Nurse Education in Practice xxx (2014) 1e7
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Learning and teaching in clinical practice
Nursing preceptors’ experiences of two clinical education models Anna-Greta Mamhidir a, b, *, Marja-Leena Kristofferzon a, b,1, Eva Hellström- Hyson a, 2, Elisabeth Persson a, 3, Gunilla Mårtensson a, b, 4 a b
Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, University of Gävle, Sweden Department of Public Health and Caring Sciences, Uppsala University, Sweden
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 16 January 2014
Preceptors play an important role in the process of developing students’ knowledge and skills. There is an ongoing search for the best learning and teaching models in clinical education. Little is known about preceptors’ perspectives on different models. The aim of the study was to describe nursing preceptors’ experiences of two clinical models of clinical education: peer learning and traditional supervision. A descriptive design and qualitative approach was used. Eighteen preceptors from surgical and medical departments at two hospitals were interviewed, ten representing peer learning (student work in pairs) and eight traditional supervision (one student follows a nurse during a shift). The findings showed that preceptors using peer learning created room for students to assume responsibility for their own learning, challenged students’ knowledge by refraining from stepping in and encouraged critical thinking. Using traditional supervision, the preceptors’ individual ambitions influenced the preceptorship and their own knowledge was empathized as being important to impart. They demonstrated, observed and gradually relinquished responsibility to the students. The choice of clinical education model is important. Peer learning seemed to create learning environments that integrate clinical and academic skills. Investigation of pedagogical models in clinical education should be of major concern to managers and preceptors. Ó 2014 Published by Elsevier Ltd.
Keywords: Clinical education Nurses Peer learning Traditional supervision
Introduction Clinical practice is a complex and pivotal part of nursing education. Registered nurses (RNs) who act as preceptors are expected to facilitate nursing students’ education so that theoretical knowledge can be linked to practical skills (Ehrenberg and Häggblom, 2007; Carlson, 2012). The clinical learning environment influences integration of theory and practice (Ehrenberg and Häggblom, 2007). Budget restraints and fewer clinical placements in clinical settings may lead to discussions about new pedagogical models for learning and teaching (Carlson, 2012). Thus, there is an ongoing search for the best learning and teaching models in clinical education. The present study reports findings from a project
* Corresponding author. Faculty of Health and Occupational Studies. Department of Health and Caring Sciences, University of Gävle, Sweden. Tel.: þ46 26 648248. E-mail addresses: [email protected] (A.-G. Mamhidir), [email protected] (M.-L. Kristofferzon), [email protected] (E. Hellström- Hyson), [email protected] (E. Persson), [email protected] (G. Mårtensson). 1 Tel.: þ46 26 648242. 2 Tel.: þ46 26 648886. 3 Tel.: þ46 70 3498411. 4 Tel.: þ46 26 648294.
investigating preceptors’ experiences of two different clinical education models: peer learning and traditional supervision. Background Peer learning is a pedagogical model based on the idea that learning involves social cognition and that experience, understanding and knowledge-building are shaped in interactions between humans. Thus, peer learning derives from theories of social learning and constructivism and from theorists such as Bandura, Piaget and Dewey (Topping, 1996, 2005; Falchikov, 2001; Secomb, 2008). Peer learning differs from traditional education in that students learn with, and from, each other without immediate intervention by a teacher or a supervisor (Topping, 2005). It is defined as the acquisition of knowledge and skills through a process of active two-way reciprocal learning between peers (Boud et al., 2001). Central to the learning process is student activity, and peer learning promotes a holistic view of learning (Boud and Falchikov, 2006). In a systematic review of use of this pedagogical model in clinical education (including twelve empirical studies), primarily positive outcomes were found, and it was suggested that peer learning has the potential to increase students’ confidence in clinical practice (Secomb, 2008). Similar findings were reported in a recent review by Stone et al. (2013), who concluded that the learning strategies in
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peer learning increase students’ confidence and competence and decrease their anxiety. Other studies of peer learning have also reported findings pointing in the same direction (Chojecki et al., 2010; Christiansen et al., 2011). Carlson (2012) described how peer learning in clinical education allows students to work in pairs during structured nursing activities. Students are encouraged to engage in critical thinking, problem-solving and collaboration. The preceptors support and give feed-back to the students, but do not e in contrast to more traditional supervision models e play an active role during the nursing activities. Traditional clinical nursing education is a teaching model in which one student is placed in a hospital department and follows an RN/preceptor during a shift. The preceptor is familiar with the routines and the culture, and his/her role is to instruct and demonstrate (Hellström-Hyson et al., 2012). Preceptors working in traditional clinical education models have requested more time for students, proper training in precepting practice and pedagogical tools (Ehrenberg and Häggblom, 2007; Carlsson et al., 2010). The content of nursing education and the academic level at which it takes place have changed in Sweden and in other European countries (Ehrenberg and Häggblom, 2007). In Sweden, nursing education involves a 3-year Bachelor’s program (180 credits) leading to a Bachelor of Science in Nursing degree. Clinical education is an essential part of the 3-year program. Established higher academic education goals (SFS, 1992:1434; SFS, 1993:100) have to be met in the clinical as well as theoretical parts of the program. The goals include students’ ability to make critical and independent judgments as well as to formulate and solve problems. Preceptors play a critical role in the process of developing students’ knowledge and skills with a view to achieving higher education goals. Preceptors’ important and complex role in clinical nursing education has previously been highlighted. In Sweden, RNs’ dual function of patient care and simultaneous student supervision responsibilities has been described as stressful (Carlsson et al., 2010; Danielsson et al., 2009). A review by Omansky (2010), including 20 studies published during the period 1999e2009, showed that the preceptor role is ambiguous and entails a heavy work load. A study describing nursing education in 20 Western European countries showed that preceptors in clinical education often had a limited academic background, that the cooperation between higher education and clinical placements was insufficient, and that little time was dedicated to supervision (Spizter and Perrenoud, 2006). Structural conditions are important and can lead to improved preceptor performance (Mårtensson et al., 2012). In a recent study, Mårtensson et al. (2012) found that feedback from and recognition by managers, being able to plan and prepare the clinical education period, and having specific preceptor training explained 31% of the preceptors’ overall view on their performance as preceptors. However, these structural conditions and professional experiences could not explain preceptors’ use of reflection and support the students’ critical thinking (Mårtensson et al., 2012). Precepting nursing students requires professional and pedagogical accountability (Luhanga et al., 2008), a supportive learning environment and suitable clinical education models. One study in which students described their experiences of two clinical education models, peer learning versus the traditional model (HellströmHyson et al., 2012), reported that peer learning gave students opportunities to assume responsibility, helped them find their professional role, and increased their cooperation skills and confidence. In contrast, when students practiced on a department using the traditional model, they described themselves as onlookers and had difficulties assuming their responsibilities. They did not always feel free to take their own nursing care initiatives, cared for many patients simultaneously and thereby felt they had
lost control. However, the students felt confident because the preceptor was always present. To the best of our knowledge, no previous study has reported on preceptors’ experiences within the context of these two different clinical education models: peer learning and the traditional model. It is important to note that both preceptor and student experiences of different clinical education models warrant investigation. Therefore, the aim of the present study was to describe nursing preceptors’ experiences of their role as preceptors in two different clinical education models: peer learning and traditional supervision. Methods Design A descriptive design with a qualitative approach was used (Polit and Beck, 2012). Setting The study was carried out in surgical and medical departments at two of three public hospitals, in one county council including 276,000 inhabitants in central Sweden. The hospitals were both full-service facilities, had together about 400 patient beds and were run by one management office. During each semester, nursing students from one university are placed in these hospitals for their clinical education periods. The two hospitals used two different clinical education models. In one of the hospitals where a peer learning model has existed since 2006, students work in pairs and these pairs have joint responsibility for a group of four patients. The nurse who is primarily responsible for these patients’ care acts as a preceptor for a pair of nursing students (Hellström-Hyson et al., 2012). In the other hospital where the traditional model is used, one preceptor supervises one nursing student at a time. The terms preceptor, supervisor and mentor are often used synonymously (Yonge et al., 2007). In the present study, the term preceptor was chosen to refer to the RN responsible for precepting, that is, teaching, reflection, feedback and evaluation during clinical education (Yonge et al., 2007). The term nursing student refers to a student enrolled in term two or six of the Bachelor’s nursing program at a university in central Sweden. Sampling A purposive sample of 20 RNs was asked to participate, the strategy being to select individuals who are knowledgeable in the area of concern and who will therefore provide the richest data (Polit and Beck, 2012). Purposive sampling was also chosen because it allows researchers to ensure variation in the interview data (Patton, 2002). Ten of the RNs worked on the departments that used the peer learning model and ten RNs worked on departments using the traditional model. The inclusion criterion was having worked on the department for at least one year. One nurse declined participation and one interview failed due to technical problems, and for this reason 18 preceptors’ interviews were included in the analysis. All participants were women, ten from the hospital using peer learning and eight from the hospital using traditional supervision. Preceptors representing peer learning ranged in age from 25 to 65 years, had worked as RNs between 1 and 29 years and as a preceptor between 1 and 25 years. Seven had taken university courses in emergency medicine, pain, nutrition or nursing care documentation. None of them had taken a course in clinical supervision. Preceptors representing traditional supervision ranged
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in age from 28 to 65 years, two had taken university courses, such as specialist education in primary health care, medicine and surgery, and three had taken courses in clinical supervision. They had worked as RNs between 5 and 30 years and as a preceptor between 3 and 20 years.
