Nurse Education in Practice 14 (2014) 722e728

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Learning and teaching in clinical practice

Improving the quality of nursing students' clinical placements in nursing homes: An evaluation study Grethe Brynildsen a, *, Ida Torunn Bjørk b, 1, Karin Berntsen c, 2, Margrete Hestetun a, 3 a

Lovisenberg Diaconal University College, Lovisenberggt. 15b, N-0456 Oslo, Norway Department of Nursing Science, University of Oslo, Postboks 1130 Blindern, N-0318 Oslo, Norway c Institute for Health Sciences, Telemark University College, Postboks 203 N-3901 Porsgrunn, Norway b

a r t i c l e i n f o

a b s t r a c t

Article history: Accepted 21 September 2014

The aim of this study was to explore students' experiences during their clinical placements in five nursing homes after implementing measures to improve the learning environment. It is vital to stimulate more future nurses to consider a career within geriatric wards and nursing homes. One way to achieve this, is to enhance nursing students' learning experiences during clinical placements in these settings. Measures to improve the learning environment were implemented as a result of a joint effort between a university college and five nursing homes. An explorative design was developed to collect empirical data concerning the students' experiences expressed through questionnaires and logs. The results generally conveyed more positive than negative experiences. Students expressed most satisfaction with peer collaboration, the placement's contribution to awareness of future nursing role and described the learning arena as exciting and interesting. They expressed less satisfaction with supervision from preceptor and how the practice site was prepared for and organized students' placements. Clinical placement arenas and educational institutions should collaborate closely to explore and develop models of supervision appropriate for the nursing home context, to build on existing potentials and resolve the issues that represent barriers for creating interesting and effective learning environments. © 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

Keywords: Nursing students Clinical placements Nursing homes Learning environment

Introduction High quality care is essential to meet the increasingly complex medical and palliative needs of nursing home residents. The proficiency of the staff in nursing homes and similar facilities is considered a crucial factor in providing health care that will limit afflictions and pain and enhance quality of life for this group of residents (Elsner et al., 1999; Curry et al., 2009). Nurses have a pivotal role in securing this quality of care. Therefore it is vital to encourage more nursing students to use their future professional expertise within aged care. Nursing homes have become important clinical placement arenas for nursing students in many countries (Robertson, 1988; * Corresponding author. Tel.: þ47 22358200; fax: þ47 22374934. E-mail addresses: [email protected] (G. Brynildsen), i.t.bjork@medisin. uio.no (I.T. Bjørk), [email protected] (K. Berntsen), [email protected] (M. Hestetun). 1 Tel.: þ47 22850577; fax: þ47 22850570. 2 Tel.: þ47 35575470; fax: þ47 35575401. 3 Tel.: þ47 22358200; fax: þ47 22374934.

Kaeser et al., 1989; Wade and Skinner, 2001; Chen et al., 2007; Berntsen and Bjørk, 2010; Grealish et al., 2010). The complexity inherent in the medical, palliative and basic care needs of the residents makes nursing homes interesting, but also demanding places for learning (Chen et al., 2007; O'Connell et al., 2008). Student nurses encounter many challenging learning situations in nursing homes, but limited access to qualified supervision and support may prevent them from fully utilizing the learning potentials (Davies et al., 2002; Lees et al., 2006; Kerridge, 2008; Xiao et al., 2008). Negative experiences during clinical placements are considered one of the reasons why nursing students hesitate to engage in aged care, and efforts to enhance the learning environment during clinical placements in nursing homes, may positively affect nursing students' attitudes and their future choice of employment (Grealish et al., 2010; McKenna et al., 2010). In this paper we present and discuss results from an evaluation study aiming to explore nursing students' experiences during clinical placements in five nursing homes after the implementation of measures to improve the learning environment.

http://dx.doi.org/10.1016/j.nepr.2014.09.004 1471-5953/© 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

