Received: 6 November 2019 | Revised: 27 February 2020 | Accepted: 13 March 2020

DOI: 10.1111/jocn.15270

ORIGINAL ARTICLE

Nursing students’ socialisation to emotion management during

early clinical placement experiences: A qualitative study

Andrea McCloughen BN, MN(MH), PhD, Senior Lecturer Mental Health Nursing and Director
of Postgraduate Advanced Studies1 | David Levy MHSc, PhD, Research Assistant1,2 |
Anya Johnson PhD, Associate Professor and Deputy Head of Discipline in Work and
Organisational Studies3 | Helena Nguyen PhD, Associate Professor in Work and
Organisational Studies and Co-Director of the Body, Heart and Mind in Business Research
Group3 | Heather McKenzie RN, BA(Hons), PhD, Deputy Head of School1

1
Susan Wakil School of Nursing and
Midwifery, Faculty of Medicine and Health, Abstract
The University of Sydney, Camperdown, Aims and objectives: To explore nursing students’ subjective experience of emotions
NSW, Australia
2 during first-year clinical placements, strategies used to manage their emotions and
Centre for Medical Psychology and
Evidence-based Decision Making, Faculty socialisation to emotion management.
of Science, The University of Sydney,
Background: Emotion regulation is a key source of stress for early career and student
Camperdown, NSW, Australia
3
Work and Organisational Studies,
nurses. Clinical placement experiences can elicit strong emotions in nursing students;
University of Sydney Business School, however, they may be unprepared for the challenge of regulating their emotions in
Sydney, Australia
real-world practice. How nursing students learn to manage their emotions in the
Correspondence clinical setting, whether they receive support for this, and how they are socialised to
Andrea McCloughen, Susan Wakil School of
Nursing and Midwifery, Faculty of Medicine
manage their emotions during placements are not well known.
and Health, The University of Sydney, 88 Design: An exploratory qualitative study.
Mallett Street, Camperdown, NSW 2050,
Australia.
Methods: Semi-structured interviews (n = 19) were conducted with first-year nursing
Email: andrea.mccloughen@sydney.edu.au students, exploring their experiences of emotion management during clinical place-

Funding information
ment. Interview transcripts were analysed using conventional qualitative content
This research was partly funded through the analysis. Reporting adheres to the COREQ Checklist.
University of Sydney Business School Freda
and Len Lansbury Early Career Researcher
Results: Interactions with patients and staff often elicited negative feelings. Structured
Support Fund and the University of Sydney guidance for emotion management by supervising staff was scarce. Students used
Business School Business of Health
Research Network grant.
informal self-reflection and interpretation to guide emotion management.
Conclusions: In the absence of strategic socialisation and formal support for effective
emotion management, students used emotional labour strategies that can negatively
impact on well-being. A focus on adequately preparing nursing students for emotion
work is a necessary component of classroom and clinical learning environments.
Structured debriefing during clinical placements may provide a relevant context
to discuss emotions arising during clinical work and to learn emotion management
strategies.
Relevance to clinical practice: Emotional competence, a fundamental ability
for registered nurses and students, supports personal health maintenance and

2508 | © 2020 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2020;29:2508–2520.
McCLOUGHEN et al. | 2509

strengthens professional practice. Students are exposed to clinical environments and

interpersonal encounters that evoke strong emotions. They need situated learning
strategies and formal support to develop knowledge and strengthen capability for
emotion management, as this is essential for promoting professional development
and patient care.

KEYWORDS

Clinical placements, education, emotional aspects, nursing students

1 | I NTRO D U C TI O N
What does this paper contribute to the wider
Internationally, there are established traditions in preregistration/
global clinical community?
undergraduate nursing education, for nursing students to have
• Emotional labour is a fundamental aspect of nursing work
“clinical placement” or “practice” experiences within healthcare set-
that can negatively affect well-being. Education provid-
tings to apply the theoretical knowledge and skills they have learnt
ers need to facilitate student nurses to strengthen their
at university or other academic settings (Birks, Bagley, Park, Burkot,
internal and external resources to mitigate the risks of
& Mills, 2017; MacDonald, Paterson, & Waller, 2016). In many parts
emotional labour.
of the world, including the United Kingdom, Scandinavia, Australia
• Nursing education should incorporate academic and prac-
and New Zealand, undertaking a practice placement, usually in a
tice-focused interventions for building knowledge and
supernumerary capacity, is an essential component of nurse educa-
skills for effective emotion management. Interventions
tion. For example, in Norway 50% of nursing education consists of
should aim to strengthen students’ understanding about
clinical practice (Helgesen, Gregersen, & Østbye Roos, 2016), while
emotional dissonance and impacts of negative emotions,
in Australia and the United Kingdom a specific number of hours of
promote self-development strategies for reflection and
professional experience placements in clinical settings are a man-
self-regulation, and enhance students’ capacity to recog-
dated aspect of nursing education (ANMAC, 2019; NMC, 2018).
nise and diminish negative impacts of workplace/clinical
While these clinical placements provide rich opportunities to gain
placement stress through self-care.
experience and develop skills, they are also often the first time that
• Formal debriefing in the clinical setting, by experienced
nursing students encounter the emotional component of nursing in
supervising clinicians, may offer nursing students a safe
practice (Thomas, Jinks, & Jack, 2015). They may find themselves
and structured environment in which to develop and
confronting death and dying, working with patients with complex
test out strategies for emotion management. This work-
healthcare needs and having challenging interactions with health-
integrated learning can provide students opportunities
care professionals. While students are introduced to these situations
to engage with context-specific emotional knowledge
in the classroom, regulating their emotions in real-world practice as
and regulation in the real world of complex clinical envi-
a trainee healthcare professional can be a challenge for which they
ronments and professional relationships.
are unprepared. Since Arlie Hochschild's (1983) seminal work on
emotional labour, considerable theoretical and empirical evidence
has accumulated showing that regulating emotions at work is a key
source of work stress in general (Grandey, 2003) and is a particular support to develop this skill and how they might be socialised about
source of stress for nurses early in their career (Cho, Laschinger, & emotion regulation during placements are not well known. This in-
Wong, 2006). Depending on the strategies used emotion regulation formation is important to progress understanding of how nursing
or in the context of patients, emotional labour can tax the psycho- students develop the knowledge and skills to regulate their emo-
logical and physiological system (Grandey, 2003). This can result in tions to provide effective patient care and to sustain a long-term
a range of detrimental outcomes (such as stress) for the individual career (Curtis, Horten, & Smith, 2012). This knowledge can also lead
(Feng & Tsai, 2012; Hülsheger & Schewe, 2011), less effective pa- to better support for nursing students during their early socialisation
tient care, turnover intentions (Cheng, Bartram, Karimi, & Leggat, experiences.
2013) and nurse absenteeism (Nguyen, Groth, & Johnson, 2016).
Clinical placement experiences can elicit fear, anxiety and un-
certainty (Houghton, 2014; Janse van Rensburg, 2019); however, we 2 | BAC KG RO U N D
know surprisingly little about how nursing students cope with situ-
ations where they need to engage in emotional labour or regulate Socialisation is a process of “learning the ropes” (Bauer & Erdogan,
their emotions (Thomas & Revell, 2015). Whether students receive 2014) or the extent to which newcomers acquire knowledge, skills
2510 | McCLOUGHEN et al.