workplaces, lasted from 25 to 40 min and were tape-recorded and transcribed verbatim. The study was carried out from March, 2010 to June, 2010.
Ethical considerations
The transcribed interviews were analyzed using latent qualitative content analysis (Sandelowski, 1998), which involves interpreting the underlying meaning and answering the ‘how’ questions; themes were constructed based on subthemes (Graneheim and Lundman, 2004). In order to understand and become familiar with the text, the transcriptions were read, re-read and the texts were divided into two content areas (peer learning and traditional model). Meaning units (words, sentences or paragraphs) were then identified based on the aim of the study. Meaning units were condensed into a descriptive text, abstracted and labeled with a code. The codes were grouped according to similarities and sorted into one theme and four subthemes where peer learning was used and correspondingly one theme and four subthemes for traditional supervision. Codes, subthemes and themes were discussed continuously with the co-investigators during the analysis process until agreement on thematic patterns was reached. The analyses were initially carried out by the first, third and fourth researcher. The second and fifth researchers read and commented on the analysis throughout the analytic process. The analysis process was transparent for all researchers during the study, and quotes are presented in the results to illustrate the preceptors’ statements.
The preceptors received information about the aim and procedure of the study; voluntary participation and confidentiality were assured. Furthermore, the participants were informed that they could withdraw from the study at any time, without any explanations or consequences. The study was approved by the Regional Ethical Review Board in Uppsala (Reg. no. 2010/002). Data collection A semi-structured interview guide (Polit and Beck, 2012) covering questions about the preceptors’ experiences of their role and the preceptorship, support and clinical learning environment was developed. The interviews were found useful in enabling understanding of the preceptors’ experiences. An interview guide can ensure that the same topics are brought up with each interviewee, and within the established topics the interviewer is free to probe a particular question (Patton, 2002). The questions formulated were inspired by the study by Hellström-Hyson et al. (2012), in which nursing students’ experiences of the two described models of clinical supervision were explored. The interviews started by taking a comprehensive perspective on precepting, that is, the preceptors were asked to describe aspects of importance in clinical education. Other questions were, for example, ‘What are the core elements of precepting?’, ‘What are the core elements in a supportive clinical learning environment?’ and ‘Can you describe a supportive preceptor role?’ Clarifying questions were asked (‘What do you mean? Can you describe or tell me more about this?’) to encourage the preceptors to share information and provide extended descriptions of their experiences. In addition, data on the preceptors’ age, gender, university courses and working time as a preceptor were collected.
Data analysis
Findings The findings are presented in two parts: the first reflecting the preceptors’ experiences of peer learning and the second the preceptors’ experiences of traditional supervision. In the peer learning model, the formulated theme was ‘The preceptor creates room for students to assume responsibility for their own learning’ and in the traditional model the theme ‘The preceptor’s ambitions and knowledge are stressed and taught’ was formulated. The two themes and the eight subthemes are presented and supported by quotations in the text (Table 1).
Procedure Peer learning model The first-line manager on each department presented the study and the criterion for participation at a staff meeting. RNs who had experience as student preceptors during the past year were invited to participate. A list of ten names from each hospital was made by the first-line managers and sent to two of the researchers (EHH and EP). The two researchers contacted the participants and conducted ten and eight interviews, respectively. These two researchers worked as clinical lecturers, and both were familiar with clinical education and preceptorship. The two interviewers were unfamiliar with the hospital, departments and preceptors they interviewed. The interviews were carried out at the preceptor’s
In the peer learning model, the preceptors created room for students to assume responsibility for their own learning and challenged the students’ knowledge by refraining from stepping in. The model was reported to encourage students’ critical thinking and independence. Taking a step back while providing support The preceptors described peer learning supervision as stimulating but challenging. In nursing care situations, it was challenging when the preceptor waited for the student to be active, to provide
Table 1 Themes and subthemes capturing the preceptors’ experiences of their role as preceptors, based on two clinical models of supervision. Peer learning model Theme Subthemes
Traditional model The preceptor creates room for students to assume responsibility for their own learning Taking a step back while providing support Creating a structure and acceptance for supervision Encouraging critical thinking and supporting development of independence Dealing with the problems of supervision
Theme Subthemes
The preceptor’s ambitions and knowledge are stressed and taught Demonstrating and gradually relinquishing responsibility Observing and controlling Reflection is important, but only done when there is time Striving for good structural conditions to create security
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care and to come forward, but the student acted more slowly than expected. In such cases, the preceptor might feel impatient and wish to intervene quickly. The preceptors described becoming aware of their own behavior; they tried to restrain themselves and adhere to the preceptor approach agreed to in the department, but it was not always easy. In cases of emergency they took over the care activities if needed. Their role was described as being to encourage and challenge the students to be active and solve different nursing problems in order to reach their individual and nursing education goals. ‘On the student wards, the students have each other and the preceptor is in the background’ (10) Creating a structure and acceptance for supervision Most of the RNs had accepted the idea of precepting in accordance with the method of peer learning used in the department. The preceptors’ schedules had been organized to accommodate peer learning, that is, the nursing colleagues supported the routines that allowed students to take care of the same group of patients from admission to discharge. Precepting two students at a time was reported not to be more time consuming than precepting only one student at a time. ‘We have decided on the ward that we nurses do like this.to manage [the supervision]. Even if the nurse/preceptor already has worked for example two morning shifts she has the first priority [before colleagues] to the rooms, where the students are responsible’ (2). Encouraging critical thinking and supporting development of independence It was stressed that peer learning supports and contributes to students’ professional development. The preceptors meant that allowing students to be responsible for a smaller group of patients enabled them to grasp these patients’ whole situation. The students first searched for knowledge so as to identify relevant solutions to different patient problems, and thereafter they confronted the preceptor with questions and solutions. The preceptors reported that this method of supervision trained students to think critically and supported independence in their nursing role. ‘First they kick it around between them, then take it up with their preceptor. The preceptors aren’t supposed to tell them everything... the students should identify [solutions] themselves, reflect and then discuss them with me’ (8) Dealing with the problems of supervision On some occasions, precepting according to the peer learning model was difficult, causing the preceptors to switch to traditional supervision. This occurred when the students did not have earlier nursing care experiences or when the student pair was very uneven in their level of knowledge. Students without earlier experience of nursing care often had problems identifying patients’ care needs. In order to prevent such situations in the department, the two first weeks of the students’ clinical practice period were planned and carried out using traditional supervision. One preceptor was responsible for one student, allowing enough time to grasp that student’s needs, and after the two weeks, switching over to the peer learning was seldom a problem. ‘Using [peer learning] can be difficult for example when they [the students]work together.and when they have to plan and provide for the patients’ care. then if one of the students is very
competent and the other has not developed so much and they don’t have the same level of knowledge, then it can be difficult’ (2).
