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

A constructive clinical learning environment, with satisfactory possibilities for student learning, and a focus on student learning needs, is vital to nursing education [1]. Clinical learning is carried out in complex health care settings, and students’ experiences within the clinical context are of great importance to how and what they learn. The environment should motivate students and contribute to their feeling of security, including when asking questions to achieve learning outcomes [2]. The clinical learning environment and supervision of students play a crucial part in supporting student learning and are highly dependent on the relationship between student, preceptor, and nurse teacher [3]. Nurse teachers have a multifaceted and important role in supervision, including supporting, motivating, problem-solving and monitoring [4]. Students have a responsibility to be active in their own learning [5] and preceptors and nurse teachers are both facilitators of and responsible for the students’ learning in clinical settings.

From the students’ perspective, the clinical environment has been described as non-supportive, e.g., because of organisational shortcomings, a lacking relationship between students and preceptors, and negative attitudes and behaviours on the part of preceptors [6], Students have also described inhibitors to learning arising from preceptors’ lack of engagement and feedback [7]. Preceptors were not always engaged personally or easy to reach, and students found that theory and practice were not clearly connected to each other and felt that they lacked opportunities to reflect together with their preceptors [8]. A key challenge reported by preceptors is finding adequate time to supervise students in the clinical setting and this, along with the lack of recognition by both the faculty and health care organisations, seems to undermine the importance of the role [9]. Preceptors have stated that they must strike a balance between taking care of patients and supervising students [10]. There is a risk that the clinical demands may take time from supervision and thus affect student learning [11].

In the search for new innovative pedagogical models in the clinical setting, peer learning is found to be a valuable resource [12]. In a peer learning model described by Pålsson and colleagues [13], students attending a course are divided into pairs, each supervised by one preceptor. The contribution of peers has often been underestimated, but can be a key component of clinical learning that impacts on student experiences [13‐16]. When students get the opportunity to assume responsibility for a patient’s care and share their experiences with a peer, learning may increase [14, 16]. Peer learning has also been described to contribute to developing the students’ abilities to communicate and solve problems to a greater extent than a more traditional way of learning, as well as alleviating levels of stress and anxiety [17].

Other innovative ways of developing the learning environment and supervising students include having nurse teachers and preceptors working together in models that enable for clinical wards to effectively supervise large numbers of students. Collaborative models, such as student-dedicated units, have been introduced. The teaching and learning environment at such units is developed through the collaborative efforts of preceptors and nurse teachers. A unit consists of one or two patient rooms, in which peer learning is combined with patient-centred training [18]. Several studies have reported that students have positive experiences of supervision combined with peer learning in student-dedicated units [5, 19, 20]. Students express that they become more confident as they assume increasing responsibility for patients and that they also discover their professional role when they get opportunities to work independently and are given responsibility during their clinical placements [5].

However, comparisons of students’ experiences of their learning and supervision in different models are limited. Today, we are seeing an increasing number of students, and a simultaneous reduction of the number of beds and patients in teaching hospitals, where most clinical placements occur. This calls for the highest possible standard in clinical education, and therefore it is of the utmost importance to investigate and evaluate supervision models that meet these challenges.

Students’ experiences of clinical education are relevant as they impact on the opportunities of linking the theoretical aspect of studies with clinical practice. The nursing student’s satisfaction with the learning environment and the supervisory relationship are suggested as important factors that could be used as a basis for potential development and/or reforms of learning environments in clinical settings [21]. Although theoretical conceptualisation is lacking, there is evidence that nursing students’ satisfaction with the clinical learning environment and supervision could be conceptually described and measured within the context of an internationally validated tool. The Clinical Learning Environment, Supervision and Nurse Teacher (CLES+T) [22] evaluation measure conceptualises the key components in five distinct dimensions: the ward’s pedagogical atmosphere, the leadership style of the ward manager, premises of nursing on the ward, various aspects of the supervisory relationship and the role of the nurse teacher in clinical practice in transforming theoretical knowledge into clinical practice and skills [22, 23]. Therefore, the aim of this study was to compare nursing students’ experiences of the clinical learning environment and the supervisory relationships from two different supervision models used in a Swedish nursing education. The two supervision models are peer learning in student-dedicated units, with students working together in pairs and supervised by a preceptor “for the day” (model A), and traditional supervision, in which each student shadows a preceptor in her/his work within nursing care (model B).

Out of 381 eligible students, 244 filled out questionnaires, yielding a response rate of 64%. Of these, 170 students (90% women) got supervision in model A and 74 students (88% women) in model B. The students’ mean age was 28 years and the range was between 21 and 50/51 years in both groups. There was no difference between the groups in the proportion of students who were in semesters 3 and 4, respectively (Table 1). However, there was a significant difference between the three hospital settings as regards the organisation of supervision. In wards using model A, 90% of students received supervision from more than one preceptor, while in those using model B, the proportion of students supervised by more than one preceptor was 68%.

This study is one of the few that has compared nursing students’ experiences of different supervision models. The main findings were that both models yielded overall satisfaction among students concerning the learning environment (pedagogical atmosphere, leadership style of the ward manager, premises of nursing on the ward) and the supervisory relationship, as measured with CLES+T. However, model A was rated significantly higher by students than traditional supervision, model B, on items indicating that the ward was a good learning environment, and that staff were generally easy to approach and interested in supervising students.