and understanding of their new jobs, connect with others in the or- them. Menzies (1959) suggests that attempts to mitigate the risks of
ganisation, and acquire insight into the culture, processes and people intense and poorly managed anxiety, through socially constructed
(Ellis, Bauer, & Erdogan, 2015, p. 301). Socialisation is a joint process defence mechanisms, are problematic. For example, detachment
where organisations introduce aspects of the organisational cul- or denial of feelings can be difficult for students who lack skills to
ture and “established way of doing things,” while newcomers play manage disturbing feelings arising in clinical relationships, and when
a role in seeking cues about what to do and how to do it, to facili- little attempt is made to help an individual positively face stressful
tate their own adjustment (Bauer & Erdogan, 2014). Van Maanen experiences, his/her capacity to tolerate and deal effectively with
and Schein’s (1979) seminal work on organisational socialisation anxiety is diminished.
proposed six tactics for organisations to structure socialisation for Smith (2011) associates caring in the context of nursing, with
newcomers, including the serial tactic (use of role models/ experi- labour. She explains that caring cannot be disconnected from emo-
enced staff to socialise the newcomer) and the investiture tactic (use tions, and similar to physical or technical labour, emotion manage-
of feedback to affirm identity and characteristics of newcomers). ment can be difficult and require effort. Smith (2011) describes
In nursing, socialisation encompasses learning the values, attitudes emotion work/labour as intervening to shape our actions when
and beliefs of the profession, and students encounter this socialisa- there is a gap between what we actually feel and what we think we
tion process when first engaging with the clinical setting and then should feel. Hochschild's (1983) ground-breaking work identified
with each subsequent clinical placement (Houghton, 2014). Key to emotional labour as being guided by feeling rules that come from
student nurses socialisation in clinical environments is a desire to within us, the reaction of others and social conventions. Hochschild
feel “part of the team” and achieve a sense of belonging. “Fitting (1983) and other scholars (e.g. Grandey, 2003; Smith, 2011) suggest
in” increases students' confidence, resilience and motivation to that emotions are managed through two main strategies, surface
learn (Gilbert & Brown, 2015; Grobecker, 2016) while a diminished acting and deep acting. Surface acting comprises suppression of
sense of belonging is associated with distress, anger and detachment genuine emotions or simulating unfelt emotions, via body language
(Kern, Montgomery, Mossey, & Bailey, 2014). Feeling confronted and and facial expressions, to portray an appropriate response (Delgado,
overwhelmed by the clinical environment and patients’ conditions, Upton, Ranse, Furness, & Foster, 2017; Grandey, 2003; Theodosius,
lack of confidence, or feeling intimidated and unwelcome by staff 2008). For example, a nursing student might take a deep breath
can lead students to feel disconnected and lacking a sense of place and smile in an effort to present a “professional face,” rather than
in the clinical setting (Gilbert & Brown, 2015). Tactics that can help display their discomfort or distress by crying in front of a patient.
nursing students adapt to the clinical learning environment include Deep acting involves modifying the experienced emotions (inside
support and information from registered nurse role models within feelings) to produce the desired emotions so that the experience and
the organisation, to encourage and supervise the student to “fit in” expression of the emotion are genuinely felt (Delgado et al., 2017;
and develop necessary practice skills (serial), and provision of inter- Theodosius, 2008). This might involve imagining or verbal and phys-
active feedback where students receive positive affirmation and ical prompting so that desired feelings will show on our face (Smith,
gain insight into their performance (investiture) (Houghton, 2014). 2011). For example, nursing students might psyche themselves up
Nursing students’ early clinical placement socialisation experiences through self-talk to get into the right frame of mind and feel confi-
can strongly affect the course of long-term adjustment, triggering dent to interact with a critically ill patient. In this way, they experi-
either a success or failure cycle and can interfere with their com- ence authentic excitement about the interaction rather than anxious
mitment to a future in nursing (Curtis et al., 2012; Gilbert & Brown, feelings. Hochschild (1983) originally proposed that both types of
2015). During the placement, if students are not explicitly socialised strategies comprise emotional labour and are harmful to well-being
about how to regulate their emotions, or not supported to do so, as they both require effort and resources; however, later research
they are likely to look for cues about how to respond from senior has found that surface acting is more detrimental than deep acting
nurses (Mackintosh, 2006). Indeed, there is evidence that when the (Grandey & Gabriel, 2015; Judge, Woolf, & Hurst, 2009). Hülsheger
focus of the socialisation is on professional and technical issues, this and Schewe’s (2011) meta-analysis found surface acting to be an in-
can exacerbate the challenges for nursing students (Mackintosh, effective emotion regulation strategy associated with impaired psy-
2006) who are unsure about how to best manage their emotional chological health and lower performance.
experiences. In this paper, we draw together the two literatures on sociali-
Historically, students' socialisation to nursing has occurred in sation and emotion management to explore the emotions nursing
anxiety-provoking clinical contexts. Isabel Menzies' (1959) seminal students experience during their early encounters in a quasi-profes-
work highlights concentrated impacts for nurses and students when sional role, the strategies they use to manage their emotions and the
bearing the stresses arising from patient care including, confronting types of socialisation related to management of emotions that they
the threat and reality of suffering and death, engaging in work that is experience. This inquiry can inform how healthcare and tertiary or-
often distasteful and a work situation that can arouse mixed feelings ganisations can develop effective support structures to enable nurs-
of guilt, anxiety and resentment. Furthermore, nurses and students ing students to develop effective emotion regulation strategies to
often carry their patients’ distress in addition to their own subjective facilitate their commitment to the profession and build the skills for
anxieties, which can amplify the psychological demands placed on effective patient care and their own well-being.
McCLOUGHEN et al. | 2511

3 | M E TH O DS Interviews, averaging 51 min duration, were audio-recorded and tran-

scribed verbatim. They commenced with interviewers briefly explain-
3.1 | Design ing the motivation for the study and then explored how students were
socialised to manage strong emotions during clinical placement and
The qualitative data reported in this paper form the embedded the particular strategies used to regulate their emotions. Interviews
method within a larger study with a quantitative component. The incorporated primary questions that prompted students to describe
concurrent embedded design incorporated one data collection their clinical experiences and impressions of their recent placement,
phase, during which quantitative and qualitative data were collected and to identify the kinds of emotions they and others’ experienced
simultaneously. This mixed methods design is based on the premise and strategies they used to manage them. Recruitment for interviews
that broader perspectives are gained by using different methods to continued to data saturation (Fusch & Ness, 2015). Participation was
acquire different types of data, rather than using one predominant informed and voluntary, requiring written consent. The study was
method alone (Creswell, 2009). The two forms of data can be in- conducted at University of Sydney and approved by University's
tegrated, or remain separate, but provide an overall composite as- Human Research Ethics Committee (2016/571).
sessment of an issue (Creswell, 2009). Data were collected during
September 2016–December 2018. The quantitative data collection
used a pre–post within-person design to survey nursing students 3.3 | Data analysis
prior to and following one first-year clinical placement. Surveys were
administered online. In addition to the surveys, students had the Interview data were subjected to conventional qualitative content
option to participate in an individual and/or focus group interview. analysis (Graneheim & Lundman, 2004). Data were managed using
Qualitative interviews explored students’ perceptions about how Excel spreadsheets. Data were sorted into preliminary topics re-
socialisation processes influenced their regulation of emotions. The lated to socialisation, belonging, behaviours, relationships, context
consolidated criteria for reporting qualitative research (COREQ) has and emotion management, and meaning units were developed, con-
guided the reporting of this study (see File S1). Aims for the qualita- densed and abstracted into codes and categories. Qualitative re-
tive inquiry were to explore how nursing students are socialised dur- searchers (authors 1, 2 and 5) developed and reviewed the codes,
ing early clinical placement to manage their emotions and to identify and categories were iteratively refined and developed during regu-
the type of emotion regulation strategies used by nursing students lar meetings until reaching consensus. Five main categories were
during early clinical placement. identified: self-socialisation, emotion management, working with
facilitators, working with registered nurses and workplace culture.
The researchers collectively interpreted the underlying meanings of
3.2 | Participants and data collection these categories and formulated two main themes.