Traditional model In the traditional model, the preceptors’ individual ambitions influenced the preceptorship and their own knowledge was emphasized as being important to impart. Preceptors demonstrated, observed and gradually relinquished responsibility to the students. Demonstrating and gradually relinquishing responsibility Preceptors using the traditional supervision model mentioned that it is important for students to observe the preceptor if they are to learn how nursing care should be provided. They invited students to follow their actions in relation to different nursing care situations and when the care was provided, the patient’s problems and care needs were presented to the students. Demonstration was emphasized as an important step in teaching, owing to the preceptors’ long experience of working with patients and with tasks of a technical nature. After a demonstration, the students were encouraged to test the different care activities by themselves. Sometimes the preceptors did not have time to demonstrate owing to a heavy workload or acute care situations. In such situations, they focused on patients’ needs, and the students observed the care provided. The preceptors’ ambition was to share their experience with the students, thereby contributing to students’ development of in-depth knowledge of nursing care. ‘For instance, if I’m going to mix an intravenous solution or prepare an injection, first I demonstrate and then the student can do the same thing, while I supervise of course, I want to see they’ve understood’ (8) ‘When things are stressful then it’s like they just run after me and I don’t havetime to show them like I’d like to.’ (2)
Observing and controlling The preceptors’ responsibility to observe and control students’ nursing care activities was highlighted and related to their responsibility for patient safety. Observations and controls were described as necessary in order to follow students’ skill development in nursing care. The students were encouraged to ask questions and to inform the preceptors about their planned care activities before they delivered care. The ambition was to teach students to be open minded and to try to see the whole patient, to participate in rounds and become knowledgeable about medications. ‘I want to have control over what they do, because I’ve seen others who let their students go and they might be very competent, but I’m the one who’s responsible, it’s mostly medications’ (5)
Reflection is important, but only done when there is time The need for reflection together with the student after care situations was stressed. They wanted to discuss what aspects of the care situation were good or problematic and they wanted to provide correction or advice. Reflection at the end of the day did occur, but it was often difficult due to staff shortages. In that sense, reflection was subordinated, even though the preceptors felt it was important for the students and themselves to deal with questions and the experiences of the day. ‘There are fewer and fewer of us on the shifts, there’s no time to reflect yourself, which might be necessary sometimes, and the
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students need it for sure, because they naturally have lots of questions, about what they saw and experienced’ (5)
Striving for good structural conditions to create security The preceptors’ goal was to ensure good structural prerequisites so as to create a secure context for students during their clinical practice period. Upper level management’s commitment to and recognition of the value of supervision were called for, as was greater management responsibility for shortcomings in the organization of supervision. The nurse manager had been asked to relieve the preceptors of some patient responsibilities during intensive student supervision periods. The current system in which all nurses made their individual schedules, often changed by the nurse manager, led to difficulties in matching the preceptors’ and students’ schedules. ‘Support from management, well, not like I would like it’ (2) ‘More and more difficult, hard to get the schedules to match [preceptor and student], because we have these individual schedules and there’s no continuity like before’ (9) The clinical lecturer was reported to contribute to nursing development by helping preceptors keep up to date on nursing education changes and new demands. Supervision courses were stressed as being necessary to carrying out the preceptor role. Discussion The themes ‘The preceptor creates room for students to assume responsibility for their own learning’ and ‘The preceptor’s ambitions and knowledge are stressed and taught’ describe the preceptors’ experiences and approaches to their preceptorship, with respect to two models of clinical nursing education: peer learning and traditional supervision. Using the peer learning model, the preceptors created space for students to take responsibility for their own learning process. The preceptors’ felt they could take a step back while providing support, they had created a structure for supervision, which was accepted at the department, encouraged the students’ critical thinking and supported their independence. Using traditional supervision, preceptors’ individual ambitions influenced the preceptorship and their own knowledge was emphasized as being important to impart. They wanted to improve the structural conditions of the preceptorship, but lacked manager support and felt they had little opportunity to effect change. The findings in the present study will be discussed in light of Spreizter’s (1995) description of psychological empowerment and its four inherent components (meaning, competence, self-determination and impact). According to Spreitzer (1995), not only structural conditions but also psychological empowerment is an important component of workplace empowerment. Psychological empowerment involves individuals’ feelings and views on their working role and includes: meaning e a fit between work- and taskrelated goals, beliefs, behaviors and the individual’s own ideals and goals; competence e the individual’s confidence in his/her ability to carry out tasks with skill; self-determination e the individual’s sense of choice or control over his/her work methods, work rates and work performance and; impact e the degree to which individuals are able to influence administrative and operative work outcomes. These characteristics reflect an active approach to the work role because the individual can influence the role and the context (Spreitzer, 1995). Meaning e at the department, using peer learning, the overall higher education goals seemed to match the preceptors’ own goals. They expected, encouraged and challenged the student pairs to be
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active in their own learning process, to search for knowledge, and to practice critical thinking and problem-solving in relation to their patients’ specific needs. Preceptors’ behaviors, such as openness, trust and skepticism, promote critical thinking during clinical education (Myrick and Yonge, 2004). The preceptors tried to refrain from stepping in and to make room for the students to take the initiative, but this was sometimes difficult. The preceptors’ behavior indicates that they considered peer learning meaningful, because this approach promoted students’ personal and professional growth but was also in accordance with preceptors’ own beliefs (Spreitzer, 1995). Students who act independently increase their self-confidence and develop in their professional role (Ponzer et al., 2004). The present findings are in line with students’ experiences of peer learning in clinical education (Hellström-Hyson et al., 2012). In contrast, during traditional supervision, a discrepancy was found between higher education goals and preceptors’ experiences of their preceptorship. The preceptors’ long experience may lead them to believe that observing and controlling students were two of the most important tasks of the preceptor. A professional preceptor is alert, in control and at the center of several activities (Murray and Main, 2005). Such an approach may, on the one hand, lead to imitative forms of learning that internalize poor practice. On the other hand, students meet experienced preceptors who can help them to develop their professional role. However, nursing care is complex and qualified, and preceptors have to balance students’ skills development with patient safety. Öhrling and Hallberg (2001) stated that precepting should entail empowering students in clinical practice. Empowerment reduces feelings of helplessness, and thus pedagogical strategies that promote such a process must be used. Not interfering with students may sometimes be difficult, but encouraging students to act independently is a sign that preceptors feel secure in their professional role (Hellström-Hyson et al., 2012). Integration of nursing education into higher education has resulted in new demands on preceptorship. The traditional approach, where preceptors demonstrate tasks and control students, must be transformed into supervision that promotes reflection and critical thinking (Mårtensson et al., 2012). There are differences between the clinical and the theoretical parts of nursing education as regards meeting higher education goals. Theoretical education at universities to a greater extent than clinical education helps students, for example, apply research findings and learn how to effect change in clinical practice (Florin et al., 2011). Competence e using peer learning, confidence in performing tasks and being innovative was mirrored among the preceptors. According to the preceptors’ expert knowledge, if student pairs were found to differ greatly in knowledge, peer learning did not promote their professional development. The preceptors trusted their judgment and switched to traditional supervision. The students consequently received more individual time with the preceptor. Peer learning entails less individual time spent with the preceptor, which is a negative aspect to consider (Secomb, 2008). The preceptors’ behavior described above could also be reflected in relation to self-determination e that is, the preceptors felt confident in their expert knowledge and felt they had choices in dealing with difficulties that arose. Using peer learning, the preceptors’ schedules had been adapted to the preceptorships, which may reflect the component impact; thus, the preceptors were able to influence administrative conditions to achieve the best precepting outcomes, which were supported by management. In contrast, when using traditional supervision they strived to create good structural conditions for precepting, such as adapting schedules and setting aside time, but they felt there was little support and interest on the part of
