feedback system where feedback was given only when a dire issue needed to be addressed. In the hospital with high student intake, staff could be heard within the ward complaining about the students crowding the ward, mismanaging resources, late coming and poor time management, lack of seriousness etc. Student Intake High student intake placed constraints on quality experiential learning in one study hospital with nurses and doctors complaining about the same. The ward rounds could not accommodate all the students and most nursing students opted not to attend because the round was too crowded, and they could not follow what was going on. Productive engagement between staff and students became difficult with some students retreating away to use their phones or chat with their peers. Conversely, in the other hospital, student numbers were lower and could be accommodated more comfortably in the unit, enhancing opportunities for experiential learning. In this unit, one-on-one engagements between staff and nursing students during the care delivery were common. Placement duration The placement duration was two to four weeks long. Students with longer rotations had more exposure to social learning opportunities such as the ward nurses, doctors and peers from other institutions. Nurses interviewed felt that two weeks was short for students to benefit from the placement. Environmental factors influencing social learning Workplace culture Workplace culture dictated the kind of practices and modelled to students that would shape their professionalism. Whilst compassion towards mothers was observed in both units, time management, punctuality, records management and infection prevention and control practices diverged substantially. Leadership shaped punctuality for both staff and students. Where there was laxity, poor time management, lateness or even abscondment, the same was emulated by students. In one hospital, laxity in time management and punctuality was emulated by students who came late or missed shifts. Whether positive or negative, the students adopted the modelled culture prevailing. Physical space and layout of the unit An open ward in one study hospital was conducive to peer-to-peer discussions, accommodated more members and allowed for free movement and flexibility in practice. However, it was not conducive for staff-student engagements and supervision as students were moving from one place to another making it hard for the teacher to be in close contact with them. The situation was exacerbated by the high student intake as described in the previous section. In contrast, sub-divisions in the other hospital restricted students to a particular sub-unit per shift enabling close supervision and engagement with nurses. Here, the nursing students were observed attending ward rounds religiously. This was facilitated again by the layout of the ward meaning that the ward round took place in each sub-ward, enabling the group around the consultant to be smaller and the discussions audible. Attitude towards students From the observations, attitudes towards the students appeared to vary with individual nurses. Some ward nurses felt that students caused confusion in the unit and were not willing to learn. In an interview, a student expressed that staff did not appreciate their contribution and that their opinion of student’s presence in the unit was negative and discouraging. One nurse pointed out that students were hard to work with but despite that, they were available and open to teaching them: Nurse –“Sometimes students are hard to work with, but with me, I find myself because they come to learn, I inform them so much. You are allocated to me as a student. So, you have come to learn. Just be free to ask me what questions you might need. Once you are here, that is for the students, you don't know this procedure, just feel free and ask me. I find myself working well with the students. So, I inform them so much. If we are located together, I will work as a team.” Discussion Social learning dynamics explored in our two study settings aligned with substantive frameworks: Wenger’s Communities of Practice[30] and Bandura’s social learning theory[31]. Our findings demonstrated social learning as the backbone of learning in the clinical environment onto which other learning avenues were anchored. Two core themes were identified: 1) social learning opportunities in the clinical learning environment and 2) the influences on social learning. As per the CoP framework, new knowledge was disseminated, and evidence-based practice was catalysed through engagements with ward teachers, meetings and group collaborations. Most of the learning in the CLE has been attributed to role modelling, which was also found in our study to be an important social learning modality [32]. Within the study setting, role modelling took place under the boundaries of the SCToL, where professional behaviours were modelled during ward rounds, handovers, and as staff delivered care. Influences on social learning were critical in the success of social learning processes. Therefore, it is essential to understand these influences, which can be amended for the success of social learning in imparting professionalism to students on clinical placement. Personality factors This study revealed that personality factors, such as student initiative and approachability on the part of nurses, were dominant factors impacting social learning. These factors affected students' integration, participation and engagement within a CoP, participation being key to a newcomer’s transition to a practitioner and consequently expert in the practice. Unfortunately, nurses interviewed reported that many students lacked interest in and passion for nursing. Students on the other hand, are keen to observe and identify professional, knowledgeable, competent nurses[33, 34]. In the present study, they were drawn to and sought help and advice from staff who displayed good interpersonal skills and professional behaviours. Interpersonal skills were considered first before competence and knowledge when deciding from whom to seek help and advice. The downside is that students might miss out on benefitting from an otherwise competent and resourceful person because they are not friendly, approachable or lack compassion towards mothers. These findings align with those from an Australian study where students' initiative and preparedness for learning, welcoming and friendly facilitators, workplace culture in terms of acceptable behaviours, feedback and facilitators’ role modelling emerged as the most important factors influencing nursing students’ learning in the CLE[35]. Conversely, students’ learning objectives and set goals were found to be the least important factors[35] demonstrating that the unintentional and unstructured nature of social learning[32] is a strong driving force for learning in the clinical learning environment. This was evident in our study setting as students were observed to only refer to their objectives when preparing for assessments, which was normally on the actual day of assessments. A study in Iran on the hidden curriculum also had similar findings [6]. The two studies, however, were not specific to social learning in the CLE. Staff personalities and values determined the behaviours they would model to the students. This current study showed that values shaping Professional Identity Development (PID) such as empathy, compassion and caring, can be fostered and developed through role modelling in the CLE. In line with this, nursing students in Iran also reported that competence, knowledge, empathy, friendliness and proper communication with patients aligned with the modelling of professional values and behaviours [36]. The same applies to the medical field where competence, empathy and compassion have been linked to positive role modelling [28]. Environmental factors Workplace Culture The culture within a CoP dictates the kind of practices and behaviours that are modelled. Indeed, core nursing values previously imparted from past experiences and basic training are either reinforced or unlearnt. In her commentary, Chen discusses some of the negative consequences of the hidden curriculum in nursing [15, 37], transmitted via culture [37, 38], to include reinforcing negative organisational culture and reversing what is learnt in the formal curriculum such as respect and teamwork. Apart from shedding light on day-to-day professional practices that form part of the culture, we further highlight the significant role of leadership in shaping the norms of a CoP[39]. It is, therefore, upon the leadership of the unit to steer the culture in the right direction[40], thereby creating an environment where positive professionalism is modelled to students and learning is promoted[41]. Attitude towards students Unfortunately, the workload and working environment of nurses in our setting contribute to a negative attitude towards students where they are viewed as added responsibility and an inconvenience within the units. These in turn affect the students’ sense of belonging; a prerequisite for learning within the CoP[5, 10] and a key factor in participation and professional identity development. Newcomers' participation contributes to practice development as they come with new ideas, knowledge, perspectives and questions that challenge the norm and catalyse innovation [29]. Poor attitudes portrayed by negative communications towards students inhibited them from contributing to the development of practice by hindering participation and collaboration between students and staff. Structure of clinical placement Experiential Learning Experiential learning, which was the backbone of the clinical practicum for the nursing students, conforms with the principles of Legitimate Peripheral Participation (LPP) and the CoP and promotes self-efficacy, an element of SCToL[12]. Experiential learning builds confidence in the students through hands-on practice and catalysed intra and inter-disciplinary engagements and collaborations in our NBUs. Healthcare is a multidisciplinary field in which success in care delivery relies on interdisciplinary teamwork. These collaborations fostered teamwork, a critical soft skill to utilise in their future workstations. Hands-on practice, however, presents the challenge of students being turned into handymen to lessen the burden of menial tasks such as cleaning and sponging babies. There is a need to find a balance between hands-on practice for clinical learning and the over-engagement of students in service tasks. Feedback With experiential learning, feedback is essential for optimum learning outcomes [19]. Constructive feedback provides vicarious reinforcement which builds learners' self-efficacy, and confidence[9, 28] and improves students’ attitudes towards clinical practice cementing their sense of belonging. This aligns with Wenger’s CoP where participation is driven by acknowledging and appreciating members’ contributions [11]. In a study in Malawi, clinical preceptors confirmed that their roles included encouraging active participation, positive role modelling to nursing students, modelling interdisciplinary teamwork, and providing constructive feedback[21]. In our study setting, feedback was unstructured, ad-hoc, vertical, and mostly negative, and it did not reflect appreciation of students' efforts. The ward nurse and doctors were heard talking to the students negatively whenever they did something wrong. Lack of constructive feedback led to discouragement and disengagement amongst students. Feedback sessions away from practice would benefit reflection, illuminating