All nursing students at the participating university enrolled in a first-

year Bachelor of Nursing (BN) or preregistration Master of Nursing 4 | FI N D I N G S
(MN) clinical subject, and undertaking clinical placements, were eli-
gible to participate in the study. Students received study information Twenty-one students were recruited for interviews. However,
during a lecture session. Subsequently, students were invited to par- two students did not appear for a scheduled focus group and did
ticipate in the study and sent a participant information and consent not respond to follow-up. The remaining 19 nursing students (10
form via a notification through the digital eLearning site for their Bachelor of Nursing students and 9 Masters of Nursing students)
subject. Students could indicate on the consent form whether they participated. Four students participated in a focus group inter-
agreed to be contacted for a single one-to-one or focus group inter- view, and remaining students participated in individual interviews.
view. Notification information included a link to the preplacement Participants were aged between 18–53 years, with the majority
survey. Following the clinical placement period, students received an- being under 25 years (n = 12) and predominantly female (n = 17).
other electronic notification with a link to the postplacement survey. Age range and gender were representatives of the broader nurse
Students who completed the surveys, and consented to being con- student cohort.
tacted about an interview, received a direct email about scheduling a During clinical placement, first-year nursing students were so-
convenient time. A researcher, external to the Nursing School, with no cialised to being both students and nurses, and to the healthcare
academic or other relationship with students (third author), delivered setting/workplace, via a range of formal and informal processes.
information and communicated with students about the study. More formalised approaches to socialise students to nursing oc-
Experienced qualitative nurse researchers (first and last authors), curred relationally through contact with the clinical facilitator and/
not teaching the participants’ subjects at the time of interview, con- or registered nurses who were paired with students. Socialisation
ducted the semi-structured focus group and individual interviews occurred during interpersonal interactions that incorporated de-
on campus. The researchers held a pre-existing interest in the emo- briefing, guidance, role modelling, education and demonstration.
tion work of nursing and how students learned to manage emotions. Students also engaged in an informal process of self-socialisation
2512 | McCLOUGHEN et al.

that involved independently reflecting on and evaluating their and generally, but not always, students were paired with a registered
observations and experiences, and developing personal interpre- nurse (RN) to work alongside each shift. The RN–student pairing was
tations to make sense of, inform and guide their current and fu- a formal mechanism for student learning and safety on placement.
ture practice. Self-socialisation occurred from direct or observed Students acknowledged that CFs and RNs held primary support
interpersonal interactions, engaging with work/organisational pro- roles and they expected them to be key resources when managing
cesses, and observing and interacting with the workplace milieu difficult situations during placement;
and culture.
Students experienced and managed emotions within the pro- If you have a bad placement or things happen, you go to
cess of being socialised to the broader nursing profession and staff or talk to your Facilitator.
the workplace context more specifically. Students’ emotional re- (BN10)
sponses could be activated during any interpersonal interaction
(with patients, family or staff), and it was through an integrated Students wanted CFs and RNs to spend time with them and be
process of observation, practice and engagement with oth- helpful and encouraging. Students viewed regular structured time
ers that they learned about “acceptable” ways to behave and to with the CF as providing opportunities to seek and receive feedback
demonstrate and regulate their emotions as a nurse. The two key on practice, guidance to develop particular skills, and education to
themes developed from this study were (a) proactive structured strengthen knowledge. Students identified CFs who demonstrated
guidance for students’ emotion management is scarce and (b) in- interest in their learning and positively interacted with them, as “pas-
formal self-reflection and interpretation guide students’ emotion sionate” and “easy to get along with.” When actively engaged with sup-
management. portive CFs, students felt valued and experienced a sense of “being
looked after” and “cared about.”

4.1 | THEME 1: Proactive Structured guidance for She always encouraged us with positive comments … she
students’ emotion management is scarce: Staff didn't came to us every single day and spent time with us, and
discuss any emotional things with me I can see through her attitude … she has passion, pas-
sion that she likes to help us, with her experience and
Typically, students found it difficult to anticipate how they would knowledge…
feel when on clinical placement, and most did deliberately focus on (BN6)
potential emotional experiences. Beyond the idea of speaking with
peers or staff, they did not plan for how they might manage strong Students perceived RNs who acted in a teaching capacity and
personal emotions and did not anticipate the need for specific emo- worked with them beyond simply completing tasks to “challenge
tion regulation mechanisms. Some students stated they received no their thinking” and “ask for rationales” to inform practice, to be es-
formal education about strategies for emotion management, prior to pecially helpful. In that context, students felt confident to seek ad-
participating in clinical placement. One student illustrated this when vice and ask questions and saw the environment as supportive for
reflecting on a placement in a surgical ward: patients.

[Prior to placement] I didn’t really think about that [strong They (nursing staff in general) all really want to teach the
emotions] too much but yeah, so I think that wasn’t really student nurse and they are happy to do it, so whenever, if
a huge factor of my thinking, not on my radar, but I guess I have any concerns I can ask them and they teach me in a
I would have just talked to the nurses I think or probably soft [gentle] way and then um, I can say that the nursing
just talked to my housemates or something. … [Academic principles [used by staff, demonstrate] that they care for
staff] will say you can talk to your facilitator and they all patients
make it very known, make sure you have a support sys- (BN2)
tem, but they don’t really offer a lot of specifics on what
you can do, like different strategies… Some students experienced a sense of disinterest by CFs. CF
(BN1) disengagement from a student was perceived as “absence of care,”
which affected the student's ability to fully interact with the clini-
cal environment and negotiate staff interactions. Students also felt
4.2 | Socialisation during Interactions with Clinical that, on occasion, RNs largely left them to manage alone. Students
Facilitators and Registered Nurses mainly felt “alienated” when the clinical facility was particularly
busy. While students acknowledged that RNs may have found it
Students were linked with a clinical facilitator (CF) who was broadly difficult to look after them in those circumstances, they felt “un-
responsible for facilitating student learning in the clinical setting, welcomed” and “in the way.” One student said “Because they were
McCLOUGHEN et al. | 2513

really busy they ignore you … they don't really care about what I about a patient dying said “I talked to the Clinical Facilitator about it
will do” (BN3). and she comforted me” (BN3). A student who was feeling stressed
about a practice error, felt compelled to apologise to their RN and
We weren’t paired off with any nurses … and I was still report to the CF, but did not specifically seek additional emotional
very fresh and I didn’t really understand what was ex- support.
pected of me, so I just kind of lingered around and didn’t
know how to help. … and our Facilitator didn’t seem to I was really panicked and I felt sorry that I did something
care, she didn’t interfere much with that, she just kind of wrong … I did something wrong and I needed to say sorry
let it happen… to the nurse … and report this to my facilitator. I felt like
(BN4) I have to report it. I did feel a bit bad, the nurse and fa-
cilitator [said] it’s good I learned my lesson … and I was
When students identified CFs as “interested” and “approach- thankful they would let it slide.
able,” they felt “free to talk,” “confident to ask questions” and (BN5)
“safe to seek reassurance.” While some students referred to reg-
ular debriefing sessions where students would meet with the CF RNs generally did not proactively offer structured support to help
and “share what we had seen and gone through” (BN4), other stu- students manage their emotions and did not typically instigate con-
dents expressed disappointment at “not having the chance to sit versations with students about their emotional responses. Students
down and debrief or anything” (MN1). Students recognised that in referred to a “general check in” where RNs would “ask if you're okay,”
addition to enhancing clinical knowledge and skills, if structured but “not ask specifically about [how] you are managing” (BN9). One
time like debrief sessions were used well, they offered a poten- student reflected that RNs “did not discuss emotional things with me
tially “therapeutic space” where they could talk through their whatsoever” (BN8), even though he had the impression that “they
experiences. weren't really expecting us to be emotionally strong.” The student re-
ferred to an interaction with an aggressive patient.
We would debrief at the end of the week, I think probably
more frequently would be better um, it just helps I guess. Like especially with that really aggressive patient, they
…By the end of the week, there was so much [to talk kind of expected me to crack. The nurses’ station was
about], that everyone was trying to fight to get a word right across from it, so when I was in the room and he was
in. I think daily, or a couple of times a week, it’s probably yelling … like I can see one or two of the RNs just looking
therapeutic to discuss [emotional things] and get input out, seeing if anything’s going on. But never, they never
from your Facilitator. came, so I thought I did alright, and they didn’t really
(BN4) [check with me afterwards].
(BN8)
When experiencing difficult or negative emotions during clinical
placement, some students sought comfort from the CF and wanted Working together with a supportive RN was particularly help-
to “vent their frustrations.” Often this was a default communication ful when students were undertaking “difficult work.” A well-placed,
mechanism, rather than a conscious and specific strategy to learn how comforting statement or action from a calm and attentive RN could
to manage their emotions. alleviate the student's anxiety and build confidence. Occasionally, RNs
initiated these interactions when they could see a student was feeling
Talking to the Facilitator … she was quite open to anxious; “[When] they expect that I’m going to have emotion, they al-
hearing our frustrations… [At one point] I went down ways touch my hand, hold my hand” (BN2). One student reflected on
and had a meeting with my Facilitator and a few other her placement in a surgical ward and recounted her first time doing a
nursing students and ah, I expected that to make me dressing change.
feel better, honestly it didn’t help at all because even
though it felt nice to vent to people, the other students The first one [I did] for the patient, was to change the
seemed to have had a great day and you know, misery dressing for his sutures. The wound was at the back and
loves company. it was quite hard and I was really nervous about chang-
(MN6) ing the wound, so I was really shaking. I was shaking and
then the nurse just said that, you just calm down, it’s
Some students achieved a form of emotional release in the pro- going to be fine.
cess of “reporting” or speaking up about challenging issues. One stu- (BN3)
dent who experienced a patient dying said, “I feel relaxed when I tell
something to the Facilitator that needs to be written down about my The students’ relationships with CFs and RNs did not incor-
placement” (BN2). Another student who became sad when hearing porate formal support for emotion management. When feeling
2514 | McCLOUGHEN et al.