The number of preceptors per student varied largely in both model A, where students had a designated “preceptor of the day,” and model B, where the preceptor could change from 1 day to another. Students supervised in model A, to a greater extent than those supervised in model B, perceived it was beneficial to have more than one preceptor. This is in contrast with a study by Sundlers et al. [31], also using the CLES+T scale, where the clinical learning environment was studied in relation to three models of supervision. They found that students who had the same preceptor all the time were more satisfied with their relationship with the preceptor than those who had different preceptors each day, whether they followed patients in rooms specifically designated for student training and had a number of preceptors or followed a designated personal preceptor, but also received supervision from others [31]. It was not stated if the students worked in pairs in the student-dedicated rooms. Omer et al. [32] explored and compared students’ perceptions of two supervision models. One model was characterised by intensive preceptorship and the other by increasing independence and self-directed learning. The model with intensive preceptorship was perceived as more satisfactory, which according to the authors could be due to the students not being mature enough to act autonomously for their patients’ interests. However, comparisons of studies in an international perspective are precarious, because of large variations between countries in the organisation of supervision and in preceptors’ roles and responsibilities.

Most of the items concerning the wards’ preparedness and organisation of supervision, the preceptor’s role, and students’ professional progress were rated higher by students who had been supervised in model A. The area “professional progress” included some questions about collaboration with peers. Students who had experiences of working continuously with a fellow student rated items on collaboration and impact on problem-solving ability and reflection higher than students without such experiences. The literature reviews by Secomb [12] and by Stone et al. [17] underline that peer learning has many benefits, e.g., students have described how they discuss and reflect as well as identify and solve problems together. Students in model B were fairly positive to collaborating with peers, although this model does not presuppose a structure with students in pairs all the time.

Students in model A found that they were given the opportunity to work autonomously and to discuss and reflect on care situations with peers, and they experienced, to a greater extent than those in model B, that they developed independence and got a comprehensive picture of patients during their clinical placement. This is in line with other studies where similar supervision models are evaluated [5, 16, 18]. In the study by Hellström-Hyson et al. [5], students appreciated the opportunity to identify and solve problems on their own, with an experienced preceptor within reach. Loke and Chow [25] found that students’ personal development and learning skills grew through peer learning. Thus, being able to cooperate with peers during clinical placement seems to encourage critical reflection and independent thinking, which is important for developing deeper knowledge.

Negative aspects of peer learning and the number of preceptors in the patient-centred supervision models have also been discussed in earlier studies. Loke and Chow [25] described that negative experiences of peer learning were related to having many different preceptors involved in supervision. Sundler et al. [31] concluded in their study that student dissatisfaction with the learning environment was not only associated with having many preceptors, but also with the preceptors’ attitudes and approaches, as well as with having a newly graduated nurse as preceptor. We found, in contrast, that students in model A experienced a greater advantage from having more than one preceptor than students in model B, and also that they felt that having several preceptors contributed to the assessment of their learning outcomes. Much like Trede et al. [33], we argue for shifting from a focus on individual supervision to a focus on collective responsibility for creative workplace environments to promote student learning.

Generally speaking, all students in the current study were satisfied with the relationships with their preceptors. The relationships were equal and based on mutual understanding. Whether students were involved in model A or B, they were encouraged to use reflection as a tool for learning. No difference was found between the groups in their perception of the preceptor’s role in making room for reflection and questions, which may indicate that reflection is used as a valuable tool for feedback and for translating theory into practice [34, 35].

The important role of the nurse teacher, e.g., as a pedagogical expert, was also underlined in this study. This is supported by a number of studies, which have highlighted that the student-teacher relationship is crucial to learning [32, 36]. Studies based on the students’ perspective have also emphasised the important role that visits from the academic nurse teacher play in bridging the theory-practice gap during student placements and helping students reflect on clinical practices [24]. The role also includes supporting fulfilment of theoretical assignments and clarifying the learning outcomes of the course to both the preceptor and the student. Papastavrou et al. [21] have emphasised the role of the nurse teacher in influencing the entire nursing staff to be involved in the students’ learning process.

In this study, the role of the preceptor was described as more prominent on wards where students were supervised with peer learning compared with wards using traditional supervision. The reason for this is unclear, but the nurse teacher was experienced more as a member of the nursing team (preceptor and nurse teacher), able to impart his or her pedagogical expertise, on wards where students were supervised with the patient-centred, peer-learning model. The preceptor and nurse teacher also collaborated in their support of the students’ learning in such a way that the encounters between the student, the preceptor and the nurse teacher were experienced as relaxed and congenial by the student (Table 2). Our study also shows that the wards, in model A, to a greater extent dedicated resources to supervision, and that students experienced that the wards had a clear structure for receiving students and an explicit model facilitating supervision. Altogether, this might have contributed to a closer cooperation between the academic nurse teacher and the preceptors, and contributed to the students’ positive experience of the learning environment. The literature indicates that there is an increased need for university teachers to be available regularly, to both students and staff [37], irrespective of supervision model. Calpin-Davies [38] emphasised that teachers have a distinct advantage over preceptors in helping students, as they are highly aware of the students’ stage of learning, and can adjust teaching and explanations accordingly. Students in the study by Löfmark et al. [39] gave higher ratings for university teacher supervision than preceptor supervision, which might be explained by the teachers’ familiarity with learning outcomes for clinical placements and how they can be achieved and assessed.

A good learning environment for students in clinical placements is dependent on engagement and collaboration between preceptors and academic nurse teachers. This study also indicates that a supervision model for students based on peer learning in student-dedicated rooms with many preceptors can be more satisfying than a model with traditional supervision, where each student is dependent on a single preceptor. A particularly good learning environment is found on wards with an explicit structure for receiving students, offering supervision from more than one preceptor, and a pedagogical atmosphere where staff are generally interested in supervising students and easy to approach. In the search for the best quality in clinical education, supervision models must be systematically evaluated and compared in order to meet future needs and challenges. Longitudinal evaluation of the effect on students’ learning outcomes is needed.