Nurse Education Today 35 (2015) 1289–1294

Contents lists available at ScienceDirect

Nurse Education Today journal homepage: www.elsevier.com/nedt

Nurse teacher models in clinical education from the perspective of student nurses — A mixed method study Margareta Gustafsson a,⁎, Agneta Kullén Engström b, Ulla Ohlsson a, Annelie J. Sundler c,d, Birgitta Bisholt e a

School of Health and Medical Sciences, Örebro University, Örebro, Sweden School of Health, University of Borås, Borås, Sweden School of Health and Learning, University of Skövde, Skövde, Sweden d School of Health, Care and Social Welfare, Mälardalens University, Västerås, Sweden e Department of Nursing, Karlstad University, Karlstad, Sweden b c

a r t i c l e

i n f o

Article history: Accepted 17 March 2015 Keywords: Nursing education Clinical education Mixed methods Nurse teacher Student nurse Triangulation

s u m m a r y Objectives: The aim was to describe and compare the clinical teacher's role in different models of clinical practice from the perspective of student nurses. Design and Settings: The study took place in collaboration with two Swedish universities that applied different educational models in clinical practice. A mixed method approach was used. The quantitative part had a comparative design and the qualitative part had a descriptive design. Participants: The study group consisted of 114 student nurses (response rate 87%). Fifty-three of them had met clinical teachers employed at the university and not participating in the daily clinical work (University Nurse Teachers, UNTs), whilst 61 had met clinical teachers dividing their time between teaching and nursing (Clinical Nurse Teachers, CNTs). Eight students participated in the qualitative part of the study. Methods: A questionnaire including the CLES + T scale was used to ascertain the students' perception of the clinical teacher's role, complemented by interviews directed towards an enrichment of this perception. Results: Students meeting CNTs agreed more strongly than those meeting UNTs that the teacher had the ability to help them integrate theory and practice. Whilst spontaneous meetings between students and CNTs occurred, students mostly met UNTs in seminars. Students meeting UNTs felt alone but did appreciate having someone outside the clinical environment to provide support if they did not get along with their preceptor. Conclusions: In the case of UNTs, it is important that they keep their knowledge of clinical issues updated and visit the clinical placement not only for seminars but also to give students emotional support. In the case of CNTs, it is important that they are members of the faculty at the university, take part in the planning of the clinical courses and are able to explain the learning goals to the students. © 2015 Elsevier Ltd. All rights reserved.

Introduction In Sweden, nursing became an academic subject in the middle of the 1990s and the education in the nursing programme was required to be based on theories generated by research in this discipline. This requirement also applied to the education in clinical practice, whereby the student nurses’ clinical experiences and practical skills should be linked to theoretical reasoning (Kapborg, 1998). A significant person for the students in connection with the clinical placement is the clinical teacher. The function of the clinical teachers is to support the students’ integration of theory with practical learning and their fulfilment of learning outcomes, at the same time serving as a link between the academic

⁎ Corresponding author at: School of Health and Medical Sciences, Örebro University, SE–701 82 Örebro, Sweden. Tel.: +46 19 30 36 43. E-mail address: [email protected] (M. Gustafsson).

http://dx.doi.org/10.1016/j.nedt.2015.03.008 0260-6917/© 2015 Elsevier Ltd. All rights reserved.

organization and the healthcare organization (Brown et al., 2005; Price et al., 2011; Löfmark et al., 2012; Kristofferzon et al., 2013; Saarikoski et al., 2013). A research programme involving co-operation between Swedish universities has investigated differences between various organizations of the clinical practice from the perspective of the student nurses (Bisholt et al., 2014; Blomberg et al., 2014; Sundler et al., 2014). In the present study we have examined the role of the clinical teacher in different clinical educational models.

