Nursing students' perception of the clinical learning environment and supervision in relation to two different supervision models - a comparative cross-sectional study.

BACKGROUND: Knowledge concerning nursing students' experiences of the clinical learning environment and how supervision is carried out is largely lacking. This study compares nursing students' perceptions of the clinical learning environment and supervision in two different supervision models: peer learning in student-dedicated units, with students working together in pairs and supervised by a "preceptor of the day" (model A), and traditional supervision, in which each student is assigned to a personal preceptor (model B). METHODS: The study was performed within the nursing programme at a university college in Sweden during students' clinical placements (semesters 3 and 4) in medical and surgical departments at three different hospitals. Data was collected using the Clinical Learning Environment, Supervision and Nurse Teacher evaluation scale, CLES+T, an instrument tested for reliability and validity, and a second instrument developed for this study to obtain deeper information regarding how students experienced the organisation and content of the supervision. Independent t-tests were used for continuous variables, Mann-Whitney U-tests for ordinal variables, and the chi-square or Fischer's exact tests for categorical variables. RESULTS: Overall, the students had positive experiences of the clinical learning environment and supervision in both supervision models. Students supervised in model A had more positive experiences of the cooperation and relationship between student, preceptor, and nurse teacher, and more often than students in model B felt that the ward had an explicit model for supervising students. Students in model A were more positive to having more than one preceptor and felt that this contributed to the assessment of their learning outcomes. CONCLUSIONS: A good learning environment for students in clinical placements is dependent on an explicit structure for receiving students, a pedagogical atmosphere where staff take an interest in supervision of students and are easy to approach, and engagement among and collaboration between preceptors and nurse teachers. This study also indicates that supervision based on peer learning in student-dedicated rooms with many preceptors can be more satisfying for students than a model where each student is assigned to a single preceptor.

Lecturers' reflection on the three-part assessment discussions with students and preceptors during clinical practice education: A repeated group discussion study.

Assessment of students' learning and achievement requires active involvement of participating students, preceptors and lecturers. The lecturers have overall responsibility for both the content of the assessment and students' learning. The aim of the present study was to investigate lecturers' reflections on the mid-course discussion and final assessment that are part of nursing students' clinical practice education. The design was descriptive and had a qualitative approach. Repeated group discussions were undertaken with 14 lecturers at two university campuses in Norway. Five categories were identified: preparing for the three-part discussion, creating a collaborative atmosphere, facilitating student learning, verifying student learning, using the assessment tool to create the assessment discussion; one theme emerged: 'being able to see and justify students' learning processes'. Lecturers' reflections on both assessment discussions and students' learning proceeded from a clear pedagogical viewpoint.

Nursing students' and preceptors' experience of assessment during clinical practice: A multilevel repeated-interview study of student-preceptor dyads.

Nursing students' learning process during clinical practice is dependent on the quality of their assessment, and the feedback that is given, however an issue that is very little examined. The aim of this study was to investigate student-preceptor dyads and their experiences of mid-course discussions and final assessment. Data were collected through repeated semi-structured individual interviews with 13 dyads close in time to the assessment discussions, and were analyzed by searching for similarities and differences in their experiences. Both students and preceptors shared the view that the preparations before the discussions caused uncertainty, but they described different reasons. Both students and preceptors meant that the assessment tool was used in a structured way. The feedback mediated to students emphasized what was important to concentrate on in the next part or next period, but less about the individual students' progress. The student-preceptor dyads did not share the view of what content had been in focus in the discussions and there were variations in the details. Conclusions can be drawn that one of the crucial elements of an assessment discussion, to give students constructive feedback in relation to learning outcomes, was not fulfilled.

Nursing students' perceptions of using the Clinical Education Assessment tool AssCE and their overall perceptions of the clinical learning environment - A cross-sectional correlational study.