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Background Despite the recent development of clinical skills centers with advanced technology which allows for simulation of most clinical skills, good clinical learning arenas are still crucial in learning nursing skills, clinical reasoning and developing as a professional nurse (Benner et al., 2010). The complexity that characterizes nursing home residents' medical and caring needs, represents many learning opportunities in this respect. Students, clinical preceptors as well as faculty have acknowledged that clinical placements in nursing homes provide opportunities for acquiring both fundamental and more specialized nursing skills (Abbey et al., 2006; Banning et al., 2006; Chen et al., 2007). Such skills include those of essential nursing, manual handling and infection control, nutrition monitoring, physical assessment, medication administration, interpersonal and communication skills, and case management. Providing social activities, relating to residents' family and friends, end of life care, and assessing the residents' needs when frailty increases, are other core skills that students gain experience with in the nursing home setting (Keeling, 2010; Carlson and Bengtsson, 2014). Both positive and negative experiences have been described regarding the learning environment in nursing homes. Students seem to perceive the overall learning environment in nursing homes as moderately positive (Berntsen and Bjørk, 2010), but even though students are more satisfied than dissatisfied with their clinical placements in nursing homes, they also seem to score this learning environment significantly lower than hospital settings (Skaalvik et al., 2011). Negative attitudes towards elderly care from students and faculty may prevent the students from discovering the learning opportunities (Happell, 2002; Kerridge, 2008; Schrader, 2009). Limitations of resources and qualified staff are found to affect both the quality of care and the guidance of students (Kerridge, 2008; Skaalvik et al., 2011). Some students are satisfied with the support they receive from mentors and nursing home staff, but students also experience lack of supervision and professional dialog with the preceptors and mentors who can help them link theory and practice (Banning et al., 2006; Chen et al., 2007; Skaalvik et al., 2012). Happell (2002) emphasized that both educational institutions and the nursing profession share a responsibility for influencing the attitudes of nursing students towards working with the elderly. This can be achieved by highlighting the importance of essential aspects of nursing care and providing a high standard of clinical supervision. It is also important to ensure that students are continually exposed to the knowledge base on which aged care practice is founded. In a literature review on student placements in nursing homes (Lane and Hirst, 2012), two major considerations related to the learning environment emerged. The first consideration was the importance of having faculty with relevant knowledge, who are also committed to link theory to actual practice during students' placements. Second, it seemed that formalized strategies or educational models were needed to enhance the students' learning experiences. Other studies have emphasized the need for close collaboration between placement arenas and educational institutions (Campbell and Jeffers, 2008; Grealish et al., 2010). One of the characteristics of nursing education is that students learn in close collaboration with other students, especially in the skills centers and during clinical placement periods. In the context of this study, peer learning refers to 1st and 3rd year nursing students learning with and from each other, collaborating, sharing ideas, knowledge and experiences during clinical placements in nursing homes (Seecomb, 2008). Peer learning can help first year students to deal more effectively with the challenges during initial

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clinical placements, increase their confidence in clinical practice and develop their knowledge, skills and attitudes (Roberts, 2008; Seecomb, 2008; Christiansen and Bell, 2010; Stables, 2012). At the same time peer learning can help more experienced students to consolidate their teaching skills and gain confidence and heightened readiness for mentorship and professional practice through their peer relationship with the novice students (Christiansen and Bell, 2010; Stables, 2012). Research design An explorative design was developed to collect empirical data between the fall of 2008 and summer of 2010. The focus in this study was to explore students' experiences during clinical placements in five nursing homes as expressed through questionnaires and logs, after implementing the following measures:  An introductory program for all the students on the first day of the clinical placement, aiming to inform and motivate students by introducing them to the values and knowledge which guides practice and care in the five nursing homes.  Close follow-up from preceptors and others during the first fourteen days of the placement period.  Mutual frames for instruction, guidance and learning to secure more structured and competent follow-up for each student.  Using The Model of Practical Skill Performance (Bjørk and Kirkevold, 2000) as a tool for reflection and learning (results will be presented in a separate paper).  Meetings on a regular basis between preceptors and faculty  Coordination of supervision to first and third year students and utilizing the potential of peer learning. The nursing homes differed in design and size and had different facilities, and each had their own institutional culture. They were run by a non-profit organization and had the same overall values, policies and operating guidelines. Participants Between 2008 and 2010, 260 1st and 3rd year students in a Bachelor program in nursing participated in the project. The student group comprised 4 groups of 1st year students (n ¼ 150) and 6 groups of 3rd year students (n ¼ 110). The placement periods lasted from 7 to 9 weeks. Eleven teachers and more than 80 clinical preceptors (mainly registered nurses with a BSN degree) were involved, some for the entire project period, and some part of the time. Only the students participated in the evaluation study. Instrumentation Data were collected using student logs and a questionnaire which contained three sections: 1) Demographic variables, 2) The Clinical Learning Environment Inventory (CLEI) (Chan, 2001, 2003, 2007; Berntsen and Bjørk, 2010) and 3) A locally developed questionnaire. The CLEI is a survey instrument developed to assess student nurses' perception of psycho-social aspects of the clinical learning environment (Chan, 2001, 2003). It consists of 42 items categorized into six subscales: individualization, innovation, involvement, personalization, task orientation and satisfaction. Each subscale contains seven items with evenly distributed positive and negative statements. Students responded to each item using a 4 point Likert scale: 5 (strongly agree), 4 (agree), 2 (disagree) 1 (strongly disagree). Missing and invalid responses were scored as 3. Negative items or statements were reversed ahead of statistical analysis to