uneasy, anxious or frustrated, students did not receive particu- helping them and interacting with them was I think the
lar guidance and strategies to regulate their emotions. However, best part of that.
when they perceived CFs and RNs to be interested in them and (MN3)
helpful, they did seek opportunities to talk about their expe-
riences and looked for, and frequently received, gestures of Students learned to understand that RNs had differing views and
support. approaches to working with them, and appreciated a need to manage
that complexity. They worked out that they had a responsibility to con-
tribute to the collegial relationship with nurses and in turn participate
4.3 | THEME 2: Informal self-reflection and in the work of the team. Students realised that they needed to demon-
interpretation guide students’ emotion management: strate initiative to let RNs know what they could do and that they were
I felt really bad, and I was going to cry, so I took a eager to learn more.
deep breath
There were some nurses you’d look forward to spending
Students were highly active in personally trying to manage their the day with and some that you wouldn’t. Cos you know
own emotions during clinical placement, as they participated in that they would be the ones who you just kind of follow
a process of reflection and interpretation focused on regulating them around, and they don’t really talk to you or they just
emotions. Reflecting on feelings, emotions and emotion manage- um, kind of ignore you. And just give you the most basic
ment strategies was an inherent part of what is conceptualised things to do that you’ve done a million times before…You
here as students’ self-socialisation. Students engaged in self- learn to overcome it I guess … put yourself out there …
socialisation to being a (student) worker, to being a nurse and to go out of your way to speak to them … actually help and
the workplace environment/culture, with a particular focus on get involved. …The students also have to take initiative,
the healthcare team and teamwork. These processes involved because if they [nurses] see that you’re just following
students’ (a) reflecting on placement experiences; (d) interpreting them around and you don’t take initiative, and you don’t
these experiences with a view to coping with the current place- be proactive then they kind of feel that … you won’t con-
ment and planning for future professional practice; and (c) mak- tribute much, so they won’t bother explaining more, like
ing sense of unfamiliar workplace cultures. Informal socialisation getting you involved kind of thing.
was separate from the direct learning experiences and formal pro- (MN3)
cesses of socialisation that occurred when working with CFs and
RNs, although these may have influenced and informed reflection Students tried to make sense of unfamiliar workplace cultures
and interpretation processes. and varied team member roles, by looking closely at how the mul-
tidisciplinary team interacted with each other, with them and with
patients. Students had limited opportunities to interact directly with
4.4 | Socialisation to the workplace and clinicians other than CFs and RNs; “We didn't interact at all with the
healthcare team doctors or anyone else” (MN8). However, they were able to observe
interprofessional interactions and noticed conflicting communica-
A key aspect of students’ self-socialisation to nursing was recog- tion styles and embedded hierarchies at play. They needed to work
nising the significance of the multidisciplinary team and acknowl- out what that meant for them as students and nurses. One student
edging the importance of feeling part of it. Students appreciated observed collegial goal setting and planning between a doctor and
nurses “assigning us tasks” and “talking to us about interesting nurse and some doctors “interacting really well and joking” with
things going on in the ward” (MN6). Being included contributed nurses (MN2). Conversely, MN5 referred to a “power play between
to feeling more confident, as students recognised that “feeling a nurse and patients that you would traditionally expect from doc-
engaged,” and “being acknowledged” by staff were indicators of tors or specialists” and BN4 noted that nurses were largely ignored
their acceptance into the team, and being treated more like nurses by busy doctors. She translated this disregard as a need to render
and less like students. Feeling like a “real” nurse, who was actively herself invisible.
contributing to patient care, was both exhilarating and confirm-
ing for students as they felt assured that they had made the right The doctors don’t make eye contact. You’re walking down
choice of profession. the hallway and they don’t budge, you have to creep past
them, they’re busy.
I think the part I enjoyed the most was um, actually feel- (BN4)
ing like I was making a difference and like, looking after
the patients, not just being like um, someone who was Minimal contact with the broader interdisciplinary group coupled
there to observe or um, just follow the nurse around I with lack of clarity around ward culture meant that some students were
guess. So yeah, like communicating with the patients and uncertain about the role or expectations of nurses within the team and
McCLOUGHEN et al. | 2515