Background In connection with the transformation of the nursing education from vocational to academic education, the role of the clinical teacher changed (Saarikoski et al., 2009, 2013). In the academic organization the teachers are not only to teach but also to do research, and their time for practical clinical work is limited (Carr, 2007; O’Driscoll et al.,

1290

M. Gustafsson et al. / Nurse Education Today 35 (2015) 1289–1294

2010). Instead preceptors, ideally highly competent clinical nurses, have taken over the task of supervising the student nurses in the daily patient care and supporting their socialization into the nursing role (Corlett, 2000; Ehrenberg and Häggblom, 2007; Kristofferzon et al., 2013). Studies have also shown that student nurses consider the clinical nurses to be the best suited to teaching practical skills and do not want to receive “hands on” education from the clinical teacher (Corlett, 2000; Forrest et al., 1996). However, studies based on the students’ perspective have also stressed the fact that visits of a clinical teacher have an important role to play in connection with the clinical placement. Students have indicated that the clinical teachers bring objectivity to the clinical experience and help them reflect on practice (Forrest et al., 1996; Kristofferzon et al., 2013; Price et al., 2011), support fulfilment of theoretical assignments (Price et al., 2011), clarify the learning goals of the course for the preceptor and the student (Brown et al., 2005), facilitate the relationship between the preceptor and the student and also provide personal support for students and reduce their feeling of being abandoned (Brown et al., 2005; Price et al., 2011). In Swedish universities, different clinical educational models mean different roles for the clinical teachers. In one model the clinical teachers have posts at the university involving both teaching and research. They visit the clinical settings for meetings with students and preceptors but do not participate in the daily clinical work. In another model the clinical teachers work part-time teaching and part-time nursing. Ever since the nursing programme moved into the universities (and not only in Sweden), the debate in the academic world has concerned whether nurse teachers have the competence to integrate theory and practice if they do not participate in the work of the clinic (Maslin-Prothero and Owen, 2001; Barrett, 2007; Ousey and Gallagher, 2010). It is against this background that the present study was undertaken, its aim being to describe and compare the clinical teacher’s role in different models of clinical practice from the perspective of student nurses.

education (SFS [Swedish Code of Statutes], 1992:1434; SFS, 1993:100). Thus they were three-year programmes leading to both a professional degree and a Bachelor's degree. Clinical training accounted for approximately half of the time and credits. It took place either in clinical skills laboratories at the university or in connection with clinical placement in nearby care organizations. Even though there are central directions in Sweden regarding length of the education and learning objectives, the university colleges of nursing education are free to decide about the order of courses and the organization of the education. Consequently the organization of the clinical education differed between the two universities.

Methods

University B

Design

At University B the students also had a clinical nurse as preceptor during the clinical placement (Table 1). This preceptor’s role did not differ from that of a preceptor at University A. During the clinical placement the students also met a clinical teacher, hereinafter referred to as the Clinical Nurse Teacher (CNT). The CNT’s role was to introduce the student to the clinical placement, take part in assessment and grading of the students, give support to the preceptors, hold seminars with the students for the purpose of integrating theory and practice and give feed-back on written reflections of the student. The CNTs were employed by the healthcare organization and worked part-time as clinical nurses and part-time as teachers. They had an affiliated position at the university, meaning that they were members of the Nursing faculty. They attended regular meetings where there was discussion of the education as a whole, also meetings at the university concerning the organization of the clinical practice (Table 2). At the university, a lecturer was responsible for the administration of the clinical course but never visited the students during their clinical placement. Both the UNTs and the CNTs were required to have a Master’s degree in Nursing and to have completed at least one pedagogic course for higher education (Table 2).

A quantitative study with comparative design and a qualitative study with descriptive design took place in spring 2011 in collaboration with two Swedish universities. A mixed method approach was used in order to elucidate the research question from different perspectives. Quantitative and qualitative data were collected and analysed in parallel and then the findings were integrated in the stages of interpretation and conclusion (Östlund et al., 2011). Sampling Inclusion criteria for the study were being a student nurse doing a course involving clinical practice in the final term of the nursing programme. Students at two Swedish universities were enrolled for the study. Both universities had a course with clinical practice in the final term of the education, 4 and 5 weeks respectively, with professional role and leadership as learning objectives. All students registered on the courses in question (n = 143) received written information about the study and were asked whether they were willing to participate. However, 12 reported that they had not met any nurse teacher during the clinical placement. Of the remaining 131, ten declined to participate and seven submitted questionnaires which were not fully answered. Thus the study group included in the quantitative part of the study consisted of 114 student nurses (response rate 87%). Eight of them participated in the qualitative part of the study. Settings The nursing programmes at the two universities followed government regulations indicating length and learning objectives for the