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secure the same direction in values. The possible range for the total scale is 42e210, and the possible range for the subscales is 7e35. This study used a Norwegian translation of the instrument (Berntsen and Bjørk, 2010). The third part of the questionnaire was developed to measure specific learning experiences related to the project and its implementation. This part consisted of 13 positively charged items. Students responded to the statements using a similar 4 point Likert scale as in the CLEI instrument, but given other values when analyzed: 4 (strongly agree), 3 (agree), 2 (disagree) and 1 (strongly disagree). Missing and invalid responses were scored as 9. The items were computed individually. All students at the participating university college wrote logs during clinical placements as a way of verbalizing and reflecting on learning experiences and communicating these to their preceptors and teachers, who in turn gave guidance and feedback. To obtain information about the students' learning experiences related to the project, we asked them to write a log about experiences with the introductory program and follow-up during the first fourteen days of the placement periods. Data collection The questionnaire was answered by the students following each placement period. From 2008 to 2010, 206 of 260 students (79.2%) answered the questionnaire. The logs were written during the placement period and collected by the project leader through an electronic learning platform. From 2008 to 2010 253 logs were collected, representing a response rate of 97.3%.

Overall satisfaction with the learning environment All the scores from the CLEI instrument for all the 1st and 3rd year students in the project were above 50% of total maximum score, indicating that most students were more satisfied than dissatisfied with the learning environment in the nursing homes. Table 1 shows that the computed mean for the total scale was 150.8, with true scores varying between 83 and 195. The results from the subscales varied between 20.3 and 27.0, with “Satisfaction” (27.0), “Personalization” (26.8) and “Student involvement” (26.7) gaining the highest scores and “Innovation” (20.3) the lowest score of the six subscales. Independent samples test showed a significant difference between the 1st and 3rd year students only for the subscale “innovation”. On this subscale the 1st year students scored significantly higher than the 3rd year students (20.79/19.65: p ¼ 0.014). The results from the locally developed questionnaire showed the same tendency as the CLEI instrument regarding overall satisfaction. Students were generally more satisfied than dissatisfied. The results presented in Table 2, item 1e13 illustrates that all the scores for the 1st and 3rd year students were above 50% of total maximum score. A ManneWhitney U Test was performed to identify differences between 1st and 3rd year students. Significant differences were found on items 2 (p < 0.000), 8 (p ¼ 0.002), 10 (p ¼ 0.001) and 11 (p < 0.000). Table 3 outlines the six main categories that emerged from the analysis of the logs. The logs conveyed the students' experiences during the first two weeks of the clinical placement period. Generally the contents of the logs support the overall results from the questionnaires, highlighting more positive than negative experiences. Preparation for clinical placement

Data analysis Data from the questionnaire were optically scanned and entered into SPSS version 18. Descriptive and inferential analyses were conducted. The logs were analyzed using qualitative content analysis. An inductive approach was chosen, allowing categories to emerge directly from the data material (Graneheim and Lundman, 2004; Hsieh and €s, 2007). Because of the extensive Shannon, 2005; Elo and Kynga contents of the logs, a selection of every 5th log was analyzed after an initial analysis of the first 15 logs, totaling 66 analyzed logs. All four authors collaborated through the analysis process, validating the main categories that emerged from the logs.