opportunities for improvement and appreciation of students' efforts. Indeed, the nurses did express their appreciation for the role played by the students in filling the gap created by understaffing. Ward managers and nurses should incorporate feedback sessions in the practicum timetable to improve the clinical practicum experience for nurses and students. Feedback shouldn’t be vertical but multi-directional, constructive, unbiased, and timely[9] and facilitating sharing of ideas, mutual learning and continuous improvement. Student evaluation of clinical learning could be introduced. Although hierarchy and power dynamics may influence the ability of students to speak out, students should be allowed to give feedback on role modelling in the CLE and behaviours contrary to their core values that may affect their PID[14]. Structured student feedback could facilitate self-reflection and improvement by staff to become better role models[9]. Education on the effects of the hidden curriculum contributes to better feedback for both parties. Indeed, a previous study found that after students were educated on hidden curriculum, they were able to speak out against practices that went against their nursing core values[14]. Placement duration and high student intake Short placement duration is a barrier to clinical learning[35]. In the current study, most students were in the newborn units for two weeks with few having extended periods of four weeks. The short duration was inadequate for positive role modelling to impact professionalism in future nurses. The high student intake worsened the situation. This caused confusion and staff could be heard complaining about this. The high ratio of students to nurses makes productive interaction and engagement difficult between the staff and students and chances for one-on-one interactions few. Nursing ratios should be considered when posting students to give students adequate attention and to avoid overloading nurses and straining the wards with unbalanced student numbers. Strengths The first author found no previous published literature on the application of social learning in clinical education in Kenya. Therefore, this work provides insight into social learning during clinical practicum as experienced by nursing students in this setting. The study employed the ethnographic approach of non-participant observations[42] which enabled the researchers to immerse themselves in the environment and obtain deeper insights into the social interactions between learners and models as they provided care to newborns. Methodological triangulation of observation data and interview data provided a strong evidence base. Students and staff across the cadres were interviewed to capture diversity. Limitations The study findings are not generalisable to all hospital environments because data were collected in two different-level public hospitals, with different service capacities and resources. Data were not collected in the private hospitals, which is a different context from public hospitals. There is a possibility of the existence of different dynamics due to contextual differences in the other adult wards. The mother study, from which the data were drawn, did not aim to examine clinical teaching models, but rather how socialisation and communication amongst staff, including students, happened. Recommendations Social learning frameworks should be incorporated in nurse training curricula and continuing professional development (CPD) programs for students and staff, to facilitate the creation of the right environment for social learning and clarity of roles and responsibilities within the CLE. It should be clear that teaching in clinical areas goes beyond clinical skills but crosses over to professional behaviours associated with nursing. This will result in modelling professionalism and the development of all-round professionals. Nurse leaders should be sensitised to the norms being propagated in their units, considering the impact this has on the student nurse. Change of culture does not happen overnight, however, students and staff alike can be intentionally exposed to environments with positive professional cultures. This can be facilitated by posting students to different kinds of facilities, therefore increasing their chances of exposure to positive professional behaviours. Training institutions and practicum destinations should work together to design timetables that do not overwhelm the nurses and doctors and allow students to gain the most from role models in the LMIC CLE. Conclusion Though there is limited literature from Africa on social learning in the CLE, the dynamics happening within our NBUs demonstrate that social learning is a significant contributor to learning taking place. The onus of creating a conducive practicum destination lies not only with the practicum destination or hospital but also with the training institution. Training institutions should collaborate with hospitals on how best the CLE should be structured to allow productive socialisation between the nurse and student, in a way that the ward nurse is not overburdened. We advocate the value of considering social learning models in the design, implementation and evaluation of clinical learning for nursing students. Finally, there is room for further research on integrating social learning theories in nursing curricula and the application of the same in teaching and learning for students on clinical placements. Abbreviations CLE -Clinical Learning Environment NBU -Newborn Unit Social Theories of Learning (SToLs) Low -and -middle Income Country -LMIC Non-participant observations -NPOs In-depth Interviews - (IDIs) Community of Practice - (CoP) Socio-Cognitive Theory of Learning -(SCToL) Health Care Workers -(HCWs) Kenya Medical Research Institute -KEMRI Scientific Ethics Review Unit -SERU Oxford Tropical Research Ethics Committee -OxTREC H1 -Hospital 1, H2 -Hospital 2 Continuous Medical Education -CME Infection Prevention & Control -IP&C Declarations Ethics approval and consent to participate This study was conducted in accordance with the principles of the Declaration of Helsinki. Research ethics approval was obtained from the Kenya Medical Research Institute (KEMRI)(KEMRI/SERU/CGMR-C/241/4374) and the Oxford Tropical Research Ethics Committee (OxTREC)(OxTREC 519-22) [26]. Written informed consent was collected from all interviewed participants [26]. Permission for non-participant observation was obtained verbally from each facility. No patients were involved in the study, and no clinical or medical interventions were carried out. Participants were informed of the voluntary nature of their participation and their right to withdraw at any point without any consequences. Clinical trial number: not applicable Consent for publication All participants gave informed consent for the use of anonymised quotations in publications arising from this study. No identifiable personal data are included in this manuscript. Availability of data and materials The dataset for this study was obtained from Non-Participant Observations and in-Depth interviews conducted with Healthcare Workers, Trainees and Students delivering care to newborns in two public hospitals in Kenya. Due to participant confidentiality, the dataset is not publicly available. The datasets used and analysed during the current study are available from upon written request, the Director, Kenya Medical Research Institute. Competing interests The authors declare that they have no competing interests Funding This study is supported by the Wellcome Trust Grant (#207522) through an award to ME as a Senior Fellowship, that also supported JJ, CW and CB. CB received further funding from the Nuffield Department of Medicine, University of Oxford and the Medical Research Council [grant number MR/N013468/1] towards her DPhil studies. Authors' contributions CB and CW were joint co-PIs in the mother study, the Pathways Study, and conceptualised, designed, and oversaw the conducting of the study. CB, a PhD fellow, provided senior oversight to the project. CB and CW developed the data collection tools, and together with JJ, they refined the tools. CB and CW obtained research ethics approval with support from JJ. CW and JJ collected the data. CB, CW and JJ analysed the data with supervision provided by CB and CW. JJ drafted the manuscript with guidance from CB and CW. CB, CW and DO provided revisions, and all authors read and approved the final manuscript. Acknowledgements We acknowledge the healthcare workers, interns, students, and trainees who participated in this research. We also acknowledge the hospital leadership, departmental heads, and unit managers, whose support contributed to the study's success. References Shahr, H.S.A., S. Yazdani, and L. Afshar, Professional socialization: an analytical definition. Journal of medical ethics and history of medicine, 2019. 12 . . Maginnis, C., A discussion of professional identity development in nursing students. Journal of Perspectives in Applied Academic Practice, 2018. 6 (1): p. 91-97. Flott, E.A. and L. Linden, The clinical learning environment in nursing education: a concept analysis. Journal of advanced nursing, 2016. 72 (3): p. 501-513. Stoffels, M., et al., Learning in and across communities of practice: health professions education students’ learning from boundary crossing. Advances in Health Sciences Education, 2022. 27 (5): p. 1423-1441. Asadi, M., et al., The state of clinical education and factors affecting effective clinical education: the point of view of nursing and midwifery students. BMC Med Educ, 2023. 23 (1): p. 967. Lúanaigh, P.Ó., Becoming a professional: What is the influence of registered nurses on nursing students' learning in the clinical environment? Nurse Education in Practice, 2015. 15 (6): p. 450-456. Mbakaya, B.C., et al., Nursing and midwifery students’ experiences and perception of their clinical learning environment in Malawi: a mixed-method study. BMC nursing, 2020. 19 : p. 1-14. Gcawu, S.N. and D.R. van Rooyen, Clinical teaching practices of nurse educators: An integrative literature review. Health SA Gesondheid (Online), 2022. 27 : p. 1-9. Graven, M., Wenger, E. (1998). Communities of Practice: Learning, meaning and identity. Journal of Mathematics Teacher Education, 2003. 6 (2): p. 185-194. Wenger-Trayner, E. and B. Wenger-Trayner, . 2015. Mukhalalati, B., et al., Applications of social theories of learning in health professions education programs: a scoping review. Frontiers in medicine, 2022. 9 : p. 912751. MacMillan, K., The hidden curriculum: what are we actually teaching about the fundamentals of care? Nursing Leadership (Toronto, Ont.), 2016. 29 (1): p. 37-46. Kelly, S.H., The hidden curriculum: Undergraduate nursing students’ perspectives of socialization and professionalism. Nursing Ethics, 2020. 27 (5): p. 1250-1260. Abbaspour, H., et al., The consequences of hidden curriculum for nursing professionalism: a qualitative study. Journal of Qualitative Research in Health Sciences, 2023. 12 (2): p. 100-106. Kamphinda, S. and E.B. Chilemba, Clinical supervision and support: Perspectives of undergraduate nursing students on their clinical learning environment in Malawi. Curationis, 2019. 42 (1): p. 1-10. Van der Heever, M. and G. Donough, Undergraduate nursing students’ experience of clinical supervision. Curationis, 2018. 41 (1): p. 1-8. Croxon, L. and C. Maginnis, Evaluation of clinical teaching models for nursing practice. Nurse education in practice, 2009. 9 (4): p. 236-243. Vitale, E., Clinical teaching models for nursing practice: a review of literature. Professioni Infermieristiche, 2014. 