University A At University A the students were assigned a personal preceptor from among the clinical nurses in the clinical placement (Table 1). The preceptor’s role was to supervise the students in the daily patient care, facilitate their learning of practical skills and take part in assessment and grading of the students’ performance. There were also head preceptors, who had an overall responsibility for the students at the clinic/ department. Their role was to introduce the students to the clinical placement, schedule their placement, take part in assessment and grading of the students, give support to the preceptors and develop the learning environment. Head preceptors had posts in the healthcare organization and worked part-time as clinical nurses. The clinical teacher, hereinafter referred to as the University Nurse Teacher (UNT), was employed by the university and visited the students during their clinical placement and arranged seminars for the purpose of integrating theory and practice. If necessary, the UNT also participated in the final assessment and grading of the individual student together with the head preceptor and the preceptor. Most of their working hours, the UNTs taught student nurses at the university (Table 2).

Table 1 Facilitators in the clinical education at the two participating universities. University A

University B

Employed by the university: UNT (university lecturer and clinical teacher) Employed by the healthcare organization Head preceptor Preceptor

Employed by the university: University lecturer Employed by the healthcare organization CNT (clinical nurse and clinical teacher) Preceptor

M. Gustafsson et al. / Nurse Education Today 35 (2015) 1289–1294 Table 2 The role of the UNT and the CNT. UNT

CNT

Employment

Employment

• Employed by the university • Work as a university lecturer

• Employed by the healthcare organization • Work part-time as a clinical nurse • Affiliated to the university, member of the faculty

Similar functions • Organize seminars with the students at the clinical placement for integration of theory and practice • Provide support for the preceptors • Take part in the assessment and grading of the student Similar education • Master’s degree in nursing • At least one pedagogical course

1291

UNT and the role of the CNT were described with mean values (m) and standard deviations (SD) so as to enable comparison with previous studies. However, differences in the students’ ratings were analysed by means of a non-parametric test, the Mann-Whitney U-test, taking into account that responses were given on ordinal scale level. Significance level was set to 0.05. The statistical analyses were performed using IBM SPSS Statistics 20 (IBM, Armonk, NY, USA). The interviews were subjected to qualitative content analysis as described by Graneheim and Lundman (2004). The text was read and re-read in order to get an overall sense of the content, then read more closely in order to identify meaning units, which were thereafter condensed, abstracted and coded. The codes were then sorted into subcategories based on their similarities and differences and sorted into categories. Finally, the categories were organized into themes. Ethical Considerations

Data Collection Data collection by means of questionnaires took place at the universities within one week after the students had completed their clinical practice. The students answered questions about age, gender, education or work in health care before admission to the nursing programme, the location of the clinical practice and the organization of the supervision. Finally the Clinical Learning Environment, Supervision and Nurse Teacher (CLES + T) evaluation scale (Saarikoski and Leino-Kilpi, 2002; Saarikoski et al., 2008) was included in order to compare the roles of the clinical teachers. The interviews with the students took place in a secluded room at the ward during their clinical practice. Each interview lasted between 60 and 70 minutes. The interviews focused on students’ experience of the teachers’ role in the clinical placement. The interviews were digitally recorded and transcribed verbatim. Data were collected by the end of week four and five of the students' final placements. The students had previous experience of the teacher organizations acquired during clinical placements in the three-year nursing program. Instrument The Clinical Learning Environment, Supervision and Nurse Teacher (CLES + T) scale was developed for evaluating the learning environment in the clinical placement from the perspective of the students (Saarikoski and Leino-Kilpi, 2002; Saarikoski et al., 2008). The Swedish version of the CLES + T has proved to be a reliable and valid instrument in psychometric tests among Swedish student nurses (Johansson et al., 2010). The scale includes five sub-domains but only items concerning the “Role of the nurse teacher (NT) in clinical practice” (9 items) were analysed in this study. The term “nurse teacher” refers here more specifically to “a qualified NT employed by an educational institution, whose role spans both theoretical and clinical teaching” (Saarikoski et al., 2008). In the questionnaire it was made clear to the students at University B that the items concerned the role of the CNT. The items could be divided into the following subgroups: NT enabling integration of theory and practice (3 items), level of co-operation between placement staff and NT (3 items) and relationship between student, mentor and NT (3 items). The students responded to the items on a 5-point Likert-type scale: “fully disagree” (1), “disagree to some extent” (2), “neither agree nor disagree” (3), “agree to some extent” (4) and “fully agree” (5). Cronbach’s alpha was 0.92 for the nine items concerning the Role of the nurse teacher and varied between 0.87 and 0.89 for the sub-groups of items. Data Analysis The chi-square test and the independent samples t-test were used for statistical analyses of differences in characteristics between the student groups. Students’ ratings of the items concerning the role of the