Most of the students agreed that information from the school had prepared them well for the placement period, but the results (Table 2, item 1) also convey some dissatisfaction with the information ahead of the clinical placement. More students, however, agreed that teaching and skill training in the school had prepared them for practice (Table 2, item 2). On this item 1st year students scored significantly higher than the 3rd year students (p < 0.000). Table 1 CLEI: Total and subscale scores for all 1st (n ¼ 121) and 3rd (n ¼ 85) year students.

a

Total scale

Ethical considerations Personalizationb

The study was assessed by a research committee and an ethics consultant at the university college and was approved by the leaders of the university college and the nursing homes. Written and verbal information was given both about the project and the evaluation study. Students were able to choose clinical placements in other nursing homes than the ones involved in the project, and were ensured verbally and in writing that answering questionnaires and logs was voluntary. Questionnaires were answered anonymously, and contents of the logs were anonymized upon final collection, so that neither the persons nor the practice locations involved could be identified in any way. Results The results will be presented thematically, and the results from the survey and students' logs will be highlighted together when the results are connected to the same themes.

Student involvementb

Satisfactionb

Task orientationb

Innovationb

Individualizationb

All students 1st year 3rd year All students 1st year 3rd year All students 1st year 3rd year All students 1st year 3rd year All students 1st year 3rd year All students 1st year 3rd year All students 1st year 3rd year

N

Mean

205 120 85 206 121 85 205 120 85 206 121 85 206 121 85 206 121 85 206 121 85

150.80 152.68 148.12 26.80 27.31 26.19 26.70 26.59 26.82 27.00 27.55 26.16 25.40 25.39 25.52 20.30 *20.79 *19.65 24.40 24.85 23.78

*Significant difference between 1st and 3rd year students (p ¼ 0.014). a Possible range 42e210. b Possible range 7e35.

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In the logs students reported that they looked forward to the upcoming placement period, but the logs also pointed to some apprehension as to what they would experience and what was expected of them. Expectations reported by students in the logs also related to how the rest of the placement period would proceed. A little bit excited and nervous for how the eight weeks are going to turn out... ... looked forward to first day in uniform in practice, to meet patients, their families and employees (1st year student).

Table 2 Locally developed questionnaire: mean scores on item 1e13 for all 1st and 3rd year students (n ¼ 206). Item nr

Statements

1st year (n ¼ 121)

3rd year (n ¼ 85)

1

Information from the school prepared me well for clinical placement Teaching and skill training in the school prepared me for clinical placement On the first day I was met in a way that created positive expectations to the placement period The reception and introduction at the placement site contributed to an early overview of learning opportunities The reception and introduction at the placement site helped me to feel confident as a student Preceptor regularly supervised me in actual patient situations I received good supervision from other staff at the practice site Supervision from the teacher contributed to increased learning outcome I took initiative to seek guidance from the staff at the practice site I took initiative to seek guidance from the teacher Assignments from the school was consistent with learning opportunities at the practice site I benefitted from collaborating with other students at the practice site The placement period has contributed to increase awareness for my future nursing role

2.71

2.65

*3.07

*2.71

3.12

3.09

2.73

2.85

2.92

2.98

2.53

2.73

2.98

2.85

*2.97

*2.67

3.40

3.37

2.94

2.61

*3.16

*2.78

3.53

3.41

3.40

3.46

2 3

It will be interesting to see how this evolves, and I'm looking forward to a period I hope and believe will be exciting (3rd year student).

Introductory program and the first encounter with the nursing homes The results from the local questionnaires indicated that both the 1st and 3rd year students were satisfied with the introductory program and their first encounter with the nursing homes. Most of the 1st and 3rd year students agreed that they were received in a way that created positive expectations (mean ¼ 3.12/3.09), and that the reception in the nursing homes contributed to a feeling of confidence (mean ¼ 2.92/2.98). Most students also agreed that the reception in the nursing homes provided an early overview of learning opportunities, although this score was somewhat lower (mean ¼ 2.73/2.85). In their logs most students reported that they experienced the introductory program as a “soft start”, which prepared them for the placement, boosted their confidence and gave them a positive motivation for the clinical placement. Students especially appreciated hearing about the values of the organization, cultural work among residents and the minister's presentation of “end-of-life” care. A few students found the program too extensive and part of the content irrelevant. Most students reported that they were received well in the nursing home and in the ward. They felt welcome and experienced the staff as polite, friendly, including and showing an interest in the students. I think the introductory day was a positive experience … To me it meant that I didn't feel that I was thrown into something which I didn't know much about. But that I got helpful information and was received well. A small glimpse of what awaited us and what is expected of us (1st year student) I got the impression that we were really welcome and that they really wanted students there, which is very positive. I got a positive impression of the practice site and the staff … (3rd year student)