67 (2): p. 117-125. Dube, A. and M.A. Rakhudu, A preceptorship model to facilitate clinical nursing education in health training institutions in Botswana. CURATIONIS Journal of the Democratic Nursing Organisation of South Africa, 2021. 44 (1): p. 2182. Mhango, L., et al., The roles and experiences of preceptors in clinical teaching of undergraduate nursing and midwifery students in Malawi. Malawi Medical Journal, 2021. 33 (Postgraduate Supplementary Iss): p. 35. Felstead, I., Role modelling and students' professional development. British Journal of Nursing, 2013. 22 (4): p. 223-227. Jayasekara, R., et al., The effectiveness of clinical education models for undergraduate nursing programs: A systematic review. Nurse Educ Pract, 2018. 29 : p. 116-126. . Forber, J., et al., In pursuit of an optimal model of undergraduate nurse clinical education: An integrative review. Nurse Education in Practice, 2016. 21 : p. 83-92. Wanyama, C., et al., Protocol for the Pathways Study: a realist evaluation of staff social ties and communication in the delivery of neonatal care in Kenya. BMJ open, 2023. 13 (3): p. e066150. Tadayon, R., Bandura's social learning theory & social cognitive learning theory. Retrieved March, 2012. 8 : p. 2019. Horsburgh, J. and K. Ippolito, A skill to be worked at: using social learning theory to explore the process of learning from role models in clinical settings. BMC medical education, 2018. 18 : p. 1-8. Matusov, E., N. Bell, and B. Rogoff, Situated Learning: Legitimate Peripheral Participation. JEAN LAVE and ETIENNE WENGER. American Ethnologist, 2009. 21 (4): p. 918-919. Wenger, E., Communities of practice: Learning, meaning, and identity . 1999: Cambridge university press. Sashkin, M., SOCIAL LEARNING THEORY Albert Bandura Englewood Cliffs, NJ: Prentice-Hall, 1977. 247 pp., paperbound. Group & Organization Management, 1977. 2 (3): p. 384-385. Charters, A., Role modelling as a teaching method. EMERGENCY nurse, 2000. 7 (10). O'Mara, L., et al., Challenging clinical learning environments: Experiences of undergraduate nursing students. Nurse education in practice, 2014. 14 (2): p. 208-213. Eller, L.S., E.L. Lev, and A. Feurer, Key components of an effective mentoring relationship: A qualitative study. Nurse education today, 2014. 34 (5): p. 815-820. McTier, L., N.M. Phillips, and M. Duke, Factors Influencing Nursing Student Learning During Clinical Placements: A Modified Delphi Study. J Nurs Educ, 2023. 62 (6): p. 333-341. Kareshki and Hossein, The Consequences of Hidden Curriculum for Nursing Professionalism: A Qualitative Study. Journal of Qualitative Research in Health Sciences, 2023. 12 . Chen, R., Do as we say or do as we do? Examining the hidden curriculum in nursing education. Canadian Journal of Nursing Research Archive, 2015: p. 7-17. Raso, A., et al., The hidden curriculum in nursing education: a scoping study. Medical education, 2019. 53 (10): p. 989-1002. ALFadhalah, T. and H. Elamir, Organizational culture, quality of care and leadership style in government general hospitals in Kuwait: a multimethod study. Journal of healthcare leadership, 2021: p. 243-254. Tsai, Y., Relationship between organizational culture, leadership behavior and job satisfaction. BMC health services research, 2011. 11 : p. 1-9. Pollard, C., et al., Clinical education: a review of the literature. Nurse education in Practice, 2007. 7 (5): p. 315-322. Roller, M.R. and P.J. Lavrakas, Applied qualitative research design: A total quality framework approach . 2015: Guilford Publications. Footnotes JJ is a Kenyan BSC. Biochemistry graduate with an interest in health systems research. CW is a Kenya-trained paediatric and neonatal nurse whose research interest is in medical education, health systems and newborn/child health in low and middle-income countries CB is a UK-based researcher with interests in realist evaluation and health systems in Low- and Middle-Income Countries. She is a qualified medical doctor. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6503314","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492597257,"identity":"f6e2c64d-e0e0-49a9-8c94-26d0fd6f8240","order_by":0,"name":"Juliet Jepkosgei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIie2QMUvEMBiGvxLILed1DZykfyElg4s/Jlnulgs43nBgRaiDB645BPEvSP9AoFCX3n5wS6uz4HiDVNOKTo11FMwz5Ut4eN8vAB7PHyRITGAEACXtZA8wGQ0rYBXGvxWMfpFkAJjUX9Oggi5KZqrl23xzdT17rSCnGKH6abcEenJz7yhmFVEydTveZlpAzjHCnC9K4Me7yq3IlKk7ojKQzV6maIynKgWpiflBadicRi+ZXX9//qk0Q0rCxJQcdYrAnZJYJUwcSnFmRMHjzVq1ynucdrsUhBPS/2Oxzh/qw4pG5HGbBQeYReHosn5erE4pCfuLxbr/HmwEEb0vkaNwiyPF4/F4/h0fd6BeA3genfkAAAAASUVORK5CYII=","orcid":"","institution":"Kenya Medical Research Institute","correspondingAuthor":true,"prefix":"","firstName":"Juliet","middleName":"","lastName":"Jepkosgei","suffix":""},{"id":492597258,"identity":"9b0657cd-57f8-4ee5-a6ca-e437e0bb3cdf","order_by":1,"name":"Conrad Wanyama","email":"","orcid":"","institution":"Kenya Medical Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Conrad","middleName":"","lastName":"Wanyama","suffix":""},{"id":492597260,"identity":"5d9d1096-cc3e-458b-baad-6581d9eeef37","order_by":2,"name":"Dorothy Oluoch","email":"","orcid":"","institution":"Kenya Medical Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Dorothy","middleName":"","lastName":"Oluoch","suffix":""},{"id":492597261,"identity":"e4eed0ae-8a13-4c6b-982a-4eb8b7b9e291","order_by":3,"name":"Claire Blacklock","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Claire","middleName":"","lastName":"Blacklock","suffix":""}],"badges":[],"createdAt":"2025-04-22 10:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6503314/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6503314/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88038083,"identity":"a171e7b6-1930-473d-97c9-3894308698aa","added_by":"auto","created_at":"2025-07-31 16:35:59","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":338892,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDiagram illustrating the interaction of influences on social learning and social learning opportunities which impact on uptake of competencies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6503314/v1/84b6cf344c47175fe700ac2a.jpeg"},{"id":88039119,"identity":"f943cebf-9a7b-49f4-9b97-5ff558a7a613","added_by":"auto","created_at":"2025-07-31 16:43:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1532607,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6503314/v1/a4b1d6c6-eaaf-47de-89bb-3bceafd32cf5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Social Learning Dynamics in the Clinical Learning Environment(CLE) Experienced by Nursing Students in Two Kenyan Newborn Units (NBUs)","fulltext":[{"header":"Background","content":"\u003cp\u003eThe journey to becoming a nurse is consolidated through professional socialisation, meaning the acquisition of knowledge, skills, attitudes, roles, values, and culture associated with a certain profession, through interaction with qualified members of that profession [1-3] leading to professional identity development (PID)[3]. For nurses, professional socialisation takes place both in the classroom during formal training, and in the clinical learning environment (CLE) during their clinical practicum [3-5], with students commonly spending more total time in the clinical environment than the classroom during their training [6].These clinical learning environments provide real-life exposure to patient care and clinical decision-making. As such, learning experienced in the clinical learning environment is responsible for developing essential clinical and non-clinical nursing competencies[7, 8] and bridging the theory-practice gap, under the mentorship and supervision of qualified nursing colleagues [9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFundamental to \u0026nbsp;professional socialisation is the phenomenon of social learning characterised by its unintentional, unstructured, tacit and dynamic nature [10, 11]. Social learning occurs through participation in a sociocultural context[12] and is consequently a prominent teaching and learning paradigm within the clinical learning environment[12]. Despite often being unintentional and unstructured, social learning is an important avenue through which the hidden curriculum[13] consisting of values, behaviours, norms and culture of a Community of Practice(CoP) is conveyed [14, 15].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLiterature on applying Social Theories of Learning (SToLs) in health education and research on the same is scarce[12], especially in low-resource settings. \u0026nbsp;Mukhalalati et al reported the implementation of SToL interventions in the Health Profession Education Program (HPEP) led to collaboration, improved learning outcomes and Professional Identity Development (PID)[12]. \u0026nbsp;Despite this evidence of the value of SToLs in the clinical environment, the focus often remains on the more structured processes of clinical teaching and education [9]. This is demonstrated in numerous studies on students\u0026apos; and nurses\u0026rsquo; experiences within the Clinical Learning Environment (CLE), and supervision and assessment[16, 17]. However, social learning techniques such as role modelling, feedback, discussions, reflection and group collaborations to implement clinical education are also described [9, 18-20]. An example is the preceptorship model; a clinical teaching model, which leverages role modelling and feedback from the preceptor in the transformation of the student into a graduate nurse [9, 21]. \u0026nbsp; Role modelling, a social learning technique, described in the Socio-Cognitive Theory of Learning(SCToL) as the acquisition of behaviours through observation and imitation, has also been credited for the acquisition of clinical competencies [22].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe clinical learning environment is rich in social learning opportunities for nursing students on clinical placement to develop their professionalism, however, the potential of social learning as a formal strategy for clinical teaching has not been fully explored in nurse education [9, 19, 23-25].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Objective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBroad Objective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study, whose relevant findings are drawn from the Pathways Study [26], explored the social learning dynamics impacting the professional socialisation of nursing students in the Newborn Units (NBUs) of two public hospitals in the LMIC setting of Kenya.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpecific\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;To identify opportunities for social learning that foster clinical learning and professional development of nursing students\u003c/p\u003e\n\u003cp\u003e2. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; To identify social learning drivers and barriers to effective clinical learning and professional development among nursing students\u0026nbsp;\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eDesign\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRelevant qualitative data from the Pathways Study,[26] were extracted and analysed in this current study. (JJ, CW)\u003ca href=\"#_ftn1\" name=\"_ftnref1\" title=\"\"\u003e\u003c/a\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy sites\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study sites were 2 high volume newborn units in two public teaching and referral hospitals in Kenya (table 1 below), purposively selected to represent NBUs from two different levels of teaching and referral hospitals in Kenya. Both sites admit nursing students for clinical practicum rotations. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Comparison table providing a summary of contextual information relevant to the results and findings of the study, specific to the data collection period and nursing fraternity.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKey: H1-Hospital 1 (1st data collection site) H2-Hospital 2 (2nd data collection site)\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAspect\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eH1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eH2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eTertiary-level Teaching and referral hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eSecondary-level Teaching and Referral Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNBU Layout\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eSub-divided into sub-wards catering to various categories of patients.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eOpen layout\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContext\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eA specialist hospital NBU that received pre-registration nursing officer interns, post-graduate paediatrics medical trainees, sub-speciality neonatal fellow trainees, and basic nursing and post-basic specialist nursing trainees.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003egeneral hospital NBU that receives pre-registration (intern) nursing. nutrition, medical and clinical officers in addition to basic and post-basic nursing trainee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-participant observations (NPOs) were first undertaken in the units followed by in-depth interviews (IDIs) in the two wards by two qualified researchers (JJ, CW). \u0026nbsp;A semi-structured interview guide was used to collect data. The interview guide was developed as part of the larger study, The Pathways Study, and is available in the published protocol for that study[26]. The interview guide explored the formation of social ties and communication between staff as they delivered care in two neonatal units in Kenya. Non-participant observation focused on nursing students\u0026apos; socialization with staff and peers, participation in care provision, and learning situations and affordances within the ward. In-depth interviews were undertaken to gain an understanding of the dynamics around communication, social ties and advice-seeking behaviours amongst students and Health Care Workers (HCWs) providing care to newborns. IDIs were conducted mainly in English with some participants occasionally switching to Swahili in some sections. IDIs were recorded, transcribed, translated and transcripts de-identified. NPOs were recorded in the form of observation notes while IDIs were recorded, transcribed and transcripts deidentified. \u0026nbsp;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe core study team (JJ, CW, CB\u003ca href=\"#_ftn2\" name=\"_ftnref2\" title=\"\"\u003e\u003c/a\u003e\u003csup\u003e2\u003c/sup\u003e) engaged in weekly reflexivity sessions where they discussed emerging patterns in the data. NPO and IDI data relevant to social learning dynamics within the NBU clinical learning environments were exported to NVivo 12 Plus and thematic analysis conducted by JJ. Inductive codes were grouped into two broad themes with sub-themes under each providing more detailed findings within each theme (JJ). The coding framework used for this analysis is available as supplementary data file (Appendix 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical Underpinnings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe drew on two theoretical frameworks to explore the social learning dynamics in two case study newborn units in Kenya:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1) Albert Bandura\u0026rsquo;s socio-cognitive theory of learning - first developed in 1977 and subsequently refined, \u0026nbsp;explains how observation and interaction with others are principal facilitators of learning and reproduction of behaviour[27]. Bandura\u0026rsquo;s model proposes role modelling, where the teachers within a social context \u0026nbsp;model behaviours which are reproduced \u0026nbsp;by learners, as they engage in the \u0026nbsp;cognitive processes [28]. Vicarious reinforcement (where wanted behaviour is rewarded)and vicarious punishment (where unwanted behaviour is discouraged through punishment)are determinants of imitation and reproduction of observed behaviour[12].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2) Communities of Practice (CoP) \u0026ndash; With a related theory of Legitimate Peripheral Participation (LPP), the Communities of Practice theory stems from the work of Lave and Wenger in 1991 on apprenticeship. A CoP is a group of people with a common interest engaged in innovating and sharing knowledge through social participation[11, 12]. The CoP is charged with propagating competencies, including the non-clinical ones, to newcomers. LPP theory emphasises learning within a sociocultural context, the CoP, where newcomers\u0026apos; participation results in their identity development and contribution to the practice development[10-12, 29]. Social learning processes are postulated to, therefore, occur within the CoP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch ethics approval for the Pathways Study was obtained from the Kenya Medical Research Institute (KEMRI)(KEMRI/SERU/CGMR-C/241/4374) and the Oxford Tropical Research Ethics Committee (OxTREC)(OxTREC 519-22) [26]. Informed consent was collected from all participants [26].\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eTable 2: Data Collection Summary Table\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTool\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital 1 -H1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital 2 -H2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-participant observations (NPOs) shifts\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e16\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003e9\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e25 Shifts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Hours\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e40\u0026nbsp;Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003e41 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;81 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIn-depth Interviews (IDI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eCadre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCadre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;No.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e62 Participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eMedical doctors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMedical Doctors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eNursing Officers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNursing Officers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eNursing Students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNursing Students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eNutritionist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNutritionist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMedical Officer Intern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eClinical Officer Intern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNutrition Interns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo organising themes emerged, with five sub-themes:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eOpportunities for social learning\u003col style=\"list-style-type: lower-alpha;\"\u003e\n \u003cli\u003eConversational interactions\u003c/li\u003e\n \u003cli\u003eObservational interactions\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n \u003cli\u003eInfluences on Social Learning:\u003col style=\"list-style-type: lower-alpha;\"\u003e\n \u003cli\u003ePersonality factors,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEnvironmental factors\u003c/li\u003e\n \u003cli\u003eStructure of clinical placements\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Summary of main themes and sub-themes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"677\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 677px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 1: Social Learning Opportunities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 433px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConversational\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObservational (Role Modelling)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWard Teacher\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eWard nurse\u003c/p\u003e\n \u003cp\u003eWard Doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeetings\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eWard rounds\u003c/p\u003e\n \u003cp\u003eHandover\u003c/p\u003e\n \u003cp\u003eContinuous Medical Education (CMEs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup Collaborations\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePeer-to-peer\u003c/p\u003e\n \u003cp\u003eIntra-professional\u003c/p\u003e\n \u003cp\u003eInter-professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModelled practices\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePunctuality \u0026amp; Time management\u003c/p\u003e\n \u003cp\u003eDocumentation \u0026amp; Records Management\u003c/p\u003e\n \u003cp\u003eInfection Prevention \u0026amp; Control (IP\u0026amp;C) practices\u003c/p\u003e\n \u003cp\u003eRespect, empathy \u0026amp; compassion towards mothers.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTeamwork\u003c/p\u003e\n \u003cp\u003eLeadership\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWork ethic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 677px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 2: Influences on Social Learning\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonality factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStructure of clinical placements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnvironmental factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudents\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eInitiative \u0026amp; pro-activeness\u003c/p\u003e\n \u003cp\u003eAttitude\u003c/p\u003e\n \u003cp\u003eInterest\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTeachers\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eApproachability/Friendliness\u003c/p\u003e\n \u003cp\u003eCommunication style\u003c/p\u003e\n \u003cp\u003eWillingness to teach/help\u003c/p\u003e\n \u003cp\u003eRespect towards mothers\u003c/p\u003e\n \u003cp\u003eKnowledge \u0026amp; Competence\u003c/p\u003e\n \u003cp\u003eWork ethic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eExperiential learning\u003c/p\u003e\n \u003cp\u003eFeedback mechanism\u003c/p\u003e\n \u003cp\u003eStudent intake\u003c/p\u003e\n \u003cp\u003ePlacement duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eOrganisational culture\u003c/p\u003e\n \u003cp\u003ePhysical space/layout of the unit\u003c/p\u003e\n \u003cp\u003eAttitude towards students\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: Opportunities for Social Learning in the clinical learning environment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLearning opportunities which facilitated social learning processes in the clinical learning environment included participation, communication, engagement, collaboration, modelling, reinforcement and feedback. The students engaged with members of the community as they participated in care delivery, and this aligned with the CoP\u0026rsquo;s framework of apprenticeship. The engagement could either be conversational, involving verbal exchanges, or purely observational where the student immersed in the CoP would observe and imitate both clinical and non-clinical competencies of staff who were the role models in the environment, as described in the SCToL.