Written informed consent concerning participation was obtained from the students after they had received both oral and written information about the study. They answered the questionnaires, anonymously, in a classroom at the university and then handed them over to the researcher in sealed envelopes. The researchers had nothing to do with the teaching or grading of the students on the courses in question. The study was given ethical approval by the Uppsala Regional Ethical Review Board (reg. no. 2011/071) and was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki). Results Participating Student Groups Out of the 114 students who participated in the study, 53 (46%) had met the UNT and 61 (54%) had met the CNT when they were doing their clinical practice (Table 3). The majority of students in both student groups were female. There was no difference in age distribution between the groups. A similar proportion in both groups had had an assistant nurse education or had worked in health care before attending the nursing programme. The duration of the clinical practice differed by one week, being 5 weeks at University A and 4 weeks art University B. Most frequent in both student groups was clinical practice in a medical or surgical department at a hospital. Practice outside hospital occurred in municipal elderly care, primary care or outpatient clinics for psychiatry. Most students usually received supervision from the personal preceptor but also from others. There were no statistical differences between the student groups regarding location of the clinical practice or preceptor model used (Table 3). Four students from each university were selected for the qualitative study by lot, 6 female and 2 male. Their ages ranged from 22 to 51 years (median 24 years). Each participant was contacted by the last author (BB), received oral and written information about the study and was asked to participate in the interview. All who were asked agreed to participate in the interview. Comparisons of the Different Clinical Teachers' Roles as Perceived by the Student Nurses The students’ ratings of the UNTs’ and the CNTs’ ability to integrate theoretical knowledge and the everyday practice of nursing had the mean values 3.5 and 4.0 respectively (Table 4), showing that the students in both groups mostly agreed that the teachers had this ability. However, students meeting CNTs agreed more strongly that the teachers had the ability to integrate theory and practice (p 0.011), to operationalize the learning goals of the clinical placement (p b 0.001) and to help the students reduce the theory–practice gap (p b 0.001). Regarding co-operation between the placement staff and the teacher, the

1292

M. Gustafsson et al. / Nurse Education Today 35 (2015) 1289–1294

Table 3 Differences in characteristics between students meeting UNTs and students meeting CNTs.

Age, years, m (SD) Sex, n (%) Female Male Assistant nurse education before attending the nursing programme, n (%) Work in health care before attending the nursing programme, n (%) Duration of the clinical placement, weeks, n Location of the clinical practice, n (%) Hospital department Outside hospital Organization of supervision, n (%) Supervision by a personal preceptor but also by others Supervision by a personal preceptor only

Students meeting UNT n = 53

Students meeting CNT n = 61

p-value

26.3 (SD 5.1)

25.8 (5.4)

0.625a 0.120b

42 (79%) 11 (21%) 11 (21%) 31 (59%) 5

55 (90%) 6 (10%) 14 (23%) 30 (49%) 4

35 (66%) 18 (34%)

45 (74%) 16 (26%)

41 (77%) 12 (23%)

36 (59%) 25 (41%)

0.824 b 0.351 b b0.001b 0.415b

0.050b

a = Independent samples t-test, b = Chi-square test.