4

5

6 7 8

9 10 11

12 13

Possible range 1e4. *Significant difference between 1st and 3rd year students on item 2 (p < 0.000), 8 (p ¼ 0.002) and 11 (p < 0.000).

school were consistent with learning opportunities at the practice site (m ¼ 3.16/2.78). Again the scores for the 1st year students were significantly higher than those for the 3rd year students (p < 0.000). Similar to the questionnaire, the logs also reflected varied experiences with supervision at the practice site. Positive experiences highlighted by students in their logs, were preceptors who were attentive, gave good supervision and feedback, knew the students' schedule and communicated well with the students. Students also reported that many of the employees in the unit were accommodating, understanding, and took an interest in the students' learning. I am very pleased with the guidance and attention I have received during the first two weeks in the unit. Not only does my preceptor follow me up all the time, but I also have the feeling that everyone who works in the unit, wants the best for us. (1st year student)

Supervision The students had more varied experiences with supervision during clinical placement. Although most 1st and 3rd year students agreed that the preceptor supervised in actual patient situations (mean ¼ 2.53/2.73), this is one of the lowest scores from the locally developed questionnaire. The score for the 3rd year students was somewhat higher than for the 1st year students, but the difference was not significant. More students (mean ¼ 2.98/2.85) were satisfied with supervision from other staff at the practice site. Both groups of students agreed that they took the initiative to seek guidance from the staff at the practice site (mean ¼ 3.4/3.37), while fewer students initiated guidance from the teacher (m ¼ 2.94/2.61). On this item the 1st year students scored significantly higher than the 3rd year students (p ¼ 0.001). Most students in both groups also agreed that assignments from the

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Table 3 Main categories from the students' logs. Categories 1 2 3 4 5 6

Experiences with the first day introductory program Expectations regarding the clinical placement period Experiences related to the first encounter with the nursing homes and the wards Experiences related to guidance and supervision from clinical supervisors, other staff on the ward and faculty Experiences related to the learning arena Experiences with peer learning

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They have shown interest in my learning, given me good supervision and included me both academically and socially (3rd year student) Negative experiences reported by some of the students were inattentive and negative preceptors, insufficient supervision, inadequacies in how the unit was prepared for and organized student supervision and challenges because of language barriers and cultural differences among the staff.

lack of leadership structure and appears disorganized. (3rd year student) Both 1st and 3rd year students agreed that the placement period had contributed to increase awareness of their future nursing role (mean ¼ 3.4/3.46). Indeed, this was one of the highest scores from the questionnaire. Discussion

… I have not had continuous mentoring up to now. My nurse preceptor is often occupied, and in any case does not participate much in basic care situations. (1st year student)

Peer learning Collaboration with other students received a high score from both 1st and 3rd year students on the questionnaire (m ¼ 3.53/ 3.41). Since the logs concerned the first two weeks where students were busy getting acquainted with patients, staff and the life on the ward, only a few students reported experiences with peer learning in their logs. However, the few experiences reported in the logs, seemed to support the high score on the questionnaire, illustrated by the following quote from a 3rd year student: I also find it exciting to have first year students in the same unit. I also had third year students in my first internship (as a 1st year student), and I know what a resource it can be, which gives me higher expectations to myself in relation to my role. This can help me and give me challenges regarding guiding and instruction.