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management. This revealed their feelings of having little impact on the situation. Other studies (Ehrenberg and Häggblom, 2007; Omansky, 2010; Mårtensson et al., 2012) have reported that manager support and recognition are important, such as being given time to precept. Lack of allocated time for precepting has been described as problematic (Carlson, 2012). Spitzer and Perrenoud (2006) reported on nursing education in 20 Western European countries and showed that little time was dedicated to clinical supervision. However, preceptors using peer learning declared that precepting two students at a time is not more time consuming than precepting only one. The present findings implied management acceptance of the resources required to operate peer learning education, while it appeared more difficult for those using a traditional approach to preceptorship. This can be related to the fact that the peer learning model was implemented and supported by management. According to Spreitzer (1995), the degree of impact is related to the working context, but it also reflects an active approach to the work role because the individual preceptor can influence the role and the context. These results confirm Spreitzer’s (1995) position that individuals’ sense of control in their workplace affects not only their attitude, but also their performance. Limitations of the study There are methodological limitations in our study. The interviews were conducted by two clinical lecturers, both familiar with clinical education and preceptorship. Familiarity with the context under study may be viewed as a strength, but also a weakness, as some information may be taken for granted, not noticed or not taken into consideration. A precaution was taken in this regard, in that the two interviewers were unfamiliar with the hospital, departments and preceptors they interviewed. This precaution was also considered to minimize the risk of preceptors feeling dependent on the interviewer. Qualitative content analysis was used to acquire a deeper understanding of the nursing preceptors’ experiences of their role as preceptors, in two different clinical education models. In content analysis, the concept of transferability can be discussed (Patton, 2002). Our findings cannot be generalized but are credible if persons with similar experiences recognize and can relate to the descriptions or interpretations (Patton, 2002). If this is the case, the present findings may be applied to similar preceptors’ work situations in different clinical education models. Implications and conclusions Challenging students or providing students with knowledge reflects preceptors’ experiences and approaches to their precepting, with respect to the two models of supervision: peer learning and traditional clinical supervision. Using the peer learning model, preceptors created room for students to assume responsibility for their own learning process and acted as challengers. The preceptors acted in line with the idea of peer learning (Topping, 1996, 2005), where student peers interact and learn together while performing interventions. The preceptors experienced empowerment and selfdetermination, were innovative and reported having had an impact on the precepting work. The preceptors using traditional supervision had the role of knowledge providers. Their individual ambitions influenced the preceptorship, and their own knowledge was emphasized as being important to impart. They wished to improve the structural conditions of the preceptorship, but the lack of manager support made them feel they had little opportunity to influence their work. The choice of clinical education models is important to learning. Peer learning seemed to create learning environments that
integrate clinical and academic skills. Carlson (2012) argued that preceptors in a peer learning model can use their time more efficiently, at the same time they are pedagogically sound and the approach is beneficial for students. However, there seems to be some potential for a mixed approach. This may be a way for the preceptor to feel free while meeting the students’ needs during clinical practice. The findings are promising and credible for preceptors with similar work situation experiences. Future initiatives to explore different pedagogical models in clinical education are needed and should be of major concern to managers as well as preceptors. Conflicts of interest The authors of this paper report no conflicts of interest. Acknowledgments We wish to thank the RNs who participated for sharing their knowledge and time. Financial support for the study was provided by the Faculty of Health and Occupational Studies Department of Health and Caring Sciences University of Gävle. References Boud, D., Falchikov, N., 2006. Aligning assessment with long-term learning. Assess. Eval. High. Educ. 31 (4), 399e413. Boud, D., Cohen, R., Sampson, J., 2001. Peer Learning in Higher Education. Kogan Page, London. Carlson, E., 2012. Precepting and symbolic interactionism e a theoretical look at nursing practice. J. Adv. Nurs. 69 (2), 457e464. Carlsson, E., Pilhammar, E., Wann-Hansson, C., 2010. “This is nursing”: nursing roles as mediated by precepting nurses during clinical practice. Nurse Educ. Today 30 (8), 763e767. Chojecki, P., Lammare, J., Buck, M., St-Sauveur, 1, Eldaoud, N., Purden, M., 2010. Perceptions of a peer learning approach to pediatric clinical education. Int. J. Nurs. Educ. Scholarsh. 7 (1), 1e14. Christiansen, B., Björk, I.T., Havnes, A., Hessevaagbakke, E., 2011. Developing supervision skills through peer learning partnership. Nurse Educ. Pract. 11 (2), 104e108. Danielsson, C., Sundin-Andersson, R., Hov, R., Athlin, E., 2009. Norwegian and Swedish preceptors’ views of their role before and after taking part in a group supervision program. Nurs. Health Sci. 11 (2), 107e113. Ehrenberg, A.C., Häggblom, M., 2007. Problem-based learning in clinical nursing education: integrating theory and practice. Nurse Educ. Pract. 7 (2), 67e74. Falchikov, N., 2001. Learning Together. Peer Tutoring in Higher Education. Routledge Falmer, London. Florin, J., Ehrenberg, A., Wallin, L., Gustavsson, P., 2011. Educational support for research utilization and capability beliefs regarding evidence-based practice skills: a national survey of senior nursing students. J. Adv. Nurs. 68 (4), 888e897. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today 24 (2), 105e112. Hellström-Hyson, E., Mårtensson, G., Kristofferzon, M.L., 2012. To take responsibility or to be an onlooker. Nursing students’ experiences of two models of supervision. Nurse Educ. Today 32 (1), 105e110. Luhanga, F., Yonge, O.A., Myrick, F., 2008. Precepting un unsafe student: the role of the faculty. Nurse Educ. Today 28 (2), 227e231. Mårtensson, G., Engström, M., Mamhidir, A.G., Kristofferzon, M.L., 2012. What are the structural conditions of importance to preceptors’ performance? Nurse Educ. Today 32, 105e110. Murray, C.J., Main, A., 2005. Role modeling as a teaching method for student mentors. Nurs. Times 101 (28), 30e33. Myrick, F., Yonge, O., 2004. Enhancing critical thinking in the preceptorship experience in nursing education. J. Adv. Nurs. 45 (4), 371e380. Öhrling, K., Hallberg, I.R., 2001. The meaning of preceptorship: nurses’ lived experience of being a preceptor. J. Adv. Nurs. 33 (4), 530e540. Omansky, G.L., 2010. Staff nurses’ experiences as preceptors and mentors: an integrative review. J. Nurs. Manag. 18 (6), 697e703. Patton, M.Q., 2002. Qualitative Research and Evaluation Methods, third ed. Sage, Thousand Oaks, CA. Polit, D., Beck, C.T., 2012. Nursing Research. Generating and Assessing Evidence for Nursing Practice, ninth ed. Lippincott Williams & Wilkins, Philadelphia. Ponzer, S., Hylin, U., Kusoffsky, A., Lauffs, M., Lonka, K., Mattiasson, A.C., Nordström, G., 2004. Interprofessional training in the context of clinical
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A.-G. Mamhidir et al. / Nurse Education in Practice xxx (2014) 1e7 practice: goals and students’ perceptions on clinical education wards. Med. Educ. 38 (7), 727e736. Sandelowski, M., 1998. Writing a good read: strategies for re-presenting qualitative data. Res. Nurs. Health 21 (4), 375e382. Secomb, J., 2008. A systematic review of peer teaching and learning in clinical education. J. Clin. Nurs. 17 (6), 703e716. SFS 1992:1434, 1992. Högskolelagen (The Higher Education Act). Utbildningsdepartementet, Stockholm (in Swedish). SFS 1993:100, 1993. Högskoleförordningen (The Higher Education Ordinance). Utbildningsdepartementet, Stockholm (in Swedish). Spitzer, A., Perrenoud, B., 2006. Reforms in nursing education across Western Europe: from agenda to practice. J. Prof. Nurs. Off. J. Am. Assoc. Coll. Nurs. 22 (3), 150e161.