students in both groups more often disagreed (the mean values being 3 or lower) with the statements that the teacher was like a member of the team and had the ability to convey their pedagogical expertise to the team. The student groups did not differ in their opinions about that (p 0.062 and 0.065 respectively). There was, however, a significant difference between them in that students meeting CNTs agreed more strongly that the teacher and the clinical staff worked together supporting the students’ learning (p 0.002). Students meeting CNTs also agreed more strongly that the joint meetings between the teacher, the preceptor and themselves were a comfortable experience (p 0.001), that the climate of the meetings was congenial (p 0.023) and that the focus at the meetings was on their learning needs (p b 0.001). Student Nurses' Description of the Different Clinical Teachers' Roles Four students at University A and four students at University B were interviewed. From these interviews there emerged 15 sub-categories, four categories and two themes, the latter being The UNT’s responsibility and contact with students and The CNT’s responsibility and contact with students. The UNT’s responsibility and contact with students. The first meeting with the UNT occurred after the students had completed two to three weeks of their clinical education. The students considered it to be too late if they needed to discuss being dissatisfied with their placement. If a discussion was needed earlier the students were responsible for contacting the UNT themselves. The students met the UNT earlier if they did not understand an assignment.

So then the institute people come out after two and a half weeks and make a half-time assessment. They’re there for about an hour, talking. Then there’s most likely no more contact. The students indicated that meeting with the UNT was a positive experience and they were able to discuss anything that had happened or receive help with an issue. UNTs were also needed when students and preceptors did not get along very well. Well, of course, I think that if there’s, say, conflict between the preceptor and the student, it may be a good thing if they come. Occasionally the students felt that the UNT did not show enough interest in complaints about their clinical placement. For this reason, the students chose not to contact the UNT. The students felt alone in their clinical placement when they had no one with whom to share their experiences. They expressed a desire to tell the UNT the reality of their clinical education. Both my preceptor and I told the university lecturers time after time that it maybe wasn’t such a good placement I had because it was so very quiet. But it was “Oh yes?” and then not much more. I mean, you’re very alone overall at your clinical placement. The students mostly met the UNT during seminars and clinical assessment conferences. For the clinical assessment of the student, the

Table 4 Student nurses’ assessment of the clinical teachers’ role.

Role of the nurse teacher (NT)b NT enabling integration of theory and practice In my opinion, the NT was capable to integrate theoretical knowledge and everyday practice of nursing The NT was capable of operationalizing the learning goals of this clinical placement The NT helped me to reduce the theory-practice gap Co-operation between placement staff and NT The NT was like a member of the nursing team The NT was able to transmit his or her pedagogical expertise to the clinical team The NT and the clinical team worked together supporting my learning Relationship between student, mentor and NT The common meetings between myself, mentor and NT were comfortable experience Climate of the meetings was congenial Focus on the meetings was in my learning needs a b

Total n = 114 m (SD)

Students meeting UNT n = 53 m (SD)

Students meeting CNT n = 61 m (SD)

p-valuea

3.4 (0.95)

3.1 (0.89)

3.7 (0.91)

b0.001

3.8 (1.1)

3.5 (1.17)

4.0 (0.93)

0.011

3.8 (1.11) 3.6 (1.10)

3.4 (1.11) 3.2 (1.13)

4.2 (0.98) 3.9 (0.95)

b0.001 b0.001

2.7 (1.41) 2.8 (1.26) 3.3 (1.32)

2.3 (1.06) 2.6 (1.09) 2.9 (1.22)

2.9 (1.62) 3.0 (1.37) 3.6 (1.33)

0.062 0.065 0.002

4.0 (1.15) 3.3 (1.31) 3.7 (1.15)

3.7 (1.19) 3.0 (1.29) 3.3 (1.16)

4.3 (1.03) 3.5 (1.29) 4.1 (1.02)

0.002 0.023 b0.001

Mann–Whitney U-test. Response alternatives: 1 = fully disagree, 2 = disagree to some extent, 3 = neither agree nor disagree, 4 = agree to some extent and 5 = fully agree.