BACKGROUND: Clinical education is a vital part of nursing students' learning; the importance of assessment tools and feedback in stimulating student learning has been stressed, but this needs to be studied in more detail. OBJECTIVES: To examine relationships between nursing students' perceptions of using an Assessment tool in Clinical Education (AssCE) during their mid-course discussion and final assessment, the content discussed during these meetings between the student, preceptor and nurse teacher and the students' overall perception of the clinical learning environment. DESIGN: A cross-sectional, correlational design was used. SETTING AND PARTICIPANTS: A convenience sample of 110 nursing students from one Norwegian university college with two campuses. METHODS: Data were collected with self-developed questionnaires and analysed using logistic regression with SPSS and the PROCESS macro for mediation analysis. RESULTS: There was a positive relationship between nursing students' perceptions of using the assessment tool AssCE and their overall perception of the clinical learning environment. This relationship was, in turn, mediated by the content discussed during the formative mid-course discussion and summative final assessment. CONCLUSIONS: Our conclusion is that the assessment tool AssCE supported students' clinical learning and that this relationship, in turn, was mediated by the degree to which the conversation during the assessment meeting focused on the student's knowledge, skills and professional judgement.

Validation of the tool assessment of clinical education (AssCE): A study using Delphi method and clinical experts.

The aim of the present study was to establish the validity of the tool Assessment of Clinical Education (AssCE). The tool is widely used in Sweden and some Nordic countries for assessing nursing students' performance in clinical education. It is important that the tools in use be subjected to regular audit and critical reviews. The validation process, performed in two stages, was concluded with a high level of congruence. In the first stage, Delphi technique was used to elaborate the AssCE tool using a group of 35 clinical nurse lecturers. After three rounds, we reached consensus. In the second stage, a group of 46 clinical nurse lecturers representing 12 universities in Sweden and Norway audited the revised version of the AssCE in relation to learning outcomes from the last clinical course at their respective institutions. Validation of the revised AssCE was established with high congruence between the factors in the AssCE and examined learning outcomes. The revised AssCE tool seems to meet its objective to be a validated assessment tool for use in clinical nursing education.

Preceptors' reflections on their educational role before and after a preceptor preparation course: A prospective qualitative study.

During clinical practice, preceptors play an important educational role in helping nursing students become secure and effective practitioners. For this educational role they need adequate preparation. The aim of the present prospective study was to describe preceptors' experiences of their educational role before and after attending a university preceptor preparation course. This 7.5-credit, Master's level course is offered on a part-time basis and covers one semester. The theoretical approach was self-directed and reflective learning. Twentyseven preceptors participated in group interviews before and after the course, and data were analyzed using qualitative content analysis. The findings revealed a shift in preceptors' perceptions. Their view of the educational role changed from being characterized by individual experiences and notions to being guided by personal and formal demands. Before the course, the lack of sufficient preconditions for preceptorship predominated, whereas after the course participants described ways of creating such preconditions. Before the course, the supervisory process was described as teaching, whereas after the course it was described as a learning process for students. Using reflective learning in a preceptor preparation course can develop and strengthen preceptors' view of their educational role and help them manage and create the preconditions for preceptorship.

Nursing students' and preceptors' perceptions of using a revised assessment form in clinical nursing education.

Assessment of students' learning is a crucial question when great changes occur in the higher education sector. One such educational reform is the Bologna declaration, the requirements of which have resulted in significant modifications in documents as assessment forms for clinical education. The aim of this study was to investigate students' and preceptors' perceptions of using the revised version of an assessment form, the AssCE form. Using convenience sampling, a questionnaire survey was completed by 192 nursing students and 101 preceptors. Most of the participants found that the revised AssCE form was possible to use during different years of the programme, and factors in the AssCE form were possible to combine with learning outcomes in the course syllabus. Most participants perceived that the scale added to each factor facilitated the assessment dialogue and offered possibilities to illustrate the students' development during clinical periods. Findings also showed that students were most often prepared with self-assessment before the assessment discussions. More information about the use of the AssCE form, also in combination with learning outcomes in the course syllabus, may further support the use of the form and contribute to students' development during clinical practice.

Development of instruments for assessment of knowledge and skills in performing venepuncture and inserting peripheral venous catheters.

PURPOSE: Performing venepuncture is one of the most routinely performed invasive procedures in nursing care. The aim of this study was to develop instruments for the assessment of nursing students' knowledge and skills when performing venepuncture and inserting a peripheral venous catheter. 
 METHODS: Two instruments were developed using the following steps. 1) Assessment items of importance for the procedures (venepuncture 48 items and peripheral venous catheter 51 items) were collected from focus groups including nurses, lecturers and patients. 2) The number of items was reduced using a method based on the Delphi method. Experts (n=51) reviewed the instruments in two rounds. The revised versions included 31 items for venepuncture and 33 items for peripheral venous catheter insertion. 3) Usability tests were conducted by nurses who tested the instruments to confirm that items were possible to assess. 4) Inter-rater reliability was assessed by twelve lecturers who in pairs, but independently of each other, used the instruments to assess 50 nursing students. RESULTS: Proportion of agreement and Cohen's kappa coefficient were calculated for each item to determine inter-rater reliability. Among the tested items for both instruments, the median proportion of agreement was 1 (range 0.66-1) and the median kappa was 0.52 (range 0.22-1). CONCLUSIONS: The instruments developed for assessing nursing students' knowledge and skills of venepuncture and peripheral venous catheter insertion showed satisfactory inter-rater reliability.