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConversational: Ward Teacher\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWard teachers comprised of clinical staff including nurses, medical doctors and nutritionists. They had achieved a high level of competence and status and\u0026nbsp;were viewed as experts within the community of practice. The ward nurse was the nursing students\u0026rsquo; gatekeeper to professionalisation, enabling entry into the community of practice and access to learning opportunities. Students were taught and instructed by the qualified nurses on shift. Whilst in the units, students observed and actively participated in care provision under the instruction and supervision of the ward nurses. Students would perform tasks such as changing linen, cleaning, nasogastric tube insertion and drug administration. In H1, one nurse would administer drugs from 9 am always accompanied by a student. She would teach the students how to measure and administer the drugs. Ward nurses were available to answer questions and to offer help and advice concerning nursing care. They encouraged students to be proactive, ask questions and seek assistance.\u003c/p\u003e\n\u003cp\u003eThe doctors working in the NBU also engaged with nursing students while administering care and conducting ward rounds. Often, the doctors worked with nurses, in the presence of nursing students. Doctors taught during ward rounds and engaged those present, including nursing students.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDoctor- \u0026ldquo;Students, yeah, the students that I\u0026rsquo;m allocated with.. because.. you see the students are usually very many and our unit is very busy. So, the students that you are allocated with obviously will guide them, you will be in constant communication with them.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConversational: Meetings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Three forms of meetings were observed: Ward rounds, handovers \u0026amp; CMEs. Meetings were an opportunity for nursing students to observe, engage and collaborate with experts of the profession as they demonstrated and shared knowledge. They would later reproduce what they observed as they delivered care. Meetings were an important interprofessional learning opportunity for student nurses where interprofessional teamwork was modelled.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Nursing students\u0026apos; attendance of ward rounds, whilst good in H1, was comparatively poor in H2. This could be attributed to two factors: the high number of babies that made their workload high, and the high number of trainees and students within the unit, making the ward round crowded. Nursing students would attempt to join in but would eventually drop out. During one medical round in H1, a consultant was observed directing a question to a nursing student while in H2 one neonatal fellow engaged small groups of students across the disciplines in Q\u0026amp;A sessions during the rounds. There was little participation of staff nurses in ward rounds. When asked about this in the interviews, they blamed the high workload for the lack of time to attend the ward rounds. They would present themselves upon request of the consultant. Nursing students however, felt the ward rounds were effective in the acquisition of clinical knowledge.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNurse Student: \u0026ldquo;The experience with the ward round was kind of, well, because they could discuss the diseases at a much, at a much, broader view, on how the condition is being managed. \u0026nbsp;And they could give an history on how the previous management have been and the impacts of the management to the newborn\u0026hellip;\u0026hellip;Yeah. You were free to ask a question\u0026hellip; And they [doctors and nurses] would answer you\u0026hellip;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents attended and observed the use of reports, patient files and treatment sheets during nurse handover. In H2, students were allocated patients and conducted handovers to their fellow students at the end of shifts.\u003c/p\u003e\n\u003cp\u003eIn H1, CMEs were organized and presented by nurses. The attendance comprised nurses and nursing students. In H2, doctors presented CMEs, with the nursing students left behind to manage the ward, depriving them of this learning opportunity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNurse Student: okay, there are normally CMEs but I don\u0026rsquo;t know why, I\u0026rsquo;ve never seen students going.[for CMEs]..I don\u0026rsquo;t know [why]. Maybe they [hospital staff] think we\u0026rsquo;re not here to learn, or they think these people [lecturers] will come down [to the wards] and pass the information [to us]...I\u0026rsquo;d want to attend those CMEs myself\u0026hellip;\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConversational: Group Collaborations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents demonstrated peer-to-peer collaborations while working in groups, discussing and collaborating on nursing tasks such as drug reconstitution, administration, and intubation, and during student-specific handover in H2. Students who were perceived by their peers to be more skilled or experienced, oriented and instructed new students into the unit.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNursing Student: You know, there is a lot of calculations and in class, we\u0026apos;re not like being taught [In class] how to calculate. [Instead] You get, you\u0026apos;re being taught like these are antibiotics,,\u0026hellip;Like at a specific dosage, you know? But here [ward], like, you know, it is, it\u0026apos;s the actual thing\u0026hellip; you work according to the baby\u0026apos;s kgs, that way. So, we were doing a lot of interaction within ourselves, mostly on the drug part\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNursing students also gained learning from working in collaboration with non-nursing colleagues, such as clinical officer interns, nutrition officers and interns, doctors and consultants. During an observation session, a nursing student working with a doctor took one baby\u0026rsquo;s aspirations readings and connected another to an oximeter.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObservational; Role Modelling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNursing students, on gaining entry to this professional community, observed and reproduced the clinical skills, behaviours, and norms that they observed, as illustrated below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eModelled practices\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePunctuality and Time Management\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePunctuality was observed to be an established norm in one of the study hospitals. Nurses clocked in on time, handovers were done promptly, and medication was administered at the same time daily, which was enforced by leadership. The ward manager reminded her team that once it was past the reporting time, she would draw a line in the attendance page under the last person to arrive on time and the others would then write their names below the line which would indicate the latecomers. Likewise, the student\u0026rsquo;s coordinator was also observed reprimanding the students on timekeeping and absenteeism. The students in this study hospital were punctual when reporting for shifts and absenteeism was not common. A nurse in H1 told a colleague that sitting is done after teatime, implying that staff should take breaks only after the bulk of the work is done. The case was observed to be different in H2 where time management among nurses was not strict. Some nurses reported for a shift as late as two hours past the shift start time. The afternoon handover in the same unit, would start at 1 pm and drag to 4pm. \u0026nbsp;Within the same unit, the nursing students appeared to emulate this modelled behaviour with some arriving past the reporting time and others failing to show up for shifts. Amongst the staff nurses, no action to discourage the culture was observed. On the other hand, the nurses complained about the students\u0026rsquo; lack of discipline in timekeeping and were observed to address the students directly on the matter. However, there was no rectification during the subsequent shifts, and consequently, students missed the early morning medical ward rounds, and some babies were not adequately attended to because the students assigned to them were absent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDocumentation and Records management\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePoor documentation practice was modelled in one study hospital. Staff were constantly looking for missing records and recording was not consistently done. Files did not have a central location, some were by the bedside, and others were either at the nursing station or medical table. Students followed suit and engaged in poor documentation practices which they found within the unit. The consultants complained of poorly documented treatment sheets, with some missing the unique patient numbers which the records officer complained that it resulted in a\u0026nbsp;lack of traceability of patients.\u0026nbsp;In addition, sections of some monitoring charts and kardexes were left blank. Nurses directed the blame for poor documentation on the students. No appropriate corrective measures were observed to be taken.\u003cem\u003eIP\u0026amp;C Practices\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eExemplary IP\u0026amp;C practices were consistently observed in one of the study hospitals. Hand sanitisers and face masks were placed strategically on the corridors, entrances and tables. There were posters on the walls on IP\u0026amp;C such as one titled, \u0026ldquo;Your 5 moments of hand hygiene: Before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, after touching a patient and after touching the patient.\u0026rdquo; Areas that posed risk of infection were well labelled including incubators. \u0026nbsp;A nurse was observed sending back a mum and a visitor to get and wear face masks before entering the unit. The in-charge told her juniors that sanitisation starts at the entrance. The medication nurse instructed the nursing students working with her to sanitise as they worked.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRespect, empathy \u0026amp; compassion towards mothers.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn both facilities, nurses modelled respect, compassion and empathy when they engaged and communicated with the mothers. In H2, nurses were observed counselling and consoling mothers who were in tears and anxious about their babies. Nurses took time to offer emotional support to mothers whose babies had died, a practice witnessed by students. When interviewed, students revealed that compassion, empathy and respectful care when nurses communicated with mothers were esteemed and were among the factors considered when deciding which nurse to consult. However, there were a few nurses whom the mothers were hesitant to approach because they were harsh and dismissive. The mothers, who sometimes could not distinguish between the student nurses and the registered nurses, often sought the students\u0026apos; help when they needed assistance such as medication and the insertion of tubes. Students took their time to listen to the mothers. They would try their best to assist, and if they were unable, they would escalate to the nurses. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: Influences on social learning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese were factors prevailing within the clinical environment and community of practice that would promote or hinder social learning processes. They were identified and categorised into 3 groups: Personality factors, environmental factors, and the structure of the clinical placement. The influences provide useful reflection when proposing recommendations for enhanced socialisation within the clinical environment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePersonality factors influencing social learning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudents-Initiative, pro-activeness, interest, \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome students were observed to be always on their feet and were keen to achieve competence in practical skills and fulfil their learning objectives. They engaged more with the nurses on duty and arrived on time. These students were frequently consulted by their peers and volunteered to take up extra duties. \u0026nbsp;Conversely, other students were happy to disappear into the crowd and spend time chatting and browsing their phones.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudent \u0026ldquo; Yeah. But if you are the kind of person who, you, you know what you came here and you want to gain something from the experience, you\u0026apos;ll just go to ward rounds, even if you\u0026apos;ve not been allocated there, like it was your own initiative, if you don\u0026apos;t have that initiative, you\u0026apos;ll come take the vitals and leave, the next day vitals, you go.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNurse \u0026ldquo; For the students, the challenge is some don\u0026apos;t want to learn, some are willing to learn. Some come, clock, they just loitering in the unit. Others come straight and they want to ask and learn. There are different aspects.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eApart from participating in care, some students took the initiative to learn by asking questions. A nursing student in one unit was observed taking the initiative to ask a nurse if a baby\u0026rsquo;s line needed to be flushed before she administered medication. Another male student on the\u0026nbsp;night shift within the same unit was observed consulting the night female nurse on how to use the CPAP.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWard Teacher -Interpersonal skills, willingness to teach and help, respect, knowledge,\u003c/em\u003e \u003cem\u003ecompetence, work ethic.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents sought staff who were approachable, willing to teach and competent. Competence of staff was judged by students based on demonstrated skills during the provision of care and how respected and sought after they were by their professional colleagues. Students were able to identify role models with desirable attributes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNursing Student- \u0026lsquo;When I was working, I believe it\u0026rsquo;s xxxx because she used to come early and attend to everything, not only in the office. She was still in the office, but you know still, she could come and work in the, with other students, with the babies and with other students and also the co-workers. So, it was much positive.\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructure of Clinical Placements influencing social learning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExperiential learning\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis was the backbone of the practicum and promoted social learning by giving rise to collaborations with peers, staff across the disciplines. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNursing Student \u0026ndash; \u0026ldquo;It\u0026apos;s either learning and through a procedure that the nurse I\u0026apos;m attached to is doing, and I\u0026apos;m present in that procedure or we\u0026apos;ve finished with the work and everything. When we have finished, during the time for Kardex, because Kardexing you just ask some questions, what you see has an issue, let\u0026apos;s say you want to clarify something, I ask the nurse I\u0026apos;m with. You ask her, and she gives you an alternative or gives you another way it should be done.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFeedback\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo structured feedback system was observed between the nursing officers and the nursing students in both hospitals. What was observed was an ad-hoc form of feedback system where feedback was given only when a dire issue needed to be addressed. In the hospital with high student intake, staff could be heard within the ward complaining about the students crowding the ward, mismanaging resources, late coming and poor time management, lack of seriousness etc.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudent Intake\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHigh student intake placed constraints on quality experiential learning in one study hospital with nurses and doctors complaining about the same. The ward rounds could not accommodate all the students and most nursing students opted not to attend because the round was too crowded, and they could not follow what was going on. Productive engagement between staff and students became difficult with some students retreating away to use their phones or chat with their peers. \u0026nbsp;Conversely, in the other hospital, student numbers were lower and could be accommodated more comfortably in the unit, enhancing opportunities for experiential learning. In this unit, one-on-one engagements between staff and nursing students during the care delivery were common.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePlacement duration\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe placement duration was two to four weeks long. \u0026nbsp;Students with longer rotations had more exposure to social learning opportunities such as the ward nurses, doctors and peers from other institutions. Nurses interviewed felt that two weeks was short for students to benefit from the placement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnvironmental factors influencing social learning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWorkplace culture\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWorkplace culture dictated the kind of practices and modelled to students that would shape their professionalism. Whilst compassion towards mothers was observed in both units, time management, punctuality, records management and infection prevention and control practices diverged substantially. Leadership shaped punctuality for both staff and students. Where there was laxity, poor time management, lateness or even abscondment, the same was emulated by students. \u0026nbsp;In one hospital, laxity in time management and punctuality was emulated by students who came late or missed shifts. Whether positive or negative, the students adopted the modelled culture prevailing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhysical space and layout of the unit\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAn open ward in one study hospital was conducive to peer-to-peer discussions, accommodated more members and allowed for free movement and flexibility in practice. However, it was not conducive for staff-student engagements and supervision as students were moving from one place to another making it hard for the teacher to be in close contact with them. The situation was exacerbated by the high student intake as described in the previous section. In contrast, sub-divisions in the other hospital restricted students to a particular sub-unit per shift enabling close supervision and engagement with nurses. \u0026nbsp;Here, the nursing students were observed attending ward rounds religiously. This was facilitated again by the layout of the ward meaning that the ward round took place in each sub-ward, enabling the group around the consultant to be smaller and the discussions audible. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAttitude towards students\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFrom the observations, attitudes towards the students appeared to vary with individual nurses. \u0026nbsp; Some ward nurses felt that students caused confusion in the unit and were not willing to learn. In an interview, a student expressed that staff did not appreciate their contribution and that their opinion of student\u0026rsquo;s presence in the unit was negative and discouraging. One nurse pointed out that students were hard to work with but despite that, they were available and open to teaching them:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNurse \u0026ndash;\u0026ldquo;Sometimes students are hard to work with, but with me, I find myself because they come to learn, I inform them so much. You are allocated to me as a student. So, you have come to learn. Just be free to ask me what questions you might need. Once you are here, that is for the students, you don\u0026apos;t know this procedure, just feel free and ask me. I find myself working well with the students. So, I inform them so much. If we are located together, I will work as a team.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSocial learning dynamics explored \u0026nbsp;in our two study settings aligned with substantive frameworks: Wenger\u0026rsquo;s Communities of Practice[30] and Bandura\u0026rsquo;s social learning theory[31]. Our findings demonstrated social learning as the backbone of learning in the clinical environment onto which other learning avenues were anchored. Two core themes were identified: 1) social learning opportunities in the clinical learning environment and 2) the influences on social learning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs per the CoP framework, new knowledge was disseminated, and evidence-based practice was catalysed through engagements with ward teachers, meetings and group collaborations. Most of the learning in the CLE has been attributed to role modelling, which was also found in our study to be an important social learning modality [32]. Within the study setting, role modelling took place under the boundaries of the SCToL, where professional behaviours were modelled during ward rounds, handovers, and as staff delivered care. Influences on social learning were critical in the success of social learning processes. Therefore, it is essential to understand these influences, which can be amended for the success of social learning in imparting professionalism to students on clinical placement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePersonality factors\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study revealed that personality factors, such as student initiative and approachability on the part of nurses,\u0026nbsp;were\u0026nbsp;dominant factors impacting social learning. These factors affected students\u0026apos; integration, participation and engagement within a CoP, participation being key to a newcomer\u0026rsquo;s transition to a practitioner and consequently expert