M. Gustafsson et al. / Nurse Education Today 35 (2015) 1289–1294

UNT participated mainly in the mid-course assessment and only sometimes in the final assessment. The times I’ve known, the teacher hasn’t come out for the final assessment. The CNT’s responsibility and contact with students. The students emphasized that the CNT represented the university. The CNT’s meetings with students were limited to the first day of the placement and a few other occasions. The CNT met with the student to check up on them, supervise them, ask if they had any concerns and ensure that they knew to whom they should turn for assistance. Spontaneous meetings could sometimes occur in the corridors of the ward. It happened that the students were not taken seriously and supported by the CNT, whereby they were forced to resolve issues themselves when problems arose with the preceptor. For my part I met the CNT and got a really good introduction. She’s the link, sort of. But it can happen that you just see them going past in the corridor some time. The students had often previously met the CNT at the university before commencing their clinical education. They were then contacted by the CNT by e-mail with a letter of welcome, contact details and a schedule. Information was also given regarding the patients’ most common diseases and the most common types of medication used on the ward. On the first day of their placement a 3–4-hour introduction was given. These efforts were important for the students because it gave them security. The CNT also asked after the students’ previous experience and goals within the placement. Then we got sent a list of illnesses and the commonest medicines. Well, that was the first day, and since then she’s come and seen me a few times actually. The CNT provided pedagogical support for preceptors with the intent that the preceptor would supervise in a similar manner. The CNT was familiar with the manuals, responsible for assignments, followed up on the log book, gave feedback and was responsible for weekly evaluation of how the student learned to connect with patients and next of kin. I think the main point for me this week was how I’m doing when it comes to learning to establish contact with patients and next of kin and others.... — how to interact.... And it’s the clinical teacher that provides feedback. The student, preceptor and CNT participated in the clinical assessment conference. The preceptor had overall responsibility for the clinical assessment of the student when the CNT was not present. The students indicated that it was the preceptor who decided if they would be approved because it was the preceptor who saw their performance. The students emphasized that sometimes the CNT could not explain what the requirements for approval were.

1293

knowledge of clinical practice issues can be kept up-to-date in other ways (Maslin-Prothero and Owen, 2001; Barrett, 2007; Ousey and Gallagher, 2010). The results of the present study suggest that clinical credibility does not necessarily imply participation in clinical work. The students mostly agreed that both CNTs and UNTs had the ability to integrate theory and practice. However, their ratings revealed that they perceived the CNT to have better ability in this respect. Problems with integrating theory and practice need not derive from a lack of theoretical knowledge but may instead derive from an inability to apply such knowledge to practice (Corlett, 2000). Being familiar with the issue in question may facilitate finding a theory that is appropriate to apply to the practical situation. CNTs worked as nurses and were well-informed about issues in the everyday practice of nursing at the clinical placement, which could explain the higher scores for ability to integrate theory with practice. The strong connection with clinical practice is a great advantage possessed by the CNTs. But though the UNTs do not have this advantage, they do (the students report) have others. It emerged from the interviews that the students valued the support from the UNTs in that they were able to discuss problems with them. These findings are in line with results of previous research, which showed that students perceived the UNTs to be supportive and also important as challengers for critical thinking and reflection (Kristofferzon et al., 2013). In the present study the students also stated that the UNT could help them if they had problems with the preceptor. This could be a problem in the organization with a CNT, who is a colleague of the preceptor. It is important for students to have someone outside the clinical environment who may legitimately be involved as their advocate (Brown et al., 2005). The interviews revealed that students met the CNT weekly for an exchange of reflections and occasionally also caught a glimpse of the CNT during the clinical work at the placement. The students in the organization with a UNT reported that they only had a few contacts with the teacher and also that they felt alone during the clinical placement. Such a feeling of being alone has also been reported by students in other studies, who strongly emphasized the need of support from the UNT (Brown et al., 2005; Price et al., 2011). Visits by the lecturer were stressed as important and even as very important during long placements (Price et al., 2011). However, the amount of time the lecturer spent face-to-face with them was not perceived by the students as being crucial (Brown et al., 2005). The distance between the university and the clinical placement can be a challenge in the organization with UNTs, as it can complicate making short visits to the student. In the interviews, it emerged that the UNTs did not always participate in the assessment and that the CNTs could not always explain the learning outcomes that were assessed. Clinical teachers have an important role to fill in the assessment of the students in the clinical practice as it is an exercise of authority that has to be legally secure. It is important that teachers take the responsibility for the assessment and equally important that the teachers can explain the learning goals to the students who cannot interpret these goals by themselves. Otherwise the students feel in the dark and do not know what is expected of them (Brown et al., 2005) Method Discussion

I mean it’s the CNTs that have the responsibility but it’s my preceptor that says whether I pass or fail. … understanding what they’re really after and what knowledge or experience they expect us to have…

Discussion It has been discussed for decades whether nurse teachers must engage in clinical practice to maintain clinical credibility or whether