Implementation and student evaluation of clinical final examination in nursing education.

BACKGROUND: Clinical examinations have a distinct focus, the overall aim being to demonstrate through action whether nursing students have acquired the knowledge and skills necessary to be safe and accountable practitioners. This complexity of knowledge cannot be assessed using single examinations, thus there is a need to develop multiple assessment approaches. OBJECTIVES: To describe the process of developing valid clinical examinations for nursing students at the end of the final semester and to evaluate students' perceptions of these examination formats. OUTLINE OF THE DEVELOPMENTAL PROCESS: Based on earlier research, overall goals for the degree of Bachelor of Science in Nursing and guided by both task-related and relational aspects of nursing, two clinical final examinations were developed and tested. One was a standardized test of performance in vitro using Objective Structured Clinical Examination (OSCE) based on five specific areas in which newly graduated nurses had shown deficiencies. The other was a test of performance in real conditions, in vivo, using Bedside Observation Examination (BOE) assessing nurse-patient relation, entirely based on patients' needs. NURSING STUDENTS' EVALUATION: Three classes of students (n=203) were asked to participate and answer a study-specific questionnaire. The students highly valued the two examinations and perceived that the knowledge and skills tested were relevant to nurses' work. They found the examinations stressful, but at the same time meaningful, and felt they could do themselves full justice through this form of examination. RECOMMENDATIONS: The assessment test should be chosen depending on the preferred outcome. The OSCE, with its high degree of standardization, is appropriate to use to assess task-related aspects of nursing (show how), while the BOE, with its low degree of standardization, is suitable in real settings and has the potential to capture the relational aspects of nursing (does).

Nursing students' perceptions of clinical supervision: the contributions of preceptors, head preceptors and clinical lecturers.

AIM: The aims of the study were 1) to investigate to what extent nursing students were satisfied with the supervision provided by facilitators (preceptor, head preceptor, and clinical lecturer), 2) to compare nursing students' ratings of facilitators' contribution to supervision as supportive and challenging, and 3) to examine relationships between facilitators' supportive and challenging behavior in supervision and nursing students' perception of fulfillment of expected learning outcomes in clinical education. BACKGROUND: Although there are many studies on support of students in clinical education, few have addressed this from the students' point of view or made comparisons between different facilitators. METHODS: A cross-sectional survey study was conducted during April to November 2010, where 107 nursing students, from a university in central Sweden, answered a questionnaire about supervision immediately after their period of clinical education. RESULTS: Supportive behavior in supervision was rated higher by students for all facilitator groups as compared with challenging behavior. The students rated preceptors and clinical lecturers as more supportive than head preceptors and clinical lecturers as providing more challenges than the two other facilitator groups. Supportive and challenging behavior in supervision explained 39% of the variance in students' overall learning outcomes. However, the regression coefficient was only significant for students' ratings of supportive behavior for the preceptor. CONCLUSIONS: Nursing students were satisfied with facilitators' supervision and by their contribution to fulfillment of overall learning outcomes. Comparisons showed that preceptors in a higher degree were perceived as supportive while clinical lecturers were perceived as more important as challengers for critical thinking, reflection and exchange of experiences between students. The model of supervision seems to be promising, but the roles across facilitators need to be made clearer, especially the head preceptor's role, which seemed to be the most unclear role in this model.

Nursing students' satisfaction with supervision from preceptors and teachers during clinical practice.