in the practice. Unfortunately, nurses interviewed reported that many students lacked interest in and passion for nursing. Students on the other hand, are keen to observe and identify professional, knowledgeable, competent nurses[33, 34]. In the present study, they were drawn to and sought help and advice from staff who displayed good interpersonal skills and professional behaviours. Interpersonal skills were considered first before competence and knowledge when deciding from whom to seek help and advice. The downside is that students might miss out on benefitting from an otherwise competent and resourceful person because they are not friendly, approachable or lack compassion towards mothers. These findings align with those from an Australian study where students\u0026apos; initiative and preparedness for learning, welcoming and friendly facilitators, \u0026nbsp;workplace culture in terms of acceptable behaviours, feedback and facilitators\u0026rsquo; role modelling emerged as the most important factors influencing nursing students\u0026rsquo; learning in the CLE[35]. Conversely, students\u0026rsquo; learning objectives and set goals were found to be the least important factors[35] demonstrating that the unintentional and unstructured nature of social learning[32] is a strong driving force for learning in the clinical learning environment. This was evident in our study setting as students were observed to only refer to their objectives when preparing for assessments, which was normally on the actual day of assessments. A study in Iran on the hidden curriculum also had similar findings [6]. The two studies, however, were not specific to social learning in the CLE. Staff personalities and values determined the behaviours they would model to the students. This current study showed that values shaping Professional Identity Development (PID) such as empathy, compassion and caring, can be fostered and developed through role modelling in the CLE. In line with this, nursing students in Iran also reported that competence, knowledge, empathy, friendliness and proper communication with patients aligned with the modelling of professional values and behaviours [36]. The same applies to the medical field where competence, empathy and compassion have been linked to positive role modelling [28].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEnvironmental factors\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWorkplace Culture\u003c/p\u003e\n\u003cp\u003eThe culture within a CoP dictates the kind of practices and behaviours that are modelled. Indeed, core nursing values previously imparted from past experiences and basic training are either reinforced or unlearnt. In her commentary, Chen discusses some of the negative consequences of the hidden curriculum in nursing [15, 37], transmitted via culture [37, 38], \u0026nbsp;to include reinforcing negative organisational culture and reversing what is learnt in the formal curriculum such as respect and teamwork. Apart from shedding light on day-to-day professional practices that form part of the culture, we further highlight the significant role of leadership in shaping the norms of a CoP[39]. It is, therefore, \u0026nbsp;upon the leadership of the unit to steer the culture in the right direction[40], \u0026nbsp; thereby creating an environment where positive professionalism is modelled \u0026nbsp;to students and learning is promoted[41].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAttitude towards students\u003c/p\u003e\n\u003cp\u003eUnfortunately, the workload and working environment of nurses in our setting contribute to a negative attitude towards students where they are viewed as added responsibility and an inconvenience within the units. These in turn affect the students\u0026rsquo; \u0026nbsp; \u0026nbsp;sense of belonging; \u0026nbsp;a prerequisite for learning within the CoP[5, 10] and a key factor in participation and professional identity development. Newcomers\u0026apos; participation contributes to practice development as they come with new ideas, knowledge, perspectives and questions that challenge the norm and catalyse innovation [29]. \u0026nbsp;Poor attitudes portrayed by negative communications towards students inhibited them from contributing to the development of practice by hindering participation and collaboration between students and staff. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStructure of clinical placement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eExperiential Learning\u003c/p\u003e\n\u003cp\u003eExperiential learning, \u0026nbsp; which \u0026nbsp;was the backbone of the clinical practicum for the nursing students, conforms with the principles of Legitimate Peripheral Participation (LPP) and the CoP and promotes self-efficacy, \u0026nbsp;an element of SCToL[12]. Experiential learning builds confidence in the students through hands-on practice and catalysed intra and inter-disciplinary engagements and collaborations in our NBUs. \u0026nbsp;Healthcare is a multidisciplinary field in which success in care delivery relies on interdisciplinary teamwork. These collaborations fostered teamwork, a critical soft skill to utilise in their future workstations. Hands-on practice, however, presents the challenge of students being turned into handymen to lessen the burden of menial tasks such as cleaning and sponging babies. There is a need to find a balance between hands-on practice for clinical learning and the over-engagement of students in service tasks.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFeedback\u003c/p\u003e\n\u003cp\u003eWith experiential learning, \u0026nbsp;feedback is essential for optimum learning outcomes [19]. Constructive feedback provides vicarious reinforcement which builds learners\u0026apos; self-efficacy, and\u0026nbsp;confidence[9, 28] and improves students\u0026rsquo; attitudes towards clinical practice \u0026nbsp;cementing their sense of belonging. This aligns with \u0026nbsp;Wenger\u0026rsquo;s CoP where participation is driven by acknowledging and appreciating members\u0026rsquo; contributions [11]. In a study in Malawi, clinical preceptors confirmed that their roles included encouraging active participation, positive role modelling to nursing students, modelling interdisciplinary teamwork, and providing constructive feedback[21]. \u0026nbsp;In our study setting, feedback was unstructured, ad-hoc, vertical, and mostly negative, and it did not reflect appreciation of students\u0026apos; efforts. The ward nurse and doctors were heard talking to the students negatively whenever they did something wrong. Lack of constructive feedback led to discouragement and disengagement amongst students. Feedback sessions away from practice would benefit reflection, illuminating opportunities for improvement and appreciation of students\u0026apos; efforts. Indeed, the nurses did express their appreciation for the role played by the students in filling the gap created by understaffing. Ward managers and nurses should incorporate feedback sessions in the practicum timetable to improve the clinical practicum experience for nurses and students. Feedback shouldn\u0026rsquo;t be vertical but multi-directional, constructive, unbiased, and timely[9] and facilitating sharing of ideas, mutual learning and continuous improvement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudent evaluation of clinical learning could be introduced. Although hierarchy and power dynamics may influence the ability of students to speak out, students should be allowed to give feedback on role modelling in the CLE and behaviours contrary to their core values that may affect their PID[14]. Structured student feedback could facilitate self-reflection and improvement by staff to become better role models[9]. Education on the effects of the hidden curriculum contributes to better feedback for both parties. \u0026nbsp;Indeed, a previous study found that after students were educated on hidden curriculum, they were able to speak out against practices that went against their nursing core values[14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePlacement duration and high student intake\u003c/p\u003e\n\u003cp\u003eShort placement duration is a barrier to clinical learning[35]. In the current study, most students were in the newborn units for two weeks with few having extended periods of four weeks. The short duration was inadequate for positive role modelling to impact professionalism in future nurses. The high student intake worsened the situation. This caused confusion and staff could be heard complaining about this. The high ratio of students to nurses makes productive interaction and engagement difficult between the staff and students and chances for one-on-one interactions few. Nursing ratios should be considered when posting students to give students adequate attention and to avoid overloading nurses and straining the wards with unbalanced student numbers. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first author found no previous published literature on the application of social learning in clinical education in Kenya. Therefore, this work provides\u0026nbsp;insight into social learning during clinical practicum as experienced by nursing students in this setting. The study employed the ethnographic approach of non-participant observations[42] which enabled the researchers to immerse themselves in the environment and obtain deeper insights into the social interactions between learners and models as they provided care to newborns. \u0026nbsp;Methodological triangulation of observation data and interview data provided a strong evidence base. Students and staff across the cadres were interviewed to capture diversity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study findings are not generalisable to all hospital environments because data were collected in two different-level public hospitals, with different service capacities and resources. \u0026nbsp;Data were not collected in the private hospitals, which is a different context from public hospitals. \u0026nbsp;There is a possibility of the existence of different dynamics due to contextual differences in the other adult wards. The mother study, from which the data were drawn, did not aim to examine clinical teaching models, but rather how socialisation and communication amongst staff, including students, happened.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSocial learning frameworks should be incorporated in nurse training curricula and continuing professional development (CPD) programs for students and staff, to facilitate the creation of the right environment for social learning and clarity of roles and responsibilities within the CLE. It should be clear that teaching in clinical areas goes beyond clinical skills but crosses over to professional behaviours associated with nursing. \u0026nbsp;This will result in modelling professionalism and the development of all-round professionals.\u003c/p\u003e\n\u003cp\u003eNurse leaders should be sensitised to the norms being propagated in their units, considering the impact this has on the student nurse. Change of culture does not happen overnight, however, students and staff alike can be intentionally exposed to environments with positive professional cultures. This can be facilitated by posting students to different kinds of facilities, therefore increasing their chances of exposure to positive professional behaviours.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTraining institutions and practicum destinations should work together to design timetables that do not overwhelm the nurses and doctors and allow students to gain the most from role models in the LMIC CLE.