This study used mixed methods to answer the research question. Using a scale limits the answers one receives and therefore interviews were conducted as a complement to obtain a broader description of the teachers’ roles. The qualitative component “picked up” what the quantitative method missed (Morse, 2009). Data collection and analyses progressed in parallel and findings complemented each other in the discussion of the results (Östlund et al., 2011). The nursing education at the universities included in this study did not differ from the nursing education at other Swedish universities, and the gender and age distribution did not differ from those of Swedish

1294

M. Gustafsson et al. / Nurse Education Today 35 (2015) 1289–1294

student nurses in general (Rudman et al., 2010). There appeared to be little risk of sample bias in our study. We were unable to rule out attrition bias as the students answered the questionnaire anonymously but the attrition was rather low. The students answered the questionnaire one week after they had finished their clinical course, which was an interval probably short enough to exclude memory bias. The instrument chosen for the study is well documented in terms of reliability and validity. One of the authors performed the interviews and also the content analysis of the interviews. She was not employed by either of the participating universities, nor did she have any personal connection with either of them. The findings of the analysis were discussed by all the authors together. Quotations were added in order to illustrate the findings of the interviews.

Conclusions The two clinical teacher models compared in this study have different strengths. The strength of UNTs is good theoretical knowledge that can be maintained naturally in the academic environment. The strength of CNTs is that they are well-informed about the everyday practice of nursing at the clinical placement. Whichever model is used, there lurks a risk of imbalance and deficiency, deriving either from lack of theoretical knowledge or from lack of knowledge about current clinical practice. Teachers must make every effort to avoid this risk and promote the integration of theory and practice in the students’ learning. If the UNT model is chosen, it is important that the UNTs keep their knowledge of issues in clinical practice updated. It is also important that the UNTs visit the clinical placement not only for seminars but also to give students emotional support and to participate in assessing them. In the case of the CNT model it is required that the CNT should have formal authorization from the university. It is important that the CNT is allowed to take part in the development of the learning goals and in the planning of the clinical courses and also take part in pedagogical discussions at the university. CNTs should be well-informed about the goals of the clinical course and be able to interpret and explain the learning outcomes required for approved assessment. In both models the clinical teachers are important links between the university and the healthcare organization. There is literature that describes the UNT model (Kristofferzon et al., 2013) and literature that describes the CNT model (Preheim et al., 2006). As far as we know, however, no previous study has evaluated differences between these models. There is certainly need of further research in this area. RCT studies are to be preferred when it comes to obtaining evidence concerning either of the models compared in this study. However, it is difficult to carry out experimental studies in this research area involving many stakeholders. Participating observational studies could be a way to provide more knowledge about how best to organize the clinical teachers’ role.

Acknowledgement We should like to express our gratitude to the student nurses who participated in this study and shared their experiences with us.