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Spreitzer, G., 1995. Psychological empowerment in the workplace: dimensions, measurement, and validation. Acad. Manag. J. 38 (5), 1442e1465. Stone, R., Cooper, S., Cant, R., 2013. The value of peer learning in undergraduate nursing education: a systematic review. ISRN Nurs., 1e10. http://dx.doi.org/ 10.1155/2013/930901. Topping, K.J., 1996. The effectiveness of peer tutoring in further and higher education. A typology and review of the literature. High. Educ. 32, 321e345. Topping, K.J., 2005. Trends in Peer learning. Educ. Psychol. 25 (6), 631e645. Yonge, O., Billay, D., Myrick, F., Luhanga, F., 2007. Preceptorship and mentorship: not merley a matter of semantics. Int. J. Nurs. Educ. Scholarsh. 4 (1), 1e13.
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Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Learning and teaching in clinical practice
Nursing preceptors’ experiences of two clinical education models Anna-Greta Mamhidir a, b, *, Marja-Leena Kristofferzon a, b,1, Eva Hellström- Hyson a, 2, Elisabeth Persson a, 3, Gunilla Mårtensson a, b, 4 a b
Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, University of Gävle, Sweden Department of Public Health and Caring Sciences, Uppsala University, Sweden
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 16 January 2014
Preceptors play an important role in the process of developing students’ knowledge and skills. There is an ongoing search for the best learning and teaching models in clinical education. Little is known about preceptors’ perspectives on different models. The aim of the study was to describe nursing preceptors’ experiences of two clinical models of clinical education: peer learning and traditional supervision. A descriptive design and qualitative approach was used. Eighteen preceptors from surgical and medical departments at two hospitals were interviewed, ten representing peer learning (student work in pairs) and eight traditional supervision (one student follows a nurse during a shift). The findings showed that preceptors using peer learning created room for students to assume responsibility for their own learning, challenged students’ knowledge by refraining from stepping in and encouraged critical thinking. Using traditional supervision, the preceptors’ individual ambitions influenced the preceptorship and their own knowledge was empathized as being important to impart. They demonstrated, observed and gradually relinquished responsibility to the students. The choice of clinical education model is important. Peer learning seemed to create learning environments that integrate clinical and academic skills. Investigation of pedagogical models in clinical education should be of major concern to managers and preceptors. Ó 2014 Published by Elsevier Ltd.
Keywords: Clinical education Nurses Peer learning Traditional supervision
Introduction Clinical practice is a complex and pivotal part of nursing education. Registered nurses (RNs) who act as preceptors are expected to facilitate nursing students’ education so that theoretical knowledge can be linked to practical skills (Ehrenberg and Häggblom, 2007; Carlson, 2012). The clinical learning environment influences integration of theory and practice (Ehrenberg and Häggblom, 2007). Budget restraints and fewer clinical placements in clinical settings may lead to discussions about new pedagogical models for learning and teaching (Carlson, 2012). Thus, there is an ongoing search for the best learning and teaching models in clinical education. The present study reports findings from a project
* Corresponding author. Faculty of Health and Occupational Studies. Department of Health and Caring Sciences, University of Gävle, Sweden. Tel.: þ46 26 648248. E-mail addresses: [email protected] (A.-G. Mamhidir), [email protected] (M.-L. Kristofferzon), [email protected] (E. Hellström- Hyson), [email protected] (E. Persson), [email protected] (G. Mårtensson). 1 Tel.: þ46 26 648242. 2 Tel.: þ46 26 648886. 3 Tel.: þ46 70 3498411. 4 Tel.: þ46 26 648294.
investigating preceptors’ experiences of two different clinical education models: peer learning and traditional supervision. Background Peer learning is a pedagogical model based on the idea that learning involves social cognition and that experience, understanding and knowledge-building are shaped in interactions between humans. Thus, peer learning derives from theories of social learning and constructivism and from theorists such as Bandura, Piaget and Dewey (Topping, 1996, 2005; Falchikov, 2001; Secomb, 2008). Peer learning differs from traditional education in that students learn with, and from, each other without immediate intervention by a teacher or a supervisor (Topping, 2005). It is defined as the acquisition of knowledge and skills through a process of active two-way reciprocal learning between peers (Boud et al., 2001). Central to the learning process is student activity, and peer learning promotes a holistic view of learning (Boud and Falchikov, 2006). In a systematic review of use of this pedagogical model in clinical education (including twelve empirical studies), primarily positive outcomes were found, and it was suggested that peer learning has the potential to increase students’ confidence in clinical practice (Secomb, 2008). Similar findings were reported in a recent review by Stone et al. (2013), who concluded that the learning strategies in
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peer learning increase students’ confidence and competence and decrease their anxiety. Other studies of peer learning have also reported findings pointing in the same direction (Chojecki et al., 2010; Christiansen et al., 2011). Carlson (2012) described how peer learning in clinical education allows students to work in pairs during structured nursing activities. Students are encouraged to engage in critical thinking, problem-solving and collaboration. The preceptors support and give feed-back to the students, but do not e in contrast to more traditional supervision models e play an active role during the nursing activities. Traditional clinical nursing education is a teaching model in which one student is placed in a hospital department and follows an RN/preceptor during a shift. The preceptor is familiar with the routines and the culture, and his/her role is to instruct and demonstrate (Hellström-Hyson et al., 2012). Preceptors working in traditional clinical education models have requested more time for students, proper training in precepting practice and pedagogical tools (Ehrenberg and Häggblom, 2007; Carlsson et al., 2010). The content of nursing education and the academic level at which it takes place have changed in Sweden and in other European countries (Ehrenberg and Häggblom, 2007). In Sweden, nursing education involves a 3-year Bachelor’s program (180 credits) leading to a Bachelor of Science in Nursing degree. Clinical education is an essential part of the 3-year program. Established higher academic education goals (SFS, 1992:1434; SFS, 1993:100) have to be met in the clinical as well as theoretical parts of the program. The goals include students’ ability to make critical and independent judgments as well as to formulate and solve problems. Preceptors play a critical role in the process of developing students’ knowledge and skills with a view to achieving higher education goals. Preceptors’ important and complex role in clinical nursing education has previously been highlighted. In Sweden, RNs’ dual function of patient care and simultaneous student supervision responsibilities has been described as stressful (Carlsson et al., 2010; Danielsson et al., 2009). A review by Omansky (2010), including 20 studies published during the period 1999e2009, showed that the preceptor role is ambiguous and entails a heavy work load. A study describing nursing education in 20 Western European countries showed that preceptors in clinical education often had a limited academic background, that the cooperation between higher education and clinical placements was insufficient, and that little time was dedicated to supervision (Spizter and Perrenoud, 2006). Structural conditions are important and can lead to improved preceptor performance (Mårtensson et al., 2012). In a recent study, Mårtensson et al. (2012) found that feedback from and recognition by managers, being able to plan and prepare the clinical education period, and having specific preceptor training explained 31% of the preceptors’ overall view on their performance as preceptors. However, these structural conditions and professional experiences could not explain preceptors’ use of reflection and support the students’ critical thinking (Mårtensson et al., 2012). Precepting nursing students requires professional and pedagogical accountability (Luhanga et al., 2008), a supportive learning environment and suitable clinical education models. One study in which students described their experiences of two clinical education models, peer learning versus the traditional model (HellströmHyson et al., 2012), reported that peer learning gave students opportunities to assume responsibility, helped them find their professional role, and increased their cooperation skills and confidence. In contrast, when students practiced on a department using the traditional model, they described themselves as onlookers and had difficulties assuming their responsibilities. They did not always feel free to take their own nursing care initiatives, cared for many patients simultaneously and thereby felt they had
lost control. However, the students felt confident because the preceptor was always present. To the best of our knowledge, no previous study has reported on preceptors’ experiences within the context of these two different clinical education models: peer learning and the traditional model. It is important to note that both preceptor and student experiences of different clinical education models warrant investigation. Therefore, the aim of the present study was to describe nursing preceptors’ experiences of their role as preceptors in two different clinical education models: peer learning and traditional supervision. Methods Design A descriptive design with a qualitative approach was used (Polit and Beck, 2012). Setting The study was carried out in surgical and medical departments at two of three public hospitals, in one county council including 276,000 inhabitants in central Sweden. The hospitals were both full-service facilities, had together about 400 patient beds and were run by one management office. During each semester, nursing students from one university are placed in these hospitals for their clinical education periods. The two hospitals used two different clinical education models. In one of the hospitals where a peer learning model has existed since 2006, students work in pairs and these pairs have joint responsibility for a group of four patients. The nurse who is primarily responsible for these patients’ care acts as a preceptor for a pair of nursing students (Hellström-Hyson et al., 2012). In the other hospital where the traditional model is used, one preceptor supervises one nursing student at a time. The terms preceptor, supervisor and mentor are often used synonymously (Yonge et al., 2007). In the present study, the term preceptor was chosen to refer to the RN responsible for precepting, that is, teaching, reflection, feedback and evaluation during clinical education (Yonge et al., 2007). The term nursing student refers to a student enrolled in term two or six of the Bachelor’s nursing program at a university in central Sweden. Sampling A purposive sample of 20 RNs was asked to participate, the strategy being to select individuals who are knowledgeable in the area of concern and who will therefore provide the richest data (Polit and Beck, 2012). Purposive sampling was also chosen because it allows researchers to ensure variation in the interview data (Patton, 2002). Ten of the RNs worked on the departments that used the peer learning model and ten RNs worked on departments using the traditional model. The inclusion criterion was having worked on the department for at least one year. One nurse declined participation and one interview failed due to technical problems, and for this reason 18 preceptors’ interviews were included in the analysis. All participants were women, ten from the hospital using peer learning and eight from the hospital using traditional supervision. Preceptors representing peer learning ranged in age from 25 to 65 years, had worked as RNs between 1 and 29 years and as a preceptor between 1 and 25 years. Seven had taken university courses in emergency medicine, pain, nutrition or nursing care documentation. None of them had taken a course in clinical supervision. Preceptors representing traditional supervision ranged
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in age from 28 to 65 years, two had taken university courses, such as specialist education in primary health care, medicine and surgery, and three had taken courses in clinical supervision. They had worked as RNs between 5 and 30 years and as a preceptor between 3 and 20 years.