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThough there is limited literature from Africa on social learning in the CLE, the dynamics happening within our NBUs demonstrate that social learning is a significant contributor to learning taking place. The onus of creating a conducive practicum destination lies not only with the practicum destination or hospital but also with the training institution. Training institutions should collaborate with hospitals on how best the CLE should be structured to allow productive socialisation between the nurse and student, in a way that the ward nurse is not overburdened. We advocate the value of considering social learning models in the design, implementation and evaluation of clinical learning for nursing students. Finally, there is room for further research on integrating social learning theories in nursing curricula and the application of the same in teaching and learning for students on clinical placements.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003col\u003e\n \u003cli\u003eCLE -Clinical Learning Environment\u003c/li\u003e\n \u003cli\u003eNBU -Newborn Unit\u003c/li\u003e\n \u003cli\u003eSocial Theories of Learning (SToLs)\u003c/li\u003e\n \u003cli\u003eLow -and -middle Income Country -LMIC\u003c/li\u003e\n \u003cli\u003eNon-participant observations -NPOs\u003c/li\u003e\n \u003cli\u003eIn-depth Interviews - (IDIs)\u003c/li\u003e\n \u003cli\u003eCommunity of Practice - (CoP)\u003c/li\u003e\n \u003cli\u003eSocio-Cognitive Theory of Learning -(SCToL)\u003c/li\u003e\n \u003cli\u003eHealth Care Workers -(HCWs)\u003c/li\u003e\n \u003cli\u003eKenya Medical Research Institute -KEMRI\u003c/li\u003e\n \u003cli\u003eScientific Ethics Review Unit -SERU\u003c/li\u003e\n \u003cli\u003eOxford Tropical Research Ethics Committee -OxTREC\u003c/li\u003e\n \u003cli\u003eH1 -Hospital 1, \u0026nbsp;H2 -Hospital 2\u003c/li\u003e\n \u003cli\u003eContinuous Medical Education -CME\u003c/li\u003e\n \u003cli\u003eInfection Prevention \u0026amp; Control -IP\u0026amp;C \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. \u0026nbsp;Research ethics approval was obtained from the Kenya Medical Research Institute (KEMRI)(KEMRI/SERU/CGMR-C/241/4374) and the Oxford Tropical Research Ethics Committee (OxTREC)(OxTREC 519-22) [26]. Written informed consent was collected from all interviewed participants [26]. Permission for non-participant observation was obtained verbally from each facility. No patients were involved in the study, and no clinical or medical interventions were carried out. Participants were informed of the voluntary nature of their participation and their right to withdraw at any point without any consequences.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants gave informed consent for the use of anonymised quotations in publications arising from this study. No identifiable personal data are included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset for this study was obtained from Non-Participant Observations and in-Depth interviews conducted with Healthcare Workers, Trainees and Students delivering care to newborns in two public hospitals in Kenya. Due to participant confidentiality, the dataset is not publicly available. The datasets used and analysed during the current study are available from upon written request, the Director, Kenya Medical Research Institute.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is supported by the Wellcome Trust Grant (#207522) through an award to ME as a Senior Fellowship, that also supported JJ, CW and CB. CB received further funding from the Nuffield Department of Medicine, University of Oxford and the Medical Research Council\u0026nbsp;[grant\u0026nbsp;number\u0026nbsp;MR/N013468/1] towards her DPhil studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCB and CW were joint co-PIs in the mother study, the Pathways Study, and conceptualised, designed, and oversaw the conducting of the study. CB, a PhD fellow, provided senior oversight to the project. CB and CW developed the data collection tools, and together with JJ, they refined the tools. CB and CW obtained research ethics approval with support from JJ. CW and JJ collected the data. CB, CW and JJ analysed the data with supervision provided by CB and CW. JJ drafted the manuscript with guidance from CB and CW. \u0026nbsp; CB, CW and DO provided revisions, and all authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the healthcare workers, interns, students, and trainees who participated in this research. We also acknowledge the hospital leadership, departmental heads, and unit managers, whose support contributed to the study\u0026apos;s success.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShahr, H.S.A., S. Yazdani, and L. 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Lev, and A. Feurer, \u003cem\u003eKey components of an effective mentoring relationship: A qualitative study.\u003c/em\u003e Nurse education today, 2014. \u003cstrong\u003e34\u003c/strong\u003e(5): p. 815-820.\u003c/li\u003e\n\u003cli\u003eMcTier, L., N.M. Phillips, and M. Duke, \u003cem\u003eFactors Influencing Nursing Student Learning During Clinical Placements: A Modified Delphi Study.\u003c/em\u003e J Nurs Educ, 2023. \u003cstrong\u003e62\u003c/strong\u003e(6): p. 333-341.\u003c/li\u003e\n\u003cli\u003eKareshki and Hossein, \u003cem\u003eThe Consequences of Hidden Curriculum for Nursing Professionalism: A Qualitative Study.\u003c/em\u003e Journal of Qualitative Research in Health Sciences, 2023. \u003cstrong\u003e12\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eChen, R., \u003cem\u003eDo as we say or do as we do? Examining the hidden curriculum in nursing education.\u003c/em\u003e Canadian Journal of Nursing Research Archive, 2015: p. 7-17.\u003c/li\u003e\n\u003cli\u003eRaso, A., et al., \u003cem\u003eThe hidden curriculum in nursing education: a scoping study.\u003c/em\u003e Medical education, 2019. \u003cstrong\u003e53\u003c/strong\u003e(10): p. 989-1002.\u003c/li\u003e\n\u003cli\u003eALFadhalah, T. and H. Elamir, \u003cem\u003eOrganizational culture, quality of care and leadership style in government general hospitals in Kuwait: a multimethod study.\u003c/em\u003e Journal of healthcare leadership, 2021: p. 243-254.\u003c/li\u003e\n\u003cli\u003eTsai, Y., \u003cem\u003eRelationship between organizational culture, leadership behavior and job satisfaction.\u003c/em\u003e BMC health services research, 2011. \u003cstrong\u003e11\u003c/strong\u003e: p. 1-9.\u003c/li\u003e\n\u003cli\u003ePollard, C., et al., \u003cem\u003eClinical education: a review of the literature.\u003c/em\u003e Nurse education in Practice, 2007. \u003cstrong\u003e7\u003c/strong\u003e(5): p. 315-322.\u003c/li\u003e\n\u003cli\u003eRoller, M.R. and P.J. Lavrakas, \u003cem\u003eApplied qualitative research design: A total quality framework approach\u003c/em\u003e. 2015: Guilford Publications.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e JJ is a Kenyan BSC. Biochemistry graduate with an interest in health systems research.\u003c/span\u003e\u003cdiv id=\"Par23\" class=\"Para\"\u003eCW is a Kenya-trained paediatric and neonatal nurse whose research interest is in medical education, health systems and newborn/child health in low and middle-income countries\u003c/div\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e CB is a UK-based researcher with interests in realist evaluation and health systems in Low- and Middle-Income Countries. She is a qualified medical doctor.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Professional socialisation, nursing education, clinical practicum, clinical learning environment, Social Theories of Learning (SToLs), Community of Practice (CoP), Socio-Cognitive Theory of Learning (SCToL), Role Modelling","lastPublishedDoi":"10.21203/rs.3.rs-6503314/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6503314/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs global healthcare systems continue to suffer shortages in the nursing workforce, there is an increased need for well-rounded nurses. Professional socialisation which facilitates the journey to becoming a nursing professional, happens in the classroom and during clinical practicum, with substantial learning attributed to the training received at the clinical practicum. Various teaching and learning models are used in nursing education, most of them being formal and structured in nature. However, social learning which is informal and unstructured has been credited with having a greater impact on clinical learning for nurses. However, there is a gap in understanding how social theories of learning could help to enhance clinical teaching, especially in low-resource settings. This study explored the social learning dynamics of nursing students in two Newborn Units in Kenya.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was an exploratory study where qualitative data were collected in two public hospitals. A total of 81 hours of non-participant observations were undertaken and 62 in-depth interviews were conducted. Staff and student interactions were observed as they delivered care to newborns. Staff, across cadres, and nursing students attending clinical practicum were interviewed thereafter using a semi-structured approach. Data were analysed thematically using Nvivo software. Two social learning frameworks informed data analysis: Communities of Practice and the Socio-cognitive Theory of Learning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo main themes emerged: 1) opportunities for social learning and 2) influences on social learning. Opportunities for social learning in the clinical learning environment encompassed the sub-themes: conversational (ward teachers, meetings, group collaborations) and observational (role modelling). Influences on social learning were grouped into the following sub-themes: personality factors, environmental factors and structure of clinical placement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion and Conclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSocial learning was a central learning avenue for nursing students in the clinical learning environment. Specific influences on social learning were identified, as well as measures to make social learning more successful for optimum learning outcomes. Recommendations from this study include the incorporation of social learning frameworks into nurse training, capacity building of ward staff as role models, and structuring the clinical placement and clinical learning environment for social learning to thrive.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e","manuscriptTitle":"Social Learning Dynamics in the Clinical Learning Environment(CLE) Experienced by Nursing Students in Two Kenyan Newborn Units (NBUs)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 16:27:54","doi":"10.21203/rs.3.rs-6503314/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-07-29T11:32:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-03T06:05:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-14T07:39:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-14T05:19:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-05-14T05:18:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0342b9a9-69e9-4b5a-8be0-458eca1f067a","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-31T16:27:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-31 16:27:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6503314","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6503314","identity":"rs-6503314","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}