Learning arena The logs conveyed that students found the first two weeks of the placement period very hectic and demanding. For many of the 1st year students, it was evident that the nursing home was an unfamiliar landscape, in which it took some effort to learn to navigate. The first two weeks of practice has been filled with lots of new experiences, impressions, encounters with new people and not the least meeting older people in a different way than I am used to. (1st year student) However, many students, both in the 1st and 3rd years, described the learning arena as exciting, interesting and educational and in the logs they highlighted several learning opportunities in the environment. It seems that this placement will challenge my skills and knowledge in a different way … Many complex situations that require a wide range of knowledge make me reflect more than I have done in the past. (3rd year student) On the negative side, both student groups described deficiencies associated with organization of work and people in the unit, caring routines, equipment and hygienic standards. Some reported uncertainty related to the student role. Many students from both student groups reported that they enjoyed their clinical placement. I have had to familiarize myself with many things, and I think some of this has been difficult because I experience that the unit has a

The overall results generally show more positive than negative experiences during the placement period in the nursing homes. The positive experiences conveyed by the students in this study, are also found in other recent studies of students' experiences during clinical placements in nursing homes (Berntsen and Bjørk, 2010; Carlson and Idvall, 2014). Several studies have identified both benefits and challenges related to nursing students' clinical placements in nursing homes (Rogan and Wyllie, 2003; Abbey et al., 2006; Kerridge, 2008; Xiao et al., 2008; Skaalvik et al., 2011; Carlson and Bengtsson, 2014). The present study also revealed negative aspects, but the results from the questionnaires and the logs suggest that the learning environment in the five nursing homes included in the study contained more potentials than barriers for learning. Even though there are some differences between 1st and 3rd year students, both groups conveyed mostly positive experiences, and both groups described the placement as interesting and educational in their logs. Despite different personal and academic prerequisites, learning needs and learning activities, both student groups also agreed that the placement had contributed to awareness of their future nursing role. The 3rd year students in our study focused on professional nursing leadership, guidance and an overview of the residents' medical and nursing needs during their clinical placement, while the 1st year students' focus was directed toward essential clinical nursing skills and learning to care for a limited number of residents. Thus the learning objectives and learning activities for the two student groups were adapted to their educational level. There seems to be different opinions as to when nursing students benefit from clinical placements in aged care facilities (Lane and Hirst, 2012). The students at the university college involved in this study had clinical practice in nursing homes both during first and third year of their educational program. The overall positive experience of the students in the present study may indicate a potential for creating meaningful learning experiences in nursing homes for students from different educational levels, provided that students are prepared sufficiently, and that they are supervised and challenged according to their current learning stage (Rogan and Wyllie, 2003; Abbey et al., 2006; Grealish et al., 2010; Koh, 2012). Warne et al. (2010) found that the duration of the placement was connected to levels of satisfaction with the learning environment. Students with longer placements e 7 weeks or more e reported more satisfaction. The students' clinical placements in the present study lasted from 7 to 9 weeks, and so the duration of the placements may also have affected the results in a positive way. Most of the students in the study reported positive experiences with the introductory program, stating that the program motivated them, gave them positive expectations and a feeling of confidence. Another result depicts the first days in the nursing home as very hectic and demanding, with a lot of new impressions, and many new people and routines to get acquainted with. Even though students were satisfied with the introductory program, the results also indicated that students wanted more information from the school prior to the placement period, this despite the extra information given both verbally and in writing to all the students as part of the project. The results suggest that preparing students