workplaces, lasted from 25 to 40 min and were tape-recorded and transcribed verbatim. The study was carried out from March, 2010 to June, 2010.
Ethical considerations
The transcribed interviews were analyzed using latent qualitative content analysis (Sandelowski, 1998), which involves interpreting the underlying meaning and answering the ‘how’ questions; themes were constructed based on subthemes (Graneheim and Lundman, 2004). In order to understand and become familiar with the text, the transcriptions were read, re-read and the texts were divided into two content areas (peer learning and traditional model). Meaning units (words, sentences or paragraphs) were then identified based on the aim of the study. Meaning units were condensed into a descriptive text, abstracted and labeled with a code. The codes were grouped according to similarities and sorted into one theme and four subthemes where peer learning was used and correspondingly one theme and four subthemes for traditional supervision. Codes, subthemes and themes were discussed continuously with the co-investigators during the analysis process until agreement on thematic patterns was reached. The analyses were initially carried out by the first, third and fourth researcher. The second and fifth researchers read and commented on the analysis throughout the analytic process. The analysis process was transparent for all researchers during the study, and quotes are presented in the results to illustrate the preceptors’ statements.
The preceptors received information about the aim and procedure of the study; voluntary participation and confidentiality were assured. Furthermore, the participants were informed that they could withdraw from the study at any time, without any explanations or consequences. The study was approved by the Regional Ethical Review Board in Uppsala (Reg. no. 2010/002). Data collection A semi-structured interview guide (Polit and Beck, 2012) covering questions about the preceptors’ experiences of their role and the preceptorship, support and clinical learning environment was developed. The interviews were found useful in enabling understanding of the preceptors’ experiences. An interview guide can ensure that the same topics are brought up with each interviewee, and within the established topics the interviewer is free to probe a particular question (Patton, 2002). The questions formulated were inspired by the study by Hellström-Hyson et al. (2012), in which nursing students’ experiences of the two described models of clinical supervision were explored. The interviews started by taking a comprehensive perspective on precepting, that is, the preceptors were asked to describe aspects of importance in clinical education. Other questions were, for example, ‘What are the core elements of precepting?’, ‘What are the core elements in a supportive clinical learning environment?’ and ‘Can you describe a supportive preceptor role?’ Clarifying questions were asked (‘What do you mean? Can you describe or tell me more about this?’) to encourage the preceptors to share information and provide extended descriptions of their experiences. In addition, data on the preceptors’ age, gender, university courses and working time as a preceptor were collected.
Data analysis
Findings The findings are presented in two parts: the first reflecting the preceptors’ experiences of peer learning and the second the preceptors’ experiences of traditional supervision. In the peer learning model, the formulated theme was ‘The preceptor creates room for students to assume responsibility for their own learning’ and in the traditional model the theme ‘The preceptor’s ambitions and knowledge are stressed and taught’ was formulated. The two themes and the eight subthemes are presented and supported by quotations in the text (Table 1).
Procedure Peer learning model The first-line manager on each department presented the study and the criterion for participation at a staff meeting. RNs who had experience as student preceptors during the past year were invited to participate. A list of ten names from each hospital was made by the first-line managers and sent to two of the researchers (EHH and EP). The two researchers contacted the participants and conducted ten and eight interviews, respectively. These two researchers worked as clinical lecturers, and both were familiar with clinical education and preceptorship. The two interviewers were unfamiliar with the hospital, departments and preceptors they interviewed. The interviews were carried out at the preceptor’s
In the peer learning model, the preceptors created room for students to assume responsibility for their own learning and challenged the students’ knowledge by refraining from stepping in. The model was reported to encourage students’ critical thinking and independence. Taking a step back while providing support The preceptors described peer learning supervision as stimulating but challenging. In nursing care situations, it was challenging when the preceptor waited for the student to be active, to provide
Table 1 Themes and subthemes capturing the preceptors’ experiences of their role as preceptors, based on two clinical models of supervision. Peer learning model Theme Subthemes
Traditional model The preceptor creates room for students to assume responsibility for their own learning Taking a step back while providing support Creating a structure and acceptance for supervision Encouraging critical thinking and supporting development of independence Dealing with the problems of supervision
Theme Subthemes
The preceptor’s ambitions and knowledge are stressed and taught Demonstrating and gradually relinquishing responsibility Observing and controlling Reflection is important, but only done when there is time Striving for good structural conditions to create security
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care and to come forward, but the student acted more slowly than expected. In such cases, the preceptor might feel impatient and wish to intervene quickly. The preceptors described becoming aware of their own behavior; they tried to restrain themselves and adhere to the preceptor approach agreed to in the department, but it was not always easy. In cases of emergency they took over the care activities if needed. Their role was described as being to encourage and challenge the students to be active and solve different nursing problems in order to reach their individual and nursing education goals. ‘On the student wards, the students have each other and the preceptor is in the background’ (10) Creating a structure and acceptance for supervision Most of the RNs had accepted the idea of precepting in accordance with the method of peer learning used in the department. The preceptors’ schedules had been organized to accommodate peer learning, that is, the nursing colleagues supported the routines that allowed students to take care of the same group of patients from admission to discharge. Precepting two students at a time was reported not to be more time consuming than precepting only one student at a time. ‘We have decided on the ward that we nurses do like this.to manage [the supervision]. Even if the nurse/preceptor already has worked for example two morning shifts she has the first priority [before colleagues] to the rooms, where the students are responsible’ (2). Encouraging critical thinking and supporting development of independence It was stressed that peer learning supports and contributes to students’ professional development. The preceptors meant that allowing students to be responsible for a smaller group of patients enabled them to grasp these patients’ whole situation. The students first searched for knowledge so as to identify relevant solutions to different patient problems, and thereafter they confronted the preceptor with questions and solutions. The preceptors reported that this method of supervision trained students to think critically and supported independence in their nursing role. ‘First they kick it around between them, then take it up with their preceptor. The preceptors aren’t supposed to tell them everything... the students should identify [solutions] themselves, reflect and then discuss them with me’ (8) Dealing with the problems of supervision On some occasions, precepting according to the peer learning model was difficult, causing the preceptors to switch to traditional supervision. This occurred when the students did not have earlier nursing care experiences or when the student pair was very uneven in their level of knowledge. Students without earlier experience of nursing care often had problems identifying patients’ care needs. In order to prevent such situations in the department, the two first weeks of the students’ clinical practice period were planned and carried out using traditional supervision. One preceptor was responsible for one student, allowing enough time to grasp that student’s needs, and after the two weeks, switching over to the peer learning was seldom a problem. ‘Using [peer learning] can be difficult for example when they [the students]work together.and when they have to plan and provide for the patients’ care. then if one of the students is very
competent and the other has not developed so much and they don’t have the same level of knowledge, then it can be difficult’ (2).