References Barrett, D., 2007. The clinical role of nurse lecturers: past, present, and future. Nurse Educ. Today 27 (5), 367–374. Bisholt, B., Ohlsson, U., Kullén Engström, A., Sundler Johansson, A., Gustafsson, M., 2014. Nursing students’ assessment of the learning environment in different clinical settings. Nurse Educ. Pract. 14 (3), 304–310. Blomberg, K., Bisholt, B., Kullén Engström, A., Ohlsson, U., Sundler Johansson, A., Gustafsson, M., 2014. Swedish nursing students’ experience of stress during clinical practice in relation to clinical setting characteristics and the organisation of the clinical education. J. Clin. Nurs. 23 (15/16), 2264–2271. Brown, L., Herd, K., Humphries, G., Paton, M., 2005. The role of the lecturer in practice placements: what do students think? Nurse Educ. Pract. 5 (2), 84–90. Carr, G., 2007. Changes in nurse education: being a nurse teacher. Nurse Educ. Today 27 (8), 893–899. Corlett, J., 2000. The perceptions of nurse teachers, student nurses and preceptors of the theory-practice gap in nurse education. Nurse Educ. Today 20 (6), 499–505. Ehrenberg, A., Häggblom, M., 2007. Problem-based learning in clinical nursing education: integrating theory and practice. Nurse Educ. Pract. 7 (2), 67–74. Forrest, S., Brown, N., Pollock, L., 1996. The clinical role of the nurse teacher: an exploratory study of the nurse teacher's present and ideal role in the clinical area. J. Adv. Nurs. 24 (6), 1257–1264. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today 24, 105–112. Johansson, U.B., Kaila, P., Ahlner-Elmqvist, M., Leksell, J., Isoaho, H., Saarikoski, M., 2010. Clinical learning environment, supervision and nurse teacher evaluation scale: psychometric evaluation of the Swedish version. J. Adv. Nurs. 66 (9), 2085–2093. Kapborg, I., 1998. Nursing education in Sweden: development from vocational training to higher level education. J. Adv. Nurs. 27, 372–378. Kristofferzon, M., Mårtensson, G., Mamhidir, A., Löfmark, A., 2013. Nursing students' perceptions of clinical supervision: The contributions of preceptors, head preceptors and clinical lecturers. Nurse Educ. Today 33 (10), 1252–1257. Löfmark, A., Thorkildsen, K., Råholm, M.B., Natvig, G.K., 2012. Nursing students' satisfaction with supervision from preceptors and teachers during clinical practice. Nurse Educ. Today 12 (3), 164–169. Maslin-Prothero, S., Owen, S., 2001. Enhancing your clinical links and credibility: the role of nurse lecturers and teachers in clinical practice. Nurse Educ. Pract. 1 (4), 189–195. Morse, J.M., 2009. Mixing qualitative methods. Qual. Health Res. 19 (11), 1523–1524. O'Driscoll, M., Allan, H., Smith, P., 2010. Still looking for leadership - who is responsible for student nurses' learning in practice? Nurse Educ. Today 30 (3), 212–217. Östlund, U., Kidd, L., Wengström, Y., Rowa-Dewar, N., 2011. Combining qualitative and quantitative research within mixed method research designs: A methodological review. Int. J. Nurs. Stud. 48 (3), 369–383. Ousey, K., Gallagher, P., 2010. The clinical credibility of nurse educators: time the debate was put to rest. Nurse Educ. Today 30 (7), 662–665. Preheim, G., Casey, K., Krugman, M., 2006. Clinical scholar model: providing excellence in clinical supervision of nursing students. J. Nurses Staff Dev. 22, 15–22. Price, L., Hastie, L., Duffy, K., Ness, V., McCallum, J., 2011. Supporting students in clinical practice: Pre-registration nursing students' views on the role of the lecturer. Nurse Educ. Today 31 (8), 780–784. Rudman, A., Omne-Pontén, M., Wallin, L., Gustavsson, P.J., 2010. Monitoring the newly qualified nurses in Sweden: the Longitudinal Analysis of Nursing Education (LANE) study. Hum. Resour. Health 8, 10. Saarikoski, M., Leino-Kilpi, 2002. The clinical learning environment and supervision by staff Nurses: developing the instrument. Int. J. Nurs. Stud. 39, 259–267. Saarikoski, M., Isoaho, H., Warne, T., Leino-kilpi, H., 2008. The nurse teacher in clinical practice: Developing the new sub-dimension to the clinical learning environment and supervision (CLES) scale. Int. J. Nurs. Stud. 45, 1233–1237. Saarikoski, M., Warne, T., Kaila, P., Leino-Kilpi, H., 2009. The role of the nurse teacher in clinical practice: an empirical study of Finnish student nurse experiences. Nurse Educ. Today 29 (6), 595–600. Saarikoski, M., Kaila, P., Lambrinou, E., Pérez Cañaveras, R., Tichelaar, E., Tomietto, M., Warne, T., 2013. Students' experiences of co-operation with nurse teacher during their clinical placements: An empirical study in a Western European context. Nurse Educ. Pract. 13 (2), 78–82. SFS, 1992:1434, 1992. Högskolelagen (The Higher Education Act). Ministry of Education and Research, Stockholm (in Swedish). SFS, 1993:100, 1993. Högskoleförordningen (The Higher Education Ordinance). Ministry of Education and Research, Stockholm (in Swedish). Sundler, A.J., Björk, M., Bisholt, B., Ohlsson, U., Kullén Engström, A., Gustafsson, M., 2014. Student nurses' experiences of the clinical learning environment in relation to the organization of supervision: A questionnaire survey. Nurse Educ. Today 34 (4), 661–666.