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thoroughly for both clinical and social aspects of the nursing home arena, is important for how they perceive the situation and find their way in a new and complex learning environment (Abbey et al., 2006; Robinson et al., 2008). Equally important is preparing the practice site for the student placement, and during the project there were regular meetings between the preceptors and teachers to talk about organization of the placement periods and supervision of students. The results from both CLEI, the locally developed questionnaire and the logs indicate that a majority of the students appreciated the way the practice site welcomed and included them in the working community on the wards. If the nursing homes and their wards are organized and well prepared to receive students, it seems that one of their important potentials is that they can offer a more homely atmosphere and slower pace than busy hospital wards. This probably facilitates getting to know the students and including them in their working community (Banning et al., 2006; Berntsen and Bjørk, 2010; Skaalvik et al., 2011). However, the results from our study also indicate that there is a potential for improvement in terms of routines for student information and organization of the students' placements. Students need to feel safe and included to see and take advantage of the learning potentials in the learning environment (Levett-Jones et al., 2009). Appropriate preparation, student orientation and structured educational support is important for the student's learning during clinical placements and may also affect their interest in working in the aged care setting in the future (Rogan and Wyllie, 2003; Robinson et al., 2009; Koh, 2012). The frequently portrayed challenges related to supervision of students in nursing homes (Abbey et al., 2006; Skaalvik et al., 2011; Lane and Hirst, 2012) are also reflected in our results. One of the lowest scores was related to supervision by the assigned preceptor. At the same time, the scores for supervision by the other staff on the unit were substantially higher. The project which preceded the evaluation study, used a supervision model where the students have a designated nurse as a personal preceptor. This supervision model is common in the BSN program during nursing students' clinical placements in Norway. Recent studies have found that having a personal preceptor have a positive impact on nursing students' experiences during clinical placements, both in hospital and nursing home settings (Skaalvik et al., 2011; Carlson and Idvall, 2014; Sundler et al., 2014). However, the results in the present study suggest that there may be some unmet challenges connected with this model, and that resources may not be fully utilized with a supervision model largely dependent on supervision from one particular preceptor. Creating good learning environments is a process involving both nurses, other care workers, and educational institutions. Supervision models where students work with a range of staff, and where educational institutions become active agents of change and learning, may be useful alternatives in the nursing home context, where the competence mix of the staff is different from that of hospital settings (Campbell and Jeffers, 2008; Grealish et al., 2010, 2013). Studies also point to the need for active support from faculty with knowledge and dedication towards geriatric nursing, in order to make the necessary connections between practice and its theoretical foundation (Kerridge, 2008; Lane and Hirst, 2012). In our study peer learning received a high score from the students on the locally developed questionnaire, pointing to the advantage of different student groups learning together during a clinical placement period. This is supported by other studies (Christiansen and Bell, 2010). In the project the 1st and 3rd year students collaborated both with students from the same educational level and with students on a higher or lower level. Some groups of students did not have students from another educational level assigned to the same practice site during their clinical

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placement, but the high scores from the questionnaire indicate that working with their peers is important for the students, even if the peers are from the same educational level. The high scores in the present study concur with other studies showing that peer learning has a substantial potential for supporting learning and contributing to creative and innovative learning for the nursing students (Secomb, 2008; Roberts, 2008; Grealish et al., 2013). However, peer learning cannot substitute supervision from faculty and staff at the practice site, and furthermore, it needs to be carefully planned and organized with a view to student learning outcomes and integrated in the practice site's own working and learning environment (Henderson and Newton, 2010). Limitations of the study Prior to the project, a baseline survey using the CLEI instrument and the locally developed questionnaire was conducted to provide possibilities for comparison before and after the implementations in the project. Unfortunately the response rate of the baseline study was too low to give reliable results. Also, the project was comprehensive, including a large number of students and preceptors, as well as several practice arenas, each with their particular ward cultures. It proved more difficult than we assumed to hold a firm grip on all the measures at all times with the resources available. Due to these factors we cannot say for sure to what extent the measures have affected the students' experiences. However, the different evaluation instruments show many of the same tendencies, indicating that the results convey a trustworthy picture of the students' experiences during clinical placements in the five participating nursing homes. A group of four researchers have cooperated throughout the evaluation process, strengthening the reliability of the results by continuous peer dialog, feedback and control. Conclusion The findings in this study suggests that the nursing homes, despite less qualified staff, and deficiencies related to supervision, caring routines, equipment etc., still provided the students with positive learning experiences and had a positive effect on students' perception of their future professional nursing role. This supports the view of nursing homes as important and potentially good learning arenas for nursing students. Although we cannot make firm inferences related to the outcome of the project's measures, the study has brought about results that clearly convey the potential for learning and professional development within nursing homes. Clinical placement arenas and educational institutions should collaborate closely to explore and develop models of learning and supervision appropriate for the nursing home context, models that enhance the learning environment for both students and staff. This is important not only to recruit new professionals to aged care, but to increase daily quality of care for residents in great need of caretakers with professional knowledge and skills. Acknowledgments This study was supported by a grant from The Norwegian Nurses Organisation. We would like to thank the leaders, coordinators, nurses and all the other staff in the five nursing homes involved in the project. We are also grateful to leaders, staff and students from the university college for taking part in the project and for valuable support. We especially want to acknowledge the following persons for valuable contributions throughout the empirical part of the project:

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