were unsure how to actually integrate with other professionals. They It all depends on the um, the conditions, you know … [re-
recognised the need for nurses to contribute safely to the work of the ferring to a patient in pain]. And um, and I’ll just, if I can
team and acknowledged they needed to identify a correct process or do something then I’ll do it you know, even small things or
acceptable protocol for engaging with team members outside of the listen to them or just you know, with a facial [expression]
immediate nursing staff. or you know, the body language or even, just be there
and listen to them, and they normally calm down. And I
It would have been good to, and I guess this is something personally, when I talk to the patients, I normally sort of,
I can learn as I go along, about doing rounds with you myself I’ll just calm down and … try not to talk um loud
know the NUM and the surgeon, and just knowing when (BN6)
you can invite yourself along to things and when not to.
I still try and feel my way on when it’s appropriate and Students engaged in a cognitive process of justifying why it was not
when it’s not appropriate to sort of just get involved in acceptable to demonstrate their emotions around patients and then
things like that. used physical strategies like “deep breathing” and “walking away” to
(MN1) manage expression of emotions. Some students were concerned that
they would have difficulty controlling strong emotions.
Students identified the importance of happy staff and cohesive
teams, while also recognising the significance of those issues for their If I can stop it then I have to. I have to like just take a deep
own development and future practice as nurses. They associated breath and like yeah, just like go over in my head why I
friendly and collegial nurses who were encouraging of each other, shouldn’t cry, like why I should be strong and yeah, like,
as well as being close friends, with a positive environment that was but I’ve been working on it. Like I try not to let like other
comfortable to work in (BN1). A “good team environment” was one people’s emotions like reflect on my emotions so yeah.
where students “never heard nurses talking about other nurses behind You just have to kind of like mentally process why you
their back” (MN4). Students identified the importance of humour and shouldn’t and why you should um, yeah just, how you can
friendliness between staff to diffuse strong emotions and tension and just manage your emotions, like mentally instead of just
to connect members of the team. letting it take over.
(MN3)
They were friendly with each other … I would see them
just walk around and like, start joking and laughing and Students were trying to make sense of how to manage and demon-
stuff. There’s not like anything mean about it, they just strate their emotions in the context of being a nurse (or student). They
like you know, trying to reduce the stress. were able to recognise when they felt “out of their depth” as a nursing
(BN5) student and “didn't know what to do,” and the experience of vulnera-
bility that engendered for them. They variously acknowledged feelings
of “panic,” “anxiety” and “frustration,” and these emotional responses
4.5 | Socialisation to emotion management often occurred when interacting with patients with intense expressed
emotion. Some students said that they observed RNs to learn how
Most students were making complex interpretations about their ex- they managed stressful interactions and then tried to follow their lead.
periences with patients as well as RNs. For example, reflecting on For example, BN8 reflected on looking for behavioural cues from his
the need for sensitivity and empathy with very vulnerable patients, assigned RN, when feeling scared during an encounter with an aggres-
and recognising the importance of managing one's own emotions sive patient. Other students enacted boundaries, physical or personal,
for the sake of the patient and their family. Some students grappled as a means to secure them against feeling vulnerable. Some students
with impulses to demonstrate emotional affection, for example hug- referred to removing themselves from situations where they felt un-
ging the relative of a dying patient, or an urge to express their emo- comfortable about their capacity and skills to respond appropriately,
tions, for example, through weeping. However, they identified that particularly when patients were verbally abusive, screaming in pain or
patients’ emotional needs should be prioritised over their own and very upset. Examples of students’ behaviours included, “I stayed clear
acknowledged that impulsive displays of affection might be detri- of the room” (BN10); “I went out into the corridor and calmed down a
mental or actually exacerbate a patient or relative's reactions; “I felt bit” (BN9); “I just walked away cos I don't want to observe that because
very bad as well and [was] going to be crying, [but] I cannot cry with I’m not ready for it” (BN3). Another student recognised the need to
her because it will make her feel more bad” (BN2). Other students enact a more professional nurse role when working with a patient on
were beginning to make sense of the various ways they could con- a surgical ward who was depressed and expressing suicidal ideation:
nect with a patient to help them manage discomfort and recognised
that interpersonal interactions potentially influenced both the pa- I was chatting to him and I did feel in that situation that
tient's and their own feelings. BN6 reflected on working with pa- I didn’t have enough knowledge to know what the right
tients in pain: thing to say to him was. I was sort of acting like a parent
2516 | McCLOUGHEN et al.

but then I thought, I shouldn’t be a parent here, I should In the absence of strategic support, students used emotion manage-
be a nurse and so yeah, so that made me feel vulnera- ment strategies that can have negative impacts on their well-being.
ble, and a bit out of my depth … I just didn’t feel like I
knew what I was doing … I need to make sure I keep those
boundaries … and don’t let too much of myself out as a 5.1 | Emotional labour
person, as opposed to a nurse.
(MN8) During their early clinical placement, students in this study began
to understand the stressful reality of nursing work and often per-
Students also identified the need to seek emotional support ceived themselves to be without adequate support from RNs or
from others. They invariably sought support from their peers (other CFs who seemed at times to be disinterested and disengaged. They
students), friends, family and CFs. Talking about, and through, their participated in or observed various interpersonal interactions with
learning experiences provided an important mechanism for emotion patients and staff that elicited negative feelings, which, in turn, pre-
management. BN4 referred to the importance of debriefing with ceded some form of self-management. Lopez et al.'s study (2018)
peers when “we would walk to and from the hospital together” and also highlighted how nursing students with minimal prior experience
recognised this as a scarce opportunity to talk about things. Reflection or skills can feel traumatised and stressed as they try to engage with
through informal conversations with peers and friends provided op- nursing work in the absence of expected support from clinical staff
portunities to seek reassurance and comfort. BN2 highlighted this and preceptors.
when talking about her worries for a patient she had cared for who In our study, the impetus for students to regulate their emotions
was moved to ICU. predominantly occurred in the context of interacting with patients
and families and needing to work out how to manage their emotions
When you have observed a negative situation, you can in a way that did not negatively affect others. Recognition by stu-
like … tell it out loud, say it out and share with everyone. dents of the potential impact of their emotions on patients is import-
… I have to release it, so scary. He’s in the ICU at that ant to differentiating the emotional side of nursing as being distinct
time, that night, so I don’t know what is going to [hap- to, but also underpinning the functions of, a nurse. Smith (2011)
pen] next day, is he going to be dead or is he going to highlights that for some patients a sense of nurses feeling emotional
be rescued? So when I come home, luckily I live with my towards them can be experienced as threatening; a patient needs to
friends, so I [told everyone] I need to tell you this story, feel that care is safe, and this requires nurses to manage emotions
and everyone listened to me. in a way that may be different from their natural “caring” qualities.
(BN2) Some students modulated their body language and facial expres-
sions, in an attempt to minimise communication and demonstra-
tion of emotions that were potentially inappropriate or unhelpful,
5 | D I S CU S S I O N and to influence or alter their own feelings and those experienced
by patients. Others used deep breathing and instigated physical
This study set out to explore how first-year nursing students are so- boundaries, in combination with a cognitive process of recognis-
cialised during clinical placements to manage their emotions and to ing the meaning of their emotions and rationalising how to regulate
identify the type of emotion regulation strategies nursing students them. Some students looked to RNs for cues about how to express
use. The research question was underpinned by the assumption that emotions. These attempts to manage emotions highlight aspects of
students will inevitably experience significant emotions during their emotional labour, incorporating the inducement or suppression of
early clinical placements. Hospitals, the traditional clinical placement feelings during interpersonal interactions, for the benefit of others,
setting, are dynamic contexts with high levels of complexity and un- and attempting to recognise and navigate feeling rules or norms re-
predictability. They can be challenging for the uninitiated, including garding how, when and what emotion to express in particular social
first-year students who may feel out of their depth and at times, ac- contexts (Hochschild, 1983). Within these rules, emotions are man-
tually in the way of other very busy staff caring for acutely ill and aged through the strategies of surface and deep acting (Hochschild,
vulnerable people (Cleary, Visentin, West, Lopez, & Kornhaber, 1983).
2018; Lopez, Yobas, Chow, & Shorey, 2018; McCloughen & Foster, Surface acting was the main interactive interpersonal process
2018). For most students, this will be an out-of-the-ordinary experi- employed by first-year students to manage their emotions and
ence and a largely unpredictable one, likely to elicit strong emotional emotional expressions with patients and families. Surface acting
responses. Several issues identified by our study warrant discussion was used in the context of nursing work, to display behaviours that
including emotional labour, emotion management in nursing curric- were conducive to others feeling safe, comforted and cared for
ula and debriefing. These issues highlight the concerning finding that (Theodosius, 2008). This is not surprising given students’ efforts to
formal acknowledgement and structured support for students to develop and express a professional persona indicative of being “part
manage emotions was lacking during clinical placement, despite this of the team.” However, while both surface and deep acting strat-
being a known context for students to experience strong emotions. egies can be emotionally demanding, surface acting is associated
McCLOUGHEN et al. | 2517