Traditional model In the traditional model, the preceptors’ individual ambitions influenced the preceptorship and their own knowledge was emphasized as being important to impart. Preceptors demonstrated, observed and gradually relinquished responsibility to the students. Demonstrating and gradually relinquishing responsibility Preceptors using the traditional supervision model mentioned that it is important for students to observe the preceptor if they are to learn how nursing care should be provided. They invited students to follow their actions in relation to different nursing care situations and when the care was provided, the patient’s problems and care needs were presented to the students. Demonstration was emphasized as an important step in teaching, owing to the preceptors’ long experience of working with patients and with tasks of a technical nature. After a demonstration, the students were encouraged to test the different care activities by themselves. Sometimes the preceptors did not have time to demonstrate owing to a heavy workload or acute care situations. In such situations, they focused on patients’ needs, and the students observed the care provided. The preceptors’ ambition was to share their experience with the students, thereby contributing to students’ development of in-depth knowledge of nursing care. ‘For instance, if I’m going to mix an intravenous solution or prepare an injection, first I demonstrate and then the student can do the same thing, while I supervise of course, I want to see they’ve understood’ (8) ‘When things are stressful then it’s like they just run after me and I don’t havetime to show them like I’d like to.’ (2)
Observing and controlling The preceptors’ responsibility to observe and control students’ nursing care activities was highlighted and related to their responsibility for patient safety. Observations and controls were described as necessary in order to follow students’ skill development in nursing care. The students were encouraged to ask questions and to inform the preceptors about their planned care activities before they delivered care. The ambition was to teach students to be open minded and to try to see the whole patient, to participate in rounds and become knowledgeable about medications. ‘I want to have control over what they do, because I’ve seen others who let their students go and they might be very competent, but I’m the one who’s responsible, it’s mostly medications’ (5)
Reflection is important, but only done when there is time The need for reflection together with the student after care situations was stressed. They wanted to discuss what aspects of the care situation were good or problematic and they wanted to provide correction or advice. Reflection at the end of the day did occur, but it was often difficult due to staff shortages. In that sense, reflection was subordinated, even though the preceptors felt it was important for the students and themselves to deal with questions and the experiences of the day. ‘There are fewer and fewer of us on the shifts, there’s no time to reflect yourself, which might be necessary sometimes, and the
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students need it for sure, because they naturally have lots of questions, about what they saw and experienced’ (5)
Striving for good structural conditions to create security The preceptors’ goal was to ensure good structural prerequisites so as to create a secure context for students during their clinical practice period. Upper level management’s commitment to and recognition of the value of supervision were called for, as was greater management responsibility for shortcomings in the organization of supervision. The nurse manager had been asked to relieve the preceptors of some patient responsibilities during intensive student supervision periods. The current system in which all nurses made their individual schedules, often changed by the nurse manager, led to difficulties in matching the preceptors’ and students’ schedules. ‘Support from management, well, not like I would like it’ (2) ‘More and more difficult, hard to get the schedules to match [preceptor and student], because we have these individual schedules and there’s no continuity like before’ (9) The clinical lecturer was reported to contribute to nursing development by helping preceptors keep up to date on nursing education changes and new demands. Supervision courses were stressed as being necessary to carrying out the preceptor role. Discussion The themes ‘The preceptor creates room for students to assume responsibility for their own learning’ and ‘The preceptor’s ambitions and knowledge are stressed and taught’ describe the preceptors’ experiences and approaches to their preceptorship, with respect to two models of clinical nursing education: peer learning and traditional supervision. Using the peer learning model, the preceptors created space for students to take responsibility for their own learning process. The preceptors’ felt they could take a step back while providing support, they had created a structure for supervision, which was accepted at the department, encouraged the students’ critical thinking and supported their independence. Using traditional supervision, preceptors’ individual ambitions influenced the preceptorship and their own knowledge was emphasized as being important to impart. They wanted to improve the structural conditions of the preceptorship, but lacked manager support and felt they had little opportunity to effect change. The findings in the present study will be discussed in light of Spreizter’s (1995) description of psychological empowerment and its four inherent components (meaning, competence, self-determination and impact). According to Spreitzer (1995), not only structural conditions but also psychological empowerment is an important component of workplace empowerment. Psychological empowerment involves individuals’ feelings and views on their working role and includes: meaning e a fit between work- and taskrelated goals, beliefs, behaviors and the individual’s own ideals and goals; competence e the individual’s confidence in his/her ability to carry out tasks with skill; self-determination e the individual’s sense of choice or control over his/her work methods, work rates and work performance and; impact e the degree to which individuals are able to influence administrative and operative work outcomes. These characteristics reflect an active approach to the work role because the individual can influence the role and the context (Spreitzer, 1995). Meaning e at the department, using peer learning, the overall higher education goals seemed to match the preceptors’ own goals. They expected, encouraged and challenged the student pairs to be
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active in their own learning process, to search for knowledge, and to practice critical thinking and problem-solving in relation to their patients’ specific needs. Preceptors’ behaviors, such as openness, trust and skepticism, promote critical thinking during clinical education (Myrick and Yonge, 2004). The preceptors tried to refrain from stepping in and to make room for the students to take the initiative, but this was sometimes difficult. The preceptors’ behavior indicates that they considered peer learning meaningful, because this approach promoted students’ personal and professional growth but was also in accordance with preceptors’ own beliefs (Spreitzer, 1995). Students who act independently increase their self-confidence and develop in their professional role (Ponzer et al., 2004). The present findings are in line with students’ experiences of peer learning in clinical education (Hellström-Hyson et al., 2012). In contrast, during traditional supervision, a discrepancy was found between higher education goals and preceptors’ experiences of their preceptorship. The preceptors’ long experience may lead them to believe that observing and controlling students were two of the most important tasks of the preceptor. A professional preceptor is alert, in control and at the center of several activities (Murray and Main, 2005). Such an approach may, on the one hand, lead to imitative forms of learning that internalize poor practice. On the other hand, students meet experienced preceptors who can help them to develop their professional role. However, nursing care is complex and qualified, and preceptors have to balance students’ skills development with patient safety. Öhrling and Hallberg (2001) stated that precepting should entail empowering students in clinical practice. Empowerment reduces feelings of helplessness, and thus pedagogical strategies that promote such a process must be used. Not interfering with students may sometimes be difficult, but encouraging students to act independently is a sign that preceptors feel secure in their professional role (Hellström-Hyson et al., 2012). Integration of nursing education into higher education has resulted in new demands on preceptorship. The traditional approach, where preceptors demonstrate tasks and control students, must be transformed into supervision that promotes reflection and critical thinking (Mårtensson et al., 2012). There are differences between the clinical and the theoretical parts of nursing education as regards meeting higher education goals. Theoretical education at universities to a greater extent than clinical education helps students, for example, apply research findings and learn how to effect change in clinical practice (Florin et al., 2011). Competence e using peer learning, confidence in performing tasks and being innovative was mirrored among the preceptors. According to the preceptors’ expert knowledge, if student pairs were found to differ greatly in knowledge, peer learning did not promote their professional development. The preceptors trusted their judgment and switched to traditional supervision. The students consequently received more individual time with the preceptor. Peer learning entails less individual time spent with the preceptor, which is a negative aspect to consider (Secomb, 2008). The preceptors’ behavior described above could also be reflected in relation to self-determination e that is, the preceptors felt confident in their expert knowledge and felt they had choices in dealing with difficulties that arose. Using peer learning, the preceptors’ schedules had been adapted to the preceptorships, which may reflect the component impact; thus, the preceptors were able to influence administrative conditions to achieve the best precepting outcomes, which were supported by management. In contrast, when using traditional supervision they strived to create good structural conditions for precepting, such as adapting schedules and setting aside time, but they felt there was little support and interest on the part of