The last two decades have seen widespread changes in nursing education. The clinical environment remains important for the development of nursing students' confidence in and fulfillment of intended learning outcomes. Preceptors and university teachers are an invaluable resource in preparing students for the reality of their professional roles. The current study examined Norwegian nursing students' perceptions of preceptors' and university teachers' supervision. Participants were invited to complete a version of the Nursing Facilitator Clinical Questionnaire (NFCQ) after the completion of their latest clinical practice periods. Three hundred and eighty students representing all three years of education completed the questionnaire. Data were analyzed with descriptive and inferential statistics. It was found that students highly valued teachers' and preceptors' supervision, although teachers' supervision was rated somewhat more highly. Fulfillment of learning outcomes for clinical practice was also rated highly, and the teachers' supervision was estimated, to some extent, more highly than the preceptors' supervision in this respect. The study underlines that, in addition to the estimation of satisfaction with supervision, it is important to relate supervision to the intended learning outcomes, which can be seen as a realization of that which students should know.

Nursing education in Denmark, Finland, Norway and Sweden - from Bachelor's degree to PhD.

AIM: This paper is a discussion of the similarities and differences in baccalaureate nursing education programme structures, content and pathways to postbaccalaureate education in the Scandinavian countries. BACKGROUND: For the last three decades nursing education internationally, as well as in the Scandinavian countries, has experienced ongoing reforms. The driving forces behind these reforms have been efforts for professional development within nursing and to harmonize higher education in several European countries. DATA SOURCES: The data were collected by a critical review of the guiding principles, national directives and educational structures and content of Bachelor's degree programmes from 1990 to 2008 and of further educational levels in the four Scandinavian countries. DISCUSSION: There are similarities as well as substantial differences in the educational structures, contents and lengths in the different nursing programmes. Nursing education is organized in the three cycles described in the Bologna Process, but there are differences regarding names and terms for degrees and allocation of European Credit Transfer System credits. IMPLICATIONS FOR NURSING: Policymakers need to consider more carefully the directives in the Bologna Declaration when planning and implementing nursing programmes at Bachelor's and postgraduate levels. Knowledge of the content and structure of nursing education in these countries may enhance development and cooperation between institutions. CONCLUSION: A challenge for the ministries of education in the Scandinavian countries is to compare and coordinate nursing educational programmes in order to enable nursing students, educators, researchers and nurses to study and work in Scandinavia, Europe or even globally.

Master's level in primary health care education - students' and preceptors' perceptions and experiences of the alteration in the clinical areas.

BACKGROUND: Many Western European countries are undergoing reforms with changes in higher education according to the Bologna declaration for Higher European Education Area. In accordance with these changes, the Master's degree was introduced in specialist nurse education in Sweden in 2007, and as a result changed the curriculum and modified theoretical and clinical areas. The aim of this study was to investigate students' and preceptors' perceptions and experiences of Master's level education in primary health care with a focus on the clinical area. METHODS: A descriptive design and qualitative approach was used. Interviews with ten students and ten preceptors were performed twice, before and after the clinical practice period. Interviews were audio-recorded, transcribed verbatim and themes formulated. RESULTS: Students perceived alteration in the content of the education at the Master's level such as more independence and additional assignments. The preceptors perceived benefits with the Master's level but were unsure of how to transform theoretical and abstract knowledge into practice. Writing the Master's thesis was seen by students to take time away from clinical practice. For some students and preceptors the content of the Master's level clinical practice area was experienced as vague and indistinct. The students had not expected supervision to be different from earlier experiences, while preceptors felt higher demands and requested more knowledge. Both students and preceptors perceived that education at the Master's level might lead to a higher status for the nurses' profession in primary health care. CONCLUSIONS: Students and preceptors experienced both advantages and disadvantages concerning the change in specialist nurse education in primary health care at the Master's level. The altered educational content was experienced as a step forward, but they also questioned how the new knowledge could be used in practice. The relevance of the Master's thesis was questioned. Supervision was seen by students as an introduction to the work of the district nurses' work. Preceptors perceived high demands and did not feel enough qualified for student supervision. Both groups considered it an advantage with the change in education that could result in higher status for nurses working in primary health care.

Strengthening and updating supervising staff nurses in educational workshops--an international partnership project.

As part of a collaborative project involving Tanzania and Sweden, workshops were arranged for staff nurses in order to develop a forum for discussing the raised demands for supervision of nursing students during their clinical education. The aim was to meet nurses in educational workshops to initiate a dialogue on their views and experiences of supporting and supervising nursing students in their clinical studies. Their experiences of the workshops were also requested. Two groups of nurses in Tanzania (n=30), and six groups in Sweden (n=60) participated. The content, which was agreed between the project leaders in Tanzania and Sweden was carried out either on a whole day workshops or divided at three different occasions. Questionnaires were given before and about two months after, and workshops were also evaluated with an open-ended question immediately after. The nurses both in Tanzania and in Sweden appreciated the workshops as a possibility to create a dialogue and to discuss challenges in the supervision of students. Their views and experiences of the supervision role showed awareness of staff nurses as role models and teachers. Accomplishment of this partnership co-operation through arranging workshops has shown to be an easy and simple way of giving support to staff nurses for the supervision task.