with emotional dissonance that can result in emotional exhaustion, (Foster et al., 2017). It is not clear, though, how education provid-
stress and burnout and poor health (Delgado et al., 2017; Schmidt & ers incorporate emotion management training into first-year nurs-
Diestel, 2014). Research has generally found that surface acting is an ing programs. We know anecdotally that first-year students in some
ineffective strategy for emotion regulation, with detrimental effects nursing schools engage with content related to emotion manage-
including poor psychological health, low performance and absen- ment as part of broader preparation for nursing practice. However,
teeism (Nguyen et al., 2016). If emotional labour, and in particular the study reported here indicates students are not connecting theo-
surface acting, can negatively affect nurses, and nursing students’ retical learning with their clinical practice and are not necessarily
well-being and their work with others, then building their confidence building a repertoire of strategies to draw on when emotionally chal-
in their capacity to do emotion work may well be a necessary com- lenged in clinical settings. Students in this study did not report any
ponent of the educational preparation of nurses. Smith (2011) sug- deliberate anticipatory focus on the possibility they would experi-
gests that nursing students need to learn through experience and ence strong emotions during their forthcoming placement and did
training to recognise and use their feelings to remain therapeutically not elaborate on any specific strategies they intended to use to assist
engaged with patients, rather than surface acting to the point that with regulating those emotions. It is evident that first-year students
he/she can no longer remain involved with patients except at a su- tended to fall back on their personal self-socialisation and emotion
perficial level. management strategies during stressful moments, which may be an
Students sought comfort from others and assistance to make indication that current coursework preparation is not meaningful to
sense of and manage strong subjective emotional responses emerg- them when under pressure in real-world situations.
ing within a new and challenging environment. When students Healthcare students continue to experience strong emotions
attempt to reduce anxiety and divest themselves of negative emo- throughout their educational programs, and during transition to the
tions, and work to solve problems by reflecting and talking with workplace, and they may inadequately process and manage these
peers (Lopez et al., 2018), they engage in a form of emotional so- emotions. For example, Kennedy, Kenny, and O'Meara's (2015) scop-
cial support that can facilitate active learning and build resilience ing review of student paramedic experiences of transitioning into
(Thomas & Revell, 2016). This resonates with the notion of “informal the workforce reported that new paramedics are likely to experience
communities of coping” discussed by Smith and Cowie (2010). This strong emotions related to their perceived inadequate clinical work
phenomenon demonstrates how workers turn to colleagues, instead readiness and fear of not “fitting in.” Some nursing research supports
of supervisors, for a form of peer support in which to share ex- this, suggesting that new graduate nurses can also feel inadequately
tremely negative emotions and deal with daily emotional pressures. prepared for the “reality shock” of clinical practice, particularly in
Reflection on one's own capabilities and limitations can assist nurs- settings where they feel unwelcome and/or unsupported (Phillips,
ing students to recognise these in others (Wilson & Carryer, 2008), Esterman, Smith, & Kenny, 2013). Boychuk Duchscher (2009) sem-
which is an important skill in both the early education of nursing inal work on new graduate transition shock identified that new
students and as new graduates (Hodges, Keeley, & Grier, 2005). nurses experience a wide range of emotions with overwhelming
Reflection is an aid for new graduates to assimilate the discrepan- intensity. Inadequate functional and emotional support is a key as-
cies between their perceived role and reality of being a professional pect of their traumatic adjustment. We argue for a stronger focus in
nurse, the outcome of which may be described as emotional labour preregistration curricula on formal emotion management strategies
(Hodges, Keeley, & Troyan, 2008; Thomas & Revell, 2016). Delgado and targeted support in clinical settings for development of skills to
et al.’s (2017) review of the relationship between resilience and emo- implement those strategies in appropriate, sustainable ways. In line
tional labour identified that emotional labour is inherent to nursing with Delgado et al.’s (2017) findings, we propose that nursing edu-
work and building emotional resilience is a significant intervention cation incorporate educational and practice-focused interventions
to strengthen nurses’ internal resources and offset the risks of emo- for building resilience. These interventions should inform students
tional labour. about emotions, emotional dissonance and the impacts of negative
emotions, promote self-development strategies of self-regulation,
reflection, social connection and EI skills, and enhance students’ ca-
5.2 | Emotion management in curricula pacity to decrease the negative impacts of workplace (clinical place-
ment) stress and engage in self-care.
It is reasonable to expect that education providers recognise their
responsibility for preparing first-year students for emotional chal-
lenges during placements. However, minimal research literature on 5.3 | Debriefing
this topic means it is difficult to ascertain how students are specifi-
cally prepared to manage subjective emotions during early clinical Debriefing is commonly associated with experiential learning and
experiences. Some research shows that levels of emotional intelli- development of clinical skills, particularly in relation to simulation
gence (EI) can “buffer stress” and reduce anxiety in preregistration activities (Cant & Cooper, 2011; Dufrene & Young, 2014). However,
students (Lewis, Neville, & Ashkanasy, 2017) and that scaffolding debriefing for emotional and psychological support is also a valu-
of EI education throughout nursing programs can increase EI levels able mechanism for healthcare staff to share their experiences
2518 | McCLOUGHEN et al.

and talk about the human dimension of healthcare (Maben, 2014). offloading of emotions rather than a higher order strategy to make
Schwartz rounds are a form of debriefing where hospital staff vol- sense of and manage emotions.
untarily meet once a month in a confidential environment, to dis- Core components of debriefing for nursing include reflec-
cuss the emotional, social and ethical challenges associated with tion, feedback, knowledge development and psychological safety
caring for patients and families (Maben et al., 2018). Typically, a (Reierson, Haukedal, Hedeman, & Bjørk, 2017). These intercon-
multidisciplinary team presents a case describing the emotional im- nected components demonstrate the necessary relationship be-
pacts of caring for the patient. A trained facilitator guides discus- tween the players (nursing students and CFs) and the fundamental
sion of emerging themes/issues, allowing for audience reflection on importance of a “safe environment” in which to explore cognitive
similar experiences. A comprehensive evaluation of these rounds in and emotional responses like anxiety, worry and fear that occur in
England found many staff noted changes to self (increased com- clinical practice. In Fey, Scrandis, Daniels, and Haut’s (2014) study
passion, reflection, empathy, honesty and resilience; openness to of debriefing, students identified the need to process emotions and
emotional aspects of work and learning from others) and their own defuse worries so they could engage with learning. They described
and others’ behaviours (changing how they work with patients, in- needing to “blow off steam” at the beginning of a debrief session
creased teamwork and capacity to challenge colleagues) (Maben so they could then “relax and focus” and “participate in educated
et al., 2018). conversation.” Without the opportunity for initial sharing of emo-
Debriefing is also an important support mechanism for stu- tions, students were not able to reflect deeply and explore thought
dents on clinical placement, especially initial placements where processes (Fey et al., 2014, p e253). In our study, students actively
they can experience fear, anxiety and uncertainty (Janse van looked for therapeutic space in which to seek comfort, vent frustra-
Rensburg, 2019). Bender and Walker (2013) propose that educa- tions and release emotions with CFs and peers; however, this was
tors who lead clinical placements have an obligation that extends not followed up with guided exploration and learning about emo-
beyond students’ cognitive and skill-based learning to include a tion management. We see CFs as having a key role in engaging with
focus on their psychological, emotional and moral responses to students about their experience of varied emotions during clinical
aspects of their experiences, in short, attending to the affective placement and working with them to develop and test strategies for
dimension of experiential learning. Extending the focus to include emotion management. We propose that CFs receive training in lead-
emotion management, may to some extent mitigate contemporary ing formal debrief sessions with students within the clinical setting.
examples of Menzies’ (1959) early concerns with the intense anx- The structured support of formal debrief can offer containment for
iety evoked by nursing work being given objective existence and the uncertainty experienced by students in an unfamiliar clinical set-
containment within the social structure and culture of nursing. The ting and provide guidance for students to develop context-specific
expectation that nurses will inevitably and persistently experience knowledge and skills (Janse van Rensburg, 2019).
a higher degree of anxiety need not be simply accepted as an oc-
cupational hazard; instead, processes like debriefing could be used
to assist students to deeply work through, modify and master anxi- 6 | LI M ITATI O N S
ety aroused in the clinical setting (Menzies, 1959). Rather than only
offering feedback on performance, debriefing incorporates guided This study recruited students from a single nursing school, and
reflection and integration of activities into a student's understand- data were self-reported. Participants were predominantly female
ing with the aim to reduce the gap between the learning experi- and aged <25 years old. While these demographic characteristics
ence and making sense of the experience (Smith & Cole, 2009) and are representative of the student population at the study site, the
to produce learning that is enduring. Debriefing requires mutual findings should be considered in this context and are not neces-
communication between teacher and student that draws out ex- sarily transferable to all nursing students. Future research could
planations and enables students to develop strategies that enhance incorporate a broader representation of participants with higher
future performance (Cant & Cooper, 2011). numbers of students from different Schools of Nursing, with
Regular debrief sessions with a consistent structure, in which potentially greater diversity in clinical placement experiences.
CFs guided student reflection on learning from, and making sense of, Students may have reported personal accounts based on assump-
clinical practice experiences (Cant & Cooper, 2011) did not feature tions of preferred or acceptable experiences. Future research
strongly in students’ clinical education experiences reported in this could include supplementary observational data. It may also be
study. However, students attempted to engage with peers and CFs, beneficial to report integrated qualitative and quantitative data
as a response to needing emotional support in an uncertain envi- from a mixed methods study.
ronment where they were trying to make sense of and fit with local
culture and norms. They sought out people with whom they could
talk through and reflect on clinical experiences, and who would pro- 7 | CO N C LU S I O N
vide reassurance and feedback. However, these informal and largely
unstructured interactions did not reflect the formal debriefing mod- This study found that during early clinical placements, nurs-
els described in the broader literature and illustrated more of an ing students could experience strong emotions in the context
McCLOUGHEN et al. | 2519