Please cite this article in press as: Mamhidir, A.-G., et al., Nursing preceptors’ experiences of two clinical education models, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.01.010
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management. This revealed their feelings of having little impact on the situation. Other studies (Ehrenberg and Häggblom, 2007; Omansky, 2010; Mårtensson et al., 2012) have reported that manager support and recognition are important, such as being given time to precept. Lack of allocated time for precepting has been described as problematic (Carlson, 2012). Spitzer and Perrenoud (2006) reported on nursing education in 20 Western European countries and showed that little time was dedicated to clinical supervision. However, preceptors using peer learning declared that precepting two students at a time is not more time consuming than precepting only one. The present findings implied management acceptance of the resources required to operate peer learning education, while it appeared more difficult for those using a traditional approach to preceptorship. This can be related to the fact that the peer learning model was implemented and supported by management. According to Spreitzer (1995), the degree of impact is related to the working context, but it also reflects an active approach to the work role because the individual preceptor can influence the role and the context. These results confirm Spreitzer’s (1995) position that individuals’ sense of control in their workplace affects not only their attitude, but also their performance. Limitations of the study There are methodological limitations in our study. The interviews were conducted by two clinical lecturers, both familiar with clinical education and preceptorship. Familiarity with the context under study may be viewed as a strength, but also a weakness, as some information may be taken for granted, not noticed or not taken into consideration. A precaution was taken in this regard, in that the two interviewers were unfamiliar with the hospital, departments and preceptors they interviewed. This precaution was also considered to minimize the risk of preceptors feeling dependent on the interviewer. Qualitative content analysis was used to acquire a deeper understanding of the nursing preceptors’ experiences of their role as preceptors, in two different clinical education models. In content analysis, the concept of transferability can be discussed (Patton, 2002). Our findings cannot be generalized but are credible if persons with similar experiences recognize and can relate to the descriptions or interpretations (Patton, 2002). If this is the case, the present findings may be applied to similar preceptors’ work situations in different clinical education models. Implications and conclusions Challenging students or providing students with knowledge reflects preceptors’ experiences and approaches to their precepting, with respect to the two models of supervision: peer learning and traditional clinical supervision. Using the peer learning model, preceptors created room for students to assume responsibility for their own learning process and acted as challengers. The preceptors acted in line with the idea of peer learning (Topping, 1996, 2005), where student peers interact and learn together while performing interventions. The preceptors experienced empowerment and selfdetermination, were innovative and reported having had an impact on the precepting work. The preceptors using traditional supervision had the role of knowledge providers. Their individual ambitions influenced the preceptorship, and their own knowledge was emphasized as being important to impart. They wished to improve the structural conditions of the preceptorship, but the lack of manager support made them feel they had little opportunity to influence their work. The choice of clinical education models is important to learning. Peer learning seemed to create learning environments that
integrate clinical and academic skills. Carlson (2012) argued that preceptors in a peer learning model can use their time more efficiently, at the same time they are pedagogically sound and the approach is beneficial for students. However, there seems to be some potential for a mixed approach. This may be a way for the preceptor to feel free while meeting the students’ needs during clinical practice. The findings are promising and credible for preceptors with similar work situation experiences. Future initiatives to explore different pedagogical models in clinical education are needed and should be of major concern to managers as well as preceptors. Conflicts of interest The authors of this paper report no conflicts of interest. Acknowledgments We wish to thank the RNs who participated for sharing their knowledge and time. Financial support for the study was provided by the Faculty of Health and Occupational Studies Department of Health and Caring Sciences University of Gävle. References Boud, D., Falchikov, N., 2006. Aligning assessment with long-term learning. Assess. Eval. High. Educ. 31 (4), 399e413. Boud, D., Cohen, R., Sampson, J., 2001. Peer Learning in Higher Education. Kogan Page, London. Carlson, E., 2012. Precepting and symbolic interactionism e a theoretical look at nursing practice. J. Adv. Nurs. 69 (2), 457e464. Carlsson, E., Pilhammar, E., Wann-Hansson, C., 2010. “This is nursing”: nursing roles as mediated by precepting nurses during clinical practice. Nurse Educ. Today 30 (8), 763e767. Chojecki, P., Lammare, J., Buck, M., St-Sauveur, 1, Eldaoud, N., Purden, M., 2010. Perceptions of a peer learning approach to pediatric clinical education. Int. J. Nurs. Educ. Scholarsh. 7 (1), 1e14. Christiansen, B., Björk, I.T., Havnes, A., Hessevaagbakke, E., 2011. Developing supervision skills through peer learning partnership. Nurse Educ. Pract. 11 (2), 104e108. Danielsson, C., Sundin-Andersson, R., Hov, R., Athlin, E., 2009. Norwegian and Swedish preceptors’ views of their role before and after taking part in a group supervision program. Nurs. Health Sci. 11 (2), 107e113. Ehrenberg, A.C., Häggblom, M., 2007. Problem-based learning in clinical nursing education: integrating theory and practice. Nurse Educ. Pract. 7 (2), 67e74. Falchikov, N., 2001. Learning Together. Peer Tutoring in Higher Education. Routledge Falmer, London. Florin, J., Ehrenberg, A., Wallin, L., Gustavsson, P., 2011. Educational support for research utilization and capability beliefs regarding evidence-based practice skills: a national survey of senior nursing students. J. Adv. Nurs. 68 (4), 888e897. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today 24 (2), 105e112. Hellström-Hyson, E., Mårtensson, G., Kristofferzon, M.L., 2012. To take responsibility or to be an onlooker. Nursing students’ experiences of two models of supervision. Nurse Educ. Today 32 (1), 105e110. Luhanga, F., Yonge, O.A., Myrick, F., 2008. Precepting un unsafe student: the role of the faculty. Nurse Educ. Today 28 (2), 227e231. Mårtensson, G., Engström, M., Mamhidir, A.G., Kristofferzon, M.L., 2012. What are the structural conditions of importance to preceptors’ performance? Nurse Educ. Today 32, 105e110. Murray, C.J., Main, A., 2005. Role modeling as a teaching method for student mentors. Nurs. Times 101 (28), 30e33. Myrick, F., Yonge, O., 2004. Enhancing critical thinking in the preceptorship experience in nursing education. J. Adv. Nurs. 45 (4), 371e380. Öhrling, K., Hallberg, I.R., 2001. The meaning of preceptorship: nurses’ lived experience of being a preceptor. J. Adv. Nurs. 33 (4), 530e540. Omansky, G.L., 2010. Staff nurses’ experiences as preceptors and mentors: an integrative review. J. Nurs. Manag. 18 (6), 697e703. Patton, M.Q., 2002. Qualitative Research and Evaluation Methods, third ed. Sage, Thousand Oaks, CA. Polit, D., Beck, C.T., 2012. Nursing Research. Generating and Assessing Evidence for Nursing Practice, ninth ed. Lippincott Williams & Wilkins, Philadelphia. Ponzer, S., Hylin, U., Kusoffsky, A., Lauffs, M., Lonka, K., Mattiasson, A.C., Nordström, G., 2004. Interprofessional training in the context of clinical
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