Translation of the Nursing Clinical Facilitators Questionnaire (NCFQ) to Norwegian language.

The translation and adaptation of English instruments to be used with populations speaking other languages is an important and complex process which is attracting increased attention in nursing and health-related research. The aim of this article is to describe the translation process of the Nursing Clinical Facilitators Questionnaire (NCFQ) for testing in Norway. The instrument is a 28-item-questionnaire with a Likert-type (1-5) scale ranging from the descriptions "strongly agree (1) to strongly disagree (5)". The aim of the instrument is to measure the efficiency of, and satisfaction with the supervision received from the nurse students' perspective. The NCFQ questionnaire was translated in six phases. The translation process was conducted systematically by applying the three methods described in the literature: the methods of forward-translation, back-translation and comparison followed by an empirical study (pilot test). The methods were chosen to test the quality of translation, establish semantic equivalence of the translated instrument and to estimate the cross-cultural relevance of the instrument. The translation process has given prerequisites to use the NCFQ questionnaire in a larger study and a possibility to compare different models for supervision of nursing students in the clinical part of their education.

Learning through participating on an interprofessional training ward.

Learning in clinical education can be understood as a process of becoming a legitimate participant in the relevant context. Interprofessional training wards (IPTWs) are designed to give students from educational programmes in health and social care a realistic experience of collaboration for the purpose of developing teamwork skills. IPTWs have been found to be appreciated by the students and to influence students' understanding of each other's professions. The aim of this study was to describe and analyse the students' learning on an interprofessional training ward in care for older persons through focusing on the students' ways of participating in the communities of practice on the ward. A case study design was chosen. Multiple data sources were used. The findings show that the students engaged as active participants in the care. At the same time there was sometimes a discrepancy between on the one hand expectations and goals, on the other hand actual participation. There were difficulties in making the training relevant for all the student groups involved. The findings indicate that in the planning of interprofessional education the choice of setting and learning situations is crucial with regard to the learning that will occur.

District nurses' experience of supervising nursing students in primary health care: A pre- and post-implementation questionnaire study.

Nursing students go through clinical supervision in primary health care settings but district nurses' (DNs) circumstances when supervising them are only briefly described in the literature. The aim of this study was to investigate DNs experience of supervising nursing students before and after the implementation of a new supervision model. Ninety-eight (74%) DNs answered a questionnaire before and 84 (65%) after implementation of the new supervision model. The study showed that DNs in most cases felt that conditions for supervision in the workplace were adequate. But about 70% lacked training for the supervisory role and 20% had no specialist district nurse training. They also experienced difficulty in keeping up-to-date with changes in nurse education programmes, in receiving support from the university and from their clinic managers, and in setting aside time for supervision. Improvements after the implementation of a new model chiefly concerned organisation; more DNs stated that one person had primary responsibility for students' clinical practice, that information packages for supervisors and students were available at the health care centres, and that conditions were in place for increasing the number of students they supervised. DNs also stated that supervisors and students benefited from supervision by more than one supervisor. To conclude, implementation of a new supervision model resulted in some improvements.

Nursing students' views on learning opportunities in primary health care.

AIM: To evaluate a new supervision model for nursing students' placements in primary care in Sweden and to document students' opinions on their learning experiences in this setting. METHOD: Nursing students' (n=238) opinions were collected using a questionnaire administered before and after implementation of a new supervision model for student placements in primary care. RESULTS: Respondents were generally satisfied with their placements and rated factors that supported the new model: distinct structure for following students during the placement period; continuous caring experiences with some patients; having more than one district nurse as a mentor during the period; and seminars in primary care settings. However, just one third of respondents felt that they gained insight into how nursing research could be used in patient care. CONCLUSION: The evaluation of the new supervision model and learning opportunities in primary care were positively rated by respondents. Application of nursing research and planned time for reflection were ranked low, findings that are noteworthy and should be investigated further.