of interacting with patients, families and professional staff in an Birks, M., Bagley, T., Park, T., Burkot, C., & Mills, J. (2017). The impact
of clinical placement model on learning in nursing: A descriptive ex-
unfamiliar and complex environment. However, they enter the
ploratory study. Australian Journal of Advanced Nursing, 34(3), 16–23.
clinical environment with limited forethought or planning about Boychuk Duchscher, J. E. (2009). Transition shock: The ini-
how to manage strong or negative emotions. Despite being closely tial stage of role adaptation for newly graduated registered
linked with clinical facilitators and registered nurses, who contrib- nurses. Journal of Advanced Nursing, 65, 1103–1113. https://doi.
org/10.1111/j.1365-2648.2008.04898.x
ute to socialising them to nursing via role modelling and interper-
Cant, R. P., & Cooper, S. J. (2011). The benefits of debriefing as formative
sonal interactions, students received minimal structured support feedback in nurse education. Australian Journal of Advanced Nursing,
to manage the emotional impacts of clinical work. Students used 29(1), 37–47.
an informal self-socialisation process, integrating observation, Cheng, C., Bartram, T., Karimi, L., & Leggat, S. G. (2013). The role of
practice and interpersonal engagement, to learn customary and team climate in the management of emotional labour: Implications
for nurse retention. Journal of Advanced Nursing, 69(12), 2812–2825.
acceptable ways to behave and demonstrate emotions as a nurse.
https://doi.org/10.1111/jan.12202
They primarily employed the emotional labour strategy of surface Cho, J., Laschinger, H. S., & Wong, C. (2006). Workplace empowerment,
acting to regulate their emotional expression. However, this strat- work engagement and organisational commitment of new gradu-
egy can have a detrimental impact on nurses’ psychological health ate nurses. Nursing Leadership, 19(3), 43. https://doi.org/10.12927​/
cjnl.2006.18368
and well-being. Students also sought emotional social support to
Cleary, M., Visentin, D., West, S., Lopez, V., & Kornhaber, R. (2018).
assist them to make sense of their experiences. Our findings high- Promoting emotional intelligence and resilience in undergraduate
light the need for education providers to consider how to guide nursing students: An integrative review. Nurse Education Today, 68,
nursing students’ socialisation to clinical practice, including how 112–120. https://doi.org/10.1016/j.nedt.2018.05.018
Creswell, J. W. (2009). Research design. Qualitative, quantitative, and mixed
to connect with and adjust to clinical environments, their people,
methods approaches (3rd ed.). Thousand Oaks, CA: Sage Publications.
culture and unique characteristics. There is a clear need for formal Curtis, K., Horton, K., & Smith, P. (2012). Student nurse socialisation in
educational preparation and focused practice strategies like struc- compassionate practice: A grounded theory study. Nurse Education
tured debriefing to support students to develop effective emotion Today, 32(7), 790–795. https://doi.org/10.1016/j.nedt.2012.04.012
Delgado, C., Upton, D., Ranse, K., Furness, T., & Foster, K. (2017). Nurses’
management strategies, integral to the relational aspects of nurs-
resilience and the emotional labur of nursing work: An integrative
ing work. review of empirical literature. International Journal of Nursing Studies,
70, 71–88. https://doi.org/10.1016/j.ijnur​stu.2017.02.008
AC K N OW L E D G E M E N T S Dufrene, C., & Young, A. (2014). Successful debriefing - Best meth-
ods to achieve positive learning outcomes: A literature review.
We would like to thank Mina Askovic for her assistance throughout
Nurse Education Today, 34, 372–376. https://doi.org/10.1016/j.
this project and the students who participated. nedt.2013.06.026
Ellis, A., Bauer, T. N., & Erdogan, B. (2015). New employee organizational
C O N FL I C T O F I N T E R E S T socialization: Adjusting to new roles, colleagues, and organizations.
The authors declare that there are no conflicts of interest that could In J. E. Grusec, & P. D. Hastings (Eds.), Handbook of socialization:
Theory and research (2nd ed., pp. 301–322). New York, NY: Guildford
be perceived as prejudicing the impartiality of the research reported.
Press.
Feng, R. F., & Tsai, Y. F. (2012). Socialisation of new graduate nurses to
AU T H O R S ' C O N T R I B U T I O N S practising nurses. Journal of Clinical Nursing, 21(13–14), 2064–2071.
Authors 1, 3, 4 and 5 made substantial contributions to conception https://doi.org/10.1111/j.1365-2702.2011.03992.x
Fey, M. K., Scrandis, D., Daniels, A., & Haut, C. (2014). Learning through
and design. Authors 1 and 5 collected data, and authors 1, 2 and 5
debriefing: Students’ perspectives. Clinical Simulation in Nursing,
analysed and interpreted data. All authors were involved in writing 10(5), e249–e256. https://doi.org/10.1016/j.ecns.2013.12.009
and revising the manuscript and have given final approval to the ver- Foster, K., Fethney, J., McKenzie, H., Fisher, M., Harkness, E., &
sion submitted for publication. All authors agree to be responsible Kozplowski, D. (2017). Emotional intelligence increases over time:
A longitudinal study of Australian pre-registration nursing stu-
and accountable for the content.
dents. Nurse Education Today, 55, 65–70. https://doi.org/10.1016/j.
nedt.2017.05.008
ORCID Fusch, P. I., & Ness, L. R. (2015). Are we there yet? Data saturation in
Andrea McCloughen https://orcid.org/0000-0002-5045-0558 qualitative research. The Qualitative Report, 20, 1408–1416.
Gilbert, J., & Brown, L. (2015). The clinical environment – do student
nurses belong? A review of Australian literature. Australian Journal of
REFERENCES Advanced Nursing, 33(1), 23–28.
Australian Nursing and Midwifery Accreditation Council (ANMAC). Grandey, A. A. (2003). When “the show must go on”: Surface acting and
(2019). Registered nurse accreditation standards 2019. Canberra: deep acting as determinants of emotional exhaustion and peer-rated
Author. service delivery. Academy of Management Journal, 46, 86–96. https://
Bauer, T. N., & Erdogan, B. (2014). Delineating and reviewing the role doi.org/10.5465/30040678
of newcomer capital in organisational socialization. Annual Review of Grandey, A. A., & Gabriel, A. S. (2015). Emotional labour at a cross-
Organizational Psychology and Organizational Behavior, 1(1), 439–457. roads: Where do we go from here? Annual Review of Organizational
Bender, A., & Walker, P. (2013). The obligation of debriefing in global Psychology and Organizational Behaviour, 2, 323–349.
health education. Medical Teacher, 35(3), e1027–e1034. https://doi. Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis
org/10.3109/01421​59X.2012.733449 in nursing research: Concepts, procedures and measures to achieve
2520 | McCLOUGHEN et al.

trustworthiness. Nurse Education Today, 24, 105–112. https://doi. Menzies, I. E. P. (1959). The functioning of the social system as a defence
org/10.1016/j.nedt.2003.10.001 against anxiety: A report on a study of the nursing service of a gen-
Grobecker, P. A. (2016). A sense of belonging and perceived stress eral hospital. Human Relations, 13, 95–121.
among baccalaureate nursing students in clinical placements. Nguyen, H., Groth, M., & Johnson, H. (2016). When the going gets
Nurse Education Today, 36, 178–183. https://doi.org/10.1016/j. tough, the tough keep working: Impact of emotional labor on ab-
nedt.2015.09.015 senteeism. Journal of Management, 42(3), 615–643. https://doi.
Helgesen, A. K., Gregersen, A. G., & Østbye Roos, A. K. (2016). Nurse org/10.1177/01492​06313​490026
students’ experiences with clinical placement in outpatient unit – A Nursing and Midwifery Council (NMC). (2018). Realising professionalism:
qualitative study. BMC Nursing, 15(1), 1–6. https://doi.org/10.1186/ Standards for education and training. Part 3: Standards for pre-registra-
s1291​2-016-0167-1 tion nursing programmes. London:Author.
Hochschild, A. R. (1983). The managed heart: Commercialization of human Phillips, C., Esterman, A., Smith, C., & Kenny, A. (2013). Predictors of suc-
feeling. Berkeley: University of California Press. cessful transition to registered nurse. Journal of Advanced Nursing, 69(6),
Hodges, H. F., Keeley, A. C., & Grier, E. C. (2005). Professional resil- 1314–1322. https://doi.org/10.1111/j.1365-2648.2012.06123.x
ience, practice longevity, and Parse's theory for baccalaureate ed- Reierson, I. Å., Haukedal, T. A., Hedeman, H., & Bjørk, I. T. (2017).
ucation. The Journal of Nursing Education, 44(12), 548. https://doi. Structured debriefing: What difference does it make? Nurse Education
org/10.3928/01484​834-20051​201-04 in Practice, 25, 104–110. https://doi.org/10.1016/j.nepr.2017.04.013
Hodges, H., Keeley, A., & Troyan, P. (2008). Professional resilience in bac- Schmidt, K.-H., & Diestel, S. (2014). Are emotional labour strategies by
calaureate-prepared acute care nurses: First steps. Nursing Education nurses associated with psychological costs? A cross-sectional survey.
Perspectives, 29(2), 80–89. https://doi.org/10.1097/00024​776- International Journal of Nursing Studies, 51, 1450–1461. https://doi.
20080​3 000-00008 org/10.1016/j.ijnur​stu.2014.03.003
Houghton, C. E. (2014). ‘Newcomer adaption’: A lens through which to Smith, J. R., & Cole, F. S. (2009). Patient Safety: Effective interdisciplin-
understand how nursing students fit in with the real world of prac- ary teamwork through simulation and debriefing in the neonatal ICU.
tice. Journal of Clinical Nursing, 23, 2367–2375. Critical Care Nursing Clinics of North America, 21(2), 163–179. https://
Hülsheger, U. R., & Schewe, A. F. (2011). On the costs and benefits of doi.org/10.1016/j.ccell.2009.01.006
emotional labor: A meta-analysis of three decades of research. Smith, P. (2011). The Emotional Labour of Nursing Revisited: Can Nurses Still
Journal of Occupational Health Psychology, 16(3), 361–389. https:// Care (2nd ed.). Basingstoke, England: MacMillan Education UK.
doi.org/10.1037/a0022876 Smith, P., & Cowie, H. (2010). Perspectives on emotional labour and
Judge, T. A., Woolf, E. F., & Hurst, C. (2009). Is emotional labour more dif- bullying: Reviewing the role of emotions in nursing and healthcare.
ficult for some than others? A multilevel, experience-sampling study. International Journal of Work Organization and Emotion, 3(3), 227–236.
Personnel Psychology, 62(1), 57–88. https://doi.org/10.1504/IJWOE.2010.032923
Kennedy, S., Kenny, A., & O’Meara, P. (2015). Student paramedic ex- Theodosius, C. (2008). Emotional labour in health care. The unmanaged
perience of transition into the workforce: A scoping review. heart of nursing. New York, NY: Routledge.
Nurse Education Today, 35, 1037–1043. https://doi.org/10.1016/j. Thomas, J., Jinks, A., & Jack, B. (2015). Finessing incivility: The pro-
nedt.2015.04.015 fessional socialisation experiences of student nurses’ first clinical
Kern, A., Montgomery, P., Mossey, S., & Bailey, P. (2014). Undergraduate placement, a grounded theory. Nurse Education Today, 35(12), e4–e9.
nursing students’ belongingness in clinical learning environments: https://doi.org/10.1016/j.nedt.2015.08.022
Constructivist grounded theory. Journal of Nursing Education and Thomas, L. J., & Revell, S. H. (2016). Resilience in nursing students: An
Practice, 4(3), 133–142. integrative review. Nurse Education Today, 36, 457–462. https://doi.
Lewis, G. M., Neville, C., & Ashkanasy, N. M. (2017). Emotional intel- org/10.1016/j.nedt.2015.10.016
ligence and affective events in nurse education: A narrative re- Van Maanen, J., & Schein, E. H. (1979). Toward a theory of socialization.
view. Nurse Education Today, 34–40. https://doi.org/10.1016/j. In B. M. Staw (Ed.), Research in organisational behaviour (Vol. 1, pp.
nedt.2017.04.001 209–264). Greenwich, Connecticut: JAI Press.
Lopez, V., Yobas, P., Chow, Y. L., & Shorey, S. (2018). Does building re- van Rensburg, E. S. J. (2019). Educators: Are you adequately sup-
silience in undergraduate nursing students happen through clinical porting nursing students during mental health placements?
placements? A qualitative study. Nurse Education Today, 67, 1–5. International Journal of Africa Nursing Sciences, 10, 43–48. https://doi.
https://doi.org/10.1016/j.nedt.2018.04.020 org/10.1016/j.ijans.2019.01.002
Maben, J.. (2014). Take staff support seriously with Schwartz rounds. Wilson, S., & Carryer, J. (2008). Emotional competence and nursing ed-
Health Service Journal. Retrieved from https://www.hsj.co.uk/comme​ ucation: A New Zealand study. Nursing Praxis in New Zealand, 24(1),
nt/take-staff​- suppo​r t-serio​u sly-with-schwa​r tz-round​s /50713​ 36–47.
80.article
Maben, J., Taylor, C., Dawson, J., Leamy, M., McCarthy, I., Reynolds, E.,
… Foot, C. (2018). A realist informed mixed-methods evaluation of S U P P O R T I N G I N FO R M AT I O N
Schwartz Center Rounds® in England. Health Services and Delivery Additional supporting information may be found online in the
Research, 6(37), 1–260. https://doi.org/10.3310/hsdr0​6370
Supporting Information section.
MacDonald, K., Paterson, K., & Waller, J. (2016). Nursing students' ex-
perience of practice placements. Nursing Standard, 31(10), 44–50.
https://doi.org/10.7748/ns.2016.e10230
Mackintosh, C. (2006). Caring: The socialisation of pre-registration stu- How to cite this article: McCloughen A, Levy D, Johnson A,
dent nurses: A longitudinal qualitative descriptive study. International Nguyen H, McKenzie H. Nursing students’ socialisation to
Journal of Nursing Studies, 43(8), 953–962. https://doi.org/10.1016/j. emotion management during early clinical placement
ijnur​stu.2005.11.006
experiences: A qualitative study. J Clin Nurs. 2020;29:2508–
McCloughen, A., & Foster, K. (2018). Nursing and pharmacy students’
use of emotionally intelligent behaviours to manage challenging in- 2520. https://doi.org/10.1111/jocn.15270
trpersonal situations with staff during clinical placement: A qualita-
tive study. Journal of Clinical Nursing, 27, 2699–2709.
Copyright of Journal of Clinical Nursing (John Wiley & Sons, Inc.) is the property of John
Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to
a listserv without the copyright holder's express written permission. However, users may
print, download, or email articles for individual use.